Medication Administration

Medication Administration
Chapter 31 Medication Administration A medication is a substance used in the diagnosis, treatment, cure, relief, or prevention of health problems. Nurses play an essential role in safe medication preparation and administration, and in evaluation of medication effects. In all settings, nurses are responsible for evaluating the effects of medications on patients’ ongoing health status, teaching them about their medications and side effects, ensuring adherence to the medication regimen, and evaluating the patient’s and family caregiver’s ability to self-administer medications.

Scientific Knowledge Base
To safely and accurately administer medications, you need knowledge related to: Legal aspects of health care Pharmacology Pharmacokinetics Life sciences Pathophysiology Human anatomy Mathematics Many of these concepts you have previously acquired when you took prerequisite courses. Learning medication classifications improves understanding of nursing implications for administering medications with similar characteristics. The nurse applies understanding of the physiology of medication action when timing administration, selecting routes, initiating actions to promote medication efficacy, and observing responses to medications.

Medication Legislation and Standards
Federal regulations Pure Food and Drug Act Food and Drug Administration (FDA) MedWatch program State and local regulation of medication Health care institutions and medication laws Medication regulations and nursing practice (Nurse Practice Acts) Regulations are made to protect patients. The first American law designed to regulate medications was the Pure Food and Drug Act. This law simply requires all medications to be free of impure products. Federal medication law has extended and refined controls on medication sales and distribution; medical testing, naming, and labeling; and regulation of controlled substances. Official publications such as the U.S. Pharmacopeia (USP) and the National Formulary set standards for medication strength, quality, purity, packaging, safety, labeling, and dose form. In 1993, the Food and Drug Administration (FDA) instituted the MedWatch program. This voluntary program encourages nurses and other health care professionals to use the MedWatch form to report when a medication, product, or medical event causes serious harm to a patient. State and local medication laws must conform to federal legislation. State laws control substances not regulated by the federal government. Local laws regulate the use of alcohol and tobacco. Health care institutions and medical laws establish policies to meet federal, state, and local regulations. A health care institution is concerned with preventing poor health outcomes resulting from medication use. Agency policies are often more restrictive than governmental controls. Medication regulations and nursing practice are governed by individual state Nurse Practice Acts (NPAs). Most NPAs are purposefully broad, so nurses’ professional responsibilities are not limited. The primary purpose of the NPA is to protect the public from unskilled, undereducated, and unlicensed personnel. Nurses are responsible for following legal provisions when administering controlled substances and narcotics, which are federally and state regulated. All controlled substances are handled according to strict procedures that account for each medication. Hospitals and other health care agencies have policies for proper storage and distribution of narcotics (Box 31-1). [Refer to Box 31-1 on text p. 566 for guidelines on safe narcotic administration and control.]

Case Study Esther Simmons is an 85-year-old African American woman who lives in her home. Esther is on a skilled care floor in a hospital following hip replacement surgery. Her strength and mobility are improving, and she is planning to return home with home care nursing within the week. Emilio Fernandez is a 31-year-old nursing student who is assigned to care for Esther today. While reviewing the medical record, Emilio finds that Esther has several chronic illnesses: diabetes, heart disease, hypertension, and arthritis. [Ask the class: What medication challenges can you anticipate from this information? How will Emilio and Esther establish priorities with regard to medications?]

Pharmacological Concepts
Drug names: Chemical—provides the exact description of medication’s composition Generic—the manufacturer who first develops the drug assigns the name, and it is then listed in the U.S. Pharmacopeia Trade—also known as brand or proprietary name. This is the name under which a manufacturer markets the medication. Drugs can have up to three different names: chemical, generic, and trade. Example of a well-known medication: Chemical: N-acetyl-para-aminophenol Generic: acetaminophen Trade: Tylenol, Panadol, Tempra Manufacturers choose trade names that are easy to pronounce, spell, and remember. Many companies produce the same medication, and similarities in trade names are often confusing. Therefore be careful to obtain the exact name and spelling for each medication you administer to your patients. Because similarities in drug names are a common cause of medical errors, the Institute for Safe Medication Practices (ISMP) ( and The Joint Commission (TJC) ( publish a list of medications that are frequently confused with one another.

Pharmacological Concepts (cont’d)
Classification Effect of medication on body system Symptoms the medication relieves Medication’s desired effect Medication forms Solid, liquid, other oral forms; topical, parenteral; forms for instillation into body cavities Drugs are classified according to their characteristics, use in body systems, or desired effects. Some medications can have more than one classification such as aspirin, which can be analgesic, antipyretic, or anti-inflammatory. Medications come in several forms. [Refer to Table 31-1 Forms of Medication on text page 567.]

Pharmacokinetics The study of how medications: Enter the body
Are absorbed and distributed into cells, tissues, or organs Reach their site of action Alter physiological functions Are metabolized Exit the body Nurses need to use knowledge of pharmacokinetics when administering medications, selecting the route of administration, considering the patient’s risk for alterations in medication action, and evaluating the patient’s response. Four processes are included when considering pharmacokinetics: absorption, distribution, metabolism, and excretion. For medications to be therapeutic, they must be taken into a patient’s body; be absorbed and distributed to cells, tissues, or a specific organ; and alter physiological functions.

Quick Quiz! 1. You are caring for a patient who has diabetes complicated by kidney disease. You need to make a detailed assessment when administering medications because this patient may experience problems with A. Absorption. B. Biotransformation. C. Distribution. D. Excretion. Answer: D

Case Study (cont’d) Esther needs to take many medications on a routine basis. Several of Esther’s medications have changed, and several have been added since she was admitted. Based on this assessment, Emilio determines that Esther needs to learn how to administer her medications safely at home. He knows that to help Esther manage her medications at home, he needs to learn more about her culture. He assesses Esther’s cultural beliefs and determines what factors affected her ability to manage her medications before she entered the hospital. Emilio also learns that African American patients tend to manage their medications at home better when they understand their medication regimen and when they are able to afford their medications. [Ask the class: How will Emilio determine if Esther understands and can afford her medications?]

Absorption Passage of medication molecules into the blood from the site of administration Factors that influence absorption: Route of administration Ability to dissolve Blood flow to site of administration Body surface area Lipid solubility of medication Each route of administration has a different rate of absorption. Topical administration has the slowest rate of absorption. The mucous membrane and the respiratory tract have a quick rate of absorption. IV administration has the fastest absorption rate. The oral route takes some time owing to the passage of medications through the GI tract. When the site of administration contains a rich blood supply, the medication will be absorbed quickly. Safe medication administration requires knowledge of factors that alter or impair absorption of prescribed medications. Because some medications interact with food, it is often appropriate to administer them before or after meals, with meals, or on an empty stomach.

Distribution After absorption, distribution occurs within the body to tissues, organs, and specific sites of action. Distribution depends on: Physical and chemical properties of the medication Physiology of the person taking it Circulation Membrane permeability Protein binding The rate and extent of distribution depend on the physical and chemical properties of the medication and the physiology of the patient. Once the medication has entered into the bloodstream, it is carried throughout the tissues and organs of the body. The speed of distribution depends on the vascularity of various tissues and organs. To be distributed to an organ, a medication has to pass through the organ’s tissues and biological membranes. Some membranes serve as barriers to the passage of medications. For example, the blood-brain area allows fat-soluble medications to pass into the brain and cerebrospinal fluid (CSF). Both fat-soluble and non–fat-soluble agents often cross the placenta and produce fetal abnormalities such as respiratory depression. Narcotic use can create withdrawal symptoms. The degree to which medication binds to serum proteins will affect medication distribution. Most medications bind to albumin to some extent and then cannot be pharmacologically active. The unbound or “free” medication is its active form.

Metabolism Medications are metabolized into a less potent or an inactive form. Biotransformation occurs under the influence of enzymes that detoxify, break down, and remove active chemicals. Most biotransformation occurs in the liver. Kidneys, blood, intestines, and lungs play a role. The liver is especially important because its specialized structure oxidizes and transforms many toxic substances. The liver degrades many harmful chemicals before they are distributed to the tissues. Biotransformation can also occur in the lungs, kidneys, blood, and intestines. [Ask the class: What will happen to medications if the organs used for biotransformation are not functioning correctly? Discuss. If a decrease in liver function occurs such as with aging or liver disease, a medication usually is eliminated more slowly, resulting in its accumulation. Patients are at risk for medication toxicity if organs that metabolize medications are not functioning correctly.]

Excretion Medications are excreted through:
Kidney Liver Bowel Lungs Exocrine glands Chemical makeup of medication determines the organ of excretion. [Ask students: What is the main organ for excretion? Kidneys Which type of medications are excreted through the lungs? Anesthetic gases, alcohol Why should certain medications not be taken during pregnancy? Some may pass through the placental barrier or mammary glands.] The exocrine glands excrete lipid-soluble medications. When medications exit through sweat glands, the skin often becomes irritated, requiring you to instruct patients in good hygiene practices. Medications that enter the hepatic circulation are broken down by the liver and excreted into the bile. After chemicals enter the intestines through the biliary tract, the intestines resorb them. Factors that increase peristalsis (e.g., laxatives, enemas) accelerate medication excretion through the feces, whereas factors that slow peristalsis (e.g., inactivity, improper diet) often prolong the effects of a medication. Some medications escape extensive metabolism and exit unchanged in the urine. Others undergo biotransformation in the liver before the kidneys excrete them. If renal function declines, a patient is at risk for medication toxicity. When the kidney cannot adequately excrete a medication, it is necessary to reduce the dose. Maintenance of adequate fluid intake (8 to 9 cups, or about 2 L of water/day) promotes proper elimination of medications for the average adult.

Types of Medication Action
Therapeutic effect: Expected or predicted physiological response Side effect: Unavoidable secondary effect Adverse effect: Unintended, undesirable, often unpredictable Toxic effect: Accumulation of medication in the bloodstream Idiosyncratic reaction: Over-reaction or under-reaction or different reaction from normal Allergic reaction: Unpredictable response to a medication [When leading this discussion, you can consider developing a matching game or jeopardy-type game.] Medications vary considerably in the way they act and in their types of action. Patients do not always respond in the same way to each successive dose of a medication. Sometimes the same medication causes very different responses in different patients. Therefore it is essential to understand all the effects that medications have on patients. Side effects are predictable, and often unavoidable secondary effects are produced at a usual therapeutic dose. They may be harmless or may cause injury. If the side effects are serious enough to negate the beneficial effects of the therapeutic action of the medication, the prescriber discontinues the medication. Patients often stop taking medications because of side effects. Some adverse effects are immediate, whereas others take weeks or months to develop. Health care providers report adverse effects to the FDA using the MedWatch program. Toxic effects develop after prolonged intake of a medication, or when a medication accumulates in the blood because of impaired metabolism or excretion. Excessive amounts of a medication within the body sometimes have lethal effects, depending on its action. For example, toxic levels of morphine, an opioid, cause severe respiratory depression and death. Antidotes are available to treat specific types of medication toxicity. In allergic reactions, the medication or chemical acts as an antigen, triggering the release of antibodies in the body. A patient’s medication allergy symptoms vary, depending on the individual and the medication. Among the different classes of medications, antibiotics cause a high incidence of allergic reactions. Severe or anaphylactic reactions, which are life threatening, are characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath. Immediate medical attention is required to treat anaphylactic reactions. [See also Table 31-2 on text p. 569 Mild Allergic Reactions.]

