C HAPTER 5 D RUG ORDERS

C HAPTER 5 D RUG ORDERS Learning Outcomes 5-1 Summarize the Rights of Medication Administration. 5-2 Interpret a written drug order. 5-3 Identify on physicians orders and prescriptions the information needed to dispense medication. 5-4 Locate on medication administration records or electronic medication records the information needed to administer medication. 5-5 Recognize drug orders that do not contain all the necessary information to carry out the orders safely. 5-6 Select appropriate action for confusing, incomplete, or illegible drug orders. Chapter Outline 5-1 The Rights of Medication Administration 5-2 Roman Numerals 5-3 Physicians Orders and Prescriptions 5-4 Medication Administration Systems 5-5 Medication Reference Materials Lesson Plan Anticipatory Set Introduce the rights of medication administration. Differentiate between the basic five rights and the additional rights. Distribute ten index cards to each student. On each card, have students write one of the ten rights as found on Table 5-1, page 140 in the text/workbook and listed here. (1 to 5 are basic 6 to 10 are additional rights) 1. right patient 2. right drug 3. right dose 4. right route 5. right time 6. right reason 7. right to know 8. right to refuse 9. right technique 10. right documentation On the back of each card, have them write the procedure that ensures the step (or right ) has been accomplished correctly. Have one partner in each pair shuffle her ten rights cards and place each one with the right side (not the procedure side) up to the left of the correct numbered card. This student should then ask his partner to explain the procedure for ensuring each right. After each explanation, the student should check his partner s explanation. If the explanation is correct and complete, the student should allow his partner to remove her right card. His partner should study the procedures for any rights cards that remain on the desk. Finally, the two partners should change roles and repeat the activity until each partner can correctly sequence and explain the procedures to accomplish each of the ten rights. Teaching Strategies Assign and collect the homework for Chapter 5. Check the student s answers to discover the topics within the chapter that require the most focused attention during class time. Have a health care professional visit the class and discuss their role in dosage calculations as well as the importance of math accuracy and preventing medication errors in the health care profession. Have students review the key terms for Chapter 5 using the Audio glossary and Key Term Concentration game on the student CD. Have students in groups of three; review their basic math skills using the Math Challenge game on the student CD. Encourage students to complete each review and practice section in the text/workbook and check their answers. You can also remove the answers from the back of the book and use the review and practice questions as a graded assignment. Use the Critical Thinking on the Job Activities from Chapter 5 as Think-Pair-Share assignments in class. Have student groups discuss their answers and present to the rest of the class. 54

Use the PowerPoint presentation for Chapter 5, found on the student and instructor resource CD- ROM, for a class lecture and/or review. Use the Test Your Knowledge questions for discussion. The online learning center at www.mhhe.com/ MathDosage3e contains additional activities for each chapter. Links for the Internet activities from at the end of this chapter are provided on this site. Have students navigate to this site to complete the Internet activities. Play the Spin the Wheel on the student CD with individual, small groups or within the classroom in preparation for the final evaluation. Assess Use the Additional Exercises for Chapter 5 found at the end of this document for reinforcement of chapter concepts. These exercises can also be used as chapter quizzes. Students should complete each student CD activity when directed within the text. Have students save, print, or email their completed Progress Report from the student CD for Chapter 5. The chapter review should be completed and checked in preparation for the final chapter evaluation. Using the EZTest test bank for Chapter 5, create a written test in two versions for a final evaluation of student s proficiency. Access the Instructor s Manual documents in electronic format and modify to match your curriculum needs. Use the chapter images and labels to create your own worksheets, tests, or PowerPoint presentations. C HAPTER 5 Solutions 5-1 The Rights of Medication Administration 1. The medication bottle said for optic use and the medication was instilled into the patient s ears. D. Right route 2. A blood thinner most likely should not be given to a patient with a bleeding disorder. H. Right reason 3. James F. Jones received James E. Jones medication. A. Right patient 4. The nurse charted a medication on the medication record before the patient had taken the medication. G. Right documentation 5. When a patient asks why they are getting a medication they should be told. I. Right to know 6. The dose to be administered was 1/2 teaspoon and the patient received 5mL. C. Right dose 7. The medication was ordered at bedtime and the patient took it at 9 A.M. E. Right time 8. The physician ordered Uracel and the patient received uracil. B. Right drug 9. The medication was to be given under the tongue and the patient was told to swallow it. F. Right technique Critical Thinking on the Job: Understanding the Order of Roman Numerals: The numeral with the smaller value comes immediately before the one with the larger value. Instead of adding i and x, the health care professional should subtract i from x to calculate the correct dose of 9 gr. 5-2 Roman Numerals 1. 6 2. 12 3. 9 4. 14 5. 24 6. 18 7. 5 1/2 8. 9 1/2 55

