all right chapter two legal Regulatory and ethical aspects of Drug Administration I don't know if there's a big black circle in the bottom right corner of the slides that you see I don't know how to get rid of it so if it's there I do apologize it's just something that pops up when I try to record so again I'm sorry so first of all we need to know that federal laws control how certain drugs can be given and we have state laws that can help tells us who can prescribe and dispense and administer medications and how they're to be implemented and so forth and there's also agency or facility guidelines and we'll talk about that in our in the presentations as we go along but this is some information that I added that I found in your textbook that I wanted to make sure you get so it starts right off in your notes legal and ethical legal and ethical considerations mixing medications with food or drinks so you know we think well why can't I just mix my meds with my patients food so they can take it easier you can but notice that a nurse has an ethical responsibility to notify the patient the family the provider of doing it my question is why why do we have to tell somebody because if you are just giving them a bite of food and their medications in there and they don't know it it's sort of like lying to them so it's okay to do it just tell them you're doing it if the patient is not informed it's called covert Drug Administration and it means covert like secret that's what covert is okay so you document that you do it it's not a big deal it's just unethical to not inform the patient they're getting their meds in their food okay so you crush a pill you put in their applesauce say here's your medication in your applesauce okay um be aware of foods and drinks that should not be given with medications and a really good example is grapefruit juice now I know you can't see it real well because the big old black dot there I again I don't know how to get rid of it but grapefruit juice is an example of a food or drink that affects metabolism of many drugs now it can affect absorption but mostly it affects metabolism and what it does is it actually delays metabolism of many many medications if we delay metabolism that means the drug stays in the body longer and that can make them toxic you want to follow do not Crush guidelines on medications like things that are enteric coded enteric coding is a coding that's on some medications that allows it to not dissolve until it bypasses the stomach and gets into the small intestine the pH is different there and that helps prevent stomach ulcers so enteric code you don't want to crush those the coating has a purpose extended release Time released those are sort of like a no-brainer the whole point of it is to release the medication over time if you crush it or open the capsules are going to get the medication all at once some other important terms are drug diversion and impaired nurses drug diversion is the illegal transfer of regulated drugs like narcotics from the patient to another person and we'll discuss that a little bit later and impaired nurses are nurses that obviously are under the influence of something so nurses do have a legal and ethical obligation a responsibility to protect their patients in the profession from impaired nurses which means we have to report them okay so regulations that we look at as I mentioned federal law is the control of drugs that can be given so like federal law controls drugs state laws again address who can prescribe them dispense them administer them and that process and then you might have an agency or facility guidelines that dictate how and when drugs are to be given and you know how they're recorded like who can do it and so forth and so like the time frames we're going to talk a little bit later about time frames we mentioned it in our first lecture about the hour before hour after you might have a facility that says 30 minutes before or after okay so federal laws we said that's the government so the FDA Food and Drug Administration is the organization that deals with new drugs they are the ones who supervise the testing the approval the marketing of new drugs and um there's three drug categories in the United States the controlled substances that we're going to address at the end of this presentation in more detail but drugs that can be easily abused they're dangerous they require prescription Controlled Substances such as narcotics are kept under double lock and they do require another nurse to witness the wastage of the drug and documentation of the same so let's just say you as a nurse are giving a controlled substance to a patient and the medication that you're giving them is in a tablet and when you go in the room to give it to them either you or the patient drop it okay and let's say it hits the floor well you can't pick it up blow it off and say 10 second rule here's your medication you have to get rid of it and get a new one another nurse has to witness you wasting that medication and documenting it in the narcotic record that it was wasted prescription drugs are also called Legend drugs and it's just like it sounds they require a prescription um let me see where I'm at here on my nose I'm sorry I got sidetracked they require prescription but but they're not as easily abused okay and then of course over-the-counter medications or drugs that patients can buy without a prescription but please note that in a hospital even an over-the-counter drug um has to have a prescription so let's say a patient takes tylenol at home for a headache and now they're in the hospital and they routinely take Tylenol um they have to get a prescription in the hospital for them to receive that Tylenol that's what that means distribution of Controlled Substances continued narcotics as I said they're kept under special lock they're actually under double lock they have to be signed out the contents of the cabinet where they're at are counted every shift the drug nurse or charge nurse depends upon what your