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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Student Survival Skills
- Sprache: Englisch
Anxious about managing medicines? Worried you’ll make a mistake? This handy book is an essential guide for all nursing students, enabling you to understand the theory and practice of drug administration and facilitate your confidence and competence.
This essential guide explores the theory and practice of drug administration briefly and coherently, with ‘test your knowledge’ exercises and questions throughout to assess your learning. It also includes ‘words of wisdom’- tips from real life students from their own experiences. Ideal for carrying to clinical placements, Medicine Management Skills for Nurses is an essential guide to drugs and medicine administration.
Special features:
- Pocket sized for portability- Clear, straightforward, and jargon-free
- Takes away the fear of drugs and medicines management, making it approachable, easy and fun
- Features tips and advice from real life nursing students
- Ties in with the NMC standards for pre-registration education and the Essential Skills Clusters
- Examples and questions based on real life nursing and healthcare examples
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Seitenzahl: 250
Veröffentlichungsjahr: 2013
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Contents
Cover
Half Title page
Title page
Copyright page
Preface
Introduction
Acknowledgements
The 24-Hour Clock
Chapter 1: Drug Administration: General Principles
Professionalism
Time-and-Motion Studies
Latin Abbreviations
Drug Wastage
Professional Judgement
Medication Process
Complementary Medication
Medication Errors
Paediatric Patients
Administering Drugs Safely
Test Your Knowledge
Chapter 2: Pharmacokinetics and Pharmacodynamics
Absorption
Drug Distribution
Drug Metabolism
Drug Excretion
Drug Interactions
Test Your Knowledge
Chapter 3: Drugs and Medicines
What’s the Difference Between a Drug and a Medicine?
Categories of Medicine
Medication Directions
Generic Prescribing
Types of Medicine
Medicine Storage
Vaccines
Legislation
Test Your Knowledge
Chapter 4: Oral Drug Administration
The Consumer Protection Act 1987 and Medicines Act 1968
Administration of Drugs to Patients Who Refuse Treatment
The Prescription Chart
Oral Routes
Solid Oral Medicines
Liquid Medications
Service Users
Self-Administration of Drugs
Controlled Drugs
Checking Medications for Children
Administration
Test Your Knowledge
Chapter 5: Administration of Injections
Reasons for Administering Medication by Injection
Parenteral Drug Administration
Depot Injections
Syringes
Needles
Injections
Test Your Knowledge
Chapter 6: Calculations for Working Out Dosages
Drug Dosages for Tablets and Capsules
Drug Dosages for Injection (and Any Liquid)
Infusion Devices
Syringe Drivers
Ambulatory Syringe Drivers
Gravity-Feed Drip Rates (Drops Per Minute)
Duration of Infusion
Drugs According to Body Weight
Setting Pumps to Run at Millilitres Per Hour
Test Your Knowledge
Chapter 7: Administration of Rectal and Vaginal Preparations
Insertion of Vaginal Pessaries
Insertion of Rectal Medicines
Test Your Knowledge
Chapter 8: Administration of Topical Preparations
Applying Creams and Ointments
Transdermal Patches
Eye Drops
Eye Ointment
Ear Drops
Nose Drops
Test Your Knowledge
Chapter 9: Administration of Inhalation Medications and Nebulisers
Nebulisation
Aerosolisation
Test Your Knowledge
Chapter 10: Administration of Intravenous Fluids
Types of Fluid Replacement
Dehydration
Risk to the Patient
Complications of IV Therapy
Adding Medications to Bags of Fluid
Equipment
Blood Products
Infusion Devices
Prescriptions
Preparation of Intravenous Fluids
Procedure for Disconnection of Intravenous Infusion
Test Your Knowledge
Chapter 11: Administration of Intravenous Bolus Medications
Advantages of IV Bolus Injections
Saline Flushes
Disadvantages of IV Bolus Injections
Amoxicillin Administration in Neonates
Displacement
Speed Shock
Test Your Knowledge
Chapter 12: Administration of Continuous Intravenous Infusions
Advantages of Continuous Intravenous Infusion
Disadvantages of Continuous Intravenous Infusion
Calculating the Rate
Diabetic Emergencies
Test Your Knowledge
Chapter 13: Administration Via Percutaneous Endoscopic Gastrostomy, Percutaneous Endoscopic Jejunostomy or Nasogastric Tube
Medication
Advice from the NPSA
Placement of Tubes
Parenteral Nutrition
Enteral Feeding Regimes
Nasogastric Care Plan
