Presentation on theme: "Medication Administration"— Presentation transcript:
1Medication Administration Mary Knowlton RN, MSN, NP, APRN, BC
2Pretest Name the five rights Name the three types of injections we will talk about today.Must answer both correct to receive one point. No partial credit.If I can’t read it no points.
3Overview Medication errors is a serious problem: 8th leading cause of death in the US7,000 deaths annually44% of errors occur during administration of medicationRich, V. (2005) How We Think AboutMedication Errors. American Journal of Nursing,supplement. Pg. 10.Although a large portion of your time as a nurse is spent administering medications, it should never be taken haphazardly.
4Medication Administration Medical OrderTranscriptionWhat drug information is neededPlanning/ PreparationMedication PreparationMedication AdministrationPost Medication Administration
57 Components of a Medication Order Tammie Fae MR #3/15/ Toradol 15mg IM prn painDr. Seuss
6FrequencyRoutine: administer as ordered until discontinued (BID, TID, QD)One time only: administer one dose and then discontinueStat: administer immediatelyPRN: as needed within the time interval given. Needs to have an indication stated in order.
8Transcription Transcribed from the medical record to the MAR Unit clerkNurseRole of the RN: Check MAR against medication order in chart to assure accuracy. Once completed, the nurse puts the date, time and initials on the order. ** Note allergies against new med order.
9Planning/ Preparation Drug informationActionIndicationNormal dosage range and routeAdverse effectsContraindicationDrug interactionsNursing Considerations
10Planning/ Preparation Assessment informationB/P (HTN med)Pulse (cardiac drugs like Digoxin)Pain rating (pain med)Temp (antipyretic)Time ManagementPlan to administer within ½ hour of scheduled administration timeAdministration times are set by individual facility policies.
11Planning/ Preparation LabsDrug levelsDigoxinDilantinTheophyllineElectrolytesLasix- check K+ levelsAdministering electrolytes, know level before administrationOther dataBlood glucose before insulin or oral hypoglycemic
12Where do I look for my meds?? Supply of MedicationsCassettes/Drawers for each patientAutomated medication-dispensingsystems (Pyxis)Floor StockControlled substancesopioidsantiseizure medications (phenobarbitol)Anti-anxiety medications
13Controlled Substances Medications that have a high abuse potential. There are laws and regulations to monitor the use of these medications.Locked with limited access.Inventory done by 2 nurses at set intervals.Medication counted before removal and tally kept on separate document.Waste of medications must be witnessed and documented by another nurse.
14Medication Preparation Wash handsAssemble the medications in the medication room.Remove the meds from the drawerCheck for drug expiration dateCheck for the five “rights”against the MAR**Check drawers at the beginning of your shiftin case any medications are missing, youcan order them from pharmacy. NEVER“borrow” medications from other patient’s supply.
155 “Rights” Right DRUG Right DOSE Right ROUTE Right TIME Right PATIENT Right patient: check arm band and MR #
165 “Rights” Right DRUG: Compare drug to MAR three times Taking out of cassette, in med room and at bedsideNote expiration dateKnow indication and nursing considerations
175 “Rights”Right DOSE:Validate calculations of divided doses with another nurseCheck heparin, insulin and digoxin with another nurseKnow the usual dose and question any dose outside of safe range
185 “Rights” Right ROUTE: Right route or method of administration If a change in route is needed, request new order from physicianEx: Tylenol 650mg suppository can not be changed to PO route without a new order.
195 “Rights”Right TIME:Medication given 30 minutes before or 30 minutes after time ordered is acceptable.Refer to policy and procedure manual.**Standard administration times are set by each facility.Ex: QD doseBID dose ,Know the last time of administration for any PRN drug
205 “Rights” Right PATIENT: Identify the patient by asking patient to state name and/or DOB and check armband.Compare name and medical record number on MAR with information on armband.
21Miscellaneous “rights” Right Documentation: document the name of the drug, the dose, route, and time administered. Also document the patient’s reaction.Right to Know: Patients have the right to know about the medication he or she is being given.Right to refuse: the patient has to the right to refuse treatment, but must be notified of the risks of their actions as well as the doctor should be notified.