facility has checks the order dosage the last time the drug was given before obtaining the controlled drug any wastage requires another nurse to witness as I just mentioned nurses may not borrow a drug ordered for one patient to give to another patient nurses may never use the drugs for themselves and then please notice in your book on page 14 about drug diversion I want you to read that on your own it's important so distribution of controlled substances and drugs when drugs are ordered from the pharmacy that come in a single dose unit or a pre-filled syringe they're attached to a special inventory sheet as I mentioned before it has to be counted so some individual that's receiving the narcotic group has to check the drugs return to the pharmacy assigned records stating that all the drugs order received it was in acceptable condition and again we're trying to prevent drug diversion when drugs are ordered from the pharmacy they oh sorry do I have that on there twice or did I just miss clicking so sorry there we go um a couple terms you want to be aware of and we'll talk about these more when we study the chapter on pain medications but physical dependence and psychological dependence physical dependence results in an actual physical symptoms that occur with a drug withdrawal it's like when somebody's been taken a medication in the hospital an opioid for their pain the doctor sends them home and doesn't give them any more opioids and they go through withdrawal symptoms sometimes it's called abstinence syndrome but with the physical dependence again this is not a psychological drug depend it's like not somebody addicted this is literally their body has become accustomed to it it's like drug tolerance and so when the medication is taken away from them they might have shaking increase in their heart rate experience pain confusion even seizures vomiting hallucinations it's yeah it's really uh it's a withdrawal thing okay psychological dependence on the other hand is also referred to as addiction this is a mental desire associated with taking the drug it can include anxiety anger depression it's a craving for the drug because of how it makes them feel it is not going through a physical withdrawal because the medication was taken away from them now a person may have both I'm not saying that I'm just saying these are two different things so prescription drugs okay they have often been shown to be safe and effective the nurse still has to carefully observe for any adverse effects so these are carefully tested before they're marketed their uses basically control the prescription is required that's why they're called prescription drugs majority of drugs um nurses administer in the hospital are prescription drugs then notice we have some at-risk populations the geriatric population or the older adult the Pediatric or the young you know young children infants and so forth and then the critically ill patient these are all special risk and many times the reason they're special risk is because of organ things either immature organs that are deteriorating or organs that are damaged because of their illness okay so it's very important that safety um you know we take into account safety but note that safety is not necessarily determined for children for all medications oftentimes it will say these have not been tested in children over-the-counter medications have our lower risks for patients when they're taken as they're supposed to be they're usually a lower dosage of what could be a prescription medication for example a proton pump inhibitor like Protonix prescription dose is going to be higher than the over-the-counter dose patients can buy these on their own they may have hidden chemicals in them so it's important to read labels um as I said when the patient is taking over the counter medication in the hospital they have to have a prescriber's order for them and note that herbal medications haven't been tested for safety ineffectiveness they are not regulated by the Food and Drug Administration so they do not have to prove efficacy which means Effectiveness or safety so for a drug order legal prescription both state and local agency policies restrict prescriptive authority to Physicians dentists nurse practitioners nurse midwives nurse anesthetists and physician assistants and again you're going to want to look at your State's nurse Practice Act to see who can prescribe in your state a legal prescription or order must contain the following information now I'm going to clarify something here so let's first just go along and read them we obviously need the patient's full name we need the date the order is written because some orders have a time limit that might say um you know new order after seven days okay or 14 days so you know we want the date that it's ordered so we know when that 7 or 14 days is up we need obviously the name of the drug we need the route we never want to assume the route of Drug Administration we need the dose how much does the patient get in the frequency how often do they get it if we only have a dose but we don't know how frequently you know what are we going to do right now your book mentions the duration and I want to emphasize something here to you about the duration duration in my opinion is not required in the legal prescription and if we look at what a standing order is it just simply says you take this medication until the doctor stops it or re renews it so it's really not part of the legal prescription okay so I'm saying during is not required you also need the signature of the prescriber okay now verbal or telephone orders we often just still call them a verbal order because you're taking a verbal order over the telephone but these should be for emergencies only and you want to follow your agency's policy on taking verbal orders the nurse is going to document the order or they might receive from the lab a critical lab value or they're going to call it into the doctor it's very important that the nurse document it and read it back to the