Test Your Knowledge
Chapter 14: Drugs and Specific Medical Conditions
Aspirin and NSAIDs
Paracetamol
Monoamine Oxidase Inhibitors
The Co- Drugs
Drugs Used in Specific Medical Conditions
Test Your Knowledge
Chapter 15: Pain Management
Effects of Pain
Now for the Science Bit
Pain Gate Theory
Classifications of Pain
Assessment of Pain
Strategies to Manage Pain
Analgesic Ladder
Morphine
Balanced Analgesia
Palliative Care
Test Your Knowledge
Chapter 16: Knowledge Test
Answers to Activities, Questions and “Test Your Knowledge”
Appendix 1: Specific Competencies: Medicines Management
Appendix 2: A Typical Prescription Chart
Bibliography
Websites
Index
MEDICINE MANAGEMENT SKILLSFOR NURSES
Student Survival Skills Series
Survive your nursing course with these essential guides for all student nurses:
Calculation Skills for NursesClaire Boyd9781118448892
Medicine Management Skills for NursesClaire Boyd9781118448854
Clinical Skills for NursesClaire Boyd9781118448779
This edition first published 2013© 2013 by John Wiley & Sons, Ltd
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Library of Congress Cataloging-in-Publication DataBoyd, Claire.Medicine management skills for nurses / Claire Boyd.p. ; cm. – (Student survival skills series)Includes bibliographical references and index.ISBN 978-1-118-44885-4 (pbk. : alk. paper)I.Title. II. Series: Student survival skills series. [DNLM: 1. Drug Therapy–nursing–Handbooks. 2. Medication Errors–nursing–Handbooks. 3. Pharmaceutical Preparations–administration & dosage–Handbooks. WY 49]
615.5’8–dc23
2012044639
A catalogue record for this book is available from the British Library.
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Preface
This book is designed to assist the student healthcare worker in the field of medicines management. All exercises are related to practice and the healthcare environment.
The book looks at the general principles of drug administration, and features ‘how to’ chapters covering the administration of many types of drug. All the material has been requested by students like you, who told me what they wanted in a medicines management book. It is designed to be a quick reference, one on which you can build your knowledge and skills.
At the start of your nursing career you will observe drug administration and then gradually take a more active part in the process. Don’t shy away from this, as one day you will be on your own and the patient will rely on you as being the fount of all knowledge.
Nobody expects you to be all knowing at the start of your career and you will need to have quite a few drug-related competencies signed off to prove your ability during your training. Many clinical areas also supply students with an induction pack during placement. This pack usually has a section on commonly prescribed medications used in that area. It is from this that you will build up your knowledge of cardiac drugs, renal drugs, drugs used in neurosurgical wards, drugs used in paediatric care, and so on.
The book talks about patients but often uses the community terminology of service user as well. The paediatric nurse has not been forgotten, with information throughout incorporating this branch of nursing.
The book incorporates many exercises to check understanding, to help you to build confidence and competence. It has been also compiled using quotes and tips from student nurses themselves: a book by students for students.
Claire BoydBristolOctober 2012
Introduction
Hello. My name is Claire and I am a Practice Development Trainer in a large NHS trust. Chatting to student nurses just like you, I have often been told that they have real fears about all aspects of medicines management. These fears are especially with regard to the administration of drugs, knowing that this is a skill they will have to acquire and use throughout their chosen career. Does this sound like you? Are you a little over-awed with the prospect of being let loose in your clinical area to administer drugs to the patients?
To add to the fear factor, many students complain that they are often unable to practice their drug-administration competences under supervision due to the ever-increasing demands on the preceptor (wait until you become one and see how hard it is!). They tell me that they are not getting adequate input in the area of medicines management during their training, so their thinking is, ‘how am I meant to get my competences signed off, let alone become confident and competent?.