Allergy Identification
Allergy identification bracelet and medal A patient with a known history of an allergy to a medication needs to avoid exposure to that medication in the future and should wear an identification bracelet or medal that alerts nurses and physicians to the allergy if the patient is unconscious when receiving medical care. [Shown is Figure 31-1 from text p. 569.]

Quick Quiz! 2. A postoperative patient is receiving morphine sulfate via PCA. The nurse assesses that the patient’s respirations are depressed. The effects of the morphine sulfate can be classified as A. Allergic. B. Idiosyncratic. C. Therapeutic. D. Toxic. Answer: D

Medication Interactions
Occur when one medication modifies the action of another A synergistic effect occurs when the combined effect of two medications is greater than the effect of the medications given separately. Medication interactions may occur when one medication increases or diminishes the way the other medication is absorbed, metabolized, or eliminated. Alcohol has a synergistic effect on antihistamines, antidepressants, barbiturates, and narcotics because alcohol is a central nervous system (CNS) depressant. A patient with hypertension may need to take a combination of medications, such as a diuretic and a vasodilator, to control high blood pressure through the synergistic effect of the two medications.

Therapeutic Range The minimum effective concentration (MEC) is the plasma level of a medication below which the effect of the medication does not occur. The toxic concentration is the level at which toxic effects occur. When a medication is prescribed, the goal is to achieve a constant blood level within a safe therapeutic range, which falls between the MEC and the toxic concentration. When a medication is administered repeatedly, its serum level fluctuates between doses. The therapeutic range of a medication occurs between the minimum effective concentration and the toxic concentration. [Shown is Figure 31-2 from text p From Lehne RA: Pharmacology for nursing care, ed 7, St Louis, 2010, Saunders.]

Medication Dose Responses
Onset: Time it takes for a medication to produce a response Peak: Time at which a medication reaches its highest effective concentration Trough: Minimum blood serum concentration before next scheduled dose Duration: Time medication takes to produce greatest result Plateau: Point at which blood serum concentration is reached and maintained Biological half-life: Time for serum medication concentration to be halved Medications administered intravenously enter the bloodstream and act immediately, whereas medications given by other routes take time to enter the bloodstream and have an effect. The quantity and distribution of a medication in different body compartments change constantly. Medications are ordered at various times, depending on when their response begins, becomes most intense, and ceases. Owing to specific reactions, some medications may need to be evenly administered around the clock to produce maximum effect. [Refer to Table 31-3 on text page 570 for further explanation regarding medication action.] The highest level is called the peak concentration, and the lowest level is called the trough concentration. After reaching its peak, the serum concentration of the medication falls progressively. With IV infusions, the peak concentration occurs quickly, but the serum level begins to fall immediately, The time it takes for a drug to reach its peak concentration varies, depending on the pharmacokinetics of the medication. All medications have a biological half-life, which is the time it takes for excretion processes to lower the amount of unchanged medication by half. A medication with a short half-life needs to be given more frequently than a medication with a longer half-life. The half-life does not change, no matter how much medication is given. To maintain a therapeutic plateau, the patient must receive regular fixed doses. For example, current evidence shows that pain medications are most effective when they are given around the clock (ATC) rather than when the patient intermittently complains of pain, because ATC allows the body to maintain an almost constant level of pain medication. After an initial medication dose, the patient receives each successive dose when the previous dose reaches its half-life. Safe drug administration involves adherence to prescribed doses and dosage schedules. Some agencies set schedules for medication administration. However, nurses are able to alter this schedule based on knowledge about a medication. Time-critical medications are medications whose early or delayed administration of maintenance doses more than 30 minutes before or after the scheduled dose most likely will cause harm or will result in subtherapeutic responses in a patient. Non–time-critical medications include medications in which the timing of administration will most likely not affect the desired effect of the medication if the medication is given 1 to 2 hours before or after its scheduled time. Follow your agency’s medication administration policies about the timing of medications to ensure that you administer medications at the right time. [Refer to Table 31-3 on text p. 570 for further explanation regarding medication action, and to Table 31-4 on text p. 570 Common Dose Administration Schedules.]

Routes of Administration
Oral Sublingual, buccal Parenteral ID, Sub-Q, IM, IV (epidural, intrathecal, intraosseous, intraperitoneal, intrapleural, intra-arterial) Topical Direct, body cavity Inhalation Intraocular The route prescribed for administering a medication depends on the properties and desired effect of the medication and the patient’s physical and mental condition. [Table 31-5 on text p. 571 presents factors influencing administration routes.] Each of these administration routes has pros and cons. As a nurse, you can help the prescriber decide which route will be most beneficial given the patient’s individual needs. The oral route is the easiest and the most commonly used route. Oral medications have a slower onset of action and a more prolonged effect than parenteral medications. Patients generally prefer the oral route. (Sublingual and buccal routes are shown on the next slide.) Parenteral administration involves injecting a medication into body tissues. The following are the four major sites of injection: 1. Intradermal (ID): injection into the dermis just under the epidermis. 2. Subcutaneous: injection into tissues just below the dermis of the skin. 3. Intramuscular (IM): injection into a muscle. 4. Intravenous (IV): injection into a vein. Some medications are administered into other body cavities: epidural, intrathecal, intraosseous, intraperitoneal, intrapleural, and intra-arterial, as well as intracardiac and intra-articular. Nurses usually are not responsible for administration of medications through these advanced techniques. Whether or not you actually administer the medication, you remain responsible for monitoring the integrity of the medication delivery system, understanding the therapeutic value of the medication, and evaluating the patient’s response to the therapy. Medications applied to the skin and mucous membranes generally have local effects. You apply topical medications to the skin by painting or spreading the medication over an area, applying moist dressings, soaking body parts in a solution, or giving medicated baths. Systemic effects often occur if a patient’s skin is thin or broken down, if the medication concentration is high, or if contact with the skin is prolonged. A transdermal disk or patch has systemic effects. The disk secures the medicated ointment to the skin. These topical applications are left in place for as little as 12 hours or as long as 7 days. [Ask the class to name some common transdermal medications: nitroglycerin, scopolamine, estrogen.] Nurses administer medications to mucous membranes in a variety of ways: (1) directly applying a liquid or ointment; (2) inserting a medication into a body cavity; (3) instilling fluid into a body cavity (instillation [fluid is retained]); (4) irrigating a body cavity (fluid is not retained); and (5) spraying a medication into a body cavity. The deeper passages of the respiratory tract provide a large surface area for medication absorption. Nurses administer inhaled medications through the nasal and oral passages or through endotracheal or tracheostomy tubes. Inhaled medications are readily absorbed and work rapidly because of the rich vascular alveolar capillary network present in the pulmonary tissue. Many inhaled medications have local or systemic effects. Intraocular medication delivery involves inserting a medication similar to a contact lens into the patient’s eye. The eye medication disk has two soft outer layers that have medication enclosed in them. The nurse inserts the disk into the patient’s eye, much like a contact lens, and it can remain there for up to 1 week.

Oral Route Sublingual Buccal
Sublingual administration of a tablet is shown on the left, and buccal administration of a tablet is shown on the right. Some medications are readily absorbed after being placed under the tongue to dissolve. A medication given by the sublingual route should not be swallowed because the medication does not have the desired effect. Nurses often give nitroglycerin by the sublingual route. Tell the patient not to drink anything until the medication is completely dissolved. Administration of a medication by the buccal route involves placing the solid medication in the mouth against the mucous membranes of the cheek until it dissolves. Teach patients to alternate cheeks with each subsequent dose to avoid mucosal irritation. Warn patients not to chew or swallow the medication, or to take any liquids with it. A buccal medication acts locally on the mucosa or systemically as it is swallowed in a person’s saliva. [Shown are Figures 31-3 and 31-4 from text p. 572.]

Endotracheal Route This diagram shows medication instilled through an endotracheal tube. Endotracheal tubes enter the patient’s mouth and end in the trachea, whereas tracheostomy tubes enter the trachea directly through an incision made in the neck. [Shown is Figure 31-5 from text p. 573.]

Systems of Medication Measurement
Require the ability to compute medication doses accurately and measure medications correctly Metric system (0 before the decimal only) Most logically organized Meter, liter, gram Household system Most familiar to individuals Disadvantage: inaccuracy Solution The metric system is organized into units of 10. Metric units are easy to convert and compute through simple multiplication and division. However, this system must be used with great care because moving a decimal to the right or the left will greatly affect the dose. This is why a zero (0) must always be placed before a decimal (0.1 mg) but never after a decimal (1 mg, not 1.0 mg). Household measurements are familiar to most people. Medications ordered by this method include drops, teaspoons, and tablespoons. Solutions are used for irrigations, injections, and infusions. A solution is defined as a given mass of solid substance dissolved in a known volume of fluid, or as a given volume of liquid dissolved in a known volume of another fluid. [See also Table 31-6 on text p. 573 Equivalents of Measurement.]

Metric Specifics Gram = g or gm Liter = l or L
Use lowercase letters for abbreviations for other units: Milligram = mg Milliliter = mL Convert fractions to decimals: 500 mg or 0.5 g, but NOT ½ g 10 mL or 0.01 L, but NOT 1/100 L Specific abbreviations are used for metric units. Abbreviations for grams and liters can be shown in uppercase or lowercase, but milligrams and milliliter abbreviations are always lowercase. Many actual and potential medication errors happen with the use of fractions and decimal points. Convert fractions to decimals carefully!

Nursing Knowledge Base
Safe administration is imperative. Nursing process provides a framework for medication administration. Clinical calculations must be handled without error. Conversions within and between systems Dose calculations Pediatric calculations require special caution. [Encourage students to take a Math for Meds and/or Pharmacology course and to review information from their math course.] In 2003, the Institutes of Medicine published the book To Err Is Human: Building a Safer Health System. This book created a new national awareness of problems within the health care system. It estimated that up to 98,000 people die in any given year from medical errors that occur in hospitals. This means that more people die from medical errors than from motor vehicle accidents, breast cancer, acquired immunodeficiency syndrome (AIDS), or workplace injuries. Health care experts estimate that medication-related errors for hospitalized patients cost more than $3.5 billion annually. Nurses play an important role in patient safety, especially in the area of medication administration. Nurses need to know how to calculate medication doses accurately and must understand the different roles that members of the health care team play in prescribing and administering medications. To administer medications safely, you need to have an understanding of basic mathematics skills to calculate medication doses, mix solutions, and perform a variety of other activities. Medications are not always dispensed in the unit of measure in which they are ordered. Medication companies package and bottle medications in standard dosages. Nurses frequently convert available units of volume and weight to desired doses. Therefore, be aware of equivalents in all major measurement systems. You use equivalents when performing other nursing actions, such as when calculating patients’ intake and output and IV flow rates. [See also Box 31-2 Evidence-Based Practice: Reducing Errors During Medication Administration.]

