CH 30- Administering Medications

Semisolid medication forms

- Ointment and paste: greasy drug preparations that are applied to the skin, rectum, or nasal mucosa. Pastes are thicker and less penetrating than ointments. - Cream: made of active medication, oil, and water. - Suppository and pessary: active medication mixed in an oil base. Solid at room temp but melts at body temp. Typically shaped like a small bullet and used in the rectum, urethra, or vagina. Pessaries are vaginal suppositories.

Summary of subcut injections

- Syringe used: 3 mL most common; 1 mL can be used. - Needle size and angle of entry: 25 gauge; 1/2 inch with 90-degree angle of entry or 5/8 inch with 45-degree angle of entry; bevel position does not matter. - Max volume: 0.5-1.5 mL (0.5 mL in children). - Common sites: lower abdomen, anterior thigh, and upper outer arm. - Sites for vaccines: < 1yo: anterior thigh. > 1yo: upper outer arm or anterior thigh. - Additional sites: separate sites by 1 inch. - Patient position: sitting - Administration technique: pinch site; if 2 inches of tissue can be pinched, inter the needle at a 90-degree angle; if 1 inch of tissue can be pinched, insert needle at 45-degree angle; rotate sites.

Parenteral route

Administration by infusion, injection, or implantation. Types of injections: - intramuscular (IM): within muscle - subcutaneous (subcut): beneath skin - intradermal (ID): within dermis

Reducing pain and anxiety

To minimize pain, insert needle swiftly. Inject at rate of 10 seconds per 1 mL. to avoid unnecessary discomfort. Remove quickly using same angle. Other techniques to reduce pain or anxiety: - Give sugar-coated pacifier or sugar water (must be ordered by provider), which helps to soothe children under are 1 year after injections. - Applying a topical anesthetic skin refrigerant , which works immediately. - Applying a topical anesthetic at the injection site, which works in about 30 to 40 mins. - Talking with the patient to distract. - Having the patient move their toes or fingers on the extremity used when IM injection is given. - Use products that provide cold and vibration sensations, which overwhelm the nerve effected by the injection. - Administering the most painful injection last.

Tuberculin skin test procedure and reading

Tuberculin purified protein derivative (PPD) 0.1 mL is given ID into the inner surface of the forearm. A tuberculin syringe and needle, with the bevel facing upward, is used to slowly inject the PPD, creating a wheal. Wheal must measure 6-10 mm in diameter, or test must be repeated. Patient returns in 48-72 hours to have test read. Palpate the site to check for a raised, hardened area, called an induration. If felt, measure raised area across the forearm. Note diameter in mm. Cannot state if positive or negative. Provider determines if patient has TB. TST reading of 5-15 mm can be positive for different populations.

Tuberculin blood tests

Two FDA approved tests: QuantiFERON-TB Gold In-Tube test (QFT-GIT) T-SPOT TB test (T-Spot) If patient has had the BCG vaccine or is unable to return for the skin test reading, provider orders blood test. Only need one test, and then done yearly. More accurate than the skin test. - If positive: patient infected with TB. Provider will order additional tests to determine if the person has a latent TB infection or TB disease. - If negative: unlikely they have TB.

Administration techniques for IM

Use 90-degree angle. Skin flattened or stretched over the site.

Vastus Lateralis site (IM)

Used on patients from birth through adulthood. CDC recommends this site until deltoid is appropriate size for vaccines (after 1 year or older). Patient remove clothing over thigh. Create rectangle. Think about diving thigh into three sections. With adults, each hand will cover one-third of the thigh. Place hand above the knee and the other below the greater trochanter. This is the top and bottom borders of your rectangle. Next, find midline of the thigh which creates inner border of rectangle. Midline of the outer thigh creates final border. Patient slightly lift thigh so can see injection site at bulk of the muscle.

Aspiration

Used to check if the needle is in a blood vessel. Done before medication is given. Should be done is medication manufacturer recommends it & if part of facility's policy, Insulin is not aspirated. CDC does not recommend subcut immunizations to be aspirated.

