ADMINISTRATION OF MEDICATIONS

ADMINISTRATION OF MEDICATIONS

Alteration in health related to acute or chronic conditions lead clients to seek relief of symptoms through various treatments options one of which is the medication regime. Successful medical therapy depends on the partnership of the patient and the medical staff (including the nurse). This increased collaboration among health care providers demand in-depth understanding of drug, actions, interactions, therapeutic and adverse effect and the exercise of judgment in drug administration.

Thus implementation of prescriptions or orders of the physician/pharmacist involves far more than merely carrying out tasks. As an educated, independently licensed health care provider, the nurse is always responsible for any care given (including administration of drugs) whether prescribed by the physician or planned by the nurse.

The nurses’ first responsibility is to understand the ordered therapy, its goal for the patient and how it is to be carried out. If a physician orders a medication and it is observed that the written dosage is ten times the usual dosage for that medication, instead of giving the medication because “the doctor ordered it”, call the doctor and discuss the order. More so since the patient’s state is not static, understand his condition in relation to the medication. If an oral medication is prescribed for a vomiting patient, an understanding nurse should inform the physician for change instead of just giving the drug just because “the doctor wrote it”.

What is a drug? Drug is any substance other than food which when administered alters the physiological process of the biological being. It is a chemical substance intended for use in the diagnosis, treatment, cure, mitigation or prevention of a disease. Drug is a general term used for both legal and illegal substances (either than food) which alters physiological processes. Medication or medicine is more appropriate for drugs used for therapeutic purposes.

Uses of Drugs Prevention- used as prophylaxis to prevent diseases e.g. vaccines; fluoride- prevents tooth decay. Diagnosis- establishing the patient’s disease or problem e.g. radio contrast dye; tuberculosis (Mantoux) testing. Suppression- suppresses the signs and symptoms and prevents the disease process from progressing e.g. anticancer, antiviral drugs.

Treatment- alleviate the symptoms for patients with chronic disease e.g. Anti- asthmatic drugs. Cure- complete eradication of diseases e.g. anti-biotics, anti-helmintics. Enhancement aspects of health- achieve the best state of health e.g. vitamins, minerals

Legal Aspects of Medication Preparation, dispensing and administration of medications are all covered by laws in every country. The DDA - Dangerous Drug Act. It is an act that governs the procurement and use of some drugs especially the narcotics e.g. morphine, pethedine, cocaine etc. These drugs are prescription only drugs hence cannot be bought or administered without prescription. Dangerous drugs are always kept under lock and key in the Dangerous Drug Cupboard under the care of trusted senior nurses.

Section Dangerous Drugs Record. (1) A person who supplies Class A or B, drugs shall keep on the premises from which he supplies these drugs a book of the prescription to be known as the `Dangerous Drugs Record'. (2) Before any person supplies Class A drugs he shall record in the Dangerous Drugs Record the following- (a) the name and quantity of the drug to be supplied;

(b) the name, and address, signature or thumbprint of the person to whom it is supplied; (c) the signature of the person who supplies the drug; and (d) the date of supply. (3) Where a drug is supplied under a prescription which is retained by the supplier of the drug and an entry is made in the Dangerous Drug Record book enabling the prescription to be referred to, no entry need be made in the Dangerous Drug Record or any particulars specified in the prescription.

The procurement, supply, administration and wastage (accidental during preparation of administration) are always under strict observation through recording in the appropriate books and usually shift to shift handing over especially in the wards. The student should be alert to institutional policies guiding the supply and administration of Dangerous Drugs in the various hospitals where he/she may find him/herself.

It is worth knowing that nurses are responsible for their own actions regardless of the presence of a written order. If a nurse gives an overdose of a drug because it is written by a doctor, the error is accounted to the nurse and not the doctor. The nurse should bear in mind that ALL substances are poisons: there is none that is not a poison. The right dose differentiates a poison from a remedy.

Drug Nomenclature One drug can have as much as 4 different names as follows: Chemical Name - any typical organic name; this precisely describes the constituents of the drug E.g. N-(4-hydroxyphenyl)acetamide for paracetamol

Drug Nomenclature Generic Name - is given by the manufacturer who first develops the drug; it is given before the drug becomes official. It is the name by which the drug will be known throughout the world no matter how many companies manufacture it. This name is usually agreed upon by the WHO. Often the generic name is derived from the chemical name. E.g. acetaminophen

Drug Nomenclature Official Name – this is the name by which a drug is listed in official publications such as USP (United States Pharmacopoeia), BP (British Pharmacopoeia), BPC (British Pharmacopoeia Codex), and NF (National Formulary). The above mentioned documents are sources of drug information.

