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Medication Safety

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created 6 years ago by jncanf
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Chapter 3

updated 6 years ago by jncanf

Grade levels:
College: First year, College: Second year, College: Third year, College: Fourth year

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1

THE NURSES SIX RIGHTS ARE?

1. THE RIGHT TO COMPLETE AND CLEAR ORDER
2. THE RIGHT TO HAVE THE CORRECT DRUG, ROUTE (FORM) AND DOSE DISPENSED.
3. THE RIGHT TO ACCESS TO INFORMATION
4. THE RIGHT TO POLICIES TO GUIDE SAFE MEDICATION ADMINISTRATION
5. THE RIGHT TO ADMINISTER MEDICATIONS SAFELY AND TO IDENTIFY SYSTEM PROBLEMS
6. THE RIGHT TO STOP, THINK, AND BE VIGILANT WHEN ADMINISTERING MEDICATIONS

2

THE TRADITIONAL 5 RIGHTS OF DRUG ADMINISTRATION:

1. THE RIGHT CLIENT
2. THE RIGHT DRUG
3. THE RIGHT DOSE
4. THE RIGHT TIME
5. THE RIGHT ROUTE

3

5 ADDITIONAL RIGHTS RIGHTS TO PROFESSIONAL NURSING PRACTICE (PATIENT'S RIGHTS):

1. THE RIGHT ASSESSMENT
2. THE RIGHT DOCUMENTATION
3. THE CLIENT'S RIGHT TO EDUCATION
4. THE RIGHT EVALUATION
5. THE CLIENT'S RIGHT TO REFUSE

4

THE RIGHT CLIENT

DETERMINATION IS ESSENTIAL. JOINT COMMISSION REQUIRES TWO FORMS OF IDENTIFICATION PRIOR TO THE ADMINISTRATION OF MEDICATIONS.

-CHECKING I.D. BRACELET.
-CLIENTS WITH SAME LAST NAMES HAVE WARNING HIGHLIGHTED IN BRIGHT COLOR.
-I.D. BRACELETS CODED FOR ALLERGY STATUS
-WHEN CLIENT DOES NOT HAVE I.D. BRACELET SUCH AS HEALTH DEPARTMENT, SCHOOL, HEALTH CARE PROVIDER OFFICE, THE NURSE MUST ACCURATELY IDENTIFY THE INDIVIDUAL WHEN ADMINISTRATING A MEDICATION.

5

THE RIGHT DRUG

THE CLIENT RECEIVES THE PRESCRIBED DRUG.
Rx MAY BE WRITTEN ON PRESCRIPTION PAD AND FILLED BY PHARMACIST. FOR INSTITUTIONAL CLIENTS, DRUG ORDERS MAY BE WRITTEN ON "ORDER SHEETS" AND SIGNED DAILY BY AUTHORIZED PERSON. TELEPHONE ORDER (TO) OR VERBAL ORDER (VO) MUST BE COSIGNED BY THE PRESCRIBING CARE PROVIDER WITHIN 24 HOURS.

6

COMPUTERIZED ORDER SYSTEMS (FOR Rx)

ORDERS CAN BE WRITTEN FROM ANY location AND SENT VIA MODEM. COMPUTER WILL NOT PROCESS THE ORDER UNLESS ALL INFORMATION IS INCLUDED. NO NEED TO WORRY ABOUT ILLEGIBLE ORDERS OR SIGNATURES.

7

COMPONENTS OF A DRUG ORDER ARE:

-DATE AND TIME THE ORDER IS WRITTEN
-DRUG NAME (GENERIC PREFERRED)
-DRUG DOSAGE
-ROUTE OF ADMINISTRATION
-FREQUENCY AND DURATION OF ADMINISTRATION (E.G. X 7 DAYS, X 3 DOSES)
-ANY SPECIAL INSTRUCTION FOR WITHHOLDING OR ADJUSTING DOSAGE BASED ON NURSING ASSESSMENT, DRUG EFFECTIVENESS, OR LABORATORY RESULTS
-PHYSICIAN OR OTHER HEALTH CARE PROVIDERS SIGNATURE OR NAME IF T.O. OR V.O.
-SIGNATURES OF LICENSED PRACTITIONERS TAKING T.O. OR V.O.
**IF ANY COMPONENTS ARE MISSING, THE DRUG SHOULD NOT BE ADMINISTERED**

