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The Six Rights of Medication Administration

The purpose of the VU Nursing and Midwifery student led ‘drug diary’ is to assist students in their understanding of medication administration and management.  Registered Nurses and Midwives are legally obligated, as regulated health professionals, and are accountable to the Nursing and Midwifery Board of Australia (NMBA) https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx .  Additionally, the safe and effective use of medications is clinically governed by the National Safety and Quality Standards to support medication management

https://www.safetyandquality.gov.au/standards/nsqhs-standards

The fundamental six (6) Rights of medication administration are to be adhered to at all times.  Some hospitals may implement to up to 11 rights of medication administration and it is your professional obligation to be aware of the policies of the institution in which you are working and to adhere to their requirements. Right Person, Right Drug, Right Dose, Right Route, Right Time, Right Documentation

Medications can be grouped by how they affect our bodies so it is important to have an understanding of this.  For example analgesics relieve pain, antihypertensives reduce blood pressure, antidepressants assist in reducing depression etc… These medications are then further divided by their individual therapeutic actions.  For example you may have two different medications classified as antihypertensives however Drug A may work differently to Drug B to reduce this BP.  It is important to be aware of how medications work as nurses are accountable for the drugs they administer.  

When using this ‘Drug Diary’ it is advised that you place any drugs that are unfamiliar to you into this diary and take the time consolidate the information you have included.  Through this you will then become familiar with the medications you administer.  Try to paraphrase which will assist you in understanding the medication in your own words.  If you like try grouping drugs together on the same page eg. Analgesics, Anti-Emetics etc…

McKenna, L., & Mirkov, S. (2019).  McKenna’s Drug Handbook for Nursing and Midwifery Australia and New Zealand. Wolters Kluwer is a great little handbook that can be easily carried with you to clinical.  This also includes nursing care implications.

Supplementing this is a much larger, in depth text, should you wish to learn more in depth information:

McKenna, L., & Gigi Lim, A. (2020).  McKenna’s Pharmacology for nursing and health professionals (2nd ed revised.).  Wolters Kluwer.

Symons, K., & Ermer, J.  (2020). Australian injectable drugs handbook (8th ed.).  Society of Hospital Pharmacists of Australia is what we refer to as the ‘yellow bible’ in nursing.  This will be found in every acute hospital and access is readily available either electronically (a log in is required) or through hard copy.  There is no need to purchase this handbook.  

 Key Terms/Abbreviations

Mening

Pharmacokinetics

the absorption, distribution, metabolism and excretion of drugs

Pharmacodynamics

the scientific interactions between the chemistry of the living systems and the foreign chemicals that have been introduced to those systems

Loading Dose

some medications need an initial higher dose to obtain the desired effect in a timely manner

Half Life

the time it takes for a medication to reduce to half of its peak level

Peak Level

highest concentration of the medication in the bloodstream

Generic Name

the original medication name that receives approval for use (eg.Paracetamol)

Brand Name

the name given to the generic medication by the company making it (eg. Panadol, Panamax, Dymadon)

Daily

Once a day, at the same time each day

Mane

In the morning

Nocte

At night

Bd

Twice a day, usually 12 hours apart

Tds

Three times a day, usually eight hours (8/24) apart

QID

Four times a day, usually six (6/24) apart

PRN

When necessary or as required

SR

Slow or sustained release

IR

Immediate release

 Key Terms/Abbreviations

Mening

PO

Per oral (by mouth)

PR

Per Rectum

NEB

Nebuliser

MDI

Metered Dose Inhaler

TOP

Topical (on the skin)

BE

Both Eyes

S/L

Sub Lingual (under the tongue)

Buccal

Between the cheek and gums

S/C:

Sub cutaneous

IM

Intramuscular

IV

Intravenous

NG

Nasogastric

PEG

Percutaneous Endoscopic Gastrostomy tube

https://www.safetyandquality.gov.au/sites/default/files/migrated/Recommendations-for-terminology-abbreviations-and-symbols-used-in-medicines-December-2016.pdf

Anti-Anxiety

Generic Medication Name ( And Brand Names) & Drug Class (Include Drug Schedule)

Actions (Link To Patho) & Indications

Adverse Reactions (Most Common) And Interactions (Including Drug Interactions If Any)

Methods Of Administration.  Is There An Antidote?