Drug Nomenclature Trade/Proprietary/Brand Name - is the name given to drug by the manufacturing company and so the company is the legal owner of that name. So, a single generic name can be sold under ten different trade names. Because of this trade names should not be used in writing prescriptions as it can e misleading (Kinaquine is from Kinapharma Company, and Efpac from the Effah Pharmacy and by other names from other Companies).

Classification of Medication
Medications may be classified according to: The body system that the medicine is targeted to interacts wit; e.g. cardiovascular medications, nervous system medication etc. Therapeutic usages of the medicine; e.g. antihypertensives ,neuroleptics, The diseases the medicine is used for; e. g. anticancer drugs, antimalaria drugs antihelminthics etc.

Classification of Medication
The action of the medication can also be used to classify the it; e.g. beta-adrenergic blocking agents The overall effect of the medication on the body can also be a criteria for its classification; e.g. sedatives, antianxiety drugs etc.

Forms of Drugs Solids Capsule- powder, liquid or oil form of medication enclosed in a gelatine shell. Tablet-a powdered form of medication compressed into a hard small disk or cylinder. May be a variety of colours or sizes. Enteric coated tablets are covered with a substance that is insoluble in gastric acids, thus reducing the possible gastric irritation.

Tablets Capsule

Forms of Drugs Lozenge-flat round preparation containing drug in a flavoured or sweetened base that dissolves in the mouth to release the medication; it is also called troche. Suppository-one or more drugs mixed into a firm base, such a gelatin, designed for insertion into a body cavity. The preparation melts at body temperature releasing the medication for absorption

Forms of Drugs Pill-a mixture of powdered drug with cohesive material in a round, oval, or oblong shape. Powder-a drug ground into fine particles from a solid for inhalation or application to the skin.

Forms of Drugs Semi-solids
Ointment-semisolid preparation of one or more drugs applied to the skin Liniment-medication mixed with alcohol, oil or soapy emollient, which is applied to the skin. Paste-semisolid preparation, thicker and stiffer than ointment; absorbed more slowly than ointment that penetrates through the skin.

Forms of Drugs Cream-a non-greasy semi-solid preparation used on the skin Gel or Jelly- a clear translucent semisolid that liquefies when applied to the skin

Forms of Drugs Elixir-medication is a clear liquid containing alcohol, water, sweeteners, and flavouring. Designed for oral use. Lotion-drug in liquid suspension designed for topical use. Solution-a drug dissolved in another liquid substance; may be used orally, parenterally, or externally Suspension-fine drug particles dispersed in a liquid medium. Must be shaken before use Syrup-medication dissolved in a concentrated sugar solution to mask unpleasant taste

Forms of Drugs Tincture-an alcohol or water and alcohol solution prepared from drugs derived from plants

Forms of Drugs These form/preparations of drugs are packaged as ampoules, vials, blister packs, sachets etc. Aam ampoules

Vials Blister Packs

Storage of Medications
Medications are dispensed by the pharmacy to nursing units. Once delivered, proper storage becomes the responsibility of the nurse. All medications must be stored in a cool dry place (usually in cabinets, medicine carts or fridges)

All medications must be stored in a cool dry place (usually in cabinets, medicine carts or fridges)

In less advanced countries, 3 cupboards are usually used for drug storage. Cupboard I-used for drugs for external use only; e.g. calamine lotion, detol, methylated spirit etc. These drugs are contained in distinctive bottles, usually ridged with deep colours (dark green, blue, brown) with red label marked POISON and FOR EXTERNAL USE ONLY.

Cupboard II-contains drugs for internal use only e.g. tablets, suspension, mixtures etc. All drugs must be labelled. Cupboard III-contains the dangerous drug; drugs of addiction. E.g. Morphine, pethedine etc. All drugs should be kept away from direct sunlight and at a temperature suggested by the manufacturer.

Another cupboard called the Emergency Cupboard may be stationed at or near the nurses bay for easy access. This cupboard contains drugs for emergency situations e.g. aminophylline (for asthma), hydralazine (for severe hypertension), oxytocin (for maternal bleeding), intravenous infusions (for rehydration) etc.