Vaginal route

Used to insert suppositories, tablets, creams, and foams. Typically for local infections. Most can be interred using the accompanying applicator. If none, patient can insert with finger 3 to 4 inches. Most effective if remains lying down after administration to prevent leakage. Many intended to be used at bedtime. Pad to absorb if needed.

Giving parenteral medications

Advantages: - Useful when patient has GI distress or is unconscious. - Offers good absorption compared to other routes. - The onset is more rapid than other routes. - Some types have a longer duration time (time it works in body). Disadvantages: - Pain with injection. - Risk for infection due to the injection. - An unpredictable absorption rate for those with poor circulation. Always do the following: - Follow the 9 rights of medication administration. - Check med's label against the order three times. - Know about the med you are giving (what is it, why is it ordered, how it is given, what side effects). - Label all syringes with the name of the med they contain. - Follow medical asepsis and the Bloodborne Pathogens Standard established by OSHA. - Ensure needle is not directed at your hand holding the patient when giving the injection.

Right documentation

After the medication is given, document it in the patient's health record. Should include: - provider ordering the medication - assessment done (e.g. vitals or pain level) - allergies - coaching/instructions given to patient (includes the edition date of the VIS for vaccine teaching) - name of medication - dose given - route given - lot number, expiration date, and manufacturer - how the patient tolerated the medication - additional information as needed - signature if the note is handwritten

Z-Track technique (IM injections)

Also reduces pain and discomfort for the patient. Also prevents med from tracking back through the skin. Should be used for irritating medications. The ventrogluteal site is recommended for irritating meds. Skin is pulled laterally, the site is cleansed, and injection is given.

Using an ampule

Ampules contain a single dose of medication. May contain extra than the patient needs, and is wasted. Medications in impulsed react to other substances and require the all-glass environment to remain stable. It has a pressured neck, which is snapped off during the preparation process. An ampule opener or breaker is a safety device used to snap the top off. A filter needle on a syringe is used to aspirate the medication into the syringe. This needle has a smaller filter that catches glass particles before they enter the syringe barrel. The filter must be removed before the injection is given to the patient.

Administration techniques for subcut injections

Angle depends on needle length. 5/8-inch needle = 45-degree angle. 1/2-inch needle = 90-degree angle. Pink up the tissue with index and thumb to ensure injection is given into the subcutaneous tissue.

Topical route

Applying drug to a mucous membrane or skin. Mucous membrane usually faster than skin to absorb. Provide a local effect. "Topically" usually refers to the skin, provider will indicate a more specific route (rectal, vaginal, ophthalmic, nasal, optic). - wear gloves. - use sterile applicator to remove medication from the container. Keep container sterile by using new sterile applicator each time. - rub creams gently into skin, pat lotions onto skin, and apply ointment with sterile applicator. - liniments must be rubbed into the skin. - for aerosol topical sprays, hold the bottle 3 to 6 inches from the skin and spray.

Right education

Before administering medication: - Give the name of the medication and who ordered it. - Explain the desired effect or action of the medication. - Describe common side effects of the medication. - Verify the person's allergies. Some facilities have the patient fill out a questionnaire, and MA may need to hand out a Vaccine Information Statement (VIS) which provides important information about the vaccine and common and uncommon side effects.

Nasal route

Breathed in through the nose and absorbs in mucous membrane. Local or systemic effects. MA should wear gloves, patient should blow their nose prior to administration. Sit upright, and sniff when the medication is given. Chart as "intranasal".

Acronyms for slow-release tablets

CD- controlled delivery CR- controlled release DR- delayed release ER- extended release LA- long acting SA- sustained action SR- sustained release TD- time delay TR- time release XL- extended release XR- extended release

Deltoid site (IM)

CDC recommends this site for vaccines for teens and adults. To find this site, expose upper arm. Make sure sleeve isn't acting as tourniquet. Palpate the acromion process. Place finger on acromion process and then 2 fingerbreadths below that. The bottom of the site is at the axillary fold (top of axilla). Injection site somewhere between the top and the bottom of the site. Patient can lift arm to find bulk of the deltoid muscle, where the injection should be given.

