NU 311 Skills Exam 3- Medication Administration

IV absorbs the most rapidly!

(More blood flow allows for a faster absorption. This is why IV absorbs the fastest because it goes directly into a vessel.) The medication is available immediately when it enters the systemic circulation.

Techniques for eyes (ophthalmic) topical medication administration

**Drops: a.) Hold cotton ball or clean tissue in nondominant hand on patient's cheekbone just below lower eyelid. (Rationale: Cotton or tissue absorbs medication that escapes eye.) b.) With tissue or cotton resting below lower lid, gently press downward with thumb or forefinger against bony orbit, exposing the conjunctival sac. Never press directly against patient's eyeball. (Rationale: Technique exposes lower conjunctival sac. Retraction against bony orbit prevents pressure and trauma to eyeball and prevents fingers from touching the eye. Pressure to the eyeball may cause damage.) c.) Ask patient to look at the ceiling. With dominant hand resting on patient's forehead, hold filled medication eyedropper approximately 1 to 2 cm (½ to ¾ inch) above conjunctival sac. (Rationale: Helps prevent accidental contact of eye dropper tip with eye structures, thus reducing risk for injury to eye and transfer of infection to dropper. Ophthalmic medications are sterile.) d.) Drop prescribed number of medication drops into conjunctival sac. e.) If patient blinks or closes eye, or if drops fall on outer lid margins, repeat procedure. (Rationale: Therapeutic effect of drug is obtained only when drops enter conjunctival sac.) f.) After instilling drops, ask patient to close eye gently. (Rationale: Helps to distribute medication. Squinting or squeezing of eyelids forces medication from conjunctival sac.) g.) When administering drugs that cause systemic effects, with a clean tissue apply gentle pressure to patient's nasolacrimal duct for 30 to 60 seconds. (Rationale: Prevents overflow of medication into nasal and pharyngeal passages. Prevents absorption into systemic circulation.) **Ointment: a.) Holding ointment applicator above lower lid margin, apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva from the inner canthus to outer canthus. (Rationale: Distributes medication evenly across eye and lid margin.) b.) Have patient close eye and rub lid lightly in circular motion with cotton ball, if not contraindicated If excess medication is on the eyelid, gently wipe it from inner to outer canthus. If patient needs an eyepatch, apply clean one by placing it over the affected eye so the entire eye is covered. **Inserting an Intraocular Disk: a.) Open package containing the disk. Gently press your fingertip against the disk so that it adheres to your finger. (NOTE: It is sometimes necessary to moisten gloved finger with sterile saline.) Position the convex side of the disk on your fingertip. (Rationale: Allows nurse to inspect disk for damage or deformity. Prepares disk for proper administration.) b.) With your other hand, gently pull patient's lower eyelid away from the eye. Ask patient to look up. (Rationale: Prepares conjunctival sac for receiving medicated disk.) c.) Place the disk in the conjunctival sac, so that it floats on the sclera between the iris and lower eyelid. (Rationale: Ensures delivery of medication.) d.) Pull patient's lower eyelid out and over the disk. (Rationale: ensures accurate medication delivery.) **Removing an Intraocular Disk: -Intraocular disks may remain in place for up to 1 week (duration varies). a.) Explain procedure to patient. b.) Gently pull down on patient's lower eyelid to expose the disk using non-dominant hand. c.) Using your forefinger and thumb of your other hand, pinch the disk, and lift it out of the patient's eye.

general principles of safe medication administration

1. Follow the six rights of medication administration. Never administer a medication prepared by another nurse. 2. Enter the room and inform the patient of each medication's name and purpose. Review with the patient anything they need to know for self- administration. 3. Keep tablets and capsules in wrappers. Open at bedside. Respect patient's right to refuse meds, and if they do, take appropriate action by notifying physician and documenting. 4. Know what foods are compatible with the medicine. Water is always safe. 5. Remain with the patient as they take the medicine. Provide assistance if necessary. Do not leave meds at bedside unless prescribed to do so, if so, check back later to make sure they are taken.

faster

A medication in contact with a large surface area (e.g., small intestine) will absorb _______ than those in contact with smaller surface area (e.g., stomach).

toxic effects

develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given. Ex: Toxic levels of Morphine, an opioid, cause severe respiratory depression and death. Antidotes are available to treat specific types of medication toxicity. For example, naloxone, an opioid antagonist, reverses the effects of opioid toxicity.

Right Documentation

document administration of a medication as soon as it is given; document the patents response, for example: Pain scale was a 3, patient states pain is tolerable. Documentation must include patients name, date of the order, name of medication, medication dosage, route, and frequency

Stat order

drugs given immediately and only once. Used for emergencies when patients conditions change suddenly.

QID

four times a day

PRN (as needed) order

given only when patient requires or requests it. You must assess patient thoroughly to determine whether they need the medication or not.

Excretion

the process of medications exiting the body through the lungs, exocrine glands, bowel, kidneys, and liver. A medication's chemical makeup determines the organ of excretion. Nurses should know the method of excretion for their patients' medications, in order to properly provide care.

