Lecture Lab Exam #2 Study Guide PDF

Lab Exam #2 Study Guide/ SLOs Part 1- Parenteral 1. Compare and contrast the roles of the nurse and provider in medication administration. Verifying drug orders for competencies  Basic components of a drug order:  Date and time the order was wri...

Lab Exam #2 Study Guide/ SLOs Part 1- Parenteral 1. Compare and contrast the roles of the nurse and provider in medication administration. Verifying drug orders for competencies  Basic components of a drug order:  Date and time the order was written  Client’s full name and DOB  Drug name  Drug dosage  Route of administration  Frequency of administration  PRN orders need to have indication for administration written.  Healthcare Provider’s signature  Nurses MUST have a medication order from a provider to administer the medication!!!!  CPOE (computerized physician order entry) orders are HIGHLY recommended.  In clinical, one of the first places you should look in the client’s chart (e.g. EPIC) is the he Active Orders for RN this will direct your caring interventions (medication administration and etc.). Telephone and Verbal orders  Only used in emergencies or urgent situations.  Know the policy on read-back. o This is a Joint Commission standard.  A nursing student will NEVER receive a telephone or verbal order. When a provider writes an order, the nurse is responsible for verifying: Is it a complete order? Is the drug appropriate for my client? Is the dose safe? Is the route appropriate? Is the client allergic to this med? Is this drug NOT contraindicated with other meds or the client's condition? Before giving the meds, the nurse should: Checking the client's lab values. Checking the clients' vital signs. Checking client ability to swallow. Medical Administration Record There is a law (HITECH) that all health records should be transitioned to electronic by 2015. A MAR can be electronic or hand written. There is ALWAYS a hospital policy on when and who checks MAR for accuracy. If the nurse cannot read the MAR or an order, the nurse should ALWAYS clarify.  Hopefully this problem will diminish with electronic health records. Before giving medications from the MAR it is essential to verify that the MAR is correctly written from the orders. Refer to the three check procedure. How to navigate electronic charting?  Specifically the Sim Chart in SLS.. Independent Double Check Procedure Double checks reduce the risk of bias that occurs when the person preparing and checking the medication is likely to see what they expect to see, even if an error has occurred. Each person separately checks each component of the work process. The person asking for the double check must not influence the individual checking the product in any way. Who can name initiative that was started due to serious outcome of an improper double check? When performing a double check, the nurse administering the medications will: Present syringe and (vial if possible) to the second licensed nurse. The syringe DOES NOT have to be in the vial. Say, “I need to give my client insulin today Show the nurse the clients MAR, dose, and any nursing implications. Ask the nurse to verify the dose? The second nurse will: Look at order and any nursing implications. Look at the vial. Do the math independently (if necessary). Check the syringe for the right dose. Client’s Right to Med Admin The client has the right to be fully informed about med. The client should be educated on the drug does, the side effects and if any complication could occur by not taking the meds. A client can refuse meds………..but………. Talk to client about reason for refusal. Always report refusals of meds to the provider. 2. Identify the different ways to classify medications. Chemical name Describes the drug’s chemical composition and molecular structure. Generic name Approved by the US Adopted Name Council. Starts with a lower case letter ( ibuprofen) Trade Name The drug has a registered trademark; use of the drug’s name is restricted to the patent owner/ producing company. Starts with a upper case letter (Mortrin)   Therapeutic Classification (Classification) Therapeutic usefulness in treating particular disease/ disorder. The therapeutic class provides a summary of the major therapeutic effects of the medication (general summary of how the drug works like antihypertensive, antianxiety, antibiotic). General information Angiotensin Converting Enzyme (ACE) Inhibitor Lowers blood pressure by blocking the conversion of angiotensin I to angiotensin II. Beta Blocker Blocks stimulation of beta 1-adrenergic receptors. Calcium Channel Blocker Inhibits the transport of calcium into the myocardial and vascular smooth muscle cells  Pharmacologic Classification (Sub-classification) The way a drug works at the molecular, tissue, and body system levels. Specific information on how that drug works  Analogy for medication classification Example: Lisinopril Therapeutic Class: Antihypertensive Pharmacologic Class: ACE inhibitor Drug Look-Alikes  How do you prevent med errors from look-alike drugs?  