Medication Administration

Unit VI

Part 2 (lecture)

Keith Rischer, RN, MA, CEN, CCRN

Today’s Objectives…

Differentiate the various effects of drugs on the body

Explain how age, illness, time of administration, & absorption affect drug action

Describe the relationship between mechanism of action of most commonly used drugs and nursing assessment and implications for the nurse

Minnesota Nurse Practice Act

Legal aspects r/t the nurse(6) Engaging in unprofessional conduct, including,

but not limited to, a departure from or failure to conform to board rules of professional or practical nursing practice … to the minimal standards of acceptable and prevailing professional or practical nursing practice, or any nursing practice that may create unnecessary danger to a patient's life, health, or safety. Actual injury to a patient need not be established under this clause.

Laws and Regulations

Drug legislation in the U.S.Pure Food and Drug Act - 1906Harrison Narcotic law of 1914 – defined

narcoticFederal Food, Drug and Cosmetics Act of

1938 established the FDA, set standards r/t safety, potency, efficacy.

Durkham-Humphrey Amendment of 1952 differentiates between prescription and non-prescription drugs.

Laws and Regulations

Controlled Substance Act 1970Categorizes controlled substancesLimits refillsEstablished programs to prevent and treat

drug dependence FDA instituted the MedWatch program in

1993

Consumer Rights

Drugs are safe, pure, effective and reliable Clients have the right to quality health

information r/t drugs and medicationsName, of drug, purpose, action, possible

adverse side effects.

Consumer Rights

Patients have a right to:To refuse any medicationsTo have qualified person assess medication

history including allergiesNot to be given unnecessary medications

Safety

The Joint Commission Oxycontin vs. OxycodoneHydromorphone vs. Morphine Ephedrine vs. EpinephrineHydralazine vs. Hydroxyzine

ISMP Institute for Safe Medication Practices

http://www.ismp.org

Schedule of Controlled Substances

Schedule I: High potential for abuseNo medical use exists

Heroin

Schedule II: Potential for abuse, physical and psychological dependenceHas accepted medical useNo refills

Methadone, Morphine, Fentanyl, Oxycontin, Percocet

Schedule of Controlled Substances

Schedule III: intermediate potential for abuseHas accepted medical useMay Refill 5 times

Vicodin, Tyl. #3

Schedule IV: Less abuse potential.May refill 6 times within 6 monthsBenzodiazepines, Ambien

Schedule V: Minimal abuse potentialCough suppressants with codeine

Controlled Substances

Drugs kept in locked drawer Forms for recording the use of these drugs Nurse verifies the number of a specific

drug available If drug wasted, second nurse acts as a

witness Drugs are counted each shift with 2 RNs

Pharmacokenetics

Study of action of drugs within the body Must consider before

administering meds

Absorption Distribution Metabolism Excretion

Pharmacokenetics: Absorption

Process by which drug passes into the bloodstreambetter the blood supply faster the absorption

GI tract: variable IV: immediate Subcutaneous: depends on local blood flow Intramuscular: depends on local blood flow Topical: slow, incomplete Inhalation: rapid Rectal: may be erratic

Pharmacokenetics: Absorption

Factors influencing absorption Dose form and route Influence of pH Blood flow to site Solubility of drug

Time Action Profile Onset Peak Duration

Pharmacokenetics: Distribution

Transportation of drug from site of absorption to site of action.

Vascular organs receive drug first, then skin and muscles.

Chemical/physical make up of the drug determines to which area of body drug will be attracted.

Pharmacokenetics: Metabolism

The process of altering or changing the drug into a less active form.

Caution: this process may be impaired in the elderly or in someone with liver disease

Biotransformation

Pharmacokenetics: Excretion

Process by which drug is eliminated from the body.

Caution: since the kidneys/liver of older adults are less efficient, they may require smaller doses of a drug.

Promote adequate fluid intake

Medication Pharmokinetics

Morphine Tylenol Ibuprofen Atenolol Coumadin

Why is pharmokinetics relevant if your patient has renal or liver disease?

