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CHAPTER 47 UNIT 4 PHYSIOLOGICAL INTEGRITY PRESCRIPTION MEDICATIONS SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES Nurses administer prescription medications...

CHAPTER 47 UNIT 4 PHYSIOLOGICAL INTEGRITY PRESCRIPTION MEDICATIONS SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES Nurses administer prescription medications under the Safe Medication supervision of providers. These medications can be CHAPTER 47 habit‑forming, have potential harmful effects, and Administration and require monitoring. Error Reduction Uncontrolled substances These medications require monitoring by a provider, but do not generally pose a risk of misuse or The providers who can legally write prescriptions addiction. Antibiotics are an example of uncontrolled prescription medications. in the United States include physicians, advanced practice nurses, dentists, and physician assistants. Controlled substances Medications that have a potential for misuse and dependence PROVIDER RESPONSIBILITIES and have a “schedule” classification. Heroin is in Schedule I and has no medical use in the United States. Medications Obtaining clients’ medical history and performing in Schedules II through V have legitimate applications. a physical examination Each subsequent level has a decreasing risk of misuse Diagnosing and dependence. For example, morphine is a Schedule II Prescribing medications medication that has a greater risk for misuse and dependence Monitoring the response to therapy than phenobarbital, which is a Schedule IV medication. Modifying medication prescriptions as necessary NURSE RESPONSIBILITIES KNOWLEDGE REQUIRED PRIOR TO MEDICATION ADMINISTRATION Having knowledge of federal, state (nurse practice acts), and local laws, and facilities’ policies that govern the Medication category prescribing, dispensing, and administration of medications Medications have a pharmacological action, therapeutic use, Preparing and administering medications, and body system target, chemical makeup, and classification evaluating clients’ responses to medications for use during pregnancy. For example, lisinopril is an Developing and maintaining an up‑to‑date knowledge angiotensin‑converting enzyme inhibitor (pharmacological base of medications they administer, including uses, action) and an antihypertensive (therapeutic use). mechanisms of action, routes of administration, safe dosage range, adverse effects, precautions, Mechanism of action contraindications, and interactions Maintaining knowledge of acceptable practice and This is how the medication produces its therapeutic effect. skills competency For example, glipizide is an oral hypoglycemic agent Determining the accuracy of medication prescriptions that lowers blood glucose levels primarily by stimulating Reporting all medication errors pancreatic islet cells to release insulin. Safeguarding and storing medications Therapeutic effect This is the expected effect (physiological response) for MEDICATION CATEGORY which the nurse administers the medication to a specific AND CLASSIFICATION client. One medication can have more than one therapeutic effect. For example, one client might take diphenhydramine NOMENCLATURE to relieve allergies while another takes it to induce sleep. Chemical name: A medication’s chemical composition Adverse effects (N‑acetyl‑para‑aminophenol). These are undesirable and potentially dangerous responses Generic name: Official or nonproprietary name the United to a medication. Adverse effects can be inadvertent or States Adopted Names Council gives a medication. Each predictable. Some are immediate; others take weeks or medication has only one generic name (acetaminophen). months to develop. For example, the antibiotic gentamicin Trade name: Brand or proprietary name the company that can cause hearing loss. manufacturers the medication gives it. One medication can have multiple trade names (Tylenol, Tempra). Toxic effects Medications can have specific risks and manifestations of toxicity. For example, nurses monitor clients taking digoxin for dysrhythmias, a manifestation of cardiotoxicity. Hypokalemia places these clients at greater risk for digoxin toxicity. FUNDAMENTALS FOR NURSING CHAPTER 47 Safe Medication Administration and Error Reduction 277  Interactions Stat prescriptions Medications can interact with each other, resulting in A stat prescription is only for administration once and beneficial or harmful effects. For example, giving the immediately. For example, a stat prescription instructs the beta‑blocker atenolol concurrently with the calcium nurse to administer digoxin 0.125 mg IV bolus stat. channel blocker nifedipine helps prevent reflex tachycardia. Medications can also increase or decrease the actions of Now prescriptions other medications, and food can interact beneficially or A now prescription is only for administration once, but up harmfully with medications. to 90 min from when