Chapter 53. Medication Administration

Interactions

Interactions may occur between two prescription or nonprescription drugs or between a drug and food and may cause serious effects. The greater the number of drugs the patient takes, including over-the-counter medications or supplements, the greater the chance of a drug interaction. Page 1089 Drug-Drug Interactions When two drugs are taken at the same time, there are several possible interactions. In some cases, the effects of both drugs are increased, causing either a toxic or beneficial effect. For example, when alcohol is combined with diazepam (Valium), there is the potential toxic effect of severe central nervous system depression because one drug intensifies the effect of the other. An example of a beneficial effect is the combination of acetaminophen and codeine, which increases the activity of both drugs, allowing the physician to prescribe a lower dose of each. In fact, this combination of drugs is available in one tablet (Tylenol® with codeine). In other cases, the effects of both drugs are decreased, or one drug cancels out the effect of the other. For example, combining propranolol (Inderal®) with albuterol (Proventil®) causes each drug to lose its effectiveness. In still other cases, the effect of one of the drugs is increased by the other. For example, the effect of digoxin (Lanoxin®) is increased by the presence of furosemide (Lasix®), but the furosemide still works at the same degree of effectiveness as when administered alone. Drug interactions can lead to adverse reactions. For example, a patient who takes the prescription blood modifier (anticoagulant) warfarin (Coumadin®) to prevent blood clots must avoid taking aspirin for pain relief. Taking these drugs together increases the risk of uncontrolled bleeding. To help prevent unintentional drug interactions, thoroughly check the patient's medication use. Be sure to ask about medications prescribed by specialists as well as OTC drugs and supplements. Question the patient about past and present use of alcohol and recreational drugs as well as herbal remedies. Update the chart as needed. If you detect a potential for drug interactions, notify the physician. Drug interaction checkers are available online. Also teach patients about possible drug interactions and how to avoid or minimize them. For example, patients may need to take certain drugs at least 4 hours apart. As an example, the hormone replacement drug Synthroid® and calcium should not be taken together. Instruct patients to call the office if they think their drugs are interacting adversely. Drug-Food Interactions Interactions between a drug and food can alter a drug's therapeutic effect. For example, taking tetracycline with milk can reduce the drug's effectiveness because of decreased absorption from the GI tract. The drug-food interaction between a monoamine oxidase (MAO) inhibitor (such as Parnate®, an antidepressant drug) and aged cheese or meat or other foods containing high levels of tyramine can produce a toxic effect. This interaction can cause a dangerous hypertensive crisis in which the patient's blood pressure rises quickly to dangerous levels, possibly leading to stroke and death. A food that may interact with drugs is grapefruit and grapefruit juice. Interactions with some heart or blood pressure medications, such as Nifedipine, might cause irregularities in heartbeat, called arrhythmia. Some drug-food interactions can affect the body's use of nutrients. For example, the cholesterol-lowering drugs cholestyramine resin (Locholest®) and colestipol HCl (Colestid®) may reduce the body's absorption of fat-soluble vitamins (A, D, E, and K) from food. When teaching a patient about drug-food interactions, specify exactly which foods to avoid and when. For example, a patient may drink milk or eat food several hours before or after taking tetracycline, whereas a patient taking an MAO inhibitor must avoid foods that contain high levels of tyramine at all times. Explain what to expect if an interaction occurs and describe how to deal with it. Adverse Effects Adverse effects or reactions associated with a drug and reported are somewhat predictable and range from mild adverse reactions, such as stomach upset, to severe or life-threatening allergic responses. For example, certain cholesterol-lowering medications, called statins (e.g., Lipitor®), can increase the likelihood of painful muscle disorders. Unpredictable adverse effects also can occur; they are unique to each patient. Elderly patients and patients with liver or kidney disease are more susceptible than others to adverse effects because these conditions affect drug metabolism and excretion. When drugs are not metabolized properly or excreted from the body quickly enough, drugs can reach toxic levels, even with normal doses. Page 1090 To help prevent adverse effects, teach the patient to take the drug at the right time, in the right amount, and under the right circumstances. For example, the patient may need to take a cephalosporin with food to avoid nausea and diarrhea. Also teach the patient to recognize significant adverse effects and to call the office if any of them occur. The patient also should report any change in overall health because that change could be drug-related. Tell patients to inform each of their doctors of any adverse reactions (including allergic reactions) they have had to drugs. Previous adverse reactions may prompt a doctor to adjust a dosage or select a different drug. A history of drug allergies may contraindicate the use of a particular drug. Complete Medication List Patients must inform the doctor of all substances they use regularly or periodically. This includes prescription and OTC drugs, plus herbals and supplements. It also includes past and present use of alcohol and recreational drugs. When patients have more than one doctor, tell them to inform each doctor about all medications they are taking. Encourage them to keep up-to-date medication lists with dosages (some patients keep this information on their home computers). This information can help patients and healthcare professionals prevent and monitor for drug interactions. The list should be kept on the patient chart and updated with every visit to the physician's office. Patient Compliance To help ensure that patients comply with instructions, confirm that they completely understand the name, dosage, and purpose of each drug prescribed for them. If patients must take more than one drug at a time, be sure they know the correct and relevant information for each one. In addition, cover each of the following points when educating patients about drugs: Explain how and when to take each drug to ensure its safety and effectiveness. Some drugs should be taken with food to minimize gastrointestinal irritation. Others should be taken on an empty stomach for proper absorption and metabolism. Some drugs must be taken once a day in the morning; others should be taken three or four times a day. If patients' medication schedules are complex, suggest that they create an alarm, chart, calendar, or diary to remind them of what drug to take and when, or create a schedule for them. Tell patients how long to take each drug. In the case of antibiotics, advise them to take the entire course of the drug as scheduled, even if they feel better before finishing it. In the case of medicines prescribed for chronic disease, advise patients that they will need to continue taking the medication unless the doctor tells them to stop. Be aware that some drugs, such as prednisone, must be tapered off slowly to prevent adverse reactions. Explain how to identify possible adverse effects of each drug and safety measures related to adverse effects. For example, instruct patients to avoid certain activities, such as driving or operating machinery, while taking a drug that causes drowsiness. If appropriate, inform patients that misuse of the drug may lead to dependence, and mention the dangers of drug dependence. Tell patients not to save medications that are over one year old or share them with anyone else. Old medications and those taken by people other than the patient for whom they were prescribed can cause severe, unexpected adverse effects. Advise patients to check the expiration date on all drugs and to discard them by wrapping in a tightly sealed container and placing in the trash. Flushing is not recommended due to possible water contamination. Some pharmacies will also dispose of medications for patients. Suggest that patients avoid alcohol when taking certain drugs. Alcohol interacts with some drugs, causing adverse effects such as lethargy, confusion, or coma. Tell patients to ask their pharmacists where to store each medication. Some drugs must be refrigerated. Others should be kept in a dry, cool area. Drugs should not usually be kept in a hot, damp place, such as a bathroom. They must always be kept out of the reach of children. Tell patients to take their drugs in a well-lit area so they can read each drug label carefully before taking each dose. They should never assume that they are taking the right medication without reading the label on the container. If patients have poor vision, print the name of the drug and the dosage schedule clearly on a separate piece of paper or card to attach to the medication container. Instruct patients to call the doctor if they have any questions about their drug therapy.