Types of Medication Action

therapeutic effect side effect adverse effect toxic effect idiosyncratic reaction allergic reaction

TID

three times a day

BID

twice a day

adverse effects

unintended, undesirable, and often unpredictable effects ranging from mild (rashes or photosensitivity to light) to potentially fatal (anaphylaxis). They are sometimes immediately apparent, and other times they may take weeks to months to develop.

Right Patient

use 2 patient identifiers. These identifiers could be the patients name, medical record number (identification number), or date of birth. DO NOT use patients room number as identifier. Compare the patient's identifiers on the MAR with those on his or her identification bracelet.

Now

used when a patient needs a medication quickly but not as soon as a now order; you have up to 90 minutes to give the drug after you receive the order.

what can long-term use of nasal medications cause

worsening of nasal congestion because of rebound effects

Right Time

Every 8 hours is a different medication schedule than 3 times a day...understand the difference -STAT medications are to be given immediately -You have 30 minutes before and 30 minutes after a prescribed time to administer time critical medication -Non-critical medications may be given 1 to 2 hours before the scheduled time -Clinical judgment is required with PRN medications

Ventrogluteal

The ventrogluteal site involves the gluteus medius and minimus and is a safe injection site for adults and children. To locate the ventrogluteal site, place the heel of the hand over the greater trochanter of the patient's hip with the wrist almost perpendicular to the femur. Use the right hand for the left hip, and the left hand for the right hip. Point the thumb toward the patient's groin, the index finger points to the anterior superior iliac spine, and extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle. The injection site is the center of the triangle (Fig. 22-17). To relax this site, patients lie on their side or back, flexing the knee and hip.

How to prevent lipoatrophy and lipohypertrophy complications from insulin

You can prevent this by alternating areas within a site

lipoatrophy

a breakdown of subcutaneous fat at the site of the insulin injection. It usually occurs after several injections at the same site

lipohypertrophy

a build-up of subcutaneous fat tissue at the site where insulin has been injected continuously

Idiosyncratic Reactions

a response to a medication or therapy that is unique to an individual. It is a unpredictable effect in which a patient overreacts or underreacts to a medication or has a reaction different from normal.

Standing order

carried out until HCP cancels/prescribed number of days run out

Distribution is affected by

circulation, cell membrane permeability, and protein binding

Ampule

contains single doses of injectable medications in a liquid form and are available in sizes from 1 - 10 mL or more. They are made of glass/constricted, rescored neck that you snap off. You have to use a filter needle to aspirate- this is using a filter needle to draw up medication. (prevents glass particles from being drawn up in syringe). Do not use filter needle to give medication. Open system.

Be familiar with the ISMP's Do Not Use list of Abbreviations (Error Prone Abbreviations) **** review this list (there is a document)

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the Six Rights of Medication Administration

REMEMBER MR. PDT 1. right medication 2. right route 3. right patient 4. right dose 5. right time 6. right documentation

Subcutaneous injections

Subcutaneous injections involve depositing medication into the loose connective tissue underlying the dermis. The best subcutaneous injection sites include the outer aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs. Figure 12-13 in the book has a nice picture to look at. Choose an injection site that is free of skin lesions, bony prominences, and large underlying muscles or nerves. Site rotation prevents the formation of lipohypertrophy or lipoatrophy in the skin.

Peak levels

the highest level of serum concentration of a medication that usually occurs just before the body ABSORBS the last of the medication. This level is drawn whenever the drug is expected to reach its peak concentration.

Therapeutic effect

the intended or desired physiological response of a medication. Some medications have many therapeutic effects

Trade name

the name used to market the medication; it has the symbol TM at the upper right of the name indicating a manufacturer trademark of the drug it suggests the action of the drug

Generic name

the official name that is listed in official publications such as the United States Pharmacopeia (USP)

Absorption

the passage of medication molecules into the blood from the site of administration.

how to select equipment for each time of injection

*These decisions are based on the quantity and type of medication prescribed and the body size of the patient. Intramuscular Injection · 1-3 mL syringe · use a blunt tip to withdrawal med from the vial then replace with needle to give meds. · Appropriate size needle-23 gauge When giving the medication: - Keep skin taught (pull it apart) - Insert the needle fast - Inject the medication slowly - Always aspirate for blood - if blood appears you are not in the muscle - Given at 90 degree angle These are given in: - Ventrogluteal (hip)- preferred - Dorsogluteal (upper buttock) -Vastus Lateralis (leg) - Deltoid (arm) Subcutaneous Injection · Use of a 1-3 mL syringe or an insulin syringe for INSULUN USE ONLY · Appropriate size needle- 25 gauge When giving the medication: - Pinch the skin - Insert needle fast - Inject medication slowly - Give at 45-90 degree angle depending on the amount of skin patient has. If obsese patient pinch skin and give at 90 degree angle. - Find out where last injection was given- it is good to rotate sites in anatomical area These are given in: - upper arm - the abdomen - the thigh - buttocks Intradermal Injection · Use Tuberculin (TB) syringe · appropriate needle size: 25-27 gauge pre attached · When giving the medication: - insert needle directly into dermis only (approximately 3mm [1/8"]) under skin - insert medication slowly - stretch the skin taught at the injection site - give at a 5-15 degree angle These are given in: - the forearm Z-track technique: type of IM injection technique used for irritable medicines and to prevent leakage of the medication into the subcutaneous tissue How to perform the z-track technique: pull subcutaneous layer away from injection site, inject needle, aspirate, administer IM medication, leave needle in muscle for about 10 s after, take needle out, let subcutaneous layer slide back over

