NCSBN- Pharmacology and Parenteral

Pharmacology terms and responsibilitieso Medication nomenclature

Medication nomenclature: some examples

Chemical Name Generic Name Trade (Brand) Name

Tall Man lettering

3,4dihydroxyphenethylamine hydrochloride dopamine Intropin DOPamine

4-[2-[4-(4-hydroxyphenyl)butan-2-ylamino]ethyl]benzene-1,2-diol

dobutamine hydrochloride

Dobutrex DOBUTamine

Chemical name: description of a medication's chemical and molecular structure/composition

Generic name: description assigned by the U.S. Adopted Name Council; identified by lowercase letters

Trade (brand) name: manufacturer's registered name for a medication; the name is capitalized and treated as a proper noun

TALL MAN    lettering: one part of a drug's name is written in capital letters (tall man letters) to

distinguish it from the other look-alike and sound-alike drugs, e.g., predniSONE and prednisoLONE

used to help prevent medication errors

High-alert drugs: medications with a high potential to cause harm if administered incorrectly to the client

Learn more about high-alert drugs from The Food and Drug Administration.

6. Controlled substanceso medications controlled by the federal Controlled Substances Act (CSA) because they have a

higher risk for abuseo controlled substances in the United States - 5 categories

Schedule I - category of drugs with high abuse potential and no medical use (generally unsafe), e.g., heroin, lysergic acid diethylamide (LSD), and marijuana

Schedule II: high risk for abuse or physical or psychological dependency but also have safe and accepted uses, e.g., morphine, amphetamines, short-acting barbiturates, cocaine

Schedule III: less potential for abuse or addiction than Schedule II, e.g., paregoric, various analgesic compounds containing codeine

Schedule IV: medically useful category of drugs with less potential for abuse or addiction than Schedule II drugs, e.g., chloral hydrate, diazepam, meprobamate, phenobarbital

Schedule V: lowest potential for abuse of all categories, medically acceptable uses e.g., antidiarrheals and antitussives with opioid derivatives

o providers must register with the Drug Enforcement Agency (DEA) to prescribe these medications and include their DEA number on the prescription

As a general rule, classes of drugs have the same generic "last" name:"PRILS" = ACE inhibitors (enalapril, lisinopril)"SARTANS" = angiotensin receptor blockers (losartan, valsartan)"TRIPTANS" = treatment of acute migraine headache "STATINS" = lower LDL cholesterol (simvastatin, rosuvastatin)"DIPINES" = calcium channel blockers (amlodipine, nifedipine)"PRAZOLES" = proton pump inhibitors (omeprazole) "AZOLES" = antifungals (miconazole)

2. Pharmacodynamics (how a medicine changes the body) - it's the mechanism of drug action and its relationship between drug concentration and responses of the body

o Used to help predict if the medication will assist the client or will produce a significant change in the client

o Replaces a missing substanceo Destroys or inhibits a pathogeno Stimulates, suppresses, or disrupts a process

Before you start studying, take a few moments for ground yourself with meditation, prayer, or contemplation. When you are focused on the present moment, you will be less likely to worry about the future or obsess about the past.

3. Pharmacokinetics (how the body affects the drug) o Consists of four processes: absorption, distribution, biotransformation (metabolism) and

excretion absorption: movement of the drug through blood circulation from the site of

administration to target tissue onset of action: the time between the administration of a medication and the

beginning of its effects duration: amount of time that a medication exerts its effects, therapeutic and

adverse bioavailability: amount of drug that reaches the target tissue

distribution process by which the drug diffuses or is transferred from the intravascular

space (blood stream) to extravascular space (body tissues) factors affecting distribution

blood flow to the tissue, e.g., vasoconstriction reduces drug distribution and vasodilation enhances drug distribution

solubility of the drug binding of the drug to macromolecules in the blood or tissue ability to cross barriers, e.g., blood-brain barrier, placenta

metabolism (biotransformation): chemical conversion or transformation of drugs into compounds that are easier to eliminate

phase I: oxidation, reduction, or hydrolysis by the cytochrome P-450 enzyme system

phase II: conjugation of substance, improves renal excretion half-life: time it takes the amount of drug administered to decrease to 50% of

the peak drug level excretion: elimination of unchanged drug or metabolite from the body, through renal,

biliary, or pulmonary processes route of excretion depends on the drugs chemical properties kidneys are responsible for excreting most drugs

4. Factors affecting pharmacokineticso client influences

body mass index cultural guidelines genetic and ethnic factors

pathophysiological impact environmental and immunological factors developmental (growth and development) factors nutritional and dietary restrictions

o drug-related factors dose timing route and administration drug-drug interactions

potentiate inhibit: decrease or blunt the effectiveness of another medication incompatible: agent that usually causes harm to the client or causes complications

with the administration of another medication drug-diet interactions drug metabolism

If you learn drug classifications, it may be easier to remember specific medications and their indications for use, adverse effects, and client/family teaching. Refer to our Drug Classifications guide for more details.

3. Therapeutic rangeo range of concentrations at which a drug or other therapeutic agent is effective with minimal

toxicity to most people o common drug examples: acetaminophen, aminophylline, digoxin, lithium, phenytoin,

propranolol, theophylline4. Peak and trough levels

o peak: point in time after the administration when a medication exerts its strongest therapeutic and adverse effects; a serum blood sample is drawn (about 1 hour) after the drug is administered

o trough: the lowest drug level that is needed to reach therapeutic range; a serum blood is drawn (about 30 minutes) before medication administration

5. Drug effectso therapeutic: desired primary effect for which drug is giveno side effect: undesirable or unpleasant client response to pharmacotherapy that tends to be a

nuisanceo adverse: undesired responses to pharmacotherapy that are harmful to the client or make

administration of the drug very difficult or harmfulo toxic: dangerous or harmful adverse effect including secondary effect; hypersensitivity, tissue

and organ damageo cumulative: occurs when drug is administered too frequently or when excretion of the drug is

impaired, may lead to adverse and toxic effectso hypersensitivity: immunological response of client; allergy and anaphylaxiso tolerance: over time the drug loses its therapeutic effect; requires increased dosing to produce

same effect, not predictive of addictiono dependence: disruption of a homeostatic function set-point when an agent is stopped leading to

clinical indicators of withdrawal psychic: predictive of addiction physical: not predictive of addiction

o subtherapeutic: not reaching therapeutic effect due to low dosing6. Administration routes

o Oral (PO) types

1. capsules, elixir, powder, sprinkles, tablets2. timed release tablets or capsules (CR, XR, XL)

preferred route of administration1. less expensive

2. fewest complications3. amenable to home therapy

rate of absorption affected by1. gastric HCl2. perfusion to GI tract3. rate of gastric emptying4. presence of interacting foods or drugs

effects on mechanism of action1. exposes drug to endogenous HCl2. time spent in stomach

1. food in stomach: drug spends more time in stomach2. empty stomach: drug is passed out of stomach quickly

3. food or drug may bind to drug or block absorption4. may require injection if action is severely affected

first-pass metabolism1. orally administered drugs primarily absorbed from small intestine

1. enter portal circulation and travel to liver2. immediate transformation via liver enzymes

2. destroys a larger percentage of the active ingredient than injected agents, requiring a larger dose when compared to injected agents

