medications (exam 2)

Common forms of liquid medications are elixir, syrup, suspension, and solution.

Elixir- contains water, alcohol, sweetener, and the medication. Ex: the combination medication hydrocodone and acetaminophen. Syrup- contains water, concentrated sugar, and the medication. Ex: valproic acid (antiepileptic med that comes in an oral syrup). Suspension- contains small, fine particles of the medication that do not dissolve completely in water. Shake or stir a suspension immediately prior to administration. Ex: ampicillin (antibiotic med that comes in an oral suspension). Solution- contains medication dissolved in water or 0.9% sodium chloride. Ex: furosemide (loop diuretic that comes in an oral solution).

Injectable Medications: routes

Routes for medications administered parenterally: you can administer many medications by multiple routes. When prescribing medications, the provider will specify which route to use. Make sure to give medications by the right route. Intradermal- intradermal injections administer small amounts of fluid (less than 0.1 mL) into the dermis. Sites for intradermal injections should be easily accessible for monitoring (relatively hairless, free of wounds/lesions/tattoos). The forearm and upper back are often chosen for administration of intradermal injections. This route is used to perform diagnostic testing for TB and allergies. A small syringe- usually a tuberculin syringe- and a 25 or 27 gauge, 6.35 - 16 mm (¼ - ⅝ in) needle is usually chosen to administer the infection. After cleaning the injection site, pull the skin taut using your nondominant hand to decrease the client's discomfort and make the insertion of the needle easier. Insert the needle at a 5-15 degree angle with the bevel (edge of needle that is sloped) up and advanced around 3mm (1/8 in). Inject the medication slowly; a small bleb (bubble) should appear. After injecting the medication, withdraw the needle at the same angle it was introduced. Subcutaneous- subcutaneous injections are administered into the tissue just below the dermis. The absorption rate of medications administered subcutaneously is slower than for medications given intramuscularly. Anticoagulants (heparan, enoxaparin, and insulin) are administered subcutaneously. Sites for subcutaneous injections include the outer posterior aspects of the upper arm, the abdomen, the upper back, the upper area of the hip below the waist, and the anterior and interior aspects of the thighs. These sites are convenient and have good blood supply. Administer heparin and enoxaparin in the abdomen. When administering medication into the abdomen, choose a site that is at least 2 inches away from the umbilicus. Always choose a site with no skin lesions, and avoid areas over bony prominences. In most cases, only administer small volumes of medications (0.5 - 1 mL). The needle size and angle of injection vary depending upon the site, the client's body weight, and amount of subcutaneous tissue present. Typically, subcutaneous injections are administered with a 24 - 30 gauge, 12 to 16 mm (5/8 - 1/2 in) needle. The shorter needle is inserted at a 45 degree angle, and the longer needle is inserted at a 90 degree angle. In general, use a needle length that is half the width of the injection site skinfold. If the skin fold is 1 inch or less, insert the needle at a 45 degree angle. Use a 90 degree angle if the skin fold is greater than 1 inch. Intramuscular- IM injections are used to administer larger volumes of medications. Because of the increased blood supply, muscle tissue is often the site for medication injections (morphine, cyanocobalamin) and some vaccinations (hepatitis B, tetanus). Muscles have greater vascularity than subcutaneous tissue. Therefore, the absorption rate for IM injections is faster than the subcutaneous route. However, there can be a risk of complications (nerve injury, abscesses, fibrosis, thrombosis- blood clots). Identify landmarks and select the correct needle size when administering IM injections. The needle size depends on the size of the client, muscle being used for the injection, and viscosity of the medication. Medications that are thicker (more viscous) require a larger gauge needle. Assess the muscle and surrounding area for the presence of lesions, tenderness, and nodules; these are contraindications (reasons why it shouldn't happen) to administering an IM injection. Larger muscles (ventral gluteal, vastus lateralis) can receive larger amounts of medication (1 mL) for older infants and young children, and 2mL for older children/older adults/and individuals who are thin. Some adults have muscles that are developed enough to tolerate up to 3mL of medication. a) Ventrogluteal muscle- preferred injection site for children and adults because it isn't close to any major nerves or blood vessels. Locate the site for injection into the ventrogluteal muscle by placing your palm on the client's greater trochanter with your thumb pointed toward the client's groin. The index finger should lie across the anterior superior iliac spine, and the middle finger just under the iliac crest. The injection site is in the middle of the triangular area formed by the index finger, middle finger, and iliac crest. b) Vastus lateralis muscle- located on the anterolateral aspect of the thigh and is generally a well-developed muscle in kids and adults. It is the preferred site of IM injections for infants. The vastus lateralis extends from the midline of the anterior thigh to the midline of the lateral aspect of the thigh. When determining the site for injection into the vastus lateralis, select an area that is in the middle third of the thigh between the greater trochanter and just above the knee. c) Deltoid muscle- located in the upper arm. It is relatively small and not well developed in adults, although it can be used for immunizations for adults and children older than 18 months. The deltoid is located near many nerves and arteries, so it is usually not the best choice for IM injections. If using the deltoid site, administer no more than 1mL of solution. To determine the injection site, find the center of the upper arm that is 3 - 5 cm (1-2 in) below the acromion process. Intravenous injection- used for administering medication and providing fluids, electrolytes, and nutrition. a) Short peripheral IV catheter- less than 3 in long. The tip of the catheter rests in a superficial vein in one of the client's extremities. b) Central lines- terminate in the superior vena cava. Central lines include peripherally inserted central catheters (PICC), tunneled and nontunneled central venous catheters, and implanted ports. Peripherally inserted central catheters- nurses who have advanced education and training insert PICC lines peripherally into a vein in the upper arm and thread it so that the tip of the catheter lies in the superior vena cava. PICC lines can be used for clients requiring administration of long-term IV medications, vesicant medications, and parenteral nutrition. Nontunneled central venous catheters- inserted into either the subclavian vein in the upper chest, or through the internal jugular vein by a physician or advanced practice nurse. It is commonly used in cases of trauma and critical care. Regardless of the site of insertion, the tip of a central catheter lies in the superior vena cava.

