Kinn's Chapter 30 Administering Medications

When would a TST be contraindicated?

-A severe reaction to a past TST (e.g., necrosis, ulcers, blisters, or anaphylaxis), -A history of a positive TST result, -A live virus vaccine less than 4 to 6 weeks earlier (A TST and a live virus vaccine can be given on the same day, or the TST can be given 4 to 6 weeks after the vaccine).

Mixing Insulins:

-Air needs to be added to both regular and NPH vials before any insulin is drawn up -Regular insulin must be drawn up in the syringe first and then NPH is added -Insulin is measured in units -Double-check that no air bubbles are in the syringe and the right dose was measured -Air bubbles take up space. If air bubbles are present, discard the syringe and start over -Patients receiving insulin must rotate their injection sites -This prevents tissue damage and absorption issues with the insulin -Insulin is typically stored in the refrigerator and should be warmed to room temperature prior to administration -Cloudy insulins (e.g., NPH) are suspensions and need to be mixed before drawing up the insulin. Mix cloudy insulins by gently rolling the vial between your hands -Clear insulin (e.g., Regular insulin) does not need to be mixed or rolled in your hand.

Intradermal Injections:

-Given just under epidermis, -Causes momentary burning or stinging, -Small amounts of medication are injected, -Examples of intradermal injections: Mantoux tuberculin skin test (TST), Intradermal flu vaccine, Allergy testing.

Reducing Pain and Anxiety with injections:

-Giving a sugar-coated pacifier or sugar water (must be ordered by the provider), which helps to soothe children under age 1 year after injections, -Applying a topical anesthetic skin refrigerant (e.g., Pain Ease), which works immediately, -Applying a topical anesthetic (e.g., EMLA cream) at the injection site, which works in about 30 to 40 minutes, -Talking with the patients to distract them from the procedure, -Having patients move their toes or fingers on the extremity used when an IM injection is given (Have patients "play the piano" with their fingers when giving a deltoid injection.), -Using products that provide cold and vibration sensations (e.g., Buzzy), which overwhelm the nerves affected by the injection, -Administering the most painful injection last.

Patients may not receive a live virus vaccine if they

-Had another live virus vaccine less than 28 days ago -Are pregnant or may be pregnant in the next month -HPV vaccine is also contraindicated with pregnancy -Are immunocompromised (e.g., cancer, leukemia, HIV/AIDs) -Are receiving chemotherapy or high-dose steroid therapy -Had recently received a blood transfusion, immune (gamma) globulin, or antiviral medication.

Mantoux tuberculin skin test (TST)procedure:

-If a 6 to 10 mm wheal does not appear, repeat the test at least 2 inches from the site -Do not massage the area -The patient must return in 48 to 72 hours for the reading -When reading it, use a millimeter ruler, accurately measure the distance between the two points.

Minimize pain with injections:

-Insert subcut and IM needles swiftly, -Inject medication at rate of 10 seconds per 1 mL, -Remove needle quickly using the same angle as used for entry.

Intramuscular Injections:

-Involve placing medication into the muscle, There are more blood vessels in the muscles, Absorption is faster than in subcutaneous layer -Aqueous (watery) medications should be given with a higher gauge needle than that used for oil-based injections. -Several vaccines (hepatitis A and B, tetanus [Td], pertussis [Tdap], influenza, meningococcal), Antibiotics and medroxyprogesterone (Depo-Provera).

Subcut sites and injections:

-Involve placing medication into the subcutaneous layer, under the dermis -Subcutaneous layer has fewer blood vessels than the muscles do -Common medications given via subcutaneous route include: Several vaccines (MMR, varicella, shingles, polio), Enoxaparin (Lovenox), Heparin, Insulin -Sites: Abdominal site, Outer posterior aspect of upper arm, Anterior aspect of thigh.

Parenteral medication administration has several advantages:

-It is useful when the patient has gastrointestinal distress or is unconscious -It offers good absorption compared to other routes, such as the oral route -The onset (time medication starts working) is more rapid than with other routes -Some types of parenteral medications have a longer duration time (time it works in the body).

Reasons for false-positive TST reactions include:

-Lung infection with nontuberculous mycobacteria (NTM). This organism is found in the water and soil and is inhaled -Previous bacillus Calmette-Guérin (BCG) vaccine. Many foreign-born patients from countries with high risk of TB may have received BCG abroad. BCG vaccine has been approved by the FDA but is used in very limited situations -Incorrect administration or reading of the TST.

