NCLEX-RN: Pharmacology

Pharmacology: Administering Medications

Focus topic: Pharmacology

If the facility has a computerized medication administration program, follow the steps to properly administer and document medications.

Pharmacology: Oral Medication

Focus topic: Pharmacology

 

Assessment
A. Assess that oral route is the most efficient means of medication administration.
B. Check medication orders for their completeness and accuracy.
C. Research unfamiliar drugs.
D. Review client’s record for allergies, lab data, etc.
✦E. Assess client’s physical ability to take medication as ordered.

  • Swallow reflex present.
  • State of consciousness.
  • Signs of nausea and vomiting.
  • Uncooperative behavior.

F. Check client’s medication administration record (MAR) with previous day’s MAR to make sure you have the correct medication for the client.
G. Assess correct dosage when calculation is needed.

Implementation
A. Preparing oral medications.

  • Obtain client’s MAR. Medication record may be a drug card, medication sheet, drug Kardex, or electronic medication sheet, depending on the method of dispensing medications in the hospital.
  • Compare the MAR with the most recent physician’s order.
  • Perform hand hygiene.
  • Gather necessary equipment.
  • Follow the hospital/agency policy for administration with client identifiers, check for order and bar code scanning.
  • Retrieve the medication.
  • Compare the label on the bottle or drug package to the MAR. Scan bar code on drug package or bottle.
  • Correctly calculate dosage if necessary and check the dosage to be administered with another nurse.
  • Pour the medication from the bottle into the lid of the container and then into the medicine cup. With unit dosage, take drug package and place in medication cup. Do not remove drug from drug package.
  • Check medication label again to ensure correct drug and dosages.
  • Place medication cup on a tray, if not using medication cart.
  • Return the multidose vial bottle to the storage area. If medication to be given is a narcotic, sign out the narcotic record sheet with your name as directed per hospital policy.

B. Administering oral medications to adults.

  • Take medication to client’s room; scan bar code on bracelet, scan bar code on medication package; check against medication card, sheet, or electronic record.
  • Place client in sitting position, if not contraindicated by his or her condition.
  • Tell the client what type of medication you are going to give and explain the actions this medication will produce.
  • Check the client’s identifying band and ask client to state name and date of birth so that you are sure you have correctly identified him or her.
  • If prepackaged medication is used, read label, take medication out of package, and put into medication cup.
  • Give the medication cup to the client.
  • Offer a fresh glass of water or other liquid to aid swallowing, and give assistance with taking medications.
  • Make sure the client swallows the medication.
  • Discard used medicine cup.
  • Position client for comfort.
  • Record the medication on the appropriate forms.

C. Administering oral medications to children.

  • Follow the procedures for the previous intervention, keeping the following guidelines in mind. a. Play techniques may help to elicit a young child’s cooperation.

b. Remember, the smaller the quantity of diluent
(food or liquid), the greater the ease in
eliciting the child’s cooperation.
c. Never use a child’s favorite food or drink as
an enticement when administering medication
because the result may be the child’s
refusal to eat or drink these later.
d. Be honest and tell the child that you have
medicine, not candy.

  • Assess child for drug action and possible side effects.
  • Explain medication action and side effects to parents.

Pharmacology: Narcotic Medication

Focus topic: Pharmacology

A. Check medication sheet for narcotic orders.
B. Check dose and time last narcotic administered.
C. Unlock and open narcotic drawer and find appropriate narcotic container.
D. Follow agency/hospital policy for count prior to removing the medication for the client.
E. Check narcotic sign-out sheet and be sure that number of narcotics matches number on sign-out sheets.
F. Rectify situation before proceeding with narcotic administration if narcotics and sign-out sheets do not coincide.
G. Sign out for narcotic on narcotic sheets, after taking narcotic out of drawer or cupboard.
H. Lock drawer or cupboard after taking out medication.
I. Sign out narcotics on MAR according to usual procedure.
J. For unit narcotic stock, check narcotics every 8 hours.

