NUR1013 Principle of Medication Administration PDF

Principle of Administration of Medications AOM 1 NUR1013 Winsy Wan  Learning Objectives By the end of this lecture, students should be able to: 1) Define common terms related to administration of medications AOM 2) Understand Basic principles of AOM: 3 check and 5 rights...

Principle of Administration of Medications AOM 1 NUR1013 Winsy Wan  Learning Objectives By the end of this lecture, students should be able to: 1) Define common terms related to administration of medications AOM 2) Understand Basic principles of AOM: 3 check and 5 rights 3) Describe Various routes of AOM, able to verbalize the steps and the related techniques used to deliver medication 4) Calculate Correct drug dosage 5) Understanding Roles of Nurse in medication administration 6) Discuss on LAB result related to AOM 2  Why are Drugs being prescribed? 處方 Types of drug Description Palliative Relieves symptoms of diseases but does not affect the disease itself Curative 治療 Cures a disease or condition Supportive Supports body function until other treatments or the body’s response can take over 替代品，代替物 Substitutive Replaces body fluids or substances Chemotherapeutic Destroys malignant cells Restorative 恢復作用的 Returns the body to health Nurses should know the indication of medication for patient! Drug Effects  Therapeutic effect = Desired effect o MUST KNOW: Reason (Primary effect) for drug prescription  Side effect = Secondary effect o Un-intended, usually predictable o May be harmless or potentially harmful o Adverse effects/ reactions  Drug Toxicity o Harmful effects resulting from Over-dosage (We need to know Maximum dosage) Drug Accumulation in blood due to impaired metabolism or excretion (We need to know patient’s profile) 4  DRUG ALLERGY ◎ Immunologic reaction to drug: body produces antibodies when first exposed to a foreign substance (antigen) Mild reactions o Skin rash/ Urticaria Severe reactions (anaphylactic reaction o Itching/ Pruritus >>> life threatening o Angioedema o Wheezing and dyspnea o Diarrhea or Vomiting VS o Acute shortness of breath (SOB) o Rhinitis o Acute hypotension o Lacrimal tearing o Tachycardia o Swelling in mouth & tongue 除咗問有冇allergy history之外，要記住問埋related (subjective feelings) signs and symptoms! 5  WHO Supervise Nurses in AOM? ANY Legal document? 6 The Nursing Council of Hong Kong Code of ethics and professional conduct for Nurses in Hong Kong (NCHK, 2015) Provide Safe & Competent practice Maintain standard of Professional Practice Collaborate with colleagues/ stakeholders towards goal Principles for good practice in AOM (NCHK, 2017) Safe & effective AOM in all settings Exercise professional judgement apply necessary knowledge and skills in all situation Legal issues related to AOM  Nurse Responsibilities for good practice in AOM (NCHK, 2017) 1. Understanding local policies + practices on AOM 2. Assessing clients’ conditions before administering 3. Administering medication correctly 4. Ensuring proper use of medication administration devices + disposal of residual medication and devices 5. Evaluating client’s progress with proper documentation 6. Ensuring proper handling and safe custody of medication in accordance with local policies and relevant ordinances 7. Educating the client and his/her caregivers 8. Reporting medication incidents 9. Up keeping knowledge of medication  (1) Proper Storage of medications ✓ Drug trolley with locked Key ✓ Dangerous Drugs Administration (DDA)_Cap 134 Safety (2) Proper Handling of medications Issues ❖ 3 check 5 rights (strictly follow) ❖ clean procedure (+ non-touch technique) regarding ❖ Never reuse leftover drugs ❖ Ensure patient’s taken drugs AOM (3) Careful drug effect Monitoring ❑ Look for contraindication ❑ Patient’s understanding & compliance 10 Any consequence if violate?  