Special Considerations When Giving Enoxaparin:

-Make sure the drug is clear and colorless or pale yellow, -Do not push any air or 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 of bruising, -Using your finger and thumb, pinch a fold of skin 1 to 2 inches away from the umbilicus in the lower abdomen, -Push the entire needle into the skin, -Press down on the syringe plunger and inject the medication, -Hold the pinched skin the entire time during the injection, -Remove the needle, -Do not rub or massage the site after the injection, -Hold pressure to the site after the injection until the bleeding has stopped.

Finding the Deltoid IM injection site:

-Palpate the acromion process -Place a finger on the acromion process and then 2 fingers below that -The top of the site is 1 to 2 inches (or 2 fingerbreadths) below the acromion process -The bottom of the site is at the anterior axillary fold (top of the axilla) -The injection site should be somewhere between the top and the bottom of the site -Once the medical assistant finds the site, it is a good idea to have the patient lift his or her arm -The medical assistant can find the bulk (biggest part) of the deltoid muscle -The injection should be given into the bulk of the deltoid muscle.

Sublingual and Buccal medications

-Patient should not eat or smoke prior to taking this medication -Patients should not chew or swallow this medication -Water can be taken prior to this medication to wet the mouth -No liquids can be taken until this medication has dissolved -Patients should alternate cheeks used to dissolve this medication to avoid mucosal irritation.

Guidelines for Parenteral Medications:

-Prepare and store medications in a separate area, away from the exam rooms, -Never transport medication in your pockets, -Never give an 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).

After giving a medication, the medical assistant must document it in the patient's health record the following:

-Provider ordering the medication , -Assessment done (vital signs or pain level) Allergies , -Coaching/instructions given to patient, -Name of medication, Dose given, -Route given, Lot number, expiration date, and manufacturer (usually only required for vaccines and controlled substances), -How the patient tolerated the medication Additional information as needed, -Signature if the note is handwritten (an electronic health record [EHR] uses automatic signatures for documentation entries).

Medical assistant's role with IVs can include:

-Scheduling a patient for an IV infusion, -Assisting nurse with checking on patient, -Common concerns with IV therapy: Edema, , -Blood moving up the IV tubing, -Almost-empty bag of fluids, -Patient who is having difficulty breathing or who has increased audible wheezing, -These common concerns need to be communicated immediately to the nurse.

Taking medication on an empty stomach:

-Some medications must be taken with food and others with a full glass of water, -Medications that need to be taken on an empty stomach need to be taken 1 hour before meals or 2 hours after meals.

When inserting a suppository provide the following information:

-Supplies gloves, and water-soluble jelly (K-Y Jelly) -Review the storage directions -Remove the wrapping from the suppository -Lubricate the pointed part of the suppository with water-soluble jelly -Place the person in the SIMS position for rectal suppositories -Carefully insert the suppository pointed side first -For adults and older children: Use the gloved index finger to push the medication in. Both vaginal and rectal suppositories should be inserted about 3 to 4 inches. Have the person slowly breathe to help with the discomfort -For small children: Use the gloved little finger to insert the medication. Rectal suppositories should be advanced about 2 inches.

Needle and syringe needed to give an intradermal injection

-Syringe: 1 mL -Needle: 1/4 to 5/8 inch -Gauge 25−27 -Angle of entry: 5 to 15 degrees with bevel facing upward -Maximum volume: 0.1 mL -Common sites: Forearm, upper arm, and back -Additional sites: Separate by at least 2 inches -Patient position: Sitting with arm extended -Administration: Pull skin taut at injection site

DELTOID IM injection site:

-Syringe: 3 mL -Needle: 1-11 yr: 5/8 - 1 inch, Adults: 5/8 - 1 ½ inch, By Weight: <130 lb: 5/8 inch, 130-152 lb: 1 inch, Females 152-200 lb/males 152-260 lb: 1 - 1 1/2 inch, Females >200 lb/males >260 lb: 1 1/2 inch -Needle gauge: 22-25 G -Angle of Entry: 90 degrees (bevel does not matter) -Max volume: 1 mL for teens and adults.

VENTROGLUTEAL IM injection site:

-Syringe: 3 mL -Needle: Birth-28 days: 5/8 inch, 1 mo-12 yr: 1 inch, 12+ yr: 1 - 1 1/2 inch -Needle gauge: Children: 22-25 G, Adults: oil-base: 18-21 G; aqueous: 20-25 G -Angle of Entry: 90 degrees (bevel does not matter) -Max volume: Birth-1 yr: 1 mL, 1-11 yr: 2 mL, 12+ yr: 3 mL.