7. Inhaledo absorption rate affected by

integrity of lung tissue proper administration of drug perfusion to pulmonary vasculature

o aerosols information common to aerosol delivery of drugs

1. goal - to deliver high concentration of drug in the lungs with limited systemic effects2. most commonly used in the treatment of asthma, COPD, wheezing3. effectiveness of delivery depends on

1. slow, deep inhalation and 2. holding breath for 5 to 10 seconds after inhalation3. size of particles (most desirable is 1 to 5 microns)4. amount of drug reaching lungs and GI system

metered-dose inhaler (MDI)1. advantages

1. less expensive, more portable than nebulizer

2. delivers high concentration of medication with few side effects2. disadvantages

1. higher risk of dispensing medication into mouth2. very young, very old, and weak clients may have difficulty activating device3. technique must be correct for medication delivery

1. canister must be shaken before each use2. hand-breathing coordination required3. medication remaining in canister can be difficult to determine

3. technique without spacer: administer one puff using MDI1. shake canister for 2 to 5 seconds2. hold MDI with thumb under the mouthpiece and the index and middle fingers

on top of the canister3. positioning mouthpiece - client has two options

1. place mouthpiece of MDI in mouth with opening pointing toward the back of the head; client tightens lips around mouthpiece

2. position MDI 1 to 2 inches in front of widely opened mouth pointing toward back of the head; lips should not touch mouthpiece

4. inhale deeply and exhale completely5. tilt head back slightly and simultaneously inhales slowly and deeply through

mouth while depressing canister6. continue to inhale slowly for 2 to 5 seconds, then hold the breath for 10

seconds4. technique with spacer

1. insert mouthpiece of MDI into spacer2. shake canister for 2 to 5 seconds3. insert mouthpiece of spacer device into mouth being careful not to cover

exhalation vents on spacer4. breathe normally through spacer

1. depress canister, spraying one puff into spacer2. inhale slowly and fully for 5 seconds3. hold breath for 10 seconds

5. rinse mouth after using MDI with or without a spacer6. wait 20 to 30 seconds between puffs before administering second puff or additional

medication with MDI 7. divide the number of doses in the container by the number of doses used per day to

determine how long the MDI will last8. nebulizer

o advantage - delivery of finer aerosol, less risk of oral medication deliveryo disadvantage - not portable; very young, very old, and debilitated clients may have difficulty setting

up equipmento procedure

add medication to nebulizer cup with diluent and attach nebulizer cup to nebulizer insert mouthpiece of nebulizer into client's mouth; may use face mask if client unable to

follow instructions instruct client to inhale slowly and deeply, hold breath for a second, then passively exhale;

dyspneic clients may limit breath-holding to every fourth or fifth breath turn nebulizer on and verify release of mist

1. tap medication cap toward end of treatment session2. reinforce use of breath-holding

check client's heart rate before and during treatment after finishing treatment

1. turn nebulizer off2. follow agency policy for storing and cleaning tubing and medication cup3. provide oral rinse to client4. check bilateral breath sounds, peak flow rates, SaO2, and heart rate

9. nasal sprayo gently blow nose before administrationo shake containero tilt head slightly back

o occlude one nostril, insert spray tip into the other nostrilo activate spray and gently inhale

10. dry powdero rotacap inhalerso requires high airflow: avoid use with children and older clients and in high humidityo contraindicated for severe asthma exacerbations

11. Topicalo transdermal medications

analgesics antidepressants hormones cardiac medications

o absorption rate affected by skin integrity tissue perfusion

o applied locally, but has systemic effectso remove previous patch and wash the area to prevent further absorption prior to applying the next

doseo use cautiously with older clients due to increased rate of absorption through aging skin

12. Transmucosalo types: vaginal, sublingual (under the tongue), buccal (in the pouch of the cheek), rectalo absorption rate affected by

length of exposure perfusion of tissue integrity of mucosa presence of food or smoking

o suppositories - wear gloves for procedure; remove foil wrapper and lubricate the suppository if necessary

rectal suppositories 1. if used for systemic indication, have client defecate if possible to allow facilitation of

medication2. position client on left lateral position and insert just beyond internal sphincter3. instruct client to retain the medication for 20 to 30 minutes for stimulation of

defecation and 60 minutes for systemic absorption vaginal suppositories

1. position client supine with knees bent, feet flat on bed and close to hips (a modified lithotomy position)

2. use application device to insert suppository13. Intradermal

o slower absorption rateo administration

use tuberculin syringe1. calibrated in 0.1 mL and 0.01 mL2. needle: 25 to 27 gauge3. length: 1/4 to 1/2 inch

dose: 0.1 to 0.01 mL angle 10 to 15 degrees from the skin to the deposit the medication below the epidermis; a

wheal will form under the skin14. Subcutaneous (SubQ): implants, injection

o parenteral administration of medication into the loose tissue between the skin and muscle (medication must not enter muscle)

o administration needle type

1. use 5/8 inch needle, greater than 21 gauge2. insulin syringes come in many smaller sizes: 5/16 inch or 8 mm and the pen needles

are 1/2 inch (12.7 mm), 5/16 inch (8 mm) and 3/16 inch (5 mm) lengths inject medication into subcutaneous tissue to avoid muscle use 45-degree or 90-degree angle

aspiration not required do not massage injection site

rotate injection sites

o suitable medications for subcutaneous administration isotonic nonviscous non-irritating water-soluble small volumes of medication (0.5 to 1 mL)

o contraindications shock, cardiac arrest decreased perfusion to tissue

Learn about needles used for insulin injection at BD Diabetes.

7. Intramuscular (IM)o four common sites: ventrogluteal, dorsogluteal, vastus lateralis, and deltoid o absorption affected by the muscle's perfusion, fat content, and degree of vasoconstrictiono administration

verify need to aspirate four common sites: ventrogluteal, dorsogluteal, vastus lateralis, and deltoid inject medication into large muscle; avoid soft tissue other than muscle, especially

nerves and vessels needle angle: perpendicular (90 degrees) to tissue being injected children

younger than 18 months: use vastus lateralis muscle older than 18 months: use vastus lateralis, ventrogluteal, deltoid

inject up to 2 mL for children (deltoid should be limited to 0.5-1 mL)

adults (18 years and older) injection sites: vastus lateralis, ventrogluteal, and deltoid muscles inject up to 3-5 mL for adults (deltoid should be limited to 0.5-1 mL)

o needle length for injections infants 0 to 12 months: 5/8 inch toddlers and preschoolers: 5/8 up to 1 inch school-age and adolescent: 5/8 up to 1½ inch adults: 1 to 1½ inch older or debilitated adults: 5/8 to 1 inch

o landmarks for IM injections ventrogluteal muscle

index finger of non-dominant hand on anterosuperior iliac spine (iliac crest, upper, outer buttocks)

form a V with index finger and middle finger; aim opening of V laterally, the middle finger pointed towards the iliac crest and index finger pointed toward the anterosuperior iliac spine.