In advanced hospitals, use is made of computer controlled dispensing units for a more secure storage of medications. This is made possible through soft wares on computers which has patient’s particulars and medication orders. With a password, the nurse selects the medication needed; the drawer with the medication opens and the drug is delivered.

Some medications such as insulin, vaccines and ATS (anti-tetanol serum) must be stored in medication refrigerators to preserve their potency.

ROUTES OF DRUG ADMINISTRATION
The route of drug administration is the path by which a drug is brought into contact with the body. Drugs are introduced into the body by several routes; it is paramount for the nurse to ensure that the pharmaceutical preparation is appropriate for the route specified

Enteral– administering medication through the gastro-intestinal route; e.g.
Oral Sub-lingual Rectal

2. Parenteral Route Intravenous Intramuscular Intrathecal Intradermal Subcutaneous etc.

Routes Of Drug Administration
3. Topical Route (usually for local effect) On the skin Nasally On the cornea In the ear etc. 4. Inhalation [Pls Read and make notes on 3 and 4 above]

Enteral Route Drug is administered through the gastrointestinal route Oral route – it is the most commonly used route for most drugs because it is Safe Convenient Least expensive

The medicine is swallowed with fluid or is given through a tube. This route is contraindicated in patient on nil per os, or patients with operations of the GIT. 2. Sub-lingual; the drug is placed under the tongue to dissolve slowly and be absorbed.

drugs can also be administered into the buccal cavity (into the superior posterior aspect of the cheek next to the molars. Drugs administered through these routes act quickly due to the thin and large vascularisation which permits quick absorption into the blood stream

3. Drugs can also be administered into the rectum. The suppository gradually dissolves at body temperature and releases the drug which is then absorbed through the mucous . Rectal administration of drug is contraindicated in diarrhoea, rectal prolapse or rectal surgeries.

Parenteral Route – this means introduction of medicines by injection into body tissues or blood vessels. Because this is an invasive procedure, sterile technique must always be applied. It has the following advantages: Rapid and predictable absorption By pass GIT enzymes and gastric acid hence used for drugs that can be destroyed by gastric acid and GIT enzymes

Can be used for unconscious and uncooperative patients. However, it Needs strict asepsis Pain is associated with the injection More expensive Self administration is difficult because it is difficult/needs skilled person Difficulty in correcting overdose errors Risk of infection or local irritation

Intramuscular injection- the drug is administered into the muscle and it passes through capillary walls to enter the blood stream. Advantages More rapid absorption than subcutaneous injection; onset of action is about minutes Absorption can be hastened by drug preparation (aqueous is faster than oil)

More painful than SQ. Vasoconstriction cannot be used to slow down preparation Subcutaneous Route-drug is injected beneath the skin to permeate capillary wall and enter the blood stream Advantages Slow absorption rate (onset of action about 20minutes)

Rate of absorption can be altered by preparation of drug (oil preparations are slow to be absorbed, local vasoconstriction. Disadvantages Only smaller volumes can be administered compared to IM injections Irritating drugs may produce severe pain and local necrosis.

Intravenous Route- drug is administered directly into the blood stream. Advantages Rapid onset of action within 1-2 minutes Most irritating substances may be given Very large volumes of drug may be given Preferred route of medication in emergencies 100% bioavailability of drug.

Dangerous complications e.g. embolism and immediate toxic effects Very technical; getting the vein regulating the right dose per minute Requires greater care.

Topical Applications-medications are applied to the skin or mucous membrane for local effect or for absorption into the blood stream. Although a large number of topical drugs are applied to the skin, other topical drugs include the eye, nose, ear, rectal and vaginal preparation. Creams, lotions, ointments etc. are usually for local effects, however, small amounts are absorbed into the system resulting in systemic effects

Inhalations-gaseous and volatile substances such as anaesthetic agents, oxygen are administered by inhalation using nebulizers positive pressure apparatus. The drugs are almost immediately absorbed into systemic circulation due to larger surface area, high vascularization and high permeability

Advantages Drug is delivered close to the target tissue if local action is desired There is rapid absorption if systemic effect is desired.

