PHARMACOLOGY 9.

Right Assessment
MODULE 3: NURSING PROCESS 10. Right Evaluation
NURSING RESPONSIBILITY Other “Rights”
 Proper drug storage
The Nursing Process  Careful checking of transcription of orders
 Patient safety
 Close consideration of special situations
 Prevention and reporting of medication errors
 Monitoring for therapeutic effects, side effects,
toxic effects

ASSESSMENT
• Data collection
– Subjective, objective
– Data collected on the patient, drug,
environment
• Medication history
• Nursing assessment
• Physical assessment
• Data analysis

Constant System Analysis

• A “double-check”
• The entire “system” of medication administration
• Ordering, dispensing, preparing, administering,
documenting
• Involves the physician, nurse, nursing unit, pharmacy
department, and patient education

EVALUATION
 Ongoing part of the nursing process
 Determining the status of the goals and
outcomes of care
 Monitoring the patient’s response to drug therapy

Administering Medications
1. Right Patient
2. Right Medication
3. Right Dosage
4. Right Route
5. Right Time
6. Right Documentation
7. Right Client Education
8. Right to Refuse
  having sufficient drug knowledge to recognize
and question erroneous orders
 actions delegated to other persons – orderly
cannot give medications
 monitor client’s response to a medication
 following safe practices – the ten rights

Medication Systems
 Each facility has a system for administering
medication
 Be familiar with this process & need to learn at
each new facility
 Basics of medication administration guidelines
should always be observed

Medication Orders
 Full name of client
 Generic or trade name of drug
 Dose, route, frequency
 Date, time and signature of provider
 The nurse will need to look up the medication
ordered to know it’s classification, safe dose, action,
how to administer, and side effects
 The nurse should know why the medication is
ordered

Life Span Considerations

• Pregnancy
• Breast-feeding
• Neonatal
• Pediatric
• Geriatric

Pregnancy
First trimester is the period of greatest danger for drug-
induced developmental defects
Drugs diffuse across the placenta
FDA pregnancy safety categories

PREGNANCY CLASSIFICATION
Class A
Studies failed to demonstrate fetal anomalies.
Class B
Animal studies have not demonstrated a fetal
risk.
Information in human is not available
Class C
Studies in animal have revealed an adverse
effect
Class D
There is a positive evidence of fetal risk but in
some cases may warrant the use of these
The day shift charge nurse is making rounds. A patient tells the drugs
nurse that the night shift nurse never gave him his medication, Class X
which was due at 11 PM. What should the nurse do first to Studies in animal and human have revealed
determine whether the medication was given? abnormalities
1. Call the night nurse at home.
2. Check the Medication sheet. Breast-feeding
3. Call the pharmacy. • Breast-fed infants are at risk for exposure to drugs
4. Review the nurse’s notes. consumed by the mother
• Consider risk-to-benefit ratio
The patient’s Medication sheet lists two antiepileptic medications
that are due at 0900, but the patient is NPO for a barium study. Pediatric Considerations: Pharmacokinetics
The nurse’s coworker suggests giving the medications via IV • Absorption
because the patient is NPO. What should the nurse do? – Gastric pH less acidic
1. Give the medications PO with a small sip of water. – Gastric emptying is slowed
2. Give the medications via the IV route because the – Topical absorption faster through the skin
patient is NPO. – Intramuscular absorption faster and irregular
3. Hold the medications until after the test is completed. • Distribution
4. Call the physician to clarify the instructions. – TBW 70% to 80% in full-term infants, 85% in
premature newborns, 64% in children 1 to 12
Know your drug years of age
Clients expect you to be knowledgeable – Greater TBW means fat content is lower
You gain this knowledge be looking up medications – Decreased level of protein binding
 Drug hand book – Immature blood-brain barrier
 PDA • Metabolism
 Pharmacist – Liver immature, does not produce enough
microsomal enzymes
Legal Responsibilities – Older children may have increased
The nurse is responsible for metabolism, requiring higher doses
 safe and accurate administration – Other factors
 • Excretion • Effects can range from no significant effect to directly
– Kidney immaturity affects glomerular causing disability or death
filtration rate and tubular secretion
– Decreased perfusion rate of the kidneys Common classes of medications involved in serious errors

Summary of Pediatric Considerations

 Skin is thin and permeable
 Stomach lacks acid to kill bacteria
 Lungs lack mucus barriers
 Body temperatures poorly regulated and
dehydration occurs easily
 Liver and kidneys are immature, impairing drug
metabolism and excretion