sites for children

- Based on the evidence, the recommendation for pediatric IM injection sites includes use of the anterolateral thigh for infants up to 12 months of age, deltoid in children 12 months and older, and ventrogluteal site for children of all ages. - The vastus lateralis muscle is another injection site used in adults and is the preferred site for administration of biologicals(e.g., immunizations) to infants, toddlers, and children

How to give liquid medication

- Gently shake container. Use unit dose container with correct amount of medication. Gently shake container. Administer medication packaged in a single dose cup directly from single dose cup. Do not pour medicine into another cup. (Rationale: Shaking container ensures medication is mixed before administering. Prevents contamination of inside of cap.) - Administer medications in ONLY ORAL USE SYRINGES prepared by pharmacy. Oral syringe allows for accurate measuring of small doses of liquid medications

Techniques for rectal medication administration

- Have patient in left side lying sims position with upper leg flexed forward. a.) Close room curtain or door. (Rationale: Maintains privacy and minimizes embarrassment.) b.) Perform hand hygiene, arrange supplies at bedside, and apply clean gloves. (Rationale: Reduces transfer of microorganisms, helps nurse perform procedure smoothly.) c.) Assist patient in assuming a left side-lying Sims' position with upper leg flexed upward. d.) Keep patient draped with only anal exposed. (Rationale: Maintains privacy and facilitates relaxation.) e.) Examine condition of anus externally, and palpate rectal walls as needed (e.g., if impaction is suspected). Dispose of gloves by turning them inside out and placing them in proper receptacle if they become soiled. f.) Apply new pair of clean gloves (if previous gloves were soiled and discarded). g.) Remove suppository from foil wrapper, and lubricate rounded end with water-soluble lubricant. Lubricate gloved index finger of dominant hand. If patient has hemorrhoids, use a liberal amount of lubricant and handle area gently. (Rationale: Lubrication reduces friction as suppository enters rectal canal.) h.) Ask patient to take slow deep breaths through mouth and to relax anal sphincter. (Rationale: Forcing suppository through constricted sphincter causes pain.) i.) Retract patient's buttocks with nondominant hand. With gloved index finger of dominant hand, insert suppository gently through anus, past internal sphincter, and against rectal wall, 10 cm (4 inches) in adults or 5 cm (2 inches) in infants and children. (Rationale: Suppository needs to be against rectal mucosa for eventual absorption and therapeutic action.) j.) Withdraw finger, and wipe patient's anal area. (Rationale: Provides comfort.) k.) Discard soiled supplies and gloves by turning them inside out and dispose of them in appropriate receptacle. Perform hand hygiene. (Rationale: Reduces transfer of microorganisms.) l.) Ask patient to remain flat or on side for 5 minutes. (Rationale: Prevents expulsion of suppository.) m.) If suppository contains laxative or fecal softener, place call light within reach so patient can obtain assistance to reach bedpan or toilet. n.) If the suppository was given for constipation, remind patient not to flush the commode after the bowel movement. (Rationale: Allows staff to evaluate results of the suppository.)

What if patient has swallowing difficulty

- If patient has difficulty swallowing and liquid meds are not an option, use pill-crushing device to crush pills (place tablet between 2 cups and grind and crush) Mix ground tablet in small amount of soft food (custard or applesauce)

Techniques for topical medication administration

- applying drugs locally to skin, mucous membranes, or tissue; usually in lotions, patches, pastes, and ointments; use gloves and applicators. There are a variety of methods and formulations for applying medication to the skin. -Adhesive-backed medicated disks applied to the skin provide a continuous release of medication over several hours or days. -Topical administration avoids puncturing the skin and decreases the risk for infection and tissue injury that may occur with injections. -Rotation of application sites helps reduce the severity of localized reactions, which may occur with topically applied medications. - Systemic effects from topical drugs occur if the skin is thin, if the drug concentration is high, or if contact with the skin is prolonged

