Lecture 2 2011 1 pharm (student)-1


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Lecture 2 2011 1 pharm (student)-1

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