9. 11 1/2 10. 25 11. 19 12. 8 1 2 13. 21 4 17 21 14. 26 12 14 26 15. 11 8 3 11 16. 10 5 5 10 17. 16 23 7 16 18. 7 16 9 7 19. 18 21 3 18 20. 25 30 5 25 Critical Thinking on the Job: The Importance of the Right Dose: The pediatrician made the initial error by not specifying the dose. This error does not relieve the health care professional of her responsibilities. They are/should have recognized that one of the rights of medication administration the right dose was missed in this order. They should have called the physician to clarify the desired dose. Critical Thinking on the Job: The Importance of the Right Drug: The health care professional should have read the label 3 times to be certain that he had the correct drug. If the label was shown to the physician, the error could have been avoided. 5-3 Physicians Orders and Prescriptions 1. Prescription A includes all required elements. The patient s name is Ann Pechin, the drug is Lopressor, the dose is 50 mg given in 1 tablet (tab i), the route is oral (po), the frequency is three times a day (tid), 90 tablets are to be dispensed at one time, and the prescription may be refilled five times. The card includes the physician s name, signature, and prescriber number. 2. 90. The section Quan tells the quantity to dispense. 3. Three times a day. The frequency tid is in the section labeled Sig. 4. 50 mg. This information appears after the drug name. 5. 180 days or approximately 6 months. The patient takes one tablet three times a day, or 3 tablets per day. The 90 tablets in the original prescription will last 30 days. Each refill will last another 30 days. Five refills will last 150 days. Thus, the original order and the refills will last 180 days, approximately 6 months. 6. Prescription B does not include adequate information to determine the dose. Amoxil oral suspension comes in strengths of 50 mg/ml, 125 mg/ml, and 250 mg/ml. A teaspoon of each yields a different dose. The physician must specify the solution strength. 7. 100 ml; however, the pharmacy technician still needs to know the solution strength. 8. One teaspoon (1 tsp) 9. It cannot be refilled. Refills is marked 0. 10. Every 8 hours (q8h) 11. Prescription C does not include the following: Dose since Norvasc comes in 2.5, 5, and 10 mg tablets it is unknown which to use Complete first name of the patient Frequency of the dosing Form of the medication 12. 30; however, the pharmacy technician still needs to know the strength of the tablets. 13. One; 1 po, but the frequency of dosing needs to be clarified. 14. 2 refills are indicated. 15. Without knowing how frequently the patient is to take the medication, it is not possible to determine how long 30 tablets will last. 56