Techniques for ear (otic) topical medication administration

- ear medications; usually in solutions instilled by drops; must be room temperature; cannot occlude ear canal with medicine dropper what would happen if you were to administer cold otic drops? vertigo or nausea; could debilitate a pt for several minutes a.) Perform hand hygiene, and arrange supplies at bedside. Apply clean gloves (if drainage is present). (Rationale: Reduces transmission of microorganisms; helps nurse perform procedure smoothly.) b.) Warm medication by running warm water over the bottle (without damaging the label directions or allowing water to get into the bottle). (Rationale: Prevents nausea and vertigo that may occur if the medication is too cold.) c.) Have patient assume side-lying position (if not contraindicated by patient's condition) with ear to be treated facing up, or patient may sit in chair or at the bedside. Stabilize the patient's head. (Rationale: Position provides easy access to ear for installation of medication. Ear canal is in position to receive medication. Stabilizing the head promotes safety during installation with a dropper.) d.) For adults and children older than 3 years, gently pull the pinna up and outward; in children 3 years of age or less, pull the pinna down and back. (Rationale: Straightening of ear canal provides direct access to deeper external ear structures. Developmental differences in younger children and infants necessitate different methods of med. admin.) e.) If cerumen or drainage occludes outermost portion of ear canal, wipe out gently with cotton-tipped applicator. Do not use the cotton-tipped applicator to clean the ear canal. (Rationale: Cerumen and drainage harbor microorganisms and can block distribution of medication. Use of cotton-tipped applicator to clean the ear canal may force wax inward, occluding the canal.) f.) Instill prescribed drops holding dropper 1 cm (½ inch) above ear canal. g.) Ask patient to remain in side-lying position for a few minutes. Apply gentle massage or pressure to tragus of ear with finger.

Administering Oral Medications

- for tablets: patient may wish to hold solid medications in hand or cup before placing in mouth. Offer water or preferred liquid to help patient swallow medications. - For orally disintegrating formulations(tablets or strips): remove medication from packet just before use. Do not push tablet through foil. Place medication on top of patients tongue. Caution against chewing it. - For sublingually administered medication: Have patient place medication under tongue and allow it to dissolve completely. Caution patient against swallowing tablet. - For buccal administered medications: Have patient place medication in mouth against mucous membranes of cheek and gums until it dissolves. - For powdered medications: Mix with liquids at bedside and give to patient to drink. - For crushed medications mixed with food: Give each medication separately in teaspoon with food. - For lozenge (cough drop like): Caution patient against chewing or swallowing lozenge - For effervescent medication (designed to dissolve in water): add tablet or powder to glass of water. Administer immediately after dissolving.

Techniques for nasal topical medication administration

- nasal medications: drugs administered by spray or drops -Inhalation of medicated aerosol spray: distributes medication throughout the nasal passages and the tracheobronchial airway. - There are 2 types of devices designed for this purpose: metered-dose inhalers (MDIs) and small-volume nebulizer. -to administer nose drops- place patient in supine position and tilt their head back. - to administer nasal spray- place patient in upright position, tilt head forward, instruct patient to insert tip of nasal spray into appropriate nares and occlude other nostril with finger. Have patient sniff in while spraying.

Techniques for vaginal medication administration

- often topical; foam, jelly, cream, or suppository; discharge is often smelly - vaginal suppositories should be stored in refrigerator. **have patient in dorsal recumbent position a.) Remove suppository from wrapper, and apply liberal amount of water-soluble lubricant to smooth or rounded end (see illustration). Be sure that suppository is at room temperature. Lubricate gloved index finger of dominant hand. b.) With nondominant gloved hand, gently separate labial folds in the front-to-back direction. c.) With dominant gloved hand, insert rounded end of suppository along posterior wall of vaginal canal entire length of finger (7.5 to 10 cm [3 to 4 inches]). (Rationale: Proper placement of suppository ensures equal distribution of medication along walls of vaginal cavity.) d.) Withdraw finger, and wipe away remaining lubricant from around orifice and labia with a tissue or cloth. (Rationale: Maintains comfort.)

Z-track technique

- pulling the skin laterally before injection to prevent leakage of meds into subQ tissue, seals medication in the muscle, and minimizes irritation. -To use the Z-track method, apply the appropriate-size needle to the syringe, and select an IM site, preferably in a large, deep muscle, such as the ventrogluteal. Pull the overlying skin and subcutaneous tissues approximately 2.5 to 3.5 cm (1 to 1½ inches) laterally (to the side) with the ulnar side of the nondominant hand. Hold the skin in this position until you have administered the injection. After cleansing the site, inject the needle deeply into the muscle. If there is no blood return on aspiration, slowly inject the medication. Keep the needle inserted for 10 seconds to allow the medication to disperse evenly. Then release the skin after withdrawing the needle. This leaves a zigzag path that seals the needle track wherever tissue planes slide across each other.

How do you give medications through a nasoenteric or nasogastric tube?