injection site: between index and middle fingers low potential for injury

vastus lateralis muscle anterior, lateral aspect of thigh between greater trochanter and knee use middle third of muscle to inject low potential for injury

deltoid muscle

locate lower edge of acromion process (protrusion at end of clavicle) move straight across upper arm to midpoint of the lateral aspect of deltoid

muscle this line is the base of a triangle pointing toward the elbows

injection site is 1 to 2 inches below acromion process alternate method: place four fingers across the deltoid muscle placing the top

finger just below the acromion process with injection site just under the third finger

higher potential for injury: radial, brachial, and ulnar nerves and brachial artery lie under triceps along the humerus

use only for small volume (0.5-1 mL) injections dorsogluteal muscle: location of sciatic nerve varies between people; avoid using this

site because of high risk of sciatic nerve injury8. special types of IM injections 

o Z-track method indication: parenteral medications likely to harm or irritate tissue technique

after drawing up the appropriate medication amount, add a 0.2 mL airlock, change the needle to ensure the medication is not tracked into the SubQ tissue during needle insertion

select a large, deep muscle, e.g., ventrogluteal pull skin tightly down or laterally before injection inject medication and continue to hold tissue in position allow needle to remain in place for 10 seconds after injection withdraw medication and quickly release skin so that layers of tissue move over

needle track to "seal" the medication in placeo depot injection

intramuscular injection of a drug in an oil suspension that results in a gradual release of the medication over a period of time (from several days to weeks to months)

administer regular dose of agent first in controlled setting to prevent sustained allergic reaction

examples: Somatuline Depot (used to treat acromegaly) and Clopixol Depot (used to treat schizophrenia)

injection techniques, needle angle, landmarks, Z-track method

If a question asks what the client needs, use Maslow's hierarchy to help determine which need to address first.

8. Intravenous (IV)o flow rate dependent on stable cardiovascular statuso titration of dose

usually based on therapeutic effect and dosage/kilogram requires accurate calculations

o catheters 26 gauge (smallest) to 14 gauge (largest); 3/4 inch to 1 1/4 inch in length

24 gauge to 26 gauge suitable for neonates, children, delicate veins blood products require minimum of 22 gauge; larger is better because infusion

time and risk of occlusion decrease with increasing size winged needles are associated with high risk of infiltration 14 gauge is never inserted outside of the operating room

blood must flow around inserted catheter (but ease of flow and risk of phlebitis increase as size increases)

o complications of IV therapy insertion site: air embolism, bleeding, hematoma, site infection miscalculation of rate or incorrectly programming infusion control device IV solution: extravasation, infiltration, hypervolemia catheter: catheter dislodgement, malposition, migration, rupture; catheter-related

occlusion, thrombosis; infection, sepsis, catheter-related sepsis

View a video demonstration and find more information about IV insertion by visiting the Dalhousie Medicine Common Currency Project Web site.

5. locations for IV therapyo peripheral

insertion site: usually a peripheral vein in the arm; may be scalp or foot in infants

bedside procedure for insertion and withdrawal indications: short-term IV therapy

follow agency policy or discontinue after 72 hours insert catheter in new location if IV needed after 72 hours

uses short-term IV therapy medication: repletion of fluids and electrolytes; nutrition isotonic infusions, blood products, solutions not to exceed 10%

complications: thrombophlebitis, bleeding, infection, extravasation, infiltration, occlusion

nursing care monitor site for edema, redness, induration, drainage, paresthesia, pain,

temperature assess vital signs, breath sounds, I&O, peripheral edema, nutritional status

and possibly daily weight and compare to baseline data maintain dry, transparent occlusive dressing follow agency guidelines for documentation, reusing IV tubing, dressing

changes and types of dressings, insertion site changes6. non-tunneled central venous

o indications emergent situations and trauma lack of suitable peripheral veins short-term therapy, critical care, surgery

o procedure sterile procedure performed at bedside

place client in Trendelenburg position, with rolled towel between shoulder blades (potentially contraindicated for clients with respiratory conditions, spinal deformities, increased intracranial pressure)

subclavian, internal jugular or femoral veins used, with catheter ending in superior vena cavao size and appearance

can have up to 4 lumens or ports usually 6 to 8 inches in length

o dressing changes require using aseptic techniqueo unused ports must be routinely flushed with heparin solution and clampedo uses

hypertonic solutions vasoconstricting agents pressure monitoring fluid resuscitation

o complications : thrombophlebitis, bleeding, infection, extravasation, occlusion 7. peripherally inserted central catheters (PICC)

o smaller, longer (40 to 65 cm catheters) and more flexible than other central lineo procedure

sterile procedure performed at bedside inserted through a peripheral vein in the upper arm, usually either the basilica, cephalic or

brachial vein; catheter ends before superior vena cavao can stay in place for as long as a year if properly maintainedo must measure and document external length of PICC with each dressing changeo unused ports must be flushed with heparin solution and clamped

8. tunneled central venous catheters: part of the catheter is encased in subcutaneous tunnel; tissue granulates onto cuff surrounding catheter creating a barrier and anchor

o inserted surgically through the subclavian veino useful for frequent, long-term IV therapyo typically no dressing is required after cuff healso types

Broviac Hickman Groshong

o complications

5. implanted port (vascular access devices (VAD)

o surgically implanted o dense septum with reservoir and attached cathetero painful needle insertion: Huber (non-coring) needle must be used to access porto must always confirm needle placement before medication administrationo requires flushing after each use; unused port is flushed monthly with heparin solution

Comparison of Central Venous Catheters

  Non-tunneled Peripherally Inserted Central Catheter (PICC)

Tunneled Implanted Port

Insertion Procedure sterile (with client in Trendelenburg position)

bedside sterile surgical surgical

Dressing sterile sterile sterile none required

Insertion Site subclavian or internal jugular ending in superior vena cava

antecubital fossa or upper extremity; ends before superior vena cava

subclavian upper chest, upper extremity

Uses hypertonic solutions, vasoconstricting agents, pressure monitoring, fluid resuscitation

suitable for all infusions, long-term therapy

frequent long-term IV therapy

intermittent, long-term therapy

Unique Features triple lumen catheter used for monitoring

teach client to protect arm and care for insertion site

types: Broviac, Hickman, Leonard

access: Huber (non-coring) needle through silicone septum

Note: All central venous catheters require Luer-Lok connections and x-ray confirmation of tip placement before therapy begins.

View an online educational video about PICC lines from MayoClinic.com.

6. methods of IV administrationo continuous infusion - risk of fluid volume overloado infusion control device (pump) - preferred due to decrease risk of fluid volume overload

mechanical control of rate and volume types: syringe (small volume), peristaltic action, and microchamber verify volume infused without using pump indicators every hour

o IV push: administration by boluso secondary infusion (piggyback, rider, intermittent)o patient-controlled analgesia (PCA) pump

client has limited control of opioid dosing pump has prescribed dosing parameters including basal rate and bolus dose benefits

avoids delay of therapy avoids frequent IM injections

greater sense of client control lower incidence of respiratory depression when used with short-acting opioids

7. IV therapy solutions : used to replace fluids, electrolytes, and nutrients; also rapid administration of drugs

o isotonic crystalloid solutions - osmotic pressure similar to plasma; expands extracellular fluid without changing osmolarity

o hypotonic crystalloid solution - exerts less osmotic pressure than plasma; fluids shift into interstitial spaces and cells, causing cells to swell

o hypertonic crystalloid solution - exerts more osmotic pressure than plasma; osmosis pulls fluids out of the cells, causing them to shrink

o hypertonic colloid solutions - also expand intravascular volume plasma but colloids contain molecules too large to pass through semipermeable membranes

8. additional equipment for IV therapyo volumetric deviceo Luer-Lok: collared slip-lock that fits onto a female catheter hubo filter

place as close to insertion site as possible potentially rupture under excessive pressure various sizes (in microns) depending on solution removes particulate matter, microorganisms, and air

