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CHAPTER 11
ADMINISTRATION OF MEDICATION
AND INTRAVENOUS THERAPY
PRETEST
True or False
1. A drug is a chemical that is used for treatment,
prevention, or diagnosis of disease.
2. The generic name of a drug is assigned by the
pharmaceutical manufacturer who develops the
drug.
3. The Rx symbol comes from the Latin word recipe and
means "take."
4. An anaphylactic reaction can be life threatening.
5. The dorsogluteal site is the most common site for
administering injections in infants.
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PRETEST, CONT.
True or False
6.
A subcutaneous injection is given into muscle tissue.
7.
The purpose of aspirating when administering an
injection is to make sure the needle is not in a blood
vessel.
8.
The Mantoux tuberculin test is administered through
a subcutaneous injection.
9.
The peripheral veins of the arm and hand are used
most often for administering IV therapy.
10. Chemotherapy is the use of chemicals to treat
disease.
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Content Outline
Introduction to Administration of Medication
1. Pharmacology: The study of drugs
a. Includes:
•
Preparation
•
Use
•
Action of drugs in the body
2. Drug: A chemical that is used for the
treatment, prevention, or diagnosis of disease
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Introduction to Administration of
Medication, cont.
3. Most drugs: produced synthetically
a. Can also be obtained from:
•
Animals
•
Plants
•
Minerals
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Introduction to Administration of
Medication, cont.
4. In the office, medication may be:
a. Administered: given to patient at office
b. Prescribed: Physician provides patient with
a handwritten or computer-generated
prescription to be filled at a pharmacy
•
Can also be telephoned or faxed to pharmacy
c. Dispensed: Medication given at office for
patient to take at home (e.g., drug samples)
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Introduction to Administration of
Medication, cont.
5. Legal Aspects
a. Administer medication only under direction
of physician
•
Unlawful to administer medication without
physician's consent
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Introduction to Administration of
Medication, cont.
6. Routes of Administration
a. Oral
b. Sublingual
c. Inhalation
d. Rectal
e. Vaginal
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Introduction to Administration of
Medication, cont.
f. Topical
g. Intradermal
h. Subcutaneous
i. Intramuscular
j. Intravenous
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Introduction to Administration of
Medication, cont.
7. Route depends on:
a. Type of drug
b. Dosage form
c. Intended action
d. Rapidity of response
desired
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Introduction to Administration of
Medication, cont.
8. Most common route of administration in
office:
a. Parenteral: Refers to
sites located outside
gastrointestinal (GI) tract
•
Most commonly used to
refer to administration of
medication by injection
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Introduction to Administration of
Medication, cont.
9. Drug References
a. For drugs used in office, MA must be
familiar with:
•
Indications
•
Adverse reactions
•
Route of administration
•
Dosage
•
Storage
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Introduction to Administration of
Medication, cont.
b. Package insert (PI)
•
Manufacturer includes with each medication
– Also included with drug samples and
injectable medications
•
Contains information on the drug
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Introduction to Administration of
Medication, cont.
c. Drug References
•
Contain drug information
•
Example: Physician's Desk Reference (PDR)
– Contains information on major prescription
pharmaceutical products available in U.S.
– Consists of actual drug PI
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Food and Drug Administration
1. Federal agency in DHHS (Department of
Health and Human Services)
2. Responsible for:
a. Determining if the following are safe before
human use:
•
New food products
•
Vaccines
•
Medical devices
•
Cosmetics
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Food and Drug Administration, cont.
3. Determines safety and effectiveness of
both prescription and over-the-counter
(OTC) drugs
4. Drug manufacturer: must submit
application for a new drug to FDA
a. For review and approval
b. Before product can be released for human
use
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Food and Drug Administration, cont.
5. FDA also determines if medication will
be available with or without a
prescription
a. Prescription drugs: must bear following
label:
•
Caution: Federal law prohibits dispensing
without a prescription
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Food and Drug Administration, cont.
b. Nonprescription medication: FDA
determines to be safe and effective for use
without physician supervision
•
Has low incidence of adverse reactions when
used properly
•
Examples:
– Mild pain relievers
– Topical antibiotics
– Topical corticosteroids
– Cold medicines
– Laxatives
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Drug Nomenclature
1. Each drug has four names:
a. Chemical Name: precise description of
chemical composition
•
Used most by manufacturers and pharmacists
b. Generic Name: assigned by manufacturer
who developed the drug
•
Often shortened derivative of chemical name
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Drug Nomenclature, cont.
c. Official Name: name under which drug is
listed in official publications
•
Example: U.S. Pharmacopeia (USP)
•
Sets standards for each drug to regulate the
following:
-
•
Strength
Purity
Packaging
- Safety
- Labeling
- Dosage form
Generic name frequently used for official name
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Drug Nomenclature, cont.
d. Brand Name: name under which
pharmaceutical manufacturer markets the
drug
•
A drug may be marketed by more than one
company
– Generic drug may have several brand
names.
– Example:
1) Generic name:
acetaminophen
2) Brand names:
Tylenol, Tempra,
Apacet
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Drug Nomenclature, cont.
e. MA must be familiar with generic and brand
name:
•
For each drug prescribed or administered in the
office
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What Would You Do?
What Would You Not Do?
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What Would You Do?
What Would You Not Do?
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Classification of Drugs Based on
Preparation
1. Forms
a. Liquid
b. Solid
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Classification of Drugs Based on
Preparation, cont.
2. Same medications may be available in
both liquid and solid form
a. Permits administration to different types of
patients
b. Example: antibiotic
•
Liquid prep: administered to young children
•
Solid prep: administered to older children
(tablets, capsules)
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Liquid Preparations
1. Elixir
a. Drug dissolved in alcohol and water
b. Sweetened and flavored
•
Example: Dimetapp Elixir
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Liquid Preparations, cont.
2. Emulsion
a. Mixture of fats or oils in water
•
Example: Soyacol Emulsion
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Liquid Preparations, cont.
3. Liniment
a. Drug combined with oil, soap, alcohol, or
water
b. Applied externally, using friction to produce
heat or warmth
c. Example: Heet liniment
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Liquid Preparations, cont.
4. Lotion
a. Aqueous preparation that contains
suspended ingredients
b. Used to treat external skin conditions
•
Soothes, protects, and moistens skin
•
Destroys harmful bacteria
– Example: Caladryl lotion
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Liquid Preparations, cont.
5. Solution
a. Contains one or more completely dissolved
substances
•
Solute: dissolved substance
•
Solvent: liquid in which it is dissolved
b. Example: Polysporin ophthalmic solution
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Liquid Preparations, cont.