No need to fear: this book will at least give you the knowledge behind the skill, increasing your confidence and competence prior to really getting stuck in with the ‘hands-on’ element in your clinical area. In short, this book is designed to support you, the student nurse, as well as those who are newly qualified (congratulations on your wonderful achievement). Also, with the ever-changing face of health care, it is also aimed at those of you who are now expected to administer medications, namely the assistant practitioners.
This book contains the information and exercises I deliver to student nurses and assistant practitioners during their medicines management training. I hope that I have made the writing style informal but brief, as though I am sitting beside you to help you along the way. All the answers to the activities, questions and ‘Test your Knowledge’ exercises can be found at the back of the book.
Remembering my own time as a student nurse, it was being let loose with the drug trolley that most scared me: what if I made a mistake? Times have not changed, as many of you have informed me that you need a book to increase your theoretical knowledge, as well as to advise on the practicalities.
OK, I’m going to be totally honest here. Many years ago, when I had not long been qualified (in my first week in the job: beat that!), I made a drug error. We were rushed off our feet at work and I gave a patient a drug containing paracetamol not long after he had already received his regular paracetamol. Once I realised my mistake (and stopped crying) I took all the appropriate steps: informing the matron and the medic, apologising to the patient, filling out all the paperwork, writing my reflected piece for the portfolio, and so on. In short, the patient did not come to any harm but I still come out in a cold sweat when I thinking about it. One thing I do know is that I have never knowingly made another drug error in my life, taking my time and not rushing whenever I administer medicines. And that is my message to you: take your time when administering medication, and never cut corners.
Throughout the book student have added their own words of wisdom, in the form of tips for their peers from their own experiences, or queries they may have had. The book is designed to take you from your first day ‘on the job’ to your qualification, and beyond. It covers all areas of medicines management, for the acute hospital to the community, adults and paediatrics.
The book is designed to be a companion to the Royal Marsden Hospital manual of Clinical Nursing Procedures (and student edition), the recognized manual of excellence in health care. Nursing is a dynamic field and the book is evidence-based and looks at the theory and practice of drug administration briefly and coherently. The pharmaceutical industry is forever evolving and new drugs are coming onto the market regularly. Take time to talk to your patients to gain an understanding of drugs you may not have seen before. Pick up the new editions of the British National Formulary (adult and paediatric editions) and dip into this source of information regularly.
Please remember that there are many areas within the clinical skill of drug administration that a student is not permitted to undertake. For instance, you may not give intravenous drugs. This does not mean that you can’t observe these drugs being prepared and administered by professionals. Never perform any task that you are not permitted to undertake, even if you are asked to do so.
My final tip to you is never administer a drug to anyone without knowing what it does and why it has been prescribed.
Acknowledgements
As always, first acknowledgements go to the student nurses I have had the honour of teaching in the skill of medicines management. As with the other books in the Student Survival Skills Series, it is their tips and quotes that have been used throughout the book.
Acknowledgements also go to North Bristol NHS Trust: to Jane Hadfield (Head and Learning and Development) and Stephen Taylor (research dietician; for the use of his images) and to all my friends and colleagues in the Staff Development Department.
Thanks also go to Magenta Styles (Executive Editor at Wiley-Blackwell) for first approaching me about this exciting project and for her guidance and direction in writing this book, and to the Project Editor Catriona Cooper.
This book is dedicated to my loving family: my wonderful husband Rob (for the photographs), Simon and Louise and David for allowing me to use photographs of their body parts: nose, ears, eyes and fingers (what did you think I meant?). Thank you, my family, for supporting me in my book-writing foray.
The 24-Hour Clock
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Chapter 1
DRUG ADMINISTRATION: GENERAL PRINCIPLES
LEARNING OUTCOMES
By the end of this chapter you will have an understanding of the general principles of drug administration.
PROFESSIONALISM
You may well worry about making mistakes. Everyone is human after all and prone to error. The key is to minimise where the faults can occur. As health carers we always put the patient first and apply our professionalism. As with any clinical skill we need to highlight the importance of vigilance, knowledge and professionalism when administering drugs, as many drug errors occur when staff fail to follow correct procedures or do not recognise the limitations of their own knowledge and skill.
