Chapter 23 Mathematics Review and Medication Administration Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.

Fractions Definitions Types of Fractions Numerator: Top number of a fraction Denominator: Bottom number of a fraction Types of Fractions Proper fractions: Numerator is less than the denominator Improper fractions: Numerator is larger than the denominator Mixed fractions: Consist of a whole number plus a fraction Give examples of proper fractions, improper fractions, and mixed fractions.

Fractions Changing an Improper Fraction to a Whole or Mixed Number Divide the denominator into the numerator. Changing a Mixed Number to an Improper Fraction Multiply the denominator into the whole number. Add the numerator to the product; the sum is now the new number. Reducing Fractions to the Lowest Term Find a number that will evenly divide into the numerator and the denominator. Give an example of changing an improper fraction to a whole number. Give an example of changing a mixed number to an improper fraction. Provide an example of reducing a fraction to its lowest term.

Fractions Determining Which Fraction Is Larger If the denominators are the same, the fraction with the larger numerator is the larger fraction. If the denominators are different, you must find a “common denominator.” Finding a common denominator means to find a number into which both denominators can be divided. After the common denominator is found, an equivalent numerator for each fraction must be found. (Divide the first denominator into the equivalent denominator; multiply the answer by the first numerator.) Give an example in which a nurse might have to determine which fraction is larger.

Fractions Adding Fractions That Have the Same Denominator Add the numerators and place the sum of the numerators over the denominator. Adding Fractions That Have Different Denominators Find common denominators for all fractions in the problem. Find the equivalent numerators.

Fractions Adding Mixed Numbers Add the fractions of the mixed number. Then add the sum of the fractions to the whole number. Subtracting Fractions with the Same Denominator Subtract the numerator and place it over the denominator. Subtracting Fractions with Different Denominators Find a common denominator, and then subtract. Provide an example of adding a mixed number. Provide an example of subtracting fractions with different denominators.

Fractions Subtracting Mixed Numbers Multiplying Fractions When the numerator of the top fraction is smaller than that of the bottom fraction, borrow one whole number from the whole number of the mixed fraction and express it as a fraction. Multiplying Fractions Multiply the numerators; multiply the denominators. Multiplying Fractions and Mixed Numbers Change the mixed number to an improper fraction. Multiply. Give an example of multiplying fractions with different denominators.

Fractions Dividing Fractions Dividing Fractions and Whole Numbers Write the problem down correctly; invert the second fraction. Multiply. Dividing Fractions and Whole Numbers Change the whole number to a fraction Divide. Give an example of dividing fractions with whole numbers.

Decimal Fractions The decimal fraction is a type of fraction that uses a decimal to indicate the denominator of the fraction. The placement or position of the decimal point determines whether the denominator is 10, a multiple of 10, or a division of 10.

Decimal Fractions Names of Decimal Places .0001 Ten thousandths .00001 One hundred thousandths .0001 Ten thousandths .001 Thousandths .01 Hundredths .1 Tenths 1. Unit (whole number) 10 Tens 100 Hundreds 1000 Thousands 10,000 Ten thousands 100,000 One hundred thousands

Decimal Fractions Names of Decimal Places (continued) A decimal point found left of a whole number means that the number is a fraction of a whole number. A decimal point found after a number means that it is a whole number. A number without a decimal point is understood to have an “invisible” decimal point behind it. Give an example of a fraction when the decimal is to the left of a number. Describe an “invisible” decimal point.

Decimal Fractions Adding Decimals Subtracting Decimals Align the decimal point of each decimal fraction in a column. Add. Subtracting Decimals Subtract. Rounding a Number A number found after the decimal point that is 5 or larger can increase the number before it by one whole number. Give an example of adding and subtracting figures with decimal points. Give an example of rounding a number up or down.

Decimal Fractions Multiplying Decimals Dividing Decimals Multiply. Decimal points in the problem do not have to be aligned. The decimal place in the answer is determined by how many numbers are found to the right of the decimal points in the numbers multiplied. Dividing Decimals Change a decimal fraction in the divisor to a whole number by moving the decimal point all the way to the right. Move the decimal point in the dividend the same number of places moved in the divisor. Give examples of multiplying numbers with decimal points.

