DOMINICA STATE COLLEGE Faculty of Health Sciences

ASSOCIATE OF SCIENCE GENERAL NURSING

PHARMACOLOGY HSC132

INDIVIDUAL ASSIGNMENT

Presented to Mrs. L. CASEY STEADMAN By Rebekah R. Roberts 10BROR00498

18.11.2011

CONTENTS

ACKNOWLEDGEMENTS SCENARIO/ ASSIGNEMNT QUESTION BODY REFERENCES

3 4 6 17

ACKNOWLEDGEMENTS
For assistance in making this assignment what it is, the student would like to thank all the persons who assisted her in any form. The student is extremely grateful and sincerely appreciative of your assistance and is therefore obliged to you.

The lord has guided and assisted the student throughout her life, giving her wisdom, strength and courage. And as such she recognizes that all good that she is and produces is a manifestation of his glory and bountiful blessings.

SCENARIO
Kylie Thomas is a 19 year old student who had an appendectomy 8 days ago and has been readmitted with a wound infection. Kylie is an insulin dependent diabetic, with a history of epilepsy that is controlled by carbamazepine, 600mg BD. Kylies wound is oozing and she is febrile. She complains of abdominal pain and of nausea. Her blood sugar level is 275mg/dL. She is seen by the doctor who orders: Soluble insulin 10 units stat and then as per sliding scale on medication sheet. Collection of wound swab IV therapy of normal saline 1 litre to be administered over six hours via giving set with a burette. y y y IV antibiotics of Ampicillin 300 mg given QID for 24 hours. IM pethidine 75 mg and IM metoclopramide 10 mg PRN/QID for 48 hours Oral paracetamol 1 g QID/PRN for 48 hours.

y y y

Kylie is discharged on day five on amoxicillin 500mg TDS for 1 week. Write an essay in which you discuss the management of the clients care focusing on the nurses role in quality use of medications. Include in the essay: 1. Discuss the principles surrounding the collection of the wound swab and the commencement of the IV antibiotics. 2. Explore the processes relating to the administration of the IV antibiotics and IV therapy, with an emphasis on safety and best practices.

3. Calculate the (a) flow rate of the IV infusion. (b) Drop rate using the following flow factors. (i) 10 gtt/mL (ii) 15gtt/mL

4. Discuss the principles involved with administering the IM pethidine to Kylie; include the ethical, legal, professional and safety issues involved. 5. Develop a health teaching plan that can assist Kylie to correctly manage her discharge medications (carbamazepine, amoxicillin and soluble insulin.

BODY
Administration of medications is an important aspect of nursing care and one that can be either detrimental or valuable to the patients recovery. Use of medications as treatments for disease conditions can be very effective when prescribed and administered correctly. The use of these pharmacological methods along with non-pharmacological and nursing interventions ensures holistic and comprehensive care for the patient. The combined use of these methods ensure the best care possible leading to quick recovery, reduced anxiety and increased acceptance by the patient of the disease and health condition. In using medications and administration of drugs, the student would take several factors into consideration. The client, in this case Kylie, should be respected as an individual and her consent should be obtained before any treatment is given or medication is administered. The student recognizes that she should co-operate with other members of the medical team in direct contact with Kylie and her case to ensure the best care possible for Kylie. Professional knowledge should be maintained and confidential information should be protected to ensure trust with Kylie. In treatment and medication administration the student should and will act to identify and minimize the risks of provision of care to Kylie and other members of staff. In the medication administration, the student has taken into consideration the indications, contraindications, adverse effects, dosage and administration of the prescribed drugs and advice to the patient upon discharge to assist her in proper

medication use. The medications that Kylie have been prescribed are; carbamazepine, regular insulin, Normal saline, Ampicillin, pethidine, metoclopramide, oral paracetamol and amoxicillin. These drugs are respectively used for the treatment of partial and secondarily generalized tonic-clonic seizures, diabetes Mellitus 1, fluid deficit, bacterial infections, severe pain, gastric stasis, fever and bacterial infections. These drugs can have several side effects such as drowsiness, fatigue, depression, visual disturbances, rashes, diarrhoea and hypersensitivity. In the case of amoxicillin and carbamazine; these medications cause Gastrointestinal tract disorders, that the student has researched, is dealt with by taking metoclopramide, one of the drugs prescribed for Kylie, for which precautions should be taken since she is diagnosed with seizures.

DISCUSS THE PRINCIPLES SURROUNDING COLLECTION OF A WOUND SWAB AND COMMENCEMENT OF IV ANTIBIOTICS.

For collection of a wound swab several things must be done, before, during and after the procedure. Specimens taken from wounds can harbour many microorganisms. In the case of Kylie, who has undergone an appendectomy a few days ago, the micro organisms wound most likely be some such as streptococcus faecalis, Escherichia coli, clostridium perfringens and other gram negative bacilli. Material from the infected wound will be able to reveal a variety of microorganisms, both aerobic and anaerobic, but mostly anaerobic as they are consistently present in the gastrointestinal tract and are likely to invade other parts of the body such as the peritoneum. This would be present in Kylies case, where she has post-operative wound drainage.

