Dosage and calculations
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The document discusses safe medication administration practices for nurses. It covers the nurse's legal responsibility to safely administer medications, the six rights of administration, types of medication prescriptions, tools to minimize medication errors, using the nursing process, and providing atraumatic care when giving medications to pediatric patients.
Dosage and calculations
- 1. Dosage and Calculations: Desired over Have
- 2. Safe Dose Identify the nurse’s legal responsibility of med administration Identify the six rights of safe administration Use the nursing process to administer med safely to clients of all ages Identify components of a med prescription Describe strategies to minimize medication errors Identify strategies to deliver traumatic care to pediatric clients when administering med Recognize risks for adverse med reactions
- 3. Administration Nurse are responsible for Preparing, administering, and evaluating client responses to meds Developing and maintaining an up to date knowledge base of meds administered, including uses, mechanisms of action, routes of administration, safe dosage range, side/adverse/toxic responses, precautions, and contraindications Skill competency Knowledge of acceptable practice Determining accuracy of med orders Reporting all med errors Safeguarding and storing medications
- 4. 6 Rights of Administration Right client Right med Right route Right time Right dose Right documentation
- 5. The Right Client The right client by the Joint commission requires two client identifiers to be used when administering meds. Acceptable identifiers include the client’s name, an assigned identification number, telephone number, birth date, or other person-specific identifier
- 6. The Right Medication The right medication should be sure this is the medication prescribed by the primary care provider Check the med label to ensure it matches the MAR verify the medication’s expiration date Consult a med guide or pharmacist if unfamiliar with the medication prescribed
- 7. The Right Route The right route compare the route instruction written on the med label with t he route instruction written by the primary care provider Clarify any discrepancies with the primary care provider or supervisor
- 8. The Right Time The right time ensure it is the correct time for administration Check the health care facility’s guideline for acceptable med administration time variations. Acceptable practice may include safely administering meds 30 mins. before or after the prescribed time
- 9. The Right Dose The right dose ensure the dose is what has been prescribed Perform any necessary conversions or calculations Check before cutting or crushing any meds. (A complete list is available at http://www.ismp.org/Tools/DoNotCrush.pdf
- 10. The Right Documentation Do not record any medications before administration Document on the MAR immediately after giving the medication Indicate on the MAR any medications not given. Document in the nurse’s notes the medication omitted and the reason it was not given Only document meds that you have given
- 11. Types of Medication Prescriptions Routine order/standard order May or may not have a termination date Without a specified termination date, the order will be the effect until the primary care provider discontinues it or the client is discharged Certain meds (opioids, antibiotics) must be reordered within a specified amount of time or will automatically be discontinued
- 12. Types of Medication Prescriptions Single/one time order A single/one time order is to be given at a specified time or as soon as possible For example: furosemide (Lasix) 40 mg PO at 1000
- 13. Types of Medication Prescriptions PRN order A PRN order stipulates at what dosage, what frequency, and under what conditions a medication may be give. The health care professional uses clinical judgment to determine the client's need for the med For example: acetaminophen (Tylenol) 325 mg PO every 3 hr. PRN
- 14. Types of Medication Prescriptions Standing orders Standing orders may be written for specific circumstances and/or for specific units For example: the critical care unit has standing orders to treat a client with asystole
- 15. Components of a Medication Prescription Name of client Date of order Time of order Name of med Dosage Route of administration Time and frequency: exact times or number of times per day Signature of prescribing provider
- 16. Medication Errors Common med errors include Wrong medication or IV fluid Incorrect dose or IV rate Wrong client, route, or time Administration of known allergic medications Omission of dose Incorrect discontinuation of meds or IV fluids
- 17. Using the Nursing Process Using the nursing process to administer meds safely Assessment data collection Obtain information regarding the client's condition relevant to med administration Obtain necessary pre-administration data (heart rate, blood pressure) Omit or delay doses as indicated by client’s condition identify client allergies Determine if the medication prescription is complete – to include name of client, date and time, name of medication, dosage, route of administration, time and frequency, and signature of prescribing provider Interpret the med prescription accurately Question the provider if the prescription is unclear or seems inappropriate for the client’s condition
- 18. Using the Nursing Process Planning using the nursing process in medication administration: Calculate and measure doses accurately Be sure the medication is the correct strength For example: Heparin is available in strengths of 10 units, 100 units, 1000 units or 10,000 units per 1 mL Verify high alert medications with a colleague if necessary Avoid distractions during medication preparation
- 19. Using the Nursing Process Implementing: Always use the six right medication administration Only administer medications that you have prepared Follow correct procedures for all routes of administration Use verbal orders only for emergencies Follow agency protocol for telephone prescriptions Follow all laws and regulations when administering controlled substances Omit or delay a dose if client questions size of dose or appearance of medication
- 20. Using the Nursing Process Evaluation: Evaluate client response to a medication, and document and report appropriately Recognize side/adverse effects, and document and repost appropriately Report all errors and take corrective measures immediately
- 21. Medication Error If an error occurs: Assess the client for any signs of an adverse reaction Notify the client’s primary care provider and the supervisor Document the event, along with the actions taken in response to the event to treat or prevent adverse reactions Document the event on an incident report according to agency policy Evaluate the cause of the error in order to prevent a reoccurrence
