Principles and Methods of Drug Administration

Medication Administration Nursing Responsibilities - Standard precautions - Patient privacy - Patient preparation - Drug preparation

Nursing Implications Associated with Drug Administration Consult references/pharmacist Observe for ADR’s Report drug reactions Record observations Withhold drug if needed - notify provider

Medication Orders The nurse must ensure the patient receives the correct medication Orders should include the following: Name Date/time Drug name Dose Route Time/frequency administration Prescriber’s signature

Medication Orders Controlled substances - Opioids, barbiturates, ect. double-locked - Keys with charge nurse - Log administration of drugs - End-of-shift count - Waste controlled substance with witness

Medication Orders Types of orders - Standing orders - pre-written, no call - Verbal orders - telephone to nurse - repeat back to provider - To be written and signed by the provider asap

The Seven Rights of Medication Administration Right drug Right dose Right patient: name and birth date Right time Right route Right documentation Patient’s right to refuse

Medication Preparation Know the seven rights Drug reference available Know drug action, contraindications, usual dosage, and side effects Check label 3 times - removing drug from container or drawer - on comparison with MAR - before giving to patient (if unit dose) - Before returning to drawer (if multi-use container)

Important Considerations Enlist the patients Utilize the pharmacists Prepare one patient’s medication at a time Minimize need for calculations or compare answers with another nurse’s Two licensed nurses must double check high alert drugs before administration, i.e. insulin, heparin

Important Considerations Always report errors Never give an unlabeled drug Don’t confuse drug names Date and initial (multiuse vials or containers) If you didn’t prep it, don’t give it

Important Considerations for Medication Administration 2 identifiers for safety: name and DOB If you gave it, chart it Do not chart for someone else or have someone else chart for you Do not transport or accept a container that is not labelled Do not put down an unlabeled syringe

Important Considerations for Medication Administration Watch the patient take it and swallow it Assess patient’s response If a patient refuses a medication: do not force it, chart it If you elect to omit a dose based on your nursing judgment, let another nurse help make the decision. If medication is not given, document, “dose omitted because…” Report to the provider

Commonly Used Abbreviations Joint Commission on Accreditation of Healthcare Organization (JCAHO) approved abbreviation list institutional policy and list of used abbreviations

Routes of Administration Enteral - Via the GI Tract - Powders - Pills - Tablets - Liquids or suspensions - Suppositories

Routes of Administration Percutaneous - Through the skin or mucous membranes - Topical - Instillation - Inhalation

Routes of Administration Parenteral - Methods other than the GI tract; needle route - Intramuscular (IM) ‏ - Subcutaneous (SC) ‏ - Intradermal - Intravenous (IV) ‏ - Ampules - Vials

Enteral Administration Tablets, pills, capsules - absorbed more slowly from GI tract into the bloodstream than via any other route - (PO) route relatively safe - Do not crush enteric coated or sustained release pills - Only divide scored pills - Liquid medications: children and patients who cannot swallow pills

Oral Medications Unit dosage system: most common Med stays in package until administration May place prepackaged medications in the same cup until administered Involve the patient and include teaching Patient refusal: return unopened medication to the drawer, document reason, notify provider

Oral Medications From multi-dose containers, pour pill into the cap, drop into a medicine cup Label cup with med name, dose Do not touch meds with bare hands Falls on floor? Toss it. Working on med cart? Add clean field

Enteral Administration of Liquid Medications PO, or via a NG, gastrostomy, or jejunostomy tube No liquids to unconscious patients: aspiration Some liquid medications are not to be followed by water; some may stain the teeth Use calibrated cup or syringe (but not IV syringe) Measure liquids at bottom of meniscus

Enteral Administration of Tubal Medications NG tubes: liquid meds to unconscious patients, dysphasic patients, those too ill to eat Use liquid form or crush tablets and open capsules if allowed – give separately in warm water Not all tablets are safe to use when crushed and not all capsules are safe to use when opened