16. Three times a day (TID) before meals (AC). If no time is specified, AC medications are usually given 30 minutes before meals. 17. Instilled into the left eye (OS) 18. Once a day (qd) 19. 0.4 mg 20. Orally (po) 21. Twice a day (BID) 22. 0.25 mg 23. Once a day (QD) at bedtime (HS) 24. Sublingually (SL) 25. Seven. Risperdal is administered once a day. The patient would need seven pills for the week. Critical Thinking on the Job: When in Doubt, Check: By using her critical thinking skills, the health care professional has prevented a serious error. The Lasix order appears to be 600 mg. However, she realizes that the second zero of 600 is actually the loop of the q from the Digoxin order. The intended dose of Lasix is 60 mg. If she had not checked the physician s orders, she might have given 10 times more than the physician intended. When in doubt, always verify the order written on the chart. In this case if daily was used instead of qd, the error would not have occurred. 5-4 Medication Administration Systems 1. The special instructions (hold for systolic BP < 110) indicate that the Accupril is not to be given if systolic blood pressure is below 110. You must first check the patient s blood pressure. 2. 5 mg 3. The time 0630 is listed. The patient should receive her insulin at 6:30 A.M. 5. The Maalox order includes the instruction 2 H PC and HS, which means 2 hours after meals and at bedtime. The times 1000 1400 1900 would be 2 hours after this facility s mealtimes of 0800, 1200, and 1700. The time 2200, or 10:00 P.M., represents the patient s bedtime. 6. Each dose for this patient is 30 ml. 7. 45 units (45 U)/mL 8. No times are indicated because the Dulcolax is to be given prn, or only if the patient has a need for it. 9. Normodyne, Atrovent, Buspar 10. C. Dulcolax and B. Humulin 11. C. The order indicates that the medication is to be administered prn, but does not indicate why the patient would need it or the dose that should be given. B. The order does not include the route the medication should be administered. 12. Oral (po) 13. 2 puffs 4 times a day via a multi-dose inhaler (MDI) 14. The Furosemide should be given as soon as possible. Stat means immediately. 15. Viroptic should be instilled into both eyes. OU means both eyes. 16. Ancef should be administered by IVPB, or intravenous piggyback. 17. Dilantin, Ancef, Viroptic 18. 3 doses of Adalat, Ancef, and Dilantin 6 doses of Viroptic 1 dose of Furosemide would be given on the day of the order. 19. The patient will receive Viroptic 6 times a day. 20. Furosemide and Ancef 4. The route is Sub-Q, or subcutaneous injection. 57

5-5 Medication Reference Materials 1. B 2. C 3. D 4. A 5. Take one teaspoonful by mouth every 8 hours until gone Name Address Rx: Jeannies Kucharek Mark DeSantis 123 Baker Drive Owosso, MI 48867 989-555-1234 Amoxil 250 mg/5ml Date 1/23/2012 C HAPTER 5 H OMEWORK S OLUTIONS Referring to Prescription 1 1. Take 1 tablet three times a day by mouth 2. oral 3. refills are not specified, so no refills can be given Mark DeSantis 123 Baker Drive Owosso, MI 48867 989-555-1234 SIG: Refills: Prescription 2 1 tsp. p.o. q8h until gone MD1234567 Referring to Prescription 3 Mark Desantis, MD 6. The order is for ear drops, but the instructions are for the drops to be used in the left eye. The physician must be contacted to determine if this order is for the ear or for the eye. Name Address Jeannies Kucharek Date 1/23/2012 Mark DeSantis 123 Baker Drive Owosso, MI 48867 989-555-1234 Rx: Synthroid 0.1 mg Name Jeannies Kucharek Date 1/23/2012 QUANTITY: #30 Address SIG: tab i po tid Rx: Cortisporin Otic Drops Prescription 1 MD1234567 Referring to Prescription 2 4. Before filling, you must know the quantity to dispense. Contact the physician to learn this quantity or to find the number of days the patient is to be on the medication QUANTITY: SIG: Refills: Prescription 3 5 ml gtts. ii os quid 0 MD1234567 Referring to MAR1 7. subcutaneously 8. 4 times Mark Desantis, MD 58