Charting Medications

Whenever a patient receives some form of treatment, such as medication, a record is kept of that treatment. Special problems or circumstances are also recorded, such as new symptoms, the patient's own statements, and how the patient tolerated the medications or treatment. Most charting in the physician's office is documented on a progress note or a medication administration record (MAR). These documents are essential to serve as communication tools for all healthcare members who are connected to that patient. The medical record is considered a legal document and is taken as proof that medication or treatment was administered to the patient. All chart entries must be factual, accurate, complete, current, organized, and confidential. Avoid using words or statements that can be interpreted as your opinion. For example, if a patient gags and spits up cough syrup that you just administered, you would not write that the patient did not like the taste of the medication; you would simply state, "patient experienced difficulty in swallowing medication and expelled medication." Avoid terms like "appear" or "seems," which can lead you to draw assumptions without objective data to support them. Be specific. Chart what the patient said or did, not what you think. Use abbreviations when appropriate because they allow you to say a great deal in a small space. Page 1091 Review your office's medical records to keep consistent with the charting methods used in them. Follow these few simple rules: Before you begin, make sure you have the right chart and the right location in the chart. Chart medications directly from the physician order. Be specific. Do not write, "Gave Demerol for pain in the evening." Instead, write, "(Date), Demerol 100 mg given IM in right upper outer quadrant of gluteus maximus for c/o sharp pain, rated 7 on a scale of 10, in left arm, lot number, expiration date, initials." If using paper charts, do not leave gaps or skip lines. If an entry does not fill a complete line, draw a straight line to fill the gap. Put your signature or first initial and last name and title at the right side directly after the note. If you make an error, do not erase it. Draw a line through the mistake. The mistake should still be visible, so do not black it out. Initial it and then rechart the information correctly. Follow the specific procedure for making corrections in an electronic health record. Never use ditto marks. Write neatly in longhand or carefully enter into the electronic chart and check your note before submitting it. Ensure that your spelling is accurate. Use abbreviations and correct symbols. Most facilities have an approved abbreviation list to use as a reference. If you are unsure about charting, check with your supervising licensed practitioner. See Figure 53-17 for an example of complete and accurate charting.

