ATI RN Pharmacology for Nursing (8th edition) PDF

CHAPTER 2 UNIT 1 PHARMACOLOGICAL PRINCIPLES MEDICATION CATEGORY CHAPTER 2 Safe Medication AND CLASSIFICATION Administration and NOMENCLATURE Error Reduction...

CHAPTER 2 UNIT 1 PHARMACOLOGICAL PRINCIPLES MEDICATION CATEGORY CHAPTER 2 Safe Medication AND CLASSIFICATION Administration and NOMENCLATURE Error Reduction Chemical name is the name of the medication that reflects its chemical composition and molecular structure (isobutylphenylpropanoic acid). The providers who can legally write prescriptions Generic name is the official or nonproprietary name the United States Adopted Names Council gives a medication. in the United States include physicians, advanced Each medication has only one generic name (ibuprofen). practice nurses, dentists, and physician Trade name is the brand or proprietary name the company assistants. These providers are responsible for that manufactures the medication gives it. One medication can have multiple trade names (Advil, Motrin). obtaining clients’ medical history, performing a physical examination, diagnosing, prescribing CONSIDERATIONS medications, monitoring response to therapy, Nurses administer prescription medications under the and modifying prescriptions as necessary. supervision of providers. Some medications can be habit-forming, or have potential harmful effects and Nurses are responsible for having knowledge require more stringent supervision. of federal, state (nurse practice act), and local Uncontrolled substances require monitoring by a provider, but do not generally pose risks of misuse and addiction. laws, and facilities’ policies that govern Antibiotics are an example of uncontrolled prescription prescribing and dispensing medications; medications. preparing and administering medications; and Controlled substances have a potential for misuse and dependence and have a “Schedule” classification. Heroin is evaluating clients’ responses to medications. in Schedule I and has no medical use in the United States. Nurses should develop and maintain an Medications in Schedules II through V have legitimate applications. Each subsequent level has a decreasing risk up-to-date knowledge base of medications they of misuse and dependence. For example, morphine is a administer, including uses, mechanisms of action, Schedule II medication that has a greater risk for misuse and dependence than phenobarbital, which is a Schedule routes of administration, safe dosage range, IV medication. adverse effects, precautions, contraindications, and interactions. Nurses can help reduce adverse FDA REGULATIONS events related to medications by determining the New drugs in development undergo the rigorous testing procedures of the U.S. Food and Drug Administration accuracy of medication prescriptions, reporting (FDA) to determine both effectiveness and safety before all medication errors, safeguarding and storing approval. However, new drugs can have unidentified or unreported adverse effects. Nurses observing these can medications, following legal mandates when report them to MedWatch on the FDA’s website. administering controlled substances, calculating The FDA’s Pregnancy Risk Categories (A, B, C, D, X) have previously classified medications according to medication doses accurately, and understanding their potential harm during pregnancy, with Category the responsibilities of other members of the A being the safest and Category X the most dangerous. Teratogenesis from unsafe medications is most likely to health care team regarding medications. occur during the first trimester. Before administering any medication to a client who is pregnant or could be pregnant, determine whether it is safe for use during pregnancy. FDA labeling requirements implemented in 2015 require medication manufacturers to include guidance for administration to clients who are pregnant, lactating, or of reproductive potential. RN PHARMACOLOGY FOR NURSING CHAPTER 2 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION 11  MEDICATION PRESCRIPTIONS Components of a medication prescription Each facility has written policies for medication Client’s full name prescriptions, including which providers can write, receive, Date and time of the prescription and transcribe medication prescriptions. Name of the medication (generic or brand) Strength and dosage of the medication Use verbal prescriptions only for emergencies, and follow Route of administration the facility’s protocol for telephone prescriptions. Nursing Time and frequency of administration: exact times or students cannot accept verbal or telephone orders. number of times per day (according to the facility’s policy or the specific qualities of the medication) Types of medication prescriptions Quantity to dispense and the number of refills Routine or standing prescriptions Signature of the prescribing provider Single or one-time prescriptions Medication reconciliation Stat prescriptions The Joint Commission requires policies and procedures for PRN prescriptions medication reconciliation. Nurses compile a list of each client’s current medications, including all medications with their dosages and frequency. They compare the list with new medication prescriptions and reconcile it with the provider to resolve any discrepancies. This process should take place at admission, when transferring clients between units or facilities, and at discharge. 