9. 5/23/12 the first odd day after the order 10. 3 11. 12 midnight Order Medication, dose, date duration frequency Init. route 5/21/12 heparin 5,000 units sub-q q12h 5/22/12 Procan SR 500 mg tab-sr po q6h 5/22/12 digoxin [Lanoxin] 125 mg tab po daily odd days 5/22/12 furosemide [Lasix] 40 mg tab po daily TCP Hospital Medication Administration Record D/C date init. 05 Feb 12 Dates Administered Times 22 Feb 23 Feb 24 Feb 25 Feb 26 Feb 27 Feb 28 Feb 0900 2100 0600 1200 1800 0900 0900 2400 C HAPTER 5 REVIEW Check Up 1. Administer one 2-mg tablet of Dilaudid orally when necessary for pain, as often as every four hours. 2. Administer one 30-mg tablet of Codeine orally four times a day. 3. Instill 2 drops in the right eye 4 times a day (gtts ii od QID). 4. twice (Refills: 2) 5. instilled into the right eye (od) 6. The label should include for ophthalmic use. 7. every 8 hours (q8h) 8. by inhalation, using a metered dose inhaler (MDI) 9. 1000 (Q6H, 6 hours later) 10. 8 tablets. Each dose is 2 tablets. The patient may have one dose every 6 hours, so she can receive 4 doses per day. 11. 200 mg 12. twice a day (BID) 13. Intravenous (IV) 14. 10 mg 15. 8:00 P.M. is 2000. Trental and Rocephin are administered at 2000. 16. three times a day (TID) 17. He should be served breakfast at 8:00 A.M. Mr. Simons is scheduled to be given Propulsid at 7:30 A.M. This medication should be given 30 minutes before breakfast. In addition, he is scheduled to be given Trental at 8:00 A.M. Trental should be given with food. 18. Order B for Tobramycin violates the Right Time Rule. The order is for tobramycin every 8 hours, but the times given are every 6 hours. Order C for Rocephin does not list a specified route. Order D for Propulsid does not list a specific frequency. The abbreviation AC means before a meal. It cannot be assumed that this means it should be given before every meal. A frequency is still required. 19. OD, instilled into the right eye 20. 1.25 mg 21. 0800, 1400, and 2000 (8 a.m., 2 p.m., 8 p.m.) 22. A. Heparin and D. Proventil 23. 4 hours later, or 0600; The medication card indicates that Benadryl should be administered whenever necessary (PRN) every four hours (q4h). If Margaret Bell has a dose at 0200, the next dose will be at 0600. 24. q8h, every 8 hours 25. He would receive 3 doses per day, and they would be spaced throughout the day. For instance, at 0800, 1400, and 2000. (8 a.m., 2 p.m., 8 p.m.) 26. B. Bleph-10 does not give the dose. (Do not interpret the 10 in Bleph-10 as the dose.) C. Premarin does not give the route. 27. Determine if the patients ate at lunchtime. Determine if any medications have to be taken on an empty stomach. Double-check your calculations to ensure that they are correct and that your answers make sense. Make sure you use the appropriate measuring device to administer medications. Finally, ensure that there are no time considerations for administering these medications after a meal. 59

28. Ask patients their names before administering medication. Verify their names with patient identification bracelets. Do not administer drugs that are typically prescribed for the elderly to children or vice versa. Critical Thinking The order includes the abbreviation stat, which means immediately. You must carry out the order as quickly as possible. However, the order does not include all necessary information. Lasix is available in several strengths, including 10-mg, 20-mg, and 40-mg tablets. Before carrying out this order, contact the prescribing physician and determine which strength was intended. Have the physician rewrite the order or countersign it after you have rewritten it so that it lists the correct dose. Promptly obtain a tablet of the correct strength and administer it to the patient by mouth. Case Study 1. Tell Mr. Burke to take one Xanax tablet with breakfast, lunch, and dinner. One tablet three times a day with meals. 2. Give Mr. Burke 120 tablets at one time (Quan: 120). You may refill the prescription once (Refills: 1). Internet Activity According to the article on cephalexin, the usual adult dose of cephalexin is 1 to 4 g daily, in divided doses. If the patient receives 500 mg q6h, the patient will receive 500 mg every 6 hours or 4 times a day. Four doses of 500 mg is a total of 2000 mg, or 2 g per day. This amount is within the acceptable range. You may want to check for more information by using cephalexin as your search word. 60