-Do not administer medications into nasogastric tubes that are inserted for decompression. -Preferably, medications administered by enteral tubes should be in liquid form. If liquid form is not available, you will need to modify the form of the medication tablet by crushing or dissolving it. However, you cannot crush sustained-release, chewable, long-acting, or entericcoated tablets and capsules. Therefore do not administer these medications by enteral tubes. -Administering meds through enteral tubes cannot be delegated. -Keep the head of the bed elevated for 15 to 30 minutes after medication administration. -The NAP monitors for signs of aspiration, such as coughing, choking, gagging, or drooling of liquid or moistened pills after swallowing, and informs the nurse immediately if these occur. If the medication is not compatible with the feeding solution, or if patient needs to take medication on an empty stomach, stop the feeding 15 to 30 minutes before medication administration. -Fill graduated container with 50 to 100 mL of tepid water (cold water causes gastric cramping). -Whenever possible, use liquid medications instead of crushed tablets, but if you have to crush tablets, the tubing must be flushed before and after the medication to prevent the drug from adhering to the inside of the tube. In addition, make sure concentrated medications are thoroughly diluted. Never add crushed medications directly to the tube feeding. -Crush tablets using a pill-crushing device to grind pills into a fine powder. If a pill-crushing device is not available, place tablet between two medication cups and grind with a blunt instrument. Dissolve in at least 30 mL of warm water. -Capsules: Ensure that contents of capsule (granules or gelatin) can be expressed from the covering (consult with pharmacist). Open capsule, or pierce gelcap with sterile needle, and empty contents into 30 mL of warm water. You can also dissolve gelcaps in warm water. -Prepare patient by placing in a High-Fowler's position (if not contraindicated by patient's medical condition). -Apply clean gloves. -If a continuous enteric tube feeding is infusing, adjust the infusion pump to hold the tube feeding. Feeding solution should not infuse while residuals are checked or while medications are administered. -Check placement of feeding tube by observing gastric contents and checking pH of aspirate contents. Gastric pH should be 4 or less. -Check for gastric residual. Connect syringe to end of feeding tube, then pull back slowly to aspirate gastric contents. Return aspirated contents to stomach. -To administer more than one medication, give each separately, and flush between medications with 15 to 30 mL of water. -Follow last dose of medication with 30 to 60 mL of water. -Return in 30 minutes to check patient's response to meds.

Techniques for oral medication administration

-For tablets: Some patients wish to hold solid medications in hand or cup before placing in mouth. Offer water or juice to help patient swallow medications. -For orally disintegrating formulations (tablets or strips):Remove medication from blister packet just before use.Do not push the tablet through the foil. Place medication on top of patient's tongue. Caution patientagainstchewing the medication.

how to administer insulin. How do you mix cloudy with clear insulin?

-Insulin injections (SubQ injections) need to be rotated within the site, and are absorbed at different rates at different sites: Abdomen - Arms - Thighs - Buttocks. Timing should be determined by meals and current blood glucose levels. -If more than one type of insulin is required to manage the patient's diabetes, you can mix two different types of insulin into one syringe if they are compatible. This may result in a patient response to insulin that is different than the response that would occur if the insulins had been given separately. Never mix insulin glargine (Lantus) or insulin detemir (Levemir) with any other types of insulin. *Mixing Insulin: •Roll cloudy bottle of insulin between hands to re-suspend the insulin. •Wipe off the tops of both insulin vials w/ alcohol swab. •Verify with MAR •If mixing rapid- or short-acting insulin with intermediate- or long-acting insulin, take insulin syringe and aspirate volume of air equivalent to dose to be withdrawn from intermediate- or long-acting insulin first. If two intermediate- or long-acting insulins are mixed, it makes no difference which vial is prepared first. •Insert needle, and inject air into vial of intermediate- or long-acting insulin. Do not let the tip of the needle touch solution. •Remove the syringe from vial of insulin without aspirating medication. •With the same syringe, inject air, equal to the dose of rapid- or short-acting insulin, into the vial and withdraw the correct dose into the syringe •Remove the syringe from rapid-short acting insulin and remove any air bubbles to ensure dose. •Verify short-acting dosage with MAR, have another nurse verify. Determine which point on syringe scale combined with units of insulin should measure - Verify the combined dosage •Place the needle of the syringe back into the vial of intermediate- or long-acting insulin. Be careful not to push plunger and inject insulin in syringe into the vial. •Invert the vial, and carefully withdraw the desired amount of insulin into syringe •Withdraw needle and check fluid level in syringe - Keep needle of prepared syringe sheath or capped until ready to administer. ** Should be within 5 min of prep.

meds that require a double check by another nurse for safe administration

-Some institutions require that medications prepared for parenteral administration be verified by another nurse. -Verify insulin doses with another nurse. -Verify any meds you add to IV fluid with another nurse.

what to do in the event of a medication error

-The priority when an error is made is the safety of the patient. The nurse assesses and examines the patient's condition and notifies the physician or prescriber of incident as soon as possible. Once patient is stable, the nurse reports the incident to the appropriate person in the institution.Then the nurse files a written incident report that must be filed within 24 hours.The reportincludes patient ID, location and time of incident, factual description of what occurred and whatthe nurse did, patient's outcome, signature of nurse involved. This does NOT become a permanent part of the medical record. Do NOT refer to it in the nurses' notes.

Medications that can be crushed

-tablets that are pre-scored (***cannot ever crush enteric-coated pills)

Right Medication

Always do medication reconciliation on a patient. Always compare the HCP order with the MAR when the medication is ordered. When preparing medications from bottles or containers, compare the label of the medication container with the MAR 3 times. (1). Before removing the container from the supply drawer of shelf. (2). As the amount of medication order is removed from the container and put into the cup or syringe. (3). At the patients bedside before administering the medication to the patient.

Techniques for buccal medication administration

Have patient place medication in mouth against mucous membranes of cheek and gums until it dissolves.

