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Preparing and Administering Medications
Chapter 7 Preparing and Administering Medications Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Calculation Methods Fraction Method Ratio or Proportion Method Dimensional analysis First change dosages to the same unit of measurement if they are different. Reduce to the simplest terms. Calculate the dosage. Use common sense to check the answer. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Insulin Must be very accurate in insulin calculations. A small error makes a big change in insulin dosage. Use the correct syringe, the correct insulin, and the correct dose. Should always be rechecked by another nurse for maximum accuracy. There are many kinds of insulin, but all come in a standardized dose called a unit. Available in two strengths, U-100 and U-500. Should be drawn up only in a special insulin syringe. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Intravenous Infusions
Flow Rates Three mathematical procedures the nurse must be familiar with regarding IV infusions: Calculating the flow rates for IV fluid administration Making modifications in flow rates for infants Calculating total administration time for IV fluid The rate at which IV fluids are given is the flow rate, and this is measured in drops per minute. The drop factor is the number of drops per milliliter of liquid and is determined by the size of the drops. The drop factor is different for different manufacturers of IV infusion equipment, and it must be checked by reading it on the infusion set itself. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Calculating Dosages for Infants and Children
Clark’s Rule Body surface area (BSA) Nomogram Drug dosages are calculated to give the highest possible blood and tissue concentration of a medication without causing overdosage or adverse effects. Because infants are very sensitive to medications, and because infants and children are so much smaller than adults, almost all dosages given to infants and children are smaller than those given to adults The Joint Commission on Accreditation of Healthcare Organizations now asks that all dosages for children be weight based, preferably in kilograms. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Enteral Medications Medications given directly into the GI tract Oral; Box 7-1, Oral Medication Forms Nasogastric or PEG Rectal Can you identify an advantage of oral medication? What might be a disadvantage of oral drug administration? What type or form is used with rectal drug administration? Why would medications be given through a PEG or NG tube? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Oral Administration Asepsis Steps to administer: Procedure 7-1 Getting ready Preparing the medication Administering the medication What should the nurse do to get ready for administering oral medications? What should the nurse do if the medication falls onto the floor before he or she administers the drug? If the patient would like to take the medication in 10 minutes, what should the nurse do? How does the nurse document if the patient refuses the medication? What container is best suited for administering liquid to an infant? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Oral Administration (cont.)
Solid form Liquids How are lozenges administered? What can you instruct the patient to do to facilitate swallowing? If the patient has several drugs that should be taken, which ones should be administered first? How do you read liquid measurement? When giving an infant medication from a syringe or dropper, where should you place it in the infant’s mouth? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Nasogastric Administration
Appropriate patients PEG tube Medication forms: Liquids Pills: crushed, add water If the drug comes in pill form, what should the nurse check before crushing the drug? What types of patients would have an NG or PEG tube in place? Where is the NG tube located in the patient? The PEG tube? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Procedure for Administering Nasogastric Medications
Aspirate stomach contents Listen for gurgling sounds in the stomach Listen for breath sounds Put medication into the tubing Instill medications via gravity Add water to tube following medication administration Why does the nurse check placement of the NG tube before drug administration? Why should the nurse instill 50 mL of water after administering drugs in the NG or PEG tube? After drug and water administration, how long should the NG or PEG tube be clamped? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Rectal Administration
Getting Ready Preparing the medication Administering the medication Concluding What patient symptoms or conditions may prohibit rectal drug administration? Why would rectal medication administration be considered over oral administration? Can you identify some disadvantages of rectal drug administration? What special considerations may apply to children after rectal drug administration? When administering an enema to a patient with constipation, how does the nurse evaluate the patient’s response? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Standard Precautions Protect health care workers Centers for Disease Control (CDC) Sharps container for disposal of needles When should the nurse use standard precautions in the clinical area? Is it important for the nurse to recap the needle after medication administration? What are examples of blood-borne pathogens? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Parenteral Administration