6. Spirit
a. Drug combined with alcohol solution that is
volatile: evaporates readily
•
Example: aromatic spirit of ammonia
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Liquid Preparations, cont.
7. Spray
a. Fine spray of medicated vapor
b. Often used for throat and nose conditions
c. Example: Dristan nasal spray
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Liquid Preparations, cont.
8. Suspension
a. Drug that contains solid insoluble drug
particles in a liquid
b. Must be shaken before administration
•
Example: Amoxicillin oral suspension
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Liquid Preparations, cont.
9. Suspension aerosol
a. Solid or liquid drug particles suspended in a
gas
b. Dispensed in a cloud or mist
c. Example: Proventil inhalation aerosol
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Liquid Preparations, cont.
10.Syrup
a. Drug dissolved in sugar, water, and
flavoring (to disguise unpleasant taste)
b. Example: Robitussin cough syrup
11.Tincture
a. Drug dissolved in alcohol or alcohol and
water
b. Example: Tincture of iodine
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Solid Preparations
1. Tablet
a. Powdered drug that has been pressed into
a disc
b. Some are scored: marked with indention so
can be broken into halves or quarters for
proper dosage
c. Example: Tylenol tablets
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Solid Preparations, cont.
2. Chewable tablet
a. Powdered drug that has been flavored and
pressed into a disc
b. Often used for antacids, antiflatulents,
children's medications
c. Example: Pepto-Bismol chewable tablets
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Solid Preparations, cont.
3. Sublingual tablet
a. Powdered drug that has been pressed into
a disc
b. Dissolves under the tongue
•
Permits rapid absorption into bloodstream
c. Example: nitroglycerin sublingual tablets
(Nitrostat)
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Solid Preparations, cont.
4. Enteric-coated tablet
a. Coated with substance: Prevents tablet
from dissolving until it reaches intestines
b. Purpose of coating:
•
Prevents drug from being destroyed by gastric
juices
•
Prevents drug from irritating stomach
c. Must not be crushed or chewed:
•
Releases active ingredients prematurely in
stomach
•
Example: Ecotrin enteric-coated aspirin
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Solid Preparations, cont.
5. Capsule
a. Drug contained in a gelatin capsule that is
water-soluble
b. Prevents patient from tasting drug
c. Example: Benadryl capsules
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Solid Preparations, cont.
6. Sustained-release capsules
a. Contain granules that dissolve at different
rates
b. Provides gradual and continuous release of
medication
c. Reduces numbers of doses required
d. Example: Contact 12-hour SR capsules
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Solid Preparations, cont.
7. Caplet
a. Drug contained in oblong tablet
b. Smooth coating for easier swallowing
c. Example: Advil caplets
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Solid Preparations, cont.
8. Lozenge
a. Drug contained in a candy-like base
b. Circular and dissolves on tongue
c. Example: Chloraseptic throat lozenges
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Solid Preparations, cont.
9. Cream
a. Drug combined in a nongreasy base
b. Semisolid preparation
c. Applied externally to skin
d. Example: Hydrocortisone topical cream
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Solid Preparations, cont.
10.Ointment
a. Drug with an oil base
b. Semisolid preparation
c. Applied externally to skin
d. Usually greasy
e. Example: Cortisporin topical ointment
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Solid Preparations, cont.
11.Suppository
a. Drug mixed with a firm base
b. Melts at body temperature
c. Shaped in cylinder or cone for easy
insertion into a body cavity
•
Rectum
•
Vagina
d. Example: Preparation H suppositories
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Solid Preparations, cont.
12.Transdermal patch
a. Patch with adhesive backing that contains a
drug
b. Applied to skin
c. After being absorbed through skin: drug
enters circulation
•
Example: Nictine transdermal patch (Nicoderm)
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Classification of Drugs Based on
Action
1. Drugs classified according to action
they have on body
2. For common drugs administered in
office, MA should know:
a. Category to which drug belongs
b. Primary use
c. Major therapeutic effects
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Systems of Measurement for
Medication
1. Three systems used in United States for
prescribing, administering, and
dispensing medication:
a. Metric: used most often because it provides
a more exact measurement
b. Apothecary: occasionally used
c. Household: used by patients taking liquid
medication at home
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Systems of Measurement for
Medication, cont.
2. Units:
a. Weight: heaviness of an item
b. Volume: amount of space occupied by a
substance
c. Length: linear measurement of distance
from one point to another
•
Not used to administer medications
•
Used in other aspects of medical office
(measure head circumference in centimeters
[cm])
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Metric System
1. System most often used to administer
medications
2. Developed in France in 18th century
3. Pharmaceutical companies: use it to
measure and label medications
4. Uniform decimal scale based on units of 10
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Metric System, cont.
5. Basic units
a. Gram: unit of weight
•
For measuring solids
b. Liter: unit of volume
•
For measuring liquids
c. Meter: linear unit
•
For measuring length and distance
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Metric System, cont.
6. Units most often used to administer
medication:
a. Milligram (weight)
b. Gram (weight)
c. Milliliter (volume)
d. Cubic centimeter: amount of space
occupied by 1 ml (1 ml = 1 cc)
•
These two units can be used interchangeably
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Metric System, cont.
7. Specific guidelines must be followed in
notation of metric units and doses to:
a. Read prescriptions and medication orders
b. Record medication administration
c. Avoid medication errors
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Metric System, cont.
8. Metric Notation Guidelines
a. Metric unit abbreviations
• Weight
– Microgram: mcg
– Milligram: mg
– Gram: g
– Kilogram: kg
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Metric System, cont.
• Volume
– Milliliter: ml
– Cubic centimeter: cc
– Liter: L
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Metric System, cont.
b. Do not use a period with the abbreviation of
metric units
•
May be mistaken for another letter or symbol
– Correct:
1) mg
2) ml
– Incorrect:
1) mg.
2) ml.
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Metric System, cont.
c. Use Arabic numerals
•
To express the quantity of the dose
– Correct: 4 mg
– Incorrect: iv mg (MULTIMEDIA: This needs
a line added over the numerals and under
the period--see page 456 of the 6th ed)
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Metric System, cont.
d. Place the numeral that expresses the
quantity of the dose in front of the
abbreviation
•
Leave a space between the quantity and the
abbreviation
e. Write a fraction of a dose as a decimal
•
Correct: 0.5 g
•
Incorrect: ½ g
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Metric System, cont.
f. If the dose is a fraction of a unit:
•
Place a zero before the decimal point
– Focuses on the fractional dose
– Reduces possibility of misreading the dose
as a whole number
•
Example:
– Correct: 0.5 g
– Incorrect: .5 g
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Metric System, cont.
g. Do not place a decimal point and a zero
after a whole number
•
Decimal point may be overlooked: results in
tenfold overdose error
– Correct: 1 ml
– Incorrect: 1.0 ml
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Metric System, cont.
h. Conversion Equivalents:
• Weight:
– 1000 micrograms = 1 milligram
– 1000 milligrams =
– 1000 grams =
1 gram
1 kilogram
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Metric System, cont.