Oral route (po)

- Coat the mouth or throat and should not be immediately followed with water. - Those that require water for swallowing need more than a sip. Some meds requires a glass of water after taking the med. - Use straw for liquid meds that stain teeth. - Should only be measured with a plastic medication cup or an oral medication syringe. Notify provider is patient has trouble taking med due to nausea, vomiting, or problems swallowing.

Preparing parenteral medication

- If looks abnormal in color or clarity, discard. - Some medications will have precipitate at the bottom of the vial. If this is normal for that medication, make sure to mix it prior to withdrawing medication. If it is abnormal, a chemical reaction may have occurred and needs to be discarded. - If expired, discard. - If is no longer sterile, discard.

Special situations

- If the needle breaks during an injection or if it separated from the syringe, pull out the needle, if it is visible. Discard into sharps container. If is not visible, mark the spot with a pen and yell for help. If was given in the arm, place a tourniquet above the spot to prevent the needle from moving in the body. Notify provider immediately. - During IM injection, if you hit a bone, pull the needle out 1/4 inch and give the medication. - Have patient wait 15 mins after injections help you to monitor symptoms. If experiencing any usually symptoms, call provider immediately.

Special considerations when giving Enoxaparin

- Make sure drug is clear and colorless or pale yellow. - Do not push any air of drug out of the syringe before giving the injection unless your healthcare provider tells you to. The air allows the medication to enter slower, reducing the risk or bruising. - Using finger and thumb, pinch skin 1-2 inches away from the umbilicus in the lower abdomen. Push entire needle into skin. Inject. Hold pinched skin the entire time during injection. Remove needle. Do not rub or massage the site after. Hold pressure to the site after the injection until bleeding stops.

Solid medication forms

- Tablets: solid formed by compressed powdered medications; may be coated. - Chewable tablets: designed to be chewed prior to swallowing. - Caplet: coated, ovat medication tablet. - Capsule: medication in a hard or soft gelatin shell. - Scored tablet: a notched tablet, which can be split into half with a pill cutter or splitter. - Enteric coated tablets or capsule: coated to pass through the acidic environment of the stomach. Breaks down in the base of the environment of the intestines. Should not be cut, crushed, or chewed. - Buffered: solid medication containing the active medication and an antacid. The antacid neutralizes the stomach acid and thereby reduced stomach irritation. - Fast-dissolving tablet or film strip: also called oral disintegrating tablets. Solid form of medicine that is placed on the tongue (or buccal) and breaks down rapidly in the presence of saliva. - Extended release tablet or capsule: designed to break down over time. Should not be crushed, cut, or chewed because may cause overdose. - Effervescent tablet: contains an acid substance and carbonate or bicarbonate. When placed in water, it releases carbon dioxide, creating a carbonated drink. - Lozenge (troche): flat, round form containing active medication and a sweetened flavoring; dissolves on the tongue. Used for local treatment of the mouth and throat. - Powder: non potent powdered medication that must be mixed with a liquid before it can be taken.

Subcut injection sites

- Upper outer arm: expose arm. Extends 3 inches above the elbow to about 3 fingerbreadths below the acromion process. Stay away from shoulder area. - Abdomen: patient remove clothing, provide drape if needed. Located below coastal margins to the iliac crests. Stay 2 inches away from the waistline and any scars. - Anterior thigh: place one hand above the knee and the other hand below the greater trochanter. The site is the middle one-third of the thigh. Extends from front midline to the back midline, around outer thigh. Usually only the middle one-third from the front midline to the out thigh is used. Not done on the back of the leg. - Subcscapular portion of the back - Flank region