Enteral Administration of Suppositories Rectum or vagina Dissolves at body temperature and absorbed directly into the bloodstream infants, patients intolerant of oral preparations, N/V Store in cool place

Administration of Vaginal Medications Usually for yeast infections Some products are used to induce labor Use gloves Provide privacy

Percutaneous Administration skin /mucous membranes Mostly local action; some act systemically topical applications (ointments, creams, powders, lotions, and transdermal patches), instillations, and inhalations Absorption is rapid, short duration

Percutaneous Administration Ointments - oil-based; semisolid; skin or mucous membrane Creams - Semisolid, non-greasy emulsions; external application Lotions - Aqueous, soothing: pruritus, protectant, cleansing, astringent

Percutaneous Administration Transdermal Patches Adhesive-backed, medicated patches -sustained, continuous release of medication over hours/days Eye drops and Eye Ointments - Don’t touch the dropper or the tube to the eye (p 70 Fig 2-18) Eardrops - ‘Otic’ solutions must be at room temperature when applied - Use only droppers supplied with medications for administration

Percutaneous Administration Nose drops - individual use only Nasal sprays - absorbed quickly; less medication used, wasted Inhalations - mucous membranes ofrespiratory tract - relatively limited effect or a systemic effect - used by respiratory therapy and anesthesiologists

Percutaneous Administration Sublingual medications - under the tongue, rapidly absorbed - tablet or a liquid squeezed from capsule - Do not give water after as water reduces absorption - tablet should dissolve (no swallowing) Buccal medications - between the gum and the cheek, preferably above the molar - Follow same administration guidelines as SL

Parenteral Administration Intramuscular (IM) ‏ Subcutaneous Intradermal Intravenous (IV) ‏ Rationale for using these methods include: - Absorption rate - No oral route - Emergencies - Drug is destroyed in the GI tract

Parenteral Administration Equipment - Syringes - barrel, plunger, and tip - calibrated in milliliters, minims, insulin or heparin units - Types - Tuberculin syringe (for allergy testing/treatments, TB testing and small quantities) - Insulin syringe - One and three milliliter syringes - Safety-Lok syringes

Parts of a Syringe. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3 rd ed.]. St. Louis: Mosby.)

Tuberculin Syringe Calibration (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13 th ed.]. St. Louis: Mosby.)

Calibration of U100 Insulin Syringe (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13 th ed.]. St. Louis: Mosby.)

Reading the Calibrations of a 3-mL Syringe

Safety-Glide Syringe

Parenteral Administration Equipment - Needles - Parts are the hub, shaft, and beveled tip - Opening at the needle’s beveled tip is the lumen - Size of the diameter of the inside of the needle’s shaft determines the gauge of the needle; the smaller the gauge, the larger the diameter - Needle gauge selection is based on the viscosity of the medication

Parts of a Needle (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13 th ed.]. St. Louis: Mosby.)

Parenteral Administration Equipment - Needle length - Selected based on the depth of the tissue into which the medication is to be injected - Intradermal: 3/8 to 5/8 inch - Subcutaneous: ½ to 5/8 inch - Intramuscular: 1 to 1 ½ inch - Intravenous needles - Butterfly (scalp needle) ‏ - Over the needle catheter

Needle Length and Gauge (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13 th ed.]. St. Louis: Mosby.)

Parenteral Administration Equipment - needleless devices - sheath or guard - IV caths: blunt-edged cannulas, valves, or needle guards - IV tubing: recessed and shielded needle connectors to reduce needle sticks

Parenteral Administration Intramuscular (IM) injections - Site selection - Gluteal sites: ventrogluteal (gluteus medius) - Vastus lateralis muscle (thigh) - Rectus femoris muscle (thigh) - Deltoid muscle (arm) - Z-track method - Used to inject irritating meds

Locating IM Injection for Ventrogluteal Site (C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3 rd ed.]. St. Louis: Mosby.)

Giving IM Injection in Vastus Lateralis Site on an Adult (C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3 rd ed.]. St. Louis: Mosby.)