So, why do drug errors occur? Well, research tells us that mistakes happen due to:
Professionalism in nursing
Nurses are expected to display competent and skilful behaviour.
TIME-AND-MOTION STUDIES
Question 1.1 How much time do you think nurses spend during a shift dispensing and administering drugs?
The UK Department of Health informed us in 2007–2008 that ’Each hospital in England and Wales administers about 7,000 medicine doses each day, and this activity can take up a substantial amount of nurses’ time.’ (Safety in Doses: Improving the Use of Medicines in the NHS, 2007–2008, Department of Health)
The Department of Health report A Spoonful of Sugar (2001) estimated that 40% of nursing time is spent administering medicines.
However, there are more up-to-date studies and research suggesting that the nurse’s time is broken down into these categories:
documentation, 35.3%;
medication administration, 17.2%;
care co-ordination (handovers, etc.), 20.6%;
patient care activities, 19.3%;
patient assessment (observations), 7.2%.
Whichever time-and-motion study you wish to go by, it is obvious that a large proportion of the nurse’s time is spent on drug administration.
LATIN ABBREVIATIONS
We have all seen the medic on the TV hospital soap opera shouting ‘adrenaline stat!’ in the emergency room but what does ‘stat’ actually mean? Well, it means we need to be conversant with Latin abbreviations, that’s what it means.
Have a go at seeing how many of the Latin abbreviations you know in Activity 1.1.
Activity 1.1
Here is a list of Latin abbreviations used when prescribing. What do they mean?
STATOMQDSACONQQHBDPCTDSODPRNTIDWe tend to use specific accepted abbreviations in health care to do with medicines, such as mg, PRN, IV, etc., but not mcg as we write micrograms in full so as not to get confused with mg. Healthcare workers are told not to use abbreviations in their written care plans, medical records, etc., as mistakes can happen. Terms may have two meanings: for instance, DOA can be taken to mean dead on arrival or date of admission.
DRUG WASTAGE
Another area of investigation by the Audit Office concerns wastage of drugs: the Audit Office found that Primary Care Trusts could save almost £7 million each year if general practitioners (GPs) prescribed more efficiently. Wastage costs the National Health Service (NHS) approximately £200 million. I’m sure we have all met the elderly neighbour with bottles of pills dating back 10 years or more collecting dust in their bathroom cabinets. As health carers we all need to deliver better patient education, explaining why that course of antibiotics that the GP prescribed needs to be completed, even if the patient is feeling better.
Here’s a question: what do you think about schemes to recycle drugs back to the pharmacist to be redistributed to other patients? What if the bottles have been opened and the drugs spilled over a dirty floor and put back in the bottle (perhaps even licked by the dog!). Would you like to take them? Only use sealed bottles and unopened blister packs, I hear you say, but what if these had been stored on top of a heater for the last 6 months and become unstable?
PROFESSIONAL JUDGEMENT
When administering medication, we need to be aware of the following.
It is not solely a mechanistic task to be performed in strict compliance with the written prescription of a medical practitioner.
It requires thought and the exercise of professional judgement (Dougherty and Lister, 2011).
What does this actually mean? Let’s look at an example.
Question 1.2 If a patient has senna and lactulose prescribed and informs you that they have opened their bowels four times that day, do you administer their prescribed laxatives?
Also remember, it is very easy to get distracted, and lose concentration in the clinical area, so always concentrate on the job in hand.
MEDICATION PROCESS
The medication process is made up of four parts.
Prescribing
: it is often the nurse who notices that a doctor has prescribed something to which the patient is allergic, perhaps because the nurse knows the patient better.
Dispensing and preparation
: a nurse should not use trade names for drugs as confusion may occur, for example Voltarol instead of diclofenac sodium. Perhaps the pharmacist has reconstituted the medication with the wrong transport medium, for example sodium chloride instead of water for injection.
Administration
: you need to be very clear which route a medication should be given through and that the dose has been calculated correctly.