Timing of vaccines

2 types: - Live virus vaccines: microorganism is alive but attenuated (weakened) in the lab. - Inactivated vaccines: microorganism is dead. Included toxoid vaccines made from modified toxins of microorganisms. Immunization schedules indicates the person's age and the timing between doses. If administered too early or before patient reaches specific age, will have to be revaccinated. Provider will postpone vaccinations when patients have moderate or severe acute illness. Specific vaccines not given if person has severe allergic reaction to a vaccine component, to latex, or to a prior dose. Patients may not receive a live virus vaccine if: - were vaccinated with another live virus vaccine less than 28 days earlier. - are pregnant/may become pregnant in next month. HPV vaccine is also contraindicated with pregnancy. - are immunocompromised. - are receiving chemotherapy or high-dose steroid therapy. - recently received blood transfusion, immune (gamma) globulin, or antiviral medication.

Hypodermic needles

A hypodermic needle attaches to a hypodermic syringe. The needles come with the syringes or packaged separately. Parts of the needle: - Hub: attaches or screws onto the syringe - Hilt: where the needle attaches - Bevel: slanted end of the shaft - Lumen: hollow space inside the needle; the size is indicated by the gauge number.

Using a vial

A plastic or glass container with a rubber stopper that is covered by a cap. Contain powdered or liquid med. Liquid can be a parenteral medication, sterile normal saline (0.9% sodium chloride), or sterile water. Single dose- Ff a vial needs to be entered more than once for a single patient as part of a single procedure, then a new needle and syringe must be used. Discard vial after procedure. Single-dose vials do not contain any ingredients that would prohibit microorganism growth. Multidose vials- label will clearly state it is a multidose vial. Contain antimicrobial preservative the prevents growth of bacteria. Only good for 28 days once opened (unless manufacturer states otherwise). New expiration date should be written on the label. If manufacturers expiration date comes sooner, earlier date must be used. Each time the multidose vial is entered, the rubber stopped must be disinfected, and a sterile needle and syringe must be used. Vial is under pressure- need to add air into the vial before you draw out the amount of liquid you need. Amount of air added should equal the amount of liquid drawn out. Make sure you have correct amount before removing needle. Never inject unneeded medication back into the vial once the needle has been removed.

Aspiration (IM injections)

Aspirate prior to injection. Once needle is in the site, pull back on the plunger for 5 seconds and check the barrel of the syringe. Lack of blood in the barrel means the needle is not in a blood vessel, so safe to inject medication. If blood in barrel, remove needle, discard syringe, and restart procedure. Immunizations don't need to be aspirated per the CDC.

Hypodermic syringes

Attache to needles and hold the medication for the injection. Come in many sizes (1, 3, 5, 6, 10, 12 mL). Can have either Luer-lok or a slip tip. Has calibration marks (measurement for the med).

Liquid medication forms

Can be swallowed, rubbed on the skin, or instilled in the nose, eyes, or ears. Active medication is mixed with water, alcohol, or both. If medication dissolves in water, it is a solution: - Tincture: very potent solution of alcohol or alcohol and water and the active medicine. - Fluid extract: alcoholic plant source extractions; very concentrated and more potent than tinctures. - Spirit: an alcoholic solution with substances that easily evaporate. - Elixir: clear sweetened liquid preparation that contains alcohol. - Syrup: a sugar and water solution that contains flavoring and medicinal substance. If the active medication does not dissolve and becomes suspended in the liquid, it is called suspension. Over time the drug will settle to the bottom of the container- be sure to shake suspensions before pouring medication. - Emulsion: oil and water. - Gel and magma: consists of minerals and water. Gels are semisolids that contain finer particles than magmas. The minerals settle out with standing. Shake before using. - Liniment: rubbed on the skin; used to reduce pain and stiffness. - Lotion: water-based suspension that is applied to the skin. - Aerosol: suspension of medication in gas, usually used for respiratory or sinus conditions.