8

NURSES MUST DO/KNOW WHAT WHEN IT COMES TO DRUG ORDERS:

-QUESTION ANT ORDERS THAT ARE INCOMPLETE OR UNCLEAR, GIVE DOSAGE OUTSIDE ITS RECOMMENDED RANGE, OR CONTRADICT THE CLIENTS ALLERGY OR LABORATORY TEST RESULTS.
-NURSES ARE LEGALLY LIABLE IF THEY GIVE A PRESCRIBED DRUG AND THE DOSAGE IS INCORRECT OR THE DRUG IS CONTRAINDICATED FOR THE CLIENT'S HEALTH STATUS.
-ONCE THE DRUG HAS BEEN ADMINISTERED, THE NURSE BECOMES LIABLE FOR THE PREDICTED EFFECTS OF THAT DRUG.

9

TO AVOID ERROR A DRUG LABEL SHOULD BE READ 3 TIMES:

1. AT THE TIME OF CONTACT WITH THE DRUG BOTTLE/CONTAINER OR THE PREPACKAGED DRUG UNIT.
2. BEFORE MEASURING THE DRUG
3. AFTER MEASURING THE DRUG.
*FIRST DOSE AND PRN MEDICATIONS SHOULD BE CHECKED AGAINST THE ORIGINAL ORDERS.

10

NURSING INTERVENTIONS RELATED TO DRUG ORDER:

-NURSE SHOULD BE WELL VERSED IN CLIENTS HEALTH HISTORY AND PREVIOUSLY PREFORMED ASSESSMENTS.
-CHECK THAT DRUG ORDER IS COMPLETE AND LEGIBLE. IF NOT NOTIFY NURSE MANAGER OR HEALTH CARE PROVIDER.
-KNOW CLIENTS ALLERGIES
-KNOW WHY CLIENT IS RECEIVING MEDICATION.
-CHECK LABEL THREE TIMES BEFORE GIVING MEDICATION.
-KNOW DATE MEDICATION WAS ORDERED AND ANY ENDING DATE.

11

THE RIGHT DOSE

MORE THEN JUST THE DOSE PRESCRIBED, IT IS THE DOSE PRESCRIBED WITHIN GUIDELINES FOR DRUG ADMINISTRATION FUNCTION. NURSES MUST CALCULATE EACH DRUG DOSE ACCURATELY, CONSIDERING THE VARIABLES: THE DRUGS AVAILABILITY AND THE PRESCRIBED DRUG DOSE.
**RECHECK THE CALCULATIONS OF DRUG DOSES IF A FRACTION OF A DOSE OR AN EXTREMELY LARGE DOSE IS CALCULATED. WHEN IN DOUBT CONSULT A PEER OR PHARMACIST.**

12

THINGS TO CONSIDER FOR THE RIGHT DOSE:

-CLIENTS RENAL AND HEPATIC FUNCTION IS A CONSIDERATION BECAUSE MANY DRUGS ARE CLEARED BY THE KIDNEYS.
-CLIENT'S WEIGHT IS ANOTHER IMPORTANT CONSIDERATION IN MULTIPLE CONTEXTS SUCH AS PEDIATRICS AND MANY MEDICAL, SURGICAL, AND CRITICAL CARE SITUATIONS.

13

TWO FREQUENTLY USED METHODS OF DRUG DISTRIBUTION ARE?

STOCK DRUG METHOD AND UNIT DOSE METHOD

14

STOCK DRUG METHOD

THE RUGS ARE DISPENSED TO ALL CLIENTS FROM THE SAME CONTAINERS

15

UNIT DRUG METHOD

DRUGS ARE INDIVIDUALLY WRAPPED AND LABELED FOR SINGLE DOSES FOR EACH CLIENT.; THIS METHOD HAS HAS REDUCED DOSAGE ERRORS BECAUSE NO CALCULATIONS ARE REQUIRED.

16

AUTOMATED DISPENSING CABINETS (ADCs)

ASSIST THE NURSE IN CORRECTLY AND QUICKLY ADMINISTERING MEDICATIONS. THIS IMPROVES CLIENT CARE BY PROMOTING ACCURATE AND QUICK ACCESS TO MEDICATIONS, LOCKED STORAGE FOR ALL MEDICATIONS, AND ELECTRONIC TRACKING FOR CONTROLLED SUBSTANCES. IT SAVES TIME, DECREASES COST ASSOCIATED WITH THE ADMINISTRATION OF MEDICATIONS, AND ALLOWS THE ABILITY TO AUTOMATICALLY COLLECT DOCUMENTATION INFORMATION.