Dose Calculation Methods
Verify medication calculations with another nurse to ensure accuracy. The ratio and proportion method Example: 1:2 = 4:8 Formula method Dose ordered × Amount on hand = Amount to Dose on hand administer Dimensional analysis Factor-label or unit factor method In a proportion, the first and last numbers are called the extremes, and the second and third numbers are called the means. When multiplying the extremes, the answer is the same as when multiplying the means. Because of this relationship, if you know three of the numbers in the proportion, calculating the unknown fourth number is easy. In the example, 1 and 8 are the extremes, and 2 and 4 are the means. The formula method requires you to first memorize the formula. Estimate the answer, and then place all the information from the medication order into the formula. Label all parts of the formula, and ensure that all measures in the formula are in the same units and system of measurement before calculating the dosage. Current evidence shows that nursing students who use dimensional analysis often calculate medications more accurately than when they use the formula method.

Prescriber’s Role Prescriber can be physician, nurse practitioner, or physician’s assistant. Orders can be written (hand or electronic), verbal, or given by telephone. The use of abbreviations can cause errors; use caution. Each medication order needs to include the patient’s name, order date, medication name, dosage, route, time of administration, drug indication, and prescriber’s signature. Health care institutions have specific regulations regarding the ordering of medications. Medication orders are given by writing an order on a form in the patient’s medical record, in an order book, or on a legal prescription pad. Some prescribers use a desktop, laptop, or handheld electronic device to enter medication orders; some use the telephone. If the order is given verbally to the nurse, it is called a verbal order. When a verbal or telephone order is received, the nurse who took the order writes the complete order or enters it into a computer, reads it back, and receives confirmation from the prescriber to confirm accuracy. The prescriber countersigns the order at a later time, usually within 24 hours after giving it. Nursing students cannot take verbal or telephone orders. Many hospitals are implementing computerized physician order entry (CPOE) to handle medication orders to decrease medication errors. In using this system, the prescriber completes all computerized fields before the order for the medication is filled, thus avoiding incomplete or illegible orders. The use of abbreviations when ordering medications is often the cause of medication errors. Only approved abbreviations can be used. You will need to refer to your specific health care facility for the list of approved abbreviations. Additionally, The Joint Commission has a list of its approved abbreviations. [Refer to Table 31-7 on text pp. 579, 580, and 581 for an ISMP list of error-prone abbreviations and dose designations.] [Refer to Box 31-3 on text p. 578 for recommendations to reduce medication errors associated with verbal medication orders and prescriptions, and to Figure 31-6 on text p. 582 for an example of a medication prescription.]

Types of Orders in Acute Care Agencies
Standing or routine: Administered until the dosage is changed or another medication is prescribed prn: Given when the patient requires it Single (one-time): Given one time only for a specific reason STAT: Given immediately in an emergency Now: When a medication is needed right away, but not STAT Prescriptions: Medication to be taken outside of the hospital Types of medication orders depend on the urgency, or how frequently they are needed. A standing order is carried out until the prescriber cancels it by another order, or the prescribed number of days elapses. It often indicates a final date or number of treatments or doses. A prn order indicates that the prescriber ordered a medication to be given only when a patient requires it. A STAT order signifies that a single dose of a medication is to be given immediately and only once.

Pharmacist’s role Prepares and distributes medication Distribution systems (unit dose or automatic medication dispensing system [AMDS]) Area for stocking and dispensing medication Nurse’s role Assess patient’s ability to self-administer, determine whether patient should receive, administer medication correctly, and closely monitor effects; do not delegate this task. Medication error When administering medications, many health care providers take a role, each with a pivotal part, to ensure that the patient’s safety is maintained. The pharmacist prepares and distributes prescribed medications. The pharmacist mixes IV solutions. Most medications are delivered in common forms and doses. The pharmacist works with other health care providers to provide information regarding medication side effects, toxicity, interactions, and incompatibilities. Medications are distributed in many formats. You will want to discuss the formats used by your health care facility. The most common medication administration systems include unit dose and automated medication dispensing systems (AMDSs). The unit-dose system uses carts containing a drawer with a 24-hour supply of medications for each patient. Each drawer is labeled with the name of the patient and his or her designated room. The unit dose is the ordered dose of medication that the patient receives at one time. [AMDSs are discussed on the next slide.] The nurse’s role in administering medications is as crucial as those of physicians and pharmacists. Nurses need to ensure that the right medication is ordered, that it is administered correctly, and that it is given on time. Do not delegate any part of the medication administration process to nursing assistive personnel. Medication errors can cause the patient harm. [Additional information is discussed in a subsequent slide.]

Automated Medication Dispensing System
Shown is an automated medication dispensing system (AMDS). AMDSs control the dispensing of all medications, including narcotics. Each nurse accesses the system by entering a security code. Some systems require bioidentification as well. With these systems, you place your finger on a screen to access the computer. You select the patient’s name and his or her drug profile before the AMDS dispenses a medication. With these systems, you are allowed to select the desired medication, dosage, and route from a list displayed on the computer screen. The system causes the drawer containing medication to open, records it, and charges it to the patient. Systems that are connected to the patient’s computerized medical record then record information about the medication (e.g., medication name, dose, time) and the nurse’s name in the patient’s medical record. Some systems require nurses to scan bar codes to identify the patient, the medication, and the nurse administering the medication before recording this information in the patient’s computerized medical record. Agencies that implement AMDS with bar-code scanning often reduce the incidence of medication errors. [Shown is Figure 31-7 from text p. 582.]

Medication Errors Report all medication errors.
Patient safety is top priority when an error occurs. Documentation is required. The nurse is responsible for preparing a written occurrence or incident report: an accurate, factual description of what occurred and what was done. Nurses play an essential role in medication reconciliation. A medication error can cause or lead to inappropriate medication use or patient harm. Errors include inaccurate prescribing or administration, or giving a drug via the wrong route or frequency. It is important to feel comfortable in reporting an error and not fear repercussions from managerial staff. Even when a patient suffers no harm from a medication error, the institution can still learn why the mistake occurred and what can be done to avoid similar errors in the future. When an error occurs, the nurse first assesses and examines the patient’s condition and notifies the health care provider of the incident as soon as possible. Once the patient is stable, the nurse reports the incident to the appropriate person in the institution (e.g., manager, supervisor). The nurse is responsible for preparing a written occurrence or incident report that usually needs to be filed within 24 hours of the error. The report includes patient identification information; the location and time of the incident; an accurate, factual description of what occurred and what was done; and the signature of the nurse involved. The occurrence report is not a permanent part of the medical record and is not referred to anywhere in the record. This legally protects the nurse and the institution. Agencies use occurrence reports to track incident patterns and initiate quality improvement programs as needed. Nurses play an essential role in medication reconciliation. Whenever a nurse admits a patient to a health care setting, he or she compares the medications that the patient took in the previous setting (e.g., home, another nursing unit) with his or her current medication orders. When the patient leaves that setting for another setting (e.g., skilled care facility, intensive care unit), the nurse communicates the patient’s current medications to the health care providers in the new setting. The nurse also reconciles the patient’s medications when he or she is discharged from an agency or is seen in an outpatient setting. Many agencies have computerized or written forms to facilitate the process of medication reconciliation. Advances in technology have helped to decrease the occurrence of medication errors. [Refer to Box 31-4 Steps to Take to Prevent Medication Errors and Box 31-5 Informatics and Medication Safety) on text p. 583 for medication safety information.] [See also Box 31-6 on text p. 584 Process for Medication Reconciliation.]

Case Study (cont’d) Emilio anticipates that Esther will have difficulty getting her medicine from the pharmacy because of her hip replacement. Emilio asks Esther about her relationships with family and friends and assesses her spiritual and religious preferences. He asks Esther to identify family and friends who can help her when she goes home. After discovering that Esther is active in her church, Emilio gets permission from Esther to contact the church’s minister. Emilio asks the minister to identify church members who are able to help Esther get to the pharmacy or to go to the pharmacy for her. Because Esther was so independent before her surgery, Emilio knows that Esther may become discouraged when she gets home. She will need help at home until she completely heals from her surgery. Emilio finds out that Esther has a strong sense of spirituality. Therefore, he encourages Esther to use spirituality-based coping methods when she goes home.

Quick Quiz! 3. If a nurse experiences a problem reading a physician’s medication order, the most appropriate action will be to A. Call the physician to verify order. B. Call the pharmacist to verify order. C. Consult with other nursing staff to verify. D. Withhold the medication until physician makes rounds. Answer: A

Critical Thinking and Medication Administration
Knowledge Experience Psychomotor skills (how to) Attitudes Be disciplined; take your time. Be responsible and accountable. Standards Ensure safe nursing practice. You will use knowledge from many disciplines when administering medications to understand why a particular medication is prescribed for a patient and how the medication will alter the patient’s physiology to have a therapeutic effect. Experience will be gained as students learn to administer medications on a weekly basis. Medication administration requires both knowledge and psychomotor skills. Students will practice medication administration in skills laboratory. Every step of safe medication administration requires a disciplined attitude and a comprehensive, systematic approach. The attitude nurses need to possess when administering medications to patients includes responsibility and accountability. The American Nurses Association’s Scope and Standards of Nursing Practice addresses medication administration.

Keys to accuracy Avoid distractions and follow the same routine. Administer only medications you prepare, and never leave prepared medications unattended. Document medications immediately after administration. Use clinical judgment in determining the best time to administer prn medications. When preparing medications, check the medication container label against the medication administration record (MAR) three times. To reduce medication errors, nurses need to avoid distractions and follow the same routine when preparing medications.

The Six “Rights” The six rights of medication administration contribute to accurate preparation and administration of medication doses: 1. Right medication 2. Right dose 3. Right patient 4. Right route 5. Right time 6. Right documentation Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors. Regardless of how the nurse receives a medication order, he or she compares the prescriber’s written orders with the medication administration record (MAR) or the electronic medication administration record (eMAR) when medication is initially ordered. When performing medication calculations or conversions, have another qualified nurse check the calculated doses. An important step in safe medication administration is making sure that you give the right medication to the right patient. Before administering a medication, use at least two patient identifiers. Always consult the prescriber if an order does not designate a route of administration. Likewise, if the specified route is not the recommended route, alert the prescriber immediately. You need to know why a medication is ordered for certain times of the day, and whether you are able to alter the time schedule. A medication order is required for every medication that you administer to a patient. If any question arises about a medication order because it is incomplete, illegible, vague, or not understood, contact the prescribing health care provider before administering the medication. Never document that you have given a medication until you have actually given it.

Right Patient Nurse using bar-code scanner to identify patient during medication administration. [Shown is Figure 31-8 from text p. 586.]