In taking a wound swab the universal precautions should be taken, such as asepsis (in this case surgical), informing the patient of the procedure and seeking consent. Patients stress, anxiety or fear should be alleviated by stress reduction strategies and encouraging communication. Administer pain medication as needed, as ordered. Privacy should be provided for the patient. Conditions that could affect the testing process, as well as the outcomes (diabetes mellitus 1) should be identified beforehand. The procedures should be followed correctly to prevent contamination of swab and ensuring correct diagnosis. The wound should be irrigated with sterile saline to reduce the risk of introducing superfluous organisms into the collected specimen. Irrigation should be done until all visible debris has been washed away. Sterile gauze should then be applied to absorb excess saline and to expose the culture site. The margins of the wound should be separated while wearing sterile gloves. The swab should be pressed and rotated several times over the clean wound surface to extract tissue fluid containing potential pathogens. The swab should then be immediately placed into the appropriate transport container. The specimen should be labelled properly with the date and time of collection, anatomic site or source of the specimen, type of specimen (postsurgical wound), examination required, patients diagnosis and current antibiotic therapy.

When IV antibiotics are to be commenced several points must be taken into consideration.

Clinical examinations should be done along with blood cultures taken from the central line if central venous catheters are present. Assessment of the client should be done and the potential IV site should be assessed. The patient should be given a test dose to assess the effects on the body before the administration of the IV medication is given.

EXPLORE THE PROCESSES RELATING TO THE ADMINISTRATION OF THE IV ANTIBIOTICS AND IV THERAPY, WITH AN EMPHASIS ON SAFETY AND BEST PRACTICES. Intravenous method of drug administration includes the injection of quantities of a therapeutic fluid such as blood, plasma, saline, glucose or other drugs directly into somebodys vein at an adjustable rate. Antibiotics are a class of drug designed to work against bacteria. They can either actively kill bacteria to stop an infection or they can interfere with bacterial reproduction. Delivering antibiotics intravenously means that the drugs act quickly, this can be critical in an emergency situation. When IV therapy or drugs are being administered safety and best practices should be emphasised to ensure the best care possible for the patient and safety to other patients and members of staff. Intravenous antibiotics are usually administered through an intravenous catheter connected to an infusion pump. The medications can be injected directly into the catheter, or injected into a bag of sterile saline solution for a slow infusion into the bloodstream. The delivery method depends on the patient and the medication in question.

Before any drug is administered several things must be done to ensure safety and to follow procedures. As with all aspects of care the nursing process must be used. The student is aware that she should assess the patient for any diseases and drugs that could be contraindicated with the present drug administration. The patients vital signs and medical state should be assessed along with the patients medical and history forms to ensure that the numbers of adverse effects or allergic reactions are limited. The assessment should be focused according to the medication to be administered.

The student realizes that before the therapy is administered the patients consent should be sought and planning of the intervention should be done. The time for the procedure, its suitability for the client, eating before and after and the scheduling of other activities for the client should be considered. In performing the procedure the student nurse is aware that the vial should be lightly shaked and air bubbles should be left for a few seconds to dissipate. The syringe and needle should be the correct size and length and should not be expired as leakage might occur. Asepsis should be maintained during procedures. The ten rights of medication administration should be adhered to. The nurse must ensure that the medication, the right route, the correct dose and the patient are correct. The client should be correctly educated and has a right to refuse the medication. The right assessment, tailored for the medication to be administered should be done prior to administration of medication. The right time and manner for the administration of the drug should be done. The evaluation and documentation done post administration should be correct as well.

Calculate the (a) flow rate of the IV infusion. (b) Drop rate using the following flow factors. (i) 10 gtt/mL (ii) 15gtt/mL

The flow rate of the IV infusion is important and as such should be correctly calculated. The flow rate can be calculated by dividing the one thousand mls of normal saline by six hours to give the flow rate of the normal saline in one hour. From doing this calculation the flow rate would equal one hundred and sixty-six mls (166 mls) in an hour.

The drop rate can be calculated by multiplying 1000 mls by 10 gtt and multiplying 6 hours by 60 minutes. The sum of these numbers can then be divided and they then give the drop rate of the normal saline. This calculation brings the figure to 27.7 or 28 drops a minute. The calculation of the drop rate using a 15 dropper uses the same calculations as above except that the 1000 in the start is multiplied by 15 instead of 10. The calculation brings the end figure to 41.6 or 42 drops per minute.

DISCUSS THE PRINCIPLES INVOLVED WITH ADMINISTERING THE IM PETHIDINE TO KYLIE; INCLUDE THE ETHICAL, LEGAL, PROFESSIONAL AND SAFETY ISSUES INVOLVED. The student is aware that pethidine (Meperidine hydrochloride), an opioid agonist analgesic produces analgesia, euphoria and sedation. This drug is used for relief of moderate to severe pain. It is to be used cautiously with in persons with fever and persons who have undergone recent GI surgery like Kylie. The IM route, by which this medication will be administered to Kylie, is the most preferred for repeated injections.

