Pharmacology and Nutrition

LEARNING OUTCOMES

At the end of the topic, students should be able to;

1. Explain responsibilities and implications during administration

2. Explain legal aspects of drug administration and implications in nursing practice.

 

Scope of Nursing Responsibilities

1.     Nurses are liable for action and omission and duties delegated to others.

2.     Nurses have a legal, moral and ethical responsibility for every drug they administer.

3.     The law requires health professional to be safe and competent practitioners and permits compensation to those harmed or injured.

4.     Actions that safeguard patients from drug-induced injury includes:

è Use correct techniques or precautions.

è Observe for and chart drug-effects explicitly.

è Keep their knowledge base current

è Refer to authoritative sources

è  Question a drug order that is unclear or appears to be erroneous.

è Refuse to give a drug or refuse to allow others to order or administer a drug that may be harmful to the patient.

5.     Nurses are entrusted with potent and habit-forming drugs.

6.     Nurses must establish a therapeutic alliance with the client and a respectful and trusting relationship to facilitate the highest level of self-care attainable.

7.     Although there are hundreds of drugs available, a knowledge base can be established by studying a drug that is representative of each classification.

8.     Clinical experience is a useful tool in learning because it enables the student nurse to:

§  Note which drugs are commonly used to treat disease specific s/s.

§  Observe which drugs are most effective in relieving s/s.

§  Note the frequency with which certain drugs are administered.

§  Witness individual differences in client’s different reactions to a specific drug.

§  Relate knowledge to real life situations

Implementation: Preparing Drugs for Administration

1. Ensure cleanliness of your hands, work area, and supplies.

2. Ensure availability of supplies.

 3. Ensure adequate lighting.

4. Decrease environmental distractions.

Remember the Rights of Medication Administration

1. The Right Drug

 After checking the order, the nurse selects the right medication.

When using a non-unit dose system, the label on the container should be read three times: when taking the container from its location, when removing the medication from the container, and when returning the container to its storage place. For unit dose administration, the three checks should be carried out.

These are checking the medication

1) when removing it from its location in the drawer, bin, or refrigerator

2) when comparing it to the client’s medication administration record; and

(3) before administering it to the client. Use special care when administering drugs whose name sounds like another drug. Never use medication from a container that is unlabeled or whose label is illegible or defaced.

NURSING IMPLICATION:

1. Carefully check the order.

2. Check the medication against the order.

3. Do not administer a medication someone else has prepared.

4. If using a unit dose system, do not open the unit packaging until you are at the client’s bedside.

Safe administration of the right medication requires that the nurse become familiar with basic information about the drug, including its action, contraindications for use, usual dosage, and side effects. To accomplish this, current reference books should be available on the nursing unit.

 2. In the Right Dose

Determining the correct amount of a drug is sometimes difficult because three measurement systems are used in ordering medications. The nurse must be familiar with household measures, the apothecary system, and the metric system and must be able to convert from one system to another

To prepare the right amount of medication, the nurse must have developed skills in using measuring devices such as medication cups, droppers, and syringes. When preparing a liquid medication for oral administration, shake all suspensions and emulsions to ensure proper distribution of the ingredients. Examine the measuring device. Most have measurements for the three systems: for example, a metric measure (mL) for milliliters; an apothecary measure (oz) for ounces; and a household measure (tsp and tbsp) for teaspoon and tablespoon, respectively.

NURSING IMPLICATION:

2.1. Be familiar with the various measurement systems and the conversions from one system to another.

2.2. Always use the appropriate measuring device and read it correctly (e.g., measure liquids for oral administration at the meniscus).

2.3. Shake all suspensions and emulsions.

2.4. When measuring drops of medication with a dropper, always hold the dropper vertically and close to the medication cup.

2.5. When removing a drug from a multiple dose vial, inject an amount of air equal to the amount of fluid to be withdrawn.

 2.6. Do not attempt to divide unscored tablets and do not administer tablets which have been broken unevenly along the scoring

3. To the Right Client

Once the medication has been properly prepared, the next step is to identify the right client. Although techniques suggested for identifying the right client might seem unnecessary to the student assigned to administer medications to only one client, it is important to understand and practice the principles to avoid errors when administering medications to several clients. Nurses, therefore, should make it a habit to employ proper identification procedures regardless of the number of clients involved. In general, take every opportunity to be certain that you are administering the medication to the right client. If the client is in bed, check the name tag on the bed. Always check the client’s wrist identification band. If the client is physically and mentally able, ask him/her to state his/her name.