Abbreviations used in drug administration
a.c before meals aq water bd or bid twice a day g gram im intramuscular iv intravenous p.c after meals tid three times a day qid four times a day h hourly

MEDICAL ORDERS A prescription is a written instruction from a licensed prescriber concerning the form and dosage of a drug to be issued to a patient. It is a medication order. However, in certain situations, a verbal order may be given directly or through the telephone. Medication orders may be written on the client’s medical records sheets (folder) or on a legal prescription pads

Medical Orders Types of Medication Orders
Generally, there are 2 types of orders: Standing orders Self-terminating orders

Medical Orders Standing orders are carried out until it is cancelled by another order; that is until the prescriber discontinues or modifies the dosage or frequency with another order or until a prescribed number of days has elapsed as determined by the agency policy. E.g. Insuline 10U SC qd at 1800 (6pm). This order has no limit and must be continued until it (order) is modified or discontinued.

Medical Orders A prn order, like IM Morphine 15mg q4h prn, is a standing order; there is no direction as to when it should be stopped. The order does not specify the number of days or number of dosages of the drug to be received. Self-terminating Order: this order specifies the number of days or the number of dosages of the drug the client is to receive.

Medical Orders E.g. Caps Tetracycline 250mg PO q6h x 5 days. This implies that on the 5th day, when patient receives the 20th dosage, the order ends; the day (time) of the first dose marks day 1. A stat order is an order for a single dose of a medication but it must be given immediately; as soon as possible. This ‘once and immediately’ order is usually given in emergency or serious situations.

Medical Orders A medication order must have the following: 1.The full name of the patient: writing the full name of the patient prevents a state of confusion when two patients bear the same first or last name. Also, the patient’s number (In-patient or out-patient) may be added and also the ward if on admission.

Medical Orders Date and Time the order is written: this is important to establish when an order is given and when it was carried out. It also helps to determine when an order automatically terminates. The Form and Name of the drug: the name and form of the drug to be administered should be written using preferably the generic name. In cases where trade names are used which nurse is not familiar with, clarification should be sought from the prescriber or the pharmacopoeia.

Medical Orders 4. Dosage of the drug: dosage of the drug includes the amount, frequency or time(s) of administration and the strength. E.g. Caps Tetracycline 500mg tid x 5 days; 500mg (amount), tid (frequency). IVF 50% (strength) Dextrose 5ml (amount) nocte (time) x 2 days (duration).

Medical Orders 5. Route of Administration and special directives about its administration. Since it is possible for one drug to have several possible routes of administration, it is important that the route preferred by the prescriber is stated in the order. If for any reason a prescribed route is contraindicated in the patient, the nurse should notify the prescriber rather than choosing another route on his/her own accord.

Medical Orders Special directives may include ‘ give slowly over 20, 30, 40 etc. minutes; take before, after or with meals; etc. 6. Signature of the Prescriber: the signature makes the medical order a legal request. Without it, the order is invalid. NB: for medical orders taken verbally, the nurse signs it, to be co-signed by the prescriber later.

Dose Calculation and Conversions
When prescriptions are issued for medication orders to be carried out, it becomes necessary at times to calculate doses to be given especially when the drugs are dispensed in lager doses or strengths; or the units are different.

Measurements (units) can be in the Metric system e.g. gram (g), meter (m) etc. Apothecary System e.g. grain (gr), minim (m), pint (pt). Household System e.g. drop (gtt), teaspoon (tsp) or tablespoon (tsp)

Metric 1ml 15ml 30ml 500ml 1000ml 4000ml Apothecary 15 minims 4 fluid drams 1fluid ounce 1pint 1 quart 1gallon Household 15 drops (gtt) 1tablespoon

Metric 1mg 60mg 1g 4g 30g 500g 1000g (1kg) Apothecary 1/60 grain (gr) 1grain (gr) 15 grains (gr) 1 dram (D) 1ounce 1.1 pound (lb) 2.2 (lb)

Trial Question 1 If a prescription given orders Inj. Cephalexin 500mg IV qid x 2 days but the pharmacy dispenses 2g in 10ml, the dose to be administered is ………… Trial Question 2 If Inj. Heparin units SC is ordered but 40,000 units per ml vial is supplied from the pharmacy, how many millilitres should be administered?