Maintaining Patients’ Rights
To be informed about a medication To refuse a medication To have a medication history To be properly advised about experimental nature of medication To receive labeled medications safely To receive appropriate supportive therapy To not receive unnecessary medications To be informed if medications are part of a research study In accordance with The Patient Care Partnership (American Hospital Association, 2003) and because of the potential risks related to medication administration, a patient has the following rights: To be informed of the name, purpose, action, and potential undesired effects of a medication To refuse a medication regardless of the consequences To have qualified nurses or physicians assess a medication history, including allergies and use of herbals To be properly advised of the experimental nature of medication therapy and to give written consent for its use To receive labeled medications safely without discomfort in accordance with the six rights of medication administration To receive appropriate supportive therapy in relation to medication therapy To not receive unnecessary medications To be informed if medications are part of a research study [Ask students if they have questions about these rights. Discuss any concerns.] Know these rights and handle all inquiries by patients and families courteously and professionally. Do not become defensive if a patient refuses medication therapy, recognizing that every person of consenting age has a right to refusal.

Quick Quiz! 4. Nurses are legally required to document medications that are administered to patients. The nurse is mandated to document which of the following? A. Medication before administering it B. Medication after administering it C. Rationale for administering it D. Prescriber rationale for prescribing it Answer: B

Assessment Medical history
Allergies Medications Diet history Patient adherence to therapy Patient’s perceptual or coordination problems Patient’s current condition Patient’s attitude about medication use Patient’s understanding of and adherence to medication therapy Patient’s learning needs Begin your assessment by asking a variety of questions that help you better understand your patients’ current medication management routine, their ability to afford medications, and their beliefs and expectations about medications. A patient’s medical history provides indications or contraindications for medication therapy. Inform the other members of the health care team if the patient has a history of allergies to medications and foods. Assess information about each medication that the patient takes, including length of time the medication has been taken, current dosage, and whether or not the patient experiences side effects or has had adverse effects from the medication. A diet history reveals a patient’s normal eating patterns and food preferences. A patient with perceptual fine-motor or coordination limitations has difficulty self-administering medication. The ongoing physical or mental status of a patient affects whether a medication is given or how it is administered. Observe the patient’s behavior for evidence of dependence or avoidance. Be aware that his or her cultural beliefs about Western medicine sometimes interfere with medication compliance. The patient’s knowledge and understanding of medication therapy influence willingness or ability to follow a medication regimen. Serious errors can occur when patients do not understand information about their medications. [See Box 31-8 on text p. 587 Nursing Assessment Questions, and Box 31-9 on text p. 588 Cultural Aspects of Care: Influences in Medication Administration.]

Case Study (cont’d) Emilio finds out that Esther will be going home in a few days. Before she can leave, she needs to learn how to self-administer her medications safely. Older adult patients often have difficulty with medication adherence because they have difficulty affording medications. They often take medications out of their normal containers, have difficulty opening packages, and often have problems related to health literacy. [Ask the class: Based on this information, what should Emilio include in a teaching care plan for Esther? What would the teaching outcome be? Discuss.] The older adult’s body undergoes structural and functional changes that alter medication actions and influence the manner in which nurses provide medication therapy.

Nursing Diagnosis Anxiety Ineffective health maintenance
Readiness for enhanced immunization status Deficient knowledge (medications) Noncompliance (medications) Impaired swallowing Effective therapeutic regimen management The list of nursing diagnoses (on the slide) may apply to patients during the administration of medications. [Discuss possible “related to” modifiers of the diagnoses.]

Planning Always organize your care activities to ensure the safe administration of medications. Setting goals and related outcomes contributes to patient safety and allows for wise use of time during medication administration. Provide the most important information about the medications first. On discharge, ensure that patients know where and how to obtain medications. Collaborate with a variety of health care providers when administering medications. First, it is important to collaborate with the patient’s family or friends whenever possible. Family members often reinforce the importance of medication regimens in the home setting. Also, nurses often collaborate with the prescriber, the pharmacist, and case managers to ensure that patients are able to afford their medications. [See also Box 31-7 Nurses’ Six Rights for Safe Medication Administration on text p. 587.]

Case Study (cont’d) Emilio plans a teaching session with Esther. His goal is that Esther will be able to self-administer her medications safely and correctly. Strategies: Emilio plans to sit with Esther at a table in a room that is well lit and has limited distractions (TV off). He will include Esther’s caregivers in educational sessions. He will ask Esther’s caregiver to bring all of her medications from home to the hospital. They will compare the medications Esther has at home with the ones she is going to take home to determine which medications Esther understands. [Ask the class to provide three additional teaching strategies (given on the next Case Study slides).]

Implementation: Health Promotion
Teach the patient and family: Medication benefit How to take the medication correctly Symptoms of side effects Safe use and storage of medications Help the patient and family establish a medication routine. Refer them to community resources for transportation as needed. Several nursing interventions promote adherence to the medication regimen and foster independence. Teach the patient and family about the benefit of a medication and the knowledge needed to take it correctly and to integrate the patient’s health beliefs and cultural practices into the treatment plan. Help the patient and family establish a medication routine that fits into the patient’s normal schedule. Patients cope better with problems caused by medications if they understand how and when to act. All patients need to learn the basic guidelines for medication safety, which ensure proper use and storage of medications in the home. Make referrals to community resources if the patient is unable to afford or cannot arrange transportation to obtain necessary medications. [See also Box on text p. 590 Patient Teaching: Safe Insulin Administration.]

Implementation Acute care Restorative care Special considerations
Receiving, transcribing, and communicating medication orders Accurate dose calculation and measurement Correct administration Recording medication administration Restorative care Special considerations Infants and children (dosing, psychological prep) Elderly Polypharmacy The process of verifying medical orders varies among health care agencies. Nurses follow agency policy and current national patient safety standards when receiving, transcribing, and communicating medication orders. The procedure for medication measurement is systematic to lessen the chance of error. For safe administration, adhere to the six rights of medication administration. Follow all agency policies when documenting medication administration. After administering a medication, record the name of the medication, dose and route, and exact time of administration immediately on the appropriate record form. Regardless of the type of medication activity, the nurse remains responsible for instructing patients and families on medication action, administration, and side effects. Children vary in age, weight, surface area, and the ability to absorb, metabolize, and excrete medications. All children require special psychological preparation before receiving medications. In addition to physiological changes of aging, behavioral and economic factors influence an older person’s use of medications. [See also on p. 590 Box Components of Medication Orders; on text p. 591 Box Tips for Administering Medications to Children; Box Focus on Older Adults: Safety in Medication Administration; and on p. 592 Figure 31-9 Effects of aging on medication metabolism. (From Lewis SM et al: Medical-surgical nursing, ed 7, St Louis, 2007, Mosby.)] [Polypharmacy is discussed on the next slide.]

Case Study (cont’d) Emilio plans to assess Esther’s health literacy by determining her ability to understand what she reads and to do simple medication calculations. If she has poor health literacy, he will ensure that information is presented at a level that Esther can understand and will arrange for help from family, friends, and/or home care nurses. Emilio will review with Esther information about the medications: desired effect, dose, frequency, and adverse effects. He will show her how to use a medication organizer but will encourage her to leave medications in their original containers. [Ask the class: What evaluation strategies would be appropriate for these teaching strategies?] [Additional teaching strategy is shown on next slide.]

Case Study (cont’d) Emilio will provide patient teaching materials that include helpful pictures to enhance Esther’s understanding of prescribed medications. He will ensure that print and pictures on the teaching sheets are large enough for Esther to see. [Ask the class: What evaluation strategy would be appropriate for this teaching strategy?]

Polypharmacy Definition: when a patient takes two or more medications to treat the same illness, takes two or more medications from the same chemical class, uses two or more medications with the same or similar actions to treat several disorders simultaneously, or mixes nutritional supplements or herbal products with medications. Taking over-the-counter (OTC) medications frequently, lack of knowledge about medications, incorrect beliefs about medications, and visiting several health care providers to treat different illnesses increase the risk for polypharmacy. When the patient experiences polypharmacy, the risk of adverse reactions and medication interactions with other medications and food is increased. To minimize risks associated with polypharmacy, frequent communication among health care providers is essential to make sure that the patient’s medication regimen is as simple as possible.

Evaluation Value patients’ participation in evaluation.
Ensure that patients understand their medication schedules and are able to safely administer their medications. Be alert for reactions in patients taking several medications. Evaluate patient responses: Physiological measures Behavioral responses Rating scales Patient statements Evaluation of medication administration is an essential role of professional nursing that requires assessment skills, critical thinking, analysis, and knowledge of medications, physiology, and pathophysiology. The goal of safe and effective medication administration involves the patient’s response to therapy and ability to assume responsibility for self-care. When patients do not experience expected outcomes of medication therapy, investigate possible reasons and determine appropriate revisions to the patient’s plan of care. Evaluation is more effective when you value your patients’ participation. Therefore, partner with your patients and include them in the evaluation process. To determine whether patients understand their medication schedules, ask them to explain when they take their medications and if they are able to take them as prescribed. When patients struggle with their medication schedule, determine barriers to medication adherence (e.g., cost, lack of knowledge), and remove these barriers if possible. Ask patients to describe this effectiveness. Ask if they are satisfied with their medications and how they make them feel. Use patients’ statements and responses to questions when determining the effectiveness of medications. Including patients in the evaluation process empowers them and helps them become more actively involved in their care. Use knowledge of the desired effect and common side effects of each medication to compare expected outcomes with actual findings. A change in a patient’s condition is often physiologically related to health status or to results from medications, or to both. The most common type of measurement that the nurse uses is a physiological measure. The type of measurement used varies with the action being evaluated, the reading skill and knowledge level of the patient, and the patient’s cognitive and psychomotor abilities. [Table 31-8 on text p. 593 contains examples of goals, expected outcomes, and corresponding evaluative measures.]

Case Study (cont’d) Emilio decides on the following strategies to help Esther: Ask Esther questions about her medications, such as, “Why are you taking these medications?” and “When do you take your medications?” Ask Esther to write out a medication schedule that includes how much of each medication she should take and when to take it. Have Esther verbalize symptoms related to the possible adverse effects of medications she is taking and identify what to report to her health care provider. Have Esther set up her own medications for one day, and evaluate her accuracy. [Ask the class: What other steps can Emilio take to help Esther take her medications properly at home? Discuss.]

Oral = By mouth Topical Skin, nasal, eye, ear, vaginal, rectal Inhalation Irrigation Parenteral Injection Each of these administration routes requires knowledge and psychomotor skills. In the nursing skills laboratory, you will learn each of these methods according to the school and health care facility standards. We will review key points about these routes on the next slides.

Oral Administration Easiest and most desirable route
Food may decrease therapeutic effect. Aspiration precautions Enteral or small-bore feedings: Verify that the tube location is compatible with medication absorption. Follow American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines. Use liquids when possible. If medication is to be given on an empty stomach, allow at least 30 minutes before or after feeding. Risk of drug-drug interactions is higher. Patients usually are able to ingest or self-administer oral medications with a minimum of problems. Food delays stomach emptying, which may decrease the therapeutic effects of oral medications. Protect the patient from aspiration by assessing his or her ability to swallow. [See also Box on text p. 593 Protecting the Patient from Aspiration.] Special consideration is needed when administering medications to patients with enteral or small-bore feeding tubes. Failing to follow current evidence-based recommendations from the American Society for Parenteral and Enteral Nutrition (ASPEN) can result in tube obstruction, reduced medication effectiveness, and increased risk of medication toxicity. When liquid medications are not available, crush simple tablets or open gelatin capsules and dilute in sterile water. Do not use tap water. Tap water often contains contaminants (e.g., pathogens, heavy metals) that can interact with a medication and affect its bioavailability. If a medication needs to be given on an empty stomach or is not compatible with the feeding, it needs to be held at least 30 minutes before or 30 minutes after medication administration. Before giving a medication by this route, verify that the location of the tube (e.g., stomach, jejunum) is compatible with medication absorption. Monitor the patient closely for adverse reactions. The risk for drug-drug interactions is high when two or more medications are given by this route because they can interact as soon as they are administered. [See also Box on text p. 594 Procedural Guidelines: Giving Medications Through an Enteral Tube (Nasogastric Tube, G-Tube, J-Tube, or Small-Bore Feeding Tube.]

