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Lecture 2 2011 1 pharm (student)-1

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Transcript

  • 1. Lecture 2 NUR 307 Juan M Gonzalez BSN, RN
  • 2. Drug Administration
    • Nurses have a duty to protect their patients
    • Administration of medications is a large part of what nurses are responsible for
    • Just because it’s ordered does not mean that we can’t question it
    • Patient safety will ALWAYS come first
    • Remember, the 1 st way a nurse can kill a patient is with drugs
  • 3. Nurses’ Responsibilities
    • Nurses are responsible and held accountable for all medications they administer
    • You must know the drugs before you give them
    • Just knowing a part of a medication is not enough
    • If you don’t know it.. DON’T GIVE IT
  • 4. What do I need to know??
    • Trade and generic name
    • Classification
    • Intended use & therapeutic effect
    • Contraindications & special consideration
    • Dose ranges & safety
    • Expected side affects
    • Adverse reactions
      • How to intervene for them
  • 5. What else do I need to know?
    • Your patient
      • Why are they taking it?
      • Do they need it?
      • What has your assessment revealed?
      • What are you responsible for?
      • Is this safe?
      • Is it beneficial?
  • 6. Bad, Bad, Bad
    • Toxic Epidermal Necrolysis
      • Sloughing off
    • Stevens-Johnson Syndrome
      • 1-14 days
      • Do they have a cold?
    • Anaphylaxis
      • Can’t breathe
    • Allergic reaction
      • Itchy
  • 7. Be RIGHT all the time
    • Right Patient
    • Right Med
    • Right Dose
    • Right Route
    • Right Time
    • Right to Refuse
    • Right Documentation
    • Right to Know/Be Informed/Education
    • Right Indication
  • 8. Three Times’ the charm!
    • Your not Santa- check it # times!!!
      • MAR
      • Preparation
      • Administration
  • 9. No More UH-OHs
    • Preventing Errors in Medication
      • Have complete information about the patient, including allergies
      • Be current on medication warnings
      • Appropriate labeling of medications
      • Avoid distractions
  • 10. Ways of Noncompliance
    • Not taking the medication
    • Taking it on a different schedule
    • Changing the dose &/or times
    • Taking too much of it
    • Not following dietary guidelines
      • Many meds have food and fluid restrictions
      • Many need to be taken on an empty stomach
  • 11. Orders & Times
    • Orders
      • STAT, immediately, now, single, repeat, prn
      • Standing, routine, pre-med
    • Times
      • BID, TID, QID
      • 2X, 3X,4Xs daily
      • Typically times start @ 9am
    • Abbreviations
      • See chart page 20
  • 12. Common Effects & Interventions
    • Drowsiness
      • Switch from day to evening dosing
      • Teach safety
        • No driving, fall precautions
    • Nausea
      • Take with food or small snack
    • Absorption interference
      • Take in-between meals
  • 13. Measurements
    • Metric
      • Safest one to use
      • Memorize this one
    • Apothecary/Household
      • Officially on the ‘do not use’ list
      • Only focus on the teaspoon & tablespoon equivalents
  • 14. Routes
    • Enteral
      • PO (oral)
      • NG (nasogastric tube)
      • GT (gastrostomy tube)
    • Topical
      • Cream or fluid
    • Parenteral
      • Uses a needle to deliver the drug
  • 15. Enteral
    • Tablets & caplets