Decimal Fractions Dividing Decimals (continued) Place the decimal point in the answer directly over the decimal point in the dividend after moving the decimal point in the dividend. If a decimal point is in the divisor, but not in the dividend, move it the same number of places as the divisor. Remember, there is an unexpressed decimal point at the end of all whole numbers. Add zeros after the decimal point in the dividend as needed. If the dividend contains a decimal fraction and the divisor does not, leave the divisor as it is. Give examples of dividing numbers with decimal points.

Decimal Fractions Changing Fractions to Decimals Divide the numerator by the denominator. Changing a Decimal Fraction to a Common Fraction To change a decimal fraction to a common fraction, give the decimal fraction a denominator according to the position of the decimal point in the decimal fraction. Demonstrate how to change a fraction to a decimal. Give an example of how to change a decimal to a fraction.

Percents The word “percent” and its symbol, %, mean “hundredths.” A hundredth is a fraction of a whole number; therefore, a number followed by percent sign (%) is a fraction. The denominator of the fraction is understood to be 100.

Percents Changing a Percent to a Decimal Fraction Remove %; move the decimal point two places to the left to indicate “hundredths.” Changing a Fraction to a Percent Change a fraction to a percent by dividing the numerator by the denominator. Multiply the answer by 100. Label the answer with the percent symbol, %. Multiplying by Percent Change the percent to a decimal. Multiply. Give examples of how to: change a whole number to a percent change a fraction to a percent multiply a percent.

Ratios Ratios show the relationship of one number or quantity to another number or quantity. Numbers of a ratio are separated by a colon. A ratio is also a fraction. The value of a ratio is not changed if both terms are multiplied or divided by the same number. When numbers are written in ratio, they must all be expressed in the same units. A fraction may be written as a ratio. Give examples of situations in which ratios are seen within health care.

Proportions Proportion shows that the relationship between two ratios has equal value. Definitions Means: inner terms of the proportion Extremes: outer terms of the proportion Set up the left side of the proportion as the “known” side using information that is known or given.

Proportions Set up the known side. Set up the unknown side. Use x for what you are trying to find. Set up the units in the same position on each side of the problem. Multiply the means. Multiply the extremes Solve for x (divide the number with the x into the number on the opposite side of the problem). Label the answer with the unit of measurement that accompanies the x in the problem. Demonstrate how proportions are basic algebra. Give examples of how to solve for x.

Proportions Review of Proportion Method Set up problems in the same order on both sides. Multiply the means; multiply the extremes. The number multiplied with the x is always that number with the x to the right of it. Divide the number with the x into the number on the other side of the problem. Label the problem by looking to see what unit of measurement the x is with the proportion.

The Metric System The metric system is based on the decimal system. The decimal system uses the divisions and multiples of a unit, which is always in ratios of tens. The metric system uses the following units: liter (L) = volume (amount) of fluids gram (g) = weight of solids meter (m) = measure of length

The Metric System Smaller units of the system are designated by the following prefixes: deci = 0.1 of the unit (liter, gram, meter); tenths centi = 0.01 of the unit; hundredths milli = 0.001 of the unit; thousandths Larger units of the system are designated by the following prefixes: deka = 10 times the unit (liter, gram, meter) hecto = 100 times the unit kilo = 1000 times the unit Give examples of an item that is equal but is displayed differently, such as 1000 mg = 1 g. Give an example of kilograms to grams in which the amounts are equal.

The Metric System Units of Weight Units of Volume 1 gram (g) = 1000 milligrams (mg) 0.001 gram (g) = 1 milligram (mg) 1 kilogram (kg) = 1000 grams (g) 0.001 kilogram (kg) = 1 gram (g) Units of Volume 1 liter (L) = 1000 milliliters (mL) 0.001 liter (L) = 1 milliliter (mL) 1 milliliter (mL) = 1 cubic centimeter (cc) Give examples in which metric units of weight would be used. Give examples in which metric units of volume would be used.

The Metric System Approximate Equivalents of the Metric System and the Apothecary System Volume 1 milliliter (mL) = 15 or 16 minims 4 or 5 milliliters (mL) = 1 fluid dram 30 milliliters (mL) = 1 fluid ounce 500 milliliters (mL) = 1 pint 1000 milliliters (mL) = 1 quart Give an example of a typical household item and determine what the equivalent would be in mL. Such as a pint of milk = 500 mL.

