Medication Administration

True or false: Because of professional ethics, the nurse does not tell the patient what medications they are taking.

False.

True or false: Having the patient tell the nurse his name is a reliable means of patient identification.

False. Need TWO means of patient identification.

True or false: If a drug is prepared by the manufacturer using the apothecary system, the nurse can calculate the dose using the metric system.

False. A conversion would need to be made first!

Intramuscular injections

Fast absorption --> greater blood supply many risks possible weight and amount of adipose tissue influence needle size needle size = 1 to 2" gauge = 18-22 volume = 1 to 3 mL angle of insertion = 90 degrees Locations - ventrogluteal - vastus lateralis - deltoid - dorsogluteal

Fastest route of drug administration

IV

3 med checks before administration of medication

PPA 1) as you're pulling the medication 2) as you're preparing the medication 3) at the bedside right before administering the medication

Absorption

Passage of medication molecules into the blood from the site of administration Factors that alter absorption: - route - ability of medication to dissolve - blood flow to site of administration - body surface area (increased surface area = increased absorption) - lipid solubility of medication (BBB)

Parts of a syringe

Plunger is used to fill the syringe; touch only the outside of the syringe barrel and handle the plunger to maintain sterility

The most common syringe, gauge, and needle length to use when giving an IM injection to an adult are: a. 3-5 mL syringe; 20-26 gauge; 2-3" needle b. 5-10 mL syringe; 18-19 gauge; 1-2" needle c. 3-5 mL syringe; 19-22 gauge; 1-2" needle d. 1-2 mL syringe; 19-22 gauge; 5/8-1" needle

c. 3-5 mL syringe; 19-22 gauge; 1-2" needle Need longer needle for IM The smaller the gauge number, the bigger the diameter!

A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? a. insert the IV catheter into the back of the client's hand b. massage the area of the venipuncture site vigorously c. insert the IV catheter without using a tourniquet d. apply traction to the skin proximal to the insertion site to stabilize the vein

c. insert the IV catheter without using a tourniquet

Serum electrolyte concentrations are most commonly given in terms of: a. mgm% b. g/100 mL c. mEq/L d. mEq/100 mL

c. mEq/L

When administering eye drops, the nurse minimizes the risk of transmitting infection by: a. cleansing the eyelids by wiping from outer to inner canthus b. applying gentle pressure to the patient's nasolacrimal duct after instilling drops c. removing crusts and drainage from eyelids before instilling drops d. asking the patient to look up before instilling drops into the conjunctival sac

c. removing crusts and drainage from eyelids before instilling drops

A nurse is caring for a client receiving fluid through a peripheral catheter. Which of the following findings at the IV site should the nurse identify as infiltration? a. purulent exudate b. warmth c. skin blanching d. bleeding

c. skin blanching + edema, and coolness indicate infiltration

When giving an IM injection to an average size adult, one should: a. bunch skin and give injection at 45 degree angle b. bunch skin and give injection at 90 degree angle c. spread skin and give injection at 90 degree angle d. inject needle at 60 degree angle without touching skin

c. spread skin and give injection at 90 degree angle spread skin = Z-track method bunch skin = subQ injection

In choosing the best site to give any injection, which of the following factors should be considered: a. size of patient b. amount of solution c. condition of patient's skin d. anatomic landmarks to insure safety e. all of the above

e. all of the above

Which of the following would be appropriate nursing action(s) for a patient receiving a vaginal suppository? a. allow the patient to insert her own b. provide a peri-pad c. provide frequent perineal care d. refrigerate vaginal suppositories and creams e. all of the above

e. all of the above

Oral route

easiest and most commonly used have a slower onset of action and a prolonged effect than parenteral medications food may interfere or be helpful protect against aspiration enteral feedings

Therapeutic effect

expected or predicted physiological response that a medication causes

One-time order

given only once at a specified time common for preoperative medications or medications given before diagnostic examinations

Duration

time during which the medication is present in concentration great enough to produce a response

Onset

time it takes after a medication is administered for it to produce a response

Peak

time it takes for a medication to reach its highest effective concentration

PRN orders

to be given only when a patient requires it use objective and subjective assessment and discretion in determining whether or not it is needed * big source of med errors if contain a range (q4-6h)

Client's rights

- informed about a medication - refuse a medication - medication history - receive medications safely - not to receive unnecessary medications - informed of medication involved in research

How do you instill eye drops?