administration of powdered medications

use and administer reconstituted medication in the same way as other liquid medications (oral, IV, IM, or subcutaneous).

Insulin sources-

variety of sources. The source can affect the insulin's onset, peak, and duration times. In the US, available forms of insulin are produced using recombinant technology. Manufactured human insulin is identical to insulin that is produced by the human body. Human insulin analogs are modified to alter the rate of absorption and the duration of action.

Use of syringes: injections

Calibrated syringes- when measuring injectable medications, use a calibrated syringe to ensure accurate measurements. Most liquid dosages are labeled and prepared in strengths per milliliter. Syringes are calibrated by milliliter; depending on the size of the syringe, the calibrations can be in tenths or hundredths of a milliliter. Some syringes have a luer-lock tip. Luer-locks are designed to securely hold a needle in place, as well as to administer medications as part of a needleless system. In this case, the luer-lock syringe is attached to a hub on IV tubing or a saline lock for administration of medication, minimizing the risk of needlestick injuries. Syringe size- base the choice of syringe size on the volume of the medication to administer. Use the syringe with the calibration that is closest to the volume of medication you will administer and with calibrations that allow for the most accurate measurement. Syringes from 3 to 5 mL are often used for subcutaneous, intramuscular, and intravenous administration. Tuberculin and insulin syringes hold 0.3 - 1 mL of fluid. Tuberculin syringes are calibrated (marked) in hundredths of a millimeter, while insulin syringes are calibrated in units. Use the proper syringe when administering liquid oral and injectable medications. Tuberculin syringe- narrow and calibrated (marked) in hundredths of a milliliter. Each long mark on the syringe represents 1/10 of a milliliter. Use this syringe to administer very small volumes of medication. 3 mL syringe- calibrated in tenths of a milliliter, so each mark represents 1/10 of a mL. This size of syringe is often used to administer subcutaneous, intramuscular, and intravenous medications in amounts less than 3mL. Long marks on the syringe represent 1mL of volume. Larger syringes- 5mL syringes are for administering medications if the dose is greater than 3mL. A 10mL syringe is used to add diluent when reconstituting a medication.

Solid medications:

Forms of solid medications: Tablets- med compressed into a disk-like shape. A scored tablet has a line marked into it to make it easier to divide into two equal parts. Don't divide tablets that aren't scored. The pharmacist will split the pill (do not split pills in an inpatient setting). Enteric-coated tablet- med coated with a compound that will not dissolve until the tablet passes through the stomach and is exposed to the fluids in the small intestine. This prevents irritation of the stomach lining. Troche- a flat, round tablet (lozenge) designed to be dissolved in the mouth and not swallowed. Capsule- med encased in a container made of gelatin. In a sustained release capsule, the med is contained in small beads with a coating that allows release over a period of time (usually 12-24 hours). The coating allows once or twice a day dosing. Caplet- a cross between a capsule and a tablet. Some client's find these easier to swallow.