Medication Error Inappropriate medication use Resulting in patient harm (long or short term) while medication is in control of health care professional, patient, consumer Cause: professional practice, health care products, procedures, systems…… Examples: non-compliance in 3 check 5 rights, improper communication, product wrong labeling & packaging, irrelevant education….. Hospital Authority Risk Alert https://www.ha.org.hk/visitor/ha_visitor_index.asp?Parent_ID=10142&Content_ID=697&Ver=HTML Can be Preventable  Medication Error No verifying on Contributing Missed dose/ Not alert for contraindication factor: Extra dose the duration of with allergic Non-compliance (e.g. “stat” drug history for checking medication) Without verifying correct Look alike & Wrong Wrong route identity & Sound alike scheduling of (PR/PV) acknowledging (Clonazepam time “not matched”! VS Clobazam) How to ensure Drug Safety?  Dangerous Drugs Administration (DDA) Dangerous drugs Ordinance 134 香港法例第134章《危險藥物條例》for controlling manufacture, supply, possession, administration Common types of DD: Stimulants, Hypnotics, Tranquilizers, Sedatives Examples are Bromazepam, Clobazam, Clonazepam, Codeine, Diazepam, Fentanyl, Hydrocodone, Lorazepam, Midazolam, Morphine, Oxycodone, Pethidine… 15  Locked in Double–door cabinet Practical DDA key hold by ward shift in charge Guideline of When counting? DDA Storage 1/ regular basis (weekly) 2/ every time when drugs taken out from storage & Handling DDA administration: Two Authorized Staff Never leave any DD pr drugs unattended Report & record for any missed drugs Discarded DD or damaged vials properly 16  Drug Supply System Pharmacy Individual patient dispensing: Ward Stock ❖ Individually supplied medication o bulk stock of commonly used ❖ With patient Labelled Weekly refill by pharmacist ❖ supply 3-5 days stocks (in acute o Different among ward & setting) specialty ❖ will re-supply if patient is not o Based on Ward nature discharged yet  How NURSES facilitate 有疑必問 throughout the process? Communication Confirm Correct Orders with doctor (when any doubt) Requesting drug supply from pharmacy Appropriate Storage and Management of drugs Administer Medication Appropriately (3 check 5 right) HA Guideline “no medication should be administered to patient if drug order is unclear or when there is doubt in appropriateness and safety of the patients.”  Hospital Authority Standard Drug Formulary implemented the Formulary since 2005 ensure equitable access by patients to cost-effective drugs of proven safety & efficacy through standardization of policies on drugs + drug utilization 4 categories of drugs in the HA drug formulary: 1) General drugs 2) Special drugs 3) Self-financed items (SFIs) with safety net 4) SFIs without safety net 25 26 27 Medication Order 28  Licensed Medical Practitioner (under Medical Registration Ordinance Cap 161 of the HKMC, HKSAR ) Institute information/ prescriber’s office information Doctor’s name, code & signature Valid “On Date” & “Off Date” Medication Patient identity (Full name, Hospital no. or HKID or passport no) Order Drug allergy history Diagnosis (+/-) Body weight (especially for neonates) Drug Name, Form, Route, Strength Dosage instruction (Conditional) Drug Specific duration (Time) / dosage 29  Right Patient Allergic history (Name & Hospital No.) Diagnosis Prescription: Date Doctor name, code Signature, 30  Right Time with Correct set time Right Drug Right Dosage Right Route 31  RISK ALERT ISSUE 73 - APR 2024 Alert for any Drug-Drug interaction or contraindication! Alert for any allergic history with contraindication!  RISK ALERT ISSUE 74 - JUL 2024 Remember to (1) Ask patient allergic history! (1) Verify his/her allergic history in MAR! Before starting AOM 1) Medication Cart Key (Drug safety) 2) Disinfection (Infection Control) 3) Countersign/ Counterchecking (as YOU are a student) Pre-reading on the MAR -> Verify for valid prescription -> check any medication need to give to patient -> any doubt -> any PRN medication or conditional medication -> any essential assessment 34 Assessment (1) Check against on patient profile for related record -> Blood pressure for anti-hypertensive drug -> H’stix for DM drug -> Input and output chart for diuretics etc. (2) Bedside patient assessment -> Identification + Allergy (MUST!) -> Evaluation on last drug effect -> Patient current condition & readiness -> Any contraindication etc. 35  3 CHECKs ALERT for Allergic History + Right documentation 1st 3 CHECKS 1st: before taking medication out from container 2nd: after taking drug out from container 3rd: before returning drug container to trolley 2nd 3rd Five Rights 37  Right PATIENT Identification checking (IMPORTANT!!!!) 