• Volume:
– 1000 milliliters =
1 liter
– 1000 liters
=
1 kiloliter
– 1 milliliter
=
1 cubic centimeter
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Apothecary System
1. Older and less accurate than metric system
a. Gradually being phased out for measurement
of medications
2. Developed in England in 18th century
3. Units
a. Weight
•
Grain
•
Dram
•
Ounce
•
Pound
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Apothecary System, cont.
b. Volume
•
Minim
•
Fluid dram
•
Fluid ounce
•
Pint
•
Quart
•
Gallon
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Apothecary System, cont.
c. Length
•
Inch
•
Foot
•
Yard
•
Mile
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Household System
1. Less accurate than metric or apothecary
2. Frequently used in United States
3. May be only system patient can
a. Understand
b. Safely use to take liquid medication at home
(e.g., teaspoon)
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Household System, cont.
4. Volume: only household unit used to
administer medication
a. Drop (gtt)
b. Teaspoon
c. Tablespoon
d. Ounce
e. Cup
f. Glass
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Converting Units of Measurement
1. Conversion: changing from one unit of
measurement to another
2. Required when medication ordered in a
unit different from medication label
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Controlled Drugs
1. Controlled drug: a drug that has restrictions
placed on it by the federal government because
of its potential for abuse
2. Classified into five categories called
schedules
a. Based on abuse potential
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Schedule I
a. Schedule I
•
High potential for abuse
•
No accepted medical use
•
May lead to severe physical or psychological
dependence
•
Not available for prescribing
•
May be used for research with appropriate
limitations
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Schedule I, cont.
•
Examples:
– Heroin
– LSD
– MDMA (Ecstasy)
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Schedule II
b. Schedule II
•
High potential for abuse
•
Accepted medical use
•
Abuse may lead to severe psychological or
physical dependence
•
Prescription must be in writing
•
Emergency telephone order permitted
– Written prescription: must be provided
within 7 days
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Schedule II, cont.
•
No refills allowed
•
Manufacturer's label: marked C-II
•
Examples:
– Demerol
– OxyContin
– Percocet
– Ritalin
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Schedule III
c. Schedule III
•
Intermediate potential for abuse
•
Accepted medical use
•
Abuse may lead to:
– Low to moderate physical dependence
– Moderate to high psychological dependence
•
Telephone and fax orders permitted
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Schedule III, cont.
•
If authorized by physician:
– Prescription can be refilled:
1) Up to 5 times
2) Within 6 months from issue date
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Schedule III, cont.
•
Prescription expires 6 months from issue date
•
Manufacturer's label: marked C-III
•
Examples:
– Tylenol w/ codeine
– Vicodin
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Schedule IV
d. Schedule IV
•
Low potential for abuse
•
Accepted medical use
•
Abuse may lead to limited physical or
psychological dependence
•
Telephone and fax orders permitted
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Schedule IV, cont.
•
If authorized by physician:
– Prescription can be refilled:
1) Up to 5 times
2) Within 6 months from issue date
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Schedule IV, cont.
•
Prescription expires 6 months from issue date
•
Manufacturer's label: marked C-IV
•
Examples:
– Darvon
– Xanax
– Valium
– Ambien
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Schedule V
e. Schedule V
•
Very low potential for abuse
•
Accepted medical use
•
Abuse may lead to low physical or psychological
dependence
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Schedule V, cont.
•
Prescribing policies determined by state/local
regulations
– In most states:
1) Number of refills: determined by
physician
2) Prescription expires: 1 year from issue
date
3) Some available without prescription to
patients >18 years
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Schedule V, cont.
•
Manufacturer's label: marked C-V
•
Examples:
– Cough suppressants with small amounts of
codeine
– Antidiarrheals containing paregoric
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Controlled Drugs, cont.
3. To administer, prescribe, or dispense
controlled drugs:
a. Physician must register annually with Drug
Enforcement Administration (DEA)
•
Assigned a DEA number
•
Must put on all prescriptions for controlled
drugs
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The Prescription
1. Physician's order authorizing the
dispensing of a drug by a pharmacist
2. Can be authorized in different forms
a. Handwritten
b. Computer-generated
c. Telephoned to pharmacy
d. Faxed to pharmacy
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The Prescription, cont.
3. Abbreviations and symbols used to:
a. Write a prescription
b. Record medication info in patient's chart
4. Keep all prescription pads in a safe
place
a. Out of reach of individuals who may want to
obtain drugs illegally
b. Stock supply should be locked in a drawer
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Parts of a Prescription
1. Date
a. Pharmacist cannot fill prescription without
date
b. Prescription expires after a certain length
of time after being issued
•
Usually 1 year except for controlled drugs
c. After prescription expires: cannot be filled
(or any refills left on prescription)
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Parts of a Prescription, cont.
2. Physician's name, address, telephone
number, and fax number
a. Preprinted on form
b. Identifies physician issuing prescription
c. Provides info if pharmacist has a question
and needs to contact office
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Parts of a Prescription, cont.
3. Patient's name and address
a. Used for insurance billing and to properly
dispense medications
4. Patient's age
a. Important in dispensing medications:
•
Pharmacist double-checks physician's order
•
Makes sure proper dose is being dispensed
based on age
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Parts of a Prescription, cont.
b. Most common errors in dosage occur with
elderly and children
•
Metabolize drugs differently
•
May not require the standard dose
c. Also allows pharmacist to make sure drug
is age-appropriate
•
Some drugs should not be taken by a certain
age group
•
Example: ciprofloxacin (Cipro) should not be
taken by individuals <18 years (can cause
cartilage damage)
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Parts of a Prescription, cont.
5. Superscription
a. Rx symbol: Latin for recipe and means
"take"
6. Inscription
a. Name of drug and dosage
b. Example: Amoxil 250 mg
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Parts of a Prescription, cont.
7. Subscription
a. Directions to pharmacist
•
Generally used to designate number of doses to
be dispensed
b. To prevent prescription from being altered:
•
Use both numbers and letters to indicate
quantity
•
Example: #30 (thirty)
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Parts of a Prescription, cont.
8. Signatura (sig)
a. Latin for write or label
b. Indicates information to be included on
medication label
•
Directions for taking medication at home
•
Name of medication
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Parts of a Prescription, cont.