Medications: by weight

Many meds are prescribed by weight (especially peds) to ensure correct dosing. Accurate weights ensure that overdosing and underdosing don't occur. Infants are at higher risk of medication toxicity due to incorrect dosage calculations b/c of immature physiologic processes that affect the absorption, distribution, metabolism, and excretion of meds. Every medication has unique dosing recommendations. Dosages vary depending on age, weight, diagnosis, medical condition, and route of administration.

Powdered Medications: reconstitution

Reconstitution: from powder to liquid. Some meds are unstable in liquid form for an extended period of time. This means you need to reconstitute these medications from a powder to a liquid shortly before administration to make sure the medication is stable. When reconstituting a powdered medication, add an appropriate fluid (diluent) directly to the bottle or vial of medication. To make sure that you have accurate dosing, read the manufacturer's label for the amount of diluent to add to the vial because this varies with each medication. The info on the medication label varies among manufacturers and medications.

Medication Administration Record (MAR)

When transcribing a medication administration on paper, record the name of the medication, dose, route, frequency, date, and expiration of the prescription. MARs contain (client's identifying info, current date, prescription info, time of medication administration) and can also include instructions if a medication should be taken with food.

labeling a vial for powdered medications

after reconstituting a vial of powdered medication, it is important to label the vial. Reconstituted medications are not stable for a long period of time, and they have specific alerts for storage. This info is found on the label, vial, or manufacturer's insert. Add this info to the label to make sure you are administering the medication safely. The label must include the dosage strength of the reconstituted medication, date and time of preparation, date and time of expiration, storage method, and your initials.

Insulin syringes:

always administer insulin in a syringe that matches the concentration of the insulin preparation. U-100 (100 units of insulin per milliliter) is most commonly prescribed. It should be administered subcutaneously with a U-100 insulin syringe. These insulin syringes are marked with orange caps. U-5- insulin is a concentrated insulin and the syringe is marked with green caps. Lower dosage syringes: use these to administer smaller doses of insulin. Because the calibrations are smaller, these syringes allow administration of a more accurate dose. These syringes are calibrated in 1-unit increments. For a client who requires less than 30 units of insulin, the lower dose syringe is used. For clients requiring greater than 50 units of insulin, the higher dose syringe should be used. Mixing 2 types of insulin: whenever a provider prescribes 2 types of insulin for the same time of day, determine if you can mix them. Only short or rapid acting insulin can be mixed with another insulin. If you can mix the 2 types of insulin, plan to administer them in the same syringe so the client receives 1 injection instead of 2.

Syringes for powdered medications

always use an oral syringe with oral medications, and a parenteral syringe with parenteral medications, to prevent inadvertent administration of medication via an incorrect route. Oral syringes don't have a luer-lok hub (weird shaped ending) because there is no need for a needle to administer oral medications. Syringes for parenteral use have a luer-lok hub to secure the needle to the syringe for injectable medications. Syringes are used to draw up the correct amount of diluent. Make sure to use the proper syringe for medication administration (either oral or parenteral).

Using measuring devices:

before administering any medication, calculate the dose. Then choose the appropriate measuring tool. Always use a calibrated oral syringe, dropper, or medicine spoon to administer doses less than 5 mL. Household spoons are not accurate. Medication cups- administer doses of 5-30 mL. Medicine spoons- calibrated in 1-10 mL increments.

Client education:

clients often administer their own insulin at home, so education is important. Start education as soon as the client is informed about the diagnosis of diabetes mellitus or gestational diabetes. Teach about the storage of insulin, syringes, and monitoring supplies, preparation and administration of insulin, and identifying treatments of complications (hypo/hyperglycemia). Inform the client about onset, peak, and duration of the insulin prescribed. Insulin pens- convenient way to inject insulin. They have a disposable needle, an insulin filled cartridge inside, and a dial to measure the dose. The client would dial the dose before injecting the medication. Jet injectors are similar to insulin pens, but these devices inject insulin into the subcutaneous tissue without the use of a needle. Jet injectors are expensive, and they can cause the skin to bruise. External infusion pumps- an insulin pump delivers regular or rapid acting insulin subcutaneously over 24 hours. The pump is set to infuse insulin at a set basal rate that closely mimics secretion of insulin by the pancreas. The client can program the pump to deliver higher or lower doses of insulin based on the time of day and individual insulin needs. Clients can deliver bolus doses to cover carbohydrate intake from meals and snacks. A bolus dose can also cover high blood glucose levels. The insulin pump is small, and a client can wear it in a pocket or on a belt. The pump contains a syringe with insulin. The syringe is connected to a needle that's placed subcutaneously.