2 personal identifiers: Patient name + Hospital no. ALERT: Open-ended Question Procedure: 1/ Ask “What is your name?”, instead of asking patient “Are you Chan Tai Man?” 2/ Cross-check with bracelet with prescription sheet 3/ Cross-checking between package & prescription sheet Right Chemical name A very precise description of drug’s chemical composition, Drug identifying drug’s atomic and molecular structure Generic name: The name assigned by the manufacturer who first develops the drug. Often generic name is derived from chemical name. Trade/ brand name: Name selected by the drug company selling drug and is copyrighted. A drug can have several trade names when produced by different manufacturers. Paracetamol, acetaminophen, Tylenol, Excedrin, Calpol, Panadol….. RISK ALERT ISSUE 68 - JAN 2023  Drug form/preparation tablet, capsule, suspension, syrup, ointment, cream, spray…… According to Prescription According to Patient’s situation (e.g. swallowing ability, injection site) Drug Action Therapeutic effect: Determine whether drug is correctly prescribed without contraindication: side effect/allergic reaction/drug interaction/ NPO/ site infection…. NURSE: drug name VS prescription carefully + critical thinking  Safe Therapeutic dosage Right o o adult VS children Familiar with usual dosage range DOSE (common drug) e.g. paracetamol must not exceed 4000 mg/ 24 hours for adult Correct drugs calculation Dilution or Split of Drugs Measurement methods 單位要相同 轉單位, 你ready未 ??  *Metric Apothecaries’ Household 1 ml 15 minims 15 drops (gtt) 4-5 ml 1 fluid dram 1 teaspoon Volume 15 ml 4 fluid drams 1 tablespoon (tbsp) measurement: 30 ml 1 fluid ounce 1 fluid ounce (oz) approximate 500 ml 1 pint 1 pint equivalents 1,000 ml 1 quart 1 quart 4,000 ml 1 galloon 1 galloon 1 L = 1000 mL; 1 oz = 30 mL Metric Apothecaries’ 1kg=1000gm Weight 1 mg 1/60 grain measurement: 60 mg 1 grain 1 gram (g) = 1000 milligram (mg) approximate 1g 15 grains 1 mg = 1000 microgram (mcg) equivalents 4g 1 dram 30 g 1 ounce Do not use μg for micrograms 500 g 1.1 pound (lb) 1 kg 2.2 lb 1000 mL=1 L Cubic centimeters cc = mL Do not use cc for milliliters  Dosage Calculations SAME UNITS Medication dosage in tablet form Dosage calculation example Medication order: digoxin 0.125 mg PO How many tablets? 0.125mg/0.0625mg = 2 tablets 44  Dosage Calculations 單位要相同 Medication dosage in solution form Dosage calculation example: o Medication order: Erythromycin suspension 250 mg PO o Pharmacy delivers bottle with label stating “5ml contains 125 mg of erythromycin” o Require: 10 ml of erythromycin suspension 45  Challenge TIME You are going to administer the following order to Mrs. White: Dilantin (syrup) 750mg PO stat How many ml of Dilantin will you give to her ???? Thinking… 125 mg / 5ml 125mg/ 5ml ? mg/ 1 ml 25mg/ 1ml 750mg = ? ml  Right ROUTE Summary table of several ROUTES of administration with advantages + disadvantages Refers to Textbook p. 852-853 (TABLE 35.6) Route of administration Route meaning Example of medication Per oral (PO) By mouth Panadol Buccal Between the cheek and gum Midazolam Sublingual (SL) Under the tongue Nitroglycerin Inhalation Into the lungs Albuterol Intranasal Within the nose Midazolam Aural Drops into ear Levofloxacin Ocular Drops in the eye Betaxolol opthalmic Intravenous (IV) Into the vein Furosemide Intramuscular (IM) Within the muscle Pethidine Subcutaneous (SC) Within the fatty layer Actrapid Intradermal Within the dermal layer of