Patient Consent Form

Many physicians require that a patient sign a consent form before receiving an injection. A consent is necessary for vaccines, for example. This form provides general information regarding the medication or vaccine and lists the possible side effects or adverse reactions. If a consent form is needed, make sure that the patient signs the form and that you have answered any questions prior to giving the injection.

Handling Medication Errors

Medication errors are a serious, yet inevitable, problem. Great care should always be taken to prevent them. However, if an error does occur, no matter the cause, it must be reported. Immediately tell the licensed practitioner. Not reporting an error is unethical and in some cases illegal, especially if a serious consequence occurs. Most facilities require that an incident report be completed. This form documents the error. It is completed and then signed by everyone involved, as well as your supervisor. Errors also are reported online through an online program developed by the U.S. Pharmacopeia and the Institute for Safe Medical Practices. Reporting errors at these sites provides information to assist in the prevention of errors.

Inhalation Therapies

nhalation therapy is medication that is delivered into the respiratory system during inhalation. This medication can be administered through the mouth or nose. There are a number of disorders for which the physician may order an inhaler or aerosol form of medication. For example, an oral inhaler is frequently used by patients with asthma, whereas a nasal inhaler is frequently used for local treatment of nasal congestion. Nasal inhalers also are used to administer medicines for systemic effect, such as a vasopressin derivative for nocturnal bedwetting. Some types of influenza vaccines are now delivered by nasal inhalation. Always read the inserts for inhaled drugs for a detailed description of the exact procedure for the type of inhalation you will be administering. Procedure 53-8, at the end of this chapter, provides the basic steps of the procedure, as well as needed patient education.

Forms of Packaging for Parenteral Drugs

A cartridge is a small barrel prefilled with a sterile drug. It slips into a special, reusable syringe assembly. An ampule is a small glass or plastic container that is sealed to keep its contents sterile. It must be opened and used with care, as described in Procedure 53-3, at the end of this chapter. A vial is a small bottle with a rubber diaphragm that can be punctured by needle. A vial contains a liquid or powder, which must first be reconstituted with a diluent (liquid used to dissolve and dilute a drug), as described in Procedure 53-4, at the end of this chapter. It may contain a single or multiple doses. This procedure requires two needles and syringe sets—one for inserting the diluent into the vial and another to draw and administer the reconstituted drug—to avoid using a contaminated needle. The first needle is considered contaminated when you set it down to mix the diluent and the drug

Buccal and Sublingual Administration

Although buccal and sublingual drugs are placed in the mouth, they do not continue along the GI tract. Instead, they dissolve and are absorbed in the buccal area (between the cheek and gum) or the sublingual area (under the tongue), where they are placed. The medication is absorbed through tissue that is rich in capillaries and the drug enters the bloodstream directly. Because the drug does not pass into the stomach or intestines before absorption, it produces a therapeutic effect more quickly than do oral drugs. Specially formulated tablets may be given by the buccal or sublingual routes. When you administer buccal or sublingual medications, your role usually includes teaching the patient how to administer these medications at home. See Procedure 53-2, Administering Buccal or Sublingual Drugs, at the end of this chapter.

Intravenous

Although intravenous (IV) injections are not commonly performed in a medical office or by medical assistants, certain drugs may be administered this way. Drugs also may be mixed and dissolved into a solution (a homogeneous mixture of a solid, liquid, or gaseous substance in a liquid) and given by IV infusion (slow drip) into a vein. Examples of IV drugs include powerful antibiotics, chemotherapeutic drugs, emergency drugs, and electrolytes. Because these drugs are introduced directly into the bloodstream, they produce an almost immediate effect. They also can cause sudden adverse reactions. Although in most cases a licensed practitioner must administer an IV drug, you may assist by laying out supplies and equipment. When assisting with any intravenous medications, gather the ordered drug and a tourniquet, bedsaver pad, gloves, iodine and alcohol swabs, venipuncture device, tape, and gauze pad, as ordered. Obtain other supplies and equipment depending on the specific type of infusion or injection being administered.