prescriber include the date and then also sign it note that this is not a repeat back if the doctor gives you an order over the phone or the lab calls and gives you a critical value and you just repeat it back but you haven't written it down let's just say then you hang up the phone and a code gets called and you have to run down the hall and tend to a code what happened to that order it pretty much just disappeared so you write it down and read it back then basically the prescriber will co-sign that order typically it's within 24 hours to make it valid but you obviously want to know your agency's policy on the time frame and then or whether or not an LPN can even take a verbal or a telephone order all right types of drug orders okay we have what is called a standing order also referred to as a routine order and this is the one that I associated in our previous slide about duration notice that it says the drug is to be given until it's discontinued or renewed so there's no time frame on here so the duration is not listed so a drug is to be given until it's discontinued or until it's renewed so that's why I say duration is not one of the requirements for a drug order emergency or Stat orders must be given immediately typically they say within 30 minutes of the order being given a single or one-time order is just like it sounds it's given at a specified time like before an x-ray or before surgery but it's one time it's not like a stat it's not given right now the doctor May order it today but say give it tomorrow morning 30 minutes before such and such of an x-ray okay so it's just a one-time thing before that x-ray as needed or PRN administered on an as needed basis based upon the nurse's judgment and safety so oftentimes they have a time frame associated with them a Time variable like every four hours or Q4 hours PRN if it's Q4 hours PRN the nurse has to check the last time it was given think about it if it's every four hours and patient's in pain well has it been four hours since they got it I better check right does that make sense okay good so it's again very important that you understand your nurse Practice Act regarding um Drug Administration responsibilities okay so you need to know what you as an LPN can do your state law which is your nurse practice act as well as your health care agency will determine the level of authority and responsibility of the nurse and different levels of nursing will have different levels of authority and accountability so know your interest Practice Act it's again state by state responsibilities vary in each nurse Practice Act even though they're very similar they're still going to vary and there's a link to your nurse Practice Act all nurses have legal responsibility for their actions nurses accept ethical and legal responsibility for good judgment and actions it's also very important for the nurses to take responsibility for monitoring the effects of the drugs given and we've already covered this in chapter one we're not only going to give a medication or that high blood pressure but we're going to monitor and make sure that the medication is working doing what it's supposed to do are there any adverse effects has the blood pressure bottomed out on them okay nurse Practice Act determines the level of responsibility and authority of the nurse some states recognize license of a nurse from another state we call those compact States and again you just want to see what your state does nursing process is used in giving drugs as we've already discussed review your role as the LPN looking at your nurse Practice Act and then teaching I've already told you this but just reiterating teaching is part of the implementation phase of the nursing process so when we're teaching our patients about their medications the RN should initiate the teaching and the LPN should reinforce it and again it can be the exact same teaching we just as an LP and you just can't initiate the teaching but by all means you continue to teach your patient about the medication I believe we already covered this what's the difference between assessment and evaluation in the nursing process I'm pretty sure that that was something that we did talk about um and maybe it's on this slide where I have it color coded let me just pull this up and look okay I do but it's actually got that big old black ball on it um both are assessment assessment is done before or prior to an intervention and evaluation is done after the intervention the two words I want you to get are actually covered so assessment done prior to the intervention evaluation is done after so I checked the blood pressure before I do the medication make sure it's in a safe range that they can have the med then after I give the med I wait sufficient amount of time 45 minutes an hour check the blood pressure again to see if the medication brought it down but also did it bring it down too far because that would be an adverse effect okay okay so in the nursing process we have those five steps we've already talked about they should be considered or used when administering medications once again keep in mind that we follow the nursing process in order professional and implied legal ethical requirement of nurses is using the nursing process note that the patient family teaching falls under implementation Administration system nurses must check or verify that the drug order is correct confirm the order you have with the mar the cardex or the electronic medical record with your prescriber's order so wherever it has been copied down make sure it matches the doctor's order electronic medical record EMR many facilities now use a bar coding Drug Administration system that's integrated with the EMR and we'll look at what that bar coding thing looks like in just a second I guess I got that on there twice so sorry cardx pen and paper flip chart it's been used for many many years it has a lot of important information about the patient things that are taking place any new orders and stuff but it's just a copied place for