Topical Medications Skin Use gloves.
Use sterile technique if the patient has an open wound. Clean skin first. Follow directions for each type of medication. Transdermal patches: Remove old patch before applying new. Document the location of the new patch. Ask about patches during the medication history. Apply a label to the patch if it is difficult to see. Document removal of the patch as well. Topical medications are medications that are applied locally, usually to skin, but also to mucous membranes. Apply each type of medication according to directions to ensure proper penetration and absorption.

Nasal Instillation Patients with nasal sinus alterations sometimes receive medications by spray, drops, or tampons. The most commonly administered form of nasal instillation is decongestant spray or drops, which are used to relieve symptoms of sinus congestion and colds. Caution patients to avoid abuse of medications because overuse leads to a rebound effect in which nasal congestion worsens. Saline drops are safer as a decongestant for children than nasal preparations that contain sympathomimetics. It is easier to have the patient self-administer sprays because he or she is able to control the spray and inhale as it enters the nasal passages. For patients who use nasal sprays repeatedly, check the nares for irritation. Nasal drops are effective in treating sinus infections. Position patients to permit the medication to reach the affected sinus. The left drawing shows positioning to reach the sphenoid and ethmoid sinuses. The right drawing shows positioning to reach the frontal and maxillary sinuses. Severe nosebleeds are usually treated with packing or nasal tampons, which are treated with epinephrine, to reduce blood flow. Usually a physician or an advanced practice clinician places nasal tampons. [See Box on text pp Procedural Guidelines: Administering Nasal Instillations, for step-by-step guidelines. Drawings shown are from the procedural guidelines on text p. 596.]

Topical Medications Eye instillation Intraocular instillation
Avoid the cornea. Avoid the eyelids with droppers or tubes to decrease the risk of infection. Use only on the affected eye. Never allow a patient to use another patient’s eye medication. Intraocular instillation Disk resembles a contact lens. Teach patients how to insert and remove the disk. Teach about adverse effects. Medications commonly used by patients include eyedrops and ointments, including over-the-counter (OTC) preparations such as artificial tears and vasoconstrictors. Many patients, especially older adults, receive prescribed ophthalmic medications for eye conditions such as glaucoma or after cataract extraction. Age-related problems, including poor vision, hand tremors, and difficulty grasping or manipulating containers, affect the older adult’s ability to self-administer eye medications. Instruct patients and family members about proper techniques for administering them. Determine the patient’s and the family’s ability to self-administer through a return demonstration of the procedure. Showing patients each step of the procedure for instilling eyedrops can improve adherence. The cornea of the eye has many pain fibers and thus is very sensitive to anything applied to it. Medications delivered intraocularly resemble a contact lens. Place the medication into the conjunctival sac, where it remains in place for up to 1 week. Patients require teaching about monitoring for adverse reactions to the disk. They also need to know how to insert and remove the disk.

Topical Medications (cont’d)
Ear instillation Structures are very sensitive to temperature. Use sterile solutions. Drainage may indicate eardrum rupture. Never occlude the ear canal. Do not force medication into an occluded ear canal. Internal ear structures are very sensitive to temperature extremes. Instill eardrops at room temperature to prevent vertigo, dizziness, or nausea. Although the structures of the outer ear are not sterile, sterile solutions are used in case the eardrum is ruptured. The entry of nonsterile solutions into middle ear structures can result in infection. If a patient has ear drainage, be sure that the eardrum has not ruptured. Never occlude or block the ear canal with the dropper or irrigating syringe. Forcing medication into an occluded ear canal creates pressure that injures the eardrum. The figure shows placement of an eardrop. [See step-by-step guidelines on p. 597 in the text Box Procedural Guidelines: Administering Ear Medications.] [Shown is the figure from p. 597 in the procedural guidelines.]

Topical Medications: Vaginal Instillation
Vaginal medications are available as suppositories, foam, jellies, or creams. Because vaginal medications are often given to treat infection, discharge is usually foul smelling. Follow aseptic technique, and offer the patient frequent opportunities to maintain perineal hygiene. Shown on the left is insertion of a suppository into the vaginal canal. Solid, oval suppositories come individually packaged in foil wrappers and sometimes are stored in the refrigerator to prevent them from melting. After a suppository is inserted into the vaginal cavity, body temperature causes it to melt and be distributed and absorbed. Give a suppository with a gloved hand in accordance with standard precautions. Patients often prefer administering their own vaginal medications and need privacy. The diagram on the right shows instillation of medication into the vaginal canal. Foam, jellies, and creams are administered with an applicator inserter. [See step-by-step guidelines in Box on text p. 598 Procedural Guidelines: Administering Vaginal Suppositories.] [Shown are the figures from p. 598 in the procedural guidelines.]

Topical Medications: Rectal Instillation
The photo on the left shows removal of a rectal suppository from its wrapper. Rectal suppositories are thinner and more bullet-shaped than vaginal suppositories. The rounded end prevents anal trauma during insertion. Rectal suppositories contain medications that exert local effects such as promoting defecation, or systemic effects such as reducing nausea. Rectal suppositories are often stored in the refrigerator until administered. Sometimes it is necessary to clear the rectum with a small cleansing enema before inserting a suppository. The diagram shows insertion of a rectal suppository. [See step-by-step guidelines in Box on text p. 599 Procedural Guidelines: Administering Rectal Suppositories.] [Shown are the figures from p. 599 in the procedural guidelines.]

Administering via Inhalation
Aerosol spray, mist, or powder via handheld inhalers; used for respiratory “rescue” and “maintenance” Pressurized metered-dose inhalers (pMDIs) Need sufficient hand strength for use Breath-actuated metered-dose inhalers (BAIs) Release depends on strength of patient’s breath. Dry powder inhalers (DPIs) Activated by patient’s breath Produce local effects such as bronchodilation Some medications create serious systemic side effects. Patients who receive medications by inhalation frequently suffer chronic respiratory disease such as chronic asthma, emphysema, or bronchitis. Inhaled medications are often described as “rescue” or “maintenance” medications. Rescue medications are short-acting and are taken for immediate relief of acute respiratory distress. Maintenance medications are used on a daily schedule to prevent acute respiratory distress. The effects of maintenance medications start within hours of administration and last for a longer time than those of rescue medications. Because patients depend on inhaled medications for disease control, and current evidence shows that many patients do not use their inhalers correctly, patients need to learn how to self-administer inhalers safely and effectively. Some patients use a spacer with the pressurized metered-dose inhaler (pMDI). (Breath-actuated metered-dose inhalers [BAIs] and dry powder inhalers [DPIs] do not use spacers.) The spacer is a 4- to 8-inch ( to cm)-long tube that attaches to the pMDI and allows the particles of medication to slow down and break into smaller pieces, which improves drug absorption in the patient’s airway. Spacers have a face mask for infants and children younger than 4 years of age. They are especially helpful when the patient has difficulty coordinating the steps involved in self-administering inhaled medications. When patients do not use their inhalers and spacers correctly, they do not receive the full effect of the medication. Therefore, patient education is essential. One important aspect of patient teaching is to help the patient determine when the MDI, BAI, or DPI is empty and needs to be replaced. To calculate how long medication in an inhaler will last, divide the number of doses in the container by the number of doses the patient takes per day.

Administering via Irrigation (cont’d)
Usually use sterile water, saline, or antiseptic solutions on Eye Ear Throat Vagina Urinary tract Use aseptic technique if a break is noted in the skin or mucosa. Use clean technique when the cavity is not sterile. Irrigations cleanse an area, instill a medication, or apply hot or cold to injured tissue. Some medications irrigate or wash out a body cavity and are delivered through a stream of solution. Use aseptic technique if a break is noted in the skin or mucosa. Use clean technique when the cavity to be irrigated is not sterile, as in the case of the ear canal or vagina.

Medication Administration Parenteral
Parenteral = Injection into body tissues Invasive procedure that requires aseptic technique Risk of infection Skills needed for each type of injection Effects develop rapidly, depending on the rate of medication absorption. Parenteral administration entails injecting into body tissues and involves several components revolving around medication preparation. Medication equipment includes syringe, ampule, or vial. Upon completing medication preparation, administration occurs via various routes. When preparing medications, the nurse checks the medication container label against the medication administration record (MAR) three times. After a needle pierces the skin, risk for infection is present. Each type of injection requires certain skills to ensure that the medication reaches the proper location. [See Box on text p. 600 Preventing Infection During an Injection.]

Medication Administration Parenteral (cont’d)
Syringes Luer-Lok Non–Luer-Lok Sizes from 0.5 to 60 mL Larger sizes to administer IV medications and to irrigate wounds or drainage tubes May be prepackaged with a needle attached, or— You may need to change a needle A variety of syringes and needles are available, each designed to deliver a certain volume of a medication to a specific type of tissue. Syringes consist of a cylindrical barrel with a tip designed to fit the hub of a hypodermic needle and a close-fitting plunger. Luer-Lok syringes have needles that are twisted onto the tip and lock themselves in place. This design prevents inadvertent removal of the needle. A larger volume of a syringe creates discomfort. You sometimes change a needle based on the route of administration and the size of the patient.

Types of Syringes Types of syringes are shown: A, 5-mL syringe. B, 3-mL syringe. C, Tuberculin syringe marked in 0.01 (hundredths) for doses less than 1 mL. D, Insulin syringe marked in units (50). The tuberculin syringe (C) is calibrated in sixteenths of a minim and hundredths of a milliliter and has a capacity of 1 mL. Use a tuberculin syringe to prepare small amounts of medications (e.g., intradermal, subcutaneous injections). A tuberculin syringe is useful when small, precise doses are prepared for infants or young children. Insulin syringes (D) are available in sizes that hold 0.3 to 1 mL and are calibrated in units. Most insulin syringes are U-100s, designed to be used with U-100 strength insulin. Each milliliter of U-100 insulin contains 100 units of insulin. [Shown is Figure from text p. 601.]

Parts of a Syringe The parts of a syringe are the plunger, barrel, and tip. Fill a syringe by pulling the plunger outward while the needle tip remains immersed in the prepared solution. Touch only the outside of the syringe barrel and the handle of the plunger to maintain sterility. Avoid letting any unsterile object touch the tip or inside of the barrel, the hub, the shaft of the plunger, or the needle. [Shown is Figure from text p. 601.]