“Into the skin” Routes for administration Parenteral rationale/Advantages Disadvantages Costs Which route is commonly used when a patient undergoes allergy testing? Why would the parenteral route be preferred over the oral route? What effect occurs in the liver that causes the oral dosage to be higher than the IV dosage of the same drug? What is the difference between aseptic and sterile technique related to drug administration? Are pregnant healthcare workers at greater risk of exposure to blood-borne pathogens such as hepatitis B or HIV? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Basic Equipment Syringes: Figure 7-3 Types of syringes: Figure 7-4 Volume of medication: mL or m Which syringe would the nurse select when administering volumes less than 1 mL? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Needles Needles: gauge Hub Specialized needles Guide for needle selection: Table 7-1 Needleless system: Figure 7-6 Which is the larger needle, a 16-gauge or a 25-gauge? What does the nurse consider when selecting the length of the needle? When would a patient receive patient-controlled analgesia (PCA)? What is the difference in route of PCA compared to PCEA? Needleless systems have become popular as a type of delivery system because of safety issues associated with needle disposal. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Procedure for Preparing and Administering Parenteral Medications
Procedure for medication administration: Procedure 7-3 Determine sight for administration Use of equipment Package Medication characteristics When inspecting sterile packages, what are considerations to which the nurse should pay close attention? When should the nurse return medications to the pharmacy? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Forms of Parenteral Medications
Vials: Figure 7-7 Ampules: Figure 7-8 Mix-O-Vial: Figure 7-9 Single or Multidose vials Can you describe the procedure the nurse should follow when inserting a needle through the rubber diaphragm of a vial? If the vial contains a powder, the nurse adds the recommended fluid. This is referred to as reconstitution of the drug. How does the nurse determine the type of diluent to use for drug reconstitution? When withdrawing medication from an ampule, the nurse uses a special needle that contains a filter to prevent glass shards from being drawn up into the syringe. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Forms of Parenteral Medications (cont.)
Combining drugs in one syringe Mixing insulin Prefilled syringes IV solutions Secondary or “piggyback” Why must the nurse inject air into a vial before withdrawing the drug? Which insulin is drawn up first when mixing Regular and NPH insulin? When the nurse opens a multidose vial, what should be added to the label? Can you think of an instance when a prefilled syringe would be helpful? What amount of solution volume do secondary infusions usually contain? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Administering Intradermal Injections
Uses Skin anatomy and needle angle: Figure 7-13 Bleb Equipment and technique What instructions will the nurse provide to the patient following an intradermal injection? What needle gauge and length is used when administering intradermal medications? Can you think of a drug or situation when an intradermal injection may be given? What type of symptoms will the nurse observe if the patient is allergic or reacting to the medication given intradermally? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Administering Subcutaneous Medications
2 mL into the loose connective tissue Slow onset, longer duration Placement: Figure 7-14 Sites: Figure 7-15 Technique Why do medications that are administered subcutaneously have a slow onset and long duration of drug action? What length of needle is commonly used when administering subcutaneous medications? Why is it important to rotate sites when administering medications subcutaneously? To make sure the needle has not accidentally entered a vein or artery, you would typically pull back on the plunger (aspirate) and check the syringe for blood. With what medication do you NOT aspirate prior to administering? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Administering Intramuscular Medications
Location Absorption Equipment Sites: Box 7-3 Technique What is the maximum amount of volume that can be administered intramuscularly to infants? How does the nurse determine the needle length for an IM injection? How do the techniques for injection differ when you compare the IM to the Z-track technique? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Administering Intravenous Medications
Onset and absorption Dosing and scheduling considerations Equipment Sites: Figures 7-18 (adult) and 7-19 (children) Venipuncture and intravenous infusion Procedure 7-4 Can you identify an advantage of IV medication administration over IM administration as it relates to dosing? If you were preparing to insert an IV into an adult patient, which site would you look at first? What should the nurse do if he or she notes the solution to be hazy before administering it? At what angle to the patient’s skin should the nurse place the IV needle before insertion? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Modifications in Technique for Specific Situations