17

NURSING INTERVENTIONS RELATED TO THE RIGHT DOSE INCLUDE:

-CALCULATE THE DRUG DOSE CORRECTLY, WHEN IN DOUBT RECALCULATE THE DRUG DOSE AND CHECK WITH ANOTHER NURSE.
-CHECK THE PHYSICIANS DESK REFERENCE (PDR), THE AMERICAN HOSPITAL FORMULARY, THE DRUG PACKAGE INSERT, OR OTHER DRUG REFERENCES FOR THE RECOMMENDED RANGE OF SPECIFIC DRUG DOSES.

18

THE RIGHT TIME IS?

THE TIME THE PRESCRIBED DOSE SHOULD BE ADMINISTERED. DRUGS MAY BE GIVEN WITHIN 1 HOUR BEFORE OR AFTER THE TIME PRESCRIBED.

19

DRUGS WITH LONG HALF LIVES ARE GIVEN ____ TIMES A DAY, AND DRUGS WITH SHORT HALF LIVES ARE GIVEN ____TIMES A DAY.

ONE; SEVERAL

20

SOME DRUGS ARE GIVEN?

BEFORE MEALS, AND OTHERS ARE GIVEN WITH MEALS OR WITH FOOD DEPENDING ON THE EFFECT OF THE GASTROINTESTINAL (GI) ENVIRONMENT ON ABSORPTION OF THE DRUG.

21

WHEN DO MEDICATION ERRORS MOSTLY OCCUR?

DURING ADMINISTRATION

22

NURSES NEED TO DOCUMENT ____________?

**EVERYTHING**

23

MILITARY TIME ________ ADMINISTRATION ERRORS AND ____________ DOCUMENTATION

REDUCES; DECREASES

24

NURSING INTERVENTIONS RELATED TO THE RIGHT TIME INCLUDE:

-ADMINISTER DRUGS AT THE SPECIFIED TIMES
-ADMINISTER DRUGS THAT ARE AFFECTED BY FOODS BEFORE MEALS.
-ADJUST MEDICATION SCHEDULE TO FIT THE CLIENT'S LIFESTYLE, ACTIVITIES, TOLERANCES, OR PREFERENCES.
-CHECK IF CLIENT IS SCHEDULED FOR ANY DIAGNOSTIC PROCEDURES SUCH AS ENDOSCOPY OR FASTING BLOOD TESTS THAT CONTRAINDICATE THE ADMINISTRATION OF MEDICATIONS.
-CHECK THE EXPIRATION DATE, DISCARD OR SEND BACK TO PHARMACY IF DATE HAS PASSED.
-ADMINISTER ANTIBIOTICS AT EVEN INTERVALS

25

THE RIGHT ROUTE

NECESSARY FOR ADEQUATE OR APPROPRIATE ABSORPTION.

26

COMMON ROUTES OF ABSORPTION INCLUDE:

-ORAL (BY MOUTH): LIQUID, ELIXIR, SUSPENSION, PILL, TABLET, OR CAPSULE.
-SUBLINGUAL (UNDER THE TONGUE FOR VENOUS ABSORPTION)
-BUCCAL (BETWEEN THE GUM AND CHEEK)
-VIA FEEDING TUBE
-TOPICAL (APPLIED TO THE SKIN)
-INHALATION (AEROSOL SPRAYS)
-INSTILLATION (IN NOSE, EYE, OR EAR)
-SUPPOSITORY (RECTAL OR VAGINAL)
-4 PARENTERAL ROUTES: INTRADERMAL, SUBCUTANEOUS (SUBQ), INTRAMUSCULAR (IM) OR INTRAVENOUS (IV).