NURSING IMPLICATIONS:

3.1. Check the tag on the client’s bed.

3.2. Check the client’s identification band.

3.3. Ask the client to state his/her name.

3.4. Ask parents to tell you the name of their child.

3.5. Address the person by name before administering the medication.

3.6. Always double check orders that the client questions.

 

4. At the Right Time

The prescriber’s order will specify the number of times a day the medication is to be given. It may also state the exact hours of administration or give general guidelines such as directions to administer with meals or before meals. If no exact time is given, drug administration is frequently planned according to a standard agency administration schedule. Medication administration schedules are based on knowledge of the desired effect of the drug, the characteristics of the drug itself, possible interactions with other drugs, and the client’s daily schedule.

The schedule established for drug administration is important, and the nurse adheres to the schedule. A routine schedule helps to prevent administration of doses too close together or too far apart and is important in maintaining a relatively constant blood level of drugs that are given several times a day. As a general rule, the nurse should always be certain that a medication is administered within 1⁄2 hour of the time it is ordered to be given. 

NURSING IMPLICATIONS;

4.1. To achieve maximum therapeutic effectiveness, medications are scheduled to be administered at specific times.

4. 2. The nurse should adhere, as closely as possible, to the scheduled time(s) of administration.

 

5. By the Right Route

The right route includes the correct route of administration, and administration in such a way that the client is able to take the entire dose of the drug and receive maximal benefit from it. The physician will usually specify the route by which the medication should be administered. If none is specified, the oral route is often intended, but for safety the nurse should check with the prescribing physician. However, any questions about the medication order should be discussed with the prescriber before administration of the first dose.

Drugs may be administered in a variety of ways. Not all drugs may be administered by all of the possible methods. Many drugs, however, are available in several forms, permitting administration by more than one route. The method by which a drug is administered affects such factors as the absorption, speed of onset, dose, and side effects.

Although nurses may not be responsible for administration by all of these routes, they need to be familiar with the terminology. Nurses assist physicians in administration of drugs by some of these routes, e.g., intraarticular. When assisting a physician in administering a medication, the nurse ensures that the seven rights of administration are followed.

Common Routes of Drug Administration

PRIMARILY FOR LOCAL EFFECTS

topical application—to mucous membranes or skin

 intra-articular—within the cavity of a joint

intracardiac—into a chamber of the heart

intradermal or intracutaneous—into the dermal layer of the skin

intrathecal—into the spinal fluid

inhalation—into the respiratory tract

PRIMARILY FOR SYSTEMIC EFFECTS

By the gastrointestinal tract: buccal or transmucosal—in the cheek

oral—by mouth

sublingual—under the tongue

rectal—in the rectum

By injection: intramuscular—into a skeletal muscle

intraosseous—into the bone marrow

intratracheal—into the trachea

intravenous—into a vein

subcutaneous—into the subcutaneous tissue

The extra care taken by the nurse to ensure that the seven rights are adhered to may help to prevent mistakes, which can occur particularly when other staff members performing administration procedures are not as familiar with the client’s history and condition as the nurse is. The nurse retains responsibility for the drugs he/she prepares for administration. If the nurse has concerns about the safety of administering a particular drug to a particular client or about the route of administration, the physician should be asked to prepare and administer the medication, as well as to record the procedure on the client’s record. It is also important to provide information and support for the client during procedures that may be uncomfortable, such as intrathecal administration of medications. Always be certain to record the procedure and the client’s ability to tolerate the procedure on the client’s record. Administering a drug so that the client is able to take the entire dose and receive maximal benefit from it includes several nursing activities: 1. The nurse must gain the client’s cooperation. Explanation about the administration procedure should be given and the client’s ability to understand must be considered.

2. Special administration techniques may be required because of the client’s developmental level.

3. Some medications are administered in such small amounts or have such an unpleasant taste that they must be diluted or mixed in another vehicle, such as juice, in order for the client to take the entire dose. It is important for the nurse to know with which liquids specific drugs may be mixed without significantly altering the properties or actions of the drug. Consult with a pharmacist if questions arise about drug-vehicle compatibility.

4. If several drugs are to be administered at the same time, the order in which the nurse administers these drugs may be important. For example, it may be difficult for the client to turn for an injection. In this situation, oral medications should be administered first, followed by the injection and positioning of the client for maximum comfort. Also, some drugs have a local soothing effect on mucous membranes of the mouth or throat. Such drugs should be administered following other oral medications and should be followed by little or no water.

As a general guide, when administering oral medications, the sequence used would be:

(1) drugs that require special assessments, such as those for which an apical pulse or blood pressure assessment is required;

(2) other tablets and capsules;

 (3) liquid preparations except for syrups intended for local soothing or anesthetic actions;

(4) sublingual preparations; and

(5) antacids and liquid preparations intended for local soothing or anesthetic actions which are given with instructions not to eat or drink fluids for 20 to 30 minutes.

NURSING IMPLICATIONS:

5.1. Be sure you know the prescribed route by which a medication is to be administered.

5.2. If no route is specified in the physician’s order, the prescribing physician should be questioned about the intended route.