Patient Education about Medications

As a medical assistant, you have an important role in patient instruction about medications. This role may vary depending upon your state, training, or place of employment, but the importance of drug education should not be underestimated. Specific instructions should be given about all the drugs a patient is taking, whether prescription or over-the-counter (OTC). Patients also should know how to take and record their medications safely and correctly. Over-the-Counter Drugs Even though patients can obtain OTC drugs without a prescription, they need to know several important facts to use them safely. Patients should not treat themselves with OTC drugs as a way to avoid medical care. For example, OTC drugs are available to treat recurrent yeast infections. Nonetheless, a patient should consult a doctor the first time she develops an infection. Patients also should know that OTC drugs may not produce enough therapeutic benefit in some cases or be dangerous when used in combination with other substances. For example, a combination of the OTC medication acetaminophen (Tylenol®) and alcohol can cause liver damage. In addition, some OTC drugs may even mask symptoms or aggravate a problem. Many OTC drugs contain more than one active ingredient. These extra ingredients, such as aspirin, acetaminophen, or caffeine, can cause allergic reactions or other undesirable effects. Excess caffeine can cause elevated heart rates. Too much acetaminophen (Tylenol®)—over 4 grams in 24 hours—can inadvertently be taken, causing severe liver damage. Prescription Drugs Before patients begin drug therapy, they should be informed of certain considerations (such as when and how to take the drug) and drug safety precautions. First you must check a credible drug information resource about any drug with which you are not familiar. As part of your patient education, provide instructions orally and, if possible, in writing. For commonly prescribed medications, you can obtain preprinted information sheets or create one using an electronic health record (EHR) program. Most pharmacies now routinely provide these with each dispensed drug. See Figure 53-15. An important aspect of this kind of information is teaching the patient how to read a prescription drug label. Instruct the patient to be particularly alert for special instructions and warning labels, such as those shown in

Patient Condition

Before administering a drug, assess the patient's overall condition. For example, does the patient have a viral infection? Vaccines are not recommended if the patient has a viral infection such as a common cold. In addition, review the patient's drug list to ensure that any medications already being taken will not interfere with the ordered drug or route of administration. Also, verify again that the ordered dose is appropriate for the patient's age and weight.

Rectal Administration

Certain medications, such as drugs used to treat constipation, nausea, and vomiting, may be administered by the rectal route. These medications may be given in the form of suppositories or enemas and may produce local or systemic effects. See Procedure 53-12, at the end of this chapter.

Pediatric Patients

Children pose special challenges in drug administration and use. Their physiology and immature body systems may make drug effects less predictable because drugs are absorbed, distributed, metabolized, and excreted differently in children than in adults. Therefore, plan to observe a pediatric patient closely for adverse effects and interactions. A child's small size increases the risk of overdose and toxicity. These factors require dosage adjustments and careful measurement of small doses. To help administer drugs safely to pediatric patients, always check your calculations for providing a prescribed dose, and then ask a licensed practitioner to double-check them. Administration sites and techniques for a child may differ from those for an adult. For example, fewer IM injection sites can be used for a young child. Also, the technique for eardrop administration varies slightly (see the Assisting with Eye and Ear Care chapter). When dealing with an infant or young child, teach the parents—not the patient—about the drug. With an older child, include parents and patient in the teaching session. Be sure to use age-appropriate language when speaking to children. Patience and sensitivity are important when working with pediatric patients. The first memorable exposure to an office visit may often determine how the child will react to physician visits for years to come. Infants and children can sense when you are irritated or annoyed. Pay close attention to your nonverbal communication as well as your verbal communication. New mothers are often apprehensive about invasive procedures when it concerns their children and this apprehension is often reflected in the child. Empathy and compassion are needed to ensure that the office visit is a pleasant one. Administering medications to a pediatric patient may become a challenge if the child is not cooperative. It is important to ensure that the child receives the full dose as ordered. Oral Medications When administering oral medications to children, follow these guidelines: Administer the medication to the side of the tongue; this method prevents the child from spitting out the medication. Hold the child until you are sure the medication is swallowed. In some cases you may gently hold the child's mouth closed to ensure that the medication is swallowed. Page 1087 If a small amount dribbles from the mouth, do not attempt to give more medication to the child. If the child vomits within 5 minutes and you can see the medication in the vomit, you should readminister the medication after the child is calm. If you are unsure of readministering medication, consult with the physician. If the medication comes only in tablet form and the child is unable to swallow a tablet or capsule, check a creditable drug reference to see if the medication can be crushed and given with food, such as applesauce.

Introduction

Drug administration is one of the most important and most dangerous duties for a medical assistant. By following the procedures for proper drug administration, you can help restore patients to health. If you calculate dosages inaccurately, measure drugs incorrectly, or administer drugs improperly, patients' medications may have no therapeutic effect, may worsen their disease or abnormal condition, or may even cause them to die. To administer drugs safely and effectively to all patient groups, including pediatric, pregnant, and elderly patients, you must know and understand the principles of pharmacology (see the Principles of Pharmacology chapter) and how to perform dosage calculations (see the Dosage Calculation chapter). This chapter prepares you to understand the fundamentals of drug administration, including the following: Rules and responsibilities of drug administration. Rights of drug administration. Routes of medication administration. Techniques needed to administer drugs. Special patient considerations. Patient education. Your role may vary depending upon the state and practice where you are employed. Many states have medical practice acts that define the exact duties of medical assistants in drug administration. For example, an act may specify which drugs you are allowed to administer and by which routes. Because state laws vary, you need to research the scope of practice for medical assistants in the state where you will work.