- tilt head backward, open eyes, & look up - pull lower lid down against cheekbone - place the prescribed dose of eye medication in the lower conjunctival sac, never directly onto the cornea! The cornea of the eye has many pain fibers. - close eye gently to allow the drop to fall into the conjunctival sac - to prevent overflow into nasal & pharyngeal passages, instruct client to apply pressure over inner canthus next to nose for 30-60 seconds following administration

Polypharmacy

2 or more medications for same illness 2 or more medications from same class 2 or more medications with same/similar actions that treat several disorders Mixing of herbal/nutritional products with medications

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.

Choosing needle length

According to patient's size and weight and the type of tissue into which the medication is to be injected

Parenteral administration

Administration of medications via injection into the body: - invasive procedure --> use sterile technique - risk of infection - need to ensure medication reaches intended location - effects develop rapidly (depending on rate of absorption)

Distribution

After absorbed, the medication is distributed to body tissues/organs (the site of action) Rate/extent depends on: - physical/chemical properties of medication - physiology of client ** circulation (blood flow to liver decreases with age) ** membrane permeability ** protein binding (decreased albumin with age)

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.

Classification of medications

Based on: - effects on body system - symptoms relieved by medication - medication's desired effect

TB syringe

Calculated in hundredths of a mL Gauge: 25-27 Needle: 3/8-5/8" Intradermal injection

Insulin syringe

Calculated in units Use for INSULIN ONLY Gauge: 29-32 3/8-1/2" needle SubQ injection

Standing orders or routine medication orders

Carried out until the prescriber cancels it by another order or a prescribed number of days elapse Given 30 minutes before and 30 minutes after scheduled time window

Administration of otic medications

Children: upward & backward pulling of pinna Adults: downward & backward pulling of pinna

Parenteral needles

Choose according to clients size and tissue used Longer for IMs, shorter for subcut The bigger the gauge number, the smaller the needle outer diameter

Client's rights re: medication

Informed about medication Refuse a medication Medication history Receive medication safely Not to receive unnecessary medications Informed of medication involved in research

Intraocular administration

Into conjunctiva

As the needle gauge becomes smaller, the needle diameter becomes __________

Larger Selection of a gauge depends on the viscosity of the fluid to be injected or infused

Parenteral syringes

Leur-loc/non Leur-loc *used for IM and subQ injections TB syringes Insulin syringes

Excretion

Medications are excreted by the: - kidneys - liver - bowel - lungs - exocrine glands Chemical makeup of medication determines organ of excretion

Metabolism

Metabolized into a less potent/inactive form Biotransformation: enzymes detoxify, break down, & remove active chemicals Occurs mostly in the liver, but also in the kidneys, blood, intestines, & lungs

Now orders

More specific than a one-time order and is used when a patient needs a medication quickly but not right away as in a STAT order nurse has up to 90 minutes to administer

Parts of a needle

The hub - fits onto the tip of a syringe The shaft - connects to the hub The bevel - slanted tip; creates a narrow slit when injected into tissue that quickly closes when the needle is removed

In order to minimize a patient's discomfort, the nurse administers an injection using all of the following techniques except: a. slapping injection site before inserting needle b. holding the syringe steady while the needle remains in the tissue c. positioning the patient to reduce muscular tension at the injection site d. selecting proper anatomical landmarks for injection sites

a. slapping injection site before inserting needle

Pharmacokinetics

The study of how medications enter the body, reach their site of action, metabolize, and exit the body. ADME

True or false: When preparing liquid medications for oral administration, the nurse should always read the label for instructions.

True.

Mild allergic reaction symptoms

Urticaria Rash Pruritus Rhinitis

Which of the following type of drugs is absorbed into the body most rapidly? a. a liquid given orally b. a gelatin capsule given orally c. an enteric coated pill given orally d. ointment applied to the skin

a. a liquid given orally

In the unit-dose system of drug administration: a. each dose of a drug is in an individual package b. drugs for each patient are in individual compartments for a limited time c. each patient is responsible for his medications d. drugs are stored on nursing units in bulk containers

a. each dose of a drug is in an individual package

The two most important anatomic landmarks to use when giving an IM injection into the ventrogluteal muscle area: a. greater trochanter, anterosuperior iliac spine b. crest of ileum, inferior gluteal fold c. upper outer quadrant of buttock, inner aspect d. crest of ileum, gastrocnemius quadrant of outer buttock

a. greater trochanter, anterosuperior iliac spine

The viscosity of the medication to be injected guides the nurse in selecting the: a. needle gauge b. needle length c. syringe size d. syringe calibration

a. needle gauge

The safest and most convenient route of drug administration is: a. oral b. dermal c. respiratory d. intravenous

a. oral

The anatomical structures used to locate the posterior gluteal site are MOST easily identified when the patient assumes a _______ position a. prone b. supine c. Fowler's d. Trendelenburg

a. prone

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should should the nurse implement to prevent infection? a. thread the IV catheter so that the hub rests at the insertion site b. shave excess hair from around the insertion site c. cleanse the site with hydrogen peroxide before IV catheter insertion d. palpate the site carefully just before inserting the IV catheter

a. thread the IV catheter so that the hub rests at the insertion site Reduces the risk of contamination along the length of the catheter