9. Intrathecalo types

spinal epidural: standard drug instillation and liposomal instillation of morphine

o direct administration of opioids and local anesthetic agents into epidural space or intrathecal spaceo benefits

lower systemic side effects lower dosing of therapeutic agents

o dose-dependent effects itching, nausea, vomiting respiratory depression, urinary retention

o adverse effects: delayed respiratory depression10. Intraosseous infusion

o percutaneous placement of intravenous catheter into a marrow cavity In adults, inserted in the tibia or sternum

in children, inserted in the proximal or distal tibia o used when peripheral blood vessels are collapsed or inaccessible

11. Ophthalmico preparation

wash hands and apply gloves - rinse powdery residue from gloves instruct client to recline or tilt head back instruct client to look up

o technique - eye drops

Instilling Eye Drops 

1. Wash hands and apply gloves; rinse powdery residue from gloves

2. Instruct client to recline or tilt head back

3. Instruct client to look up

4. Pull lower lid down and to the side

5. Apply drop at lower, outer aspect of eye (lower conjunctival sac)

6. Apply mild pressure to inner canthus for 1 minute to decrease systemic absorption

7. Instruct client to gently close eyes

8. Wait 2 to 5 minutes before instilling additional eye drop (in same eye)

o technique - eye ointment apply a thin line of ointment along the edge of the lower lid moving from inner canthus to

outer canthus instruct the client to gently close the eye and move the eye around

12. Otico ear drops preparation

warm medication ensure tightly sealed medication container run container under warm water

position client on unaffected side with affected ear facing up remove ear drainage or cerumen with cotton-tip applicator; avoid pushing cerumen into ear

canal open ear canal

In a child younger than age 3, pull the lobe down and back In a child older than 3 years, pull the pinna up and back

o instillation of drops fill dropper with medication hold dropper about 1/2 inch above ear canal gently squeeze bulb on dropper to instill prescribed number of ear drops instruct client to remain in place for 5 to 10 minutes repeat in other ear if necessary after waiting 5 to 10 minutes

o if cotton balls are prescribed - place in outermost part of ear canal and remove in 15 minutes13. Medication delivery

o Single dosing

bolus: a single dose administered IV, from a syringe (usually), and at one time STAT: give right away or immediately one-time: prescription is administered only one time loading dose: prescribed amount of medication

administered (usually larger than normal) at the beginning of therapy to establish a therapeutic blood level

administered as single or divided doses followed by maintenance therapy

o Intermittent dosing as needed (PRN) IV push: indicates a bolus of medicine in a syringe

it does not mean the medication is "pushed in"  the nurse must know the rate of the bolus injection and compatibility with IV solution

IV piggy-back: small volume IV containing a medication infused over short period of time o Continuous dosing

transdermal infusion system subcutaneous implant or pump IV infusion

continuous IV infusion titration of drip rate according to predetermined parameters within an acceptable

range based on amount/client weight/time14. Nursing responsibilities

o All medications must have a signed, provider prescriptiono Administer drug as indicated: typically allowed 30 minutes before through 30 minutes after

prescribed time to administer medication o Prior to administering a medication

know and understand medication incompatibilities verify drug safety in pregnancy and lactation review hepatic and renal function before administration obtain cultures before beginning anti-infective therapies know lab values or other test results prior to administration

o Individualize pharmacotherapy according to developmental stage or Erickson's Stages of

Development o Older adults

may retain lipid-soluble drugs longer serum levels of water-soluble drugs may be higher than normal

many medications may cause confusion in the elderly o Establish baseline data for monitoring medication effectivenesso Remain up-to-date on information about medications, including evidence-based practice guidelines

o Understand concepts, i.e., indications, naming of drugs, related to medication classification o Avoid distractions while dispensing and administering medication

Refer to the American Geriatrics Society's Beers Criteria 2012 for more information about medications that are potentially inappropriate for use in older adults.

10. Five rights of medication administrationo right dose: check medication label against the adminstration record

PATIENT SAFETY - Check medication label against the adminstration record three times while preparing the medication!1. When first taking the medication out of the container2. Just before opening the medication package or pouring the dose3. Just before replacing the container in the storage area or giving a unit dose to

the client

o right time: check facilities policies, usually 30 minutes before or 30 minutes after the ordered time

o right route: Check the medication order that the route is specifiedo right drug

proper mixing or dilution speed of infusion or push accurate dosage calculations

o right client check ID bracelet for client name and birth date (depending on facility, include bar code

check of ID bracelet) have client state full name and birth date verify information using medication administration report (MAR)

Learn more about the Five Rights of Medication Use from the Institute for Safe Medication Practices (ISMP).

11. Other rights of medication administration includeo right documentation

document immediately after medication is given on MAR or computerized medical record

document if client refuses medication include drug, time, dose, route, signature

o right assessment vital signs, ability to swallow, pain check client data, lab tests, and diagnostic studies before administration

o right education about the medication - important to stay up-to-date on medications expectations

o right evaluation, i.e., response to therapyo right to refuse medication

nurse should explain any problems associated with not taking a medication notify health care provider

o client privacy and client rights

Watch a video about the 10 Rights of Medication Administration.

Learn more about patient safety related to pharmacotherapy from The Joint Commission International Center for Patient Safety.

12. Medication errorso higher rate of medication errors associated with

high-alert drugs poor communication clients over the age of 60 years poorly written prescriptions, use of ambiguous abbreviations, and misunderstanding of

prescription's meaning prescribing errors - mistakes made by provider in prescribing drugs involving unsuitable

drug choices, dosing errors, incompatibilities, and contraindications failure to reconcile client medication list at client hand-offs most common nursing medication errors

incorrect dose, time, route, and client

multiple routes of administration for single drug on medication administration record (MAR)

o preventing medication errors perform medication reconciliation

reconcile medications at any client hand-off: admission, transfer, discharge, postoperatively, and at shift change

involves comparing the client's list of medications with the prescriptions may involve client and family in reconciliation

avoid distractions while dispensing and administering medication complete check of client's rights: dose, time, route, drug, and client check client identifiers on each page of MAR check client data, lab tests, and diagnostic studies before administration read medication labels three separate times

typical identifiers in acute care setting - follow agency guidelines check client wristband with name and medical record number ask client for first and last name; avoid revealing client's name to client 

clarify poorly written prescriptions; never attempt to interpret complete client admission assessment

history allergies identify the accurate list of client's medications

maintain up-to-date drug information clarify questions with research or consulting with the pharmacy refer to agency policy for administration guidelines

report medication errors and problems according to agency policy

Learn more about medication errors from The Institute for Safe Medication Practices.

NCSBN Learning Extension offers a continuing education course called Medication Errors: Detection and Prevention. To find out more about this course, or any of the other courses offered, visit the NCSBN Learning Extension Web site.