Administration Site

Drugs may be administered for either local or systemic effects. Generally, drugs that have local effects are applied directly to the skin, tissues, or mucous membranes. Drugs that produce systemic effects are administered by routes that allow the drug to be absorbed and distributed in the bloodstream throughout the body. These various routes are discussed in the Drug Routes and Equipment section of this chapter. Before you administer a drug, you must check the site of administration. For example, if you are asked to give an oral medication, you would make sure the patient can take the medication. You may ask if the patient is nauseated, can swallow a pill, or has had anything to eat or drink, depending upon the medication. For an injection, you must locate and inspect the injection site. Find the appropriate injection site by using anatomical landmarks. Inspect the skin by checking for the following conditions, which may eliminate the site: Moles Scars Birthmarks Traumatic injury Redness Rash Edema Cyanosis Burns Tattoos Side of a mastectomy Paralyzed areas Warts If you are unsure about any of these conditions, inform the physician.

Methods of Injection

Injections are the most common method of drug administration in a medical office. You need to be knowledgeable about all injection methods: intradermal, subcutaneous, intramuscular, and intravenous. Intradermal An intradermal (ID) injection is administered into the upper layer of skin at an angle almost parallel to the skin, as described in Procedure 53-5, at the end of this chapter. Common sites for intradermal injections are the forearm and back. Intradermal injections are usually used to administer a skin test, such as an allergy test or a TB test. When choosing an injection site on patients, avoid scarred, blemished, or hairy areas because those features interfere with your ability to interpret test results on the skin. The drug is injected under the top skin layer and a little bubble or wheal is raised. If the body reacts to the drug, erythema (redness) and induration (hardening) occur. This reaction generally takes place 15 to 20 minutes after an allergy test and from 48 to 72 hours after a TB test. Subcutaneous A subcutaneous (subcut) injection provides a slow, sustained release of a drug and a relatively long duration of action. Generally, 1 mL or less of a drug can be delivered by a subcut injection (Procedure 53-6, at the end of this chapter). Various drugs, such as insulin and heparin, are commonly administered by a subcut injection. Common subcutaneous injection sites include an area on the back between the shoulder blades, the outer sides of the upper arms and thighs, and the abdomen (except for a 2-inch area around the umbilicus). To prepare for a subcut injection, select a site away from bones and blood vessels. Do not use an area that is edematous (swollen), scarred, or hardened or one that has a large amount of fat because these areas may not have the capillary network needed for absorption. When patients need regular subcut injections, remember to rotate injection sites systematically. Begin the rotation pattern by giving injections in rows in the same area of the body (such as the abdomen). After all those sites have been used once, proceed to the next area on the body (such as the right leg) and follow a similar pattern there. Rotating sites promotes drug absorption and prevents hard subcutaneous lumps from forming. At the injection site, ensure that you can pinch at least a 1-inch skin fold for the injection. If a patient is frail, dehydrated, or thin, you may need to use a site other than the back or abdomen to provide the necessary fold of skin

Medications by Injection

Medications given by injection are called parenteral medications. Parenteral administration is the administration of a substance such as a drug by muscle, vein, or any means other than through the GI tract. Although the parenteral route offers the advantage of rapid drug action, it has several potential drawbacks. Parenteral administration poses more safety risks for the patient because after the drug has been injected, it cannot be retrieved. Parenteral administration also increases your risk of potential exposure to bloodborne pathogens when you perform injections and dispose of used needles. To minimize risks, follow Standard Precautions during injections. Also adhere to Occupational Safety and Health Administration (OSHA) and Environmental Protection Agency (EPA) regulations for disposing of contaminated needles and other sharp items. Offices must provide a rigid, puncture-proof container for collecting disposable sharp instruments. This container must be self-sealing and must have a lock-tight cap and a safety neck. After using a needle, lancet, or syringe, engage the safety mechanism, then immediately place it in the sharps container. See Figure 53-4. To avoid puncturing yourself, always ensure the safety mechanism is engaged and do not force the needle, lancet, or syringe into the container. If you do accidentally stick yourself, notify the physician at once so you can be treated. OSHA requires medical follow-up for all workers who have been accidentally punctured. Never let a sharps container become full. When the container is two-thirds full, seal it and follow your office procedure for container disposal.