2.1 Knowledge required prior to medication administration Medication category/class Toxic effects Precautions/ Medications have a pharmacological Medications can have specific risks and Contraindications action, therapeutic use, body system manifestations of toxicity. They develop These are conditions (diseases, age, target, chemical makeup, and after taking a medication for a lengthy pregnancy, lactation) that make it classification for use during pregnancy. period of time or when toxic amounts build risky or completely unsafe for clients For example, lisinopril is an ACE up due to faulty metabolism or excretion. to take specific medications. inhibitor (pharmacological action) and For example, nurses monitor clients For example, tetracyclines can stain an antihypertensive (therapeutic use). taking digoxin for dysrhythmias, developing teeth. Therefore, children a manifestation of cardiotoxicity. Mechanism of action Hypokalemia places these clients at younger than 8 years should not take these medications. Another example is that greater risk for digoxin toxicity. myasthenia gravis is a contraindication This is how medications produce their therapeutic effect. Medication interactions for fentanyl, an opioid analgesic. For example, glipizide is an oral Some medications require caution hypoglycemic agent that lowers blood Medications can interact with each other, with some conditions. glucose levels primarily by stimulating resulting in beneficial or harmful effects. For example, the kidneys excrete pancreatic islet cells to release insulin. For example, giving the beta blocker vancomycin without changing it. Therefore, atenolol concurrently with the renal impairment requires caution Therapeutic effect calcium channel blocker nifedipine when administering this medication. helps prevent reflex tachycardia. This is the expected effect (physiological response) for which the nurse An example of an undesirable interaction Preparation, dosage, administers a medication to a specific is giving omeprazole, a proton pump inhibitor, concurrently with phenytoin, administration client. One medication can have more than one therapeutic effect. an anticonvulsant. This can increase It is important to know any specific the blood level of phenytoin. considerations for preparation, safe One client might take diphenhydramine dosages, dosage calculations, and to relieve allergies while another Obtain a complete medication history, and be knowledgeable of how to administer the medication. takes it to induce sleep. clinically significant interactions. For example, morphine is available in many Adverse effects Be aware that medications can also formulations. Oral doses of morphine are generally higher than parenteral doses These are undesirable and potentially interact beneficially or harmfully with food and with herbal and dietary supplements. due to extensive first-pass effect. Clients dangerous responses to a medication. who have chronic, severe pain (cancer) For example, the antibiotic gentamicin generally take oral doses of morphine. can cause hearing loss. Adverse effects can be inadvertent or predictable. Some Nursing implications adverse effects are immediate and others take weeks or months to develop. Know how to monitor therapeutic effects and adverse effects, prevent and treat adverse effects, provide comfort, and instruct clients about the safe use of medications. 12 CHAPTER 2 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION CONTENT MASTERY SERIES  RIGHTS OF SAFE MEDICATION Right route ADMINISTRATION The most common routes of administration are oral, topical, subcutaneous, IM, and IV. Additional routes Right client include sublingual, buccal, intradermal, transdermal, Verify clients’ identification before each medication epidural, inhalation, nasal, ophthalmic, otic, rectal, administration. The Joint Commission requires two vaginal, intraosseous, and via enteral tubes. client identifiers. Select the correct preparation for the route the provider Acceptable identifiers include the client’s name, an prescribed (otic versus ophthalmic topical ointment assigned identification number, telephone number, birth or drops). date, or another person-specific identifier (a photo Always use different syringes for enteral and parenteral identification card). medication administration. Check