Write purpose of drug on order (script). Don’t have drugs listed consecutively on medication administration record (MAR).  Write drugs using special lettering. Example: HumuLIN vs HumaLOG Example of Look alikes: Celebrex and Celexa and Cerebyx Lamictal and Lamisil Losec and Lasix Serzone and Seroquel Zantac and Zyrtec Drug Schedule Also known as “controlled substance schedule” which have different levels of oversight and regulations. This is for the meds (controlled substances) that have the potential risk for abuse and dependence. Schedule 1 is the highest risk and Schedule 5 is lowest risk. Ecstasy - Schedule 1 oxycodone (OxyCONTIN) - Schedule 2 LORazepam (Ativan) - Schedule 4 Wasting narcotics requires 2 RN’s. 3. Describe the five commons types of medication orders. Five types of drug orders: 1. Routine med orders – carried out until provider cancels it or the number of specified days have elapsed. 2. One-time (single) order: once the drug has been given, you cannot give it again without a new order. 3. STAT (immediate) order –they too are one-time orders but must be given immediately. The difference between a one-time order and a stat order is the urgency, typically w/in 30 minutes 4. Now/ASAP – given within 90 min depending on what book you read. 5. PRN (as needed/whenever necessary) order. Example: Tylenol for pain 1-3, one Percocet for 4-6 and two Percocet for pain 7-10.  Joint Commission does not allow: a) Q.D. b) QD Know these abbreviations c) QOD Time- q8, bid, tid, qid, a.c., q 4 hr, q 6, hr, q 12 hr d) U/u or IU Drug e) MS, Route MSO4, MgS04 Measurement/Form f).5mg or How do you say these orders verbally? 1. Digoxin 0.25 mg po BID Digoxin 0. 25 mg by mouth twice a day 2. Ibuprofen 400 mg po q4h PRN for mild pain Ibuprofen 400 mg by mouth every 4 hours for mild pain 3. Tylenol 325mg 1-2 tabs po q8hr prn fever greater than 38.5˚C Tylenol 325 mg 1-2 tabs by mouth every 8 hours as needed for fever greater than 38.5 4. Apply the six rights of medication administration to the preparation and administration of and Parenteral and Nonparenteral medications. The Six Rights should be Checked Three Times: 1. When removing the medication (Automated Dispensing System -ADS- or Pyxis) 2. When preparing the medication 3. In the room with the client. If you Do Not Have the Med and MAR It is Not a Check You can easily transcribe the wrong med  6 Rights of Med Admin 1. Right Client Joint Commission requires TWO identifiers.  Full name, DOB, MRN Learn the agency’s policy on the TWO identifiers. ALWAYS Check armband against the MAR and ask the client. Room number is NOT an identifier. Bar-coding is an ADJUNCT and not to take the place of the nurse's eyeballs!! WTCC ‘policy’ in lab and practicum is: Name, DOB and MRN. 2. Right Drug Is this medication appropriate for the client. Right drug includes right assessment. When checking drugs; use the generic name because there is a less likely chance of a med error. Hospitals carry generic drugs that may look different to the ones dispensed by the client's pharmacy. Many times, hospitals will have premade labels with the barcode so the med can be scanned. When pulling medication into a syringe, the nurse MUST label the syringe.  ALWAYS check the expiration date on the med. 3. Right Dose Know and look up recommended dose ranges. Is this safe for the client? Verify ordered dose is safe. If dose is weight based, ensure you have the right weight/units of measure. Big difference in 150kg and 150 lbs. Verify drug calculations with another nurse, especially HIGH ALERT medications. Use hospital approved device if administering a liquid (e.g. oral syringe). Frequent med errors: not splitting pills. Refer to article on Bb called ISMP Best Practices Hospitals. 4. Right Time There are hospital protocols for standard medication administration times. (Refer to Callahan Table 2-2 p. 128). Usually written in military time Consider interactions with food, other meds, and bioavailability of med. Omit or delay drugs if there is a specific reason Must document the reason and call the provider. It is okay to hold a drug if it is not safe to give, but must get an order to hold or d/c the med. Most facilities (but not all) now have a one-hour window on either side of the scheduled time before drug is considered ‘late’. Meds due at 0900 hours can be given between the 0800 – 1000 hours. However, this depends on the med…. Insulin and antibiotics are examples of time sensitive medication and must be given within a 30 min window. 5. Right Route If it is unsafe or not possible to admin by prescribed route, call provider. Different routes = different rates of absorption. IV medication has the most rapid absorption. Document site of administration if given IM and Subcut. Make sure you are not injecting an oral solution (or an injectable given orally). Refer to article on Bb called ISMP Best Practices Hospital. 