1. Nursing Management of Clients with Stressors Requiring Medication Administration Regulatory Needs Pharmacology Principles The Nurse’s Role NUR101 Fall 2010 K. Burger, MSEd, MSN, RN, CNE Lecture # 10 PPP by: Sharon Niggemeier RN, MS (J. Garnar & R.Kolk) Revised 1006,1007 KBurger

2. Pharmacology Pharmacology: is the study of chemicals/drugs and their effects on living organisms. Drugs (legal and illegal) are chemicals intended to elicit a specific effect. Drugs alter physiological functions in the body, they do not create a new function in a tissue or organ. Drugs also create unwanted effects in addition to the desired effect.

3. Terminology Pharmacotherapeutics: use of drugs to treat or prevent disease. It can be preventative, palliative, or restorative. “Why a drug is prescribed”. Pharmacokinetics: (means "drug movement") the study of the concentration of a drug during the processes of absorption, distribution, biotransformation (metabolism), and excretion of a drug. “What the body does to the drug” Pharmacodynamics: study of the mechanism of drug action on living tissue at the cellular level. “What the drug does to the body”

4. Nursing Responsibilities Nurses are liable for their actions, omissions, and for those duties they may delegate to others. They are personally responsible…legally, morally and ethically…for every drug they administer.

5. Nursing Responsibilities Obtaining current knowledge base of drugs Referring to authoritative sources in professional literature (PDR, journals, etc.) (less than 5yrs old) Questioning a drug order that is unclear or that appears to contain an error Refusing to administer a drug if there is a reason to believe it will be harmful. Performing correct techniques and precautions Monitoring client response and documenting drug effects Patient and family education

6. Nursing Process & Drug Administration ASSESSMENT – Thorough collection of data Information about the medication Action – side effects – appropriate dose Age specific considerations – routes Information about the client What other medications are they taking Allergies or other problems w/ meds Gag reflex – Impaired swallowing Dietary and/or Fluid restrictions Cultural and/or religious influences Genetic factors Vital signs Lab values – renal & liver function / protein & albumin Age Pregnant/breast feeding

7. Nursing Process & Drug Administration The result of this assessment is the NURSING DIAGNOSIS PLANNING: include goals that directly relate to the nursing diagnosis and specific outcome criteria (goals)

8. Nursing Process & Drug Administration IMPLEMENTATION Using correct techniques of preparation and administration to deliver medications safely. Monitoring the client for therapeutic and non-therapeutic effects of the drug Client education for safe and accurate self-administration of the drug. EVALUATION of the nursing care provided based on the level of achievement of the outcome criteria.

9. Critical Thinking The nurse is preparing to administer prescribed antibiotics to an adult hospitalized client suffering from a wound infection. When the nurse offers the oral medication to the client, he says “ I’m not taking those. Pills make me gag and throw up.” Write a nursing diagnosis that addresses this problem.

10. Critical Thinking Write an outcome statement for your diagnosis.

11. Critical Thinking What are some interventions for this problem?

12. Critical Thinking How will you evaluate this process?

13. Legal Aspects of Pharmacology Purpose and Scope of Legal Controls: Protect public health and safety Laws govern testing, production, distribution, prescription and the administration of drugs.

14. Federal Medication Laws 1906 Pure Food & Drug Act Disclosure of dangerous ingredients 1912 Sherley Amendment No fraudulent claims of action 1914 Harrison Narcotic Act Established regulations for narcotics 1938 Food,Drug,CosmeticAct Drugs must be tested and proved safe 1952 DurhamHumphrey Amendment Established list of drugs needing RX 1962 Kefauver-Harris Amendment Drugs must be proven effective 1970 Controlled Substances Act Strict controls on distribution 1978 Drug Regulation Reform Act Shortened drug investigation time