The Metric System Approximate Equivalents of the Metric System and the Apothecary System (continued) Weight 60 milligrams (mg) = 1 grain (gr) 1000 milligrams (mg) = 15 grains 4 grams (g or gm) = 1 dram 30 grams (g) = 1 ounce 0.45 kilogram (kg) = 1 pound (lb.) 1 kilogram (kg) = 2.2 pounds (lbs.) Give an example of a typical over-the-counter medication in which the label could provide grains. Aspirin. Give an example of how to figure how many grains equals x mg.

The Metric System Metric Measurements of Length The basic unit of length is the meter. The meter is equal to 39.37 inches. 0.001 meter = 1 millimeter (mm) 0.01 meter = 1 centimeter (cm) 0.1 meter = 1 decimeter (dm) 10 meters = 1 decameter (dam) 100 meters = 1 hectometer (hm) 1000 meters = 1 kilometer (km)

The Metric System Metric Measurements of Length Most frequently used equivalents 1 meter (m) = 1000 millimeters (mm) 0.001 meter (m) = 1 millimeter (mm) 1 meter (m) = 100 centimeters (cm) 1 centimeter (cm) = 10 millimeters (mm) 1 millimeter (mm) = 0.1 centimeter (cm)

Pediatric Considerations Young’s Rule A method for the calculation of the appropriate dose of a drug for a child 2 years of age or older; applies to children up to the age of 12 Age of child _ (Age of child + 12)  Average adult dose = Child’s dose Give an example utilizing Young’s rule.

Pediatric Considerations Clark’s Rule A method of calculating the approximate pediatric dosage of a drug for a child Weight of child (lbs.) 150  Average adult dose = Child’s dose Give an example utilizing Clark’s rule.

Pediatric Considerations Fried’s Rule This rule is used for infants younger than 2 years of age. Age in months 150  Average adult dose = Child’s dose Give an example utilizing Fried’s rule.

Pediatric Considerations Estimating Body Surface Area in Children Body surface area is defined as the total area exposed to the outside environment. Use body surface area scale to find the correct surface area (SA). SA (m2) 1.73 m2  Adult dose = Child’s dose Give an example and estimate the body surface area of a toddler.

Pharmacology This is the study of drugs and their action on the living body. Substances derived from plants and animals, from vitamins and minerals, and from synthetic sources can be used as drugs in the treatment and prevention of disease. The action of any drug on the body is a complicated process.

Pharmacology Pharmaceutical Phase Pharmacokinetic Phase The making of the drug until absorption of the drug takes place in the patient’s body Pharmacokinetic Phase The movement of the drug’s active ingredients from the body fluids into the entire system and to the site where the intended action of the drug takes place Pharmacodynamic Phase Interaction of the drug’s active ingredient with the intended body tissues; the body’s cells respond to the action of the drug and change as the drug is metabolized Provide an example of the pharmaceutical phase. Provide an example of the pharmacokinetic phase. Provide an example of the pharmacodynamic phase.

Pharmacology Drug Dosage The dosage is the amount of a drug prescribed for the patient by the physician. A dose of medicine refers to a single prescribed amount of drug given at one time. Nurses must become familiar with therapeutic dosages of frequently used drugs to confidently administer dosages of medication to each patient. Give an example of a typical over-the-counter medication and its dosage.

Pharmacology Drug Actions and Interactions Two general types Local: Affect only the area where the drug is placed Systemic: Affect the entire body Drug interaction: One drug alters another drug Potentiation: One drug increases the action or effect of another drug Incompatibility: Drugs that do not combine chemically with other drugs Antagonist: Drug that will block the action of another drug Give an example of a drug interaction. Give an example of an antagonist. Give an example of a potentiation effect.

Pharmacology An idiosyncratic response to a drug is an individual’s unique hypersensitivity to a particular drug. A reduced response to a drug is called tolerance. An adverse drug reaction is a harmful, unintended reaction to a drug administered at a normal dosage. Contraindications are conditions under which the drug should not be given. Interactions are modifications of the effect of a drug when administered with another drug. Give an example of an idiosyncratic response. Give an example of an adverse drug reaction.