      • Watch for 1 st -pass problem
        • Inactivated before they can do their job
      • Enteric coating- don’t crush
      • Time released- don’t crush
        • SR, XR, LA
    • Sublingual
      • Under the tongue
    • Buccal
      • Between gum & cheek
    • NG/GT
      • Meds must be crushed or in liquid form
  • 16. Topicals
    • Creams
      • Most common
      • Vary in texture
      • Used for the local effect OR systemic condition
        • Need to know which one and why
    • Patches
      • Make sure the old one is off
      • Rotate sites
    • Liquids
      • Flushes, irrigation, drops
    • Inhalants
      • Rapid onset
  • 17. Parenteral
    • Intradermal (ID)
      • Allergy shots
    • Subcutaneous
      • Insulin, Heparin, vaccines
    • Intramuscular (IM)
      • Pain meds, anti-infectives
    • Intravenous (IV)
      • Directly into the bloodstream
  • 18. Errors
    • Preventable
    • National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
    • #1 cause of preventable patient morbidity & death
    • NO acceptable rate (%) of errors
  • 19. Reporting Errors
    • At the Federal Level (FDA)
    • MEDWATCH (1992)
    • NCC MERP (1995)
    • Reporting errors will also help others avoid making similar mistakes
    • Safety 1 st
  • 20. Documenting Errors
    • Every facility has a policy & procedure
    • Must include what was done about the error (VS, labs, antidote)
    • List who was notified
    • Incident Reports
    • Sentinel Event
  • 21. Categorizing Errors
    • Categories A-I
    • Category A- No actual error
    • Category B-D- Error, no harm
    • Category E-H- Error,harm
    • Category I- Error, DEATH
    • See page 89, figure 9.2
  • 22. Reduction/Prevention
    • Risk Management
    • Education
      • Patient
      • Staffing
  • 23. Big Brother
    • Government & other agencies are in place to track errors
      • FDA’s safety administration & adverse event reporting program (MEDWATCH)
      • Institute for Safe Medication Practices (ISMP)
      • MEDMARX
        • Anonymous reporting program (hospitals)
  • 24. ANTHRAX
    • Bioterrorism Agent
    • Carried by ‘hoofed’ animals
    • Can be spread a variety of ways
    • ‘ spores’
    • S/S appear with 1-6 days of exposure
    • Manifestations depend on how it was acquired
  • 25. Manifestations of Anthrax TYPE DESCRIPTION SYMPTOMS Cutaneous Most common Open wound Curable if Tx within 1 st few weeks Skin lesion turn into black scabs Can’t be spread person-to-person Gastrointestinal Rare, ingested Lethal (50%)- if not Tx Sore throat, swallowing probs, cramps, diarrhea, abdominal swelling Inhalation Least common Most dangerous Must be Tx within days 1 st - fever, fatigue Then SOB, Cough Death within 4-6 days
  • 26. Anthrax Treatment
    • Ciprofloxacin
      • Over-use leads to resistant strains
      • Minimize Rx
      • Only given if proven contamination
    • Vaccine
      • Not 100% proven
      • Limited to those with high risk of exposure
      • 3 injection at 2 week intervals, then 3 more injections at 6, 12, and 18 months
      • Yearly booster
  • 27. Using the Nursing Process in Pharmacology
    • The 5 Steps of the Nursing Process
      • Assessment
      • Diagnosis
      • Planning
      • Intervention
      • Evaluation
  • 28. The Nursing Process in Pharmacology
    • The nursing process guides decisions about drug administration to ensure patient safety and to meet medical and legal standards.