6. Right Documentation Scan medications first to complete check three but do not save until administered. Initial on the MAR AFTER the med is given. SCAN ALL MEDS EVERY TIME!!! The nurse must document the reason if the drug was held, refused, omitted, or delayed. There is a comment section for documentation (if needed).  Nurse is responsible for documenting any preassessment data on the med. ALWAYS document injection sites (if applicable). Additional Rights  Med Admin Rules of Thumb o ALWAYS check medication against MAR. o NEVER proceed with administration if something is unclear. o NEVER give a med you are not familiar with. o USE YOUR RESOURCES: drug book, pharmacist, or provider. o ALWAYS listen to the client if the client questions the drug, STOP AND CLARIFY!!!!! o DO NOT open a unit dose package until you get into the room. o ONLY obtain and prepare one client's meds at a time. o NEVER give a medication you did not prepare. High Alert Meds Institute for healthcare improvement (IHI) focused on four categories: 1. Sedatives 2. Anticoagulants 3. Narcotics and Opiates 4. Insulins Meds more likely to cause harm. High alert meds REQUIRE an independent double check. 5. Discuss National Patient Safety Goals for medication administration. Use Medicines Safely (under pt safety goals) Use at least 2 ways to ID pts. For Example, use the pt’s name and DOB. This is done to make sure that each clinet gets the correct medicine and treatment. Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups, basins. Do this in the area where medicines and supplies are set up. Take extra care with pts who take medicines to thin their blood. Record and pass along correct  Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up.  Take extra care with patients who take medicines to thin their blood.  Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Give the patient written information about the medicines they need to take. Tell  the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. Part 2- Non-parenteral 6. Describe the physiological mechanisms of medication action, including absorption, distribution, metabolism, and excretion of medications. Pharmacokinetics: They study of how medications are absorbed (stomach), distributed (blood stream), metabolized (liver), and excreted (urine/feces) Factors that affect absorption: Absorption equals the movement of the drug from its site of administration into the bloodstream. Absorption characteristics vary according to the route Oral, Subcut, IM. Dosage formulation: How the drug dissolves. Blood flow (vascularity): at the site of administration, more blood flow the faster it will absorbed Body surface area: intestine has larger surface area than stomach so it absorbs faster than stomach Lipid solubility: High lip solubility it absorbed faster because cell membrane is a lipoid, food can affect absorption Route: oral, subcut, IM, Ability to dissolve: Routes A drug’s route of administration affects the rate and extent of absorption of that drug. Which drugs do you think absorb the fastest? Parental drugs absorb fastest followed by enteral drugs (absorption through GI tract or duodenal *feeding tube*), then topical A Rule of Thumb: More blood equals faster action. When considering routes, think about the best route for client's needs. Parental route and absorption Increased blood flow = increased absorption rates. 1. Intravenous: the fastest route because it goes directly into blood stream 2. Intramuscular: muscles are very vascular 3. Subcutaneous: because it is within the tissue 4. Intradermal Absorption rate increases in IM or SQ by massage or applying heat. 1. This causes increased blood flow to area. Distribution: The transport of a drug in the body by the bloodstream to its site of action. Blood flow effects distribution. Membrane permeability. Protein-Binding Albumin is most common blood protein and transports drugs in body. Low albumin can increase risk for drug toxicity when drugs pass through the albumin, more of the drug is available in their system. If 2 drugs are highly protein bound, they may compete for the site of the albumin molecule Drug-drug interactions: Competing for receptor site on albumin. one drug decreases or increases the action of another drug that is administered at the same time Metabolism and Biotransformation: Liver degrades many harmful substances before it reaches the tissues. If liver function is decreased, medication is eliminated more slowly and the risk for medication toxicity increases. Bioavailability equals the extent of drug absorption into systemic circulation. First pass effect: “The initial metabolism in the liver of a drug absorbed from the gastrointestinal tract before the drug reaches systemic circulation through the bloodstream.” A