  • One off-going and one on-going nurse check the narcotics.
  • Number of medications listed on sign-out sheets must match remaining number of narcotics.
  • Each narcotic sheet is checked for accuracy.

K. For automated dispensing system, enter ID code number and user password and continue with dispensing process.

Pharmacology: Patient-Controlled Analgesia

Focus topic: Pharmacology

Patient-controlled analgesia (PCA) is a delivery system with which clients self-administer predetermined doses of analgesic medication to relieve their pain. It is a safe method of analgesic administration for acute and chronic pain, including conditions such as postoperative, cancer, and end-of-life pain.

A. Advantages of PCA.

  • Provides consistent level of pain control.
  • Allows client to self-administer pain medication.
  • Allows client to feel in control of pain management.
  • This method of administration:
    a. Optimizes the daily management of postoperative pain.
    b. Contains the following variables that are determined and set based on client individual characteristics and needs. These include:
    (1) Initial load.
    (2) Loading dose.
    (3) Demand dose.
    (4) Lockout interval to prevent overdosing.
    (5) Background infusion rate and 1-hour or 4-hour limits.
    (6) May be programmed to deliver continuous infusion, a bolus dose, or both.
    c. Concerns include errors and pump failure.

B. Procedure.

  • PCA infuser pump is prepared and attached to IV.
  • Morphine sulfate or Dilaudid (hydromorphone) is delivered in loading dose as ordered and initiates pain management.
  • Client is instructed in PCA use and continues to self-administer narcotic.
  • Dose calculation is double checked with another RN.
    a. PCA infuser delivers in milliliters.
    b. Maximum rate of administration is based on client needs with preset maximum.
    c. Four-hour limit is set for infuser.

C. Recording and reporting.

  • Record drug, concentration, dose, time started, lockout time, and amount of IV solution infused and remaining solution. Many agencies have special PCA documentation forms.
  • Record regular assessment of client response to analgesia on PCA medication form, in nurses’ notes, on pain assessment flow sheet, or on other documentation according to institutional policy.
  • Teaching
    a. Give instructions while client is pain free or in pain-reduced state—preop is best.
    b. Push PCA button at first pain indication.
    c. Inform client of nonpharmacologic strategies to help relieve pain.
    d. Only the client pushes the button, not family and friends.
  • e. Explain regimen to the family so they can support and help the client (but not push the button for the client).
    f. Inform client and family that client will not overdose with PCA if only the client pushes the button.
    4. Gerontologic considerations.
    a. Dosage considerations.
    (1) Reduced renal and liver function slows opioid metabolism and excretion, causing a faster peak effect and a longer duration of action of the opioid.
    (2) Start low and titrate upward slowly until pain relief is achieved.
    b. Adjust PCA use if client becomes confused.
    c. Get orders to lower the dose, lengthen the lockout, or add a nonopioid analgesic to reduce the opioid dose.
    d. Confusion may be caused by pain rather than by the medications.
  • Pediatric.
    a. PCA is an effective means of pain control in children as young as 5 years old who can understand the concept.
    b. Must consider a client’s developmental and cognitive levels and motor skills.
    c. Particularly effective with adolescents because it leads to feelings of control.
    (1) Epidural analgesia: used for acute pain during labor, after surgery; chronic pain.
    (2) Safe, efficient; rarely complications.
    (3) Administered into the epidural space that contains a network of vessels, nerves, and fat.
    (4) Analgesic is distributed by diffusion through the dura mater into the cerebrospinal fluid, by blood vessels in the epidural space.
    (5) Analgesic acts by binding to opiate receptors in the dorsal horn of the spinal column blocking transmission of the pain impulse to the cerebral cortex.

Pharmacology: Parenteral Medications

Focus topic: Pharmacology

Assessment
A. Determine appropriate method for administration of drug.