- 22. Tools for Safe Medication Practice The institute for safe medication for practice is a nonprofit organization working to educate health care providers and consumers regarding safe medication practices. Tools have been developed to decrease the risk of medication errors. Go to http://www.ismp.org for a complete list
- 23. Tools for Safe Administration Practice Error-Prone Abbreviation List Certain abbreviation have been associated with a high number of medication errors IU International Units
- 24. Medication Errors Confused medication Name List The names of some medications look and sound alike, which can lead to medication errors For example: Actos confused with Actonel
- 25. Medication Errors High-Alert Medication List Some medications, if given in error, have a high risk for resulting in significant patient harm For example: adrenergic agonist IV (epinephrine) – Insulin, subcutaneous/IV
- 26. Medication Errors Tall Man Letters Tall Man Letters are recommended for differentiating between look-alike medications names acetoHEXADINE (Dimelor) & acetaZOLAMIDE (Acetazolam)
- 27. Medication Errors A high number of medication errors have been associated wit the inappropriate placement of zeros The universal guideline is to always use a leading zero before a decimal, but never a trailing one For example this prescription reads five tenths of a milliliter .5 mL It could easily be mistaken as 5 milliliter, or 10 times the intended dose. A leading zero is placed before the decimal point to ensure that the dose is read correctly 0.5 mL: Always use a zero before a decimal point when the dose is less than one 5.0 mL reads five milliliters it could easily be mistaken as 50 milliliters. The trailing zero should not be placed following the decimal point to ensure that the dosage is read correctly 5 mL: never use a trailing zero following a decimal point
- 28. Medication Errors Sound-alike medications be careful with: Common medication suffixes – the use of med suffixes has the potential for causing med errors. There is no standardized nomenclature or definition. Suffixes may be confused with medical abbreviations, acronyms, dosing intervals, etc. For example: ER, XL, and SR all indicate some type of delayed response. This response may be delayed until the medication has passed through the stomach or the medication may be delivered over a longer interval than a similar med that has immediate release
- 29. Safe and Atraumatic Care Atraumatic care is the provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminates or minimizes the psychological and physical distress experienced by children and their families in the health care system
- 30. Safe and Autraumatic Care Prevent or minimize physical stressors: Educate on environment, diagnosis, treatment Use non-threatening models (dolls) Make environments less threatening; provide ”safe areas” Keep a neutral thermal environment Explain all noises, including alarms Close doors to room when possible to allow privacy Allow rest periods between invasive procedures Allow transitional items at bedside, such as blankets and dolls
- 31. Safe and Autraumatic Care Prevent or minimize child/parent separation Ask parents about interventions that are comforting for the child if they choose to be together Always accompany the parents to the bedside on the first visit Allow parents to hold their child, providing accommodation for equipment such as ventilators and monitors
- 32. Safe and Autraumatic Care Promote autonomy Orient parents to the environment as well as time limitations related to visitation Allow parents and children time to be alone together when possible Encourage parents to take time for themselves to eat and sleep Ask children and parents if they wish to be together for procedures Respect their decision Use time structuring to maintain a consistent and normal schedule
- 33. Safe and Autraumatic Care When administering medications to pediatric clients, use the same six rights of medication administration that are used for adult clients
- 34. Safe and Autraumatic Care Developmental approach for infants (birth to 1 year) Place in a semi-reclining position for oral medication Expect that the infant may spit or drool and be ready to collect as much of the discarded medication as possible Use an appropriate dosing device (such as an oral syringe, a hollow spoon, or a dropper) to deliver a precise dose Allow the parent to give the medication with a health care professional observing
- 35. Safe and Autraumatic Care Developmental approach for toddlers (1-2 years) Allow the child to touch and become familiar with the dosing device Give simple choices (i.e. a cup or a spoon, but the medication must be taken now) Follow home routines Disguise the taste of the medication if necessary
- 36. Safe and Autraumatic Care Developmental approach for preschoolers (3-5 years) Check with the child or the child’s parent about the child’s ability to swallow pills. Crush tablets and capsules if necessary Allow the child to participate in decisions regarding how the medication will be administered: when, from whom, and where. The child’s parent may be the best person to administer the medication Explain to the child what the medication will do Use therapeutic play with dolls or stuffed animals
- 37. Safe and Autraumatic Care Developmental approach for school-aged children (6-12 years) Check with the child or the child’s parent about the child’s ability to swallow pills. Crush tablets and capsules if necessary Allow the child to have a sense of control by participating in decision making regarding how the medication will be administered Explain the purpose of the medication to enhance cooperation Praise the child after administration
- 38. Safe and Autraumatic Care Development approach for adolescents (12- 20 years) Give clients in this age group detailed information about medications, including the purpose, effects, side effects, availability of an alternative, etc. Provide honest information regarding the medication Encourage questions
- 39. Safe and Autraumatic Care Selecting the appropriate size equipment to safely administer pediatric meds When using a calibrated syringe, be sure to choose the appropriate size to get the most precise measure of med These syringes are commonly used to administer precise pediatric meds. They do not accommodate a needle are also available for home use
- 40. Safe and Autraumatic Care Liquids: Liquids must be measured accurately especially when small doses (less than 1 m: or less than 1 tsp) are prescribed. Many devices such as standard medicine cups are not accurate for measuring small doses, and the household tsp comes in many different sizes and shapes Liquid meds should be measured in specifically marked droppers or hollow-handled medicine spoons, or drawn into needleless syringes if the volume prescribed is less than 5 mL Prescriptions for liquid meds should be written in mg, mL or mg/mL, not in tsp.