Using a profiled sterile cartridge

Comes filled with a single dose of medication. Can be more than what provider ordered. May come with or without needle. A safety needle can be attaches to the Luer-Lok on the profiled cartridge. A reusable cartridge holder is needed to dispense the medication. Must assemble the cartridge and reusable cartridge holder prior to giving med.

Right patient

Correctly identify the patient. Patient should state full name and date of birth and should match with the order and patient's health record. In some facilities, patients have identification bracelets. Use that to compare with patient stating name and DOB and patient's EHR.

Intradermal flu vaccine

Currently the only intradermal vaccine. Fluzone Intradermal contains less antigen than the IM flu vaccines, adults 18-64. Given in deltoid area. Prefilled microinjection syringe containing 0.1 mL of med. Syringe contains a 30-G micro needle.

Specialty syringe units

Designed so that patients can administer their own medication. The dose of an insulin pen can be set by the dial. Patient needs to change the needle with each dose. EpiPen and other epinephrine pens are automatic injector systems. Dosed for adults and children.

Guidelines for parenteral medications

Ensure needles are tightly covered and placed on a trap when carrying to the exam room. Bring only one patient's med at a time. Guidelines when selecting injection site: - Never give injection near bones or blood vessels. - Avoid scar tissue, a change in skin pigmentation or texture, or abnormal growth. - Avoid abrasions, lesions, wounds, bruises, and edematous areas. - Select a site that is large enough to hold the amount of medication injected. - Avoid sites recently used (within the last month). According to the Immunization Action Coalition, it is safe to give subcut and IM vaccines into a tattoo, but not a good idea to inject into a newly tattooed area. If you have to, inject into lighter pigmented area. Dark pigments may mask a reaction or an infection.

Right route

Ensure using the same route as ordered. Check three times along with the name of the medication before medication is given.

Right dose

Ensuring you give the correct dose. Dose of the medication is on the order. May need to calculate, have two qualified people calculate the amount.

Right medication

Ensuring you give the correct medication. Check the medication order against the label three times (with activities in between): - when you get the medication from the storage area. - before preparing the medication. - before you return the medication to the storage area.

Ventrogluteal site

Excellent for oil-based medications and irrigating medications. Patient remove clothes and in side-lying position. Use the hand opposite of the injection site. - Place palm of hand on the patient greater trochanter. - Your fingers need to point toward the patient's head, and your thumb to their groin. - Place index finger on the anterior superior iliac spine. - Move your middle finger back along the iliac crest toward the patient buttock. The positioning of your index and middle fingers forms a triangle. Injection point is at the center or the triangle.

Incorrect tuberculin skin test readings

False-positive reaction means the person reacted to the test even though no M. tuberculosis is present. Reasons for a false-positive: - lung infection with nontuberculosis mycobacteria (NTM). This organism is found in the water and soil and is inhaled. - previous vaccination with bacillus Calmette-Guerin (BCG) vaccine. Many foreign born patients from countries with a high risk of TB may have received BCG abroad. - Incorrect administration or reading of the TST. False-negative reaction means the person may not have reacted to the test even though they are infected. Reasons: - weakened immune system - exposure to TB infection within previous 8-10 weeks - very old TB infection - patient younger than 6 mo - recently received a live virus vaccine, had a viral infection, or received corticosteroids or immunosuppressive medications - incorrect administration or reading of the TST.

Intramuscular injections (IM)

Faster absorption than subcut. Medication given IM are aqueous (watery) and with a higher gauge needle than used for oil-based meds. Common meds: - several vaccines: hep A and B, tetanus-diphtheria (Td), or with pertussis (Tdap); influenza; and meningococcal. - antibiotics and medroxyprogesterone (Depo-Provera).

Right time

For most medication orders, time is part of the order (STAT, monthly, etc). Vaccines are a little different- review the patient's vaccination history and their age. Using immunization schedules or the immunization tables in the EHR can help you determine what vaccines are due.