drug that is considered to have a first pass rate means that it is significantly metabolized by liver before reaching circulation High first pass effect = low bioavailability (large portion of drug is processed into inactive metabolites in the liver and therefore smaller amount will pass into circulation). Bioavailability= portion of drug entering circulation when introduced into body and is able to have an active effect. Excretion: The elimination of drugs from the body: Kidneys: Kidney cannot adequately excrete drug, dose must be reduced if someone has kidney failure or chronic kidney disease bc they’re at risk for med toxicity Liver: Bowel: Biliary Excretion: drugs secreted into bile then carried into gut to be secreted Lungs: ppl who go into surgery need to breathe anesthesia ppl who have bronchitis or pna their lungs will be more compromised during surgery Therapeutic effect: Expected and predicted physiological effect of the medication Adverse Drug Reactions: Any reaction to a drug that is harmful or unintended. May or may not be preventable. Monitoring and first dose administration should include: clsensitivity (allergic reaction) Toxic Effects Side Effects o Predictable and many times an unavoidable secondary effect of the medication. o Depending on the severity of the side effect, the provider and client will need to do a ‘cost and benefit’ review of the medication. Hypersensitivity (Allergic reaction) Involves the client's immune system. Reactions: Mild Severe Antibiotics have the highest incidence of allergic reactions.  Toxic Effects: After prolonged intake of drug or when drug accumulated because of impaired metabolism and excretion. too much of the drug in the blood, excessive effect of medication Toxic levels of morphine causes respiratory depression Under “Nursing Assessment” in Davis is “Toxicity and Overdose” for some medications Know the antidotes for the toxic effect. Interactions: When one medication modifies the action of another. Can occur with food and natural products as well. Synergistic Effect: The therapeutic effect of both medications bring a greater effect. Antagonist Effect: One drug decreases the effectiveness of the other. Timing of Medication: Goal of drug therapy is to keep the dose of the medication within the therapeutic window, below the toxic concentration and above the MEC. Minimum effective concentration (MEC): is the plasma level of a medication below which the effect of the drug does not occur. Peak, onset and duration describe the drug effect. Onset: amount of time it takes to produce a therapeutic effect after drug administration Peak: is the time it takes for a med to reach it max therapeutic response Duration: time when drug concertation is sufficient to elicit a therapeutic response Therapeutic Drug Monitoring:  Peak Level: - time it takes for a medication to reach its highest effective concentration. Highest blood level.  Trough level: minimum blood serum concentration of medication reached just before the next scheduled dose (trough levels are drawn 30 minutes before third dose typically). Lowest blood level. o Onset: amount of time it takes to produce a therapeutic effect after drug administration  Duration: amount of time a drug maintains its therapeutic effect. Many variables can affect the duration of drug action  Measures: o Adequate drug exposure. o Maximize therapeutic effect. o Minimizes drug toxicity. Peak and trough levels are measured to make sure med is not in toxic levels. If peak is too high and tough is not too low then it is not in therapeutic range.  Peak level is drawn 1 hour after IV dose of med. Trough measured 30 min before next dose is given Therapeutic Index Ratio of a drug’s toxic level to the level that provides therapeutic benefits. Example: Lithium Carbonate Therapeutic level 0.6 - 1.2mEq/L Toxic levels greater than 1.5mEq/L Example: Digoxin Therapeutic level is 0.8ng - 2ng/mL Toxic level is greater than 2.0ng/mL Both are examples of a narrow therapeutic window. Blood levels will need to be drawn to make sure the drug does not go to toxic levels. Half-Life  The time it takes for one half of the original amount of a drug to be removed from the body. A measure of the rate at which a drug is removed (excreted) from the body. Longer half-lives results in greater time to reach a therapeutic or steady-state level. Half life of a drug will influence dosing intervals.  