Principles and Methods of Drug Administration

Chapter 2

Medication AdministrationNursing Responsibilities - Standard precautions - Patient privacy - Patient preparation - Drug preparation

Nursing Implications Associated with Drug AdministrationConsult references/pharmacistObserve for ADR’sReport drug reactionsRecord observationsWithhold drug if needed - notify provider

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

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

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

The Seven Rights of Medication AdministrationRight drugRight doseRight patient: name and birth dateRight timeRight routeRight documentationPatient’s right to refuse

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)

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

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

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

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

Commonly Used AbbreviationsReview pages 48-56 Joint Commission on Accreditation of Healthcare Organization (JCAHO) approved abbreviation list

institutional policy and list of used abbreviations

Routes of AdministrationEnteral - Via the GI Tract - Powders - Pills - Tablets - Liquids or suspensions - Suppositories

Routes of AdministrationPercutaneous - Through the skin or mucous membranes

- Topical - Instillation - Inhalation

Routes of AdministrationParenteral - Methods other than the GI tract;

needle route - Intramuscular (IM) - Subcutaneous (SC) - Intradermal - Intravenous (IV) - Ampules - Vials

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

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

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

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

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

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

Administration of Vaginal Medications

Usually for yeast infectionsSome products are used to induce labor

Use glovesProvide privacy

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

Percutaneous AdministrationOintments - oil-based; semisolid; skin or mucous

membraneCreams - Semisolid, non-greasy emulsions;

external applicationLotions - Aqueous, soothing: pruritus,

protectant, cleansing, astringent

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

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

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

Parenteral AdministrationIntramuscular (IM)SubcutaneousIntradermalIntravenous (IV)Rationale for using these methods

include: - Absorption rate - No oral route - Emergencies - Drug is destroyed in the GI tract

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

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.)

Tuberculin Syringe Calibration

(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)

Calibration of U100 Insulin Syringe

(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)

Reading the Calibrations of a 3-mL Syringe

Safety-Glide Syringe

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

Parts of a Needle

(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)

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

Needle Length and Gauge

(From Clayton, B.D., Stock, Y.N. [2004]. Basic pharmacology for nurses. [13th ed.]. St. Louis: Mosby.)

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

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

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.)

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.)

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.)

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.)

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.)

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

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.)

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

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.)

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

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)

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

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

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

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

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

Parenteral AdministrationNursing responsibilities - Record administration - Record information - Evaluate and record patient’s response

- Observe for ADR’s

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

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

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