Introduction to Medication Principles (part II) PDF

Introduction to Medication Principles (part II) [Kushto-Reese] - Mostly we use electronic medication orders today, and EPIC is a very common type of electronic system that we have. There are other systems in different hospitals. We would always have to find out which system your hospital is using t...

Introduction to Medication Principles (part II) [Kushto-Reese] - Mostly we use electronic medication orders today, and EPIC is a very common type of electronic system that we have. There are other systems in different hospitals. We would always have to find out which system your hospital is using their product order. There are routine or standing orders, those which are written and given to the patient until either the medications are discontinued or the patient is discharged. There are PRN orders, which are given as needed. These types of orders require some assessment and judgment on the nurse's part. If an order is written for PRN Tylenol for pain, the nurse has to assess the patient's pain level. So, they would ask the patient for a verbal report of their pain. "On a scale of zero to 10, what is your pain rating?" The patient will tell the nurse, and that will give her some information in order to decide if it's time for the medication and how much medication she should give. She has to use her judgment in many cases to determine what's appropriate for the patient. Some units have standing protocols. The emergency room, for example, may have a standing protocol to give a patient who comes in with asthma, who is wheezing, a nebulization treatment. Another standing protocol, maybe on a cardiac unit, might be for the patient to receive nitroglycerin if they're complaining of chest pain. So that there would be different protocols for different units. And you would have to just identify what those protocols are. Sometimes there's a single or one-time order. The patient may need something preoperatively, or they may need a dose of medication in an emergency to help with their pain level. There are titrated orders. Heparin is an example of one of those medications that is titrated based on lab levels and lab values. We will learn more about that. And then there are verbal orders, which are rarely used today. They really are not recommended, but in some emergency situations, the nurse may have to take a verbal order for a medication. Usually that is documented as soon as the emergency situation is under control, but they are not typical. Patient controlled analgesia is something that you may see when you start to go into the clinical setting, that you see nurses taking care of patients with PCA pumps. These pumps usually deliver medications like Morphine or Dilaudid to patients who are experiencing pain, maybe postoperatively, or for severe conditions. These pumps have a basal rate or continuous infusion rate of pain medication. And they also have a bolus rate, which is a dose the drug that the patient can provide for themselves by pushing a button as needed. There's a locked out time on that machine for safety so the patient can't push the button too many times or in too frequent intervals. Children also have PCA pumps and they usually are accompanied with a Narcan drip. If we think of Narcan as an antidote for narcotics, it sort of sounds like it doesn't make sense to give with a narcotic. However, given in low, low doses, these Narcan drips that accompany, say a morphine drip or Dilaudid drip for a child, the evidence has shown actually helps reduce the side © 2020 Johns Hopkins School of Nursing. All rights reserved. effects of the medications, which are really traumatic for children like itching and nausea. The pain team will manage per protocols and use nursing data from the pain scales and assessment of the patient to determine what the right amount of medication and type of medication it is that the patient should receive. So, your pain team is a great adjunct and resource to utilize working with your patients. Principles of drug actions, pharmacokinetics of drugs, how they're absorbed, metabolized, excreted, and the pharmacodynamics of medications, the adverse effects, tolerance, allergic reactions, et cetera. You're going to learn all about these specific details when you get to pharmacology. So, we want to be sure to get a good medication assessment when we're working with our patients. We want a medical history. What's their background? What conditions do they have? What diseases are they experiencing? What comorbidities do they have? What are their allergies? If they have allergies, what's the usual reaction? We want to make sure that we recognize a difference between maybe nausea from a medication or a rash developing, versus a severe reaction to a drug like anaphylaxis. It's very important that we know those things. We also want to know what their intolerances are. Does it make their stomach hurt? Does it give them a headache? That's different than allergies. We want to know their medication history. What medications are they currently on? What medications have they taken in the past? What's been helpful to them? We want to look at their medication record and their medication orders so that we can find out when was the medication last given? How often can they have their PRN medications? We need to look at diet and fluid orders. If they're NPO, they may not be able to receive a medication. They may have to take a medication with food, or they may have to not eat a certain amount of time before or after receiving a medication. We definitely want to look at laboratory values. What are the levels of certain medications that they're on? Are they appropriate? If they're taking a medication for their heart like Digoxin what are the Digoxin levels? Does the medication dose have to be altered for safe reasons? Here's an example of a medication administration record or MAR. The