Techniques for sublingual medication administration

Have patient place medication under tongue and allow it to dissolve completely. Caution patient against swallowing tablet

intramuscular

Into a muscle

intradermal

Into the dermis of the skin; just under the used; ex: TB skin test or allergy testing

subcutaneous

Into the subcutaneous tissue of the skin

Deltoid Muscle

Locate the deltoid muscle by fully exposing the patient's upper arm and shoulder and asking the patient to relax the arm at the side or support the patient's arm and flex the elbow. Do not roll up any tight-fitting sleeve. Allow the patient to sit, stand, or lie down (Fig. 22-19, B). Palpate the lower edge of the acromion process, which forms the base of a triangle in line with the midpoint of the lateral aspect of the upper arm. The injection site is in the center of the triangle, about 2.5 to 5 cm (1 to 2 inches) below the acromion process (see Fig. 22-19, A). You locate the apex of the triangle by placing four fingers across the deltoid muscle, with the top finger along the acromion process. The injection site is then three finger widths below the acromion process.

quickly

Medications applied to mucous membranes and respiratory airways absorb _________

What constitutes a legal medication order?

The order sheet is the most reliable source and only legal record of drugs patient is to receive. Ensures patient receives correct medication." •Regardless of how you receive the order, you compare the prescriber's written orders with the MAR when the medication is initially ordered. •Verify medication information whenever new MARs are written or distributed or when patients transfer from one nursing unit or health care setting to another. •Know dangerous abbreviations and clarify if unsure! •Each order needs to include the patient's name, the drug ordered, dosage, route of administration, and time(s) of administration. •Written orders need to be transcribed either by hand or electronically on an MAR. • The transcribed order includes the patient's full name; date the order is written; date the medication order expires, medication name, dose, and frequency (time ordered); and route of administration. •The transcriber makes sure the patient's room and bed number are accurate on the form. Transcription errors are one of the most common sources of medication errors. •With unit-dose systems, only one transcription is necessary. •When you transcribe an order in written form, be sure the names, dosages, symbols, and abbreviations are legible and not smudged. **Always clarify an order that is not legible. •When checking an order transcribed by a unit secretary, check the accuracy and legibility of every element. •An RN is responsible for checking and initialing all transcribed orders against the original orders.

Trough Levels

The point at which the lowest level of serum concentration of a drug. This level is drawn as a blood sample 30 minutes before administering the drug.

Right Route

The prescribers order must indicate a route of administration, if a route is not specified consult the prescriber immediately. Do not aspirate when giving a SubQ injection

Vastus Lateralis

The vastus lateralis muscle is another injection site used in adults and is the preferred site for administration of biologicals (e.g., immunizations) to infants, toddlers, and children. The muscle is thick and well developed and is located on the anterior lateral aspect of the thigh. It extends in an adult, from a handbreadth above the knee to a handbreadth below the greater trochanter of the femur (Fig. 22-18). Use the middle third of the muscle for injection. The width of the muscle usually extends from the midline of the thigh to the midline of the thigh's outer side. With young children or cachectic patients, it helps to grasp the body of the muscle during injection to be sure that the medication is deposited in muscle tissue. To help relax the muscle, ask the patient to lie flat with the knee slightly flexed and foot externally rotated or assume a sitting position.

Intradermal Injections

To administer an injection intradermally use a tuberculin or small syringe with a short , fine-gauge (25 to 27) needle. The angle of insertion for an intradermal injection is 5 to 15 degrees (see Fig. 22-9). You inject only small amounts of medication (0.01 to 0.1 mL) intradermally. If a bleb does not appear, or if the site bleeds after needle withdrawal, the medication may have entered subcutaneous tissues. In this situation skin test results will not be valid.

What if an oral medication is ordered for a patient who has a nasogastric tube ordered for a suction? How would you administer the med?

Turn off suction administer meds then push saline through the tube to make sure the medication is not stuck in the tube and then leave off for 30 minutes so meds can disolve

How The Joint Commission (TJC) requires a nurse to take a verbal order.

Verbal orders are to be accepted only in emergency situations when the prescriber has no time to write the order. When a nurse takes a verbal order, he or she writes the order on the MAR and then reads back the complete order to the HCP who made the order. Clearly identify the patient . Write "VO" (verbal order) or "TO" (telephone order), including the date and time, name of patient and complete order on the order and sign , HCP must co-sign within 24 hr. The nurse writes the name of the prescriber next to that of the nurse.

Mixing Meds from Vial and Ampule

When mixing meds from a vial and an ampule, prepare meds in vial first - then withdraw meds from ampule using same syringe and filter needle. When mixing two vials- do not contaminate one med with another -ensure that final dose is accurate a.) Prepare medication from vial first b.) Determine on syringe scale what the combined volume of meds should measure c.) Using the same syringe, prepare the second medication from d.) Withdraw filter needle from ampule, and verify fluid level in syringe - change filter needle to appropriate needle or needleless device. keep needle capped or sheathed until administration. e.) Check syringe carefully for total combined dose of medications

Intramuscular injections

When selecting an IM site, determine that the site is free of pain, infection, necrosis, bruising, and abrasions. Also consider the location of underlying bones, nerves, and blood vessels and the volume of medication you will administer.