identification bands for name and Know how to administer medication safely and correctly. identification number. Check for allergies by asking clients, looking for an Right documentation allergy bracelet or medal, and reviewing the MAR. Immediately record the medication, dose, route, time, Use barcode scanners to identify clients. and any pertinent information, including the client’s response to the medication. Document the medication Right medication after administration, not before. Correctly interpret medication prescriptions, verifying For some medications, in particular those to alleviate completeness and clarity. pain, evaluate the client’s response and document it Read medication labels and compare them with the later, perhaps after 30 min. MAR three times: before removing the container, when removing the amount of medication from the container, Right client education and in the presence of the client before administering Inform clients about the medication: its purpose, what the medication. to expect, how to take it, and what to report. Leave unit-dose medication in its package To individualize the teaching, determine what the clients until administration. already know about the medication, need to know about When using automated medication dispensing systems, the medication, and want to know about the medication. perform the same checks and adapt them as necessary. Right to refuse Right dose Respect clients’ right to refuse any medication. Use a unit-dose system to decrease errors. If not Explain the consequences, inform the provider, and available, calculate the correct medication dose. document the refusal. Check a drug reference to ensure the dose is within the usual range. Right assessment When performing medication calculations or conversions, have another qualified nurse check the Collect any essential data before and after administering calculated dose. any medication. For example, measure apical heart rate Prepare medication dosages using standard before giving digoxin. measurement devices (graduated cups or syringes). Some medication dosages require a second verifier Right evaluation or witness (some cytotoxic medications). Automated Follow up with clients to verify therapeutic effects as well medication dispensing systems use a machine to control as adverse effects. the dispensing of medications. Right time MEDICATION ERROR PREVENTION Administer medication on time to maintain a consistent therapeutic blood level. Administer time-critical medications 30 min before COMMON MEDICATION ERRORS or after the prescribed time. Facilities define which Wrong medication or IV fluid medications are time-critical; usually this includes Incorrect dose or IV rate medications that require a consistent blood level Wrong client, route, or time (antibiotics). Administration of an allergy-inducing medication Administer non-time-critical medications prescribed Omission of a dose or administration of extra doses once daily, weekly, or monthly within 2 hr of the Incorrect discontinuation of a medication or IV fluid prescribed time. Inaccurate prescribing Administer non-time-critical medications prescribed Inadvertently giving a medication that has a more than once daily (but not more than every 4 hr) similar name within 1 hr of the prescribed time. RN PHARMACOLOGY FOR NURSING CHAPTER 2 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION 13  Online Video: Look-Alike, Sound-Alike Medications USING THE NURSING PROCESS TO Interpret the medication prescription accurately. The PREVENT MEDICATION ERRORS Institute for Safe Medication Practices (ISMP) is a nonprofit organization working to educate health Assessment care providers and consumers about safe medication practices. The ISMP and the FDA identify the Be knowledgeable about the medications administered. most common medical abbreviations that result in Use appropriate resources. misinterpretation, mistakes, and injury. For a complete ◯ Providers, including nurses, physicians, list, go to the ISMP website. and pharmacists ◯ Error-Prone Abbreviation List: abbreviations that ◯ Poison control: 1-800-222-1222 (24/7) have caused a high number of medication errors ◯ Sales representatives from drug companies ◯ Confused Medication Name List: sound-alike and ◯ Nursing pharmacology textbooks and drug handbooks look-alike medication names ◯ Physicians’ Desk Reference ◯ High-Alert Medication List: medications that, if a ◯ Professional journals nurse administers them in error, have a high risk for ◯ Professional websites resulting in significant harm to clients. Strategies Obtain information about medical diagnoses and to prevent errors include limiting access; using conditions that affect medication administration (ability auxiliary labels and automated alerts; standardizing to swallow; allergies; heart, liver, and kidney disorders). the prescription, preparation, and