The paediatric dose of any medication is usually smaller than the adult dose. Several rules have been devised to calculate the infants’ and children’s dosages such as Young’s Rule, Clark’s Rule and Fried’s Rule. These rule give approximate dosages. Fried’s Rule consider children under one year and so considers the adult age to be 150 months which is 12½ years. Used for children

Fried’s Rule for children under 1year Infant dose = age of child in months x Adult Dose 150 months Young’s Rule assumes a person under 12½ years is a child; for children over 1year. Child’s Dose= Age of child in years x Adult Dose Age of child in years +12

Clark’s Rule calculates the dose of a child base on his/her weight and have an advantage over the other rules in that it can be used for children of all ages. An average adult weight of 150 pounds is (approx. 68kg). Can be used for children of all ages. Child’s Dose = weight of child (in pounds) x Adult dose 150

Clarks Rule calculates the dose of a child based on his or her weight and it have an advantage over the other rules n that it can be use for children of all ages. An average adult weight of 150pounds [approx.65kg] is used Childs Dose = Weight of child in pounds × Adult Dose 150months

The Body Surface Area (BSA) method of calculating drug doses is widely used for two types of patients: Cancer patients Paediatric patients. The BSA calculations are done in two ways: 1. Using the standard chart which features the weight, BSA and dose to be taken,

2. Calculation using the formula Patient’s dose = Patient’s BSA (m²) X Drug Dose (mg) 1.73 m² The average adult is considered to have a BSA of 1.73m².The BSA of an individual is determined by drawing a straight line connecting the person’s height and weight. The point at which the line intersects the centre column indicates the person’s BSA in square meters.

E.g. If the adult dose of a drug is 100mg, calculate the approximate dose for a child with a BSA of 0.83m², using the equation above. Ans 48mg.

Nomograph to Determine BSA

Rights of Medication Administration
Medication errors can be detrimental to patients. To prevent these errors, these guidelines are - the rights- are used in drug administration. 1. Right Patient: correct identification of the client cannot be over emphasized. This can be done by asking the client to mention his/her full name which should be compared with that on the identification bracelet or the patient’s folder and medication/treatment chart for confirmation.

Beware of same and similar first and surnames to prevent the error of administering one person’s medication to another and vice versa. 2. Right Medication: before administering any medicine, compare name on medication chart/medication order with that on the medication at least 3 times-checking medication label when removing it from storage unit, compare medication label with that on treatment chart and medication label and name on treatment chart with patient’s name tag.

3. Right Time: drug timing is very especially with some drugs like antibiotics, antimalaria drugs etc. to achieve cure and prevents resistance. Some drugs must be given on empty stomach e.g. antituberculosis drugs; and some after meals e.g. NSAIDS-these must be noted and adhered to.

The interval of administration of drugs should also be adhered to because it is important for many drugs that the blood concentration is not allowed to fall below a given level and for others two successive doses closer than prescribed might increase blood concentration to a dangerous level that can harm the patient..

4. Right Dose: this becomes very important when medications at hand are in a larger volume or strength than the prescribed order given or when the unit of measurement in the order is different from that supplied from the pharmacy. Careful and correct calculation is important to prevent over or under dosage of the medication.

5. Right Route: an acceptable medication order must specify the route of medication. If this is unclear, the prescriber should be contacted to clarify or specify it. The nurse should never decide on a route without consulting the prescriber.

6. Right to information on drug/client education; the patient has the right to know the drug he/she is taking, desired and adverse effects and all there is to know about the medication. The charter on patient’s right made this clear. 7. Right to Refuse Medication: the patient has the right to refuse any medication. However, the nurse is obliged to explain to patients why the drug is prescribed and the consequences refusing medication.

8. Right Assessment: some medications require specific assessment before their administration e.g. checking of vital signs. Before a medication like Digoxin is administered the pulse must be checked. Some medication orders may contain specific assessments to be done prior to medication 9. Right Documentation: documentation should be done after medication and not before.

10. Right Evaluation; conduct assessment to ascertain drug action, both desired an side effect.

Drug Administration For convenience, especially when many patients are to receive medication at a given time. The patient should be known and folders arranged in the order in which the medications would be dispensed.

Administration of drug entails five interrelated steps: Identification of the patient Administration of the drug Adjunctive nursing interventions Recording Evaluation of effectiveness of the drug

Enteral Drug Administration
The delivery of any medication that is absorbed through the gastrointestinal tract

Oral Medication Oral medication can be by ingestion, sublingual administration (place the pill or direct spray between the underside of the tongue and the floor of the oral cavity)or buccal (place the medication between the patient’s cheek and gum). p

Oral Medication A tray or trolley should be set with:
Drug to be administered Water in a jug Glass on a saucer all in the tray Spoons Mortar and pestle (when necessary) Towel Straw Spatula Patient’s folder/treatment chart and pen

Gastric Tube Administration
Gastric tubes provide access directly to the GI system.