Parts of the Needle A needle has three parts: the hub, which fits onto the tip of a syringe; the shaft, which connects to the hub; and the bevel, or slanted tip. The tip of a needle, or the bevel, is always slanted. The bevel creates a narrow slit when injected into tissue that quickly closes when the needle is removed to prevent leakage of medication, blood, or serum. Long beveled tips are sharper and narrower, minimizing discomfort when entering tissue used for subcutaneous or IM injection. Some needles come packaged in individual sheaths to allow flexibility in choosing the right needle for a patient, whereas others are preattached to standard-sized syringes. Most needles are made of stainless steel, and all are disposable. [Shown is Figure from text p. 601.]

Types of Needles Most needles vary in length from 1/4 to 3 inches.
Top to bottom: 19 gauge, 1 1/2-inch length 20 gauge, 1-inch length 21 gauge, 1-inch length 23 gauge, 1-inch length 25 gauge, 5/8-inch length Choose needle length according to the patient’s size and weight and the type of tissue into which the medication is to be injected. A child or a slender adult generally requires a shorter needle. Use longer needles (1 to 1 1/2 inches) for IM injections and shorter needles (3/8 to 5/8 inch) for subcutaneous injections. As the needle gauge becomes smaller, the needle diameter becomes larger. The selection of a gauge depends on the viscosity of fluid to be injected or infused. [Shown is Figure from text p. 601.]

Disposable Injection Units
Disposable, single-dose, prefilled syringes are available for some medications. Be careful to check the medication and concentration because all prefilled syringes appear very similar. With these syringes, you do not have to prepare medication doses, except perhaps to expel portions of unneeded medications. On the left: A, Carpuject syringe and prefilled sterile cartridge with needle; and B, Assembling the Carpuject. On the right: C, The cartridge slides into the syringe barrel. Turn and lock the syringe into the cartridge; and D, Screw the plunger into the end of the cartridge. Expel excess medication to obtain an accurate dose (not pictured). The Tubex and Carpuject injection systems include reusable plastic mechanisms that hold prefilled, disposable, sterile cartridge-needle units. First, load the cartridge Luer tip into the plastic syringe holder, secure it (following package directions), and check for air bubbles in the syringe. Advance the plunger to expel air and excess medication as in a regular syringe. The glass cartridge can be used with needleless systems or with safety needles. After giving the medication, safely dispose of the glass cartridge in a puncture-proof and leak-proof receptacle. [Shown is Figure from text p. 602.]

Medication Administration Parenteral
On the left (A) are medications in ampules. Ampules contain single doses of medication in a liquid. Ampules are available in several sizes, from 1 mL to 10 mL or more. An ampule is made of glass and has a constricted neck that must be snapped off to allow access to the medication. A colored ring around the neck indicates where the ampule is prescored, so you can break it easily. Carefully aspirate the medication into a syringe with a filter needle. Use of a filter needle prevents particulate matter such as small glass fragments or rubber from entering the syringe. Replace the filter needle with a needle of appropriate size or a needleless access device before administering the injection. ****************************************** On the right (B) are medications in vials. A vial is a single-dose or multidose container with a rubber seal at the top. A metal cap protects the seal until it is ready for use. Vials contain liquid or dry forms of medications. Medications that are unstable in solution are packaged dry. The vial label specifies the solvent or diluent used to dissolve the medication and the amount of diluent needed to prepare a desired medication concentration. Normal saline and sterile distilled water are commonly used to dissolve medications. Unlike the ampule, the vial is a closed system, and air needs to be injected into it to permit easy withdrawal of the solution. Failure to inject air when withdrawing creates a vacuum within the vial that makes withdrawal difficult. If concerned about drawing up parts of the rubber stopper or other particles into the syringe, use a filter needle when preparing medications from vials. Some vials contain powder, which is mixed with a diluent during preparation and before injection. After mixing multidose vials, make a label that includes the date and time of mixing and the concentration of medication per milliliter. Some multidose vials require refrigeration after the contents are reconstituted. [Shown is Figure from text p. 602.]

Medication Administration Parenteral (cont’d)
If two medications are compatible, they can be mixed in one injection if the total dose is within accepted limits, so the patient receives only one injection at a time. Mixing medications Mixing medications from a vial and an ampule Prepare medication from the vial first. Use the same syringe and filter needle to withdraw medication from the ampule. Mixing medications from two vials Most nursing units have charts that list common compatible medications. If any uncertainty exists about medication compatibilities, consult a pharmacist or a medication reference. When mixing medication from both a vial and a ampule, prepare medication from the vial first. Using the same syringe and filter needle, withdraw medication from the ampule. Nurses prepare the combination in this order because it is not necessary to add air to withdraw medication from an ampule. Apply these principles when mixing medications from two vials: 1. Do not contaminate one medication with another. 2. Ensure that the final dose is accurate. 3. Maintain aseptic technique.

Mixing Medications from Two Vials
In (A), the diagram shows injecting air into vial A. B shows injecting air into vial B and withdrawing dose. C diagrams withdrawing medication from vial A. The medications are now mixed. Use only one syringe with a needle or needleless access device attached to mix medications from two vials. Aspirate the volume of air equivalent to the dose of the first medication (vial A) (A). Inject the air into vial A, making sure that the needle does not touch the solution. Withdraw the needle and aspirate air equivalent to the dose of the second medication (vial B) (B). Inject the volume of air into vial B. Immediately withdraw the medication from vial B into the syringe and insert the needle back into vial A, being careful not to push the plunger and expel the medication within the syringe into the vial. Withdraw the desired amount of medication from vial A into the syringe (C). After withdrawing the necessary amount, withdraw the needle and apply a new safety needle or needleless access device suitable for injection. [Shown is Figure from text p. 603.]

Insulin Preparation Insulin is the hormone used to treat diabetes.
It is administered by injection because the GI tract breaks down and destroys an oral form of insulin. Use the correct syringe: 100-Unit insulin syringe or an insulin pen to prepare U-100 insulin Insulin is classified by rate of action: Rapid, short, intermediate, and long-acting Know the onset, peak, and duration for each of your patients’ ordered insulin doses. Most patients with diabetes who take insulin injections learn to administer their own injections. In the United States and Canada, health care providers usually prescribe insulin in concentrations of 100 units per milliliter of solution. This is called U-100 insulin. Insulin is also commercially available in concentrations of 500 units per milliliter of solution; this is called U-500 insulin. U-500 insulin is 5 times as strong as U-100 insulin and is used only in rare cases when patients are very resistant to insulin. Use the correct syringe when preparing insulin. Use a 100-unit insulin syringe or an insulin pen to prepare U-100 insulin. Because no syringe is currently designed to prepare U-500 insulin, many medication errors result with this kind of insulin. When ordering U-500 insulin, ensure that prescribers specify units and volume (e.g., 150 units, 0.3 mL of U-500 insulin) and use tuberculin syringes to draw up the doses. Verify dose with another nurse or pharmacist before administering it to the patient. Additional safety measures common with U-500 insulin include having the insulin listed as being concentrated in computerized medication dispensing systems, making prescribers and pharmacists verify that the patient is to receive U-500 insulin when it is ordered, and stocking only U-500 insulin on patient care units when it is ordered for a specific patient. To provide safe and effective care, you need to know the onset, peak, and duration for each of your patients’ ordered insulin doses. Only regular insulin can be given intravenously. Orders for insulin injections attempt to imitate the normal pattern of a patient’s insulin release from the pancreas. Some insulins come in a stable premixed solution (e.g., 70/30 insulin is 70% NPH [intermediate] and 30% regular), eliminating the need to mix insulins in a syringe. Other patients use an insulin pen. The insulin pen provides multiple doses and allows the patient or nurse to dial in the dose, avoiding the need to use a syringe for insulin preparation.

Mixing Insulins Patients whose blood glucose levels are well controlled on a mixed-insulin dose need to maintain their individual routine when preparing and administering their insulin. Do not mix insulin with any other medications or diluents unless approved by the prescriber. Never mix insulin glargine (Lantus) or insulin detemir (Levemir) with other types of insulin. Inject rapid-acting insulins mixed with NPH insulin within 15 minutes before a meal. Verify insulin doses with another nurse while preparing them if required by agency policy. Use these principles when mixing insulins. A patient with diabetes sometimes requires more than one type of insulin. For example, by receiving a short-acting (regular) and an intermediate-acting (NPH) insulin, a patient attains more sustained control of blood glucose levels over 24 hours. Insulin is ordered by a specific dose at select times. Correction insulin, also known as sliding-scale insulin, provides a dose of insulin based on the patient’s blood glucose level. The term correction insulin is preferred because it indicates that small doses of rapid- or short-acting insulins are needed to correct a patient’s elevated blood sugar. Reliance on correction insulin is unlikely to achieve long-term glucose control; therefore it should be ordered only on a temporary basis. Before drawing up insulin doses, gently roll all cloudy insulin preparations between the palms of the hands to resuspend the insulin. Do not shake insulin vials; shaking causes bubbles to form. Bubbles take up space in the syringe and alter the dose. If more than one type of insulin is required to manage the patient’s diabetes, the nurse can mix two different types of insulin into one syringe if they are compatible. If regular and intermediate-acting insulin is ordered, prepare the regular insulin first to prevent the regular insulin from becoming contaminated with the intermediate-acting insulin. [See Box on text p. 603 Example of Correction Insulin Order; and Box on text p. 604 Procedural Guidelines: Mixing Two Kinds of Insulin in One Syringe.]

Administering Injections
Each injection route differs based on the types of tissues the medication enters. Before injecting, know: The volume of medication to administer The characteristics and viscosity of the medication The location of anatomical structures underlying the injection site If a nurse does not administer injections correctly, negative patient outcomes may result. The characteristics of the tissues influence the rate of medication absorption and thus the onset of medication action. Failure to select an injection site in relation to anatomical landmarks results in nerve or bone damage during needle insertion. Inability to maintain stability of the needle and syringe unit can result in pain and tissue damage. If you fail to aspirate the syringe before injecting an IM medication, the medication may accidentally be injected directly into an artery or vein. Injecting too large a volume of medication for the site selected causes extreme pain and results in local tissue damage.

Minimizing Patient Discomfort
Use a sharp-beveled needle in the smallest suitable length and gauge. Select the proper injection site, using anatomical landmarks. Apply a vapocoolant spray or topical anesthetic to the injection site before giving the medication, when possible. Divert the patient’s attention from the injection through conversation using open-ended questioning. Insert the needle quickly and smoothly to minimize tissue pulling. Hold the syringe steady while the needle remains in tissues. Inject the medication slowly and steadily. Many patients, particularly children, fear injections. Patients with serious or chronic illness often are given several injections daily. Thus it is important to minimize patient discomfort by following the guidelines listed. Be sure to position the patient as comfortably as possible to reduce muscular tension. [This list is from text p. 604.]