administration; and Obtain necessary preadministration data (heart using automated or independent double checks. rate, blood pressure, blood levels) to assess the Question the provider if the prescription is unclear or appropriateness of the medication and to obtain seems inappropriate for the client. Refuse to administer baseline data for evaluating the effectiveness a medication if it seems unsafe, and notify the charge of medications. nurse or supervisor. Omit or delay doses as necessary due to clients’ status. Providers usually make dosage changes gradually. Determine whether the medication prescription Question them about abrupt and excessive changes. is complete. Planning Identify client outcomes for medication administration. Set priorities (which medications to give first or before specific treatments or procedures). 2.2 Confused medication name list Sound-alike and look-alike medication names ESTABLISHED NAME RECOMMENDED NAME ESTABLISHED NAME RECOMMENDED NAME hydralazine hydrALAZINE acetohexamide acetoHEXAMIDE hydromorphone hYDROmorphone acetazolamide acetaZOLAMIDE hydroxyzine hydrOXYzine bupropion buPROPion medroxyprogesterone medroxyPROGESTERone buspirone busPIRone methylprednisolone methylPREDNISolone methyltestosterone methylTESTOSTERone chlorpromazine chlorproMAZINE mitoxantrone mitoXANTRONE chlorpropamide chlorproPAMIDE nicardipine niCARdipine clomiphene clomiPHENE nifedipine NIFEdipine clomipramine clomiPRAMINE prednisone predniSONE cyclosporine cycloSPORINE prednisolone prednisoLONE cycloserine cycloSERINE risperidone risperiDONE daunorubicin DAUNOrubicin ropinirole ROPINIRole doxorubicin DOXOrubicin sulfadiazine sulfADIAZINE dimenhydrinate dimenhyDRINATE sulfisoxazole sulfiSOXAZOLE diphenhydramine diphenhydrAMINE tolazamide TOLAZamide dobutamine DOBUTamine tolbutamide TOLBUTamide dopamine DOPamine vinblastine vinBLAStine glipizide glipiZIDE vincristine vinCRIStine glyburide glyBURIDE 14 CHAPTER 2 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION CONTENT MASTERY SERIES  Implementation Evaluation Avoid distractions during medication preparation (poor Evaluate clients’ responses to medications, and lighting, ringing phones). Interruptions can increase the document and report them. risk of error. Use knowledge of the therapeutic effect and common Prepare medications for one client at a time. adverse effects of medications to compare expected Check the labels for the medication’s name outcomes with actual findings. and concentration. Identify adverse effects, and document and report them. Measure doses accurately, and double-check dosages Notify the provider of all errors, and implement of high-alert medications (insulin and heparin) with a corrective measures immediately. colleague. Check the medication’s expiration date. ◯ Complete an incident report within the time frame Doses are usually one to two tablets or one single-dose the facility specifies, usually 24 hr. This report vial. Question multiple tablets or vials for a single dose. should include Follow the rights of medication administration Client’s identification consistently and carefully. Take the MAR to the bedside. Name and dose of the medication Do not administer medications that someone else prepared. Time and place of the incident Encourage clients to become part of the safety net, Accurate and objective account of the event teaching them about medications and the importance of Who you notified proper identification before medication administration. What actions you took Omit or delay a dose when clients question the size of a Your signature (or that of the person who completed dose or the appearance of a medication. the report) Follow correct procedures for all routes of administration. ◯ Do not reference or include the incident report in the Follow all laws and regulations for preparing and client’s medical record. administering controlled substances. Keep them in a ◯ Medication errors relate to systems, procedures, secure area. Have another nurse witness the discarding product design, or practice patterns. Report all errors of controlled substances. to help the facility’s risk managers determine how Do not leave medications at the bedside. Some facilities’ errors occur and what changes to make to avoid policies allow exceptions (for topical medications). similar errors in the future. Educate the client and anyone who will be assisting in the client’s care regarding medications. Provide verbal and written instructions. 