Insulin:

clients require insulin injections when they have an absolute or relative deficiency of insulin. Insulin is essential because it promotes the entry of glucose, potassium, and amino acids into the cells as well as the conservation of glucose into glycogen in the liver. You can administer all types of insulin subcutaneously. Clients can receive insulin either by individual injections or by continuous infusion via an insulin pump. When a client needs a rapid reproduction of blood glucose, you can administer insulin by intravenous infusion. There are 4 types of insulin you can administer intravenously: regular insulin, insulin aspart, insulin lispro, and insulin glulisine. Insulin is one of the most commonly used injectable medications.

Diluents:

common additives used as diluents to reconstitute medications for injections include 0.9% sodium chloride, 5% dextrose in water, sterile water, and bacteriostatic water. For oral medication reconstitution, you can use tap water or bottled water. Medication labeling: locate the type and amount of diluent to use for a medication on the manufacturer's label. brand/trade name is the biggest word on the label. Under it is the generic name.

Types of insulin:

many types of insulin preparations, all of which function as a substitute for naturally occurring insulin in the human body. However, they differ in regard to their onset, peak, and duration of action. Rapid acting insulin- begins to work 10-15 minutes after administration. Has the most rapid onset of action and the shortest duration of all the insulin preparations. Administer rapid acting insulin immediately before a meal to prevent hypoglycemia. Rapid acting insulin preparations are clear, and you can administer them subcutaneously or intravenously. There are 3 types of rapid acting insulin preparations: insulin lispro, insulin aspart, and insulin glulisine. Regular insulin- short acting insulin. Begins to work 30 minutes after administration. Regular insulin is clear, and you can administer it either subcutaneously or intravenously. The intravenous route is reserved for situations like diabetic ketoacidosis. Intermediate acting insulin- begins to work 1 - 2 hours after administration. NPH insulin is an intermediate acting insulin. It is a cloudy suspension with protein, which delays the onset and duration. NPH insulin is the only insulin preparation that's a suspension, and the only one that requires agitation before it is drawn into the syringe. It is often mixed with regular insulin. Administer NPH subcutaneously. Long acting insulin- duration of 18 - 24 hours. Examples are glargine, detimir, and degludec. Glargine is available as U-100 with a duration of 18-24 hours and U-300 with a duration longer than 24hrs. Glargine U-300 is an ultra long acting insulin supplied in prefilled pens for injection. Degludec is also ultra long acting because it lasts longer than 24 hrs. Long acting insulin can be administered in the morning, afternoon, or evening; however, it should be administered at the same time every day. Premixed insulin combinations- useful for clients who have difficulty mixing insulin, possibly due to poor eyesight or manual dexterity. These combination products contain one intermediate acting insulin and one rapid or short acting insulin. Examples are 70% NPH insulin and 30% regular insulin, and 70% insulin aspart protamine and 30% insulin aspart.

Manufacturer's Labels:

medication dosages vary depending on the manufacturer. In some cases, medications are prescribed in one unit but dispensed in another. Not all labels show the conversions. Medications are often available in different preparations for different routes. Refer to the info on the label to determine the route by which the medication can safely be administered. Always check the expiration date of the medication. If expired, don't administer it. If medication is left over from a single-dose preparation, don't save it for a later dose. Check the label to see whether the medication needs refrigeration or if it can be stored at room temperature after opening.

Rules for administering solid oral medications:

meds are primarily swallowed. If they cannot swallow or are on tube feeds, use a liquid form. If liquid form is not available, crush the meds using a specialized device, then mix the ground tablet into a small amount of fluid or soft food (applesauce). Don't crush medications that are delayed-release, long-acting, enteric-coated, dispensed as capsules, or irritating to mucous membranes. Medications that taste bad should not be crushed. Before crushing a medication, refer to a drug reference or consult the pharmacist. A troche (lozenge) should be allowed to dissolve in the mouth to release the medication. This type of preparation administers a medication directly to the mouth or throat. Make sure the client has not had anything to eat/drink 5 minutes prior to administering a troche and for 5 minutes after it has been fully dissolved. Other routes for administering solid oral meds are sublingual and buccal. These meds can have local or systemic effects. Instruct clients not to chew or swallow the med, or eat/drink anything until the med has been fully dissolved. Sublingual- meds under the tongue (keep med in place until fully dissolved). act faster than meds absorbed in the stomach because they are absorbed directly into the bloodstream. Buccal- meds between the client's cheek and gum, allow the medication to dissolve. Alternating sides with each buccal tablet administration prevents mucosal irritation.

