School of Nursing and Health Sciences Administration of Medicines Workbook Year 1 STUDENT S NAME: CLASS/YEAR: SEP 2017 PROGRAMME: BSc Nursing, School of Nursing and Health Sciences. DATE WORKBOOK COMMENCED: DATE WORKBOOK COMPLETED: LEARNING TEAM FACILITATOR: MENTOR(S) SIGNATURE (S)/DATE: MENTOR(S) SIGNATURE (S)/DATE: MENTOR(S) SIGNATURE (S)/DATE: Revised 06/09/17 SR & FP
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Contents Introduction 4 Important information for students, mentors and learning team facilitators 5 Learning Outcomes 6 Tips before starting the activities in this workbook 7 Administration of medicines 8 Using the BNF 14 Administration of Medicines by Injection 23 Units of measurement and medicine calculations 28 Legislation Adverse drug effects 32 Information sources and suggested further reading 33 Reflection/personal notes 34 3
Introduction to the workbook Dear student, Completing this workbook is part of your portfolio requirements for year 1. You must complete this Workbook during your Year 1 practice placements and undertake the compulsory online medicine administration formative assessment which will be available between April and May 2018 on the Skills for Practice 1 module site. The purpose of this Workbook is to assist you towards becoming a safe and competent registered practitioner in the administration of medicines and controlled medicines. Part of your Ongoing Assessment Record (OAR) includes information about medicine administration skills for year 1. Please refer to the OAR document (which you will receive prior to your first placement). The terms medicine, and drugs are used interchangeably in practice. Both words have the same meaning and include oral medicines, controlled medicines and medicines that are administered via other routes, e.g. injection, topical creams, inhalation products. During your placements, you will be given the opportunity to see prescriptions and various medicines in different forms. Therefore, it is important that you start reading about common medicines, dosages, side effects and methods/routes of administration. To help you complete the workbook, there are local policies regarding administration of medicines/safe handling of medicines policies available within your placements, and other sources of information, e.g. British National Formulary (BNF). You should also access other information sources, e.g. the library, electronic journals and the BNF on-line. Space has been provided towards the end of this workbook for you to make personal notes to supplement your knowledge and skills as you progress through the range of practice settings and the undergraduate nursing programme. You will have various opportunities to discuss this workbook with your mentors in each of your first three placements and your Learning Team Facilitator/personal tutor. It is however, your responsibility to complete the activities. The NMC Standards for Medicines Management (2008 revised cover version 2010) is an essential resource that student nurses must read before and during the completion of this workbook. This can be accessed via the website address below: http://www.nmc.org.uk/standards/additional-standards/standards-for-medicinesmanagement/ During your first three short placements (Nov Feb, Year 1): you should only observe medication administration practice. Fourth and fifth placements (April and Aug Year 1): Once you have received further education at the Clinical Skills Centre and gained further knowledge after your first three placements, you are encouraged to practice administering medications (oral, Intra muscular (IM) and Subcutaneous (SC) under direct supervision in your fourth and fifth placements. 4
Important information for students, mentors and learning team facilitators Year 1 students should only observe medicine administration in their first three short placements in year 1 (Nov Feb). During their first three placements in Nov and Feb, students in Year 1 will not have received their clinical skills sessions on the administration of medicines (oral, IM and SC). Therefore, they should not be actively participating in this skill or checking controlled medicines in their first three placements. Students are however expected to regularly observe qualified nurses carrying out this skill during their first three placements. Students are also expected to look up resources such as the BNF to read about various aspects relating to common medicines, e.g. side effects, and also refer to local policies regarding the administration and safe handling of medications. Once students have attended the medicine administration clinical skills sessions after their first three placements, they can then practice the skill of oral, IM and SC medicine administration under direct supervision in their fourth and fifth placements in year 1 (April and August). Students are required to complete this workbook during their first year; therefore, it is important that students have sufficient opportunities to complete the workbook activities. Supply and/or administration of medicine by student nurses and student midwives in relation to Patient Group Directions (PGDs). A circular (SEP 