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Principles and Methods of Drug Administration
Chapter 2
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Medication AdministrationNursing Responsibilities - Standard precautions - Patient privacy - Patient preparation - Drug preparation
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Nursing Implications Associated with Drug AdministrationConsult references/pharmacistObserve for ADR’sReport drug reactionsRecord observationsWithhold drug if needed - notify provider
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Medication OrdersThe nurse must ensure the patient receives
the correct medicationOrders should include the following: Name Date/time Drug name Dose Route Time/frequency administration Prescriber’s signature
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Medication OrdersControlled substances - Opioids, barbiturates, ect. double-
locked - Keys with charge nurse - Log administration of drugs - End-of-shift count - Waste controlled substance with
witness
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Medication OrdersTypes of orders - Standing orders - pre-written, no call - Verbal orders - telephone to nurse - repeat back to provider - To be written and signed by the
provider asap
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The Seven Rights of Medication AdministrationRight drugRight doseRight patient: name and birth dateRight timeRight routeRight documentationPatient’s right to refuse
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Medication PreparationKnow the seven rightsDrug reference availableKnow drug action, contraindications,
usual dosage, and side effectsCheck label 3 times - removing drug from container or
drawer - on comparison with MAR - before giving to patient (if unit dose) - Before returning to drawer (if
multi-use container)
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Important Considerations
Enlist the patientsUtilize the pharmacistsPrepare one patient’s medication at a time
Minimize need for calculations or compare answers with another nurse’s
Two licensed nurses must double check high alert drugs before administration, i.e. insulin, heparin
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Important ConsiderationsAlways report errorsNever give an unlabeled drugDon’t confuse drug namesDate and initial (multiuse vials or containers)
If you didn’t prep it, don’t give it
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Important Considerations for Medication Administration2 identifiers for safety: name and DOBIf you gave it, chart itDo not chart for someone else or have
someone else chart for youDo not transport or accept a container
that is not labelledDo not put down an unlabeled syringe
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Important Considerations for Medication AdministrationWatch the patient take it and swallow itAssess patient’s responseIf a patient refuses a medication:
do not force it, chart itIf you elect to omit a dose based on
your nursing judgment, let another nurse help make the decision. If medication is not given, document, “dose omitted because…” Report to the provider
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Commonly Used AbbreviationsReview pages 48-56 Joint Commission on Accreditation of Healthcare Organization (JCAHO) approved abbreviation list
institutional policy and list of used abbreviations
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Routes of AdministrationEnteral - Via the GI Tract - Powders - Pills - Tablets - Liquids or suspensions - Suppositories
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Routes of AdministrationPercutaneous - Through the skin or mucous membranes
- Topical - Instillation - Inhalation
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Routes of AdministrationParenteral - Methods other than the GI tract;
needle route - Intramuscular (IM) - Subcutaneous (SC) - Intradermal - Intravenous (IV) - Ampules - Vials
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Enteral AdministrationTablets, pills, capsules - absorbed more slowly from GI tract
into the bloodstream than via any other route - (PO) route
relatively safe - Do not crush enteric coated or
sustained release pills - Only divide scored pills - Liquid medications: children and
patients who cannot swallow pills
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Oral MedicationsUnit dosage system: most commonMed stays in package until
administrationMay place prepackaged medications
in the same cup until administered Involve the patient and include
teachingPatient refusal: return unopened
medication to the drawer, document reason, notify provider
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Oral MedicationsFrom multi-dose containers, pour pill into the cap, drop into a medicine cup
Label cup with med name, doseDo not touch meds with bare hands
Falls on floor? Toss it. Working on med cart? Add clean field
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Enteral Administration of Liquid Medications
PO, or via a NG, gastrostomy, or jejunostomy tube
No liquids to unconscious patients: aspiration
Some liquid medications are not to be followed by water; some may stain the teeth
Use calibrated cup or syringe (but not IV syringe)
Measure liquids at bottom of meniscus
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Enteral Administration of Tubal MedicationsNG tubes: liquid meds to unconscious patients, dysphasic patients, those too ill to eat
Use liquid form or crush tablets and open capsules if allowed – give separately in warm waterNot all tablets are safe to use when crushed and not all capsules are safe to use when opened