9. Refill
a. Number of times medication can be refilled
10.Physician's signature
a. Prescription cannot be filled without
physician's signature
11.DEA number
a. Must appear on prescription for a
controlled drug
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Parts of a Prescription
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Generic Prescribing
1. Physician writes prescription using
generic name
a. Pharmacist can fill prescription with drug that
offers best savings to patient
2. Physician writes prescription using
brand name
a. In most states pharmacist has option of filling
prescription with a generic drug
3. Physician wants prescription to be filled
with a specific brand:
a. Must indicate Dispense as Written (DAW) on
prescription form
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Completing a Prescription Form
1. If delegated by physician: MA can
complete prescription form
a. Physician must thoroughly review: to make
sure info is correct
b. Physician signs form
2. MA must carefully follow prescription
writing guidelines
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The Medication Record
1. Office may use a preprinted form
2. Medications that should be recorded:
a. Prescription
b. Over-the-counter
c. Vitamin supplements
d. Herbal products
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The Medication Record, cont.
3. Detailed information included for each
medication
a. Informs physician what patient is taking and how
much
4. Should be part of every patient's medical
record
5. MA may be responsible for documenting
medication information
6. Medication record includes:
a. Patient's name and date of birth
b. Any drug allergies
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The Medication Record, cont.
c. Date medication prescribed (Rx) or date
patient started taking (over-the-counter)
d. Name and dosage of medication
e. Frequency of administration
f. Route of administration
g. Whether prescription or over-the-counter
h. Refills (prescription medication only)
i. Date patient stopped taking medication
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Medication Record
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Factors Affecting Drug Action
Therapeutic Effect
1. Each medication has an intended
therapeutic effect
2. Certain factors affect action of drug in
the body
a. Causes patients to respond differently to
same drug
b. Drug therapy may need to be adjusted to
meet variations
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Therapeutic Effect, cont.
3. Factors affecting drug action
a. Age
•
Children and elderly: respond more strongly to
drugs than adults
– Smaller dose may be prescribed
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Therapeutic Effect, cont
b. Route of Administration
•
Medication administered by different routes:
absorbed at different rates
•
Oral: absorbed slowly
– Must first be digested
•
Parenteral: absorbed more quickly than oral
– Injected directly into body
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Therapeutic Effect, cont
c. Size
•
Thin person: may require smaller drug quantity
•
Obese person: may require larger drug quantity
d. Time of Administration
•
Empty stomach: oral drug absorbed more
rapidly
•
After eating: oral drug absorbed slower
•
If medication irritating to stomach: take with
food
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Therapeutic Effect, cont.
e. Tolerance
•
Same dose of a drug no longer produces
desired effect
•
Patient should notify physician
– Change in drug or dosage may be needed
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Undesirable Effects of Drugs
1. May occur immediately or delayed hours
or days
2. Includes:
a. Adverse Reactions
•
Unintended and undesirable effects that occur
along with therapeutic effects
– May be harmful: warrant discontinuing
medication (e.g., allergic reaction)
– May be harmless: referred to as side effects:
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Undesirable Effects of Drugs, cont.
•
Side effects: adverse reactions that are
harmless and often tolerated by patient to obtain
therapeutic effect
– Example: dry mouth when taking an
antihistamine
b. Drug Interactions
•
May occur when certain drugs are taken at
same time
•
Ask patient what medications he/she is taking
– Record information in chart for review by
physician
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Undesirable Effects of Drugs, cont.
c. Allergic Drug Reaction
•
Often mild: rash, rhinitis, pruritus
• Anaphylactic reaction: A serious allergic
reaction that requires immediate treatment
– Least common but most serious
– Occurs suddenly
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Undesirable Effects of Drugs, cont.
– Symptoms of Anaphylactic Reaction
1) Sneezing
2) Urticaria (hives)
3) Itching
4) Angioedema: a localized urticaria of the
deeper tissues of the body
5) Erythema: Reddening of the skin caused
by dilation of superficial blood vessel in
the skin
6) Disorientation
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Undesirable Effects of Drugs, cont.
Symptoms of Anaphylactic Reaction:
– If no treatment, symptoms increase and
progress to:
1) Dyspnea
2) Cyanosis
3) Shock
4) Decreased blood pressure
5) Weak and thready pulse
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Undesirable Effects of Drugs, cont.
Symptoms of Anaphylactic Reaction
– If treatment not initiated promptly:
1) Convulsions
2) Loss of consciousness
3) Death
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Undesirable Effects of Drugs, cont.
–
To prevent anaphylactic reaction:
1) Stay with patient after administration of
medications
2) Be especially alert after administering:
a) Allergy test
b) Penicillin
c) Allergy injections
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Undesirable Effects of Drugs, cont.
– Notify physician immediately if anaphylactic
reaction occurs
– Treatment
1) One or more injections of epinephrine
a) Reverses the life-threatening
symptoms
2) Once patient is stabilized: antihistamine
injection
a) Alleviates urticaria, itching,
angioedema, erythema
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Undesirable Effects of Drugs, cont.
d. Idiosyncratic Reaction
•
Abnormal or peculiar response to a drug that is
unexplained and unpredictable
•
Most often occurs in elderly patients
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What Would You Do?
What Would You Not Do?
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What Would You Do?
What Would You Not Do?
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Guidelines for Preparation and
Administration of Medication
1. Work in quiet, well-lit atmosphere free
from distractions
2. Always ask if you have a question about
a medication order
3. Know drug to be given
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Guidelines for Preparation and
Administration of Medication, cont.
4. Select proper drug
a. Check label three times
•
When taking it from storage
•
Before preparing medication
•
After preparing medication
b. Do not use if label is missing or difficult to
read
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Check the Drug Label
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Guidelines for Preparation and
Administration of Medication, cont.
5. Do not use drug if:
a. Color has changed
b. Precipitate has formed
c. Unusual odor present
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Guidelines for Preparation and
Administration of Medication, cont.
6. Check expiration date
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Guidelines for Preparation and
Administration of Medication, cont.
7. Prepare proper dose
a. Dose: the quantity of a drug to be
administered at one time
•
Dose too small: will not produce therapeutic
effect
•
Dose too large: could be harmful or fatal
b. Dosage range: range of quantities of the
drug that can produce therapeutic effects
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Guidelines for Preparation and
Administration of Medication, cont.
8. Identify the patient
a. By full name and date of birth
9. Make sure patient not allergic to
medication by:
a. Checking patient's record
b. Questioning patient
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Guidelines for Preparation and
Administration of Medication, cont.