13. Client privacy and client rightso privacy

cover MAR (or reduce screen) except when needed to dispense medication close door to client's room or pull the privacy curtain to obscure viewing of procedures request visitors and family members leave the client's room during medication

administration except when allowed by client avoid discussing client medication except on a "need to know" basis

o confidentiality avoid sharing information about client's medications except on a "need to know" basis avoid associating medications or medication related information to client in public areas

o informed consent provide information on medications dispensed before initial dose and during therapy

indications therapeutic or anticipated effects adverse effects risks of accepting or refusing therapy

reinforce client teachingo self-determination: client may refuse a dose of a medication or the entire course of therapy

without coercion or threats of retribution14. Client teaching

o do not crush or chew tablets unless directed to do soo discuss cutting pills with provider before doing so

managed care and insurance companies encourage pill-cutting as cost-cutting measure may result in decreased therapeutic effect or serious adverse effects cutting pills

purchase commercial pill cutter cut one tablet at a time to maintain potency ask provider to prescribe double-strength, scored tablets suitable for pill-cutting do not cut capsules, enteric-coated, sustained-release, or extended-release tablets

or capsules verify double-strength dosage form on drug label: make sure that one-half of a

double-strength tablet is the correct prescription strengtho provide drug information

name, dose, and indication administration guidelines storage resources for client and family

o prescribed dose and administration guidelines adverse reactions may subside after 4 to 6 weeks of therapy

side effects and toxicity report worsening symptoms symptom recognition and findings to report

comfort measures for symptom relief administration guidelines

foods to avoid, timing around meals dosing schedule and length of therapy preparation of drug before administration

take as directed until directed to change continue to take, even when feeling better store drugs properly: light, heat, moisture

15. monitoring and follow-up care16. avoid taking over-the-counter (OTC) drugs or call health care provider before taking17. notify other providers about drugs on medication profile (complete list of client's drugs) including

o minerals, vitaminso diet pills, over-the-counter drugso contraceptive drugs or devices, laxatives, and sleeping aidso herbal supplements

safe use involves provider notification potential benefits

client empowerment potential therapeutic effect

potential dangers toxicity purity of supplement adverse effect on prescription drug action, e.g., make prescription medication less

effective aggravation of hypertension, potassium imbalance, coagulopathies, allergies

18. Internet and international purchase of drugs and dietary supplementso counterfeit drugso unreliable purityo therapeutic equivalentso differing trade names and similar names

Learn more about medication safety and up-to-date drug information from the Food and Drug Administration (FDA).

15. Client safetyo identify and manage hazards related to pharmacotherapyo instruct client to avoid driving and performing hazardous activities until drug effect is well

establishedo safety

chemical avoid over-the-counter (OTC), herbal, and other nonprescription remedies carefully review drug profile when adding or deleting a drug from the list

physical: orthostatic hypotension, stairs, shaving, etc.o avoid administering drug with known client...

hypersensitivity pregnancy or lactation

balance of risk versus benefit some drugs used to preserve life of mother most drugs are contraindicated due to risk for fetus pregnancy categories

A: no risk to fetus in the first trimester B: may or may not show risk in animals, no risk shown in human studies C: risk shown in animals, insufficient data in pregnant women D: demonstration of human risk in selected clinical studies X: clear demonstration of risk to human fetus

hepatic or renal dysfunction

16. Total Parenteral Nutrition (TPN): Nursing Care of Clientso Nutritional support

Nutritional deficiency clinical indications for hyperalimentation include clients who

cannot use GI tract for absorption of nutrients require nutritional therapy to maintain or improve nutritional status have risk factors for malnutrition

1. body mass index for height and age below average2. admission to hospital, nursing home, rehabilitation facility3. anorexia, nausea, vomiting from agent, event, or condition4. inadequate nutritional intake, increased nutritional loss, or increased

metabolic rate unsuitable for health maintenance5. impaired ability to prepare, obtain, or eat food

1. substance abuse, older clients2. low socioeconomic status, educational deficiencies3. dysphagia, infection, multiple chronic illnesses, trauma

clinical indicators of malnutrition gold standard: pre-albumin below normal (protein deficiency) other labs: low hemoglobin, transferrin, cholesterol, total lymphocytes physical findings

1. gums and teeth in poor repair2. reddened and open areas, susceptibility to infection3. dull, dry eyes, nails, skin, hair, inadequate muscle bulk

Included on the Institute for Safe Medication Practices (ISMP) List of High-Alert Medications is all total parenteral nutrition solutions.

2. Hyperalimentationo partial parenteral nutrition

indications: central line contraindicated, prolonged postoperative ileus infusion

via large peripheral IV solutions

isotonic lipid emulsion - may be administered with IV solution hypertonic amino acid and dextrose solution

o total parenteral nutrition long-term intensive nutritional support for

trauma, major surgery, hypermetabolic state

GI impairment: inflammation, malabsorption, obstruction, side effects of chemotherapy

hyperalimentation solution contains hypertonic dextrose and amino acid solutions

25%-35% dextrose 3%-5% amino acids 10%-20% lipids

infuses via central venous catheter in subclavian or internal jugular vein includes electrolytes, minerals, trace elements, and insulin added by pharmacist prepared under strict aseptic technique

benefit individualized according to client need provides protein-sparing action: calories supplies amino acids for tissue repair and healing delivers all nutrients with lower risk of fluid overload than nutritional equivalent of

standard IV therapy

o complications from central venous catheter o selected complications from TPN solution

infection: solution provides breeding ground for microorganisms fluid imbalance

hypertonic solution infuses directly into venous circulation fluid shifts occur due to

hyperosmolar nature of solutions rapid infusion without sufficient insulin, with hyponatremia or

hypokalemia3. Nursing care

o Establish baseline data and monitor vital signs, SaO2, right atrial pressure

blood urea nitrogen (BUN), creatinine, liver function tests, pH

glucose monitoring (Accu-Chek®) minimum once a shift (due to impairment of glucose metabolism)

hyperglycemia: nausea, weakness, thirst, headache, tachypnea hypoglycemia: diaphoresis, tachycardia, hunger, trembling, confusion

fluid volume status: daily weight, intake & output every shift, edema, breath sounds nutritional status: skin, serum electrolytes, glucose, cholesterol, triglycerides infection: temperature, white blood cells, insertion site other: neurologic status refeeding syndrome (first 24 to 48 hours of therapy): bradypnea, lethargy, confusion,

weaknesso TPN intravenous system is NOT to be used for central venous pressure monitoring, withdrawal of

blood, IV "piggyback" infusions of medications, or IV bolus injection of drugso Prevent complications

rebound hypoglycemia: withdraw TPN slowly microemboli: use 0.2 µm-filter (except with lipid emulsion) administer solution at a constant rate and do not flush or irrigate the system injury: check expiration date of solution, verify TPN order hyperglycemia: verify insulin coverage, check blood glucose frequently acidosis: maintain tight glycemic control, encourage coughing and deep breathing infection

avoid contamination from oily skin or tracheostomy insert catheter with surgical asepsis refrigerate until 30 minutes before using, discard after 24 hours sterile dressing change, use aseptic technique, change tubing daily

fluid shifts, hypervolemia, osmotic diuresis do not increase infusion rate maintain tight glycemic control verify volume infused with time strip

start infusion slowly and titrate to client tolerance administer 10% dextrose if TPN infusion is interrupted carefully control infusion rate, carefully program infusion device

air emboli use Luer-Lok connections cover site with occlusive dressing clamp tubing when changing solution or tubing may need to position client in supine position or ask client to perform Valsalva

maneuver4. Client teaching for home therapy

o review purpose and procedureo verify written instructions for all procedures, troubleshooting, and complications, review procedures

and equipment record keeping infusing solution ordering supplies glucose monitoring

o verify aseptic techniqueo verify temperature in refrigeratoro review clinical indicators of infection, hypo- and hyperglycemia, hypervolemia, air embolism

When reviewing course content, spend time reading the rationales of the practice questions that you get right and the ones you miss. This is a good action to take when you have low energy levels. If you do not understand the rationales, refer to the text to clarify the subject matter.

