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MEDICATION ADMINISTRATION N116 WHAT IS MEDICATION? Substance used in diagnosis, treatment, cure, relief, or prevention of health alterations NURSES’ ROLE IN MEDICATION Prepare, administer, teach, and evaluate response to medication Evaluate side effects Ensure adherence to prescribed regimen Evaluate client’s ability to self-administer Follow legal provision when administering controlled substances Assume ultimate responsibility for the 6 “rights” PHARMACOLOGICAL CONCEPTS Drug names chemical, generic, brand Classification indicates effect on a body system Medication form tablet, capsule, elixir, suppository, soln PHARMAKOKINETICS How do meds enter the body, reach their site of action, metabolize, and exit the body Absorption- passage of meds from site into blood Distribution-within body and tissues ultimately to site of action Metabolism-after reaching site of action, med becomes inactive or less active- easier to excrete Excretion- exit body through kidneys, intestine, liver, lungs, exocrine glands MEDICATION ACTIONS Therapeutic effects- intended or desired, expected physiologic response Side /Adverse effects- SE are predictable, often unavoidable. AE or unintended, undesirable, unpredicted, severe Toxic effects- prolonged intake, accumulates in blood or tissue Idiosyncratic effects- different from normal/under or over reacts Allergic reactions- med triggers release of antibodies. Anaphylactic reactions Med interactions ROUTES OF ADMINISTRATION Oral buccal, sublingual Parenteral intradermal, subcutaneous, intramuscular, intravenous, intraosseous, intraperitoneal, intralpleural, intraarterial Topical discs, baths, patch, ointment Inhalation Intra ocular CALCULATING DOSES Meds are not always dispensed in the unit of measurement in which they were ordered. Double check calculations with another nurse for high risk meds (insulin, heparin) Double check if the answer seems unreasonable 50 tablets? 10cc IM? TYPES OF ORDERS Routine medication orders “tetracycline 500 mg po q 6 h” PRN orders “morphine sulfate 2 mg IVP q 2 h prn incisional pain” One-time order “Ativan 1 mg IV x 1 prior to MRI” STAT order: “Apresoline 10 mg IV STAT” Now order: give within 90 minutes, only once Prescriptions: RECEIVING ORDERS Verbal or telephone orders Read back “TORB” Nursing students MAY NOT take telephone orders Hand write or computer entry Send order to pharmacy for review ABBREVIATIONS NO YES Ug Cc hs SC, SQ QD iu MS HCl, KCl Microgram or mcg mL Bedtime Subcut Daily International unit Morphine sulfate Hydrochloride, potassium chloride THE SIX RIGHTS Right medication Right dose Right client Right route Right time Right documentation PATIENT RIGHTS To be informed of med’s name, purpose, action, potential side effects To refuse any medication regardless of consequences To have qualified nurse or physician assess a medication history To be advised and give consent for any experimental therapy To receive labeled medication comfortably To receive supportive therapy in addition to medication To not receive unnecessary medication To be informed if medications are part of a research study NEVER Guess about the route if not specified Document before giving a medication Withhold information about a medication Give a medication to a patient you are unable to identify Give a medication before assessing the client’s condition Force or threaten clients to take medication MEDICATION ADMINISTRATION RECORD “MAR” Compare list on MAR to original orders Name, dose, route, and exact time med given Recording immediately after giving reduces duplication errors Document site of injections Circle, yellow or in some way indicate that dose was deliberately not given, not just ”missed” Becomes part of the care chart, is a legal document ADMINISTERING MEDICATIONS Oral Easiest and most desirable method Most need 60-100 mL of water to be swallowed Seated or 90 degree angle upright Fully awake Tablets may be crushed or capsules opened to mix with carrier or make solution (some exceptions) One at a time ADMINISTERING MEDICATIONS Topical Use gloves or applicators Cleanse skin with soap and water before applying Spread evenly Apply dressing or cover if indicated Remove old patch before applying new INTRANASAL Best if client self-administers Control spray and inhale at same time Check nares for irritation EYE INSTILLATION Poor vision, hand tremor, difficulty grasping add to difficulty with administration Cornea is sensitive!\ Avoid touching eyelids or eye structure Use only on affected eye Hold lower lid with cotton ball, client looks at ceiling, dispense into conjunctival sac RECTAL ADMINISTRATION Bullet shaped suppositories-rounded end gets inserted to avoid rectal trauma Store suppositories in fridge Place past the internal and external sphincter, against rectal mucosa INJECTIONS “parenteral” Luer-lock or non luer-lock syringes Choose right type and right size of syringe Choose right site for injections INJECTIONS Subcutaneous –into loose connective tissue under the dermis. not as vascular as muscle, absorption is slower. Contains pain receptors. back of arm, abdomen, upper leg 27-25 gauge needle, 1-3 mL syringe 3/8-5/8 inch needle pinch OR spread skin 45-90 degree angle no aspiration is necessary SUBCUTANEOUS INJECTIONS SUBCUTANEOUS INJECTIONS Used for small volumes of medication children up to 0.5 mL, adults up to 1.5 mL Insulin abdomen has quickest absorption, followed by arms, thighs. “Intrasite rotation” provides consistent absorption. Heparin, Lovenox (LMWH) 2 inches from umbilicus, “love handles” do not expel air bubble from prefilled Lovenox syringe INJECTIONS Intramuscular—into large muscles fast absorption, due to muscles’ vascularity risky—verify need and justification 90 degrees ½-3 inch needle dependent on client’s subcutaneous fat depth may tolerate 0.5 mL (infant), 1mL (children), 2 mL(thin or older adults), 3mL(well muscled adults) ventrogluteal, vastus lateralis, deltoid must aspirate INTRAMUSCULAR INJECTIONS CHOOSING THE RIGHT NEEDLE FOR IM 1-1 ½ inches long for adult ½-1 inch for children or very thin adults 3 inches for very obese adults As the needle gauge gets bigger, the needle diameter gets smaller. 