these they still go on the chart in the regular doctor's order spot and they still go on the medical record so this is just like a little flip chart to help um a nurse without having to go to the main chart every time it's updated it's changed to reflect current orders and notice that the cardex is not a legal document this is discarded when the patient's discharged this is just a way to put some information that you can use about the patient without having to go to the Chart so let's just say your patient was on bed rest now they're allowed to be up in the chair um with assistance and that'd be written on a card X so you can just flip through it and find out about your patients you know activity what is their diet can they get up and go to the bathroom are they on fluid restrictions stuff like that okay so here's an example of a card X where medications can be written it's our next slide okay so that's just a picture of medication cardex and again depends upon your facility whether or not your meds are on a marmar and on a card X or if they're just in the medication administration record here you can see a nurse with a scanner scanning the patient's ID band it has like you know one of those codes on it just like you see when you go to the grocery store and then it pulls up on a screen and shows that you have the correct patient and their list of medications will pop up this is called a pixa system it's um also an electronic system when you go to that little screen up there it requires you to either like sign in or take your fingerprint ID or something like that and then you select the patient you want and you see all those little box like drawers down there the drawer will pull out for your patient and then when you pick a medication only that box opens up so it dramatically reduces errors even though it doesn't eliminate errors because remember even the person who put the medications in the box like the pharmacy or pharmacist or pharmacy tech is still a human and can still make an error so it doesn't take away the responsibility of the nurse to do their nine rights foreign drug errors drug errors can occur at any time during drug preparation when the drug is being bought to the patient at the time it's being given to the patient drug errors can even occur when the prescriber wrote it and when the pharmacy pharmacist filled it but as nurses we can make errors during these different times causes the fast pace of your unit where you're at you're hurried got a lot going on a lot of patience to care for there's not a lot of staff on your unit um so you know you're doing a lot you're multitasking or you get even interrupted during your process or preparing or giving the meds and so you lose your train of thought those are all things that can cause mid-airs so what do you do when you suspect an error well obviously I hope this is obvious to you you check your patient first okay if you made a mistake how is your patient do you need to get more data do you need to gather some vital signs do you need to do some stuff before you ever call the health care provider so check your patient because if you if you just find out you made an error and you called the doctor and you said Oh No I gave my patient the wrong medication and the doctor says well what is vital signs uh I don't know okay so notify your health care provider right away after you've gathered the necessary data contact your charge nurse follow any orders the provider gives continue to monitor your patient more than likely you're going to have to fill out an incident report so fill out whatever your agency requires the incident report does not go in the chart this is a legal document that goes to your risk management department and it's tracking errors but it does not go in the chart one of the ways the Joint Commission TJC used to be called Jayco it's no longer Jayco it's TJC and um The Institute of medicine have attempted to reduce errors is with a now what they call a do not use abbreviation list now every facility has their own do not use list there are some things that are required to not be used but every facility can choose other abbreviations that they don't want their people to use and so you want to be familiar with the do not use abbreviation list I have a lot of medications in your packet under the pages for abbreviations that you can um review and note the ones that I have in bold that are on the do not use list we'll talk about some more of these in class high alert drugs okay high alert red flag pay attention this is important they have a high risk of harm when associated with a drug error okay please note it doesn't mean these drugs are involved in more medication errors let me repeat that high alert drugs it does not mean they are involved in more medication errors what it does mean is because they are so risky they can cause significant patient harm if the patient receives the drug in error or receives a wrong dose okay so it doesn't mean they happen more often it just means that they're more serious when they do happen an acronym pinch helps remember these high alert medications P for potassium okay I for insulin and for Narcotics like our opioids C for chemo also called antineoplastics H for Heparin or any other drug that we think is an anticoagulant or effects clotting now why do you think P potassium is such a high alert medication most of you probably don't know this potassium is what is used on death row for Lethal Injections it causes the heart to stop so it's very important obviously that we're aware of how much potassium our patient gets doesn't mean we make errors a lot with potassium it's just they can be very harmful when they do happen insulin obviously their blood sugar can bottom out narcotics like opioids patients stop breathing you see what I'm saying okay another thing that we see on some medications is a black box warning with a black box warning the drug has a higher than normal risk for causing serious and even life-threatening problems in addition to its positive