10.If giving injection: determine route and
site
a. Determined by the type of injection
b. Examples:
•
Allergy injection: administered subcutaneously
(SC)
•
Antibiotic: administered intramuscularly (IM)
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Guidelines for Preparation and
Administration of Medication, cont.
c. Site must be free from:
•
Abrasions
•
Lesions
•
Bruises
•
Edema
11.Use proper technique
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Guidelines for Preparation and
Administration of Medication, cont.
12.Stay with patient after administration
13.Document information in patient's chart:
must be clear and legible
a. Date and time
b. Name of medication and lot number (if
required)
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Guidelines for Preparation and
Administration of Medication, cont.
c. Dose given
•
If dose contains a fraction of a unit: place a 0
before decimal point
– Example: 0.5 mg (not .5 mg)
•
Never place a decimal point and a zero after a
whole number
– Example: 20 mg (not 20.0 mg)
– So not misread as 200 mg
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Guidelines for Preparation and
Administration of Medication, cont.
d. Route of administration
e. Site of administration
f. Any unusual observations or patient
reactions
g. Sign record with your name and credentials
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Slide Title
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Guidelines for Preparation and
Administration of Medication, cont.
14.Always follow seven "rights" of
preparing and administering medication
a. Right drug
b. Right dose
c. Right time
d. Right patient
e. Right route
f. Right technique
g. Right documentation
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Oral Administration
1. Most convenient and most common
method to administer medication
2. Drug is given by mouth (po) in solid or
liquid form
3. Absorption of most oral drugs: small
intestine
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Oral Administration, cont.
4. Easier for many patients to swallow
tablet/capsule with a glass of water
5. Water should not be offered if patient
has taken cough syrup
a. Water dilutes
beneficial effects
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Parenteral Administration
1. Advantages (SC, IM, IV):
a. Absorbed more rapidly and completely than
oral route
b. May be only way drug can be given
•
Unconscious patient
•
Gastric disturbance
– Nausea
– Vomiting
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Parenteral Administration, cont.
2. MA usually responsible for administering
SC, IM, intradermally (ID)
a. Intravenous administration: when
immediate effect is needed
•
Usually administered by physician in emergency
situation
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Parenteral Administration, cont.
3. Disadvantages
a. Pain
•
To minimize pain of an injection:
– Insert and withdraw needle quickly and
smoothly
– Withdraw needle at same angle as that of
insertion
b. Possibility of infection at injection site
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Parenteral Administration, cont.
4. Injections that are given repeatedly:
must rotate sites (e.g., allergy
injections):
a. Prevents overuse of one site:
•
Can cause irritation and tissue damage
b. Allows better absorption of drug
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Parenteral Administration, cont.
5. Recording administration of medication
in patient's chart:
a. Record site of administration
•
Assists in proper rotation of sites
– For injections given repeatedly
•
Provides reference point if problem arises
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Parenteral Administration, cont.
6. Use medical asepsis when administering
medications (Needle and inside syringe
must remain sterile)
a. Reduces danger of microorganisms
entering patient's body
7. Follow OSHA Bloodborne Pathogens
Standard
a. To Protect MA from bloodborne pathogens
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Parts of a Needle
1. Needle
a. Hub: fits onto top of syringe
b. Shaft: inserted into body tissue
c. Lumen: opening in shaft of needle
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Parts of a Needle, cont.
d. Point: located at end of needle shaft
•
Sharp: to easily penetrate body tissues
e. Bevel: located at top and slanted
•
Makes narrow, slitlike opening in skin
– Closes quickly to prevent leakage of
medication
– Heals quickly
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Parts of a Needle and Syringe
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Parts of a Needle, cont.
f. Gauge
•
Range: between 18 and 27
•
Refers to diameter of lumen
•
As size of gauge increases, diameter decreases
•
Thick, oily medications: must be given with a
large lumen
– Too thick to pass through a smaller one
•
Large lumen: makes a larger needle track in
tissue
– Use smallest gauge needle possible: to
reduce pain and tissue damage
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Parts of a Needle, cont.
g. Length
•
Range: between ⅜ and 3 inches
•
Based on type of injection given (IM, SC, ID) and
size of the patient
-Example: Giving an IM injection to an obese
adult: requires a longer need to reach muscle
tissue
•
Length of needle: must be longer for IM injection
– To penetrate to muscle tissue
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Parts of a Syringe
2. Syringe
a. Used for inserting fluids into body
b. Made of plastic
c. Disposable
d. Syringe with attached needle packaged in:
•
Cellophane wrapper
•
Rigid plastic container
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Parts of a Syringe, cont.
e. Printed on wrapper:
•
Syringe capacity
•
Needle length
f. Syringe/needle in separate packages: must
attach needle to syringe
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Syringe and Needle Packages
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Parts of a Syringe, cont.
g. Parts of a Syringe
• Barrel: holds medication
– Contains calibrated markings to measure
proper amount
1) Most syringes calibrated in cubic
centimeters (cc)
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Parts of a Syringe, cont.
• Flange: rim at the end of the barrel
– Helps in injecting medication
– Prevents syringe from rolling when placed
on flat surface
• Plunger: moveable cylinder that slides back
and forth in the barrel
– Used to draw medication into and out of
syringe
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Parts of a Syringe
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Hypodermic Syringe
h. Types of syringes: choice based on type of
injection
• Hypodermic syringe
– Calibrated in cc
– Available in 2, 2.5, 3, and 5 cc
1) Commonly used to administer IM
injections
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Hypodermic Syringe
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Insulin Syringe
• Insulin syringe
– Designed to administer insulin injections
– Calibrated in units
1) Most common: U-100
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Insulin Syringe
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Tuberculin Syringe
• Tuberculin syringe
– To administer very small dose of medication
(e.g., tuberculin test)
– Capacity of 1 cc
– Calibrations divided into tenths and
hundredths of a cc
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Tuberculin Syringe
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Parts of a Syringe
i. Syringes also available in 10, 20, 30, 50,
and 60 cc
•
Not used to administer medication
•
Used for medical treatment
– Irrigating wounds
– Drawing fluid from cysts
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Safety-Engineered Syringes
1. OSHA stipulates requirements to:
a. Reduce needlesticks and other sharps
injuries among health care workers
2. Employers are required to evaluate and
implement safer medical devices
3. Safety-engineered syringes: built-in
safety feature to reduce risk of
needlestick injury
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Safety Engineered Syringe
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160
Safety Engineered Syringe
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Preparation of Parenteral
Medication: Vial
1. Vials
a. Closed glass container with a rubber
stopper
b. Soft metal or plastic cap
•
Protects the rubber stopper
•
Must be removed first time medication is used
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Preparation of Parenteral
Medication: Vial, cont.
a. Available
•
Single-dose
•
Multiple-dose
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Preparation of Parenteral
Medication: Vial, cont.
b. Vial may require mixing
•
Examples:
– Reconstituting a powdered drug
– Mixing vial that separates on standing
•
Roll medication between hands
•
Do not shake: causes bubbles that may enter
syringe
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Rolling Vial
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Preparation of Parenteral
Medication: Vial, cont.
e. To remove medication
from vial:
•
Inject amount of air equal
to amount of liquid to be
removed
– Prevents formation of
a partial vacuum:
makes it difficult to
remove medication
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Preparation of Parenteral
Medication: Vial, cont.