Pharmacology Factors that may affect how patients respond to medication: Age Weight Physical health Psychological status Environmental temperature Gender Amount of food in the stomach Dosage forms How does age have an effect on medication response? How does weight have an effect on medications? How does food in the stomach affect medications?

Medication Orders The nurse is ethically and legally responsible for ensuring that the patient receives the correct medication ordered by the physician. Medication orders should include the following: Patient's name Date and time of the order Name of the drug Dosage of the drug Route of administration Time or frequency drug is given Signature of the physician Any special instructions Why it is important that the nurse ensure that the medication order contains these criteria? Why is the date and time the order was written important?

Medication Orders Controlled Substances Opioids, barbiturates, and other controlled drugs that have a high possibility for abuse or addiction are double-locked. “Narcotic keys” are kept by designated nurses per shift. Each controlled drug used is logged into the narcotic log book. At the end of each shift, controlled drugs are carefully counted by a nurse from the outgoing shift and a nurse from the incoming shift. Always have a witness to the “wasting” of a controlled substance. How are controlled substances monitored by the government? Why are wasted narcotics witnessed by another nurse? Why are narcotics counted?

Medication Orders Types of Orders Standing orders Verbal orders Already written by a physician for all patients on a particular unit or area Carried out without having to call the physician Verbal orders May be given in the presence of an LPN/LVN or an RN directly or over the telephone Should be written on the chart and signed by the physician as soon as possible What is the difference between standing and verbal orders? Does the physician order these medications?

Medication Administration Six Rights Right medication Right dose Right time Right route Right patient Right documentation Why are the six rights important to follow when administering medications? Give examples of situations that could be detrimental if these six rights are not followed.

Medication Orders Important Considerations of Medication Administration If you did not pour it, do not give it. 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 labeled. Do not put down an unlabeled syringe. If given a verbal order, repeat it to the physician. If you make an error, report it immediately. Why is it important not to give a medication you did not pour or withdraw into a syringe? Why does a nurse not document a medication given for another nurse? Why is it unsafe to leave an unlabeled syringe?

Medication Orders Important Considerations of Medication Administration (continued) Never leave a medication with a patient or family member. Watch the patient take it and swallow it. Always return to assess the patient’s response. Chart as soon as possible after giving medication. If a patient refuses medication, do not force it; chart “Refused medication because of. . . .” 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 physician. Why should the nurse witness the patient taking his/her medication? Why should the nurse return after a patient has taken a medication?

Routes of Administration Enteral Via the GI tract Powders Pills Tablets Liquids or suspensions Suppositories Give an example of when the enteral route might be chosen for medications.

Routes of Administration Percutaneous Through the skin or mucous membranes Topical Instillation Inhalation Describe over-the-counter medications that can be administered by these routes: topical, instillation, and inhalation.

Routes of Administration Parenteral Methods other than the GI tract; needle route Ampules Vials Intramuscular Subcutaneous Intradermal Intravenous Describe these routes and sites for administration: subcutaneous, intramuscular, and intravenous.

Enteral Administration Preparation of Tablets, Pills, and Capsules These preparations enter the GI tract and are absorbed more slowly into the blood stream than via any other route. The slow absorption rate makes the PO (by mouth) route relatively safe. Some PO medications are irritating to the patient’s GI tract, and larger tablets may be difficult for some patients to swallow.

Administering tablets, pills, and capsules. Skill 23-1: Step 5 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Administering tablets, pills, and capsules.

Enteral Administration Preparation of Liquid Medications Liquid medications are often given to children; to patients who cannot swallow tablets, pills, or capsules; and to geriatric patients. Medications may be given PO or via a nasogastric, gastrostomy, or jejunostomy tube. Liquids must not be given to unconscious patients because of the possibility of aspirating. Some liquid medications are not to be followed by water, and some may stain the teeth. Give examples in which liquid medications should not be administered. What types of medications should not be followed by water?

Administering liquid medications. Skill 23-2: Step 13 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Administering liquid medications.

Enteral Administration Tubal Medications Nasogastric (NG) tubes are used to administer liquid medications to unconscious patients, dysphagic patients, and those who are too ill to eat. Many medications come in liquid form; if they do not, solid tablets may be pulverized in a mortar and pestle, and capsules can be opened. Not all tablets are safe to use when crushed, and not all capsules are safe to use when opened. Give an example in which tubal medications can be administered.