27 g is very fine needle, 20 g is wider Gauge is chosen based on viscosity of injectable product. Thick, sticky medication is difficult to inject through a fine needle. INTRAMUSCULAR INJECTIONS Complications such as fibrosis, nerve damage, abcesses, tissue necrosis, muscle contraction, gangrene and pain are associated with all IM injection sites EXCEPT the ventrogluteal site. Z-track method minimizes local skin irritation by sealing the medication in muscle tissue. Pull overlying skin and subcutaneous tissue 1-1/2 inches to the side. Inject needle deeply, aspirate, inject medication, wait 10 seconds, release skin after withdrawing needle. Z TRACK MINIMIZING DISCOMFORT IN IM INJECTIONS Use a sharp-beveled needle in the smallest suitable length and gauge Position the patient to reduce muscular tension Select injection site using anatomical landmarks Apply topical anesthetic spray or EMLA if available Divert pt’s attention with conversation Insert needle quickly and smoothly (DART!) Hold syringe steady with needle remains in tissue Inject medicine slowly and steadily INJECTIONS Intradermal –into the dermis (skin layer) usually for testing (allergy or TB) inner forearm or back “TB” syringe 5-15 degrees bevel up, don’t aspirate “bleb” or wheal INTRAVENOUS MEDICATION Mixtures within large volumes of IV fluids d5 ½ NS with 20K+ @ 150/hour Small bolus or injection through existing IV infusion line, or in IV access (“hep lock or saline lock”) Morphine 2 mg IVP q 2 hours prn pain “piggyback” solution of medication mixed with IV fluids and running through an existing line of fluids Ancef 1 g in 500 mL NS IVPB q 8 hours INTRAVENOUS THERAPY May be used to give medications May be for fluid replacement May be used to supply electrolytes or nutrition THE MOST RAPID means of medication administration The medication enters the bloodstream immediately Any adverse effects, errors in dosing or preparation will affect the patient immediately WHY IV THERAPY Usually the route in “stat” orders Can maintain constant therapeutic levels Alkaline or irritant medications may damage muscle and SQ tissue Only one “poke” instead of multiple injections IV MEDICATIONS Administer at prescribed rate. Nurse is responsible for verifying rate. Observe closely for adverse reactions Label all bags Check for compatibility between solutions Monitor for extravasation, phlebitis, infiltration, pain at IV insertion site INFILTRATION V EXTRAVASATION PIGGYBACK/PUSH CONTROLLING IV FLOW RATE SAFETY GUIDELINES Be vigilant during entire process of preparing and administering Know why each med is ordered for your patient Do not allow distractions during preparation Verify expiration dates of medications Use at least two patient identifiers Use identifier technology when available Clarify all unclear orders Educate patients re adverse reactions or side effects Know your limits and delegation laws. QUESTIONS NS is provided in 1 Liter bags. The physician orders NS IV at 100 mL/hour. How long will the bag last? The patient is dehydrated, and his potassium test revealed K+ level 0f 3.0. The physician orders “add 20 mEq of Potassium to each liter IV fluids.” Rather than waste the current bag, the nurse injects 20 mEq of potassium into the bag and continues the rate of 100 mL/hour. Discuss QUESTIONS A 5 year old child, Tess, needs a DPT booster. What size needle should the nurse select for this IM injection? The nurse can’t find insulin needles and his patient, Bob, needs insulin before meals. Can the nurse use a very small syringe with a TB needle instead? QUESTIONS Nancy is a resident at a care center. On Tuesday she “pocketed” her pills and spat them out into her breakfast oatmeal and stated she would not take her pills any more. On Wednesday, a. the nurse crushes the pills and mixes them into Nancy’s juice without telling her b. doesn’t bother with the pills since she knows Nancy wont take them tells Nancy she can’t go to Wii Bowling until she takes her pills other QUESTIONS The surgeon wrote “Morphine 5.0 mg IV q 2 hours prn pain.” The pharmacist transcribed this as Morphine 50 mg IV” The nurse gave Morphine 50 mg IV because that’s what it said on the MAR. The patient stopped breathing Who is responsible for this outcome? QUESTIONS What do you need to assess before giving PO meds? What do you assess before giving injectable meds? What do you assess before giving IV meds? QUESTIONS Why do we aspirate when giving IM injections? QUESTIONS Which age range might have increased medication toxicity due to slow excretion by the kidneys Infants Middle aged adults Elderly adults Teen agers QUESTIONS What medication class is aspirin? QUESTIONS Place in order of fastest absorption subcutaneous intravenous intramuscular intradermal QUESTIONS Why would a nurse choose a Z-track method for an IM injection?