•
Inject air above fluid level
– Prevents getting air
bubbles into medication
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Preparation of Parenteral
Medication: Vial, cont.
•
Remove medication by
inserting needle opening
below fluid level
– Prevents air bubbles
from entering syringe
•
Draw up correct amount of
medication
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Preparation of Parenteral
Medication: Vial, cont.
•
Remove air bubbles from
syringe by tapping barrel
with fingertips
– Air bubbles take up
space medication
should take up:
prevents patient from
receiving full dose of
medication
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Preparation of Parenteral
Medication: Ampule, cont.
2. Ampule
a. Small, sealed glass container
b. Holds a single dose of medication
c. Constriction in the stem (neck): helps in
opening it
d. Make sure no medication in stem: tap it
lightly
e. Colored ring around neck: indicates where
ampule is prescored
•
For easy opening
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Preparation of Parenteral
Medication: Ampule, cont.
f. Open by holding firmly
with gauze and breaking
off stem
•
Use a strong steady
pressure
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Preparation of Parenteral
Medication: Ampule, cont.
g. Hazard with ampule
•
Small glass particles can get into ampule: when
stem broken off
•
Prevent this by using filter needle to withdraw
medication
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Preparation of Parenteral
Medication: Ampule, cont.
h. Remove medication from ampule
•
Do not let needle touch outside of ampule
– Prevents contamination of needle
•
Do not inject air into ampule
– Could force out medication
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Preparation of Parenteral
Medication: Ampule, cont.
•
Insert needle below fluid
level
•
Withdraw medication
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Preparation of Parenteral
Medication, cont.
3. Prefilled syringes and cartridges
a. Disposable
b. Do not have to draw up medication
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Preparation of Parenteral
Medication, cont.
c. Info printed on syringe/cartridge:
•
Name of drug
•
Dose
•
Expiration date
– Example: Tubex injector
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Storage of Medications
1. Store properly following info in drug
package insert
2. Improper storage may alter
effectiveness of medication
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Reconstitution of Powdered Drugs
1. Some medications
stable for only short
period of time in liquid
form
a. Example: measles,
mumps, and rubella
(MMR) immunization
b. Must be prepared and
stored in powdered form
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Reconstitution of Powdered Drugs,
cont.
2. Liquid added to powder to
reconstitute medication
a. Diluent: liquid used to
reconstitute
•
Usually sterile water or
normal saline
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Reconstitution of Powdered Drugs,
cont.
3. Powdered drug available in:
a. Single-dose vial
b. Multi-dose vial
4. Instructions provided for reconstituting
medication
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Subcutaneous Injections
1. Administered into subcutaneous tissue
a. Consists of adipose (fat) tissue
•
Located just under the skin
b. SC tissue: located all over body
•
Certain sites more commonly used
– Where bones and blood vessels are not near
surface of skin
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Subcutaneous Injections, cont.
2. SC sites commonly used:
a. Upper lateral part of arms
b. Anterior thigh
c. Upper back
d. Abdomen
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Subcutaneous Injection Sites
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Subcutaneous Injections, cont.
3. Angle of insertion: 45 or 90 degrees
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Subcutaneous Injections, cont.
4. Medication is absorbed through
capillaries
a. Slower absorption rate than IM
5. Do not give SC injection into tissue that
is
a. Grossly adipose
b. Hardened
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Subcutaneous Injections, cont.
c. Inflamed
d. Edematous
•
May interfere with proper absorption
6. Needle length range: ½ to ⅝ inch
a. Use 45-degree angle of insertion with ⅝inch needle
b. Use 90-degree angle of insertion with ½inch needle
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Subcutaneous Injections, cont.
7. Needle gauge range: 23 to 25
8. Use proper length needle: to make sure
medication is administered into SC
tissue
a. Elderly and dehydrated patients: have less
SC tissue
•
Use shorter needle
b. Obese patients: have more SC tissue
•
Use longer needle
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Subcutaneous Injections, cont.
9. SC tissue is sensitive to:
a. Irritating solutions
b. Large volumes of
medication
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Subcutaneous Injections, cont.
10.Any medication given SC must be:
a. Isotonic
b. Nonirritating
c. Nonviscous
d. Water soluble
e. Should not exceed 1 cc
•
More than 1 cc: causes discomfort and pain
– Due to pressure on sensory nerve endings
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Subcutaneous Injections, cont.
11.Medications administered SC:
a. Epinephrine
b. Insulin
c. Allergy injections
•
Following injection: patient must wait 15 to 20
minutes
– To be observed for a reaction
•
If patient decides not to wait: must sign a waiver
form
– To protect office legally in the event of an
allergic reaction
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Intramuscular Injections
1. Administered into muscular layer of the
body
a. Located below skin and SC layer
b. Angle of insertion: 90 degrees to patient’s
skin
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Angle of Insertion
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Intramuscular Injections, cont.
2. Amount that can be injected
a. Gluteal and vastus lateralis sites:
•
Adults: Up to 3 cc
•
Very thin adults and older patients: Up to 2 cc
b. Deltoid site: no more than 1 cc
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Intramuscular Injections, cont.
3. Absorption more rapid than SC
a. More blood vessels in muscle tissue
4. Medication that is irritating to SC tissue:
often given through IM route
a. Fewer nerve endings in muscle tissue
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Intramuscular Injections, cont.
5. Most parenteral medications:
administered IM
a. Medications administered IM in medical
office:
•
Immunizations
•
Antibiotics
•
Injectable contraceptives
•
Vitamin B12
•
Corticosteroids
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Intramuscular Injections, cont.
6. Needle length range: 1 to 3 inches
Must be long enough to reach muscle
tissue
a. Average-sized adult: typically use 1½
inches
b. Child or thin adult: 1 inch
c. Obese patient: 2 inches or more depending
on amount of SC tissue
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Intramuscular Injections, cont.
7. Needle gauge range: 18 to 23
a. Depends upon viscosity of medication
8. Intramuscular Injection Sites
a. Located away from large nerves and blood
vessels
b. Should be fully exposed
•
Permits clear visualization of site
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Dorsogluteal Site
c. Dorsogluteal Site
•
Gluteal muscles are well-developed: can absorb
large amount of medication
•
Used for:
– Adults
– Children older than 3 years of age
•
Patient position: on abdomen with toes pointed
inward (relaxes gluteal muscles)
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Dorsogluteal Site, cont.