Rectal Administration
The rectum’s extreme vascularity promotes rapid drug absorption. Medications do not travel through the liver, and are not subject to hepatic alteration.

Parenteral Medication
Drug administration outside of the gastrointestinal tract. Parenteral medication is an invasive procedure and so must be carried out observing the standard infection prevention measures sterile techniques. Equipment The Syringe is one of the equipment for administration of parenteral medication.

All syringes have A tip which connects with the needle A barrel which has the calibration The plunger which fits inside the barrel. Syringes come in different shapes, sizes and colours. They may be made of glass or rubber or metal.

Syringes and Needles

The standard syringes come in 2, 3, 5 and 10cc sizes. There are the 50, 60 and 100cc syringes which are not for injection but for adding large amounts of sterile solutions to infusions or irrigating wounds. The Insulin Syringes are designed specially for use with the ordered dose of insuline. An insuline may come in concentrations of u100/cc, u80/cc, u40/cc etc.

The insuline syringe should always match the concentration of the insuline. The syringes usually have a permanently attached needles that are thin (26-30)and short (¼").

Tuberculine Syringe, caliberated in tenths and hundredths of a cubic centimeter on one side and in sixteeths of a minim on the other side, is a narrow syringe. This syringe originally designed for tuberculin injections can also be used for small and precise doses especially in children. It is used for doses of 0.5ml or less. .

Prefilled single dose syringes are already filled with a drug. If the dose ordered is lesser, the excess is expelled before administration.

The Needles are usually made of stainless steel and are usually disposable. They may be packaged with the syringe or separately. However, some special needles for surgery or special procedures may be reused and hence are sterilizes after each use.

A needle has 3 parts: The hub; the larges part which fits onto the syringe The cannular/shaft/stem; the long part which connects to the hub The bevel is the slanted part at the end of the shaft. The bevel may be short or long. The longer the bevel, the sharper the needle.

The length of the bevel selected is based on the type of injection to be given. The long bevels are sharp and produce less pain when injected into subscutaneous and muscle tissues. Short bevel needles are used for intradermal and intravenous injection to pervent occlusion of the bevel with tissue. A filter needle has a filter inside the needle to prevent drawing up particles of glass or rubber in ampoules or vials. Before injection, the filter needle should be changed with one without it.

Needles for injection has 3 variables: The slant of the bevel, The length of the cannular The gauge/diameter of the cannular. The larger the gauge number, the smaller the diameter of the shaft. The shaft varies from 3/8 to 5 inches while gauge varies from no. 14 to 30.

Thick and oily preparations need larger needle hose than aqueous one and thicker muscles need longer needle shaft. The choice of needle, thus, depends on muscle mass, type of injection the type of parenteral route for the injection

Ampoules and Vials Because parenteral drug administration is an invasive procedure, parenteral injections (preparations) are sterile. Drugs that deteriorate in solution are dispensed in tablets or powders and dissolved in solution immediately before injection.

So left over from such preparation should not be used especially if they are discoloured after some hours. Ampoules and vials are frequently used to package parenteral medication An ampoule is a glass container usually designed to hold single dose of a drug. It is made of clear glass in a particular shape with a constriction at the neck (may be coloured) for easy opening.

Because frequently the drug will be both above the constriction an and in the main portion of the ampoule, one should flick the upper portion (above the constriction) severally with the finger nails to bring all medication to the main portion of the ampoule before snapping it open after filling the neck. As it is done

A sterile gauze placed around the neck before breaking prevent cuts form the glass. A single or multiple-dose glass bottles with a sealed rubber cap is called a vial. They are usually covered with a soft metal cap that can be easily removed. The rubber capping must be cleaned with antiseptic(e.g. methylated spirit) swab before a needle is inserted. The nurse should consider the use of a filter needle to withdraw medication

Withdrawing medication from Ampoules
Wash and dry hands Select appropriate ampoule Select the appropriate needle and syringe Take ampoule and observe for expiry date, cloudiness (return to pharmacy if noticed) While holding the ampoule flick at its neck/stem repeatedly with the fingernails to return trapped contents to the base of the ampoule. File if not scored at the neck

Withdrawing medication from Ampoules
Wrap a sterile gauze at the neck of the ampoule and gently snap open. Tilt ampoule slightly to one side, uncap needle on syringe and insert needle below the level of the drug Gently pull on the plunger to draw medicine into the syringe Change needle used in withdrawing drug Expel air.