Special Dosing Considerations

Renal DiseaseChronic renal insufficiencyDiabetesCKD-dialysis dependant

Labs– GFR– Creatinine

Special Dosing Considerations

Liver DiseaseCirrhosisHepatitisETOH

Labs– AST– ALT– Bili– Albumin

Special Dosing Considerations Heart failure

CHF Diastolic Systolic

Cardiomyopathy Body size

Underweight/pediatric calculated by weight or body surface area

ObeseNormal

Developmental Factors/drug action

Developmental factors:Pregnancy InfantsOlder adults

DietFood alters drug absorption rate, metabolismNutrition can affect the action of a drug

Ex: Vitamin K – found in green leafy vegetables can counteract the effect of an anticoagulant – Coumadin

Factors affecting drug action: Elderly

Use w/caution Digoxin Nifedipine Benzodiazepines

Alprazolam Diazepam

Increased fall risk ACE inhibitors Beta blockers Ca++ channel blockers Vasodilators Diuretics Opiod narcotics Anti-depressants Benzodiazepines

Factors affecting drug action

EnvironmentalTime of administrationStress Exposure to heat and cold

Cultural, ethnic, genetic EthnopharmacyCultural factors and practices

Mechanism…Nursing Implications

Analgesics Morphine, Dilaudid, Percocet, Vicodin

Mechanism:Binds to opiate receptors in CNSProduces generalized CNS depressionOpiate effects cause vasodilation,

decreased peristalsis Nsg. Implications…

Classifications/Nursing Implications

AnalgesicsMild

TylenolNSAIDS

Ibuprofen, AspirinModerate-

Opiod Narcotics po– Tylenol #3, Vicodin, Percocet

Severe- Opiod Narcotics IV

– Morphine, Dilaudid, Fentanyl

Anticoagulants

Warfarin (Coumadin) Mech of Action Uses Nursing implications

Vitamin K clotting factors INR (0.9-1.2)…11-13 seconds clotting time

2-3 therapeutic Heparin

Mech of action Prevents conversion of fibrinogen to fibrin

Uses Nursing implications

Aspirin Mech of action Uses Nursing implications

Mechanism…Nursing Implications

Calcium Channel Blockers Diltiazem

Mechanism: Inhibits transport of calcium into myocardial and

vascular smooth muscle cells during the cardiac action potential phase.

Causes systemic vasodilation and coronary artery vasodilation as well as slowing AV node conduction and decreased cardiac contractility

Nsg. Implications…

Mechanism…Nursing Implications

Angiotensin Converting Enzyme (ACE) InhibitorsLisinopril, Enalapril

Mechanism:Blocks the conversion of angiotensin I to

vasoconstrictor angiotensin II.Net effect: systemic vasodilation

Nsg. Implications…

Classifications/Nursing Implications

Loop Diuretics Furosemide (Lasix)

Mechanism: Inhibits the

reapsorption of sodium and chloride from the loop of Henle and distal renal tubule

Increases renal excretion of water, Na+, Cl-, Mg+, and K+ causing loss of excess fluid and drop in BP

Nsg. Implications…

Medication interactions

When one medication modifies the action of another, this can occurSynergistic effect: effect of 2 drugs when

combined is greater than when meds given separately.

Beneficial: give Tylenol with oxycodone to reduce the total amount of narcotic needed.(additive effect)

Harmful: Alcohol taken with antihistamines, antidepressants, barbiturates and narcotic analgesics

Medication interactions

Iatrogenic disease: disease caused unintentionally by medical therapyEx: liver failure after prolonged use of TylenolAmiodarone and pulmonary fibrosisPregnant woman takes medication that

results in malformations in the fetus.

Nursing implications

What can nursing do to enhance desired effect/decrease adverse effects and ensure safety??HistoryAllergies

Shellfish…IodineMed dataClients conditionClients knowledge/learning needs

Drug Medication Systems

Stock Supply Unit-Dose Automated

Medication Dispensing (Pyxis)

Bar Code Medication – use of scanner

Self-administered PCA, Inhalers,

ointments etc