Monitoring
: you need to check the administration and effect of a medicine on the patient. For example, a patient prescribed diclofenac sodium must be checked to see whether they are asthmatic. Patients with hypertension or heart failure must be monitored carefully if they are given diuretics. Blood pressure, fluid input and output, and sodium and potassium, etc., must be checked.
Any one of these categories could be the weak link where a mistake can occur.
The Department of Health reports that the wrong dose, strength or frequency of a drug accounts for over a quarter of all medication incident reports.
COMPLEMENTARY MEDICATION
What about complementary medication? Anticoagulants may react with ginseng, ginkgo Biloba (for improved memory and brain circulation) and should be discontinued 36 hours prior to surgery, and the contraceptive pill can be affected by antibiotics. If in any doubt speak to a pharmacist who can give advice. Never give a drug if you are unsure. Seek advice.
Complementary medicine
A broad term used to describe medicines used in conjunction with conventional medicine.
MEDICATION ERRORS
Let’s look at some facts and figures around drug administration. According to the Department of Health:
40 000 mistakes a year are made in NHS hospitals,
2000 errors cause moderate to severe harm,
36 patients die per year,
costs are estimated to be £2 billion per year to the NHS,
the reporting rate is poor: 39% of near misses go unreported,
poor mathematics skills have been indicated in medication errors, such as the misplacement of a decimal point.
These figures are meant to be conservative, as we know that the reporting rate of medication errors is poor (39% of near misses go unreported). This is known as the iceberg effect.
Question 1.3 What is a near miss? Think of an example.
What is a drug error? Well, the Department of Health informs us that:
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer.
Because nurses predominately administer drugs, they are often the last potential barrier between a medication error and serious harm to a patient, with drug errors frequently featuring in professional misconduct cases.
Question 1.4 Apart from killing the patient, what is the worst thing you can do when you have made a drug error?
Drug Administration Routes
When administering medications, we also need to be completely conversant with the mode of administration, or route. A very sad case involved a young boy called Wayne Jowett who died as a result of being given his medication ‘ITH’ instead of intravenously (which is written as ‘IV’).
If you saw the route written as ’ITH’ on a prescription chart, what do you think this would mean? Let’s look at this and other abbreviations that you may encounter.
Activity 1.2
Here is a list of abbreviations for routes of drug administration. Can you work out what they mean?
In the North Bristol NHS Trust, very few abbreviations are permitted to be used on a drug chart: SC, IM, IV, O, NEB, TOP and INH. Everything else has to be written out in full so that mistakes don’t get made.
Keeping Updated
As well as being conversant with the route abbreviations, if we are administering drugs we need to keep ourselves updated about changes to drug names, as well as contraindications.
Paracetamol (derived from coal tar; also known as acetaminophen) can now be given by the intravenous route, but is obviously much more expensive than oral paracetamol and has a shorter half-life. This means that it is less effective over a longer time span and, as pain is considered to be the fifth vital sign, we need to be aware of this when keeping our patients comfortable and pain free.
Drug Errors and Adverse Reactions
The NHS has graded drug errors and adverse reactions, as follows.
Single-Nurse Administration
In most adult hospital settings it is one nurse who administers the medications to the patients. This is considered to be the safest option as it thought that the lone nurse will take extra care due to their sole responsibility. The exception to this is often injected drugs and controlled drugs, whereby two nurses check and sign for the drug and go to the patient’s bedside together to administer the drug.
When there are any calculations or working out to do, two nurses should also check their workings out to agree on the correct answer and dose that the patient requires.
PAEDIATRIC PATIENTS
When medication errors occur, paediatric patients have a higher risk of death than adults due to the fact that most drugs are developed in concentrations for adults, necessitating often complex weight-based calculations for paediatric doses and dilutions.
Paediatric patients
These patients are infants, children and adolescents.
One of the special safeguards the paediatric clinical areas often have in place is that two nurses have to check and sign the prescription chart. One of these should be a Registered Paediatric Nurse.
Question 1.5 Other than paediatric patients, who may be considered as another high-risk group?
ADMINISTERING DRUGS SAFELY
Drug Administration Competence
Many hospitals have drug administration competencies for staff to ’prove’ that they are competent in the clinical skill of drug administration (see Appendix 1). Only when these competencies have been signed off can a nurse in adult nursing administer medications alone.