  • 29. Assessment
    • On-going
    • Begin with a baseline assessment
      • To have measurements that you can determine effectiveness of treatment
      • Includes objective & subjective data
      • Anything & everything that is pertinent needs to be addressed
      • Systematic approach
  • 30. Subjective Data
    • Always in “” quotes
    • From the patient, family, staff, or chart
    • Subjective means words stated
    • Examples:
      • “ I don’t feel well”
      • Chart states “combative”
      • MD reported “ pt noncompliant with regimen initially ”
  • 31. Objective Data
    • Concrete
    • Measurable
    • Diagnostics
    • Physical Findings
    • Behavior
    • Disease
    • History: age, smoking/alcohol,drugs
  • 32. Objective Data Examples
    • Vital Signs
    • Behavior
      • Grimacing
      • Crying
    • Labs
      • Drug levels
      • Electrolytes
    • Disease
      • Cardiac
      • Asthma
    • History
      • Smoker
      • Alcoholism
    • Physical Findings
      • Crackles in lungs
      • 2+ pitting edema in lower extremities bilaterally
  • 33. Labs
    • Levels
      • Therapeutic vs Toxic range
    • System Function
      • Renal
        • BUN, creatinine, Na, K, etc
      • Hepatic
        • Liver enzymes
        • LFTs
      • Cardiac
        • Enzymes
        • BNP, LYTES
      • Pulmonary
  • 34. Assessment On-Going
    • New findings
    • Therapeutic Benefits
    • Adverse Effects/Side Effects
    • How will they continue taking the med
    • Financial constraints
    • Transportation
      • To/From
      • For labs
  • 35. Other Assessment Data
    • Any other medications
      • OTC
      • Herbal
      • Rx
      • PRN
      • ALL meds
      • Allergies & Sensitivities
        • Including foods
  • 36. Nursing Diagnosis
    • NANDA defines
    • Based on your assessment findings
    • Should encompass all medications
    • If there’s a med, there’s a Nursing Dx
    • Patient Focused
      • Not about you ( U )
  • 37. PLANNING
    • Establishing Goals & Outcomes
    • This where we begin prioritizing , formulating outcomes (goals), and selecting interventions to reach the goals
    • Goals
      • Long-term: within the lifetime
      • Short-term: within a few days
    • Outcomes: Objective measurements
  • 38. Goals (Examples)
    • Long-term
      • The pt will maintain adequate oxygenation =< 98% by the end of 6 weeks
    • Short-term
      • The pt will have an increase in oxygenation levels from 90% to 95% by May 26 th
    • Outcomes
      • The pt will demonstrate correct use of the incentive spirometer 2x shift
  • 39. Planning & Pharmacology
    • Medication Administration
      • Overall goal: Safe & effective administration of medication
    • Patient Education
      • Overall goal: Patients comprehend the purpose of every medication, the correct way it is to be administered, and what to do if problems arise.
  • 40. Implementation/Intervention
    • Putting the plan into action
    • This is what you will be doing for the patient
    • It is specific
      • Includes not only what, but how, when and where
      • This is how we ‘care’ for our patients
      • It’s a ‘List of Directions”
      • ANY nurse should be able to read and follow this, not just you
  • 41. Implementation/Intervention
    • Monitoring the medications
      • Effects of
      • Side effects/adverse effects
      • Compliance
      • Therapeutic benefits
      • Objective data: vs, labs, relief of s/s
      • Education
      • Scheduling on-going assessments
  • 42. Evaluating Effects
    • Comparing current status to baseline
    • Using the established goals/outcomes
    • Reassessing and revising goals and plan
    • Re-evaluating priority
    • Using findings to revise the plan, or to move on to another priority if resolved
  • 43. Anthrax Plan of Care example
    • Is it Anthrax?
    • What form?
    • What s/s is the patient exhibiting?
    • What does the patient tell you?
    • What objective data do you have?
    • What other information do you need?
  • 44. Anthrax Plan of Care example
    • What test determines it is anthrax?
    • Inhaled? Contact?
    • Difficulty breathing? Cold s/s?
    • In pain? Having trouble breathing?
    • VS, CXR, lab results?
    • How long has it been? What have they tried to help it? Did it help? Do they know how they were exposued?
  • 45. Anthrax Plan of Care example
    • Depending on what s/s the patient is exhibiting and what form of anthrax they were exposed to.
    • Will include a medication regimen with cipro, and possibly other medications in combination to alleviate s/s and treat the exposure.
  • 46. Anthrax Plan of Care example
    • Depending on what s/s the patient is exhibiting and what form of anthrax they were exposed to.
    • Will include a medication regimen with cipro, and possibly other medications in combination to alleviate s/s and treat the exposure.
  • 47. Anthrax Plan of Care example
    • For the purpose of this course, we will only focus on those interventions that apply to meds
    • Cipro is an anti-infective
    • We would be certain to include actions of assess benefits and any adverse effects
  • 48. Anthrax Plan of Care example
    • For the purpose of this course, we will only focus on the goals that apply to meds
    • Is the patient displaying s/s of improvement by taking the medication
    • Look at VS, labs, etc
    • Is the patient having any side effects?
    • Has the medication done what it needed to do?
    • Is the situation resolved, or do we modify or continue the plan?