Calculating solid dosages:

meds vary in the strength in which they are prescribed and in which they are dispensed. The nurse must ensure that the dose dispensed and administered to the client is correct.

Preventing needlestick injuries:

one of the most serious risks in the healthcare setting. A needlestick injury exposes you to a number of bloodborne pathogens (hep B, hep C, HIV). to prevent needlestick injuries, use needleless devices whenever possible. If you need to use a syringe with a needle, reduce the risk of injury by using safety syringes and by following proper procedures for disposal. A safety syringe has a mechanism that protects you from needle stick injuries. These mechanisms can be active or passive devices. An active deceive requires the nurse to activate the safety device after use by pushing the lever upward. A passive device doesn't require action by the nurse (once the device has been used, the needle retracts into the barrel). Some medications are available in prefilled syringes with a needle guard that activates when the medication is injected. Safe methods when disposing of needles/sharps: - Dispose of all needles into a sharps container immediately after use - If the sharps container is full, get a new one - Do not force a syringe into a container - Never leave needles and syringes at a client's bedside, and never place them in a pocket or waste can - Never recap, bend, or break a used needle

Liquid medications:

oral medications are also available in liquid form. Providers prescribe liquid oral medications using units like micrograms, milligrams, grams, and milliequivalents. When dispensing liquid medications, use units of milliliters and ounces. Instruct clients to use dosing spoons, medication cups, oral syringes, calibrated medication droppers.

Medication dispensing:

several healthcare professionals are responsible for medication administration. Provider writes prescriptions, the pharmacist prepares medication, and the nurse administers medication. Unit-dose system: each dose of medication (unit) is packaged separately and labeled with the medication name and expiration date. Some packages have a barcode. The unit-dose package can contain tablets, capsules, troches, suppositories, or a pre-measured amount of a liquid medication. A pharmacist can also place medications into a unit-dose package from a bulk supply. Acute and long term care settings use the unit-dose system. This helps to minimize errors during medication administration. The medication label provides information about the medication including the form, concentration, directions for use, total dose in the unit package, storage information, and expiration date. Pharmacy bulk system: a labeled container holds multiple doses of a medication.

Measuring powdered medications:

some medications become unstable when in liquid form over time. These meds are prepared in a powdered form to allow for extended storage and to retain potency. The directions for reconstitution are included on either the medication label or the package insert. Read the directions carefully in order to prepare the correct dosage of medication. Additional info on the medication label or package insert indicates the medication concentration following reconstitution.

Measuring insulin:

the standard way to measure insulin is in units. In the US, insulin is available in 2 concentrations. The most common concentration is U-100, which means there are 100 units of insulin in 1mL of solution. Sometimes a U-500 concentration is available (but this is rare and only administered by subcutaneous injection). Insulin packaging: most insulin is dispensed in vials containing 10mL of medication. For U-100 insulin, each mL contains 100 units of insulin. To calculate the total amount of insulin available in this vial, multiply 10mL by 100 units/mL. So the total amount of insulin available in this vial is 1,000 units.

Storage areas for medication:

vary among facilities. Include med carts, med rooms (store stock medications, multi dose medications, emergency medications, intravenous solutions, and medication supplies. need a code/key to enter the room), locked med cabinets in individual client's rooms (contain all the client's medications except for controlled substances), automated dispensing systems. Med carts: the meds are supplied in unit-dose packaging. The carts store each client's medications in an individual drawer labeled with the client's name. Some med carts have barcode scanners to verify the accuracy of meds dispensed. Pharmacy workers fill each drawer with a 24 hr supply. Lock the med cart when not in use. Use a key or passcode to unlock the cart. Automated dispensing systems: access to all medications, including controlled substances. Must use code/key to access the system and then the drawer will open, may also be a bar code to verify the accuracy of medications. Advantages of this system are adherence to controlled substance regulations, reduced medication errors and cost, and improved accuracy in documentation. Only retrieve one client's medications at a time.