VASTUS LATERALIS IM injection site:

-Syringe: 3 mL -Needle: Birth-28 days: 5/8 inch, 1-12 mo: 1 inch, 1-18 yr: 1 - 1 1/4 inch, 18+ yr: 1 - 1 1/2 inch -Needle gauge: Children: 22-25 G, Adults: oil-base: 18-21 G; aqueous: 20-25 G -Angle of Entry: 90 degrees (bevel does not matter), -Max volume: Birth-1 yr: 1 mL, 1-11 yr: 2 mL, 12+ yr: 3 mL.

Subcut injection needle and syringe:

-Syringe: 3 mL most common; 1 mL could be used, -Needle: 25 gauge; 1/2 inch with a 90-degree angle of entry -5/8 inch with a 45-degree angle of entry; the bevel position does not matter -Maximum volume: 0.5-1.5 mL (0.5 mL in children) -Sites: Lower abdomen, anterior thigh, and upper outer arm Sites for vaccines <1 year of age: anterior thigh >1 year of age: 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, insert the needle at a 90-degree angle; if 1 inch of tissue can be pinched, insert the needle at a 45-degree angle; rotate sites.

Besides giving the VIS prior to the vaccination, the medical assistant must document the following in the patient's health record:

-The edition date of the VIS. This is found on the back at the bottom right corner. Make sure to have the latest edition of the VIS -The date the VIS is provided and the date the vaccine is administered. Usually this is done on the same day -The office address, name, and title of the person who administers the vaccine, and The vaccine manufacturer and lot number.

TST Two-Step Testing:

-The initial TST may be negative, and the person may have a false-negative reaction -Receiving a second TST can help body "remember" infection, thus causing a more accurate reading, This is called the booster effect or booster phenomenon. The second TST can be done 1 to 3 weeks after the initial test was read -New residents in long-term care facilities (e.g., nursing homes) usually have a two-step TST done -Healthcare students and professionals also need to have a two-step TST -Once the two-step TST has been completed, they need yearly TSTs, If the time since the last TST exceeds 1 year, they may need to complete another two-step TST.

Tuberculin purified protein derivative (PPD) Intradermal injection procedure:

-The site should be 2 to 4 inches below the elbow -Pull the skin taut at the injection site -A tuberculin syringe and needle, with bevel facing upward, at a 5- to 15-degree angle, is used to slowly inject PPD, creating a wheal.

When multidose vials are opened (cap is removed or stopper is punctured):

-They are only good for 28 days (unless manufacturer states otherwise) -The new expiration date should be written on the label -If the manufacturer's expiration date is shorter than the 28 days, then the shorter date must be used.

Preparing a liquid oral medication:

-Using the marker, write the medication name and dose on the appropriate medication cups -Place the plastic medication cup on a high even surface -Uncover the bottle and place the cover on the counter making sure the inside is facing up -Palm the label of the medication bottle -Position yourself so you are eye level with the medication cup.

Preparing a solid medication:

-Using the marker, write the medication name and dose on the appropriate medication cups -Remove the cover and hold the cover so the inside is facing up -Carefully pour the correct number of tablets into the cover -When you have the correct number of tablets, pour the tablets from cover into the paper cup.

Sign or symptom of anaphylaxis

-Warm feeling -Flushing -Shortness of breath -Dyspnea -Wheezing -Throat tightening -Difficulty swallowing -Cough -Anxiety -Pain or cramping -Vomiting or diarrhea -Unconsciousness -Shock -Palpitations -Dizziness.

Reasons for false-negative results with:

-Weakened immune system -Exposure to TB infection within previous 8 to 10 weeks -A very old TB infection -Patient is younger than 6 months old -Recently received a live virus vaccine (e.g., measles, yellow fever, chickenpox), or had a viral infection (e.g., influenza), or received corticosteroids or immunosuppressive medications (a false reaction may occur up to 5 to 6 weeks afterward) -Incorrect administration or reading of TST.

If the medical assistant is administering the nasal medication:

-Wear gloves -Patients should blow their nose prior to receiving the medication -They should sit in an upright position -The patient should sniff when the medication is given -Intranasal medications should be charted as "intranasal" or "NAS."

When the medical assistant applies a topical medication to a patient's skin, it is important to do the following:

-Wear gloves, Use a sterile application (tongue blade or swab) to remove medication from the container -To keep the container sterile, a new sterile applicator must be used each time -Rub creams gently into the skin -Pat lotions onto the skin -Liniments must be rubbed into the skin -Apply ointments using a sterile applicator -For aerosol topical sprays, hold the bottle 3 to 6 inches from the skin and spray.