Gauge and length (needles)

Gauge (G): the higher the gauge number, the smaller the lumen, thinner the walls, and used for more superficial injections. Bends easily. The smaller the gauge number, thicker of the needle wall and lumen size, used for deeper injections. Medications viscosity is important factor when selecting the gauge of needle. Wider lumen needles (smaller gauge) are better for thicker medications. A finer lumen needle (larger gauge) is better for watery medications. Needle length refers to length of the shaft- dependent on type of injection and size of the patient.

Two-step testing

In some patient who have had a TB infection, the body "forgets" to react to the TST. Can occur if infection was many years before. The first test is a false-negative, but the second can help the body "remember" the infection, causing a more accurate (positive) reading. This is the booster effect, or booster phenomenon. Second TST can be done 1 to 3 weeks after the initial test was read. New residents in long-term care facilities usually have a two-step TST done. Healthcare students and professionals also. Once completely, need yearly TSTs. If exceed the 1 year, may need to do another two-step TST.

Tuberculin skin reaction categories

Induration > or = to 5 mm considered positive: - people with HIV - organ transplant - immunosuppression - recent contract with a person with TB - fibrotic changes on a chest x-ray consistent with prior TB. Induration > or = to 10 mm considered positive: - recent immigrants (< or = 5 yrs) from high-risk areas - injection drug users - people living or working in high-risk areas - children <4yrs or children exposed to high-risk adults Induration > or = to 15 mm considered positive: - no know risk for TB

Ocular route

Instilled (poured drop by drop) into eye to treat infection, soothe irritation, anesthetize the eye, or dilate the pupils before examination or treatment. Squeezer or dropper, eye ointments. Avoid injury the eye by touching it with the tip or applicator. Always keep tip/applicator sterile. If gets contaminated, throw it away.

Otic route

Instilled in ear. Treat infection or inflammation, or soften cerumen.

Intradermal injections (ID)

Just under the epidermis. May cause momentary burning or stinging since drug is dispersed in an area with many nerves. Small amounts are injected. In ambulatory care, these injections may be give: - Mantoux tuberculin skin test (TST) - Intradermal flu vaccine - Allergy testing Recommended intradermal sites: - Upper arm - Forearm - Upper back

Patient coaching

Let patients know when medication contains alcohol. Not good for patients who are recovering addicts or have other health issues, like diabetes.

Subcutaneous injections (subcut)

Placing the medication into the subcutaneous layer, under the dermis. Has fewer blood vessels than the muscles do. Medication absorbs slower. May have discomfort or pain, since subcutaneous tissue contains pain receptors. Commons medications: several vaccines (e.g. measles-mumps-rubella [MMR], varicella, shingles [ZOSTAVAX], and polio), enoxaparin (Lovenox), heparin, and insulin.

What are the 9 rights of medication administration?

Medication Dose Route Time Patient Education To refuse Technique Documentation

Inhalation route

Meds for the nose, throat, and lungs can be inhaled. Small particles of meds are aerosolized in a fine mist. Absorbs into mucous membrane or alveoli in lungs. Meter-dose inhalers (MDIs) and nebulizers are common.

Rectal route

Most common- suppositories and enemas. Absorbs slowly and irregularly through mucous membrane. Useful when cannot tolerate oral medications or if constipated. Give time to work before using the bathroom. Supplies needed: gloves and water-soluble jelly. Tips: - remove wrapping - lubricate the pointed part with the jelly - be in Sims position (side-lying, with the knee drawn up toward the chest) - insert carefully pointed side first - for adults & older children: use gloved index finger to push in 3 to 4 inches. Slowly breathe to help with discomfort. - for small children: use gloved little finger to insert about 2 inches.

Monitoring IV therapy

Needle in a catheter starts the IV. Needle is removed, and catheter is hooked up to the IV tubing that runs from the insertion site to the IV bag. Nurse takes care of starting the IV, adjusting flow, and monitoring patient. MAs schedule patients for IVs. Sometimes MAs assist nurses. Common issues: - edema or increasing pain at IV insertion site - blood moving up the IV tubing - almost-empty bag of fluids - patient who is having difficulty breathing or who has increased audible wheezing.