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Enteral Administration of Suppositories
Rectum or vaginaDissolves at body temperature and absorbed directly into the bloodstream
infants, patients intolerant of oral preparations, N/V
Store in cool place
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Administration of Vaginal Medications
Usually for yeast infectionsSome products are used to induce labor
Use glovesProvide privacy
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Percutaneous Administrationskin /mucous membranesMostly local action; some act systemically
topical applications (ointments, creams, powders, lotions, and transdermal patches), instillations, and inhalations
Absorption is rapid, short duration
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Percutaneous AdministrationOintments - oil-based; semisolid; skin or mucous
membraneCreams - Semisolid, non-greasy emulsions;
external applicationLotions - Aqueous, soothing: pruritus,
protectant, cleansing, astringent
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Percutaneous AdministrationTransdermal Patches Adhesive-backed, medicated patches
-sustained, continuous release of medication over hours/days
Eye drops and Eye Ointments - Don’t touch the dropper or the tube to the
eye (p 70 Fig 2-18)Eardrops - ‘Otic’ solutions must be at room
temperature when applied - Use only droppers supplied with
medications for administration
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Percutaneous AdministrationNose drops - individual use only Nasal sprays - absorbed quickly; less medication
used, wastedInhalations - mucous membranes ofrespiratory tract - relatively limited effect or a systemic
effect - used by respiratory therapy and
anesthesiologists
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Percutaneous AdministrationSublingual medications - under the tongue, rapidly absorbed - tablet or a liquid squeezed from capsule - Do not give water after as water reduces
absorption - tablet should dissolve (no swallowing)
Buccal medications - between the gum and the cheek,
preferably above the molar - Follow same administration guidelines as
SL
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Parenteral AdministrationIntramuscular (IM)SubcutaneousIntradermalIntravenous (IV)Rationale for using these methods
include: - Absorption rate - No oral route - Emergencies - Drug is destroyed in the GI tract
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Parenteral AdministrationEquipment - Syringes - barrel, plunger, and tip - calibrated in milliliters, minims, insulin or
heparin units - Types - Tuberculin syringe (for allergy
testing/treatments, TB testing and small quantities) - Insulin syringe - One and three milliliter syringes - Safety-Lok syringes
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Parts of a Syringe
.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
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Tuberculin Syringe Calibration
(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)
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Calibration of U100 Insulin Syringe
(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)
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Reading the Calibrations of a 3-mL Syringe
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Safety-Glide Syringe
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Parenteral AdministrationEquipment - Needles - Parts are the hub, shaft, and beveled tip - Opening at the needle’s beveled tip is
the lumen - Size of the diameter of the inside of the
needle’s shaft determines the gauge of the needle; the smaller the gauge, the larger the diameter
- Needle gauge selection is based on the viscosity of the medication
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Parts of a Needle
(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)
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Parenteral AdministrationEquipment - Needle length - Selected based on the depth of the
tissue into which the medication is to be injected - Intradermal: 3/8 to 5/8 inch - Subcutaneous: ½ to 5/8 inch - Intramuscular: 1 to 1 ½ inch - Intravenous needles - Butterfly (scalp needle) - Over the needle catheter
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Needle Length and Gauge
(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)
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Parenteral AdministrationEquipment - needleless devices - sheath or guard - IV caths: blunt-edged cannulas, valves, or needle guards
- IV tubing: recessed and shielded needle
connectors to reduce needle sticks
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Parenteral AdministrationIntramuscular (IM) injections - Site selection - Gluteal sites: ventrogluteal (gluteus
medius) - Vastus lateralis muscle (thigh) - Rectus femoris muscle (thigh) - Deltoid muscle (arm) - Z-track method - Used to inject irritating meds
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Locating IM Injection for Ventrogluteal Site
(C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
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Giving IM Injection in Vastus Lateralis Site on an Adult
(C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
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Rectus Femoris Muscle A. Child/Infant B. Adult
(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)
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Giving IM Injection in Deltoid Site
(C, from Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
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Figure 23-20
A, Z-track method. B, Using an air lock. C, Administering IM injection
by airlock technique.