27

NURSING INTERVENTIONS RELATED TO THE RIGHT ROUTE INCLUDE:

-ASSESS THAT CLIENT CAN SWALLOW BEFORE GIVING ORAL MEDICATIONS.
-DO NOT CRUSH OR MIX MEDICATIONS IN OTHER SUBSTANCES. DO NOT MIX IN SWEET STUFF TO TRICK CHILDREN. DO NOT MIX MEDICATIONS IN INFANTS FORMULA FEEDING.
-USE ASEPTIC TECHNIQUE WHEN ADMINISTERING DRUGS.
-GIVE DRUGS THAT ARE APPROPRIATE SITES FOR THE ROUTE.
-STAY WITH CLIENT UNTIL ORAL DRUGS HAVE BEEN SWALLOWED.
-IF MEDICATION MUST BE MIXED WITH ANOTHER SUBSTANCE, EXPLAIN THIS TO THE CLIENT.

28

THE RIGHT ASSESSMENT

REQUIRES COLLECTION OF APPROPRIATE DATA BEFORE ADMINISTRATION OF DRUG.

E.G. APICAL HEART RATE BEFORE ADMINISTRATION OF DIGITALIS PREPARATIONS, SERUM BLOOD SUGARS FOR INSULIN. ....ETC...ETC

29

THE RIGHT DOCUMENTATION REQUIRES THE NURSE TO IMMEDIATELY RECORD THE APPROPRIATE INFORMATION ABOUT THE DRUG ADMINISTERED INCLUDING:

1. THE NAME OF DRUG
2. THE DOSE
3. THE ROUTE
4. THE TIME AND DATE
5. NURSES INITIALS OR SIGNATURE

30

DOCUMENTATION OF CLIENT'S RESPONSE TO THE MEDICATION IS REQUIRED WITH A VARIETY OF MEDICATIONS:

1. NARCOTICS (HOW EFFECTIVE WAS THE PAIN RELIEF?)
2. NONNARCOTIC ANALGESICS
3. SEDATIVES
4. ANTIEMETICS
5. UNEXPECTED REACTIONS TO THE MEDICATION, SUCH AS GI IRRITATION OR SIGNS OF SKIN SENSITIVITY.

31

THIS TO REMEMBER FOR THE RIGHT DOCUMENTATION

DELAYING CHARTING COULD RESULT IN FORGETTING TO CHART THE MEDICATION AND ANOTHER NURSE COULD RE-ADMINISTER THE DRUG ASSUMING THAT THE DRUG WAS NOT ADMINISTERED BECAUSE IT WAS NOT CHARTED.

DO NOT SIGN OFF MEDICATIONS PRIOR TO ADMINISTRATION BECAUSE THE MEDICATION MAY NOT BE ADMINISTERED TO THE CLIENT FOR SOME REASON.

32

THE RIGHT TO EDUCATE

REQUIRES THAT ALL CLIENTS RECEIVE ACCURATE AND THOROUGH INFORMATION ABOUT THE MEDICATION AND HOW IT RELATED TO THEIR PARTICULAR SITUATION. ALSO INCLUDES: THERAPEUTIC PURPOSE, EXPECTED RESULT OF THE DRUG, POSSIBLE SIDE EFFECTS OF THE DRUG, ANY DIETARY RESTRICTIONS OR REQUIREMENTS, SKILL OF ADMINISTRATION, LABORATORY TEST RESULT MONITORING.

33

INFORMED CONSENT

IS A PRINCIPLE, IS BASED ON THE INDIVIDUAL HAVING THE KNOWLEDGE, NECESSARY TO MAKE A DECISION. AN INFORMED CLIENT CLIENT/FAMILY IS CRITICAL TO PREVENTING MEDICATION ERRORS.

34

THE RIGHT EVALUATION

REQUIRES THAT THE EFFECTIVENESS OF THE MEDICATION BE DETERMINED BY THE CLIENT'S RESPONSE TO THE MEDICATION.
**EVALUATE THE THERAPEUTIC EFFECT ON THE MEDICATION AS WELL AS ANY SIDE EFFECTS AND ADVERSE REACTIONS. IF THE NURSE DOES NOT DO THIS, THE NURSE RUNS THE RISK OF BEING SUED**

35

THE RIGHT TO REFUSE

CLIENTS CAN AND DO REFUSE TO TAKE MEDICATIONS. **NEVER FORCE MEDICATIONS ITS AGAINST THE LAW**
NURSES RESPONSIBILITY TO DETERMINE, WHEN POSSIBLE, THE REASON FOR THE REFUSAL AND TO TAKE REASONABLE MEASURE TO FACILITATE THE CLIENTS TAKING THE MEDICATION.
EXPLAIN TO CLIENT THE RISK OF NOT TAKING MEDICATIONS, AND REINFORCE THE REASON FOR THE MEDICATION.
**REFUSAL MUST BE DOCUMENTED IMMEDIATELY, AND FOLLOW-UP IS ALWAYS REQUIRED. PROPER PERSON'S SHOULD BE INFORMED WHEN OMISSION MAY POSE A SPECIFIC THREAT TO THE CLIENT.