Medication Administration Injections: Subcutaneous
Medication is placed in loose connective tissue under the dermis. Absorption is slower than with IM injections. Administering low-molecular-weight heparin requires special considerations. A patient’s body weight indicates the depth of the subcutaneous layer. Choose the needle length and angle of insertion based on the patient’s weight and estimated amount of subcutaneous tissue. The subcutaneous route provides medication delivery under loose connective tissue, with minimal vascular supply and increased pain receptor presence. Small needle width and length are required, and administration is best in outer aspects of the deltoids and thighs, as well as in the abdomen. The angle can be 45 or 90 degrees (shown later). Because subcutaneous tissue is not as richly supplied with blood as the muscles, medication absorption is somewhat slower than with IM injections. Because subcutaneous tissue contains pain receptors, the patient often experiences slight discomfort. Administration of low-molecular-weight heparin (LMWH) requires special considerations. When injecting the medication, use the right or left side of the abdomen at least 2 inches from the umbilicus (the patient’s “love handles”) and pinch the injection site as you insert the needle. Administer LMWH in its prefilled syringe with the attached needle, and do not expel the air bubble in the syringe before giving the medication. Use U-100 insulin syringes with preattached 25- to 31-gauge needles when giving U-100 insulin, and 1-mL tuberculin syringes when giving U-500 insulin. Recommended sites for insulin injections include the upper arm and the anterior and lateral portions of the thigh, buttocks, and abdomen. Rotating injections within the same body part (intrasite rotation) provides greater consistency in the absorption of insulin. Injections are to be given at least an inch (2.5 cm) away from the previous site. No injection site should be used again for at least 1 month. The rate of insulin absorption varies based on the site; the abdomen has the quickest absorption, followed by the arms, thighs, and buttocks. Only small volumes (0.5 to 1.5 mL) of water-soluble medications are given subcutaneously because the tissue is sensitive to irritating solutions and large volumes of medications. In children, smaller volumes up to 0.5 mL are given. Collection of medications within the tissues causes sterile abscesses, which appear as hardened, painful lumps under the skin. Choose the needle length and angle of insertion based on the patient’s weight and an estimation of the amount of subcutaneous tissue. Generally, a 25-gauge, 5/8-inch needle inserted at a 45-degree angle, or a 1/2-inch needle inserted at a 90-degree angle deposits medications into the subcutaneous tissue of a normal-sized patient. Some children require only a 1/2-inch needle. If the patient is obese, pinch the tissue and use a needle long enough to insert through fatty tissue at the base of the skinfold. Thin patients often do not have sufficient tissue for subcutaneous injections; the upper abdomen is usually the best site in this case. To ensure that a subcutaneous medication reaches the subcutaneous tissue, follow this rule: If you can grasp 2 inches (5 cm) of tissue, insert the needle at a 90-degree angle; if you can grasp 1 inch (2.5 cm) of tissue, insert the needle at a 45-degree angle.

Subcutaneous Injections
On the left, the diagram indicates sites recommended for subcutaneous injections. The photo on the right shows subcutaneous heparin being administered in the abdomen. The best subcutaneous injection sites include the outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs. The site most frequently recommended for heparin injection is the abdomen. Alternative subcutaneous sites for other medications include the scapular areas of the upper back and the upper ventral or dorsal gluteal areas. The injection site chosen needs to be free of skin lesions, bony prominences, and large underlying muscles or nerves. [Shown are Figures and from text p. 605.]

Comparison of Angles of Insertion for Injections
Comparison of angles of insertion for intramuscular (90 degrees), subcutaneous (45 to 90 degrees), and intradermal (15 degrees) injections. [Shown is Figure from text p. 605.]

Injections: Intramuscular
Faster absorption than subcutaneous route Many risks, so verify the injection is justified Needles Very obese: 3 inches; use different route Thin: ½ to 1 inch Amounts: Adults: 2 to 5 mL can be absorbed Children, older adults, thin patients: up to 2 mL Small children and older infants: up to 1 mL Smaller infants: up to 0.5 mL The IM route provides faster medication absorption than the subcutaneous route because of the greater vascularity of muscle. However, IM injections are associated with many risks. Therefore, whenever administering a medication by the IM route, first verify that the injection is justified, meaning that no alternative sites are available. The angle of administration is 90 degrees with larger needle width and length owing to muscle penetration. Use a longer and heavier-gauge needle to pass through subcutaneous tissue and penetrate deep muscle tissue. Weight and amount of adipose tissue influence needle size selection. For example, a very obese patient often requires a needle 3 inches long, whereas a thin patient requires only a 1/2- to 1-inch needle. Because most agencies have needles that range in length from 3/8 to 1 1/2 inches, investigate different medication routes when IM injections are ordered for patients who are obese. Muscle is less sensitive to irritating and viscous medications. A normal, well-developed adult patient tolerates 2 to 5 mL of medication into a larger muscle without severe muscle discomfort. However, larger volumes of medication (4 to 5 mL) are unlikely to be absorbed properly. Children, older adults, and thin patients tolerate only 2 mL of an IM injection. Do not give more than 1 mL to small children and older infants, and do not give more than 0.5 mL to smaller infants.

Injections: Intramuscular (cont’d)
Assess the muscle before giving the injection. Properly identify the site by palpating bony landmarks. Be aware of potential complications with each site. The site needs to be free of tenderness. Minimize discomfort. Insertion angle is 90 degrees. Repeated injections in the same muscle cause severe discomfort. With the patient relaxed, palpate the muscle to rule out any hardened lesions. Minimize discomfort during an injection by helping the patient assume a position that helps to reduce muscle strain. Other interventions such as distraction and applying pressure to the IM site decrease pain during an IM injection. When selecting an IM site, consider the following: Is the area free of infection or necrosis? Are local areas of bruising or abrasions evident? What is the location of underlying bones, nerves, and major blood vessels? What volume of medication is to be administered? Each site has different advantages and disadvantages. Failure to select injection sites by anatomical landmarks leads to tissue, bone, or nerve damage.

Landmarks: Ventrogluteal IM
A, Landmarks for ventrogluteal site. B, Locating ventrogluteal site in patient. The ventrogluteal muscle involves the gluteus medius; it is situated deep and away from major nerves and blood vessels. This site is the preferred and safest site for all adults, children, and infants, especially for medications that have larger volumes and are more viscous and irritating. The ventrogluteal site is recommended for volumes greater than 2 mL. Research shows that injuries such as fibrosis, nerve damage, abscess, tissue necrosis, muscle contraction, gangrene, and pain are associated with all common IM sites except the ventrogluteal site. Locate the ventrogluteal muscle by positioning the patient in a supine or lateral position. Flexing the knee and hip helps to relax this muscle. Place the palm of your hand over the greater trochanter of the patient’s hip with the wrist perpendicular to the femur. Use the right hand for the left hip, and use the left hand for the right hip. Point the thumb toward the patient’s groin and the index finger toward the anterior superior iliac spine; extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle; the injection site is the center of the triangle. [Shown is Figure 31-20A and B from text p. 606.]

Ventrogluteal IM Injection
C, Giving intramuscular injection in ventrogluteal muscle using the Z-track method.

Vastus Lateralis Site for IM Injection
A, Landmarks for vastus lateralis site. B, Giving intramuscular injection in vastus lateralis muscle. The vastus lateralis muscle is another injection site for adults and children. The muscle is thick and well developed, is located on the anterior lateral aspect of the thigh, and extends in an adult from a handbreadth above the knee to a handbreadth below the greater trochanter of the femur. Use the middle third of the muscle for injection. The width of the muscle usually extends from the midline of the thigh to the midline of the outer side of the thigh. With young children or cachectic patients, it helps to grasp the body of the muscle during injection to be sure that the medication is deposited in muscle tissue. To help relax the muscle, ask the patient to lie flat with the knee slightly flexed or in a sitting position. The vastus lateralis site is often used for infants, toddlers, and children receiving biologicals. [Shown is Figure from text p. 607.]

Deltoid Site for IM Injection
A, Landmarks for deltoid site. B, Giving intramuscular injection in deltoid muscle. Although the deltoid site is easily accessible, this muscle is not well developed in many adults. The potential for injury is present because the axillary, radial, brachial, and ulnar nerves, as well as the brachial artery, lie within the upper arm under the triceps and along the humerus. Use this site for small medication volumes (2 mL or less). Carefully assess the condition of the deltoid muscle, consult medication references for suitability of the medication, and carefully locate the injection site using anatomical landmarks. Use this site only for small medication volumes, when giving immunizations, or when other sites are inaccessible because of dressings or casts. To locate the muscle, fully expose the patient’s upper arm and shoulder. Do not roll up a tight-fitting sleeve. Have the patient relax the arm at the side and flex the elbow. The patient may sit, stand, or lie down. Palpate the lower edge of the acromion process, which forms the base of a triangle in line with the midpoint of the lateral aspect of the upper arm. The injection site is in the center of the triangle, about 3 to 5 cm (1 to 2 inches) below the acromion process. You can also locate the site by placing four fingers across the deltoid muscle, with the top finger along the acromion process. The injection site is then three fingerwidths below the acromion process. [Shown is Figure from text p. 607.]

Z-Track Method in IM Injections
A, Pulling on overlying skin during intramuscular injection moves tissue to prevent later tracking. B, Z-track method of injection prevents deposit of medication into sensitive tissue. It is recommended that, when administering IM injections, the Z-track method be used to minimize local skin irritation by sealing the medication in muscle tissue. The Z-track method for IM injections protects subcutaneous tissues from irritating parenteral fluids. To use the Z-track method, put a new needle on the syringe after preparing the medication, so no solution remains on the outside needle shaft. Then select an IM site, preferably in a large, deep muscle such as the ventrogluteal muscle. Place the ulnar side of the nondominant hand just below the site, and pull the overlying skin and subcutaneous tissues approximately 2.5 to 3.5 cm (1 to 1 1/2 inches) laterally or downward. Hold the skin in this position until you administer the injection. After preparing the site with an antiseptic swab, inject the needle deep into the muscle. Grasp the barrel of the syringe with the thumb and index finger of the nondominant hand, and slowly inject the medication at a rate of 10 seconds per milliliter if no blood return is noted on aspiration. The needle remains inserted for 10 seconds to allow the medication to disperse evenly rather than channeling back up the track of the needle. Release the skin after withdrawing the needle. This leaves a zigzag path that seals the needle track where tissue planes slide across one another. The medication cannot escape from the muscle tissue. Injections using this technique result in less discomfort and decrease the occurrence of lesions at the injection site. [Shown is Figure from text p. 608.]

Injections: Intradermal
Used for skin testing (TB, allergies) Slow absorption from dermis Skin testing requires the nurse to be able to clearly see the injection site for changes. Use a tuberculin or small hypodermic syringe for skin testing. Angle of insertion is 5 to 15 degrees with bevel up. A small bleb will form as you inject; if it does not form, it is likely the medication is in subcutaneous tissue, and the results will be invalid. Because these medications are potent, they are injected into the dermis, where blood supply is reduced and medication absorption occurs slowly. Sometimes patients have a severe anaphylactic reaction if the medications enter the circulation too rapidly. Skin testing requires that the nurse be able to clearly see the injection sites for changes in color and tissue integrity. Intradermal sites need to be lightly pigmented, free of lesions, and relatively hairless. The inner forearm and the upper back are ideal locations. Use a tuberculin or small hypodermic syringe for skin testing. The angle of insertion for an intradermal injection is 5 to 15 degrees, and the bevel of the needle is pointed up. As you inject the medication, a small bleb resembling a mosquito bite appears on the surface of the skin. If a bleb does not appear, or if the site bleeds after needle withdrawal, chances are good that the medication entered subcutaneous tissues. In this case, test results will not be valid.

