AmericanNurseToday.com September 2018 American Nurse Today 99 FOCUS ON...Medication Management M ost nurses administer medications every day. Because it’s such a frequent, repetitive task, we may take our knowledge and skills for granted. For that reason, we should peri- odically revisit the principles of medication administration that we learned in nursing school and re- mind ourselves that medication ad- ministration, like nursing, is both an art and a science. The science behind medication administration is our knowledge of pharmacology, pathophysiology, and anatomy and physiology that guides us to make safe decisions and anticipate complications. The science helps us understand why a medication is ordered (a beta- blocker manages a fast heart rate and hypertension) and what its potential adverse effects might be (beta-blockers cause bronchial con- striction, which may lead to dysp- nea in a patient with asthma). The art comes from how we im- plement plans to improve a pa- tient’s physical condition and in- crease his or her chance of a good outcome. We advocate and collab- orate with other healthcare team members, and we reach beyond our current knowledge to specialized resources when something about the patient’s condition doesn’t “feel” right and we want to see if he or she is experiencing an adverse ef- fect that we aren’t familiar with. The following case study illustrates how the art and science combine to The art and science of medication administration This case study illustrates nursing skills and critical thinking in action. By Sophia Beydoun, MSN, RN
Transcript
AmericanNurseToday.com September 2018 American Nurse Today 99
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Most nurses administermedications every day.Because it’s such afrequent, repetitivetask, we may take our
knowledge and skills for granted.For that reason, we should peri-odically revisit the principles ofmedication administration that welearned in nursing school and re-mind ourselves that medication ad-ministration, like nursing, is bothan art and a science.
The science behind medication
administration is our knowledge ofpharmacology, pathophysiology,and anatomy and physiology thatguides us to make safe decisionsand anticipate complications. Thescience helps us understand whya medication is ordered (a beta-blocker manages a fast heart rateand hypertension) and what itspotential adverse effects might be(beta-blockers cause bronchial con-striction, which may lead to dysp-nea in a patient with asthma).
The art comes from how we im-
plement plans to improve a pa-tient’s physical condition and in-crease his or her chance of a goodoutcome. We advocate and collab-orate with other healthcare teammembers, and we reach beyond ourcurrent knowledge to specializedresources when something aboutthe patient’s condition doesn’t “feel”right and we want to see if he orshe is experiencing an adverse ef-fect that we aren’t familiar with.
The following case study illustrateshow the art and science combine to
The art and science ofmedication administration
This case study illustrates nursing skills and critical thinking in action.
By Sophia Beydoun, MSN, RN
100 American Nurse Today Volume 13, Number 9 AmericanNurseToday.com
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achieve optimal patient outcomes.The patient is typical of many whoare admitted to an acute-care facili-ty—he has multiple comorbiditiesand is taking multiple medications.
The patientYou’re assigned to care for Mr. Smith,a 75-year-old man admitted 2 daysago for difficulty breathing and in-
creased edema in both feet. His ad-mission diagnosis is heart failure(HF) exacerbation. Before you startyour shift, you review his history,medications, and admission labwork.
History. Mr. Smith’s medical his-tory includes biventricular HF (lastejection fraction was 50%), chronicobstructive pulmonary disease, atri-
al fibrillation, hypertension, benignprostatic hypertrophy, type 2 dia-betes, and stage 3 chronic kidneydisease. He has no known medica-tion or food allergies.
Medications. Mr. Smith’s medica-tion orders include: bumetanide 1mg by mouth twice daily, spirono-lactone 25 mg by mouth daily, dilti-azem 240 mg extended-release by
Both nursing students and experienced nurses can benefit from these tips.• Understand the purpose of the medication as it relates to individual patients; some medications have many therapeutic uses.• Monitor both therapeutic and adverse outcomes of medications, including medications administered by the previous shift.• Check if the dose ordered for your patient is within the recommended range. This will get easier as you learn the appropriate
doses. If you’re not sure, collaborate with a pharmacist.
Drug classification Commonly used Assessment data Lab data to review Interactions Side effects
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mouth daily, metoprolol 100 mg bymouth twice daily, apixaban 2.5 mgby mouth daily, hydralazine 25 mgby mouth three times per day, in-sulin glargine subcutaneous 10units at bedtime, insulin aspart 2 to12 units subcutaneous per slidingscale before meals and at bedtime,hydrochlorothiazide 12.5 mg bymouth daily, losartan 50 mg by
mouth twice daily, isosorbide dini-trate 10 mg by mouth three timesper day, tamsulosin 0.4 mg bymouth at bedtime, fluticasone andvilanterol one puff inhalation daily,and clopidogrel 75 mg by mouthdaily.
Laboratory results. Mr. Smith’s ad-mission electrolyte panel was sodi-um 135 mEq/L (within normal lim-
• Pay attention to trends in vital signs and labs; drastic changes from baseline may determine whether you hold or administer a medication.• Teach patients and caregivers about medications, including rationale, dosage, proper administration, and adverse effects.• Learn drugs by pharmacologic classification. Below is an example (classifications of various cardiovascular drugs) of how to
structure what you learn.
Drug classification Commonly used Assessment data Lab data to review Interactions Side effects
Central-acting • Clonidine (Catapres) • BP No applicable lab • Vasodilator • Hypotensionadrenergic • Apical HR values to review medications • Bradycardia • Beta-blockers • Calcium channel blockers
Vasodilator • Hydralazine • BP No applicable lab • Nitrates • Hypotension (Apresoline) values to review • Any medication used to manage blood pressure (beta- blockers, ACI, ARB)
Anticoagulants • Apixaban (Eliquis) • BP and HR (signs • Hemoglobin and • Aspirin products • Bleeding • Enoxaparin (Lovenox) of hypovolemia hematocrit • NSAIDs • Bruising • Heparin subcutaneous secondary • PT, INR (warfarin) • Antiplatelet agents • Intracranial injection or infusion to bleeding) • aPTT (heparin (e.g., clopidogrel) hemorrhage • Warfarin (Coumadin) • Basic neurologic infusion) assessment • Platelet count (orientation) • Signs of bleeding in gums, stool, or urine
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white blood cell count is 5,000/mcL (WNL), red blood cell count is4,600,000/mm3 (below normal), he-moglobin is 11 g/dL (below nor-mal), and platelets are 189,000/mcL(WNL).