36

MEDICATION ERRORS

ARE DEFINED AS, "ANY PREVENTABLE EVENT THAT MAY CAUSE OR LEAD TO INAPPROPRIATE MEDICATION USE OR HARM TO A PATIENT."

37

CAUSES OF MEDICATION ERRORS

INCREASED NUMBER OF DRUGS, VIOLATION OF FIVE-PLUS-FIVE-RIGHTS, LACK OF DRUG KNOWLEDGE, MEMORY LAPSES, TRANSCRIPTION, DISPENSING, DELIVERY PROBLEMS, INADEQUATE MONITORING, DISTRACTIONS, STAFF BEING OVERWORKED, LACK OF STANDARDIZATION, CONFUSING PACKAGING PRESCRIPTION, EQUIPMENT FAILURES, INADEQUATE CLIENT HISTORY, AND POOR INTERDEPARTMENTAL COMMUNICATION.

38

BAR CODE LABEL REQUIREMENTS FOR HUMAN DRUG PRODUCTS AND BLOOD

2002 FDA, BAR CODE WOULD CONTAIN THE DRUGS NATIONAL DRUG CODE THAT "UNIQUELY IDENTIFIES THE DRUG, ITS STRENGTH AND ITS DOSAGE FORM"

39

COMPUTERIZED PRESCRIBER ORDER ENTRY (CPOE) SYSTEMS

INTERACT WITH LABORATORY, PHARMACY, AND CLIENT DATA

40

WITH BAR CODING, THE CLIENTS MEDICATION ADMINISTRATION RECORD (MAR)

IS PART OF THE DATABASE THAT IS ENCODED IN THE CLIENT'S WRISTBAND, IS ACCESSIBLE TO THE NURSE USING A HANDHELD DEVICE. AFTER SCANNING THE CLIENTS WRISTBAND THE NURSE WOULD SEE THE INDIVIDUALS MAR ONT HE DEVICE. THE ADMINISTER MEDICATIONS, NURSES WOULD FIRST SCAN THE DRUG'S BAR CODE, THEN THE NUMBER OF THE CLIENTS MEDICAL RECORD, AND FINALLY THEIR OWN ID BADGE CODE.

41

ABBREVIATIONS, ACRONYMS, AND SYMBOLS THAT CAN NO LONGER BE USED BECAUSE THEY CAN BE MISINTERPRESTED OR MISREAD:

-U, u (FOR UNIT)
-IU (FOR INTERNATIONAL UNIT)
-QD, Q.D., qd, q.d. (FOR EVERY DAY)
-TRAILING ZERO AND LACK OF LEADING ZERO; NEVER WRITE A ZERO BY ITSELF AFTER A DECIMAL POINT (E.G. 5.0 MG) AND ALWAYS USE A ZERO BEFORE A DECIMAL POINT (E.G. 0.5 MG)
-MS, MSO4,MgSO4.

42

2010 NATIONAL PATIENT SAFETY GOALS - 5 GOALS RELATED TO MEDICATION SAFTEY:

1. IMPROVE THE ACCURACY OF PATIENT IDENTIFICATION.
-USE AT LEAST TWO PATIENT IDENTIFIERS
2. IMPROVE THE EFFECTIVENESS OF COMMUNICATION AMONG CAREGIVERS.
-TIMELY REPORTING OF CRITICAL TESTS AND CRITICAL RESULTS
3. IMPROVE THE SAFETY OF USING MEDICATIONS.
-LABELING MEDICATIONS
-REDUCING HARM FROM ANTI-COAGULATION THERAPY.
4. REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTIONS.
-MEET HAND HYGIENE GUIDELINES
-PREVENTING MULTI DRUG-RESISTANT ORGANISM INFECTIONS
-PREVENTING CENTRAL LINE-ASSOCIATED BLOOD STREAM INFECTIONS
5. ACCURATELY AND COMPLETELY RECONCILE MEDICATIONS ACROSS THE CONTINUUM OF CARE.
-COMPARING CURRENT AND NEWLY ORDERED MEDICATIONS.
-COMMUNICATING MEDICATIONS TO THE NEXT PROVIDER.
-PROVIDING A RECONCILED MEDICATION LIST TO THE PATIENT.
-SETTINGS IN WHICH MEDICATIONS ARE MINIMALLY USED.
-ACTIVE INVOLVEMENT OF PATIENT
-IDENTIFIED SAFETY RISKS INHERENT IN PATIENT POPULATIONS.