Injections: Safety, Needleless Devices
600,000 to 1 million accidental needlesticks and sharps injuries annually in health care Common when workers recap needles, mishandle IV lines and needles, or leave needles at a patient’s bedside Exposure to bloodborne pathogens can be deadly. Most needlestick injuries are preventable. Needlestick Safety and Prevention Act Between 600,000 and 1 million accidental needlesticks and sharps injuries occur annually in health care settings. Needlestick injuries commonly occur when health care workers recap needles, mishandle IV lines and needles, or leave needles at a patient’s bedside. Exposure to bloodborne pathogens is one of the deadliest hazards to which nurses are exposed on a daily basis. Most needlestick injuries are preventable with the implementation of safe needle devices. The Needlestick Safety and Prevention Act mandates the use of special needle safety devices to reduce the frequency of needlestick injuries.

Needle With Plastic Guard
Shown is a needle with a plastic guard to prevent needlesticks. A, Position of guard before injection. B, After injection, the guard locks in place, covering the needle. Safety syringes have a sheath or guard that covers a needle after it is withdrawn from the skin. The needle is immediately covered, eliminating the chance for a needlestick injury. The syringe and the sheath are disposed of together in a receptacle. Use needleless devices whenever possible to reduce the risk of needlestick and sharps injuries. Always dispose of needles and other instruments considered sharps into clearly marked, appropriate containers. Never place used needles and syringes in a wastebasket, in your pocket, on a patient’s meal tray, or at the patient’s bedside. [Shown is Figure from text p. 608.]

Sharps Disposal This photo shows sharps disposal using only one hand.
Containers need to be puncture-proof and leak-proof. Never force a needle into a full needle disposal receptacle. [See also Box on text p. 609 Recommendations for Prevention of Needlestick Injuries.] [Shown is Figure from text p. 609.]

Injections: Intravenous
Three methods: As mixtures within large volumes of IV fluids By injection of a bolus or small volume of medication through an existing IV infusion line or intermittent venous access (heparin or saline lock) By “piggyback” infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line Advantages To administer fast-acting medication To establish constant therapeutic blood levels Less irritating method for highly alkaline medications Intravenous injections entail medication delivery directly into the blood. As a result, larger volumes can be delivered than by the subcutaneous or IM route. Volumes and rates are calculated with administration as boluses, or as continuous or intermittent infusions. With all three methods, the patient has an existing IV infusion running continuously or an IV access site for intermittent infusions. Chapter 41 describes the technique for performing venipuncture and establishing continuous IV fluid infusions. Medication administration is only one reason for supplying IV fluids. IV fluid therapy is used primarily for fluid replacement in patients unable to take oral fluids and as a means of supplying electrolytes and nutrients. When using any method of IV medication administration, observe patients closely for symptoms of adverse reactions. After a medication enters the bloodstream, it begins to act immediately, and there is no way to stop its action. Thus, take special care to avoid errors in dose calculation and preparation. Carefully follow the six rights of safe medication administration, double-check medication calculations with another nurse, and know the desired actions and side effects of every medication you give. If the medication has an antidote, make sure that it is available during administration. When administering potent medications, assess vital signs before, during, and after infusion. Administering medications by the IV route has advantages: Often, the nurse uses this route in emergencies when a fast-acting medication must be delivered quickly. The IV route is best when it is necessary to give medications to establish constant therapeutic blood levels. Some medications are highly alkaline and irritating to muscle and subcutaneous tissue. These medications cause less discomfort when given intravenously. Because IV medications are immediately available to the bloodstream once they are administered, verify the prescribed rate of administration with a medication reference or a pharmacist before giving them, to ensure that the medication is given safely over the appropriate length of time. Patients experience severe adverse reactions if IV medications are administered too quickly.

Large-Volume Infusions
Safest and easiest method of IV administration Large volumes (500 or 1000 mL) are used. If infused too rapidly, patient is at risk for overdose and fluid overload. Best practices: Standardized concentrations and dosages Standardized procedures for ordering, preparing, and administering IV medications Ready-to-administer doses when possible Medications are diluted in large volumes (500 or 1000 mL) of compatible IV fluids such as normal saline or lactated Ringer’s solution. Vitamins and potassium chloride are two types of medications commonly added to IV fluids. Because the medication is not in concentrated form, the risk of side effects or fatal reactions is minimal when infused over the prescribed time frame. Current best practices include use of IV medications that come in standardized concentrations and dosages; standardized procedures for ordering, preparing, and administering IV medications; and ready-to-administer doses when possible.

Large-Volume Infusions (cont’d)
Precautions: The nurse never prepares high-alert medications on a patient care unit. Check with a pharmacist before mixing a medication in an IV container. Ask another nurse to verify your calculations. Have that nurse watch you during the entire procedure. Ensure that the IV fluid and the medication are compatible. Prepare the medication in a syringe using strict aseptic technique. Nurses mix medications into IV fluids only in emergency situations. The nurse never prepares high-alert medications (e.g., heparin, dopamine, dobutamine, nitroglycerin, potassium, antibiotics, magnesium) on a patient care unit.

Large-Volume Infusions (cont’d)
Clean the injection port of the IV bag. Remove the cap from the needle, and stick the needle into the IV fluid. Push the medication into the IV fluid, and mix the solution by turning the IV bag gently end to end. Finally, attach a medication label in accordance with Institute for Safe Medication Practices (ISMP) safe label guidelines. Administer the medication to the patient at the prescribed rate. Do not add medications to IV bags that are already hanging. Add medications only to new IV bags. Do not add medications to IV bags that are already hanging because there is no way to tell the exact concentration of the medication. When administering medications in large IV infusions, regulate the IV rate according to the health care provider’s order. Monitor patients closely for adverse reactions to the medication and for fluid volume overload. Also check the site frequently for infiltration and phlebitis.

Intravenous Bolus or “Push”
Introduces a concentrated dose of medication directly into the systemic circulation Advantageous when the amount of fluid that a patient can take is restricted The most dangerous method for medication administration because there is no time to correct errors Confirm placement of the IV line in a healthy site. Determine the rate of administration by the amount of medication that can be given each minute. Because a bolus requires only a small amount of fluid to deliver the medication, it is an advantage when the amount of fluid that the patient can take is restricted. In addition, a bolus may cause direct irritation to the lining of blood vessels. Before administering a bolus, confirm placement of the IV line. Never give a medication intravenously if the insertion site appears puffy or edematous or the IV fluid cannot flow at the proper rate. Accidental injection of a medication into the tissues around a vein causes pain, sloughing of tissues, and abscesses, depending on the composition of the medication. Look up each medication to determine the recommended concentration and rate of administration. Consider the purpose for which an IV medication is prescribed and any potential adverse effects related to the rate or route of administration.

Volume-Controlled Infusions
Uses small amounts (50 to 100 mL) of compatible fluids. Three types of containers: volume-control administration sets, piggyback sets, and mini-infusers Advantages of volume-controlled infusion: Reduces the risk of rapid-dose infusion by IV push Allows for administration of medications that are stable for a limited time Allows control of IV fluid intake The fluid is within a secondary fluid container separate from the primary fluid bag. The container connects directly to the primary IV line or to separate tubing that inserts into the primary line. Three types of containers are volume-control administration sets (e.g., Volutrol, Pediatrol), piggyback sets, and mini-infusers. [Piggybacks are discussed on the next slides.] Volume-control administration (e.g., Buretrol) sets are small (150-mL) containers that attach just below the primary infusion bag or bottle. The set is attached and is filled in a manner similar to that used with a regular IV infusion. Follow package directions for priming sets. The mini-infusion pump is battery operated and allows medications to be given in very small amounts of fluid (5 to 60 mL) within controlled infusion times using standard syringes.

Piggyback Setup A piggyback is a small (25- to 250-mL) IV bag or bottle connected to a short tubing line that connects to the upper Y-port of a primary infusion line or to an intermittent venous access. The label on the medication follows the ISMP IV piggyback medication label format. The piggyback tubing is a microdrip or macrodrip system. The set is called a piggyback because the small bag or bottle is higher than the primary infusion bag or bottle. In the piggyback setup, the main line does not infuse when the piggybacked medication is infusing. The port of the primary IV line contains a back-check valve that automatically stops flow of the primary infusion once the piggyback infusion flows. After the piggyback solution infuses and the solution within the tubing falls below the level of the primary infusion drip chamber, the back-check valve opens, and the primary infusion again flows. [Shown is Figure from text p. 610.]

IV Piggyback Medication Label
IV piggyback medication with label following ISMP safe-labeling guidelines. [Numbers on the label indicate the following: 1. Patient name 2. Location 3. Second identifier (date of birth, financial #, encounter #, medical record #) 4. Generic name 5. BRAND name 6. Patient dose 7. Diluent 8. Route 9. Total volume 10. Bar code 11. Initials as needed 12. Expiration date as needed in a MM/DD/YYYY format 13. Other information as required by state or federal law 14. Pharmacy information if required 15. Comments] [Shown is Figure from text p. 610.]

Injections Intermittent venous access (saline lock) Advantages:
Cost savings resulting from the omission of continuous IV therapy Effectiveness of nurse’s time enhanced by eliminating constant monitoring of flow rates Increased mobility, safety, and comfort for the patient Before administration: Assess the patency and placement of the IV site. Check institution policy about the use of heparin. An intermittent venous access (commonly called a saline lock) is an IV catheter capped off on the end with a small chamber covered by a rubber diaphragm or a specially designed cap. Special rubber-seal injection caps usually accept needle safety devices. Before administering an IV bolus or piggyback medication, assess the patency and placement of the IV site. After the medication has been administered through an intermittent venous access, the access must be flushed with a solution to keep it patent. Generally, normal saline is an effective flush solution for peripheral catheters. Some agencies require the use of heparin. Nurses need to verify and follow institution policies regarding care and maintenance of the IV site.

Injections (cont’d) Administration of IV therapy in the home
Usually patients have a central venous catheter. Home care nurses assist with monitoring. Carefully assess patients and their families to determine their ability to manage this therapy at home. Begin instruction on IV care management while the patient is still in the hospital. Teach family and patient: To recognize signs of infection and complications When to notify the health care provider Regarding maintenance of the equipment Sometimes patients are discharged from an acute care setting and continue to receive IV therapy in the home. Medications such as antibiotics, chemotherapy, total parenteral nutrition, analgesics, and blood transfusions are given in the home. Patients and families need to learn how to recognize problems and what to do when these problems occur.

Medication Administration

Similar presentations

Presentation on theme: "Medication Administration"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Medication Administration

Similar presentations

Presentation on theme: "Medication Administration"— Presentation transcript:

Similar presentations

About project

Feedback