15. Controlled Substance Act Designed to promote treatment and prevention of drug dependence Established controls such as: -Prescribers are registered with the DEA. A registry number is issued to each person and is renewed annually. -Complete written records of all drugs prescribed must be kept for two years. Pharmacists record each sale in triplicate. Schedule II drug prescriptions cannot be renewed. -DEA (Drug Enforcement Agency) monitoring

16. -Health care agencies must establish policies to comply with Federal law. -All units have a record of every controlled drug on the unit and two nurses at the change of every shift count all drugs. -All controlled drugs are stored using a double lock system. Keys to medication areas are under the control of nurses on the unit. -Discarding of controlled substances must be witnessed by another nurse -Written renewal orders are required every 72 hours for narcotics and schedule II & III drugs. Controlled Substance Act - continued

17. Control Schedule Drugs with a significant potential for abuse are classified into 5 categories or schedules: Schedule I: highest potential for abuse Illicit drugs (Heroin, LSD, Marijuana) Schedule II: (Morphine, Dilaudid) Schedule III: (Vicodin, Meperidine) Schedule IV: (Valium, Xanax) Schedule V: lowest potential for abuse (OTC cough suppresant w/codeine)

18. Drug Information Resources The United States Pharmacopoeia ( USP) and the National Formulary(NF) are highly recommended for use in agencies for all health care professionals to use as a resource. Agency pharmacists are an appropriate resource for obtaining drug information on the job. Nursing drug handbooks: contain drug information along with nursing considerations.

19. Drug Information Resources -continued Physician's Desk Reference (PDR) Contains manufacturer's descriptions (package inserts) which are written using FDA standards, but may be slanted in favor of the drug being described. Package Inserts: Required by law for insertion with each new drug and must include a description, indications, precautions, dosage, and contraindications. Electronic databases and Internet

20. Medication Orders Two ways to obtain legal drugs: Prescription (Rx)- order written authorizing patient to receive medication.Prescriptions taken to pharmacy whereby the pharmacist dispenses the drug. Over the counter (OTC)- patient treats self and doesn’t need a prescribers order. Buys medications where ever they are available (Walmart, 7-11, etc.)

21. Prescriptions Written, legible prescriber’s order includes: Patient name Drug name Dose Route Frequency Date Signature

22. Types of Medication Orders STAT order: needed immediately Single order: given only once PRN order: given as needed Routine orders: given within 2 hours of being written and carried out on schedule Standing order: written in advance carried out under specific circumstances.

23. Drug Nomenclature Chemical name: Precisely describes the chemical & molecular structure of the drug. Generic name: Pharmaceutical name given by the US Adopted Names Council. This name is the same for every drug company. Proprietary or Trade or Brand name:can be copyrighted,popular name of the drug supplied by the manufacturer, easy to pronounce and easy to recognize.

24. Example for the drug Demerol Chemical name: N-methyl 4 carboxypiperidine hydrochloride Generic name: Meperidine Trade name: Demerol Brand name versus generic drug: Is the drug effect identical?????????

25. Drug Classifications Drugs can be classified various ways: Therapeutic: categorizes drugs by the disease state they are used to treat. Pharmacologic: categorizes drugs by their mechanism of action Controlled Substance Schedule Pregnancy Schedule

26. Example Drug Classifications Therapeutic Classifications  Anti-hypertensives  Analgesics Pharmacologic Classifications  Diuretics  Beta-blockers  Vaso-dilators  Non-opioids  Opioids  Non-steroidal anti-inflammatory agents

27. Standards for Drugs Purity: Must be physically pure in that it only contains the ingredients stated. (very few drugs are available in a truly pure state – THINK…what impact might this have on drug administration?) Potency: Strength of the drug, measured by standardization of weight of ingredients. Bioavailability: The degree to which a drug can reach its site of action in the body.

28. Standards for Drugs Efficacy: The effectiveness of the drug in achieving the desired biological change. Safety: The frequency and severity of adverse drug reactions (ADR) determines safety. No chemical is free of adverse effects. Investigational drugs: chemicals tested which may have potential as a new drug.