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
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Parenteral AdministrationIntradermal injections - serum, vaccine, or skin test agent - Not aspirated - Small volumes (0.1mL) injected to
form a small wheal just under the skin - Used for allergy sensitivity tests, TB
screening, local anesthetics - tuberculin syringe with 25-gauge,
3/8 to 5/8 inch needle
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Figure 23-21
Angles of insertion for intramuscular (90°), subcutaneous (45°), and intradermal (15°).
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
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Parenteral AdministrationSubcutaneous injections - loose connective tissue between the dermis
and the muscle layer (fatty layer) - absorption slower than with IM injections - Given at a 45-degree angle if the patient is
thin or at a 90-degree angle if the patient has ample subcutaneous tissue
- Usual needle length is ½ to 5/8 inch and 25 gauge
- insulin and heparin
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Subcutaneous Injection
Angle and needle length depend on the thickness of skin fold
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
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Parenteral AdministrationFluid and electrolytes will be also covered again in systems classes
Starting of IV’s and management of tubing and delivery devices will be covered in skills lab
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Parenteral AdministrationIntravenous (IV) therapy - fluid and electrolyte maintenance, restoration, replacement - Give meds, nutritional feedings - blood and blood products - chemotherapy to cancer patients - patient-controlled analgesics - Keep a vein open (KVO)
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Scope of PracticeKnow LPN SOP for practice stateOSBN LPN IV policy prohibits LPN’s
from initiating the following items: - Antineoplastic agents - Blood and blood components - Antiarrhythmics - Antiseizures - Ambulatory infusion devices - Hypertensive agents
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Parenteral AdministrationMethods of intravenous administration
- IV push - Intermittent venous access device - Intermittent infusion (or piggyback) - Continuous infusion - Electronic pumps and controllers - Patient-controlled analgesia - Volumetric chambers
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Parenteral AdministrationNursing responsibilities
- Nurse ensures that correct fluid, amount started and that the fluid is regulated to infuse over the period ordered
- To find the drops per minute (the drip rate),
find drip factor on tubing package
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Parenteral AdministrationNursing Responsibilities
- Monitor Intravenous Therapy - Check the infusion and the IV needle site at least every hour
- Flow of fluid- IV site: erythema, wetness, and edema- Phlebitis: inflamed vein- Infiltration: fluid passes into the tissues
- Assess for chills, fever, headache, nausea, vomiting, anxiousness, and dyspnea
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Parenteral AdministrationNursing Responsibilities
- Assess for Anaphylactic Shock- Respiratory distress- Skin reactions- Signs of circulatory collapse- GI signs and symptoms- Change in mental status
- Requires immediate intervention
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Parenteral AdministrationNursing responsibilities - Record administration - Record information - Evaluate and record patient’s response
- Observe for ADR’s
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Patient and Family Teachingmust be ready to learnInclude family as allowed by patientteaching enables patient to care for
selfPatient should demonstrate self-care
skillsThe patient should know about their
illness or diagnosis and treatmentThe patient should know names of all
medications, administration schedule, common side effects, provider to call, where to get prescriptions
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Promoting Cooperation with Medication regimens
Inadequate understanding of illness or disease
Cost of the medicationDevelopment of adverse effectsForgetfulnessMeasures to foster cooperation include: - Education - Resources for drug payment - Memory aids
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The Nursing Process in PharmacologyAssessment - Take med history - Collect physical status data - social networks, resources?Diagnosis and Planning - Check nursing diagnoses - Identify desired outcomes of nursing
interventions - Know why the drug is needed, how it
will be given, and common side effectsImplementation - Prepare meds safelyEvaluation