Mosby items and derived items © 2005 by Mosby, Inc. Chapter 3 Medication Administration

Mosby items and derived items © 2005 by Mosby, Inc. INJECTIONS Injections instill medications into body tissues for systemic absorption. Injected drugs are more quickly absorbed than oral medications.

Mosby items and derived items © 2005 by Mosby, Inc. Actions Therapeutic effects Side effects Adverse effects Toxic effects

Mosby items and derived items © 2005 by Mosby, Inc. Routes of Administration of Drugs Oral: sublingual, buccal Parenteral: intradermal, subcutaneous, intramuscular, intravenous Topical Inhalation Intraocular

Mosby items and derived items © 2005 by Mosby, Inc. Clinical Calculations Conversions within systems Conversions between systems Formula: Dose ordered x Amount on hand Dose on hand(OR) What you Want x what it’s In / What you’ve Got

If you have an ampoule of 500mg in 4ml, and you need 200mg to be administered to the patient. How many ml of drug to be injected? The easy way to remember this is the famous nursing equation: What you Want x what it’s In / What you’ve Got In this instance: 200mg x 4ml / 500mg = 1.6ml Mosby items and derived items © 2005 by Mosby, Inc.

Prescription states 30 mg/hour. You have a bag containing 250mg in 50ml. Therefore, at what rate (ml/hr) do you set the pump? What you Want x what it’s In / What you’ve Got 30 x 50 / 250 = 6ml Therefore the calculation shows that, to give 30mg per hour, the infusion pump rate would need to be set at 6ml per hour. Mosby items and derived items © 2005 by Mosby, Inc.

Prescriber’s Role Types of orders –Standing orders –prn orders –Single orders –Stat orders

Nurses Responsibilities Check for 6 Rights: Right drug, Right dose, Right route, Right time, Right client, Right documentation  Perform hand hygiene. (Rationale: to prevent the spread of infection)  Collect prescription and ensure that the client is available and understandable to take the medication.(Rationale: to secure informed-consent)  Check the medicine as the points: name, components, dose, expiry date(Rationale: to provide safe and efficient medication)  Prior to administration ensure you are knowledgeable about the drug(s) to be administered. This should include: therapeutic use, normal dosage, routes/forms, potential side effects,

Continued………………. contra-indications.(Rationale: to ensure safety and well- being of client and enable you to identify any errors in prescribing)  Confirm identity of client verbally and with chart, prescription, checking full name, age, date of birth: Right client.(Rationale: to ensure that the correct drug is being administered to the correct client)  Ensure that the medication has not been given till that time(Rationale: to ensure right dose) Mosby items and derived items © 2005 by Mosby, Inc.

Nurse’s Role Six rights Triple-check before administration Client assessment

Mosby items and derived items © 2005 by Mosby, Inc. Six Rights Right medication Right dose Right client Right route Right time Right documentation

Mosby items and derived items © 2005 by Mosby, Inc. Client’s Rights Information Refusal Careful assessment Informed consent Safe administration Supportive therapy No unnecessary medications

Mosby items and derived items © 2005 by Mosby, Inc. Assessment Medical history History of allergies Medication data Diet history Perceptual or coordination problems Current condition

Mosby items and derived items © 2005 by Mosby, Inc. Nursing Diagnoses Deficient knowledge (medications) Noncompliance (medications) Disturbed sensory perception Impaired swallowing Ineffective therapeutic regimen management

Mosby items and derived items © 2005 by Mosby, Inc. Implementation Client and family teaching Medication orders: receipt, transcription, communication Calculation and measurement Correct administration technique Recording

Mosby items and derived items © 2005 by Mosby, Inc. Special Considerations Infants and children Older adults –Self-prescribing –Over-the-counter medications –Misuse –Noncompliance

Mosby items and derived items © 2005 by Mosby, Inc. Oral Administration Presence of GI alterations Ability to swallow Use of gastric suction Positioning

Mosby items and derived items © 2005 by Mosby, Inc. Topical Administration Skin applications –Use of gloves or applicators –Preparation of skin –Thickness of application

Mosby items and derived items © 2005 by Mosby, Inc. Nasal Instillation Assessment of nares Client instruction and self- administration Positioning

Mosby items and derived items © 2005 by Mosby, Inc. Eye Instillation Drops, ointments, disks Assessment of eyes Asepsis Positioning

Mosby items and derived items © 2005 by Mosby, Inc. Ear Instillation Assessment of ear canal Warming of solution Straightening of canal for children and adults Positioning

Mosby items and derived items © 2005 by Mosby, Inc. Vaginal Instillation Suppositories, foams, creams Use of gloves and applicator Client positioning, comfort, and hygiene

Mosby items and derived items © 2005 by Mosby, Inc. Rectal Instillation Suppositories Use of gloves Client positioning, comfort, and hygiene

Mosby items and derived items © 2005 by Mosby, Inc. Inhalation Metered-dose inhalers (MDIs) and dry powder inhalers (DPIs) Client assessment and instruction Use of spacer Determination of doses in canister

Mosby items and derived items © 2005 by Mosby, Inc. Parenteral Administration Equipment –Syringes: sizes (volume), types –Needles: length, gauge –Disposable units: Tubex, Carpuject –Ampules –Vials

SYRINGE Mosby items and derived items © 2005 by Mosby, Inc.

Selecting the size of the needle IV injections – 21, 22., or 25G IM injections – 22 to 23 Gauge (18 to 25 G for oil based medication) Subcutaneous injections - 25 Gauge Intra dermal injections – 25 to 27G Mosby items and derived items © 2005 by Mosby, Inc.