  • Intradermal (intracutaneous): Injection is made below surface of the skin; 25–27-gauge, ⅜–½-inch needle; 0.01 to 0.1 mL.
  • Subcutaneous: Small amount of fluid is injected beneath the skin in the loose connective tissues; 25–29-gauge, ⅜–⅝-inch needle; to 2 mL. Intramuscular: Larger amount of fluid is injected into large muscle masses in the body; 23–25-gauge, ⅝–1-inch needle; up to 2 mL for deltoid and 5 mL for other sites; 21–22 gauge (1½) needles may be used for deep IM.
  • Intravenous: Medication is injected or infused directly into a vein—route used when immediate drug effect is desired.

B. Evaluate condition of administration site for presence of lesions, rash, inflammation, lipodystrophy, ecchymosis, and other problems.

  • Ventrogluteal site (client side-lying).
  • Vastus lateralis site (supine with thigh available).
  • Deltoid site (exposed upper arm).

C. Assess for tissue damage from previous injections.

D. Assess client’s level of consciousness.

  • For client in shock: Certain methods (subcutaneous) will not be used.
  • For presence of anxiety: Make sure client is allowed to express his or her fear of injections and offer explanations of ways in which injections will be less frightening.

E. Check client’s written and verbal history for past allergic reactions. Do not rely solely on client’s chart.
F. Review client’s chart noting previous injection sites, especially insulin and heparin administration sites.
G. Check label on medication bottle to determine if medication can be administered via route ordered.

Special Considerations for Administration of Insulin

Focus topic: Pharmacology

A. Clients choose one anatomic area to be used (e.g., the abdomen).
B. Systematically rotate sites within that region to maintain consistent insulin absorption from day to day.
C. When healthcare providers plan insulin injection times, blood glucose levels are used to determine when the client will eat.
D. Knowing the peak action and duration of the insulin is essential when developing an effective diabetes management plan to stabilize blood sugar.

Special Considerations for Administration of Heparin

Focus topic: Pharmacology

A. Provides therapeutic anticoagulation.
B. Reduces the risk for thrombus formation by suppressing clot formation.
C. Results from coagulation blood tests (e.g., activated partial thromboplastin time [aPTT] and partial thromboplastin time [PTT]) allow you to monitor the desired therapeutic range for IV heparin therapy.

D. Before administering:

  • Assess for preexisting conditions that contraindicate its use, including cerebral or aortic aneurysm, cerebrovascular hemorrhage, severe hypertension, and blood dyscrasias.
  • Assess for conditions in which increased risk for hemorrhage is present.

Insert needle at 15-degree angle under the epidermis for intradermal injection.

Pharmacology

Implementation
A. Preparing medications.

  • Perform hand hygiene.
  • Obtain equipment for injection: safety needle and syringe, antimicrobial wipes, medication cart or dispenser.
  • Select the appropriate size needle, considering the size of the client’s muscle mass and the viscosity of the medication.
  • Open the wipe and cleanse top of vial or break top of ampule.
  • Remove the needle guard. If using ampule, use filter needle to reduce the risk of shattered glass being injected.
  • Pull back on barrel of syringe to markings where medication will be inserted.
  • Pick up vial, insert needle into vial, and inject air in an amount equal to the solution to be withdrawn by pushing barrel of syringe down. If using an ampule, break off top at colored line, insert syringe with a filter needle attached, but do not inject air into ampule.
  • Extract the desired amount of fluid. Remove needle from container and cover needle with guard. Filter needle must be changed to the correct size and length for the type of administration.
  • Double-check drug and dosage against drug card or medication sheet and vial or ampule.
  • Place syringe on tray.
  • Check label and drug card or medication sheet for accuracy before returning multidose vial to correct storage area.
  • Return multidose vial to correct storage area or discard used vial or ampule.

B. Administering intradermal injections (if facility has computerized medication administration program follow the steps to administer properly).