3. Blood Product Administrationo Administration of blood and blood products

Blood products: red blood cells (RBCs) washed RBCs: RBCs washed with sterile saline before administration;

removes some immunoglobulins and proteins packed RBCs: blood cells are separated from plasma and platelets,

decreases risk of fluid overload autologous blood transfusion leukocyte-poor RBCs: removal of most leukocytes, fewer RBCs than packed

RBCs Plasma

serum albumin immune serum globulin factor concentrates: factors VIII and IX fresh frozen plasma: contains coagulation factors cryoprecipitate: clotting factors VII and VIII

Other blood components platelets

RhoGAM ® granulocytes

4. Purpose and method(s)o Restore blood volume

provide albumin normal serum albumin plasma protein fraction

increase oncotic pressure serum albumin red blood cells

o Increase oxygen-carrying capacity

increase hematocrit: red blood cells increase hemoglobin: red blood cells

o Enhance immunologic defense provide immunological factors

immune serum globulin granulocytes

prevent Rh-sensitizationo Enhance hemostasis

provide clotting factors cryoprecipitate fresh frozen plasma

provide platelets apheresis packs random donor packs

5. Transfusion reactions & risks associated with transfusionso Allergic reaction

most common type of reaction findings: hives and itching

may be treated with antihistamines, e.g., diphenhydramine (Benadryl)o Febrile reaction

a reaction to the white blood cells in the donated blood more common in clients who have had previous transfusions and in multi-para women findings: fever within 24 hours of the transfusion, including headache, nausea, chills, or a

general feeling of discomfort

may be treated with antipyretic, e.g., acetaminophen (Tylenol)o Transfusion-related acute lung injury (TRALI)

may occur with any type of transfusion but more common with fresh frozen plasma or platelets

more common in clients who are gravely ill findings: trouble breathing, often within 1 to 2 hours of starting the transfusion but may begin

up to 72 hours post transfusion findings are often under-recognized (which leads to a delay in treatment and an increased

mortality rate)o Acute hemolytic reaction

rare, but most serious type of transfusion reaction occurs when donor and client blood types do not match usually the result of human error, e.g., mislabeled pre-transfusion specimen, transfusion of

properly labeled blood to the wrong person, clerical errors findings: chills, fever, chest and lower back pain, nausea progressing to hypotension,

bronchospasm, vascular collapse and disseminated intravascular coagulation (DIC)o Delayed hemolytic reaction

this reaction involves the body slowly attacking the antigens on the transfused blood cells findings

usually none, but may develop fever 4 to 8 days, up to 1 month, after blood transfusion

lab findings include falling hematocrit and a positive direct antiglobulin (Coombs) test more common in clients who have had previous transfusions

6. Graft-versus-host disease (GVHD)o occurs in severely immunocompromised clients o white blood cells in a transfused blood product attack client's tissueso more common when a relative or someone with the same tissue type has donated bloodo findings: within a month of the transfusion, the client may have fever, liver dysfunction, rash,

diarrhea, pancytopeniao high mortality rate

7. Non-immune hemolysiso lysis of RBCs due to improper storage, handling, or transfusion conditionso findings: may include hemoglobinemia and hemoglobinuria

8. Disease acquisitiono bacterial

more common in platelets since they must be stored at room temperature, allowing bacteria to grow quickly

sepsiso viral (including Hepatitis B & C, HIV)o babesiosis, malaria, Lyme disease, syphilis, Chagas disease, Creutzfeldt-Jakob disease can be

spread by blood product transfusions9. Hypotension

o findings: a drop of at least 10 mm Hg in systolic or diastolic arterial blood pressure in the absence of other findings of transfusion reactions

o may be associated with use of angiotensin converting enzyme (ACE) inhibitor drugs10. Post-transfusion purpura (PTP)

o findings: thrombocytopenia, usually profoundo typically occurs 7 to 48 days after transfusion

11. Circulatory overloado caused by the infusion of blood at a rate too rapid for the client to tolerateo findings: dyspnea, orthopnea, tachycardia, sudden anxiety, progresses to pulmonary edema if

transfusion is continued

o diuretics given after or between transfusions to clients at risk of, or already in, circulatory overload

12. Avoiding transfusion reactions: screening blood donorso volunteer donors preferred - paid donors less likely to report past or present diseaseo screen for

infectious disease: hepatitis, HIV, tuberculosis, syphilis, malaria, international travel, residence in United Kingdom between 1980-1996

blood diseases, abnormal bleeding hypotension, anemia, jaundice, fever high risk behavior: male homosexual or bisexual malignancy, disease of heart, lungs, liver, allergies recent pregnancy, surgery, blood transfusion, vaccinations with attenuated virus, recent

piercings, recent tattoos 13. Nursing interventions

o Guidelines for administration signed consent forms required for blood administration retrieve the blood from the blood bank area together with another RN, compare the blood and the crossmatch slip from the blood bank

and compare data with the client's ID bracelet - verify client's name, ID number, blood type and Rh factors, donor number on the blood container and expiration date

establish baseline data and monitor (follow agency policy for frequency and duration) vital signs, SaO2, and check skin after first 15 minutes of transfusion, during

administration (as per policy), and 1 hour post transfusion  breath sounds, crackles, dyspnea, jugular vein distention

hemoglobin (Hgb) and hematocrit (HCT), urine output; serum potassium, calcium, and creatinine

prime intravenous tubing with normal saline for whole blood administration (never use dextrose solutions - may cause clumping of RBCs) and ensure the insertion site is patent

initiate transfusion slowly for 15 to 20 minutes remain at bedside question client about unusual feelings monitor vital signs every 5 minutes or follow agency policy

general benign hives may occur return transfusion record to blood bank when infusion is complete most reactions

1. are due to human error2. occur within the first 15 minutes of a transfusion

3. treat client symptomatically4. notify provider and blood bank

14. Preventing complicationso carefully verify documentation related to blood productso do not remove blood product tags or identificationo infuse transfusion at prescribed rate or follow agency policy

note volume of individual blood unit infuse via infusion control device

Blood or Blood Product Timeframe for Infusion

whole blood and packed red blood cells (about 250 mL/unit) infuse within 2 to 4 hours

platelet concentration (about 300 mL/unit) - infuse within 15 to 30 minute/unit infuse within 15 to 30 minute/unit

fresh frozen plasma (about 200 mL/unit) infuse within 30 to 60 minute/unit

albumin 5% (250 mL to 500 mL bottle) infuse 1 to 10 mL/minute

albumin 25% (50 to 100 mL bottle) infuse 4 mL/minute

o restrict use of refrigeration to that approved by blood bank do not store blood in the refrigerator used for food initiate transfusion within 30 minutes of removal from blood bank complete transfusion in 4 hours after removal from blood bank

o collaborate with provider to use autologous blood or autotransfusion premedicate with steroid or antihistamine notify blood bank of transfusion reaction to increase scrutiny of cross-match administer 10% calcium gluconate for hypocalcemia with continuous cardiac monitoring consider use of washed, filtered, irradiated, apheresis separated, or leukocyte-poor blood