Nursing Considerations/Patient Education

eg.  Paracetamol (Panadol, Panamax, Dymadon) Analgesia & Antipyretic (S4)

Used for mild pain and fever.  Blocks pain impulses: it prevents prostaglandin synthesis in CNS or other substances that sensitise the pain receptors.  Reduces fever by acting on the hypothalamus

Liver damage with toxic doses.

Increases anticoagulation if on warfarin, alcohol may increase the risk of liver damage, caffeine may increase analgesic response, barbiturates/carbamazepine/ hydantoins/ rifampicin/ sulfinpyrazone: may ↓ therapeutic effect & ↑liver toxicity with high doses or long term use: DO NOT USE TOGETHER

PO (tablets, capsules, syrup, elixir, chewable, soluable, IV, PR

N-Acetylcycteine (NAC) can be used in overdose

Be careful if liver disease, be careful of other medications that contain paracetamol, for short term use only, seek dr advice if being used for high temps

Diazepam (Valium)

Benzodiazepines (S4)

Indicated for use in the treatment of anxiety disorders and acute stress reactions

It works by exerting anxiolytic, anticonvulsant and amnestic effect. It works by promoting the activity of the gamma-aminobutyric acid (GABA). The allosteric binding of the drug at GABA-A receptor results in an increased frequency of chloride channel opening. This further contributed to reduced excitability of the neuron (Dhaliwal, Rosani & Saadabadi, 2021).  

Some serious effects of diazepam are suicidality, respiratory depression, withdrawal symptoms and dependency. Other common side-effects are sedation, fatigue, irritability and confusion.

It is known to interact with opioid drugs, alcohol, marijuana and antihistamines.

PO (capsule or syrup)

Flumazenil can be used as an antidote in case of overdosing (Kurlawala et al., 2018).

The nurse should be careful while using the drug in special populations such as pregnant women and elderly patient. Vital sign monitoring is important after the administration of the drug. In addition, education on side-effects and foods to be avoided while using the drug should be given

ANTIdepressants

Generic Medication Name ( And Brand Names) & Drug Class (Include Drug Schedule)

Actions (Link To Patho) & Indications

Adverse Reactions (Most Common) And Interactions (Including Drug Interactions If Any)

Methods Of Administration.  Is There An Antidote?

Nursing Considerations/Patient Education

Fluoxetine (Prozac, Sarafem)

Selective serotonin reuptake inhibitors (H1)

Fluoxetine can be used for the treatment of major depressive disorder, obsessive compulsive disorder and bulimia nervosa

The drug works by blocking the reuptake of serotonin into the presynaptic serotonin neurons and by increasing the reuptake of transporter protein. It produces activating effect due to the reuptake of serotonin (Sohel,  Shutte & Molla, 2020). 

 The drug is known to produce some adverse effects such as bleeding, seizure, mania, weight loss, muscle weakness and decreased orgasm.

It has much drug-drug interaction because of its metabolism at the CYP2D6 isoenzyme.  It involves drugs such as anticonvulsants, lithium salts, anxiolytics, calcium channel blockers and antidepressants (Bahar et al., 2018).

PO(liquid form, tablet and capsule)

Fluoxetine is started at a dose of 20 mg per day.

There is no antidote for the drug. In case of overdose, supportive therapy can be implemented such as airway protection, ECGs and administration of benzodiazepines for sedation (Sohel,  Shutte & Molla, 2020).

Nurses should not initiate the drug in a patient taking linezolid and it should be used with caution in patients with a history of seizures. Patient education should prioritize giving knowledge on dose, precautions needed and signs that should be immediately informed to the nursing team.

Antipsychotic

Generic Medication Name ( And Brand Names) & Drug Class (Include Drug Schedule)

Actions (Link To Patho) & Indications

Adverse Reactions (Most Common) And Interactions (Including Drug Interactions If Any)

Methods Of Administration.  Is There An Antidote?

Nursing Considerations/Patient Education

Olanzapine (Zyprexa)

Atypical antipsychotics

Used for treatment of episodes of bipolar disorder and agitation in patients with schizophrenia. It exerts action on the dopamine and serotonin receptors and blocks the action of dopamine at the post-synaptic receptor

Some of the common adverse effects observed are drowsiness, dizziness, stomach upset and weight gain. It is known to have interactions with opioid drug, alcohol, marijuana and patients taking metoclopramide

PO(in the form of tablets)

Drug toxicity may take place due to overdose and some of the clinical features of overdose are agitataion, sedation, convulsions, delirium and tachycardia. There is no specific antidote for Olanzapine. Evidence shows that supportive management is the main therapy (Keyal et al., 2017).