Safety needles

Needlestick Safety and Prevention Act Designed to rescue the risk of needle sticks after an injection. A passive safety needle is designed so the the needle is automatically covered after the injection. An active safety needle requires the healthcare professional to activate the safety device. 2 groups: - protective sheaths and hinged needle shields: a sleeve over the syringe barrel or a hinged needle shield. Cannot be uncovered once in place. - retractable needles: after the injections, healthcare professional activates a device the retracts the needle into the syringe or another chamber.

Reconstituting powdered medication

Needs to be mixed with diluent (typically sterile normal saline or sterile water is used as diluent, but other meds may be used per provider). Most common are live virus vaccines that need to be reconstituted (restore to fluid so can be injected). Write expiration date on label, along with initials and fluid used to reconstitute the medication. Four steps: 1. Remove air from the powdered medication vial and put air into the diluent vial. 2. Withdraw liquid from the diluent vial and add it to the powdered medication vial. 3. Mix the liquid with the powdered medication. 4. Add in air and withdraw the dose needed.

Uncapping and recapping needles

Never recap needle that has been used on a patient. - To uncap: hold cap with nondominant hand and syringe with dominant hand. Pull apart horizontally. - To recap: place cover on a firm, flat surface. If rolls, place a finger at the far end of the cover to hold it still. Carefully insert needle. If needle touches outside surface of the cover or any other surface, it is contaminated. Scoop up the cover and secure it onto the needle.

Transdermal route

Placed on the skin and absorbed into bloodstream. Different from topical medications, which provide a local action. Transdermal meds provide a systemic action. Use patch to adhere to skin. When replacing or teaching patient to use transdermal patches: - write the date and time on the new patch. - wear disposable gloves if changing a patch on another person. - remove old patch. Fold the sticky sides together and discard. If the old patch is not removed, the person may be at risk for an overdose. - remove and residual medication from the skin using a tissue. - decide where to apply the new patch. Select a different location. Depending on the med, it may be on the shoulder, back, upper arm, lower abdomen, or hip. Clean and dry the new site. - remove protective liner on the patch. DO not use torn patches. Do not touch the sticky side of the patch. - place the patch's sticky side on the skin. Press down to ensure it adheres to the skin. Make sure it is smooth, without folds.

Right to refuse

Refers to the patient's right to decline medication. MA should respect wishes and notify the provider, also specifying the reason if shared. Document the refusal of the medication, and identify the provider who was informed. Provider will talk with patient about other options.

Air lock technique (IM injections)

Remove bubbles in the syringe, and measure the exact amount of medication needed. One these steps are done, ass 0.2 to 0.5 moof air into the syringe. When the IM injection is given, the medication is pushed in first, followed by the air. The air creates a "lock" when needle is withdrawn. Air prevents med from tracking back up in the tissues to the skin, causing pain.

Mixing insulins

Requires about 4 injections a day, some may need two insulins at the same time. Some come premixed, others patients need to do it themselves. Important that vials do not get contaminated with another type of insulin. If by chance contamination occurs, it is better for the rapid-acting or short-acting insulin to be mixed in the intermediate-acting insulin vial. Regular insulin must be drawn up in the syringe first and then the intermediate-acting insulin after. Use drug reference information to ensure that the two insulins ordered can be mixed. Insulin is measured in units, and special insulin syringes are available. Typically insulin is stored in the refrigerator and should be warmed to room temperature prior to administration. Cloudy insulins are suspensions and need to be mixed.Mix by gently rolling the vial between your hands. Patients receiving insulin must rotate their injection sites- prevents tissue damage and absorption issues with the insulin. Goal is to avoid using the same location again for another month.