7. Apply the six rights to the administration and preparation of high alert medications (anticoagulant and antidiabetic medications) including knowledge of the related diagnostic tests and pharmacology. Insulin A hormone that treats Diabetes Mellitus (DM). HIGH ALERT Drug Independent Double Check Classified by rate of action: Long Acting Intermediate Rapid Acting Short Acting Combination Usually a combination of Rapid or Regular and NPH. Blood Glucose Monitoring  Long Acting Insulin Usually given once a day. NEVER mix with other insulin in same syringe. What if the rapid or regular is due at same time? Onset: 3 - 4 hours Peak: Never peaks (Lantus) Duration: 24 hours  Intermediate Acting Insulin Can mix with Regular or Rapid Insulin. Roll vial hands or topple before puling up dose. DO NOT shake. If giving Rapid and NPH Give within 15 minutes before a meal. Onset: 2 - 4 hours Peak: 4 - 10 hours Duration: 10 - 16 hours Ex: Humulin N & Novolin N  Rapid Acting Insulin Examples of Rapid Acting insulin lispro (Humalog) Insulin aspart (Novolog) Can give Rapid Acting 15 minutes before meal or with meal. Onset: within 15 minutes Peak: 1 - 2 hours Duration: 3 - 4 hours  Short Acting Insulin Concentration is U-100 or U-500. Example of Short Acting insulin regular (HumuLIN R or NovoLIN R). Can give insulin regular via Intravenous route. Onset: 30 - 60 minutes Peak 2 - 4 hours Duration: 5 - 7 hours  Short Acting Insulin U-500 insulin is uncommon but ordered for clients with resistance to insulin. If U-500 is ordered the order needs to include: Units and volume specified. 150 units and 0.3mL Be double and triple cautious when giving U- 500.  Insulin Syringes Use the smallest syringe (in units) available. Round insulin to nearest whole numbers. If calculation required. 30, 50, 100 unit syringes Site Rotation Absorbed quickly in abdomen and slowest in thigh. Safety Alert Insulin pens are NOT to be shared!!! Go to Davis for concise information. Appendix L   Insulin Administration and Meal Times Cold and Clammy Hot and Dry = Sugar is High Need some candy (MPS) Effects of insulin: sweating, dizziness/light headedness, hunger, shakiness  Anticoagulants Many anticoagulants are given for DVT prophylaxis or DVT treatment. Heparin (Hepalean) can be given subcutaneous or IV. Many anticoagulants are a HIGH ALERT medication. enoxaparin (Lovenox) fondaparinux (Arixtra) heparin (Hepalean) rivaroxaban (Xarelto) warfarin (Coumadin) Assess for clinical manifestations of bleeding. bleeding gums, hematuria, melena ( black tarry stool)?? Watch for drop of hematocrit & hemoglobin (H&H) Pay careful consideration to other meds that may potentiate (increase power) the effect. Any NSAID and Thrombolytic. OTC meds with blood thinning properties St. John’s Wort and alcohol.  Heparin Absorbs best in abdomen. Only give in the abdomen. NEVER massage the site after giving the injection. Laboratory tests to monitor: Monitor the aPTT (activated partial thromboplastin time). Hematocrit and hemoglobin (H/H). Monitor platelets intermittently. Very specific protocol for IV heparin. Antidote: protamine sulfate  Absorbed best in the abdomen always inject in the lower lateral abdomen 2 in away from belly button Can cause bruising & hematoma If given in the back of the arm. Use the right syringe!!! Syringe for Syringe for Insulin Heparin Both Insulin and Heparin are dosed in UNITS. NEVER use a TB syringe for Insulin NEVER use an Insulin syringe for Heparin.  Low molecular Weight Heparin A VERY expensive drug!! Follow manufacturers guidelines for administration. Give in the abdomen – NOT the back of arm. Enoxaparin is given in the abdomen (love handles). The air bubble should be by plunger. Inject medication then inject air. Be careful when activating the safety sheath on this needle, it takes some strength!! Monitor CBC, platelet count and stools for occult blood periodically. Antidote: Protamine Sulfate. 8. Recognize the client specific indication for a medication and assess the response to a medication. 9. Implement nursing actions to prevent medication errors.  Medication Errors A medication error is any preventable event that may cause or lead to inappropriate medication use or client harm while the medication is in the control of the health care professional, client, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.  Preventing Med Errors Errors involve looking at the: 6 Rights Healthcare system Errors occur when distracted (interrupted) and fail to consistently follow policies and protocols. Use available technology correctly!!! Errors can happen any time during:  Procuring Prescribing Dispensing Administering the med Monitoring the client's response **Most common cause of med error is distraction  What to do if Med Error Happens It is priority to ensure that the client is safe first. Assess the client and monitor. Always notify the provider. Must report incident to appropriate person in the facility. Use chain of command. Fill out an incident report and a near miss report.  Safe Delivery of Medications Improving the delivery of safe medications through: Automated (Medication) Dispensing Systems. It is imperative for client safety, that the nurse only remove one client's medication at a time and just before administration. Bar Coding: Allows accuracy of med inventory control Unit Dose Packing: single dose or multi-dose CPOE (computerized provider order entry):  Infection Control and Meds  When preparing meds, make sure to work on a clean surface.  