2.3 High-alert medication list The following medications and medication categories from the ISMP’s list require specific safeguards to reduce the risk of errors. Strategies include limiting access; using auxiliary labels and automated alerts; standardizing the prescription, preparation, and administration; and using automated or independent double checks. Class or category of medications Specific medications Adrenergic agonists, IV (epinephrine) Epinephrine, subcutaneous Adrenergic antagonists, IV (propranolol) Epoprostenol, IV Anesthetic agents, general, inhaled and IV (propofol) Heparin, low molecular weight, injection Cardioplegic solutions Heparin, unfractionated, IV Chemotherapeutic agents, parenteral and oral Insulin, subcutaneous and IV Dextrose, hypertonic, 20% or greater Lidocaine, IV Dialysis solutions, peritoneal and hemodialysis Magnesium sulfate injection Epidural or intrathecal medications Methotrexate, oral, nononcologic use Glycoprotein IIb/IIIa inhibitors (eptifibatide) Opium tincture Hypoglycemics, oral Oxytocin, IV Inotropic medications, IV (digoxin, milrinone) Nitroprusside for injection Liposomal forms of drugs (liposomal amphotericin B) Potassium chloride for injection concentrate Moderate sedation agents, IV (midazolam) Potassium phosphates injection Moderate sedation agents, oral, for children (chloral hydrate) Promethazine, IV Narcotics/opiates, IV and oral (including liquid Vasopressin, IV or intraosseous concentrates, immediate- and sustained-release) Warfarin Neuromuscular blocking agents (succinylcholine) Radiocontrast agents, IV Sodium chloride injection, hypertonic, more than 0.9% concentration Thrombolytics/fibrinolytics, IV (tenecteplase) Total parenteral nutrition solutions RN PHARMACOLOGY FOR NURSING CHAPTER 2 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION 15  Application Exercises Active Learning Scenario 1. A nurse is preparing a client’s medications. Which of A staff educator is reviewing the prevention of medication the following actions should the nurse take in following errors with a group of newly licensed nurses. What should legal practice guidelines? (Select all that apply.) the educator include about using the nursing process to prevent medication errors? Use the ATI Active Learning A. Teach the client about the medication. Template: Basic Concept to complete this item. B. Determine the dosage. C. Monitor for adverse effects. NURSING INTERVENTIONS: Using the nursing process D. Lock compartments for controlled substances. to prevent medication errors, list the following. E. Determine the client’s insurance status. Three assessment actions One planning action 2. Four implementation actions A nurse is preparing to administer digoxin to a client who states, “I don’t want to take that Three evaluation actions medication. I do not want one more pill.” Which of the following responses should the nurse make? A. “Your physician prescribed it for you, so you really should take it.” B. “Well, let’s just get it over quickly then.” C. “Okay, I’ll just give you your other medications.” D. “Tell me your concerns about taking this medication.” 3. A nurse is reviewing a client’s prescribed medications. Which of the following situations represents a contraindication to medication administration? A. The client drank grapefruit juice, which could reduce a medication’s effectiveness. B. The medication has orthostatic hypotension as an adverse effect. C. A medication is approved for ages 12 and older, and the client is 8 years old. D. An antianxiety medication that has an adverse effect of drowsiness is prescribed as a preoperative sedative. 4. A nurse is assessing a client before administering medications. Which of the following data should the nurse obtain? (Select all that apply.) A. Use of herbal products B. Daily fluid intake C. Ability to swallow D. Previous surgical history E. Allergies 5. A nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention? A. Taking all medications out of the unit-dose wrappers before entering the client’s room B. Checking the prescription when a single dose requires administration of multiple tablets C. Administering a medication, then looking up the usual dosage range D. Relying on another nurse to clarify a medication prescription 16 CHAPTER 2 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION CONTENT MASTERY SERIES  Application Exercises Key Active Learning Scenario Key 1. A. CORRECT: Teach the medication as part of the Using the ATI Active Learning Template: Basic Concept rights of medication administration. NURSING INTERVENTIONS B. Determining the medication’s dosage is the provider’s responsibility. Assessment C. CORRECT: Monitor for adverse effects as part of Be knowledgeable about the medication to the rights of medication administration. administer. Use appropriate resources. D. CORRECT: Lock controlled substances in a drawer, Obtain information about medical diagnoses and cart, or other compartment to prevent misuse. conditions that affect medication administration. E. The client’s insurance status does not relate to legal Determine whether the medication prescription is complete. medication administration requirements. Interpret the medication prescription accurately. NCLEX® Connection: Safety and Infection Control, Question the provider if the prescription is unclear Accident/Error/Injury Prevention or seems inappropriate for the client. Question the provider about abrupt and excessive changes in dosage. 