09) from the NMC was distributed about Patient Group Directions (PGDs) in relation to the student nurse s role in the supply and administration of medicines. Student nurses cannot supply and/or administer medicines under a PGD, even if under direct supervision (NMC 2009). PGDs are specific written instructions for the supply and/or administration of a licensed named medicine including vaccines to specific groups of patients who may not be individually identified before presenting for the treatment (NMC 2009). Further information is available at http://www.nmc.org.uk/globalassets/sitedocuments/circulars/2009circulars/nmccircular-05_2009.pdf Administration of intravenous (IV) medicines or subcutaneous (SC) infusions The administration of intravenous medicines or subcutaneous infusions is a postregistration skill, and therefore student nurses can only observe these skills throughout their pre-registration education programme. In some areas, students may be permitted to assist in priming intravenous infusions of standard fluids such as Sodium Chloride (NaCL0.9%), however, this depends on local policy. Controlled medicines Although the NMC states that student nurses can be a second signatory for the administration of controlled medicines, students and mentors should refer to the placement s local policy/protocol/guideline regarding a student s role in the administration of controlled medicines as local practices can vary widely. 5
Learning outcomes As you progress through the Nursing Programme you will be provided with opportunities to demonstrate to your mentors and supervisors that you have acquired the essential knowledge, attitude and psychomotor skills to achieve the following learning outcomes. 1. Describe the main legislation controlling the supply, storage, prescription and administration of medicines. 2. Identify NMC standards and local policies, protocols and procedures pertaining to the supply, storage, prescription and administration of medicines. 3. Demonstrate an ability to calculate medicines in weight and volume. 4. Demonstrate effective use of the various sources of information for the prescription and administration of medicines. 5. Describe routes that may be used to administer medicines. 6. Differentiate between the routes that doctors, registered nurses and student nurses may use when administering medicines and justify your answers. 7. Demonstrate how to prepare patients to receive all forms of medication and by all routes and justify your actions. 8. Describe and demonstrate the nurse's role in the safe administration of medicines. 9. State the sites that may be used to administer medicines by injection and explain the rationale for selecting particular sites. 10. Explain and demonstrate the selection of equipment for administering medicines. 11. Explain and demonstrate the cleansing and safe disposal of equipment following the administration of medicines. 6
Tips before starting the activities in this workbook: Discuss with your mentor(s) and other members of the multidisciplinary team e.g. pharmacist, about how you can find the answers to some of the questions in the activities, and how to locate any relevant policies, information, etc. Read the NMC Standards for Medicines Management (2008/cover revised 2010) (see page 3 of this workbook for the website address). Locate and read the local policy used in each of your placements regarding the administration of medicines/safe and secure handling of medicines, including controlled medicines policies and procedures for checking these. Identify the prescriptions and recording sheets used in your placements and observe how to complete these correctly after the administration of a medication. Examine a prescription and consider and observe how the nurse checks that the prescription is legal, e.g. checking for prescriber s signature and date of prescription. Also, examine when a medication has been cancelled/discontinued on the prescription. Consider: what should the nurse do if part or all of the prescription is illegible? Identify the procedure to follow if a medicine is refused by the patient or if the medicine is out of stock. Identify the procedure to follow if a patient is unable to swallow oral medications and requires these to be administered via another route, e.g. enteral route (See NEWT guidelines http://www.newtguidelines.com/) Look at the information for activity 8 (page 14) on how to use the BNF (hard copy/paper/print version). Find a paper copy of the BNF on your placement and start to practice looking up some common medications that are used in your placements and their side effects In preparation for activity 22 on page 28, have a calculator handy. An electronic version of the chapter from Lapham (2015) is on the module site reading list. This is where the calculation questions are included, so you will have to access this electronic resource. 7
Administration of medicines Please carry out the following activities: Activity 1. Briefly define the following terms: 'Controlled Medicines' 'Medicines' 'Stock Medicines' 'Pharmacology' 8