22Medication Preparation **If possible, calculate night before clinicalCalculate drug dosagePrepare one medication at a timeLeave medications in packages if possible.Use appropriate measuring devices to prepare medications.Check 5 “Rights” again before leaving medication room
23Medication Administration Bring MAR and medications to patient room.“IPIE”Check 5 “Rights”Compare wristband to MARAsk patient about allergiesOpen packages at patient bedside while performing patient educationEx: “Here is your atenolol 25mg, it is to help control your blood pressure.”Always tell patient:Name of medicationDosageIndication for use
25Post Administration Document on MAR Document client response As soon as possible AFTER administrationDocument time administeredInitialsMake sure signature/initials are in signature section of MARDocument client responseNarrative noteFlowsheetEspecially document for PRN medications and first time a new medication is administered
26Post Administration Document if refused or held Circle timeInitialReason not administeredMonitor patient for therapeutic effects.
28Oral MedicationsNEVER crush sustained release, controlled release or enteric coated pills.Capsules can not be splitMore than 3 to = dosePlace into plastic/paper administration cup without touching the med.May use pudding or applesauce for patient’s with difficulty swallowingStay with patient until all medications are taken.
29Oral Medication Module Learning exercise-not testingInstruction sheetComplete 2 “patients” by Medication Administration testing dayIdentify errorsIdentify reason patient is taking medicationIdentify nursing considerationsIdentify common side effectsHave Skills lab instructors sign your form once answers are checked
30Practice Furosemide (lasix) Identify any errors between medical order and MAR.Identify why the patient is taking this medicationDosage rangeIdentify nursing considerationsIdentify common side effects
31Look for Errors Physicians Order Lasix 20mg PO QD Pt NameAllergiesLasix 20mg PO QD-----Jia Lu, NP------MARPt NameAllergiesMedication name, dose, frequencyTimeLasix 2mgPO QD0900
32Lasix Indication: edema Dosage: WNL Nursing considerations: Monitor electrolytes especially check potassium level and s/s hypokalemia, monitor fluid volume status, monitor BP (antihypertensive effects), give in amSide effects: loss of hearing, Low K, Mg, Cl, Ca, Na, High glucose, uric acid; metabolic alkalosis, increased urine output, glycosuria, skin changes (rash, itch, purpura)
33Topical Make sure previous dose is removed, before applying new dose. Apply patches to nonhairy areas of the bodyTake care not to touch topical medications with ungloved hands
34Opthalmic Applications Instruct patient to look toward ceilingMake a pouch in the lower lid by pulling skin downward over the bony orbitInstill in conjunctival pouchClean/dry from inner to outer canthus
35Inhalant Route MDI: Metered dose inhaler Spacer: chamber attached to the end of an inhaler that assists the patient in receiving a higher % of drug with each inhalationNebulizer: Aerosolized medication either given by a hand held device or by a face mask (peace pipe)**MDI instructions page 545 SDM
36Enteral Tube Administration Use liquid form if possibleCrush pills individually and mix with mL of warm water.If medication should be given on empty stomach-stop medication for minutes before and after med administration√ Placement, Flush with water, administer medication, flush with water, administer medication, flush with water
40Equipment Needed Syringes Needles Different sizes (1ml, 3ml, 5ml) Tuberculin syringeInsulin syringeNeedlesShaft (length of the needle)Gauge (diameter)Gloves are not needed to prepare parenteral medication, but are needed to administer it.
41Equipment Needed Size Safety The smaller the number, the larger the diameterExample: 18 gauge big25 gauge smallSafetyOne handed “Scoop” techniqueSafety needlesGloves are not needed to prepare parenteral medication, but are needed to administer it.
42Opening packages What needs to stay sterile? How do I recap? How do I change needlesBlunt needles?Filter needles?Safety vs. Nonsafety?
43Drug Preparation: Ampoule Tap the top of the ampouleUse gauze or an alcohol swab to protect your fingers.Break the neck of the ampoule away from your body.Use a filter needle if availableInsert your needle into the solutionInvert the ampoule (or leave on surface)With your needle in the solution, pull back on the plunger to the appropriate dose.Ampules are glass. Filter needles should be used if available to prevent injecting glass particles into your patient.Article in Journal of Advanced Nursing Nov (Vol 48, Issue 3, p. 266) Glass contamination in parenterally administered meds. Preston, S.T., Hegadorn, KFOUND: larger gauge unfiltered needles have an increased risk of aspirating more glassSo: if you don’t have a filter needle, then use a smaller gauge needle.