The most common syringe volume, gauge, and needle length to use for a subQ injection of an average size adult are: a. 1-1/2 mL syringe; 25 gauge; 5/8" needle b. 1 mL syringe; 27 gauge; 5/8" needle c. 3 mL syringe; 27 gauge; 5/8" needle d. 1 mL syringe; 25 gauge; 3/8" needle

b. 1 mL syringe; 27 gauge; 5/8" needle

Your patient is weighed daily and has gained 2 lbs. This corresponds to how much fluid retention? a. 500 mL b. 1000 mL c. 1500 mL d. 2000 mL

b. 1000 mL 1 lb = 16 fl oz 1 fl oz = 30 mL 32 oz * 30 mL/1 fl oz = 960 mL

The Z-track method for administering an IM injection is used when the: a. amount injected is greater than 3 mL b. drug is extremely irritating to the subQ tissue c. drug is extremely potent d. pt is unconscious

b. drug is extremely irritating to the subQ tissue Never give more than 3 mL subQ

Aspiration before injection prevents which of the following complications: a. poor absorption of the medication b. injection into a blood vessel c. tracking d. over saturation of a muscle

b. injection into a blood vessel

To prevent or reduce tracking, you will use all of the following methods except: a. select an IM site b. massage c. Z-track d. needle change

b. massage massage could bring drug back to surface of skin!

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? a. insert the catheter at a 45 degree angle b. place the client's arm in a dependent position c. shave excess hair from insertion site d. initiate IV therapy in veins of the hand

b. place the client's arm in a dependent position (veins will dilate due to gravity) - should insert at 10-30 degree angle - should clip hair & avoid shaving bc can cause breaks & cuts in skin - avoid use of fragile veins like hands

Minimal information to be recorded after a drug is administered includes the name of the drug, dosage, and which of the following? a. route, manufacturer, & who administered b. route, time, and who administered c. time, route if other than oral, & initials of RN d. dosage, who administered, and who ordered

b. route, time, and who administered

The volume of medication to be injected guides the nurse in selecting the correct: a. needle gauge b. size of syringe c. needle bevel d. packaging of syringe

b. size of syringe

A nurse is preparing to administer an IM injection to a client who is overweight. Which of the following sites should the nurse select for the injection? a. the lower, medial quadrant of the buttock near the coccyx b. the side hip between the iliac crest and anterior iliac spine c. the tissue of the posterior upper arm d. the lower, inner thigh 4 finger widths above the patella

b. the side hip between the iliac crest and anterior iliac spine Ventrogluteal injection: the nurse should prepare for injection by placing a hand on the client's greater trochanter (right hand on left hip, for example) with the first two fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape. a. dorsogluteal site poses greater risks (sciatic nerve) c. this site would appropriate for subQ injections d. to inject in the vastus laterals site, the nurse should select one hand width below the greater trochanter and one hand width above the patella

The symbol "p.r.n." means: a. every hour b. when necessary c. three times daily d. after meals

b. when necessary

Plateau

blood serum concentration of a medication reached and maintained after repeated fixed doses

A nurse is providing home care for a client who is receiving tube feedings & medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene? a. the client is receiving formula at room temperature b. the feedings infuse at a slow, continuous drip over 8h each night c. the family member washes out the feeding bag with warm water once every 24h d. the family member flushes the tubing with water before and after giving medications

c. the family member washes out the feeding bag with warm water once every 24h the family member should wash out the feeding bag at each refilling throughout the day (every 4 to 8h)

A nurse is administering medications to a 4yo patient. After explaining what medications are being given, the mother states, "I don't remember my child having that medication before." What is the nurse's next action? a. give the medications b. identify the patient using two patient identifiers c. withhold the medication and verify the medication orders d. provide medication education to the mother to help her better understand her child's medications

c. withhold the medication and verify the medication orders

What is included in all drug orders?

client name order date medication name dosage route time of administration prescriber's name AND signature