products after a transfusion reaction15. Client teaching

o ensure informed consent of cliento provide information about contracting infections from bloodo provide information about administration method, monitoring, duration of transfusion, symptom

recognition and reporting such as chills, flushing, headache, chest and back pain, nausea, fever, tachycardia,

o add history of immunologic or non-immunologic transfusion reaction to client database16. Nursing care for transfusion reaction

o immediately stop transfusion, take vital signs clamp IV tubing and disconnect at hub of catheter - return entire administration set and blood

bag to blood bank (or follow agency policy) do not allow additional blood to enter client's system, do not flush tubing with saline to clear for findings of circulatory overload (cough, shortness of breath, crackles, hypertension,

tachycardia, distended neck veins)... place client with high Fowler's position, administer diuretic and oxygen as needed, monitor I &O

for findings of sepsis (including rapid onset of chills and fever, vomiting, diarrhea, hypotension, shock)... obtain blood cultures, send blood transfusion bag for analysis and treat sepsis with antibiotics, IV fluids, vasopressors, and steroids

o collaborate with provider for pharmacologic treatment

supplemental oxygen diuretics antibiotics antihistamines glucocorticoids

o monitor hemoglobin and hematocrito complete transfusion reaction form

17. Dosage Calculationso Ratio and proportion - used for calculating solid, liquid and injectable dosages

Equation description each side of the equation represents the same proportion, percentage, or ratio example: 75%

1. equal proportions:

2. equal percentages: 75% = 0.753. equal ratios: 3:4 = 7.5:10 = 75:100

both sides of the equation represent an equal relationship but are expressed with different quantities; the two sides matchTo figure the calculation, multiply the means (numbers that are closet to each other) by the extremes (numbers that are the farthest from each other). You are solving X, so X goes first.

Use a proportion equation to solve dosage calculations metric to metric conversion

1. involves multiples of 10, 100, or 10002. grams :   milligrams   : micrograms     (1 x 1000 x 1000)

1. 1 gram (g) = 1000 milligrams (mg)2. 1 mg = 1000 micrograms (mcg)3. 1 g =1,000,000 mcg

3. mcg   : mg   : grams     (1 ÷ 1,000 ÷ 1,000)1. 1 mcg = 0.001 mg2. 1 mg = 0.001 gram3. 1 mcg = 0.000001 gram

4. liters   : milliter     (1 L = 1,000 mL) 5. milliliter   : liters     (1 mL = 0.001 L)

applicable to other metric conversions18. Dosage calculation: solve for x using a proportion problem

o step one: set up proportion problem advantage: proportion problems are easy to set up both sides of equation must match: display an equal relationship of the factors (mg and tabs) first method

one side of the equation is  what you have 1. the pharmacy stocks 20 mg tabs - what you have: 20 mg = 1 tab

the other side of the equation is  what you want  1. the nurse wants to administer 40 mg; how many tablets does that require?2. what you want: 40 mg = x tabs

second method make the equation match by placing each factor on opposite sides

1. one side of the equation is a factor2. the other side is the second factor

make the equations match1. use  what you have  as the numerator on opposite sides2. use  what you want  as the denominator on opposite sides

the left side of the equation displays the relationship of the factor  mg  according to

the right side of the equation displays the relationship of the factor  tablets according to

the answers for the equations in method 1 and 2 are the same19. step two: cross multiply and divide

oo 1 (40) = x (20)o 40 = 20x

o

oo [of furosemide (Lasix) 20 mg equals a 40 mg dose]

o carefully apply the desired unit of measure to the solution

Example: The client with heart failure receives furosemide (Lasix) 40 mg by mouth daily. The pharmacy stocks furosemide 20 mg tablets. How many tablets does the nurse administer for a 40 mg dose?

4. Dosage calculation: solve for x using dimensional analysis (DA)o advantage: only one equation usedo sample problem to solve using dimensional analysis: the client receives 300 mg phenytoin

(Dilantin) by mouth daily for seizures and the pharmacy sent phenytoin 125 mg/5 mL suspension. How many mL of suspension will the nurse administer?

o set-up DA equation left side of the equation

what you are solving for (what you want) x  mL of suspension

right side of the equation available information related to unit of measure on the left side of equation: what

you know about  mL  (what you know) written as a fraction

place this information on the right side of the equation so the unit of measure from the left side appears as the denominator on the right side

allows the unit of measure (mL) to be cancelled-out in the example, the unit of measure on the left side of the equation is mL mL  must then be the numerator on the right side

find the remaining information matching the unit of measure used in the numerator in the example, this information is the prescription this information is:

place this information in the equation so the mg cancel-out

mg cancel-out

x = 12 mL/day of phenytoin elixir

5. Metric conversiono metric to metric

0.001 kg = 1 gram = 1000 mg = 1,000,000 mcg 1 mcg = 0.001 mg = 0.000001 gram 1000 mL = 1 liter, 1 mL = 0.001 liter

o metric to other 2.5 cm = 1 inch 1 kg = 2.2 lbs 1 gram = 15 grains

1 grain = 60 milligrams 30 mL = 1 ounce = 2 tablespoons

o metric to apothecary 1 mL = 15 minims = 15 drops (gtts) 5 mL = 1 fluid dram (dr)= 1 tsp

2 Tablespoon = 30 mL= 1 oz = 8 drams6. Temperature conversion

o Celsius =

o Fahrenheit =

3. Weight based dosage calculation

The child weighs 68.2 pounds. The nurse must administer amoxicillin (Amoxil) by mouth at 30 mg/kg/day in divided doses every 6 hours. How much amoxicillin does the nurse administer each day? How many milligrams of amoxicillin does the nurse administer for each dose?

o Step one: convert the weight in pounds to kilograms (1 kilogram = 2.2 pounds)

o Step two: how much amoxicillin does the nurse administer each day? insert weight (kg) into dosage equation

the nurse administers 930 mg/dayo Step three: how much amoxicillin does the nurse administer for each dose?

calculate doses/day

divide total daily dose by the number of doses

check your answer total daily dose

dose = prescription

4. Intravenous calculationsThe nurse prepares vancomycin (Vancocin) 500 mg IV in 250 mL of normal saline to infuse over 2 hours. What is the administration rate in mL/minute?

o Useful equations for calculating administration rate

administration rate expressed as

volume for 1 minute:

o The prescription is linezolid (Zyvox) 600 mg IV in 300 mL of D5W to infuse over 2 hours. The IV tubing drip rate = 10 gtts/mL. What drip rate should the nurse use?