Medications by Mouth

Medications that are put in the mouth are usually swallowed. This is called oral administration. Medications that are not meant to be swallowed also may be placed in the mouth. These methods include buccal and sublingual administration. Oral Administration Drugs that are swallowed are absorbed relatively slowly as they travel along the gastrointestinal (GI) tract. Drugs for oral administration include tablets, capsules, lozenges, and liquids. One special type of tablet you should be aware of is a scored tablet. See Figure 53-3. This means that the medication can be broken into pieces along a scored (indented) line on the tablet. Oral administration is contraindicated in patients who have severe nausea, are comatose, or cannot swallow. Certain drugs are ineffective when administered orally because the digestive process changes them chemically to an ineffective form or does not deliver them to the bloodstream quickly enough. Many drugs, however, are most effective when given orally. These include antibiotics, vitamins, throat lozenges, and cough syrups. Although these drugs are familiar to most people, as a medical assistant, you must follow certain steps to ensure that the patient understands the drug and that the drug is administered safely and effectively. The steps for oral administration are outlined in Procedure 53-1, at the end of this chapter.

General Rules for Drug Administration

No matter what drug or administration route is ordered, follow these general rules when administering drugs. Give only the drugs the physician has ordered. Written orders are preferable, but oral orders are appropriate for emergencies. If you are unfamiliar with any aspect of a drug the physician orders, consult a credible drug reference. Wash your hands before handling the drug. Prepare the drug in a well-lit area, away from distractions. Focus only on the task at hand. Perform a "Triple Check" by checking the medication three times. Check the medication three times even if the dose is prepackaged, labeled, and ready to be administered. 1st check—when you take it from the storage container and match it to the medication administration record (MAR). 2nd check—when you prepare it. 3rd check—before you close the storage container or just before you administer the medication to the patient. Calculate the dose if necessary. See the Dosage Calculation chapter. Remember, if you are unsure of your computation, ask another medical assistant or a licensed practitioner to check it. Avoid leaving a prepared drug unattended and never administer a drug that someone else has prepared. Ask the patient to state his name and date of birth to ensure correct identification. Double-check with the patient about possible drug allergies. Do not rely on documentation in his chart; he may have developed a new allergy that has not yet been added to the record. Be sure the physician is in the office when you administer a drug or vaccine. If the patient develops an anaphylactic reaction (sudden, severe allergic reaction) to the drug or vaccine, the physician must administer epinephrine. After administering the drug, ask the patient to remain in the facility for 10 to 20 minutes so that you can observe the patient for any unexpected effects. Give the patient specific instructions about the effects of the drug as well as general information about drug use. If the patient refuses to take the drug, discard it according to your facility policy. Do not flush it down the toilet or return it to the original container. Be sure to document the refusal in the patient's record and tell the physician. Page 1078 If you make an error in drug administration, tell the physician immediately. See the Caution: Handle with Care feature Handling Medication Errors. Document immediately the drug and dose administered; never document administration before giving medicine.

Pediatric Injection Sites

Pediatric patients have less muscle development than adults do, which limits the sites for intramuscular injections. The deltoid muscle is not developed enough for an injection and can be painful for the child. The sciatic nerve is larger in children; dorsogluteal injections are therefore not recommended because of the danger of hitting the sciatic nerve. The vastus lateralis and ventrogluteal sites are recommended for infants and children. The vastus lateralis site is good because it is a large and thick muscle that is developed before the child begins to walk. It is also the most desirable site for infants and children because it is not near major nerves and blood vessels. For a child who has been walking for about a year, you can use the ventrogluteal or dorsogluteal site. For an older, well-developed child, use any adult site. The vastus lateralis site is an easier site if you need to incorporate restraining methods. The most common injections given to pediatric patients are vaccines. Most vaccines are given intramuscularly with a 25-gauge, ⅝-inch needle. The gauge and length vary based on the size of the patient. Use the shortest length needle that will allow you to reach muscle, usually ⅝ to 1 inch. In many cases, pediatric patients require more than one vaccine injection in a single limb (vastus lateralis). When this is the case, the injections should be at least one inch apart on the site and the specific location of each vaccine should be documented. Restraining MethodsSometimes a pediatric patient will need to be restrained in order for you to administer an injection. Two medical assistants may be needed to safely restrain a child while giving an injection. Common restraining methods include the following: Have the child "hug the mother." The mother holds the child in front of her, with the child's thighs extended on either side of her torso. As the mother is talking to her child, make the injection in the vastus lateralis. Weight-bearing restraining is better than muscular control. Have the child sit on the edge of the examining table and use your weight to immobilize the child's legs against the table.

Vaginal Administration

Physicians usually prescribe vaginal drugs to treat local fungal infections. The drugs also may be used for local bacterial infections. They are usually packaged as suppositories (the most common form), solutions, creams, ointments, and foams. The liquid form of vaginal medication is administered by performing a douche (vaginal irrigation). This process is similar to giving a urethral drug, but it requires a special irrigating nozzle. Patients frequently ask about administering vaginal medications, and they usually administer such medications at home. Therefore, you must be prepared to provide detailed patient education for this route of administration. The physician may ask you to administer the first dose as a means of teaching a patient the method to use at home, or you may be asked to administer a one-time-only dose. See Procedure 53-11, at the end of this chapter.