Administering tubal medications. Skill 23-3: Step 13a Administering tubal medications.

Administering tubal medications. Skill 23-3: Step 16 Administering tubal medications.

Enteral Administration Suppositories Cone-shaped, egg-shaped, or spindle-shaped medication made for insertion into the rectum or vagina Dissolves at body temperature and absorbed directly into the bloodstream Useful for infants, patients who cannot take oral preparations, and patients with nausea and vomiting Stored in cool place so they do not melt Give examples in which suppositories would be appropriate routes to administer medications. What over-the-counter medications come in suppository forms?

Percutaneous Administration With these routes, medications are absorbed through the skin or the mucous membranes. Most produce a local action, but some produce a systemic action. Drugs include topical applications, instillations, and inhalations and ointments, creams, powders, lotions, and transdermal patches. Absorption is rapid but of short duration. Give an example of which patient population might require this type of route. Asthmatic and COPD patients. Give examples of medications that are typically used in this manner.

Percutaneous Administration Ointments An oil-based semisolid medication; may be applied to the skin or a mucous membrane Creams Semisolid, nongreasy emulsions that contain medication for external application Lotions Aqueous preparations that are used as soothing agents that relieve pruritus, protect the skin, cleanse the skin, or act as astringents What is the difference between ointments, creams, and lotions?

Percutaneous Administration Transdermal Patches (Topical Disk) Adhesive-backed medicated patches applied to the skin provide sustained, continuous release of medication over several hours or days. Eyedrops and Eye Ointments Care should be taken to keep all ophthalmic preparations sterile by not touching the dropper or the tube to the eye. Eardrops Containers of solutions to be used as eardrops will be labeled “otic.” They must be at room temperature when applied. Give an example of over-the-counter medications that are available in these forms: transdermal patches, eyedrops, and ear drops.

A variety of medications are available as transdermal patches. Figure 23-4 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A variety of medications are available as transdermal patches.

Percutaneous Administration Nosedrops Nosedrops are for individual use only. Nasal Sprays Sprays absorbed quickly; less medication is used and wasted when administered in this manner. Inhalation Drugs may be absorbed through the mucous membranes of the respiratory tract. Inhalation produces a relatively limited effect or a systemic effect. This method is actively used by respiratory therapy and anesthesiologists.

Percutaneous Administration Sublingual Administration Drug is administered by placing it beneath the tongue until it dissolves. Drug may be a tablet or liquid squeezed out of a capsule. It is rapidly absorbed into the bloodstream. Buccal Administration A tablet is placed between the cheek and teeth, or between the cheek and the gums. Absorption into the capillaries of the mucous membranes of the cheek gives rapid onset of the drug’s active ingredient. Give examples in which sublingual and buccal administration would be appropriate.

Parenteral Administration Equipment Syringes Syringe consists of a barrel, a plunger, and a tip. Outside of the barrel is calibrated in milliliters, minims, insulin units, and heparin units. Types Tuberculin syringe Insulin syringe Three-milliliter syringe Safety-Lok syringes Disposable injection units What is the difference between a tuberculin and an insulin syringe? What is a Safety-Lok syringe? In what situations would a disposable injection syringe be appropriate?

Figure 23-5 Parts of a syringe. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Parts of a syringe.

Tuberculin syringe calibration. Figure 23-6 (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.) Tuberculin syringe calibration.

Calibration of U100 insulin syringe. Figure 23-7 (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.) Calibration of U100 insulin syringe.

Reading the calibrations of a 3-mL syringe. Figure 23-8 Reading the calibrations of a 3-mL syringe.

Figure 23-10 Safety-Glide syringe.

Figure 23-12 Parts of a needle. (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.) Parts of a needle.

Percutaneous Administration Equipment (continued) 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.

Percutaneous Administration Equipment (continued) 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: 5/8 to 1/2 inch Intramuscular: 1 to 1 1/2 inch Intravenous needles Butterfly (scalp needle) Over-the-needle catheter (Angiocath, Jelco)

Needle length and gauge. Figure 23-13 (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.) Needle length and gauge.