Assessment. At the start of yourmorning shift, you assess Mr. Smith.His vital signs are blood pressure(BP) 100/58 mmHg, heart rate (HR)57 beats per minute (bpm), respira-tory rate (RR) 22 even and nonla-bored, pulse oximetry 91% on 2Loxygen by nasal cannula. His 0630blood glucose level is 100 mg/dLand requires no insulin coverage.Mr. Smith’s creatinine is 2.5 mg/dL,K+ is 2.9 mEq/L, and Mg++ is 1.8mg/dL. His hemoglobin and plateletlevels are essentially unchangedfrom admission.
Clinical decision timeWith the information you’ve gath-ered, you’re now ready to apply thenursing process and the “rights” ofmedication administration (right pa-tient, right drug, right time, rightroute, and right dose) to determineif the ordered medications can beadministered safely to this patient.You realize that Mr. Smith is show-ing signs of adverse effects of themedications used to manage his HFand other comorbidities.
You call the provider to reportyour key findings, including thatMr. Smith’s BP and HR are belowthe lower side of his trends duringhis hospitalization (110-118/62-68mmHg and 60 to 65 bpm, respec-tively). You explain that there areno written BP or HR parametersto hold Mr. Smith’s cardiovascularmedications and ask whether thefollowing 0900 cardiovascular med-ications should be held based onyour assessment: losartan, isosor-bide dinitrate, diltiazem, and me -toprolol.
You also let the provider knowabout Mr. Smith’s continued hy-pokalemia and increase in creati-nine, which, along with his reduc -ed GFR, indicate kidney problems;three of Mr. Smith’s medications(bumetanide, hydrochlorothiazide,and spironolactone) could further
compromise his kidney function.The other 0900 medications
(apix aban and clopidogrel) aresafe to administer because Mr.Smith’s hemoglobin and plateletlevels remain stable.
The provider writes an order todecrease the metoprolol dose from100 mg to 50 mg two times per day,to administer 50 mg this morning,and to decrease the diltiazem ex-tended-release dose from 240 mgto 120 mg daily. The provider alsowrites orders to take afternoon vitalsigns and administer the new ordereddose of diltiazem if the patient’s HRis ≥ 60 bpm. The provider instructsyou to administer the spironolactoneas written but to hold the morningdoses of bumeta nide, losartan, andhydrochlorothiazide and re-evaluatethe next morning when the elec -tro lyte panel is redrawn. Thesemedications increase the risk ofdehydration because of increasedurination, which can lead to fur-ther renal compromise. To treat theelectrolyte imbalance, the providerorders a one-time electrolyte re-placement for K+ and Mg++ andwrites parameters for when to holdmedications that affect HR and BP.
That afternoon, Mr. Smith’s HR is62 bpm and his BP is 118/64 mmHg.These improvements indicate thatthe decision to hold the morningdoses of diltiazem, metoprolol, hy-drochlorothiazide, losartan, and bu -metanide was appropriate. You notethe HR and BP parameters for meto-prolol and diltiazem in the electron-ic health record. Because of yourcareful and diligent application ofpharmacology principles, nursingprocess, and collaboration with theprovider, Mr. Smith’s medicationdosages are adjusted to safely meethis needs.
OutcomesDuring rounds the next morning,the provider thanks you for yourinput the previous day. By apply-ing your pharmacology and anato-my and physiology knowledge,you prevented complications. Mr.Smith’s morning electrolyte panelsare K+ 4.0 mEq/L (WNL), Mg++
2.0 mg/dL (WNL), and creatinine1.9 mg/dL (lower than the previ-ous day). The decision to holdlosartan, hydrochloro thiazide, andbumetanide helped to return hiskidney function to baseline. HisBP is 118/70 mmHg and his HR is64, both WNL.
The provider explains that thedoses of diltiazem and metoprololwere high for Mr. Smith and thatthe adjustments were needed. Mr.Smith’s hemoglobin level is main-tained as well as his platelet count.The previous day’s administrationof apixaban and clopidogrel hasnot led to bleeding or affected thepatient’s hemoglobin level.
Mr. Smith is ready for discharge.You provide education, handouts,and information about the precau-tions he should take with eachmedication and how they help tomanage his HF and other medicalconditions.
Evaluate, collaborate, advocateMedication administration requirescareful thought each step of theway. (See Tips for successful med-ication administration.) Never ad-minister medications only becausethey’re ordered. Instead, criticallyevaluate patients’ labs and currentassessment data, collaborate withproviders, and advocate for yourpatients’ health and safety.
Sophia Beydoun is a member of the nursing facultyat Henry Ford College in Dearborn, Michigan.
Lilley LL, Rainforth Collins S, Snyder JS. Phar-macology and the Nursing Process. 8th ed. St.Louis: Elsevier; 2017.
Tompkins McMahon J. Improving medicationadministration safety in the clinical environ-ment. Medsurg Nursing. 2017;26(6):374-7,409.
Williams T, King MW, Thompson JA, Cham-pagne MT. Implementing evidence-basedmedication safety interventions on a progres-sive care unit. Am J Nurs. 2014;114(11):53-62.