the nurse received the prescription. For example, a now prescription instructs the nurse to Precautions, contraindications administer vancomycin 1 g intermittent IV bolus now. These are conditions (diseases, age, pregnancy, lactation) that make it risky or completely unsafe for clients to take PRN prescriptions specific medications. For example, tetracyclines can stain A PRN (pro re nata) prescription specifies at what dosage, what developing teeth; therefore, children younger than 8 years frequency, and under what conditions a nurse can administer should not take these medications. Another example is the medication. The nurse uses clinical judgment to that heart failure is a contraindication for labetalol, an determine the client’s need for the medication. For example, antihypertensive medication. a PRN prescription instructs the nurse to administer morphine 2 mg IV bolus every hour PRN for chest pain. Preparation, dosage, administration It is important to know any specific considerations for Other prescriptions preparation, safe dosages, and how to administer the Providers might write prescriptions for specific medication. For example, morphine is available in many circumstances or for specific units. For example, a critical different formulations. Oral doses of morphine are care unit has standing prescriptions for treating clients generally higher than parenteral doses due to extensive who have asystole. first‑pass effect. Clients who have chronic severe pain (with cancer) generally take oral doses of morphine. COMPONENTS OF A MEDICATION PRESCRIPTION MEDICATION PRESCRIPTIONS The client’s full name Each facility has written policies for medication prescriptions, The date and time of the prescription including which providers can write, receive, and transcribe The name of the medication (generic or brand) medication prescriptions. The strength and dosage of the medication The route of administration The time and frequency of administration: exact times TYPES OF MEDICATION PRESCRIPTIONS or number of times per day (according to the facility’s policy or the specific qualities of the medication) Routine or standing prescriptions The quantity to dispense and the number of refills A routine or standing prescription identifies medications The signature of the prescribing provider nurses give on a regular schedule with or without a termination date. Without a termination date, the prescription will be in effect until the provider COMMUNICATING discontinues it or discharges the client. MEDICATION PRESCRIPTIONS Providers must re‑prescribe some medications (opioids Origin of medication prescriptions and antibiotics) within a specific amount of time or they will automatically discontinue. Providers or nurses who take verbal or telephone prescriptions from a provider write medication Single or one‑time prescriptions prescriptions on the client’s medical record. If the nurse writes a medication prescription on the client’s A single or one‑time prescription is for administration once medical record, the facility’s policy specifies how much at a specific time or as soon as possible. These prescriptions time the provider has to sign the prescription. Nurses are common for preoperative or preprocedural medications. transcribe medication prescriptions onto the medication For example, a one‑time prescription instructs the nurse to administration record (MAR). administer warfarin 5 mg PO at 1700. 278 CHAPTER 47 Safe Medication Administration and Error Reduction CONTENT MASTERY SERIES  View Video: Safe Administration of Medications Taking a telephone prescription RIGHTS OF SAFE Only when absolutely necessary MEDICATION ADMINISTRATION Ensure that the prescription is complete and correct by Right client reading it back to the provider: the client’s name, the name of the medication, the dosage, the time to give it, Verify clients’ identification before each medication the frequency, and the route. administration. The Joint Commission requires two client To ensure correct spelling, use aids (“b as in boy”). State identifiers. Acceptable identifiers include the client’s numbers separately (“one, seven” for 17). name, an assigned identification number, telephone Remind the provider to verify the prescription and sign it number, birth date, or other person‑specific identifier within the amount of time the facility’s policy specifies. (a photo identification card). Nurses also use bar‑code Write or enter the prescription in the client’s scanners to identify clients. Check for allergies by asking medical record. clients, checking for an allergy bracelet or medal, and If possible, have a second nurse listen on an checking the MAR. extension or on a speaker in a private area (to ensure confidentiality). Right medication Correctly interpret medication prescriptions, verifying MEDICATION RECONCILIATION completeness and clarity. Read medication labels and compare them with the MAR three times: before removing The Joint Commission