Percutaneous Administration Equipment Needleless devices Devices are designed with a sheath or guard that covers the needle after it is withdrawn from the skin. Intravenous catheters have been designed with blunt-edged cannulas, valves, or needle guards to minimize injuries. IV tubing with recessed and shielded needle connectors has been designed, further reducing needlesticks. What benefits are there to needleless devices? Describe needleless IV tubing.

Percutaneous Administration Intramuscular Injections Involves inserting a needle into the muscle tissue to administer medication Site selection Gluteal sites Vastus lateralis muscle Rectus femoris muscle Deltoid muscle Z-track method Used to inject medications that are irritating to the tissues Give examples in which the gluteal site would not be an appropriate administration site. Give examples in which the deltoid muscle would not be an appropriate administration site. When should the Z-track method be utilized?

Locating IM injection for ventrogluteal site. Figure 23-15, C (C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Locating IM injection for ventrogluteal site.

Giving IM injection in vastus lateralis site on adult. Figure 23-16, C (C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Giving IM injection in vastus lateralis site on adult.

Rectus femoris muscle. A, Child/infant. B, Adult. Figure 23-17 (From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.) Rectus femoris muscle. A, Child/infant. B, Adult.

Giving IM injection in deltoid site. Figure 23-18, C (C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Giving IM injection in deltoid site.

Figure 23-19 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) A, Z-track method. B, Using an air lock. C, Administering IM injection by airlock technique.

Percutaneous Administration Intradermal Injections Introduction of a hypodermic needle into the dermis for the purpose of instilling a substance such as a serum, vaccine, or skin test agent Not aspirated Small volumes (0.1 mL) injected to form a small bubblelike wheal just under the skin Used for allergy sensitivity tests, TB screening, and local anesthetics A tuberculin syringe used with a 25-gauge, 3/8- to 5/8-inch needle Where is the dermis located? Why is it inappropriate to aspirate when administering an intradermal injection? Why is a short needle length utilized for intradermal injections?

Figure 23-20 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Angles of insertion for intramuscular (90°), subcutaneous (45°), and intradermal (15°).

Percutaneous Administration Subcutaneous Injections Injections made into the loose connective tissue between the dermis and the muscle layer Drug 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 1/2 to 5/8 inch and 25 gauge Used to administer insulin and heparin Where is the loose connective tissue located? Why is a longer needle length, when compared to an intradermal injection, utilized for a subcutaneous injection?

Figure 23-21 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Subcutaneous injection. Angle and needle length depend on the thickness of skinfold.

Percutaneous Administration Intravenous Therapy Provide fluid and electrolyte maintenance, restoration, and replacement Administer medication and nutritional feedings Administer blood and blood products Administer chemotherapy to cancer patients Administer patient-controlled analgesics Keep a vein open for quick access

Percutaneous 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 What does the term “IV push” mean? What is a “piggyback”? What are volumetric chambers?

Figure 23-23 PCA infusion pump. (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) PCA infusion pump.

Figure 23-24 Volumetric chamber.

Percutaneous Administration Nursing Responsibility The nurse must ensure that fluid of the ordered type and amount is started and that the fluid is regulated to infuse over the period ordered. To find the drops per minute (the drip rate), you must know which type of IV tubing will be used with the infusion and obtain the drip factor for the tubing to be used. Why is it important for the nurse to ensure proper infusion of the IV ordered? What is a drip rate?

Percutaneous Administration Nursing Responsibility (continued) 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. Why is it important to assess the IV site every hour? Why is it necessary to assess for chills, fever, headache, nausea, vomiting, anxiousness, and dyspnea?

Percutaneous Administration Nursing Responsibility (continued) Assess for anaphylactic shock Respiratory distress Skin reactions Signs of circulatory collapse GI signs and symptoms Change in mental status Requires immediate intervention. What is anaphylactic shock? Why does the nurse need to respond immediately to a patient who is experiencing anaphylactic shock?

Nursing Process Nursing Diagnoses Anxiety Health-seeking behaviors Injury, risk for Knowledge deficient Mobility, impaired Noncompliance: drug regimen Sensory/perception, disturbed Give an example of a patient situation in which the nursing diagnosis of “Injury, risk for” would be appropriate. Give an example of a patient situation in which the nursing diagnosis of “Noncompliance: drug regimen” would be appropriate.