how to administer lovenox (LMWH) injections

a.) Patients should be sitting or lying down and LOVENOX® Injection administered by subcutaneous (SC) injection. Pick an area on the abdomen between the left or right anterolateral and left or right posterolateral abdominal wall. Clean the injection site with a sterile alcohol swab and let dry. Administration should be alternated between the left and right sides. b.) Carefully remove the needle cap by firmly pulling it straight off the syringe and discard. If required, dose adjustment must be done prior to injection. IMPORTANT NOTE: To help minimize bruising (a common side effect), carefully wipe the needle off with sterile alcohol wipe, and DO NOT expel air "bubble" in the syringe, and this provides a barrier during the injection. c.) Gently pinch the cleansed area of the abdomen between your thumb and index finger to make a fold in the skin. Introduce the full length of the needle (bevel side facing away from the body) at a 90° angle into the skin fold held between the thumb and forefinger; inject using standard technique, pushing the plunger to the bottom of the syringe. The skin fold should be held throughout the injection. To minimize bruising, do not rub the injection site after completion of the injection. d.) Remove the needle from the injection site, keeping your finger on the plunger. During this step you can release pressure on the plunger. e.) Pointing the needle away from you and others, activate the LOVENOX® safety device by firmly pushing the plunger. The protective sleeve will automatically cover the needle, and an audible "click" will confirm shield activation. f.) Immediately dispose of the syringe in the nearest sharps collector.

Techniques for skin topical medication administration

a.) check accuracy and completeness of each MAR with prescriber's written medication order. Check patients name, drug name and dosage, route of administration, and time for administration. (Rationale: the order sheet is the most reliable source and only legal record of drugs patient is to receive) b.) When topical medications are applied to wounds or skin alterations, assess condition of patient's skin. If there is an open wound, apply clean gloves. First wash site thoroughly with mild, nondrying soap and warm water, rinse, and dry. Be sure to remove any previously applied medication or debris. Also remove any blood, body fluids, secretions, or excretions. Assess for symptoms of skin irritation such as pruritus or burning. (Rationale: Cleansing the site thoroughly promotes a proper assessment of skin surface. Assessment provides baseline to determine change in condition of skin after therapy. Application of certain topical agents can lessen or aggravate these symptoms.) c.) Further inspect the condition of the skin or membranes. Do not administer topical medications to skin if integrity is altered, unless indicated. (Rationale: Break in skin integrity can affect drug absorption and actions.) d.) Determine whether patient has known allergy to topical agent. Ask if patient has had reaction to a cream or lotion applied to the skin. Also ask if patient has allergy to latex. (Rationale: Allergic contact dermatitis is relatively common and can worsen dermatological (skin) condition. In addition, some patients may be allergic to preservatives or fragrances in topical medications. Latex allergy requires use of non-latex gloves.) e.) Determine amount of topical agent required for application by assessing affected area, reviewing prescriber's order, and reading application directions carefully (a thin, even layer is usually adequate). (Rationale: An excessive amount of topical agent can cause chemical irritation of the skin, negate drug's effectiveness, and/or cause adverse systemic effects; such as decreased white cell counts.) f.) Assess patient's knowledge of action and purpose of medication being given and interest in treating health problem. (Rationale: Reveals patient's level of understanding and whether instruction is necessary.) g.) Determine if patient is physically able to apply medication by assessing fine grasp, hand strength, reach, and coordination. (Rationale: Necessary if patient is to self-administer drug in the home.)

SubQ

absorb faster than oral, but not as fast as IM or IV

Solutions and liquid suspensions

absorb more readily than tablets or capsules.

IM medications

absorb rapidly but not as fast as IV

Acidic medications

absorb rapidly, whereas basic medications (pH >7.0) do not absorb before reaching the small intestine.

Oral

absorbs slowly, ______ medications pass through the gastrointestinal tract.

Allergic Reactions

adverse unpredictable responses to a medication. Exposure to an initial dose of a medication causes a patient to become sensitized immunologically. The medication acts as an antigen, which causes antibodies to be produced. With repeated administration, the patient develops an allergic response to the drug, its chemical preservatives, or a metabolite. Allergic reactions range from mild to severe depending on the patient and the medication. Antibiotics cause a high incidence of allergic reactions. Always record a patient's allergies in the MAR.

PC

after meals

PM

after noon

Distribution

after the medication is absorbed, the medication goes to the tissues and organs and then to the site of drug action.

Metabolism

after the medication reaches its site of action, it is metabolized into a less active or inactive form. This metabolism or biotransfusion takes place under the influence of enzymes that detoxify, degrade, and remove biologically active chemicals. Most metabolism takes place in the liver, but the lungs, kidneys, blood, and intestines also take part in breaking down the medication.