Checking with another nurse to witness the entire procedure should be done as this serves legal, professional and safety issues as pethidine (Demerol) is an opioid and therefore addictive. Wash hands identify patient introduce self and procedure to patient and seek consent. The nurse should ensure that another nurse cross checks the records and observes the procedure with the nurse. The upper outer quadrant on gluteus is the preferred site for administration of intramuscular pethidine. The area should be swabbed with alcohol. The syringe and needle should be the correct size for procedure. Injection should be placed at a 90 degree angle. Pull with the syringe to ensure placement in muscle and not vein and then push in medication. Apply deep pressure and or massage after administration. The area to be given the injection should not be cold or cool as this affects distribution of the drug in the body. The area should be warmed up to increase circulation and then the medication should be applied. After the administration of pethidine the patient should be closely monitored for changes in respiration that may signal serious adverse effects. Ethical principles should also be used in the care of Kylie. The student would ensure that beneficence, nonmaleficience and personal autonomy is maintained and ensured for the client. Beneficence would be maintained by conducting only proper and highquality practices for the patient. Under this, ensuring that the patient is properly positioned and endeavouring to maintain comfort before, during and after the procedure can be done. Proper assessment before the procedure and proper following of procedures and policies can be done. Personal autonomy would involve respecting the

patient and her wishes. Though trying to persuade her to what is best for her could be done, her point of view and her choice should ultimately be respected. DEVELOP A HEALTH TEACHING PLAN THAT CAN ASSIST KYLIE TO CORRECTLY MANAGE HER DISCHARGE MEDICATIONS (CARBAMAZEPINE, AMOXICILLIN AND SOLUBLE INSULIN. The topic of the teaching plan for Kylie would be Managing Discharge Medications and the duration of the teaching would be twenty minutes. The method of presentation would be discussion, demonstration and display. The theory would be Knowledge is Power (Anonymous). The teaching aides would include syringes and needles, medications, blood glucose meter and documents on proper medication administration. The aim of this teaching would be to give Kylie the necessary information to correctly and safely manage and self administer her medication. The objectives of the teaching would be to demonstrate the administration of soluble insulin, carbamazepine and amoxicillin and to discuss safety in medication storage and use.

OBJE CTIVE

CONTENT

TIM E

TEACHERS ACTIVITY Perform introductions and set out materials

LEARNER S ACTIVITY Listen; ask questions if there are any.

EVALUAT ION

Introduction of self, situation, purpose of being here and purpose of teaching to patient. 1 Explain time between

2 min

Explain the procedure

Participate

Evidenced

eating and taking insulin and why blood sugar testing is necessary. Demonstrate blood sugar testing and then administration of insulin to patient. Explain the storage, avoidance of alcohol and advised use of same type of syringe and brand of insulin to prevent dosage errors. 2 Explain the drug, effects, side effects, importance of taking the medication, dosage and times for administration.

min

and reasons for the procedures outlined. Demonstrate test and medication administration on patient. Teach the patient how dosage may vary due to stress, exercise or diet and why it is important to test blood sugar before taking insulin.

in demonstrati on. Ask questions as fit.

by participati on and level of questionin g.

3 min

Explanation of the drug and important information pertaining to the drug, storage and contraindications and its use.

Ask questions where necessary.

Evidenced by participati on and level of questionin g.

Explain what is amoxicillin, its effects, side effects, importance of taking the medication, dosage and times for administration.

2 min

Explanation of the drug and important information pertaining to the drug and its use.

Ask questions where necessary.

Evidenced by participati on and level of questionin

g. 4 Discuss with patient, asking for her feedback and input in measures that can be taken to ensure proper medication administration. Focus should be placed on dosage, timing, asepsis, diet and possible side effects. Conclusion and summary of teaching. Focus of important points. 2 min Give summary of teaching and hand out documents with information for further reading. Ask questions if any further information is desired. 5 min Enable and encourage discussion, encourage patients input as much as possible. Guide the discussion on the important aspects of drug administration Readily engage in discussion and rationalize points and actions in taking medications

REFERENCES

Amy M. Koch, RN, MS. Nursing Drug Guide (2008), Lippincotts DBL PETHIDINE HYDROCHLORIDE INJECTION B J.D. Gatford, R.E. Anderson, Nursing Calculations, (4th ed.). Karen O. McKay, PhD, Jennifer M. Follett, Dip Phty, MHSc. Home IV Antibiotic Therapy and Exercise Capacity in Children with CF: A Case Series. Retrieved from: http://www.cpptjournal.org/pdfs/members/fulltext/2011/march/antibiotic_therapy.pdf Mosby Nurses Pocket Dictionary. (33rd Ed.). Elsevier Mosby, New York: Chris Booker, 2007 OECS Medicine Formulary, (7th ed.).