 While giving Olanzapine to patient, it is important to frequently observe and monitor the blood glucose level of patients. In addition, education on appropriate diet and exercise is important. The patient should be educated about the rationale for drug use and the need for treatment too. Nurse should take precaution and avoid the use of the drug in breastfeeding woman. Post administration of Olanzapine, the assessment of mental status, blood sugar level and hemodynamic status should be done too (Kizior & Hodgson, 2021.

Mood stabilizing

Generic Medication Name ( And Brand Names) & Drug Class (Include Drug Schedule)

Actions (Link To Patho) & Indications

Adverse Reactions (Most Common) And Interactions (Including Drug Interactions If Any)

Methods Of Administration.  Is There An Antidote?

Nursing Considerations/Patient Education

Lithium  (Camcolit)

Antimanic agents (S4)  

It is used to treat episode of mania in patients with depression and abnormal moods.

The drug works by affecting the release of neurotransmitters and other chemicals inside the human body. It decreases presynaptic dopamine activity and inactivates the G-proteins. This action decreases excitatory neurotransmission in the brain. Patients with bipolar disorder have high number of dopamine associated G-protein units. Lithium alters the function of these subunits and corrects the dysregulation of dopamine  (Malhi et al., 2013).

Some of the adverse effects of the drug may include weakness, excessive thirst, urination, seizures and jerky movements.

The drug is known to interact with ACE inhibitors, NSAIDs and diuretics.

PO (tablet, capsule, solution) taken three to four times a day. It should be taken just as directed by the physician. Overdose of the drug may lead to severe nausea, vomiting, confusion and vision changes. There is no antidote for lithium toxicity and it can be removed by hemodialysis. This is required when patients shows serious signs of lithium poisoning or when they experience renal failure (Hedya, Avula & Swoboda, 2018)

The drug needs to be taken with precaution for patients with renal impairment and elderly patients.

The nurse should assess patient for hypersensitivity to tartrazine and history of renal or CV disease, pregnancy, lactation and those on diuretics. Examination of the patient for normal urine output, normal fluid intake and voiding pattern is important. The patient should be closely monitored in the initial stage.

The patient should be educated to take the drug as prescribed, maintain adequate fluid intake and go for frequent check-up. The drug should be discontinued when experiencing tremor or drowsiness (Finley, 2016).

Bahar, M. A., Kamp, J., Borgsteede, S. D., Hak, E., & Wilffert, B. (2018). The impact of CYP2D6 mediated drug–drug interaction: a systematic review on a combination of metoprolol and paroxetine/fluoxetine. British journal of clinical pharmacology, 84(12), 2704-2715.

Dhaliwal, J. S., Rosani, A., & Saadabadi, A. (2021). Diazepam. StatPearls [Internet].

Finley, P. R. (2016). Drug interactions with lithium: an update. Clinical pharmacokinetics, 55(8), 925-941.

Hedya, S. A., Avula, A., & Swoboda, H. D. (2018). Lithium toxicity. https://www.ncbi.nlm.nih.gov/books/NBK499992/

Keyal, N., Shrestha, G. S., Pradhan, S., Maharjan, R., Acharya, S. P., & Marhatta, M. N. (2017). Olanzapine overdose presenting with acute muscle toxicity. International journal of critical illness and injury science, 7(1), 69–71. https://doi.org/10.4103/2229-5151.201962

Kizior, R. J., & Hodgson, K. (2021). Saunders nursing drug handbook 2022 E-book. Elsevier Health Sciences.

Kurlawala, Z., Roberts, J. A., McMillan, J. D., & Friedland, R. P. (2018). Diazepam toxicity presenting as a dementia disorder. Journal of Alzheimer's Disease, 66(3), 935-938.

Malhi, G. S., Tanious, M., Das, P., Coulston, C. M., & Berk, M. (2013). Potential mechanisms of action of lithium in bipolar disorder. CNS drugs, 27(2), 135-153.

Sohel, A. J., Shutter, M. C., & Molla, M. (2020). Fluoxetine. StatPearls [Internet].  

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