Injections

Stress and anxiety will differ from child to child. When giving injections to pediatric patients, the following steps will help ensure a smooth procedure: Distract the patient. Talk to the child while giving the injection. Don't ask permission. Often the injection is performed and over before the child realizes it. Use an anesthetic topical agent prior to the injection. This can be applied in the office or at home before the patient arrives in the office. Try not to allow the child to see the syringe before giving the injection. Be swift. Do not allow a lot of time to pass before giving the injection. The faster the better. Praise the child. Say things that promote maturity and self-esteem.

Syringes

Syringes have two basic parts: a barrel and a plunger. The barrel is the calibrated cylinder that holds the drug. The plunger forces the drug through the barrel and out the needle. The syringe may be packaged with the needle attached and a guardcap over the needle, or the syringe and needle may be packaged separately. All syringes must include a needlestick prevention safety device. See Figure 53-8. Syringes come in many sizes and are calibrated according to how the syringe will be used. For example, the common 3-mL syringe is divided into tenths of a milliliter. It is used to measure most drugs. A tuberculin (TB) syringe holds 1 mL and is calibrated in hundredths of a milliliter. Insulin syringes are calibrated in units (U), commonly either 50 U or 100 U (Figure 53-9). Unlike other syringes, insulin syringes have permanently attached needles and no dead space (fluid remaining in the needle or syringe after the plunger is depressed fully). These differences help the patient self-administer the correct amount of insulin.

Drug Routes and Equipment

The physician may ask you to administer drugs by one of the routes outlined in Table 53-2. Most patients take a prescription to a pharmacy to be filled and then take oral drugs at home, so you may not need to administer these drugs in the office very often. However, you are likely to be asked to do the following: Place drugs in the patient's mouth between the cheek and gum or under the tongue. Administer a drug by any means other than by mouth (if permitted by your scope of practice and state laws). Demonstrate how to use an inhaler. Apply topical drugs (those applied to the skin). Administer or assist in administering drugs into the urethra, vagina, or rectum. Administer medications to the eye or ear, as discussed in the Assisting with Eye and Ear Care chapter. These duties require you to master a variety of techniques to give drugs safely by any route.

Rights of Medication Administration

The rights of medication administration are a set of safety checks the medical assistant should follow to prevent a medication administration error. When administering medications, the medical assistant must observe the rights of medication administration (see Table 53-1) to avoid errors and ensure patient safety. The six basic rights of medication administration include right patient, right drug, right dose, right route, right time, and right documentation. A violation of any of the six basic rights constitutes a medication error. Additional rights include right reason, right to know, right to refuse, and right technique.

Urethral Administration

The urethral route is used when antibiotic and antifungal drugs are needed locally—that is, at the site of infection—for some urinary tract infections. Depending on the nature of the infection and the duration of drug action, the physician or a nurse may instill liquid drugs only one time or several times a day for a week. Urethral administration is used in both men and women. Urethral drug administration requires passing a small-diameter urinary catheter into the bladder, instilling a drug through it, and clamping the catheter to let the drug bathe the urinary bladder walls. See Procedure 53-10, at the end of this chapter.

Preparing to Administer a Drug

To administer drugs, you should know the uses, contraindications, interactions, and adverse effects of common drugs. You should be familiar with the medications frequently prescribed in your practice. Furthermore, to be able to assume a role in patient education, you must be comfortable with all aspects of drug administration so that you can instruct patients about the drugs prescribed to them. Although the physician gives the order to administer a drug, the medical assistant has a lot of responsibility before a medication can be administered. As a medical assistant, you will often interview the patient. You must be alert to—and inform the doctor of—any change in the patient's condition that could affect drug therapy. Some preparation tasks are related to the drugs and drug allergies, administration site, patient condition, and patient consent. Drugs and Drug Allergies Before any medication is given, the physician should be aware of the current medications the patient is taking. As you learned in the Principles of Pharmacology chapter, some medications, including herbal medications, can interact in a negative way, so the physician needs to know everything the patient is taking before he orders a medication. The medical assistant is responsible for ensuring that a complete and accurate medication list is maintained on the patient's chart. This medication list must be updated every time the patient comes for an appointment. While asking about medications, you also must ask the patient about any drug allergies. Even though you may see a patient on a regular basis, be in the habit of asking about drugs and drug allergies at every patient visit. Patients often see other physicians or specialists, who may have prescribed different medications. A patient could have had a drug reaction to a medication that has been prescribed by another physician. If applicable, document in the patient chart "NKDA" or "no known drug allergies." See Figure 53-1.