the skin Mantoux tuberculosis (TB) test Endotracheal Via an ET tube Atropine Per rectum (PR) Via rectum Glycerin Per vagina (PV) Via vagina Canesten Topical/ Local application (LA) Used locally, where the medicine is applied on the area being treated Voltaren gel Transdermal Applied topically to the skin Nitroglycerin Nasogastric (NG) Via a gastric tube Activated charcoal Intraosseous (IO) Into the marrow cavity of the bone All IV medications Intrathecal Via lumbar puncture Hydrocortisone 48 Intraperitoneal (IP) Into the peritoneal cavity Heparin  Onset time of various Route of administration Route of administration Estimated onset time Intravenous (IV) 30-60 seconds Inhalation 2-3 minutes Sublingual (SL) 3-5 minutes Rectal (PR) 5-30 minutes Intramuscular (IM) 10-20 minutes Subcutaneous (SC) 15 – 30 minutes Oral (PO) 30 – 90 minutes Transdermal (topical) 49 Variable PLS THINK BEFORE!!!! ROUTE should be clearly indicated in Order 1/ ensure pharmaceutical preparation is appropriate Panadol (paracetamol): oral ( tablets or syrup), suppository (PR); Insulin SC or IV only (NO oral route) 2/ Safe in Certain route for patient  Swallowing problems patient CANNOT Oral drugs  cellulitis, phlebitis NOT for subcutaneous or intramuscular injection  Time scheduling according to Organization policy Right Time lapse (+/- 1 hour) e.g. scheduled time 0800 ➔ can be given 0700-0900 in HA TIME (Please refer to doctor’s prescription or use of medication and arrange most suitable administration time) Instruction Abbreviation Time schedule examples (24 hours) Once daily Daily 0800 or 2000 2 times per day BD or bid 0800, 2000 or 0800, 1700 3 times per day TDS or tid 0800, 1200, 2000 or 0800, 1400, 2000 4 times per day QID 0800, 1200, 1600, 2000 At night Nocte 2000 or 2100 or 2200 Every morning om 0800 After noon pm 1700 or 1800 51  Instruction Abbreviation Time schedule examples Every 4 hours Q4H 0000, 0400, 0800, 1200, 1600, 2000 Every 6 hours Q6H 0000, 0600, 1200, 1800 or 0200, 0800, 1400, 2000 Every 8 hours Q8H 0000, 0800, 1600 or 0400, 1200, 2000 (NOT common in HA) Every 12 hours Q12H 0800, 2000 or 0000, 1200 Alert (example): Before food a.c. or before Augmentin x 3/7 meal Panadol x 5/7 After food p.c. or after meal Codeine x 1/52 When required or prn NO SET TIME Morphine x 3/52 As needed Lactulose x 3 doses Immediately Stat Be a smart NURSE: Double check with the set Time schedule!!!  Right Time with Correct set time D1 D2 Right Time with Correct set time Right Drug Alert: Time for NO set time for next dose! Right Dosage prn drug Right Route 53 RISK ALERT ISSUE 75 - OCT 2024 Alert for duration of medication!!  Right Documentation Right Assessment Sign immediately after AOM Identification and allergic history Patient have Right to refuse (Respect autonomy) Conscious level → Nurses: fully informed of potential problems Any Contraindication? Not recommended for Signature: “Nil by mouth” (NPO) VS NPO except med “R”: refused Swallowing ability “W”: withhold (?Crushing or ? Thickener) “X”: not yet given? No need? Presence of diarrhea or Vomiting “O”: omit Record: MEWS, H’stix, I/O “V”: vomiting Right Patient Education (adequate drug knowledge) Right Evaluation Instruct patient to report Abnormality after Conduct appropriate evaluation + react medication immediately for any adverse effects Ensure understanding & drug Compliance e.g. recheck BP after anti-hypertensive drugs Educate Special Precaution of certain drug  Clean procedure but with non-touch technique appropriate hand hygiene Procedure Strict compliance to hospital policy (Highlights) Most Suitable form of drugs Valid prescription 3 check 5 rights principles Clear + proper documentation immediately after AOM 56  Inpatient Medication Entry (IPMOE) Benefits ◎ Reduce Medication Error ◎ Improve efficiency ◎ Streamline workflow ◎ Improve communication among caregivers ◎ Improve medication documentation 57 Workflow of IPMOE 58 59  “ But…. WHY still Medication Incident occurring after IPMOE use? 60  Topical Skin