44Drug Preparation: Ampoule Remove the needle/syringeTap the barrel of the syringe to remove air.Push the plunger to expel excess air or medication.“Scoop” the cap onto the needleChange the needleDiscard the ampoule into a sharps container
45Drug Preparation: Vial Remove the metal or plastic protective coveringSwab the top with an alcohol swabFill the syringe with air equivalent to the amount you want to withdraw from the vial.Insert the needle into the center of the rubber stopper.Instill the air from the syringeInvert the vialSelf-sealing rubber stopperMay be single or multiple use: if multiple use then mark date, time and initials when opened.Pressurized system: since it is pressurized…have to put air in, in order to get liquid out
46Drug Preparation: Vial While holding the vial and the syringe:Pull back on the plunger to the desired amount.Make sure the needle tip is in the fluid.Remove the needle/syringe from the vial once the desired amount is reachedUse the “scoop” technique to recap the needle.Change the needle before administrationSelf-sealing rubber stopperMay be single or multiple use: if multiple use then mark date, time and initials when opened.Pressurized system: since it is pressurized…have to put air in, in order to get liquid out
48Drug Preparation: Mixed Dose Insulin Gather equipment: correct insulin syringe, correct insulin vials (√ date opened), alcohol swabs, MAR, current fingerstick glucose readingRoll the “cloudy” NPH insulin vialClean the top of the vials with an alcohol swab.Instill air into the “cloudy” vial equivalent to the “cloudy” dose (NPH) with the vial remaining on the counter surface.Instill air into the “clear” insulin vial equivalent to the “clear” dose (Regular).Let’s talk briefly about insulin:Regular is fast actingNPH is longer acting…..slowly released over time….it has a protein in it that allows that slow release action.We have use a special technique to draw up insulin as to not “contaminate” our pure fast acting insulin with the cloudy slow acting NPH. So when we need it to work fast, it will.There are different types of insulin syringes…some measure 50 units, some measure 100 units. Make sure you know which one you have. The 50 unit syringes, each line measure 1 units. The 100 units measure 2 units.
49Drug Preparation: Mixed Dose Insulin Invert the “clear” vial and withdraw the desired amount.Have this dose checked by another nurse.Insert the needle into the “cloudy” vial and withdraw the desired amount.Again have the total amount checked by another nurse.
50Intradermal Administration Used for allergy and tuberculin skin testingSite: inner forearm (may use back and upper chest)Volume: mlEquipment: gloves, TB syringe (1ml, 25-27g, ⅝ or ½ inch needle), alcohol swab.Administration angle: °Forearm: one hand’s breath above wrist
51Intradermal Administration Prepare medicationGather suppliesIdentify siteDon glovesCleanse site with alcoholPull skin tautInsert needle with bevel up at degree angle ⅛ inch.Needle should be visible under skinUse the medication administration steps outlined earlier then…..Usually mark site with indeliable pen for easy identification for “reading” of allergy or PPD test.
52Intradermal Administration Push plunger to instill medication creating a wheal under skinWithdraw needle at same angle inserted.Cover site with gauze for bleeding. DO NOT massage.DO NOT RECAP. Activate safety feature. Place needle in sharps container uncapped.Use the medication administration steps outlined earlier then…..Usually mark site with indeliable pen for easy identification for “reading” of allergy or PPD test.
53Subcutaneous Administration Administered into subcutaneous tissue that lies between the skin and the muscle.Common subcutaneous injections are heparin, lovenox and insulinOnset: within a half hourVolume: up to 1mlEquipment: TB or Insulin syringe (25-27g, ½ to⅝ inch needle), gloves, alcohol swab.Administration Angle: 45° or 90 °45---pinch an inchpinch two inches
54Subcutaneous Administration Why does he have a circle around his umbilicus?Which side absorbs the quickest? What is the preferred site?Adapted from Smith, S.F., Duell, D.J., Martin, B.C. (2004) Clinical Nursing Skills Basic to Advanced, 6th Ed. Pg New Jersey: Prentice Hall
55Subcutaneous Administration Prepare medicationGather suppliesIdentify siteDon glovesCleanse site with alcoholBunch the skinHold needle like “dart”
56Subcutaneous Administration Pierce skin with quick motion at degree angle.DO NOT ASPIRATE.Inject medication slowlyQuickly remove needleDO NOT RECAP. Activate safety feature. Place needle in sharps container uncapped.