Synergistic effect

combined effect of two medications is greater than the effect of medications given separately

medication reconciliation

compares medications taken before/after facility admission and/or discharge

CPOE

computerized provider order entry provider directly enters into computer

A Z-track method for injection: a. prevents tracking b. requires the nurse to slide the surface tissue to one side before injection is given c. requires the nurse to release the skin after needle removal d. all of the above

d. all of the above

When the nurse takes the medication to Mrs. Taylor's room, the nurse should do all of the following EXCEPT: a. check the patient's identification band b. remain with the patient until she takes the medication c. check the medication after it is given d. allow another nurse to administer the medication instead

d. allow another nurse to administer the medication instead

The muscles that should be used for an intramuscular injection include: a. deltoid, gluteus medius, vastus lateralis, & rectus medius b. rectus femoris, vastus lateralis, deltoid, & biceps c. rectus lateralis, gluteus maximus, gluteus medius, & gluteus minimus d. deltoid, gluteus medius, & vastus lateralis

d. deltoid, gluteus medius, & vastus lateralis gluteus medius is where the ventrogluteal injections go

The advantages of giving a drug IM rather than subQ include all of the following except: a. increased amounts of solution may be given b. increased absorption will occur c. irritating drugs may be given with fewer side effects d. less risk to major nerves and blood vessels

d. less risk to major nerves and blood vessels greater risk!

If a nurse is preparing a medication for a patient and is called away to an emergency, which of the following should he/she do? a. have another nurse guard the medications b. put the medications back in the containers c. have another nurse finish preparing and administering the medications d. lock the medication cart & finish when he/she returns

d. lock the medication cart & finish when he/she returns

Suppositories given rectally are usually composed of substances which: a. absorb quickly b. can withstand chemical irritation c. combine with contents of the colon d. melt at body temperature

d. melt at body temperature Rectal suppositories - Sims' position to help it flow into the sigmoid process

Drugs administered sublingually are: a. applied on the skin b. placed in the buccal space c. inserted into the rectum d. placed under the tongue

d. placed under the tongue

Which of the following techniques would NOT be used to instill eardrops to an adult patient? a. pull the pinna upward and backward b. assist patient to lie on his/her side c. instill drops with the ear dropper at least 1cm above the ear canal d. pull the pinna down and back

d. pull the pinna down and back ** children <3 years of age: pull the auricle down and back

The symbol "t.i.d." means: a. before meals b. twice daily c. every two hours d. three times daily

d. three times daily

Toxic effects

develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion

Subcutaneous injections

medication placed in loose connective tissue under skin absorbs slower --> less blood supply small volume (0.5-1.5 mL) gauge = 25-32 needle length = 3/8 - 5/8 insert at 45 degree angle, unless obese (90) tissue easily irritated by large volumes/solutions client's weight indicate depth of SQ layer locations: - posterior arm - abdomen - anterior thigh - love handles - scapula Heparin! - abdomen 2" from umbilicus - DO NOT aspirate! - DO NOT massage! Insulin - rotate same body part - upper arm, anterior thighs, abdomen - rate of absorption varies with sites

Trough

minimum blood serum concentration of medication reached just before the next scheduled dose

Side effects

predictable and often unavoidable secondary effects produced at a usual therapeutic dose

Ventrogluteal

preferred and safest site for all adults, children, and infants... especially for medications that have larger volumes and are more viscous & irritating greater trochanter thumb towards groin anteriosuperior iliac spine V

What to do if a med error occurs?

report all errors!! assess client's condition notify physician follow facility policy on reporting notify supervisor fill out incident report

STAT orders

signifies that a single dose of a medication is to be given immediately and only once written for emergencies when a patient's condition changes suddenly

types of medication orders

standing/routine PRN single/one time STAT now prescriptions

Adverse effects

unintended, undesirable, and often unpredictable severe responses to medication

Idiosyncratic reaction

unpredictable effects a patient overreacts or underreacts to a medication or has a reaction different from normal

How to minimize discomfort with injections:

use sharp needle position comfortably proper site divert patient's attention insert quickly support needle inject slowly and steadily

Intradermal injections

used for skin testing (TB, allergy) medications potent --> into dermis --> blood supply less --> absorbed slowly Angle of insertion = 15 degrees Must be able to clearly see injection site to see changes Use lightly pigmented, relatively hairless, lesion-free sites (usually forearm/upper back) Must see bleb - if no bleb or bleeding occurs, in subQ tissue and results are invalid

Z-track method

used to minimize local skin irritation by sealing the medication in muscle tissue put a new needle on the syringe after preparing the medication so no solution remains on the outside needle shaft pull overlying skin and subcut tissues laterally or downward, hold until administer injection, leave needle inserted for 10 seconds to allow medication to disperse evenly rather than channeling back up track of needle, release skin after withdrawing. leaves a zigzag path that seals the needle track where tissue planes slide across one another. we use it to keep the medication in, prevent leakage, skin acts as a natural barrier/seal

Bevel placement

very end of needle ID - pointed up