If an open med (pill) drops on the floor, you need to discard it appropriately.  Unit dose system is best (individually packaged).  What to do if the med does not come in unit dose:  If injectable or liquid put a label syringe or cup.  If the med must be brought into room (i.e. eye drops, ointment), now this is client specific.  Meds should not be kept in room.  Always apply gloves if there is a potential that you will be in contact with body fluids (i.e. injections, suppositories and eye drops).  If you need to touch the medication (i.e. for splitting)  ALWAYS wear gloves for injections!!!!!!!!!!!  Follow the hospital policy.  Always perform hand hygiene before you go into a room, after you leave, after you remove gloves.  Client Medication Reconciliation  Medical information at transition points is responsible for: 50% of all medication errors. Up to 20% of adverse drug events in the hospital. It will be important to know the hospital policy on med reconciliation. 10. Discuss cultural and developmental factors that influence medication administration.  Client’s Health and Med History o Past and Current Health History. o Family History Including:  Racial, Ethnic and/or Cultural attributes associated with medications. o All Drugs Use:  Prescribed Medications  Over The Counter Medications (OTC)  Herbal Medications  Illegal Drugs and Medications o Intake of ETOH (ethyl alcohol), Tobacco and Caffeine o Diet History  Cultural Assessment Assessment Includes: Health beliefs and practices. Religious practices. Use of herbal meds, folk and home remedies. Responses to illnesses and medical treatments. Past use of medications. OTC drugs. Dietary habits. Look at pain lvl  Client Evaluation and Response to Medication before and after med admin Evaluation of med depends on: Look at lab results Therapeutic effect of med for the client. Look at side effects Specific client response to med: & adverse drug reactions Be very specific with objective data if applicable. Look at BP before Any side effects or adverse drug reactions noted. and after Med admin 11. Discuss methods used to educate a client about prescribed medications.  Client Education and Meds Client should be able to verbalize the 5 W’s and How. Who (person), what (dose), where (route), why (the reason for med), when (admin time)  Use teach back to see if the client is administering medications correctly. Need to assess clients understanding of the meds they are going to take at home after discharge. Make sure printed material is at a level the client can understand. Clients have a right to refuse meds. However the nurse should explore why the client is refusing.  Life Span considerations  Infants and Children Immaturity of organs results in unique pharmacokinetics. Some medications are contraindicated during growth and development. Higher risk of toxicity from minor med errors. Children are 3 times more at risk for experiencing a med error. 1. Multiple pediatric concentrations of oral liquid medications 2. Parents don’t know how to correctly prepare medications 3. Error in calculations and inaccurate measuring devices. 4. Similar packaging of medications and names of medications that look alike 5. Inaccurate preparation of medications that need to be diluted 6. Confusion between formulations for adults and children  Pediatrics and Dose Calculations Characteristics that effect med dosage: Drug metabolism and excretion impaired due to liver and kidney immaturity. Stomach lacks acid to kill bacteria. Skin is thinner. Lungs have weaker mucous barriers. Body temp is less well regulated and dehydrated easier. Dose calculation based on BSA or weight for pediatric patients. ALWAYS double check your math with another nurse.  Pregnant Women Most detrimental damage to fetus from medication is in the first trimester. FDA classifies drugs according to their safety usage during pregnancy. Pregnancy information is located in the Contraindication/Precautions section in the drug book. Some medications come with warnings that women should not handle med with hands. Teratogen drugs can cause birth defects. Consult drug book (and pharmacist and/or provider) if giving ANY medications to pregnant women or lactating mother.  Older Adults Declining organ function. Dose may be 1/2 to 2/3 of regular adult dose.  Some meds are more likely to cause problems in elderly and many are fall risk drugs. Always use the general rule for dosing. What is polypharmacy?: Use of multiple drugs to treat one or more conditions. - As number of meds increase so does risk for interaction. - Most likely to have adverse effects and toxicity - You want to start low and go slow when looking at dose ranges Heprin 25 gauge 5/8 in even in units draw in ml For tadpole label you put dose in ml but you wont get wrong if you put 5000 units 0.5 ml Insulin 22 gauge