requires policies and procedures for the container, when removing the amount of medication medication reconciliation. Nurses compile a list of each from the container, and in the presence of the client client’s current medications, including all medications before administering the medication. Leave unit‑dose with correct dosages and frequency. They compare the medication in its package until administration. list with new medication prescriptions and reconcile it to resolve any discrepancies. This process takes place at Right dose admission, when transferring clients between units or facilities, and at discharge. Use a unit‑dose system to decrease errors. If not available, calculate the correct medication dose; check a drug reference to make sure the dose is within the usual range. Ask another PRE-ASSESSMENT FOR nurse to verify the dose if uncertain of the calculation. MEDICATION THERAPY Prepare medication dosages using standard measurement devices (graduated cups or syringes). Some medication Nurses obtain the following information before initiating dosages require a second verifier or witness (some cytotoxic medication therapy and update it as necessary. medications). Automated medication dispensing systems use a machine to control the dispensing of medications. Health history Age Right time Health problems and the current reason for seeking care Administer medication on time to maintain a All medications clients currently take (prescription consistent therapeutic blood level. Refer to the drug and nonprescription): the name, dose, route, and reference or the facility’s policy for exceptions; general frequency of each recommendations follow. Any unexpected findings possibly from Administer time-critical medications within 30 min of medication therapy the prescribed time. Facilities define which medications Use of herbal or “natural” products for are time-critical; usually this includes medications that medicinal purposes require a consistent blood level (antibiotics). Use of caffeine, tobacco, alcohol, or illicit drugs Administer non-time-critical medications prescribed Clients’ understanding of the purpose of once daily, weekly, or monthly within 2 hr of the the medications prescribed time. All medication and food allergies Administer non-time-critical medications prescribed more than once daily (but not more than every 4 hr) Physical examination within 1 hr of the prescribed time. A systematic physical examination provides a baseline for evaluating the therapeutic effects of medication therapy Right route and for detecting possible adverse effects. The most common routes of administration are oral, topical, subcutaneous, intramuscular (IM), and intravenous (IV). Additional administration routes include sublingual, buccal, intradermal, transdermal, epidural, inhalation, nasal, ophthalmic, otic, rectal, vaginal, intraosseous, and via enteral tubes. Select the correct preparation for the route the provider prescribed (otic vs. ophthalmic topical ointment or drops). FUNDAMENTALS FOR NURSING CHAPTER 47 Safe Medication Administration and Error Reduction 279  Online Video: Look‑Alike, Sound‑Alike Medications Right documentation RESOURCES FOR Immediately record pertinent information, including MEDICATION INFORMATION the client’s response to the medication. Document the Nursing drug handbooks medication after administration, not before. Pharmacology textbooks Professional journals Right client education Physicians’ Desk Reference (PDR) Professional websites Inform clients about the medication: its purpose, Pharmacists what to expect, how to take it, and what to report. To individualize the teaching, determine what the clients already know about the medication, need to know about the medication, and want to know about the medication. MEDICATION ERROR PREVENTION Right to refuse COMMON MEDICATION ERRORS Respect clients’ right to refuse any medication. Explain Wrong medication or IV fluid the consequences, inform the provider, and document Incorrect dose or IV infusion rate the refusal. Wrong client, route, or time Administration of a medication to which the client Right assessment is allergic Omission of a dose or extra doses Collect any essential data before and after administering Incorrect discontinuation of medication or IV fluid any medication. For example, measure apical heart rate Inaccurate prescribing before giving digoxin. The Institute for Safe Medication Practices (ISMP) is a Right evaluation nonprofit organization working to educate health care providers and consumers about safe Follow up with clients to verify therapeutic effects as well medication practices. The ISMP and the FDA as adverse effects. identify the most common medical abbreviations that result in misinterpretation, mistakes, and injury. For a complete list, go to the ISMP website. 