Topical

applications on the skin absorb slowly

AD LIB

as desired

AC

before meals

AM

before noon

Parenteral Injections

intradermal subcutaneous intramuscular

What does it mean when a drug is in therapeutic range

is a range of plasma drug levels between the minimum effective concentration and the toxic concentration. When plasma levels are within the therapeutic range, there is enough drug present to produce therapeutic responses but not so much that toxicity results. When administering a drug, the objective is to maintain plasma drug levels within the therapeutic range. The width of therapeutic range determines whether or not a drug is easily administered safely. Drugs with a narrow therapeutic range are difficult to administer safely. Drugs with a wide therapeutic range can be safely administered much easier. - it is the intended or desired physiological response of a medication

Right Dose

make proper calculations if necessary

Single order

medication ordered once for a specific time; this is a one time order, often used for pre-op procedures or given before diagnostic procedures.

Z-track method

method for injecting irritating medications into muscle without tracking residual medication through sensitive tissues - recommended for IM injections

side effects

predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. They can be harmless or can cause injury, depending on the dose of the medication. Common side effect examples: anorexia, nausea, vomiting, dizziness, drowsiness, dry mouth, constipation, and diarrhea.

Vial

single or multidose plastic or glass container w/ rubber seal at top protected by metal cap. They contain liquid or dry forms of meds. (Vail will label specify solvent or diluent used to dissolve med for desired concentration.) May have two chambers - allows powder and diluent to mix. Closed system - inject air into container to permit withdrawal of solution - not always but sometime have to been drawn up w/ filter needle for required med.

viscous

syrupy: having a relatively high resistance to flow, or having a glutinous consistency and the quality of sticking, or adhering

Factors that affect the rate of absorption

the administration route, ability of a medication to dissolve, blood flow to the administration site, body surface area, and lipid solubility of a medication

Preparing an Ampule

· Tap top of ampule lightly until fluid moves from neck of ampule - this dislodges any fluid that is stuck in neck. · Place small gauze or alcohol wipes around neck and snap neck away from you · Draw up medication quickly, using filter needle long enough to reach the bottom of the ampule to access the medication. · Hold ampule upside down or set it on a flat surface. Insert filter needle into center of ampule opening. Do not allow needle tip or shaft to touch the rim of the ampule. · Aspirate medication into syringe by gently pulling back on plunger. keep needle tip under surface of liquid. Tip ampule to bring all fluid within reach of needle. · If air bubble are aspirated do not expel air into the ampule. · To expel excess air bubbles, remove needle from ampule. Hold syringe vertically with needle pointing up. Tap side of syringe to cause bubbles to rise towards needle. Draw back slightly on plunger and push plunger upward to eject air. Do not eject fluid. · Cover needle with safety sheath or cap

equipment for children

•Because of difficulty coordinating inhaler activation and inhalation, the use of a spacer device is recommended for young children •Bronchodilators are used often in children, but use with extreme caution and monitor for adverse effects such as tremors, restlessness, dizziness, gastrointestinal upset, and tachycardia

techniques for children

•Children will refuse bitter or distasteful oral preparations. Mix the drug with a small amount (about 1 teaspoon) of a sweet-tasting substance, such as jam, applesauce, sherbet, ice cream, or fruit puree. Do not use honey in infants because of the risk for botulism. Offer the child juice or a flavored ice pop after medication administration. Do not place medication in an essential food item, such as milk or formula; the child may refuse the food at a later time. •Ear drops: in children 3 years of age or less, pull the pinna down and back. •Children can be very anxious or fearful of needles. Assistance with proper positioning and holding of the child is sometimes necessary. Distraction, such as blowing bubbles and pressure at the injection site before giving the injection, can help alleviate the child's anxiety •Insert suppositories 5 cm (2 inches) in infants and children. With children, it is often necessary to gently hold or tape the buttocks together for 5 to 10 min to relieve pressure on the anal sphincter until the urge to expel the suppository is gone

Preparing a Vial

•Remove cap - If already used wipe surface with alcohol swab and allow it to dry •Take cap off needle and draw back amount of air equal to the desired amount of medication. •With vial on flat surface insert tip of needle through center of rubber seal •Inject air into air space of the vial, holding on to the plunger. •Invert vial while holding syringe and plunger; Withdraw medication (keep tip of needle in fluid). Allow air pressure to gradually fill syringe. •When desired volume is obtained. Move needle in vial's air space and tap any bubble out and eject any remaining air. •Remove needle from vial (or needleless vial access device) •Hold syringe at eye level, at 90 degree angle to ensure correct volume w/ no bubbles •If bubbles persist, tap barrel then draw back slightly, then push forward expelling bubbles but no fluid - recheck volume. **If using a powdered medication: inject diluent into vial and then roll in palms to mix - continue as liquid medication

guidelines for administering controlled substances

•Store all narcotics in a locked, secure cabinet. Automated medication dispensing system (AMDS) or a locked room. (Computerized, locked cabinets are preferred.) •Count narcotics frequently, during the opening of narcotic drawers and/or at shift change. •Report discrepancies in narcotic counts immediately. •Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used, wasted and remaining. •Use the record to document the patient's name, date, time of medication administration, name of medication, dose, and signature of nurse dispensing the medication. •If you give only part of a premeasured dose of a controlled substance, a second nurse witnesses disposal of the unused portion. Both nurses sign their names on the required form. Computerized systems record the nurses' names electronically. Do not place wasted portions in the sharps containers. Instead, dispose of medications properly following institutional policy.