Methods of Dosage Calculation for Pediatric Patients

• Body weight dosage calculations
• Body surface area method Preventing Medication Errors
 Minimize verbal or telephone orders
Geriatric Considerations o Repeat order to prescriber
Geriatric: o Spell drug name aloud
older than age 65 o Speak slowly and clearly
Healthy People 2030: older than age 55  List indication next to each order
Use of OTC medications  Avoid medical shorthand, including abbreviations and
Polypharmacy acronyms

Geriatric Considerations: Pharmacokinetics

• Absorption
– Gastric pH less acidic
– Slowed gastric emptying
– Movement through GI tract slower
– Reduced blood flow to the GI tract
– Reduced absorptive surface area due to
flattened intestinal villi
• Distribution
– TBW percentages lower
– Fat content increased Preventing Medication
– Decreased production of proteins by the liver,  Never assume anything about items not specified in
resulting in decreased protein binding of a drug order (i.e., route)
drugs  Do not hesitate to question a medication order for
• Metabolism any reason when in doubt
– Aging liver produces less microsomal  Do not try to decipher illegibly written orders;
enzymes, affecting drug metabolism contact prescriber for clarification
– Reduced blood flow to the liver  NEVER use “trailing zeros” with medication orders
– Geriatric Considerations  Do not use 1.0 mg; use 1 mg
• Excretion  1.0 mg could be misread as 10 mg, resulting in a
– Decreased glomerular filtration rate tenfold dose increase
– Decreased number of intact nephrons  ALWAYS use a “leading zero” for decimal dosages
 Do not use .25 mg; use 0.25 mg
Geriatric Considerations  .25 mg may be misread as 25 mg
• Analgesics  “.25” is sometimes called a “naked decimal”
• Anticoagulants  Check medication order and what is available while
• Anticholinergics using the “10 rights”
• Antihypertensives  Take time to learn special administration
• Digoxin techniques of certain dosage forms
• Sedatives and hypnotics  Preventing Medication Errors (cont'd)
• Thiazide diuretics  Always listen to and honor any concerns expressed
by patients regarding medications
MEDICATION ERRORS:  Check patient allergies and identification
PREVENTING & RESPONDING
Nursing pharmacology
Medication Misadventures Nurses are legally required to document medications that are
• By definition, all ADRs are also ADEs administered to clients. The nurse is mandated to document:
• But all ADEs are not ADRs A. Medication before administering it
• Two types of ADRs B. Medication after administering it
– Allergic reactions C. Rationale for administering the medication
– Idiosyncratic reactions D. Prescriber’s rationale for prescribing the medication

Medication Errors If a nurse experiences a problem reading a physician’s

• Preventable medication order, the most appropriate action will be to:
• Common cause of adverse health care outcomes A. Call the physician to verify the order.
B. Call the pharmacist to verify the order.
C. Consult with other nursing staff to verify the order.
D. Withhold the medication until the physician makes
rounds.

METRIC SYSTEM

Meter is used for linear measure, gram for weight and

liter for volume

Apothecary System
Grains, minims, drams, ounces, pounds, pints, and
quarts

Household measures
Drops, teaspoons, tablespoons and cups
Important since this is often how people take
medications

Units
mEq – drugs ordered in number of units per dose
Insulin
heparin

Milliliters
mL = milliliter. This is a VOLUME measurement. it is
1/1000 of a liter. when talking about water or similar
liquids, it is equivalent to one cubic centimeter.

Cubic Centimeter
cc = cubic centimeter. This is also a VOLUME
measurement. Most syringes measure their capacity in
cc's. If you have a 5cc syringe, it will hold ~5mL of liquid
in it.

mL and cc’s
1 mL = 1cc
1 cc = 15 to 16 minims
1 cc = 15 to 16 drops
Fluids are generally written in cc’s to standardize the
abbreviation – you may see mL’s written but this
abbreviation is being eliminated

cc’s and household measures

5 cc = 1 tsp (teaspoon)
15 cc = 1 tbs (tablespoon)
30 cc = 1 oz (ounce) = 2 tablespoons
240 cc = 8 oz or 1 cup

Milligrams
mg = milligram. This is a WEIGHT measurement. It is
1/1000 of a gram. the amount of chemical substance is
often measured in milligrams. For injectable solutions,
this will be reported as a concentration of weight to
volume, such as mg/ml (milligrams per milliliter).

Aira C. 