47.1 Error‑prone abbreviation list Some abbreviations cause a high number of medication errors. DO NOT USE USE DO NOT USE USE q.o.d., QOD every other day MS, MSO4 morphine 6 p.m. daily or Q6PM, etc. daily at 6 p.m. MgSO4 magnesium sulfate TIW, tiw 3 times weekly abbreviated medication names (AZT, KCl, full name of medication mg., mL. mg, mL (no period) HCT, PTU, HCTZ) half‑strength, bedtime HS nitro nitroglycerin (hour of sleep) decimal points without smaller units (500 mcg) or BT, hs, HS, qhs, qn bedtime or hour of sleep a leading zero (.5 mg) a leading zero (0.5 mg) SC, SQ, sub q subcutaneously trailing zero (1.0 mg, without a trailing IN intranasal 100.0 g) zero (1 mg, 100 g) IJ injection u, U, IU units OJ orange juice μ, μg mcg or microgram > or < greater than or less than x3d times 3 days @ at cc mL &, + and apothecary units metric units / per daily or intended time od, O.D., OD AD, AS, AU right ear, left ear, both ears of administration q.d, qd, Q.D, QD, q1d, i/d daily OD, OS, OU right eye, left eye, both eyes D/C, dc, d/c discharge or discontinue 280 CHAPTER 47 Safe Medication Administration and Error Reduction CONTENT MASTERY SERIES  NURSING PROCESS Use verbal prescriptions only for emergencies, and follow the facility’s protocol for telephone prescriptions. Nursing Use the nursing process to prevent medication errors. students cannot accept verbal or telephone orders. Follow all laws and regulations for preparing and Assessment/data collection administering controlled substances. Keep them in a Ensure knowledge of medication to administer and why. secure area. Have another nurse witness the discarding Obtain information about the clients’ medical diagnoses of controlled substances. and conditions that relate to medication administration Do not leave medications at the bedside. Some facilities’ (the ability to swallow, diet, allergies, and heart, liver, policies allow exceptions (for topical medications). and kidney disorders). ◯ Identify allergies. Evaluation ◯ Obtain necessary preadministration data (heart rate, Evaluate clients’ responses to medications, and blood pressure) to assess the appropriateness of the document and report them. medication and to obtain baseline data for evaluating Recognize adverse effects, and document and the effectiveness of medications. report them. ◯ Omit or delay doses according to findings, and notify Notify the provider of all errors, and implement the provider. corrective measures immediately. Determine if the medication prescription is complete: ◯ Complete an incident report within the specified with the client’s name, date and time, name of time frame, usually 24 hr. Include the client’s medication, dosage, route of administration, time and identification, the time and place of the incident, frequency, and signature of the prescribing provider. an accurate account of the event, who you notified, Interpret the medication prescription accurately. Refer what actions you took, and your signature. Do not to the ISMP lists for error-prone abbreviations, confused reference or include the incident report in the client’s medication names, and high-alert medications. medical record. Question the provider if the prescription is unclear or ◯ Medication errors relate to systems, procedures, seems inappropriate for the client’s condition. Refuse to product design, or practice patterns. Report all errors administer a medication if it seems unsafe, and notify to assist the facility’s risk managers to learn how the charge nurse or supervisor. errors occur and what changes to make to avoid Providers usually make dosage changes gradually. similar errors in the future. Question the provider about abrupt and excessive changes. Determine clients’ learning needs. Planning Identify clients’ outcomes for medication administration. Prioritize medication administration to administer critical medications first, or to know which medications need to be given prior to treatment, procedures, or meals. Implementation Avoid distractions during medication preparation (poor lighting, phones). Interruptions increase the risk of error. Prepare medications for one client at a time. Check the labels for the medication’s name and concentration. Read labels carefully. Measure doses accurately, and double‑check dosages of high‑alert medications (insulin and heparin) with a colleague. Check the medication’s expiration date. Doses are usually one to two tablets or one single‑dose vial. Question multiple tablets or vials for a single dose. Follow the rights of medication administration consistently. Take the MAR to the bedside. Only give medications that you have prepared. Encourage clients to become part of the safety net, teaching them about medications and the importance of proper identification before medication administration. Omit or delay a dose when clients question the size of the dose or the appearance of the medication. Follow correct procedures for all routes of administration. Communicate clearly both in writing and speaking. FUNDAMENTALS FOR NURSING CHAPTER 47 Safe Medication Administration and Error Reduction 281