Topical Application

Topical application is the direct application of a drug on the skin. Topical drugs can take the form of creams, lotions, ointments (salves), tinctures, powders, sprays, and solutions, which are used for their local effects. They include antibacterial and antifungal drugs, as well as corticosteroids. To apply a cream, lotion, or ointment, use long, even strokes with a cotton-tipped applicator and/or a gloved finger when rubbing it into the skin. Follow the direction of the hair growth to avoid irritating the hair follicles and skin. To apply a powder, shake it on but do not rub it in. A specialized type of topical administration that produces a systemic effect is the transdermal system (or patch). See Figure 53-13. A drug administered through the transdermal patch is absorbed through the skin directly into the bloodstream. The patch slowly and evenly releases a systemic drug, such as scopolamine, nitroglycerin, estrogen, or fentanyl, through the skin. The patient receives a timed-release dose, usually over a day or several days. See Procedure 53-9, at the end of this chapter.

Intramuscular

When a patient requires rapid drug absorption, you may be asked to administer an intramuscular (IM) injection, as described in Procedure 53-7, at the end of this chapter. An IM injection usually irritates a patient's tissues less than a subcut injection and allows administration of a larger amount of drug. Common IM injection sites include the ventrogluteal, vastus lateralis, and deltoid muscles, illustrated in Figure 53-11. The dorsogluteal is rarely used because of the chance of hitting the sciatic nerve. Before giving an IM injection, identify the site carefully to prevent injury to blood vessels and nerves in the area. As with subcut injections, rotate sites if the patient must receive regular or multiple IM injections. Take into consideration the patient's layer of fat when choosing an IM injection site. You want the injection to penetrate beyond the fat layer to muscle. If, for example, a patient is heavy in the buttocks and thighs, the deltoid may be the best site for administering an IM injection. When injecting an IM drug that can irritate subcutaneous tissues, such as iron dextran (Imferon), use the Z-track method, illustrated in Figure 53-12. To do this, pull the skin and subcutaneous tissue to the side before inserting the needle at the site. After the drug is injected, release the tissue. This technique creates a zigzag path in the tissue layers, which prevents the drug from leaking into the subcutaneous tissue and causing irritation.

Pregnant Patients

When dealing with pregnant patients, remember that you are caring for two patients at once: the mother and her fetus. When you give the mother a drug, you also may be giving it to the fetus. Some drugs can cause physical defects in the fetus if the mother takes them during pregnancy (especially in the first trimester). It is extremely important to double-check the drug in a credible drug reference for toxicology or pregnancy warnings. After administering the drug, assess the patient carefully for therapeutic and adverse effects of the drug. If the physician orders a drug for a pregnant patient, double-check the order against the pregnancy drug risk categories discussed in the Principles of Pharmacology chapter. If it is a high-risk drug, check with the physician before administering the drug. Patients Who Are Breast-Feeding Some drugs are excreted in breast milk and can thus be ingested by a breast-feeding infant. This ingestion can be dangerous because infants have immature body systems and cannot metabolize and excrete drugs that are safe for the mother. Some drugs, such as sedatives, diuretics, and hormones, can reduce the mother's flow of breast milk. Whenever a drug is ordered for a patient who is breast-feeding, check a drug reference to see whether the drug is contraindicated during lactation. If so, consult the doctor. If not, teach the mother to recognize signs of adverse drug effects in her infant. If a mother must take a drug that affects lactation, advise her to supplement breast-feedings with infant formula.

Needles

When you administer a parenteral drug, you must select the appropriate needle, syringe, and drug form to use on the basis of the type of injection. The following are methods of injection: Intradermal (ID), or within the upper layers of the skin. Subcutaneous (subcut), or beneath the skin. Intramuscular (IM), or within a muscle. Intravenous (IV), or directly into a vein. Needles consist of a hub, hilt, shaft, lumen, point, and bevel (Figure 53-6). The hub of the needle fits onto the syringe. The needle tip is beveled (sloped at the opening). The bevel helps the needle cut through the skin with minimum trauma. Needles are available in various gauges (inside diameters) and lengths (Figure 53-7). A needle's gauge is expressed with numbers. The smaller the number, the larger the gauge. For example, a 25-gauge needle is smaller than an 18-gauge needle. Use the right gauge for the type of injection and the viscosity (thickness) of the drug to be administered. For example, use a large-gauge needle for a highly viscous drug. When selecting a needle, also consider its length. It must be long enough to penetrate the appropriate layers of tissue, but not so long as to go too deep. Choose the correct needle length on the basis of the type of injection as well as the patient's size, amount of fatty tissue, and injection site. Table 53-3 lists the approximate ranges of needle gauge and length that are typically used for intradermal, subcutaneous, and intramuscular injections.