Calculations Competence
Also, in order to be able to administer intravenous medications, staff are required to pass a drug calculations test to prove mathematical ability, as poor mathematical skills have been indicated in medication errors with the misplacement of the decimal point leading to a tenfold error overdosing or under-dosing.
Activity 1.3 shows a sample question of the sort that you may be expected to answer in one of these tests.
Activity 1.3
Drug calculations sample question.
A drug is presented as 5 g in 500 mL. A patient weighing 70 kg is prescribed 10 mg/kg/h of the drug.
Remember to first work out how much of the drug the patient requires according to their body weight by using the formula weight (kg) × dose, and then using the formula:
But remember to keep the decimal units the same throughout the formula.
The Prescription Chart
Now let’s look at the prescription chart (see Appendix 2), which is used in the hospital setting. This is a typical prescription chart. The first page of this chart has a section for drug allergies or sensitivities but also includes anything to which the patient considers themselves sensitive or allergic.
Certain foodstuffs are linked to latex proteins, so if a patient informs us that they are allergic to kiwi fruit, bananas or avocado, they are probably allergic to latex because these food items have the same protein chains as latex. The patient must then be considered as latex sensitive. Any equipment used with this patient must be latex-free. This is why it is vital that a good, robust admission procedure is performed on each patient so that their medical history is fully known. Details can then be written on the prescription chart to alert colleagues; this goes on the front of the chart where it say Drug allergies/sensitivities. In this case you would write ‘allergic to bananas.’
Question 1.6 Why do you think it is important that we know not just what medications the patients are allergic to, but also what foodstuffs?
The second page of the prescription chart gives the recommended times of antibiotic therapy. Page 3 of the chart gives us code numbers for why a drug was omitted, and page 4 is where we document the rationale for a drug not being administered; that is, why it was omitted. It is classed as neglect if a drug has been omitted for no good reason, and an accident/incident form will need to be completed.
Improving Medication Safety
The National Safety Patient Agency (NPSA) has produced seven key actions to improve medication safety in its report, Safety in Doses (Table 1.1).
Table 1.1 Seven key actions to improve medication safety
Increase reporting
Increase reporting and identify actions against local risks by way of an annual medication report: clinical risk.
Implement NPSA safer medication practice recommendations
Implement NPSA recommendations – audit safer medication practice – includes alerts on anticoagulants, injectable medications and wrong-route errors.
Improve staff skills and competencies
Improve skills: preceptorship competencies will help nurses to work towards the required level of competence.
Minimise dosing errors
Minimise errors: information, training and tools to make calculations easier.
Ensure medicines are not omitted
It also can be linked with neglect when medications are not given. The NPSA reviews medicine storage and medication supply chains.
Ensure medicines are given to the correct patient
Ensure correct medications with correct patient – improve packaging and labelling of medicines – support local systems that make it harder for staff to select the wrong medicine.
Document patient’s medicine allergy status
Document: improve recording of patient’s allergy status.
Data from Department of Health (2007).
Worldwide Facts and Figures
Some facts and figures concerning drug errors worldwide:
worldwide: 17% of medication errors involve errors in calculations;
almost 50% of all intravenous injections feature a mistake, and the number of patients requiring intravenous therapy is increasing.
As stated previously, this is considered to be only the tip of the iceberg, meaning only those that have been reported.
Reports and Safety Alerts
In order to alert health carers of the problems around drug administration, the Department of Health and NPSA issue reports and safety alerts, such as Building a Safer NHS for Patients: Improving Medication Safety (Department of Health, 2004), Patient Safety Alerts and Rapid Response reports:
missed doses,
venous thromboembolism – anticoagulant therapy (warfarin),
promoting safer measurement & administration of liquid medicines,
promoting safer use of injectable medicines,
safer practice with epidural injections and infusions.
Department of Health
The government department responsible for health regulation and policy in the United Kingdom.
Venous thromboembolism (VTE)
A medical condition including deep-vein thrombosis (DVT), whereby a blood clot forms inside a vein, and pulmonary embolism (PE), whereby part of the DVT breaks off and travels to the lungs, blocking the blood flow.