  • Take medication to client’s room. Check room number against medication card or sheet.
  • Explain the medication’s action and the procedure
    for administration to client.
  • Check client’s identifying band and ask client to state name and date of birth.
  • Perform hand hygiene.
  • Select the site of injection.
  • Cleanse the area with an antimicrobial wipe, wiping in circular area from inside to outside.
  • Take off needle guard.
  • Grasp client’s forearm from underneath and gently pull the skin taut.
  • Insert the needle at 10- to 15-degree angle with the bevel of needle facing up. (See Figure 5-1.)
  • Inject medication slowly. Observe for wheals and blanching at the site.
  • Withdraw the needle, wiping the area gently with a dry 2 Ă— 2 bandage to prevent dispersing medication into the subcutaneous tissue.
  • Return the client to a comfortable position.
  • Activate safety needle and discard supplies in appropriate container.
  • Chart the medication and site used.

Insert needle at 45- or 90-degree angle for subcutaneous injection.

Pharmacology

C. Administering subcutaneous (sub q) injections.

  • Take medication to client’s room.
  • Set tray on a clean surface, not the bed.
  • Check client’s identifying band and ask client to state name and date of birth.
  • Explain action of medication and procedure of administration.
  • Provide privacy when injection site is other than on the arm.
  • Perform hand hygiene and don gloves.
  • Select site for injection by identifying anatomical landmarks. Remember to alternate sites each time injections are given.
  • Cleanse area with antimicrobial wipe. Using a circular motion, cleanse from inside outward.
  • Take off needle guard.
  • Express any air bubbles from syringe.
  • Insert the needle at a 45- or 90-degree angle.
  • Inject the medication slowly.
  • Withdraw needle quickly and massage area with wipe to aid absorption and lessen bleeding. Do not massage after administering certain drugs, e.g., heparin, insulin. Put on bandage if needed.
  • Activate needle safety feature and discard in puncture-proof container.
  • Return client to a position of comfort.
  • Chart the medication and site used.

D. Administering insulin injections: Be sure to check policy to see if another RN must verify.

  • Gather equipment and check medication orders and injection site. Opened insulin does not need to be refrigerated.
  • Perform hand hygiene.
  • Obtain specific insulin syringe for strength of insulin being administered (U50 or U100).
  • Rotate insulin bottle between hands to bring solution into suspension.
  •  Wipe top of insulin bottle with antimicrobial swab.
  • Take off needle guard.
  • Pull plunger of syringe down to desired amount of medication and inject that amount of air into the insulin bottle.
  • Draw up ordered amount of insulin into syringe.
  • Expel air from syringe.
  • Replace needle guard.
  • Check medication card, bottle, and syringe with another RN for accuracy.
  • Take medication to client’s room.
  • Double-check site of last injection with client.
  • Rotating injection site from one body area to another is no longer recommended due to variation in insulin absorption and action.
    a. Move injection site one inch from previous site.
    b. Absorption is most predictable in abdomen.
    c. Avoid injecting into extremity.
  • Provide privacy.
  • Perform hand hygiene.
  • Follow protocol for administration of medications by subcutaneous injections.

E. Administering intramuscular (IM) injections.

  • Take medication to client’s room. Check room number against medication card or sheet.
  • Set tray on a clean surface, not the bed.
  • Explain the procedure to client.
  • Check client’s indentifying band and have client state name and date of birth
  • Provide privacy for client.
  • Perform hand hygiene and don gloves.
  • Select the site of injection by identifying anatomical landmarks. Remember to alternate sites each time injections are given.
  • Cleanse the area with antimicrobial wipe. Using a circular motion, cleanse from inside outward.
  • Hold the syringe; take off needle cover.
  • Express air bubbles from syringe. Some clinicians suggest leaving a small air bubble at the tip so that all medicine will be expelled.
  • Insert the needle at 90-degree angle.
  • Pull back on plunger. If blood returns, you know you have entered a blood vessel; textbooks advocate discarding all equipment and medication and starting over with new syringe and medication.
  • Inject the medication slowly.
  • Withdraw the needle, activate safety feature, and apply pressure to area while massaging with alcohol wipe. Put on a bandage, if needed.
  • Return client to a comfortable position.
  • Discard supplies in appropriate area.
  • Chart the medication and site used.