Medication ◎ applied locally to skin or mucous membranes ◎ Preparation for topical use: o Powder o Suspension-based lotion o Cream, ointments, pastes and oil-based lotions o Aerosol spray o Transdermal patch How to USE? ❖ 3 checks 5 rights principle ❖ Infection Control measure ❖ remove OLD patch first, with proper discard ❖ Select appropriate area of skin ❖ +/- write date and time on outside of new patch 62 Transdermal Patches Topical Creams & Ointments 63 Ophthalmic 1/ Stating for ophthalmic use 2/ write down OPEN DATE 3/ Do EYE swabbing before medications 4/ Sterile preparation & technique Highlight procedure ✓ Infection control (gloves) ✓ Position: sitting or supine, with Head tilt back ✓ Ask patient look up & away (prevent tube tip or dropper from touching eye) ✓ After instilling, ask patient close & rolls eye, avoid squeezing ✓ Giving tissue (Caring) 鼻淚管 ✓ Liquid medications: pressing on nasolacrimal duct for at least 30s (prevent medication from running out of eye and down the duct, preventing systemic absorption) 64 Ointment or Eye Drop first??? Avoid contamination Of the medications EYE drops o pull down lower lid gently o dropper is held perpendicular to the eye o One drop is instilled into middle of lower fornix at a distance of one inch (as indicated) EYE ointment o Pull down lower lid gently o Squeeze A thin line of ointment along the conjunctival sac o from inner canthus to outer canthus in lower fornix Otic medications infant & child > dislodge medicine inside (2) Hold inhaler properly in both hands. Loading every time before use Open inhaler by using the Breathe in quickly to draw medicine out of thumb grip slide. the Diskus, deeply for the medicine to reach A click can be heard all parts of your lungs (4) Exhale away from the inhaler 71 72  Nebulizers o Effective in manage acute exacerbation of asthma or bronchospasm in pediatric patients o Converting liquid to fine particles 5 basic parts: o Aerosol generating procedures (AGPs) 1) A medicine cup o High potential for Cross-infection 2) a cap 3) mask or mouthpiece o Caution After SARS and COVID-19 4) thin plastic tubing connecting o Avoid use of nebulizer if possible mouthpiece to machine o Must administer in ISOLATION Room 5) air machine called a compressor https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/patient-resources-and-videos/how-to-use-a-nebulizer 73 Sharing on Interpretation on LAB result related to AOM  Therapeutic Drug Monitoring Purpose: optimizing patient clinical outcome + minimize drug induced toxicity High levels of vancomycin resulting toxicities - specifically ototoxicity (damage to hearing) & nephrotoxicity (kidney damage) Commonly measured before the fourth of fifth dose for intermittent dosing Recommended target level is 15 +/- 3 mg/L for intermittent dosing, 20 +/- 3mg/L for continuous infusion Other Parenteral medication administration Administration of medication outside the enteral routes (GI): ▪ Intradermal (ID) ▪ Subcutaneous (SC) ▪ Intramuscular (IM) ▪ Intravenous (IV) Refer to lectures later… Please stay tuned…..  Reference o Berman, A. J., Snyder, S. J., & Frandsen, G. (2022). Kozier & Erb’s fundamentals of nursing: Concepts, process, and practice (11th ed.). Pearson. o Cap. 134 Dangerous Drugs Ordinance. (n.d.). Retrieved from https://www.elegislation.gov.hk/hk/cap134 o Lau, I. T. (2015). Inpatient medication entry (IPMOE) for enhancing safety and efficacy of medication management. Retrieved from http://www3.ha.org.hk/haconvention/hac2015/proceedings/downloads/ST3.1.pdf o National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP). (n.d.). Medication error. Retrieved from http://www.nccmerp.org/about-medication-errors o The Nursing Council of Hong Kong (NCHK). (2017). Code of conduct and practice. Retrieved from https://www.nchk.org.hk/filemanager/en/pdf/Guides_to_Good_Nursing_Practice_Sep_2017_for_Website.pdf  Thanks! Any questions? Looking forward to see you all later! Enjoy! Be a “DRUG SAFETY” Nurse! Enjoy AOM everyday! 78