Withdrawing Medication from an Vial
Wash and dry hands Take the vial and observe for expiry date, direction for mixing Withdraw the appropriate diluents into a syringe with a dissecting for remove metal or rubber cap covering the rubber stopper Clean with swap containing methylated spirit Introduce needle through the middle of the rubber and release diluent into the vial.

Shake or roll between the palms till clear solution free from lump is obtained. Placing the syringe in the centre of the rubber stopper, inject air into the vial. Invert the vial and keep the needle bevel in the solution With syringe at eye level, ensure the desired dose is drawn up. Slowly and gently, withdraw needle from the vial and re-cap on a levelled surface

Using ink, mark the current date, time and initials on the vial Label the syringe with drug, dose, date and time if not to be used immediately Wash and dry hands.

If withdrawing medication from two vials (multiple-dose) and mix in one syringe, draw up from the multiple vial first then the single vial to prevent contamination of the multiple-dose vial. In case of insulin, draw up the regular insulin first before the short acting one.

Intradermal Injection
An intradermal (intracutaneous) injection is the administration of a drug into the dermal layer of the skin just beneath the epidermis. Only small volumes of drug are administered by this route; about ml. This route is indicated typically for diagnosis of tuberculosis (tuberculin testing), testing for allergens and for vaccinations (e.g. BCG)

Needle gauge with short bevel is used; about 3/8 -1/2 inches are used with the tuberculin syringe for accurate measurement. Sites for injection are the inner aspect of the fore arm, upper chest, upper back beneath the scapular.

Procedure Wash and dry hands Position client comfortably Select injection site and inspect for oedema, redness or tenderness or sites of previous injection With antiseptics swab, clean site While holding swab between fingers of non- dominant hand, pull cap off from the needle

With thumb and forefinger of non-dominant hand, stretch skin over the selected site and insert needle at an angle of 5°-15°, bevel up to about 1/8 inch below the skin. Do not aspirate; push plunger slowly to inject the drug to form a small bleb under the skin surface. Gently withdraw needle while applying gentle pressure with the antiseptic swab; do not massage

Make patient comfortable, than him and discard equipment as appropriate Document.

Subcutaneous Injections (Sc, SQ)

It is the administration of drug into the subcutaneous tissue; between the dermis and the muscle. It is usually used for insulin and anticoagulant administration. Sites used usually are lateral and anterior aspects of the upper arm and thigh, upper back below the scapulae. Drug is slowly absorbed; hence if repeated doses are given, the sites should be rotated to prevent hard painful lumps from developing as a result of irritation and poor absorption of the drug

Procedure Wash and dry hands Assemble the equipment needed with right syringe and needle. Prepare and load drug Position patient, clean site with antiseptic swab Hold swab in a non-dominant fingers, pull cap from needle With syringe in between thumb and forefingers of the dominant hand

Pinch the skin with non dominant hand Inject needle quickly and firmly at an angle of 45°-90°, release skin and grasp tip of syringe with non dominant hand and pull back the plunger to ascertain that needle is not in vein (if in vein, blood will be drawn into the syringe on pulling back the plunger). In the absence of blood in syringe, push plunger gently but firmly to inject drug

Withdraw needle while applying pressure to the site Massage site if acceptable and settle him comfortably Discard equipment as appropriate Wash and dry hands document

Intramuscular Injection (IM)
It is the administration of into the muscle tissue . The volume of medication to be administered IM vary, but usually, 5ml is considered as the maximum for large muscles e.g. gluteal muscle. However, babies, the elderly and emaciated patients are unable to tolerate this amount; 2ml is usually the maximum for them

Large healthy muscles free from abscesses, necrotic tissue, sloughing and damaged nerves and skin should be used. When a number of injections are to received, the sites should be rotated so that muscles are not overused or over irritated. The length of the needle and gauge id selected based on the volume and thickness (viscosity) of the medication and the muscle size.