Parenteral Administration (cont’d) Mixing medications –Determine compatibility of the medications –Do not contaminate one medication with another –Ensure the final dose is accurate –Maintain aseptic technique

Mosby items and derived items © 2005 by Mosby, Inc. Parenteral Administration (cont’d) Insulin –Syringes and needle sizes –Types of insulin –Mixing of insulins –Rotation of vials before withdrawal of solution

Mosby items and derived items © 2005 by Mosby, Inc. Administration of Injections Minimize discomfort –Use smallest suitable needle –Position client comfortably –Select proper site –Divert client’s attention –Insert the needle quickly and smoothly –Hold the syringe steady –Inject the medication slowly and steadily

Mosby items and derived items © 2005 by Mosby, Inc. Administration of Injections (cont’d) Subcutaneous injections –Sites: condition of area, rotation of use –Amount of solution –Length and gauge of needle –Pinch or spread skin –Angle of insertion

Site for S.C injections 1. Outer aspect of the upper arm. 2. Posterior chest wall below the scapula. 3. Anterior abdominal wall from below the breast to the iliac crest. 4. The anterior and lateral aspect of the thigh. Mosby items and derived items © 2005 by Mosby, Inc.

Sites of Subcutaneous injections Mosby items and derived items © 2005 by Mosby, Inc.

Insulin pens - Types Reusable pens Disposable pens Mosby items and derived items © 2005 by Mosby, Inc.

Insulin pens Mosby items and derived items © 2005 by Mosby, Inc.

Insulin pens Advantages and Disadvantages of Insulin Pens The reasons why some insulin users prefer insulin pens include: Insulin pens are portable, discreet, and convenient for injections away from home. They save time because there is no need to draw up insulin from a bottle - it is already pre-filled in the self-contained cartridge. They usually let you set an accurate dose by the simple turn of a dosage dial, and that may make it easier to set an accurate dose for people who have vision or dexterity problems.

Insulin pens There are also reasons why insulin pens are not right for all users, including: Insulin in pens and cartridges is often more expensive than insulin in bottles for use in syringes. Some insulin is wasted when pens are used: one to two units of insulin are lost when the pen is primed before each injection; Not all insulin types are available for use in insulin pen cartridges. Insulin pens do not let you mix insulin types, which means that if the insulin mixture you need is not available as a pre-mix, two injections must be given - one for each type of insulin. Insulin pens should only be used for self-injection. This is because the pen needle must be removed from the pen after each injection, and there is no way to completely protect the person giving the injection from getting accidentally stuck by the needle while he or she is removing it from the pen.

Mosby items and derived items © 2005 by Mosby, Inc. Administration of Injections (cont’d) Intramuscular injections –Sites: landmarks, condition of area –Amount of solution –Length and gauge of needle –Angle of insertion –Aspiration –Air-lock method –Z-track technique

Contraindications IM injections may be contraindicated in clients with;  Impaired coagulation mechanisms  Occlusive peripheral vascular disease  Edema  Shock  After thrombolytic therapy  during myocardial infarction

Mosby items and derived items © 2005 by Mosby, Inc. Administration of Injections (cont’d) Sites –Dorsogluteal –Ventrogluteal –Vastus lateralis –Deltoid

Dorso gluteal site Mosby items and derived items © 2005 by Mosby, Inc.

Deltoid site Mosby items and derived items © 2005 by Mosby, Inc.

Administration of Injections (cont’d) Intradermal injections –Skin testing –Sites –Length and gauge of needle –Angle of insertion –Formation of small bleb

Mosby items and derived items © 2005 by Mosby, Inc. Prevention of Needle Sticks Needleless devices Sharps disposal One-handed recapping technique

Intravenous injections Definition Intravenous injection is defined as the parentral administration of bolus medication directly into the vein through the existing IV line. Mosby items and derived items © 2005 by Mosby, Inc.

Methods of infusion There are three methods of administrating intravenous drugs Continuous infusion Intermittent infusion Direct Intermittent injection Mosby items and derived items © 2005 by Mosby, Inc.

Continuous infusion Continuous infusion may be defined as the intravenous delivery of medication or fluid at a constant rate over a prescribed time period, ranging from 24hours to days, to achieve a controlled therapeutic response. Mosby items and derived items © 2005 by Mosby, Inc.

Intermittent infusion: Intermittent infusion is the administration of a small volume infusion i.e ml over a period of between 20mins and two hours. This may be given as a specified dose at one time or at repeated intervals during 24hours. Mosby items and derived items © 2005 by Mosby, Inc.

Direct intermittent injection: This involves the injection of a drug from a syringe into the injection port of the administration set or directly into a vascular access device. Mosby items and derived items © 2005 by Mosby, Inc.

Intravenous Administration Large volume infusions Bolus injection Volume-controlled infusions Piggyback –Tandem –Volume-control set –Mini-infusor pump

Purposes To administer large volume of fluid. Rapid absorption is achieved. In emergencies fast- acting medications can be delivered quickly. Establishes continuous fluid infusions. To establish constant therapeutic blood levels. Medications that are highly alkaline and irritating to subcutaneous tissue are given intravenously. IV therapy is used primarily for fluid replacement in patients unable to take oral fluids. Mosby items and derived items © 2005 by Mosby, Inc.

Articles required 1.Medication chart 2. Sterile syringe (1) 3. Sterile needle (1) 4. Second needle (optional) 5. Spirit swab 6.Ampoule of medication prescribed 7.Ampoule cutter if available (1) 8.Kidney tray (1) 9. Steel Tray (1) 10.Container for discards if possible (1) Mosby items and derived items © 2005 by Mosby, Inc.