2. A. This response dismisses the client’s concerns. Planning B. This response is dismissing the client’s concerns Identify clients’ outcomes for medication administration. about taking the medication by continuing Set priorities (which medications to give first or with medication administration. before specific treatments or procedures). C. Although clients have the right to refuse a medication, provide information about the risk of refusal instead Implementation of proceeding with medication administration. Avoid distractions and interruptions during medication preparation. D. CORRECT: Although clients have the right to refuse a Prepare medications for one client at a time. medication, this response is correct in determining the Check the labels for the medication’s name and concentration. reason for refusal by asking about the client’s concerns. Then Question multiple tablets or vials for a single dose. information can be provided about the risk of refusal and Follow the rights of medication administration facilitate an informed decision. At that point, if the client consistently and carefully. still exercises their right to refuse a medication, notify the Do not administer medications that someone else prepared. provider and document the refusal and the actions taken. Encourage clients to become part of the safety net. NCLEX Connection: Pharmacological and Parenteral Therapies, ® Follow correct procedures for all routes of administration. Medication Administration Communicate clearly both verbally and in writing. Use verbal prescriptions only for emergencies, and follow 3. A. This represents a medication interaction; the client could take the facility’s protocol for telephone prescriptions. a larger dose of medication or take it at a later time. Follow all laws and regulations for preparing and B. Give this medication and monitor the client administering controlled substances. blood pressure more closely. Do not leave medications at the bedside. C. CORRECT: Age is one factor that can be a contraindication Follow the principles of client and family education for medications. to medication administration. Contraindications are Evaluation findings that indicate the client should not receive a medication and are different from instances where an Evaluate clients’ responses to medications, undesirable effect or more monitoring are needed. and document and report them. D. This is an example of a medication that Use knowledge of the therapeutic effect and common has multiple therapeutic effects. side and adverse effects of medications to compare expected outcomes with actual findings. NCLEX® Connection: Safety and Infection Control, Identify side and adverse effects, and document and report them. Accident/Error/Injury Prevention Report all errors, and implement corrective measures immediately. NCLEX® Connection: Safety and Infection Control, 4. A. CORRECT: Inquire about the client’s use of herbal Reporting of Incident/Event/Irregular Occurrence Variance products, which often contain caffeine, prior to medication administration because caffeine can affect medication biotransformation. B. Daily fluid intake is important for ensuring adequate hydration, but it is not part of the preassessment the nurse completes prior to medication administration. C. CORRECT: Determine the client’s ability to swallow to see what route or formulation of the medication the client requires. D. Surgical history is important for determining any risks or alterations in the client’s health status, but it is not part of the preassessment the nurse completes prior to medication administration. E. CORRECT: Inquire about food allergies during the preassessment to identify any potential reactions or interactions. NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention 5. A. To prevent errors, do not take unit-dose medications out of wrappers until at the bedside when performing the third check of medication administration. Encourage clients’ involvement and provide teaching at this time. B. CORRECT: If a single dose requires multiple tablets, it is possible that an error has occurred in the prescription or transcription of the medication. This action could prevent a medication error. C. Reviewing the usual dosage range prior to administration can help identify an inaccurate dosage. D. If the prescription is unclear, contact the provider, not another nurse, for clarification. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions RN PHARMACOLOGY FOR NURSING CHAPTER 2 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION 17 18 CHAPTER 2 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION CONTENT MASTERY SERIES