43

DISPOSAL OF MEDICATIONS

-FOLLOW SPECIFIC INFORMATION ON THE DRUG LABEL OR DRUG INSERT.
-UNLESS SPECIFICALLY INSTRUCTED, DO NOT FLUSH MEDICATIONS.
-IT IS RECOMMENDED THAT YOU REMOVE THE DRUG FROM ITS ORIGINAL CONTAINER AND DISPOSE OF IT INS A SEALED BAG WITH AN UNDESIRABLE SUBSTANCE SUCH AS KITTY LITTER OR COFFEE GROUNDS.

44

BEFORE DISPOSAL OF MEDICATION CONTAINERS

REMOVE ALL IDENTIFYING INFORMATION ON LABEL, NEVER LEAVE CLIENTS INFORMATION WHERE OTHERS CAN SEE

45

SAFETY RISKS FOR SAME MEDICATION ADMINISTRATION

PERCENT OF ERRORS OCCUR IN, 1. ADMINISTRATION 41%, THEN DOCUMENTATION 21%, DISPENSING 17%, PRESCRIBING 11%, MONITORING 1% AND OTHER IS 9%.

EXAMPLES OF RISK TO SAFETY:
1. PILL SPLITTING: SOME CLIENTS TRY TO SAVE MONEY BUT SPLITTING PILLS. SPLITS CAN BE UNSAFE AND DANGEROUS. A SMALL DOSE CHANGE (FROM UNEVEN SPLITS) CAN HAVE A BIG EFFECT ON THE CLIENT. CAN CAUSE FOR EXAMPLE DIMINISHED VISION, COGNITIVE PROBLEMS, AND HAND COORDINATION PROBLEMS.
2. BUYING DRUGS ON THE INTERNET: YOU DON'T ALWAYS GET WHAT YOU ORDER. SOMEONE CAN RECEIVE THE WRONG DRUG AND NOT HAVE SOMEONE TO CONFIRM THAT IT IS THE CORRECT MEDICATION. RECEIVING COUNTERFEIT DRUGS COULD ALSO BE A RISK WHEN ORDERING ON THE INTERNET.

46

COUNTERFEIT DRUGS

COPIES OR FAKE MEDICATIONS; THE LOOK LIKE THE DESIRED DRUG BUT MAY NOT HAVE THE ACTIVE INGREDIENTS, THE WRONG ACTIVE INGREDIENTS, OR THE WRONG AMOUNT OF ACTIVE INGREDIENTS. IMPROPER PACKAGING OR CONTAMINATION CAN ALSO BE A PROBLEM. LOOK LIKE THE REAL THING!

47

3 THINGS TO AVOID COUNTERFEIT DRUGS

1. PURCHASE DRUGS ONLY FROM LICENSED PHARMACIES.
2. CHECK THE COLOR, TEXTURE, SHAPE AND THE TASTE OF THE DRUG WHEN REFILLING THE PRESCRIPTION.
3. FOLLOW LEGISLATION IN PROCESS TO PROMOTE SAFE HANDLING OF DRUGS AFTER THEY LEAVE THE AUTHORIZED WHOLESALER BY INTRODUCING "PEDIGREE" REQUIREMENTS AT FEDERAL AND STATE LEVELS.

48

DO NOT CRUSH ORAL DOSAGE FORMS

-SOME MEDICATIONS CAN BE CRUSHED CONSULT YOUR PHYSICIAN, AND SOME CAN NOT.
-DO NOT CRUSH ANY MEDICATIONS THAT HAS THE SUFFIX "ER" OR "SR", AS THESE ARE EXTENDED RELEASE OR SUSTAINED RELEASE AND CRUSHING WILL CHANGE THE SPEED WITH WHICH THE DRUG IS DELIVERED.

49

STAYED ON PG 30

HIGH ALERT MEDICATIONS...


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