Adding medication by syringe to an infusion Adding medication to a plastic bag or an IV bottle Adding medication to a volume control Adding medication by piggyback infusion Administration of medication when there is only an intermittent infusion device Why is it important for the nurse to withdraw blood in the tubing when adding medication by syringe to an existing infusion? Why is it preferred that the nurse slowly add medications to a plastic bag or an IV bottle? The nurse applies a label to the volume control chamber after adding medication to it. The label should include the date, time, dosage, and medication added and should be signed with initials. Can you think of a clinical condition when an intermittent infusion device would be beneficial? What drugs or solutions may be used to flush the patient’s tubing when an intermittent fusion device is used? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Intravenous Infusion Rates
Monitoring infusion rates Calculating infusion rates Infusion pumps; syringe infusion pumps Infusion controllers and volumetric pumps Implantable pumps Venous access device Common problems with intravenous infusions How often should the nurse check the patient’s infusion? Would you expect the drug dosage for the epidural route to be larger or smaller than the IV route? If the nurse determines the IV infusion has fallen behind, what should be done? Signs of an IV infiltrating include redness, swelling of the area, and pain. Is an order required for the LPN/LVN to discontinue an IV when it has infiltrated? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Percutaneous Medications
Absorption: mucous membranes or the skin Absorption and application Inhalation What is the intended treatment area for transdermal medications? What are some disadvantages to percutaneous medication administration? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Percutaneous Administration
Factors affecting transdermal application Skin Condition Methods of Administration Why is it important to teach a patient how to correctly use a metered-dose inhaler? Can you identify a method other than through the skin in which percutaneous drug administration occurs? Why is it important for the nurse to wear gloves when administering percutaneous medication? Can you name a common form of a topical medication? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Procedures for Administering Percutaneous Medications
Applied to the area requiring treatment Common Forms: Box 7-4 Ointments should be applied sparingly. Astringents may cause a drying effect on the skin. What type of problem can silver nitrate produce on the skin and on the clothing? Burow’s solution is a common solution used in applying wet dressings. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Administering Topical Medications
Clean skin before application Gloves Lotions Ointments Excess medication Dressings Patient Education – Home Care Nitroglycerin ointment is applied to the chest, upper arm, or flank areas. Nitroglycerin ointment may be ordered in inches. Can transdermal delivery patches be worn while the patient bathes? What are the nursing considerations for patients with a lot of chest hair? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Administering Medications to Mucous Membranes
Absorption Sublingual Buccal Vaginal Ear drops: child and adult Eye Nose Respiratory Which absorbs more rapidly, a water-based or an oil-based drug? When administering ear drops to a child younger than 3 years, the earlobe is pulled gently down and back to straighten the ear canal. What is the difference between aerosol respiratory treatments and metered-dose inhalers? How can the nurse determine whether the canister of the MDI is full? What position should the patient be in after vaginal drug administration? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Precautions to Prevent Transmission of HIV
Wear gloves when touching blood, body fluids containing blood, and body fluid to which Standard Precautions apply. Wash hands and skin surfaces immediately and thoroughly with war soap and water if they get splashed with blood or body fluids. Take precautions to prevent injuries from needle sticks Health care workers are at risk for exposure to blood from patients and must consider all patients as possibly infected with bloodborne pathogens. To prevent needlestick injuries, needles are not to be recapped, bent or broken by hand, or removed from disposable syringes. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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Sites for Intramuscular Injections (Landmarks)
Deltoid muscle Dorsogluteal muscle Rectus femoris muscle Vastus Lateralis muscle Ventrogluteal muscle The deltoid muscle is easily reached but used infrequently because the muscle is small and can accommodate only small doses of medications. The dorsogluteal muscle is a common injection site for adults because it is relatively free from nerves and major blood vessels. Rectus femoris is used in both children and adults, especially for self-injection. Vastus lateralis muscle can absorb a large volume of medication. The ventrogluteal muscle is a large muscle mass that is free of major nerves and adipose tissue, and is also remote from the rectum. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
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