Polypharmacy 'Prescription Only Medicines' ( PoM ) 'Proprietary and 'Non-proprietary' names of medicines 'Formulary' and 'Non-formulary' pharmaceutical preparations' Parenteral Route of Administration and Enteral Route of Administration 9
Activity 2. Describe the roles of the following people in the prescribing, dispensing and administering medicines. Pharmacist Doctor Registered Nurse Student Nurse Care Assistant Activity 3: Identify the different forms in which medicines are available e.g. tablets, capsules. 10
Activity 4: Identify the routes for administering medicines, e.g. oral route. Which routes may nurses use to administer medicines? Activity 5: Storage a) Where are medicines and pharmaceutical products stored in your current practice placement? b) Who may hold the keys for medicinal products cupboards? c) Who may hold the keys for the controlled medicine cupboard? d) Who is responsible for the ward stock of all medicines and pharmacy products? 11
Activity 6: Explain the nurse s responsibility in the following situations: A patient refuses to take his/her prescribed medication. A patient's tablets fall to the floor. A patient is unable to swallow his/her tablets. A patient in the ward has a packet of 'Rennies' in her possession and wishes to selfadminister them. On admission to the ward, a patient is found to have various medications prescribed by a GP amongst his belongings. 12
A patient requiring medications on discharge from hospital. Two patients in the ward have the same first and surnames. A member of the nursing staff requests some mild analgesia for a headache. A nurse from another ward wants to borrow a specific medication. The care and security of the medicine trolley. A container of medicines is missing from the ward. 13
Using the BNF Information about the British National Formulary (BNF) (print version) Although you will use the electronic version of the BNF to learn about medications while you are at University, you will be required to use the print version in clinical placements. The BNF is printed and updated every 6 months and provides information on all medicines available and licensed within the UK. When you are on your clinical placement, if possible, try and find an up to date version of the BNF. At the beginning of the book, there is a contents page. Find the page where the section how to use the BNF is located (the page number will vary according to the version/year that you have). This information is very important and will help you to use the BNF effectively throughout your education programme and future nursing career. How to use the BNF: This section of the BNF includes information on: The structure of the BNF How to find information in the BNF There is also an example of a typical layout of a drug monograph and preparation record to demonstrate how to see important information about the range of medicines within the BNF. The information includes: Indications Contra-indications Hepatic impairment Renal impairment Pregnancy Breast feeding Side-effects Dose Approved name Proprietary name Activity 8: Find out what each of the following words/terms mean in relation to medications: Indications: Contra-indications: Hepatic and renal impairment: 14
Activity 9: Access this short article by Bellerby & Needham (2016) on how to use the BNF effectively. The link to this article is available on the Skills for Practice 1 module site (in Reading List, Medicine administration). This article provides some useful tips on how to use the BNF. Also, access the information on the NES website on using the BNF (the link for this is in the Skills for Practice 1 module site Reading List too, under Medicine administration). 15
Activity 10: What is the 'Non-proprietary' ('Generic') Name for the following medicines? Zantac Lasix Largactil Maxolon Prozac Activity 11 : BNF online can be accessed via the address below. You can register free on the site below: by providing your email address: https://www.bnf.org/products/bnfonline/ Using the British National Formulary (BNF) online or an up to date paper based version, find out the following information about Paracetamol:- a) Classifications b) Indications for Use c) Cautions d) Contra-indications 16
e) Side Effects f) Dosage for adults and children g) Presentation h) Methods of administration i) Cost j) Name two other proprietary medicines that contain Paracetamol 17
k) Paracetamol may be listed in the Symptomatic Relief Policy within your placement. Explain the purpose of this Policy. Activity 12: What is meant by the following terms or abbreviations? a) enteric-coated (e/c) b) sugar-coated (s/c) c) capsule d) modified release (m/r) e) NSAID f) MAOI 18
Activity 13: Explain the nurse s role in the administration of topical medicines such as creams, ointments and lotions. Activity 14: Transdermal patches allow medication to be slowly released across the skin (transdermally) and absorbed into the circulation for a stated period of time following application. a. Name 3 classifications of medicines/controlled medicines that are presented in the form of transdermal patches. b. What is the nurse's role in administering medications to patients via the transdermal route? 19