Determine hourly rate

Convert 1 hour to 60 minutes, and determine mL/minute

determine drops/minute Drip rate of IV tubing = 10 gtts/mL Multiply (units/min) x gtts/mL

3. IV flow rate using DA

The client receives epinephrine (Adrenalin) 0.25 mcg/min IV via infusion pump. The pharmacy sent epinephrine 0.1 mg in 250 mL of normal saline. What rate in mL/hr will the nurse use to program the infusion pump?

o left side of the equation: what is being solved for (what you want)x = mL/hr

o right side of the equation: what is available (what you have)

first section since x = mL/hr, the numerator in this section must be mL the information attached to mL in the example is the epinephrine solution: 1 mg

in 250 mL second section: the example asks for  mcg  , so mg must be converted to mcg third section:the example asks for we have a prescription for

need to cancel-out mcg and relate the answer to time insert prescription into equation: is what we have, what is available

fourth section: convert minutes to hours check the equation: all units of measure should cancel-out except for those that solve for

x in the example: x =

mg: cancel-out mcg: cancel-out min: cancel-out remaining units of measure: mL and hr

3. standard equation for IV flow rate

o place information about epinephrine above into equation

o the solution was sent in mg, convert mg to mcg

Points to RememberSafe Drug Administration

Gather general baseline datao vital signso laboratory resultso allergieso co-morbiditieso height and weighto liver, pulmonary, renal, neurologic, nutritional and hydration status

Identify client factors: affects on drug action due to age, cultural factors, past history Determine purpose of therapy

o indication for drugo desired therapeutic outcome

Reconcile medication profile - with client, family, nursing staff, provider Verify prescription and client

o doseo timeo calculationso dosing rangeo dispensing method

Monitor client response: therapeutic effect, adverse effects, toxicity Document findings and act on data requiring action or follow-up nursing care Document nursing care: before, during and after administration Evaluate care and process: medication errors, problems for others, agency benefit Instruct client and family about drug

o what to reporto how to administero food, substances, or activities to avoido need for follow-up care and testing

Points to Remember 2Prevent or Minimize Common Adverse Effects of Drug Therapy

Nausea, vomiting, anorexiao collaborate with provider for antiemetic; eliminate triggers; maintain NPO statuso assess and monitor fluid and electrolytes balance, bowel sounds and elimination pattern,

food intakeo teaching: small, frequent meals; breathing techniques; how to avoid triggers

Constipationo provide fluid, fiber, stool softeners; encourage ambulation

o monitor bowel sounds and pattern of elimination; review diet for fluid, fibero teaching: increase fluids and fiber; ambulate; establish regular bowel habits

Diarrheao provide hygiene, skin care; supervision to prevent injuryo assess and monitor bowel patterns, fluid and electrolyte balance, strength/weakness, skin

integrity; obtain cultures if indicatedo teaching: increase fluid intake, wash hands, avoid irritating foods

Rash, allergic reactionso screen for allergies, previous reactions, provide skin careo assess and monitor airway, breathing, blood pressure; skin integrity, indication of pruritus;

obtain cultures if indicatedo teaching: report dyspnea, pruritus, hives, worsening condition

Hypotension, dizzinesso maintain supine position during period of dizziness; encourage fluids, review medication

profileo monitor vital signs, SaO2, EKG, level of consciousness, urinary output o teaching: remain in bed; ask for help to stand; avoid alcohol or sedation

Medications causing confusion in the elderly

Points to Remember 3The following is a list of adverse effects associated with drug classes or types and associated nursing interventions

and client teaching

Antihypertensives: orthostatic hypotension, fluid and electrolyte imbalanceo Nursing interventions: assist with activity; eliminate drug interactions, vasodilators, central

nervous system depressantso Monitor: blood pressure for hypotension if they are taking a diuretic also, pulse, breath

sounds, serum electrolyte levels, edema, dizzinesso Client teaching: get help to stand, report dizziness; avoid alcohol, sedatives, over-the-counter

agents, caffeine, change positions slowly. Reinforce client to take blood pressure and pulse daily.

Anticholinergic agents: dry mouth, constipation, blurred visiono Nursing interventions: provide sips of water and oral care; assist with activity; remove

environmental hazardso Monitor: bowel pattern, vision, oral mucous membraneso Client teaching: frequent oral care, avoid dangerous activity, ask for help to stand

Anticoagulants and anti-platelet agents: bleedingo Nursing interventions: minimize invasive procedures, shaving; provide gentle oral care; assist

with activityo Monitor: bleeding, coagulation tests, complete blood count, bruising; remove adverse drug

and food affectso Client teaching: avoid dangerous activity, wear MedicAlert® identification, avoid NSAIDs,

alcohol, avoid eating food rich in vitamin K Anticonvulsants: CNS depression, myelosuppression: infection and bleeding

o Nursing interventions: assist with activity; protect airway, breathing; minimize invasive procedures

o Monitor: seizure activity, complete blood count with differential, temperature, regional redness, swelling, or drainage, monitor liver functions tests

o Client teaching: wear MedicAlert® identification, avoid dangerous activity, wash hands, avoid crowds, need for follow-up care and testing, avoid alcohol

Antidysrhythmics: new or more dangerous dysrhythmias, changes in blood pressureo Nursing interventions: maintain fluid and electrolytes balance, SaO2 >95%, sinus rhythm;

assist with position changes

o Monitor: pulmonary function test, ECG, blood pressure, pulse, SaO2, serum electrolytes, level of consciousness 

o Client teaching: ask for help to stand; report irregular pulse and technique for counting pulse, call doctor if the client develops palpitations, weakness, loss of appetite

Antiinfective agents: renal and hepatic dysfunctiono Nursing interventions: obtain cultures  before  administration, verify administration guidelines,

screen for renal and hepatic dysfunction, allergy, nephrotoxic or hepatotoxic drugso Monitor: renal function tests, liver function tests, jaundice, dark stool or urine, nausea and

vomitingo Client teaching: report nausea, vomiting, dark stool or urine, jaundice; need for follow-up care

and testing, reinforce take all medications as prescribed, report any allergic reaction, report sudden weight gain as this may indicate adverse effects on the kidney

Loop, thiazide diuretics: circulatory collapse, myelosuppression, fluid and electrolytes imbalance, ototoxicity

o Nursing interventions: verify infusion guidelines, blood pressure, serum electrolytes, and urinary output before giving

o Monitor: serum sodium and potassium, breath sounds, edema, blood pressure, urinary output 

o Client teaching: report palpitations, weakness, irregular pulse, decreased urinary output, temperature

Female hormones: thromboembolic disorders, increased risk of breast and endometrial cancer, hyperglycemia, hypercalcemia, depression, seizures

o Monitor: peripheral perfusion, edema; leg pain, tenderness; serum calcium, glucose, cytologyo Client teaching: report lumps and abnormal bleeding, muscle twitching

Medications causing confusion in the elderly

The following is a list of commonly used abbreviations you may find used in this course. Commonly Used Abbreviations

Abbreviation Definition

BP blood pressure

BUN blood urea nitrogen

Ca++ calcium

CBC complete blood count

CNS central nervous system

COPD chronic obstructive pulmonary disease

ECG (or EKG) electrocardiogram

GI gastrointestinal

gtt (gtts) drop (drops)

hr hour

Abbreviation Definition

INR international normalized ratio

IV intravenous

IVPB intravenous piggyback

K+ potassium

Kg kilogram

L liter

lb pound

LFT liver function tests, such as alanine transferase or bilirubin

LOC level of consciousness

mcg (or µg) microgram

mg milligram

MI myocardial infarction

min minute

mL milliliter

mm millimeter

Na+ sodium

NEB nebulizer

neuro neurological

NPO nothing by mouth

NSAID nonsteroidal anti-inflammatory drug

OTC over-the-counter

PEARLA pupils, equal, round, reactive to light with accommodation

PFT pulmonary function tests

PO by mouth

Abbreviation Definition

PT prothrombin time

PTT (aPTT) partial thromboplastin time (activated partial thromboplastin time)

RBC red blood cell

RFT renal function tests

SaO2 oxygen saturation of plasma

tab tablet

VS vital signs

WBC white blood cell

Wt weight