Medication Administration

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

Classification Routes of administration can broadly be divided into: Topical: Drugs are applied topically to the skin or mucous membranes, mainly for local action. Oral: used for systemic (non-local) effect, substance is given via the digestive tract. Parenteral: A drug administered parenterally is one injected via a hollow needle into the body at various sites and to varying depth. Rectal: Drugs given through the rectum by suppositories or enema. Inhalation: The lungs provide an excellent surface for absorption when the drug is delivered in gaseous, aerosol or ultrafine solid particle form.

Routes of administration

1- Topical route: I Skin A-Dermal – cream, ointment (local action) B- Transdermal- absorption of drug through skin (i.e systemic action) I. stable blood levels(controlled drug delivery system) II. No first pass metabolism III. Drug must be potent or patch becomes too large II Mucosal membranes • eye drops (onto the conjunctiva) ear drops intranasal route (into the nose)

2 -Oral route (Cont.) Advantages: 1- Convenient - portable, no pain, easy to take. 2- Cheap - no need to sterilize, compact, multi-dose bottles, automated machines produce tablets in large quantities. 3- Variety - tablets, capsules, suspensions, mixtures .

3- Buccal/Sublingual route: Some drugs are taken as smaller tablets which are held in the mouth (buccal tablet) or under the tongue (sublingual tablet). Buccal tablets are often harder tablets [4 hour disintegration time], designed to dissolve slowly. E.g Nitroglycerin, as a softer sublingual tablet [2 min disintegration time], may be used for the rapid relief of angina.

1- Holding the dose in the mouth is inconvenient. 3- Buccal/Sublingual route (Cont.) Disadvantages 1- Holding the dose in the mouth is inconvenient. 2- Small doses only can be accommodated easily.

4- Parenteral route:

4- Parenteral route (Cont.) A- Intravascular (IV): - placing a drug directly into blood stream. -May be - Intravenous (into a vein) or - intraarterial (into an artery). Advantages 1- precise, accurate and immediate onset of action, 100% bioavailability. Disadvantages 1- risk of embolism. 2- high concentrations attained rapidly leading to greater risk of adverse effects.

4- Parenteral route (Cont) B-Intramuscular :(into the skeletal muscle). Advantages 1- suitable for injection of drug in aqueous solution (rapid action) and drug in suspension or emulsion (sustained release). Disadvantages 1- Pain at injection sites for certain drugs.

4- Parenteral route (Cont) C- Subcutaneous (under the skin), e.g. insulin. D- Intradermal, (into the skin itself) is used for skin testing some allergens. E- Intrathecal (into the spinal canal) is most commonly used for spinal anesthesia . F- Intraperitoneal, (infusion or injection into the peritoneum) e.g. peritoneal dialysis in case of renal insuffeciency.

5-Rectal route: Most commonly by suppository or enema. Advantages 1- By-pass liver - Some of the veins draining the rectum lead directly to the general circulation, thus by-passing the liver. Reduced first-pass effect. 2- Useful - This route may be most useful for patients unable to take drugs orally (unconscious patients) or with younger children. - if patient is nauseous or vomiting

5- Rectal route (Cont.) Disadvantages 1- Erratic absorption - Absorption is often incomplete and erratic. 2- Not well accepted.

6- Inhalation route: - Used for gaseous and volatile agents and aerosols. - solids and liquids are excluded if larger than 20 micron. the particles impact in the mouth and throat. Smaller than 0.5 micron , they aren't retained. Advantages A- Large surface area B- thin membranes separate alveoli from circulation C- high blood flow As result of that a rapid onset of action due to rapid access to circulation.

6- Inhalation route (Cont.) Disadvantages 1- Most addictive route of administration because it hits the brain so quickly. 2- Difficulties in regulating the exact amount of dosage. 3- Sometimes patient having difficulties in giving themselves a drug by inhaler.

Mosby items and derived items © 2005 by Mosby, Inc. Metric System Grams (g), milligrams (mg), kilograms (kg) Liters (L), milliliters (ml) Mosby items and derived items © 2005 by Mosby, Inc.

Household Measurements Tablespoons Teaspoons Ounces Cups Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Prescriber’s Role Types of orders Single orders Stat orders Mosby items and derived items © 2005 by Mosby, Inc.

Mosby items and derived items © 2005 by Mosby, Inc. Distribution Systems Stock supply Unit dose Computer controlled Mosby items and derived items © 2005 by Mosby, Inc.

Parts of the Order Patient name Date and time Drug name Drug dosage Route Frequency Signature

Problems with Orders Allergies Steps Drug book Pharmacist Physician Supervisor

Drug Administration 3 checks obtaining the container removing the med replacing the container

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

Six Rights Right medication Right dose Right client Right route Right time Right documentation

Client’s Rights Information Refusal Careful assessment Informed consent Safe administration Supportive therapy No unnecessary medications

Assessment Medical history History of allergies Medication data Diet history Perceptual or coordination problems Current condition

Assessment (cont’d) Attitude about medication use Knowledge of therapy Learning needs

Nursing Diagnoses Deficient knowledge (medications) Disturbed sensory perception Impaired swallowing Ineffective therapeutic regimen management

Planning Goals and outcomes Setting priorities Continuity of care – Example: Client will verbalize therapeutic and adverse effects of medications Setting priorities Continuity of care

Implementation Client and family teaching Medication orders: receipt, communication Calculation and measurement Correct administration technique Recording

Special Considerations Infants and children Older adults Self-prescribing Over-the-counter medications Misuse Noncompliance

Evaluation Client response to medications Client and family ability to administer medications

Oral Administration Presence of GI alterations Ability to swallow Positioning

Topical Administration Skin applications Use of gloves or applicators Preparation of skin Thickness of application

Nasal Instillation Assessment of nares Client instruction and self-administration Positioning

Eye Instillation Drops, ointments, disks Assessment of eyes Asepsis Positioning

Ear Instillation Assessment of ear canal Warming of solution Straightening of canal for children and adults Positioning

Vaginal Instillation Suppositories, foams, creams Use of gloves and applicator Client positioning, comfort, and hygiene

Rectal Instillation Suppositories Use of gloves Client positioning, comfort, and hygiene

Inhalation Metered-dose inhalers (MDIs) and dry powder inhalers (DPIs) Client assessment and instruction Use of spacer Determination of doses in canister

Irrigation Medications used to wash out a body cavity delivered with a stream of solution (sterile water, saline, or antiseptic) Asepsis

Parenteral Administration Equipment Syringes: sizes (volume), types Needles: length, gauge Disposable units: Tubex, Carpuject Ampules Vials

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

Parenteral Administration (cont’d) Insulin Syringes and needle sizes Types of insulin Mixing of insulins Rotation of vials before withdrawal of solution

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

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

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

Administration of Injections (cont’d) Sites Ventrogluteal Vastus lateralis Deltoid

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

Prevention of Needle Sticks Needleless devices Sharps disposal One-handed recapping technique

Intravenous Administration Large volume infusions Bolus injection Volume-controlled infusions Mini-infusor pump

Avoiding Errors Prepare drugs alone Don’t leave drugs alone Prepare and administer Lock med cart Supervise swallowing

Steps in Administration 3 checks 6 rights Assessment Patient position Fluids Keep meds in wrappers Offer separately

Administering Narcotics Definition Record Patient name Amount Time Physician Nurse signature Waste/witness Count Discrepancies

Documentation Legal record When to record Information Omitted drugs med name dosage route time nurse initials nurse signature site of injection other information Omitted drugs reason notify MD Refused drugs

Medication Errors Reasons for occurrence Steps if error takes place