Rectus Femoris Muscle A. Child/Infant B. Adult (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13 th ed.]. St. Louis: Mosby.)

Giving IM Injection in Deltoid Site (C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3 rd ed.]. St. Louis: Mosby.)

Figure A, Z-track method. B, Using an air lock. C, Administering IM injection by airlock technique. (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6 th ed.]. St. Louis: Mosby.)

Parenteral Administration Intradermal injections - serum, vaccine, or skin test agent - Not aspirated - Small volumes (0.1mL) injected to form a small wheal just under the skin - Used for allergy sensitivity tests, TB screening, local anesthetics - tuberculin syringe with 25-gauge, 3/8 to 5/8 inch needle

Figure Angles of insertion for intramuscular (90°), subcutaneous (45°), and intradermal (15°). (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6 th ed.]. St. Louis: Mosby.)

Parenteral Administration Subcutaneous injections - loose connective tissue between the dermis and the muscle layer (fatty layer) - absorption slower than with IM injections - Given at a 45-degree angle if the patient is thin or at a 90-degree angle if the patient has ample subcutaneous tissue - Usual needle length is ½ to 5/8 inch and 25 gauge - insulin and heparin

Subcutaneous Injection Angle and needle length depend on the thickness of skin fold (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3 rd ed.]. St. Louis: Mosby.)

Parenteral Administration Fluid and electrolytes will be also covered again in systems classes Starting of IV’s and management of tubing and delivery devices will be covered in skills lab

Parenteral Administration Intravenous (IV) therapy - fluid and electrolyte maintenance, restoration, replacement - Give meds, nutritional feedings - blood and blood products - chemotherapy to cancer patients - patient-controlled analgesics - Keep a vein open (KVO)

Scope of Practice Know LPN SOP for practice state OSBN LPN IV policy prohibits LPN’s from initiating the following items: - Antineoplastic agents - Blood and blood components - Antiarrhythmics - Antiseizures - Ambulatory infusion devices - Hypertensive agents

Parenteral Administration Methods of intravenous administration - IV push - Intermittent venous access device - Intermittent infusion (or piggyback) ‏ - Continuous infusion - Electronic pumps and controllers - Patient-controlled analgesia - Volumetric chambers

Parenteral Administration Nursing responsibilities - Nurse ensures that correct fluid, amount started and that the fluid is regulated to infuse over the period ordered - To find the drops per minute (the drip rate), find drip factor on tubing package

Parenteral Administration Nursing Responsibilities - Monitor Intravenous Therapy - Check the infusion and the IV needle site at least every hour - Flow of fluid - IV site: erythema, wetness, and edema - Phlebitis: inflamed vein - Infiltration: fluid passes into the tissues - Assess for chills, fever, headache, nausea, vomiting, anxiousness, and dyspnea

Parenteral Administration Nursing Responsibilities - Assess for Anaphylactic Shock - Respiratory distress - Skin reactions - Signs of circulatory collapse - GI signs and symptoms - Change in mental status - Requires immediate intervention

Parenteral Administration Nursing responsibilities - Record administration - Record information - Evaluate and record patient’s response - Observe for ADR’s

Patient and Family Teaching must be ready to learn Include family as allowed by patient teaching enables patient to care for self Patient should demonstrate self-care skills The patient should know about their illness or diagnosis and treatment The patient should know names of all medications, administration schedule, common side effects, provider to call, where to get prescriptions

Promoting Cooperation with Medication regimens Inadequate understanding of illness or disease Cost of the medication Development of adverse effects Forgetfulness Measures to foster cooperation include: - Education - Resources for drug payment - Memory aids

The Nursing Process in Pharmacology Assessment - Take med history - Collect physical status data - social networks, resources? Diagnosis and Planning - Check nursing diagnoses - Identify desired outcomes of nursing interventions - Know why the drug is needed, how it will be given, and common side effects Implementation - Prepare meds safely Evaluation