- 41. Safe and Autraumatic Care Pills, tablets, and capsules are not recommended for young children because these items may be difficult to swallow, become lodged in the throat or esophagus, or be aspirated by a crying child Chewable tablets are available for some preparations, primarily vitamins. Check before crushing or allowing the child to chew any pill, tablet or caplet, because crushing or dilution may alter the action of the medication. Some pills may be crushed and the contents placed in food such as applesauce or ice cream
- 42. Safe and Autraumatic Care Using the principles of atraumatic care medication administration Oral medication administration Give a popsicle or ice to number the mouth before giving the child medication Mix medication with a pleasant-tasting substance such as cherry syrup Have a pleasant-tasting substance ready to eliminate the unpleasant taste of the medication
- 43. Safe and Autraumatic Care Using the principles of atraumatic care for med administration IM/SBQ med administration Apply transdermal anesthetic eutectic mixture of lidocaine and prilocain (EMLA cream) Use the smallest size needle that permits free flow of medication Bring medication to room temperature Use distraction; talk with child through procedure Cover with bandage (if age-appropriate) Hold and cuddle post-injection (if age-appropriate) or allow parents to do so Praise the child
- 44. Safe and Autraumatic Care Administering IM injectable med to children The size, wt., developmental level, and condition of the child will determine the most appropriate injection site and the size of needle to be used Infants and young children have small, underdeveloped muscles, which limits the available sites and dictates the length of needles to be used Neonate 5/8 inch length Children < 1 year 5/8 to 1” length Children > 1 year 1” length Adolescent 1 ½ -2” for gluteal site
- 45. Safe and Autraumatic Care IM injection sites The vastus lateralis located at the anterolateral thigh, is the most preferred site for IM injections in infants and children of all ages The deltoid muscle may also be used to inject small volumes of nonirritating fluid in older children
- 46. Safe and Autraumatic Care SBQ injections Use 5/8”, 23-25 gauge needle Pinch the skin to avoid muscle tissue Infants: use the fatty region of the anterolateral thigh Toddlers: use the fatty region of the anterolateral thigh or posterior area of upper arm Children: use the fatty region of the anterolateral thigh or posterior area of upper arm
- 47. Safe and Autraumatic Care IV delivery A soluset is an IV delivery device between the IV fluid bag and the IV catheter Many institutions require a volume control device for delivery of IV meds as well as an infusion pump Solusets allow the provider to give medications using the maximum amount of fuid and allows for the maximum concentration
- 48. Safe and Autraumatic Care Equipment for IV insertion Choose the appropriate size needle for the size of vein selected and the type of infusion require Newborn – 1yr 22 – 24 gauge 1 – 8 years 20 – 22 gauge More than 8 years 18 – 22 gauge
- 49. Safe and Autraumatic Care Injection sites Preferred (upper extremity) Forearm veins Veins on the dorsum of the hand Other less well known are saphenous vein or small veins on ventral surface of wrist or larger one on inner aspect of wrist proximal to thumb The veins in children in crisis are difficult to assess and cannulate. Insertion of an intraosseous needle in the lateral aspect of the tibia bone allows administration of all meds, fluids, and blood products that could be given intraosseously ( within the bone marrow) it takes approximately 60 seconds to insert.
- 50. Safe and Autraumatic Care Endotracheal tube The ET can be used to administer resuscitation medication if IV access is unobtainable. The following medications can be given via the ET tube LEAN Lidocaine, Epinephrine, Atropine, Naloxone Vascular access is preferred because absorption via the ET tube is inconsistent
- 51. Adverse Reactions to Meds Reporting adverse reactions all serious adverse reactions to medications must be reported to the Food and Drug Administration so that other health care professionals may be alerted to potential problems FDA defines a serious medication reaction as one that is life- threatening, causes death, leads to hospitalization or prolonged rehabilitation, results in serious or permanent disability The Joint Commission requires each hospital to create a process to report adverse medication reactions Most health care facility establish internal committees that review all adverse med reactions. These committees must review the events associated with adverse medication reactions, including: the med suspected of causing the adverse reaction, the treatment administered and the client’s response to treatment and any increase in length of stay in the facility
- 52. Step to Improve Client Safety Follow these steps to reduce the risk of an adverse reaction to a med Document a complete med history, including meds, food, or environmental agent allergies Eliminate excessive or duplicate medications Understand the indications, intended effects, and possible adverse reactions of each medication Anticipate adverse reactions when therapy is started or stopped Regularly monitor liver and kidney function Suspect adverse medication reaction if unexpected complications develop