5.3. Always gain the client’s cooperation before attempting to administer a dose of medication.

5.4. Consider the client’s developmental level during administration of medications.

5.5. The nurse must know what vehicles may be used with various drugs.

5.6. To achieve maximum effectiveness and client well-being, it is important to plan the order in which medications are administered.

6. Right Documentation

The right documentation includes the drug, the dosage administered, the time administered, the route and site if given parenterally, and the client’s response. Most facilities have an MAR for documenting this information; however, if the client is being medicated at home, this information may be documented on the client’s anecdotal note.

The right documentation is not only a legal requirement, but also a safety responsibility of the nurse. It is the primary method used to communicate medication administration from one nurse to the next nurse caring for a specific client. The basic principle of documentation is “if it isn’t documented, it wasn’t done.” Consequently, if the nurse does not document that a particular medication was given, a second dose may be administered by another nurse, causing the client to experience adverse reactions, even life-threatening responses.

NURSING IMPLICATIONS:

6 1. Be sure to document the medication and time administered on appropriate facility document.

6.2. Document site location after administering intradermal, subcutaneous, or intramuscular injection.

6.3. Document if client refuses medication, client’s reason, and reporting of refusal to physician.

 

7. Client Right to Refuse

The client has the right to refuse to have a medication administered. Without the client’s permission (or the permission of the legal guardian in the case of a pediatric client or a client unable to give permission who has a legal guardian), the nurse providing any treatment, including administering medications, is potentially at risk for legal complications. Because the nurse is the health care professional who most often is the one administering the medications, addressing client refusals is an important nursing function.

Most refusals by clients are the result of the client’s knowledge deficit about what the medication is and what it does. When a client refuses to take a medication, the nurse’s first action should be to assess the client’s reason for the refusal. Addressing the client’s lack of understanding of the medication will usually result in the client’s compliance.

 A proactive nursing approach is to always inform all clients about their medications before attempting to administer them. Some client refusals result from the health care professionals’ lack of knowledge of a client’s allergy to the medication that the physician was unaware of when the medication was prescribed. The physician should immediately be notified about the client’s refusal and the presence of the client’s allergy. The physician will then reassess the medication order. Other refusals are due to the client experiencing adverse effects of the medication.

For example, a client receiving a laxative or stool softener for constipation begins to have loose or diarrhea stools and refuses the next dose of the medication. This is a legitimate reason for not administering the medication and contacting the physician for an order change. Some refusals are the result of the client’s feeling powerless either because of being in an acute care facility or because of the health alteration that precipitated the need for the medication. Again, this information can be retrieved from the nurse’s assessment done as a result of the client’s refusal.

NURSING IMPLICATIONS:

The Client’s Right to Refuse

7.1. Be sure to assess client’s reason for refusing medication.

7.2. If knowledge deficit underlies client’s reason for refusal, provide appropriate explanation for why medication is ordered, what medication does, and the importance of medication for treatment of client’s health alteration.

7.3. Document if client refuses medication, client’s reason, and reporting of refusal to physician.

 

Cultural, Legal and Ethical Considerations for Nursing Practice

Nurses need to be knowledgeable about drugs that may elicit varied responses in culturally diverse patients

Pattern of communication

- may differ based on patient’s race or ethnicity

Understanding of health beliefs

-  influence how patients respond to drug therapy

 - affect patient’s adherence to the drug regimen

 

Nursing considerations:

1. Develop good IPR and due considerations of their racial-ethnic backgrounds

2. Focus on scientific aspects of patients’ drug therapy rather than asking broad or general questions.

3. Be informed about difference communication patterns across cultures:

§  Chinese=rarely complain or

§  Asians= express problem in behavioral/somatic terms

4. Always consider the patient’s cultural beliefs, attitudes and values when administering medications & in-patient education.

5. Identify any potential conflicts between medications and cultural beliefs.

6. Identify any herbal, complimentary or alternative therapies (home or folk medicines) being used.

7. Be alert to patients’ response to medications.

LEGAL ISSUES

Standard of Professional Nursing Practice

> standards for nursing practice: scope, function and role of the nurse & establish clinical practice standards

 ex. Ministry of Health Malaysia: CPGs

       => written policies and procedures

*standards of care help to determine whether the nurse is acting appropriately when performing professional duties

 

ETHICAL ISSUES

Based on fundamental principles:

Beneficence

The ethical principle of doing or actively promoting good, related nursing actions include determining how the patient is best served

Autonomy

Self-determination and the ability to act on one’s own related nursing actions include promoting a patient’s decision-making, supporting informed consent, and assisting in decisions or deciding when a patient is posing no harm to himself or herself.

Justice

The ethical principle of being fair or equal in one’s actions, related nursing actions include ensuring fairness in distributing resources for the care of patients and determining when to treat.