•
Inject medication into upper outer quadrant of
gluteal area
– Located: above a diagonal line drawn from
greater trochanter to posterior superior
iliac spine
– Identify landmarks through palpation
•
Be extremely careful to maintain proper
boundary lines
– To avoid injection into sciatic nerve or
superior gluteal artery
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Dorsogluteal Site
From Leahy JM, Kizilay PE: Foundations of Nursing Practice: A Nursing Process Approach. Philadelphia, 1988, Saunders.
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Deltoid Site
d. Deltoid Site
•
Easily accessible
•
Patient position: sitting or lying down
•
Amount: no more than 1 cc should be
administered
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Deltoid Site, cont.
•
Site is small because major nerves and blood
vessels surround it
– Cannot administer large amount of
medication
– Cannot administer repeated injections
•
Make sure entire arm is exposed
– Completely pull up sleeve
– If cannot pull up sleeve: remove arm from
sleeve
1) Tight sleeve constricts arm: causes
bleeding from puncture site
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Deltoid Site, cont.
•
To locate site:
– Palpate lower edge of acromion process
– Forms the base of a triangle in line with
midpoint of lateral side of arm, opposite the
axilla
– Can also be located by placing four fingers
horizontally across the deltoid muscle with
top finger along acromion process; site
located three finger widths below acromion
process
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Deltoid Site
From Leahy JM, Kizilay PE: Foundations of Nursing Practice: A Nursing Process Approach. Philadelphia, 1988, Saunders.
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Vastus Lateralis Site
e. Vastus Lateralis Site
•
Thick muscle away from major nerves and blood
vessels
•
Recommended for: infants and children younger
than 3 years
– Gluteal muscles are not well developed yet
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Vastus Lateralis Site, cont.
•
To locate site:
– Proximal boundary: hand's breadth below
greater trochanter
– Distal boundary: hand's breadth above the
knee
– Bounded by midanterior thigh on the front of
the leg and midlateral thigh on the side of
the leg
•
Patient position: Easier to give lying down but
patient can be sitting
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Vastus Lateralis Site
From Leahy JM, Kizilay PE: Foundations of Nursing Practice: A Nursing Process Approach. Philadelphia, 1988, Saunders.
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Ventrogluteal Site
f. Ventrogluteal site
•
Growing in acceptability because:
– SC layer is small at this site
– Muscle layer is thick
– Located away from major nerves and blood
vessels
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Ventrogluteal Site
From Leahy JM, Kizilay PE: Foundations of Nursing Practice: A Nursing Process Approach. Philadelphia, 1988, Saunders.
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Z-Track Method
9. Z-Track Method
a. Used for administering medication that:
•
Irritate SC tissue
•
Discolor skin
– Example: iron dextran injection
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Z-Track Method, cont.
b. Sites used
•
Dorsoglutel
•
Ventrogluteal
•
Vastus lateralis
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Z-Track Method, cont.
c. To administer injection:
•
Pull skin and SC tissue to the side
•
Administer injection and remove needle
•
Release skin: causes a zigzag path through
tissue
– Seals off needle track
1) Prevents medication from reaching SC
layer or skin surface
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Z-Track Method
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What Would You Do?
What Would You Not Do?
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What Would You Do?
What Would You Not Do?
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Intradermal Injections
1. Administered in dermal layer of skin
a. Angle of insertion: almost parallel to skin
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Intradermal Injections, cont.
2. Absorption is slow:
a. Only small amount of medication can be
injected
•
0.01 to 0.2 cc
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Intradermal Injections, cont.
3. ID injection sites: where skin is thin
a. Anterior forearm
b. Middle of back
c. Upper arm
4. Needle length range: ⅜ to ⅝ inch
5. Needle gauge range: 25 to 27
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Intradermal Injections, cont.
6. Tuberculin syringe used
a. Capacity of syringe is small: 1 cc
b. Calibrations divided into tenths and
hundredths of a cubic centimeter
•
Can administer very small amount of medication
– Required with an ID injection
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Tuberculin Syringe
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Intradermal Injections, cont.
7. Used to administer skin tests
a. Allergy tests
b. Tuberculin test
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Intradermal Injections, cont.
8. Procedure for skin testing
a. Medication is injected until a wheal forms
•
Wheal: small raised area because of distention
of skin
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Intradermal Injections, cont.
b. Results are read and interpreted at proper
time
•
Allergy tests: 15 to 20 minutes
•
Tuberculin test: 48 to 72 hours
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Intradermal Injections, cont.
c. If no reaction occurs
•
Wheal disappears within a short period of time
•
Puncture site: only visible sign left
d. Positive reaction: results in induration and
erythema
•
Only criteria used to assess reaction: extent of
induration (not erythema)
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Tuberculin Testing
Tuberculosis (TB)
1. Infectious disease that usually attacks
lungs
2. Caused by: tubercle bacillus
(Mycobacterium tuberculosis)
a. Rod-shaped bacterium
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Tuberculosis, cont.
3. Symptoms
a. Fatigue
b. Weakness
c. Unexplained weight loss
d. Low-grade fever
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Tuberculosis, cont.
e. Night sweats
f. Cough producing mucopurulent sputum
g. Occasional hemoptysis (coughing up blood)
h. Chest pain
4. Not highly contagious
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Tuberculosis, cont.
5. Individuals who are infected may not
develop disease
a. Body defenses protect them as follows:
•
Fibrous wall (capsule) builds around TB organisms
•
Some bacteria may remain alive in capsule in
dormant (inactive) state
•
Patient experiences no symptoms
•
Cannot spread disease to others
b. Patient is said to have a latent tuberculosis
infection (LTBI):
•
Usually has a positive reaction to TB test
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Tuberculosis, cont.
6. LTBI may develop into active TB:
a. Shortly after infection or many years after
infection
b. TB bacteria break out of capsule: cause
symptoms of active TB
c. Occurs in 10% of patients with LTBI
d. Most likely to occur when body defenses
are weakened
•
During a serious illness
•
Patients with immune disorder (e.g., AIDS)
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Purpose of Tuberculin Testing
1. Detect presence of tuberculin infection
2. Recommended for:
a. Patients who have close day-to-day contact
with someone who has active TB
b. Individuals who have symptoms of TB
c. Individuals with lowered immunity (e.g.,
human immunodeficiency virus [HIV])
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Purpose of Tuberculin Testing, cont.