patient's name is listed on the top of the medication form and their date of birth. The medications are listed with a routine scheduled meds listed at the top of the page and the PRN ordered medications listed at the bottom. Typically, the patient's allergies are listed and their weight is listed for medication administration. We want to perform a physical assessment before giving our patient medications. What's their ability to swallow? If we're talking about a child or an infant or an elderly patient or a patient who has difficulty swallowing, who might have reflux, we want to know that before we try to administer a medication to them and we want to adjust accordingly. We may have to sit the patient up while we're giving them a medication or give them a medication that's easier to swallow, or maybe give them a medication in something that makes it easier to swallow. Sometimes a large pill that's difficult for patients to swallow, if we give that to them in ice cream or a small amount of pudding, then it makes it easier for them to swallow. What's their gastrointestinal motility? If the patient's vomiting or having diarrhea, they clearly are not going to be able to keep oral medications down. So we would want to know that. We may have to give that per another route once we contact the provider. Does the patient have adequate muscle mass to give, say, an IM injection? Does the patient have venous access? Do they have an IV? Is the IV patent? Are we going to get the © 2020 Johns Hopkins School of Nursing. All rights reserved. medication into them if we try to give it via that route? What are vital signs? We're always taking the patient's vital signs and noting anything that may be abnormal, or that may affect us giving them that medication. If we're them a medication, for example, that's going to decrease their blood pressure, then we want to make sure that their blood pressure isn't too low before we give that medication. We want to do a full body systems assessment. So, if we're giving a patient, or a medication to a patient who is wheezing, for example, and we want to know if it's effective, we would first listen to their breath sounds and assess them. Are they coughing, are they having trouble breathing? What's their pulse ox? And then give them the medication. Give that some time to work and then reassess or reevaluate. Once they receive the medication, are they no longer wheezing? How is their pulse ox? Are they still coughing? So, we want a body systems assessment before and after. And we want to assess the knowledge and compliance of the patient. Are they understanding what their medications are for? And are they able and willing to take the medications that you need to give them? Remember, they always have the right to refuse. So, we always want to avoid medication errors. And some of the administration errors that are made involve discrepancies in what the patient receives and what the intended drug therapy is by the provider. So, we want to make sure that if the patient questions the medication that we do as well. Sometimes the drug is not administered. A mistake is made. And so we want to report that so that we can keep track of those errors and try to change things in the system that may help prevent them. We want to make sure that meds are being administered by the correct technique and that there isn't a deliberate violation of the guidelines. The Institute of Medicine and QSEN data looks at adverse drug effects. And what they found out is that there are high risk medications that increase harm to patients. And some of those medications include narcotics, insulin, heparin, and potassium. So, we really want to be careful about these drugs, put some safety protocols in place about them because we know giving a patient too much insulin or too much potassium can actually kill someone. So, it's very important that we have safety precautions in place. And we do have lots of safety precautions for these medications. We have double-check systems. We have, if we're ministering IV potassium, for example, we have protocols on our IV pumps that have safety checks in terms of dosage and rate of delivery of the medication. So, we do have lots of systems in place to try to prevent errors from happening. We know there's increased risk in the pediatric population and the elderly due to their varying weight. And they're polypharmacy in many cases. And we know that reporting errors helps instill that culture of safety. And we can use that information to make changes that will better protect patients. Our ability to deliver a medication to a patient safely. We want to maximize communications. We know that communication between the nurse and between the whole team, the whole medical team can make a difference. We want to listen to the patient. If the patient's telling us something, then we should question that. There's barcode scanning. We talked a lot about that earlier. That helps to prevent errors and to be sure that we have the right dose and the right patient. And then there are simulation activities that you all will be involved with that I've been involved with for a long time in the school of nursing and interprofessionally with the school of medicine and school of pharmacy. We learn a lot about how to communicate and how to work together to deliver safe care to patients. And medications is a big part of that safe delivery of care. In the end, critical thinking, personal judgment, knowledge, and personal responsibility and accepting responsibility for providing © 2020 Johns Hopkins School of Nursing. All rights reserved. safety for our patients is really what guides us as professionals, as nurses. That's our number one goal, is to keep patients safe. And so we know we need to follow certain protocols and we know what we need to do if we make a mistake, and that's going to happen. © 2020 Johns Hopkins School of Nursing. All rights reserved.