Veracity

The duty to tell the truth; related nursing actions include telling the truth with regard to placebos, investigational new drugs and informed consent

Confidentiality

The duty to respect privileged information about a patient; related nursing actions include not talking about a patient in public or outside the context of the health care setting

Non-maleficence

the duty to do no harm to a patient

related nursing actions: avoiding doing any deliberate harm while rendering nursing care

What is Medication Error (MEs)?         

- a specific type of clinical problem

- a subset of adverse drug event

- potentially preventable

- common cause of adverse healthcare outcomes

- ranges in severity from having no significant effect to patient disability or death             

What to consider?

Medication Administration

System Analysis Process

-examines the entire HC delivery system; health professional involved; and any other factor that has impact on the error

Factors that lead to MEs:

è Increasing number of drugs on the market

=> increasing number of drug names to keep track of

ex. SALAD= sound-alike, look-alike drugs

LASA= look-alike, sound alike drugs

è Weakness in the system within healthcare organizations

- failure to create a “just culture”

- excessive workload with minimal time for staff prevention education

- lack of interdisciplinary communication and collaboration

Psychosocial Issues that Contribute to Errors

 1) Organizational Issues

- a study found, 50% of all ADRs begin at the prescribing stage

- presence of a pharmacist during medical rounds reduce the incidence of errors

- effective use of technologies (computerized prescriber)

- bar coding of medication packages

2) Educational System Issues

- rigorous cognitive and even physical challenges of HC study and practice, attract strong-willed intelligent people

=> expectations that one be smart and on top of things with clinical knowledge

=> denial, fear or shame about being wrong or not remembering a piece of information while on duty

How to address this issue?

Authoritative Sources

- current drug reference guides (less than 5 yrs. old)

examples: Mosby’s Drug Consult

Forward-Thinking Faculty Members

- learning is a life-long process

- adopting philosophy of “no question is a stupid question”

- allow staffs to begin career with greater confidence & with a healthy habit of self-monitoring during healthcare delivery

 

PREVENTING, RESPONDING TO, REPORTING & DOCUMENTING MEs

 Preventing MEs

- any preventable event that can lead to inappropriate medication use or harm while the medication is in the control of the professional nurse, student nurse, health professional, prescriber, patient or consumer. 

Strategies that can prevent MEs:

1. Multiple systems of check and balances.

2. Prescribers should write legible orders with accurate information or electronically if available.

3.  Consult authoritative resources: pharmacists  or current drug literature.

4. Nurses should always do “three checks” before giving the drug and consult authoritative resources.   

5. Consistent use of the “Six Rights” of medication administration.

         

Responding to, Reporting and Documenting MEs

- a professional responsibility for which a nurse is accountable

- if an error has occurred, it must be reported

- facility policies and procedures for reporting and documenting the error should be followed closely and cautiously

Steps for the nurse to take:

1.  Assess patient and attend to urgent issues of safety.

2.  Report error immediately to appropriate prescriber and nursing management personnel (ex. Nurse manager or supervisor)

3.  Have a fellow nurse or other qualified healthcare professional remain with the patient if pt. condition is deteriorating or close monitoring is needed. 

4. Implement follow-up procedures or tests as indicated by the prescriber (ex. Antidote administration)

reminder: Highest priority at all times is, patient’s physiologic status and safety.

 5. Nurse should complete all appropriate forms – including an incident report and provide needed documentation

How to document?

- only factual information about the error

- should be accurate, thorough and objective

- use of judgmental words such as “error” should be avoided

- document factual information such as:

a) medication administered

b) actual dose given

c) other details regarding the order (ex. wrong route, wrong patient and/or wrong time)

- any observed changes in the patient’s physical and mental status

- document prescriber notification, follow-up actions or orders

- patient monitoring which should be ongoing

Performing Medication Reconciliation

- a process that seeks to prevent medication errors through:

> ongoing assessment and updating of information on patient’s medication throughout the healthcare process

> timely communication of this information to both patients and their prescribers                  

3 Steps in Medication Reconciliation:

1. verification= collection of patient’s information

2. clarification= professional review of information to ensure that medications and dosages are appropriate for the patient

3. reconciliation= further investigation of discrepancies and documentation of relevant communication and changes in medication orders

Applicable Assessment and Education Tips:

1. Start with open-ended questions and gradually move to yes-no questions (details are important or even critical).

2. Avoid use of medical jargon.

3. Prompt patient to try to remember all applicable medications.

4. Clarify all unclear information to the extent possible.

5.  Record the foregoing information in the patient’s chart as the first step in the medication reconciliation process.

6.  Emphasize to the patient the importance of always maintaining current and complete medication list and bringing it to every health care visit. 

 

SELF-CHECK 1.3

1. Explain nurses’ responsibilities and implication during administration.

2. Explain the legal impact to nursing practice.