Insert needle at 90-degree angle and deep into muscle tissue for intramuscular injections.

Pharmacology

Pharmacology: Herb–Drug Interactions

Focus topic: Pharmacology

A. Mixing herbs with traditional medicines may increase or decrease the effects—in some cases this can be dangerous.

  • Unlike prescription medicines, herbal products are not regulated by the Food and Drug Administration (FDA).
  • More than 60 million Americans spend $4 billion annually on herbs; more than 15 million adults are at risk for potential drug–herb interactions.
  • Table 5-1 lists some of the most popular herbs and their interactions with specific drugs.

B. On the whole, herbal medicine is safe and a gentle form of therapy. However, if the health problem is serious or the person is taking strong orthodox medications, teaching is indicated.
C. Client teaching with herbs.

  • When completing a nursing history, ask about taking herbs.
  • Educate yourself about herbs—check for known side effects, drug interactions, and potential risk with certain drugs.
  • Remind the client to tell his or her physician about any herbs being taken.

D. The top five herbs clients take but do not tell their physicians about:

  • Black cohosh.
  • Echinacea.
  • Ginkgo biloba.
  • Saw palmetto.
  • St. John’s wort.
    Source: Crock, R. (September 2003). Herbal medicine consultant.

Pharmacology: Alternative Nursing: Herb–Drug Interactions

Focus topic: Pharmacology

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Pharmacology: Alternative Nursing: Herb–Drug Interactions

Focus topic: Pharmacology

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Pharmacology: Alternative Nursing: Herb–Drug Interactions

Focus topic: Pharmacology

Pharmacology

Pharmacology: Governing Laws

Focus topic: Pharmacology

Pharmacology: Federal Food, Drug, and Cosmetic Act of 1938

Focus topic: Pharmacology

A. The act is an update of the Food and Drug Act first passed in 1906.
B. It designates United States Pharmacopeia and National Formulary as official standards.
C. The government has the power to enforce standards.
D. Provisions of the act.

  • Drug manufacturer must provide adequate evidence of drug’s safety.
  • Correct labeling and packaging of drugs.

E. Amended in 1952 to include control of barbiturates by restricting prescription refills.
F. Amended in 1962 to require substantial investigation of drug and evidence that drug is effective in terms of labeling claims.

Pharmacology: Harrison Narcotic Act of 1914

Focus topic: Pharmacology

A. Provisions of the act.

  • Regulates manufacture, importation, and sale of opium, cocaine, and their derivatives.
  • Amendments have added addictive synthetic drugs to the regulated drug listing.

B. Applications of the act.

  • Individuals who produce, sell, dispense (pharmacists), and prescribe (dentists, physicians) these drugs must be licensed and registered; prescriptions must be in triplicate.
  • Hospitals order drugs on special blanks that bear hospital registry number. The following information is recorded for each dose:
    a. Name of drug.
    b. Amount of drug.
    c. Date and time drug obtained.
    d. Name of physician prescribing drug.
    e. Name of client receiving drug.
    f. Nurse’s signature and type of license (RN, LVN, or LPN).

Pharmacology: Controlled Substance Act of 1970

Focus topic: Pharmacology

A. Provisions of the act.

  • Regulates potentially addictive drugs as to prescription, use, and possession.
    a. Regulations refer to use in hospital, office, research, and emergency situations.
    b. Regulations cover narcotics, cocaine, amphetamines, hallucinogens, barbiturates, and other sedatives.
  • Controlled drugs are placed in five different schedules or categorical listings, each governed by different regulations.
    a. The regulations govern manufacture, transport, and storage of the controlled drugs.
    b. The use of the drugs is controlled as to prescription, authorization, the mode of dispensation, and administration.