Patients may not receive a live virus vaccine if they meet the following conditions:

-Were vaccinated with another live virus vaccine less than 28 days earlier, -Are pregnant or may become pregnant in the next month. -The human papillomavirus (HPV) vaccine is also contraindicated with pregnancy, -Are immunocompromised (e.g., cancer, leukemia, HIV/AIDS), -Are receiving chemotherapy or high-dose steroid therapy, -Recently received a blood transfusion, immune (gamma) globulin, or antiviral medication.

Special Situations with injections:

-With any medication, a patient can experience an anaphylactic reaction, -Anaphylaxis is a severe allergic reaction that can be life threatening, -Having the patient wait 15 minutes after an injection allows you to monitor for unusual symptoms, -If needle breaks during injection or needle separates from syringe, pull out the needle and discard in biohazard sharps container, -If needle is not visible, mark spot with pen and yell for help, -If a bone is hit during an intramuscular injection, pull the needle out about ¼ inch and give medication.

When replacing a patch or teaching a patient to use transdermal patches, follow these steps:

-Write the date and time on the new patch -Wear gloves if changing patch on another person -Remove the old patch -Fold the sticky sides together and discard -If old patch is not removed, the person may be at risk for an overdose -Remove any medication residual from the skin using a tissue -Decide where to apply the new patch -Select a different location.

Drawing up medication from an ampule

A filter needle on a syringe is used to aspirate the medication into the syringe. This needle has a small filter that catches glass particles before they enter the syringe barrel.

Extended-release

A medication designed to breakdown over time, if crushed, split, or chewed would put the patient at risk for an overdose.

Fast dissolving

A medication form that is also called oral disintegrating tablet and is placed on the tongue or by the cheek to break down.

Scored tablet

A notched tablet which can be split into half with a pill cutter.

Buffered

A solid medication containing the active medication and an antacid,

Subcut and IM Vaccines into a Tattoo:

According to the Immunization Action Coalition (www.immunize.org), it is safe to give subcut and IM vaccines into a tattoo. However, it is not a good idea to inject into a newly tattooed area, If you must inject into a tattooed area, attempt to use a lighter pigmented area, All injections pose the risk of a reaction or an infection at the injection site. Dark pigments may mask a reaction or an infection.

Vaccine Information Statement (VIS)

Created by CDC, provides information to the patient or guardian/parent on the benefits and risks of the vaccine, The National Vaccine Childhood Injury Act requires that all patients (or parents/guardians) get the appropriate Vaccine Information Statement prior to every dose of vaccine administered regardless of the age of the patient for specific vaccines.

Blood Tuberculin Tests:

FDA has approved two blood tuberculin tests: -QuantiFERON-TB Gold In-Tube test (QFT-GIT), -T-SPOT TB test (T-Spot), -The blood test replaces the skin test. -If a patient has had the BCG vaccine or is unable to return for the skin test reading, the blood test is preferred, -The error rate with a blood test is much lower than with the palpated, measured reading of the TST, -After medical assistant draws patient's blood, it is sent to laboratory for analysis, -Positive: Person has been infected with TB, -Negative: It is unlikely that the person has TB.

Check the medication label against the order

Getting the medication from the storage, Before measuring the medication, and Before you return the medication to the storage area

Lumen:

Hollow space inside the needle, the size is indicated by the gauge number

Dorsogluteal injection site

No longer a recommended IM injection site because this site poses a high risk for injury.

Hub

Part of the needle attaches or screws onto the syringe.

If you hit a bone when giving an IM injection to a patient:

Pull the needle out about 1/4 inch and give the medication.

Viscosity

Resistance to flow.

Bevel:

Slanted end of shaft

Enteric coated

Tablet designed to pass through the acidic environment of the stomach and breaks down in the base environment of the intestines.

Wheal

Tense, pale elevation of skin; must measure 6-10 mm in diameter.

Solution

The active medication dissolves in the liquid.

Suspension

The active medication does not dissolve, but rather floats in the liquid.

Live virus vaccines

The microorganism is alive, but attenuated (weakened) in the laboratory. Vaccine examples include: MMR (measles, mumps, and rubella), varicella (chickenpox), zoster (shingles), and yellow fever.

Hilt:

Where needle attaches

Aspirate

Withdraw fluid using suction.