c. What are the potential problems/side effects for patients receiving medication via the transdermal route? Activity 15: Discontinuation of medicines - How does the registered nurse know when a medicine on the prescribing sheet has been discontinued by the doctor/prescriber? Activity 16: Within your practice placements, find out how are Controlled Medicines: a. Ordered b. Delivered to the placement c. Received by the placement d. Stored e. Administered 20
f. Recorded g. Checked for stock balance h. Disposed of when prepared and unsuitable i. Destroyed if out of date Activity 17: What advice does the NMC give to registered nurses regarding the administration of homeopathic or herbal substances? Activity 18: What is meant by term non-medical prescribing? 21
Activity 19: Medication errors a) Identify factors which may lead to errors or incidents in the administration of medicines. b) What actions are taken if a medicine error occurs? c) What guidance does the Nursing and Midwifery Council (NMC) provide for registered nurses in the management of errors or incidents? 22
Activity 20: Select two medicines that are frequently prescribed in your current placement. Using the BNF, identify the following information about these medicines: Medicine 1 The reason why the patient has been prescribed the medicine, The recommended dose, according to factors such as age, weight. The form in which the medicine is prescribed, and any alternative forms. The common side effects Any special precautions. Medicine 2 The reason why the patient has been prescribed the medicine, The recommended dose, according to factors such as age, weight. The form in which the medicine is prescribed, and any alternative forms. The common side effects Any special precautions. 23
1. Define the term injection : Administration of medicines by injection (Activity 21) 2. In what forms are medicines for injection available? 3. What is the metric measure for solids? 4. What is the metric measure for liquids? 5. Explain why medicines may be administered by injection in preference to other methods: 24
6. Where may medicines for injection be stored? 7. Explain the differences between the following injection routes: Intramuscular Subcutaneous Intravenous Intradermal 25
8. By which routes may the following members of staff administer injections? Registered nurses Student nurses 9. Give an example of an injection route that may be used only by a doctor and outline the nurse s role in this procedure. 10. Which angle to the skin should the needle be when administering medicines via the: Intramuscular injection route? Angle - Why? Subcutaneous injection route? Angle - Why? 26
11 Differentiate between an injection route and an injection site. 12 What factors determine the site the nurse will use to administer medicines by the prescribed injection route? 13 What equipment will be necessary for administering an intramuscular or subcutaneous injection? 14 What would you be assessing on the patient s skin before giving an intramuscular (IM) medication or a subcutaneous (SC) medication? 15 Detail the possible complications for patients when medicines are administered by injection? 16 Identify three classifications of medicines commonly administered by injection? 27
17. Explain the following terms relating to IM injections: i) Z-track technique. ii) Depot injection. 28
Units of measurement and medicine calculations In current nursing practice, an important part of administering medicines is the need to calculate dosages. These calculations have to be performed competently and accurately to ensure that the nurse, and more importantly the patient, is not put at risk. A sound knowledge of the weights and measures involved is required to achieve this. Please refer to the year 1 numeracy tutorial slides which were delivered in semester 1 if necessary before starting the following activities. Activity 22 Read chapter 1 from the book by Lapham (2015), entitled Basics (see reference below). This book is available electronically from the library and a link is available on the Skills for Practice 1 module site (in the Reading list in the drug calculations section). Lapham, R. (2015). Drug calculations for nurses, a step by step approach.4th edition. CRC Press, Taylor and Francis group: Boca Raton. Once you have read this first chapter, try out some of the pre-test questions in section xix at the beginning of the book. This book contains a range of chapters that are all related to drug calculations for all types of placements, so please read this throughout your first year to help you revise your arithmetic/numeracy skills. Use the space below and the next page for any notes from chapter 1 that that will help you with your revision. Numeracy notes 29
Numeracy Notes 30
Numeracy Notes 31