benefits it may have like on the little insert that goes in the box it may have a black bordered box around it to show you it's a black box warning here are some examples NSAIDs like ibuprofen increased risk of heart attack and stroke most people do not know that Lamotrigine or Lamictal life-threatening rash called Stephen Johnson syndrome your fluoroquinolones like Cipro many of you heard of Cipro ciprofloxacin increased the risk of tendon rupture especially in the elderly Actos and avandia okay those are anti-diabetic medications those medications can either cause or exacerbate congestive heart failure exacerbate cause it to flare up antidepressants many of them increase the risk of suicide so with any drug that has a black box warning monitor your patient closely for any adverse effects Med reconciliation okay we often refer to it as Med Rec it's a practice of comparing your patients drug orders to all the drugs the patient has been taking this can avoid drug errors due to wrong dosages duplication of drugs leaving out a drug it's done at every Point throughout a patient's stay in the facility like when they're admitted if they're transferred from one unit to another when they're discharged in any other time that seems appropriate we're comparing and reconcile their medications because they may have medications ordered by two three different Physicians are they overlapping is something contraindicated if they're taking this medication so we're reconciling them comparing them to make sure everything is okay also with Med reconciliation it's important to teach the patients and family about carrying their most recent drug list with them and the reason for this is like when they go to a doctor if they have to go to the emergency room they can check what medications they're taking and then always update that list as changes are made anytime their medication changes fix it on the list this is really really helpful when a patient comes into a medical facility to verify what medications they're taking all right protection of health care workers we're wrapping this up all right as you know many facilities are requiring a proof of vaccinations for your preventable diseases like Hep B flu now we have facilities that are requiring the covet vaccine um they will all have written plans for reducing the risk of needle stick injuries like how you take care of Sharps what you do if you do get stuck so Sharps disposals must be provided we all know about our little Sharps Containers that you drop syringes and needles in you learn to don't recap needles to prevent risk and there's also needle-less products things that you don't even have to use a needle on or that they have a little cap that flips over the needle so the needle gets covered up if needle stick injuries do occur you want to document it and follow your agency's exposure control plan now obviously this isn't documented in a patient's chart this is if you get a needle stick injury as a nurse because we're talking about protecting health care workers again risk management would be involved in this and typically your safety guidelines for your facility gets reviewed and updated each year that's annually all right I just briefly want to go over some stuff about Controlled Substances okay Controlled Substances notice that it says most regulations are written for Controlled Substances because they're often abused both by patients and by people using them illegally after the controlled substance Act of 1970 the classes of these medications were broken down into five schedules and they have become known as scheduled drugs federal and state laws make it a crime for anyone to have Controlled Substances without a prescription nurses can possess these Controlled Substances only if they're administering the drugs to the patient for whom they were prescribed they themselves are the patient for whom the legal prescription has been ordered in other words a nurse can have it if it was ordered for her and they've been delegated the responsibility for the unit Supply we've discussed about that unit Supply where they are all kept in under double lock if it is found that the nurses violated the controlled substance laws the nurse may be punished by a fine a prison sentence or both these are the scheduled medications category one or schedule one high abuse for potential only with approved protocol are those allowed schedule two high abuse potential new prescriptions written each time that it's going to be refilled into new prescription schedule three lower potential for abuse they're often found in combination drugs maybe like Tylenol number three what's tylenol's got some codeine in it a new prescription has to be written after six months schedule four there's some abuse potential but pretty much the same rules apply for number three and then for schedule 5 medications this is the lowest abuse for potential some of these can be dispensed without a prescription like um cough medicine that might have a little bit of codeine in it this is a picture and I know you can't see it very well but it's right out of your book this is just showing you the different categories and what drugs are found in those categories okay this is an example of a controlled substance notice it says Demerol below that it says my parody and that's the generic name and next to it you'll see a Capital C with a Roman numeral two in it that is a schedule two controlled substance and then just lastly this is our last slide just want to remind you about the legal ethical considerations in nursing practice about the nurse Practice Act is from each state it does describe for you your scope of practice in the expanded nursing roles like the nurse practitioner nurse anesthetist anything like that midwives and then also describes for us our standards of care minimum standards of care American Nurse Association these kind of overlap because they also describe standards of of practice and the scope in the role of the nurse and thank you that is the end of our presentation