29. Drug Approval Process Pre-clinical testing on cells an animals Clinical testing in (4) phases I – small # of healthy people II – small # of people with the disease III – large # of people with the disease (marketing can occur after phase III) (new expedited process allows after phase II) IV – post marketing; voluntary

30. Types of Drug Preparations Drugs are prepared in several drug forms depending on the route of administration or the use that will be made of the drug. A variety of drug forms provide some flexibility in the administration of drugs. Examples: capsules, elixir, tablets, gel caps, powders, solutions, ointments, sprays,etc.

31. Essential Elements of Drug Knowledge for Nurses drug name(s): Locate in drug reference books, call pharmacist to clarify when a multitude of names for drugs causes confusion. drug classification: Note the classification it provides a general view of drug as an indicator of specific drug traits. i.e. “Antipsychotics” indications: why is this drug given? pain relief? tachycardia? combat infection?

32. Knowledge Guidelines drug action: what is the drug supposed to do? usual dose: range will vary with age, weight, gender and method of administration. route of administration: what is the preferred route desired effects: what is the therapeutic effect side effects: predictable symptoms that occur as a consequence of overall drug effects in the body. Can be mild (nausea, rash) or severe/life threatening (liver toxicity, blood dyscrasias)

33. Knowledge Guidelines untoward effects: dose related symptoms occur as dose is too high = Adverse Drug Event (ADE); or idiosyncratic symptoms – opposite of therapeutic effect. interactions with other drugs: do they potentiate drug action (additive effect) or inhibit drug action (antagonistic effect) or otherwise incompatible interactions with food: may delay absorption, may combine with active ingredient and inactivate it. precautions: when does a special condition affect the decision to use the drug?

34. Knowledge Guidelines contraindications: what conditions are adversely affected by this drug? nursing implications:. List assessments to be made and guidelines to be taken pregnancy safety: pregnancy risk categories have been established to identify the risk to the fetus (teratogenic effect). The categories range from A(no risk), B, C, D, or X (should not be used ever).

35. Knowledge Guidelines patient/family education: teach patient necessary information related to medication administration Be sure to answer questions and emphasize important points! Some health care facilities have computer printout on drugs that can be given to patients before discharge. MOST ESSENTIAL:Why does this patient need this drug?

36. Rights of Drug Administration The (5)? Rights offer guidelines for safe drug administration: Right patient Right medication Right dose Right route Right time Right documentation Right for client diagnosis Right of client to refuse

37. Standard Abbreviations CHECK JCAHO Official Do Not Use List @ www.jcaho.org Review SCCC NUR101 Lab Worksheet CHECK ISMP List of Error-Prone Abbreviations, Symbols and Dose Designations @ www.ismp.org

38. Incorporating Lab Values Medications may be prescribed based on lab results Medications may alter body functioning and lab values may denote this Nursing responsibility includes incorporating lab data with medication administration

39. Some beginning Normal Lab Values to KNOW Fasting Blood Glucose60-110 Potassium (K)3.8-5 Albumin3.5 – 5 WBC5000 – 10,000 BUN10-20 Creatinine 0.5 – 1.2

40. Drug Calculations Unit dose system, less need for calculations, still may need to calculate the number of tablets. Infusions ( such as IV) calculate drops per minute Conversions within the metric system Rarely need to calculate from apothecary system. Drug calculations will be covered in NR20Lab

41. Drug Supply & Storage Obtained from pharmacy dept. Individual Pt. Supply UNIT DOSE Stock supply – tylenol, ASA Dispensing systems – medication carts, computerized systems, ID bracelet scanning

42. Drug Abuse by Licensed Professional Need to report suspect of abuse Gatekeeper role of a professional nurse Potential loss of nursing license Assistance for licensed professional through PAP (Professional Assistance Program) NYS Education Department NYS Education Department