Legislation Activity 23 Below is some information relating to legislation for you to read and find out more about. For further information about legislation, access resources such as the current versions of the BNF and the NMC Standards for Medicines Management. Medicines act 1968: This was the first comprehensive legislation on medicines in the United Kingdom. It relates to control and regulation of how medications are manufactured, tested and quality controlled before they reach the patient. The misuse of Drugs Act 1971: This Act prohibits certain activities in relation to Controlled Drugs, in particular, their manufacture, supply and possession. Medicines liable to abuse and misuse are called Controlled Medicines/Drugs. These are controlled by the Misuse of Medicines Act 1971. These medicines are classed as Class A, Class B and Class C. Class A is identified as being the most harmful, e.g. diamorphine (heroin). Class B are classed as less harmful, e.g. cannabis, amphetamines. Class C medicines are classed as the least harmful, e.g. some pain killers, tranquillisers and anabolic steroids, although these are still regarded as potentially harmful if not used properly. All nurses should be fully aware of the range of these medicines and to comply with the law all times. The misuse of medicines regulations, 2001 There are five schedules under the regulations, each of which details the requirements for import, export, production, supply, possession, prescription and record keeping of specific medicines named in the five schedules, e.g. Schedule 1 cannabis and cannabinoids Schedule 2 opiate-based medicines used in palliative care Schedule 3 synthetic opioids Schedule 4 prescription only medicines, e.g. benzodiazepines. Schedule 5 medicines that contain very low dosages of medicines, such as codeine. Activity 24: Adverse drug reactions Please access the following NES website (link below) and undertake the activities within each section in Module 1 basic principles of adverse drug reactions i.e. Introduction, definitions, risks versus benefits, case study and key points. http://www.knowledge.scot.nhs.uk/scormplayer.aspx?pkgurl=%2fecomscormplayer%2f ADRmodule1%2f 32
Information sources Skills for Practice 1 Module site Reading list. Copies of local policies related to the administration of medicines should be available in paper format within the placement. These are also available in NHS placements via the NHS intranet. For information about the Acts and Regulations please refer to a current edition of the BNF and/or the NMC Standards for medicines management (see websites below). NMC Standards for Medicines Management (2008, revised cover 2010) http://www.nmc.org.uk/standards/additional-standards/standards-for-medicinesmanagement/ British National Formulary - BNF online http://bnf.org/bnf/index.htm National Patient Safety Agency, Medication Safety. http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/medication-safety/ The NEWT guidelines for administration of medication to patients with enteral feeding tubes or swallowing difficulties http://www.newtguidelines.com/ Suggested further reading DOUGHERTY, L., et al. eds. 2015. The Royal Marsden Hospital manual of clinical nursing procedures. 9th ed. West Sussex: Wiley Blackwell. FIFE NHS BOARD AREA MEDICINES AND THERAPEUTICS COMMITTEE. Formulary. Fife Joint Formulary. http://www.fifeadtc.scot.nhs.uk/ (accessed on 31/08/2017). LAPHAM, R., 2015. Drug calculations for nurses, a step by step approach. 4 th ed. Boca Raton: CRC Press. O BRIEN, M et al., 2011. Introduction to medicines management in nursing. Exeter: Learning Matters Ltd. 33
NHS TAYSIDE The safe and Secure Handling of Medicines Policy http://www.nhstaysideadtc.scot.nhs.uk/sshm/main/front%20page.htm (Accessed 31/08/2017) NURSING AND MIDWIFERY COUNCIL, 2006. Standards of proficiency for nurse and midwife prescribers. London: NMC. NURSING AND MIDWIFERY COUNCIL, 2015. The Code for nurses and midwives. http://www.nmc.org.uk/standards/code/ NURSING AND MIDWIFERY COUNCIL, 2009. Record keeping: guidance for nurses and midwives. London: NMC. ROYAL COLLEGE OF NURSING, 2004. Patient group directions: guidance and information for nurses. London: Royal College of Nursing. SCOTTISH EXECUTIVE, 2006. Non-medical prescribing in Scotland. Edinburgh: NHS Scotland. Other Sources of Information The current paper-based version of the British National Formulary (BNF) which is usually available on every placement Monthly Index of Medical Specialties (MIMS) Tayside Area Formulary NHS Tayside Policy for Just in Case Boxes NHS Tayside Covert (Adults) Medication Policy NHS Tayside Adverse Drug Reporting http://www.nhstaysideadtc.scot.nhs.uk/netformulary/pdf/adverse%20drug%20reactio n%20reporting.pdf Pharmacy Department Staff Nursing and associated text books Nursing and associated journals 34
Reflection and personal notes Now that you have completed the activities in the Workbook and reflected on your learning, you should find that your knowledge of Medicine Administration has developed considerably. It is recommended that you continue to use this Workbook as an information source throughout your undergraduate course and beyond. Remember to add your own information to pages provided for this purpose. Add further pages for notes as required. 35
Type of medication Dosage Side effects Contraindications Personal information/notes: 36
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Type of medication Dosage Side effects Contraindications Personal information/notes: 38
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Type of medication Dosage Side effects Contraindications Personal information/notes: 41