57Intramuscular Administration Administered into a muscle or muscle groupOnset: variableVolume: up to 4mlEquipment: gloves, 1-5 ml syringe, needle (18-23 g, ⅝ to 3 inch needle), alcohol swabRN is responsible to chose needle size and gauge.Administration angle: 90°
58Intramuscular Administration Deltoid Palpate lower edge of acromion process.Place 4 fingers across the deltoid muscle with the top finger along the acromion process. This forms the base of a triangle.Draw an imaginary line at the axilla. This forms the apex of the triangle.Injection site is the center of the triangle, 3 finger widths (1-2 inches) below the acromion process.
59Deltoid Injection Site Adapted from Smith, S.F., Duell, D.J., & Martin, B.C., (2004) Clinical Nursing Skills Basic to Advanced, 6th Ed. Pg New Jersey: Prentice Hall
60Intramuscular Administration Vastus Lateralis One hand above the knee.One hand below the greater trochanter.Locate midline of anterior thigh and midline of lateral thigh.Injection site is the lateral area of the thigh
61Intramuscular Administration Ventral Gluteal Palm of hand on greater trochanter of femur.Index finger on anterior superior iliac spine (hip bone).Middle finger extended toward iliac tubercle.Injection site lies within the triangle formed by the index and middle fingers
62Intramuscular Administration Dorsal Gluteal Locate the posterior iliac spine.Locate the greater trochanter.Draw an imaginary line between these two landmarks.Injection site is above and lateral to the line.Most dangerous site because of sciatic nerve location
63Intramuscular Administration Prepare medicationGather suppliesIdentify siteDon glovesCleanse site with alcoholPull skin tautHold needle like “dart”Insert quickly at a 90° angle
64Intramuscular Administration Stabilize needleAspirate for bloodIf no blood, instill medication slow and steadyQuickly remove needle.DO NOT RECAP. Activate safety feature. Place needle in sharps container uncapped.Massage site with alcohol swabRemove gloves
65Z-track IM Administration Method used with irritating medicationsVistarilIronUsed to “trap” medication in muscle and prevent “tracking” of solution through tissues.
66Z-track IM Administration Prepare medicationChange needle after drawing up medGather suppliesIdentify siteDon glovesCleanse site with alcoholDisplace skin laterally 1-1 ½ inches from injection siteWhile holding skin, insert needle with a darting motion, at a 90° angle.Want to use needle that is 1.5 to 2 inches long. Sometimes 2 inch needles are hard to find.
67Z-track IM Administration Stabilize needle with thumb and forefinger.Aspirate.If no blood, then inject medication slowly and steadyWait 10 secondsQuickly withdrawal needleThen release skinCover site with swab and DO NOT MASSAGEDO NOT RECAP. Activate safety feature. Place needle in sharps container uncappedRemove gloves
68Methods to Decrease the Pain of Injections Encourage client relaxation-position client to have muscle relaxedPosition prone with feet inverted for dorsogluteal injectionChange needle after preparing medication in syringeAvoid injecting into sensitive or hardened skinUse needle long enough to reach muscle“Dart” needle quickly into muscleUse smallest gauge possible
69Methods to Decrease the Pain of Injections Inject medication slowlyDo not move needle once insertedWithdraw needle quicklyUse Z-track for IM injectionsEMLA cream may be appliedApply pressure/ice to site before injection.
70ReferencesSmith, S.F., Duell, D.J., Martin, B.C. (2004) Clinical Nursing Skills, Basic to Advanced, 6th Ed. New Jersey: Prentice HillTimby, B.K. (2003) Fundamental Skills and Concepts in Patient Care, 7th Ed. Philadelphia: Lippincott