B. Application of the act for use of controlled drugs in hospitals.

  • The nurse is to keep the stock supply of controlled drugs under lock and key.
    a. Nurse must sign for each dose (tablet, mL) of drug.
    b. Key is held by the nurse responsible for administration of medication.
    c. At the end of each shift, nurse must account for all controlled drugs in the stock supply.
  • Violations of the Controlled Substance Act.
    a. Violations are punishable by fine, imprisonment, or both.
    b. Nurses, upon conviction of violation, are subject to losing their licenses to practice nursing.

Pharmacology: Prescription and Medication Orders

Focus topic: Pharmacology

A. A prescription is a written order for dispensation of drugs that can be used only under a licensed independent practitioner (LIP) or a physician’s supervision.
B. Prescriptions outside the hospital.

  • Formula to pharmacist for dispensing drugs to client.
  • Consists of four parts.
    a. Superscription (symbolized by Rx, meaning “take”).
    (1) Client’s name.
    (2) Client’s address (required only for controlled drugs).
    (3) Age (required only if age is a factor in the dose preparation).
    (4) Date (must always be included).
    b. Inscription.
    (1) Specifies ingredients and their quantities.
    (2) May specify other ingredients necessary to a specific drug form.
    c. Subscription—directions to the pharmacist as to method of preparation.
    d. Signature—consists of two parts.
    (1) Accurate instructions to client as to when, how, and in what quantities to take medication; typed on label.
    (2) Physician’s signature and refill instructions.

C. Orders inside the hospital.

  • Physician writes medication order in book, file, or client’s chart; if given over phone, nurse writes verbal order that physician later signs.
  • An order consists of six parts.
    a. Name of drug.
    b. Dosage.
    c. Route of administration with time drug was or is to be given.
    d. Reason drug is required (not always included).
    e. Length of time client is to receive drug (not always included).
    f. Signature of individual who ordered drug.
    Example: Aspirin 325 mg Ă— PO q3h for pain for 3 days.

Pharmacology: Informational Resources

Focus topic: Pharmacology

Pharmacology: Official Publications

Focus topic: Pharmacology

A. A drug listed in the following publications is designated as official by the Federal Food, Drug, and Cosmetic Act (FDC).

  • United States Pharmacopeia (USP).
  • National Formulary (NF).
  • Homeopathic Pharmacopeia of the United States.

B. These publications establish standards of purity and other criteria for product acceptability; these standards are binding according to law.

C. Publications contain information on each drug entry.

  • Source.
  • Chemical and physical composition.
  • Method of storage.
  • General type or category.
  • Range of dosage and usual therapeutic dosage.

Pharmacology: Other Publications

Focus topic: Pharmacology

A. American Hospital Formulary is a publication indexed by generic and proprietary names.
B. Physicians’ Desk Reference (PDR).

  • Annual publication with quarterly supplements.
  • Handy source of information about dosage and drug precautions.

Pharmacology: Miscellaneous Resources

Focus topic: Pharmacology

A. Package inserts from manufacturers that accompany the product.
B. Pharmacist.
C. Physician.
D. Nursing journals.
E. Pharmaceutical and medical treatment texts.

Pharmacology: Systems of Measurement

Focus topic: Pharmacology

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Pharmacology: Mathematic Conversions

Focus topic: Pharmacology

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Pharmacology: Mathematic Conversions (Continued)

Focus topic: Pharmacology

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Pharmacology: Abbreviations and Symbols for Orders, Prescriptions, and Labels

Focus topic: Pharmacology

Pharmacology

Pharmacology: Household Equivalents (Volume )

Focus topic: Pharmacology

Pharmacology

Pharmacology: Most Commonly Used Drugs

Focus topic: Pharmacology

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Pharmacology: Most Commonly Used Drugs (Continued)

Focus topic: Pharmacology

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