Switching needles

Several methods. One method is opening the new needle package and hold the packaging flaps down with nondominant hand. With dominant hand, place syringe with the covered needle between the middle and ring fingers of nondominant hand. With dominant hand, remove syringe from old needle and attach it to the new needle. Nondominant hand should be hold both needles the whole time.

Crushing medications

Some have trouble swallowing solid medications. If crushing, place in a small amount of food or liquid and ensure entire amount is consumed to get entire dose. Some solid medications have a bad taste so be sure to share that with the patient, especially parents who are giving the medication to their child. Medications that cannot be crushed: - slow- or extended-release tablets: crushing, chewing, or cutting can cause a person to get the dose faster than they should, resulting in an overdose. - enteric-coated tablets: causes the protective nature of the coating to be lost. Person could have stomach distress.

Sublingual (SL) and buccal routes

Sublingual- placed under the tongue. Buccal- placed between the cheek and the gums. Some special administration techniques: - do not eat or smoke prior to taking. - do not chew or swallow. - water can taken prior to the med to wet mouth. No liquids under after the med has dissolved. - alternate cheeks used for buccal med to avoid mucosal irritation.

Working with the needle and syringe

Syringe packaged in different ways: - By itself. Needle must be added. - With a needle. Unit must be assembled. - Syringe and needle may come reassembled. Always tighten the needle on the syringe before using. Can be assembled with clean, ungloved hands. When packaged by itself, first open the syringe. Do not touch the syringe tip to anything- needs to remain sterile because attaches to needle. While holding the syringe, open the needle package. Use the packaging flaps to hold down the needle (prevent contamination), attach needle to syringe, and lift out of packaging. Can place on counter but keep needle cover on for sterility. When packaged together, hold down package flaps, remove syringe, and attach to needle (still in package). Can place on counter. When working with the plunger, only touch the section that remains outside of the syringe when the plunger is completely pushed in. Touching the part of the plunger that goes inside the barrel could potentially contaminate the medication.

Summary of intradermal injections

Syringe used: 1 mL (tuberculin syringe). Needle size: 1/4 in to 5/8 in; 25-27 gauge. Angle of entry: 5-15 degrees with bevel facing upward. Max volume: 0.1 mL. Common sites: forearm, upper arm, back. Additional sites: separate by at least 2 inches. Patient position: sitting with arm extended. Administration: pull skin taut at injection site.

Tuberculin testing

The skin test and the blood test- approved by the FDA. The Mantoux tuberculin skin test (TST) is used to determine whether a patient is infected with Mycobacterium tuberculosis. Can be given to most patients. Patients with a history of BCG vaccination may have a positive reaction to the TST. Inform provider if has that history prior to test. Provider may've patient do blood test instead. TST is contraindicated in patient who had the following: - severe reaction to a past TST - a history of a positive TST result - a live virus vaccine less than 4-6 weeks earlier (TST and live virus can be given non the same day, OR after the 4-6 weeks).

Irrigation route

To bathe or flush open wounds or body cavities. Can be used to removed foreign bodies or debris. Bathe area in medication. Wound, eye, and ear irrigations are common. Irrigation of the external auditory canal will: - remove excessive or impacted cerumen - remove a foreign body (contraindicated if the item will absorb fluid) - treat the inflamed ear with an antiseptic solution.

VIS

Vaccine Information Statement Created by the CDC. The National Childhood Vaccine Injury Act requires that all patients get the appropriate VIS prior to every dose of vaccines administered. MA must also document the following in the patient's health record: - the edition date of the VIS. - the date the VIS was provided and the date the vaccine was administered. - the office address, name, and title of the person who administered the vaccine. - the vaccine's manufacturer and lot number.

Right technique

When administering, the MA must give the medication the correct way. Example of the right technique: - take vital signs before giving a specific medication. - obtain info about patients pan level before giving analgesic medication. - some medications must be taken with food and others with a full glass of water. Meds taken on an empty stomach need to be taken 1 hour before meals or 2 hours after meals.