In babies and young children, quadriceps muscles on the anterior and lateral aspects of the thighs are best to guard against damaging the large sciatic nerve at the gluteal muscle.

Dorsogluteal Site utilizes the gluteus maximus muscle for injection. The get the injection site, the buttock is divided into four (4) quadrants with and imaginary line. The exact site is the upper outer aspect of the upper outer quadrant of the buttocks. Venterogluteal site uses the gluteus medius and gluteus minimus for injection. It is a very desirable site because there are neither large nerves nor large blood vessels in the area; and it also it has less fatty tissues. Because it is far from the rectum, there is less risk of contamination and abscess formation

Sites for IM injections
Dorsogluteal Site Venterogluteal site Sites for IM injections

To locate the site, the nurse’s opposite hand rests on the patient’s opposite hip, fingers pointing towards (patient’s) head. The index finger is placed on the anterior superior iliac spine, the middle finger stretched dorsally pressing just below the iliac crest to form a V; a triangle is formed between the two (index and middle) fingers and the crest of the ilium which is the injection site thus the middle of the triangle.

Quadriceps Site uses the rectus femoris and vastus lateralis. The latter is located at the anterior aspect of the thigh. The site for site is midway between the greater trochanter of the femur and the knee. Deltoid normally for smaller volumes of drug than the other muscles mentioned earlier. It is lateral to the humerus; injection site about 1-2 inches below the acromium process

Quadriceps Site Deltoid Injection site

Procedure As for subcutaneous injection but the needle is introduced deeper into the muscle at 90° angle.

Intravenous Therapy Intravenous therapy is the administration of fluids, electrolytes nutrients and medication through the intravenous route. Objectives To supply fluids when patients are unable to take it liberally To provided salts needed to maintain electrolyte balance To provide nutrients e.g. glucose, protein (albumen and vitamins)

Intravenous Therapy Administer drugs for rapid actions or when drugs are irritating to the tissues Sites for intravenous therapy The site chosen for intravenous infusion depends on: Type of infusion Duration for the infusion Age of the patient.

Intravenous Therapy For adults, the veins on the arm are: Basilic vein
Median cubital vein Dorsal veins Median vein Radial vein Cephalic vein

Intravenous Therapy On the foot, the veins are; Great saphenous vein
Dorsal plexus

Intravenous Therapy Duties of the Nurse during IV Therapy
Explain the need for the IV therapy, what to expect, duration of the therapy, activities permitted during the procedure and observations to be made. Help patient to maintain activities of daily living; bathing and grooming, feeding etc. Observation should be made on the flow rate, patency of the tubing, infusion site, level of fluid in the infusion bag/bottle, patient’s comfort and reaction to therapy.

Intravenous Therapy Change dressing on the IV line as may be necessary.

Intravenous Therapy Complications to observe for during IV therapy:
Infiltration escape of fluid into subcutaneous tissue due to dislodgement of the needle causing swelling and pain. Gross infiltration may result in nerve compression injury which can result in permanent loss of function of extremity or in case of irritating medications (vesicant), significant tissue loss, permanent disfigurement or loss of function may result. When there is infiltration, the site should be changed.

Intravenous Therapy Phlebitis is the inflammation of the vein. This may result from mechanical trauma due to the insertion too big a needle (for small vein) or leaving a device in place for a long time. Chemical trauma result s from irritation from solutions or infusing too rapidly. This manifests as pain or burning sensation along the vein. On observation, there may be redness, increased temperature over the course of the vein. The site should be changed and warm compress should be applied.

Intravenous Therapy Circulatory Overload; the intravascular fluid compartment contains more fluid than normal. This occurs when infusion is too rapid or excess volume is infused. This manifests as dyspnoea, cough, frothy sputum and gurgling sounds on aspiration. Embolism; obstruction of the blood vessels by travelling air emboli or clot of the blood. It is fatal.

Intravenous Therapy Flow rate is the volume of intravenous fluid to be infused over a set period of time as prescribed by the prescriber. The flow rate should also be observed for and bottles or bags changed before blood is drawn up the infusion set or air enters the tube. Flow rate has to be calculated as: Total amount of fluid to be infused X drop factor Total time in minutes

Intravenous Therapy Factors influencing flow rate are:
Position of the extremity Patency of the tubing and Height of the infusion bottle/bag.

ADMINISTRATION OF MEDICATIONS

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ADMINISTRATION OF MEDICATIONS

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