3. Used as screening measure for early
detection of TB (before patient becomes
symptomatic)
a. Early treatment: helps prevent spread of TB
4. May be:
a. Part of health screen
b. Required for:
•
Employment
•
Entrance into college or military
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Purpose of Tuberculin Testing, cont.
5. MA responsible for:
a. Administering TB test
b. Interpreting results
6. MA must follow procedure exactly
a. To ensure accurate test results
b. If not performed correctly:
•
Patient with TB may not react to test
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Tuberculin Test Reactions
1. Tuberculin: Consists of purified protein
derivative (PPD)
a. Extracted from a culture of tubercle bacilli
•
Causative agent of TB
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Tuberculin Test Reactions, cont.
2. If patient has active or latent TB:
a. Tuberculin causes induration
•
Induration: abnormally hard spot caused by
accumulation of small sensitized lymphocytes
3. TB test reactions: based on amount of
induration present
a. Interpreted according to manufacturer's
instructions
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Tuberculin Test Reactions, cont.
4. Positive reaction: indicates presence of
TB infection
a. Does not differentiate between active and
latent forms
b. Further diagnostic procedures must be
done to make a diagnosis
•
Chest x-ray study
•
Microbiologic examination of sputum
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Tuberculin Testing Methods
1. Mantoux test
a. Most commonly used
b. Administered using intradermal needle and
syringe
c. More specific and
accurate test
•
Uses a known
amount of
tuberculin
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Tuberculin Testing Methods, cont.
2. Tine test
a. Consists of sterile plastic unit containing
four tines
•
Impregnated with tuberculin
b. Patient inoculated intradermally to a depth
of 1 to 2 mm
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Tuberculin Testing Methods, cont.
c. Disc is pressed onto the skin
•
Causes tuberculin to be deposited in skin layers
d. Amount of tuberculin cannot be precisely
controlled
•
Rarely used anymore
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Mantoux Test
1. Administered through intradermal
injection
a. Using a tuberculin syringe
•
Needle length: ⅜ to ½ inch
•
Needle gauge: 26 to 27
2. Dosage: 0.10 ml of PPD containing 5 TU
(tuberculin units)
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Mantoux Test, cont.
3. Brand names for Mantoux test:
a. Tubersol
b. Aplisol
4. Draw up proper amount of tuberculin
solution
a. Too much: may elicit reaction not caused by
a TB injection
b. Too little: may be insufficient solution to
elicit a reaction
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Mantoux Test, cont.
5. Inject solution into superficial skin layers
to form wheal
a. If injected into SC layer: wheal will not form
b. If injection too shallow: leakage of solution
onto skin
•
If patient has TB: results in false-negative test
•
Repeat test: at a site at least 2 inches away
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Mantoux Test
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Mantoux Test, cont.
6. Do not apply pressure after injecting
solution
a. Solution not intended to be absorbed into
tissues
b. May cause leakage of solution
7. Do not cover site with adhesive bandage
8. Wheal disappears on its own in a few
minutes
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Guidelines for Administering a
Mantoux Test
1. Use anterior forearm: 4 inches below
bend in elbow
a. Areas to avoid
•
Hairy areas
•
Areas with
visible veins
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Guidelines for Administering a
Mantoux Test, cont.
•
Scar tissue
•
Red, swollen areas
•
Bruised areas
•
Dermatitis or other skin irritations
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Guidelines for Administering a
Mantoux Test, cont.
2. Cleanse site with antiseptic and allow to
dry
3. Inject tuberculin into superficial layers of
skin
a. Blood at puncture site: will not affect
results
4. Read results 48 to 72 hours following
administration
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Guidelines for Reading Mantoux
Test Results
1. Read in good lighting
2. Use both inspection and palpation to
read results
3. If induration is present:
•
Rub finger lightly from area of normal skin to
indurated area
– To assess size of induration
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Guidelines for Reading Mantoux
Test Results, cont
•
Measure induration in millimeters
4. Induration: only criteria used to
determine a positive reaction
a. If erythema present without induration:
results are negative
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Guidelines for Reading Mantoux
Test Results, cont
5. Record reaction in mm
a. No induration present: record as 0 mm
6. Never record results as positive or
negative
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Guidelines for Reading Mantoux
Test Results, cont
7. Interpretation of test results depends on:
a. Measurement of the induration (in mm)
b. Individual's risk of being infected with TB
c. Individual's risk of progression to disease if
infected
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Guidelines for Reading Mantoux
Test Results, cont
8. Mantoux results interpreted as follows:
a. Positive reaction
• Vesiculation -Strongly positive reaction
– Vesiculation: formation of vesicles that are
fluid-containing lesions
• Induration of 10 mm or more: Positive
reaction
– Further diagnostic tests required to
determine if active TB is present
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Guidelines for Reading Mantoux
Test Results, cont
• Induration of 5 mm: Positive for:
– Individual who lives in close contact with
person infected with TB
– HIV-infected individual
– Individual at risk for HIV
• Doubtful reaction: Induration of 5 to 9 mm
– Retesting recommended using a different
site
• Negative reaction: induration of less than
5mm
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Tuberculosis Test Record Card
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Allergy
1. Abnormal hypersensitivity of body to
substances that are ordinarily harmless
(allergens)
a. Allergen: A substance that is capable of
causing an allergic reaction
2. Allergens enter body by:
a. Being inhaled
b. Being swallowed
c. Being injected
d. Coming into contact with skin
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Allergy, cont.
3. Common allergens
a. Plant pollens
b. Molds
c. House dust
d. Animal dander
e. Feather pillows
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Allergy, cont.
f. Dyes
g. Soaps
h. Detergents
i. Cosmetics
j. Certain foods
k. Medications
l. Insect stings
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Allergy, cont.
4. Exact cause of allergies: not fully
understood
a. May be inherited
5. Allergies can develop at any age
a. Most likely to develop in children
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Allergic Reaction
1. First time allergen enters body:
a. Stimulates body to produce antibodies
(immunoglobulin E antibodies) to the
allergen
2. Antibodies combine with allergen:
results in allergen-antibody reaction
a. Histamine released in significant amounts
•
Causes allergic symptoms
b. Respiratory and integumentary systems:
most frequently affected
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Allergic Reaction, cont.
3. Allergic symptoms
a. Can range from mild to very severe
(anaphylactic reaction)
4. Allergies appear in different forms:
depends on allergen and body system
affected
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Diagnosis
1. Best way to prevent allergic reaction:
a. Identify and avoid allergens
2. Detailed medical history: obtained by
physician
a. Most important:
•
Home and work environment
•
Diet
•
Living habits
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Diagnosis, cont.
3. PE performed to detect conditions
resulting from allergies:
a. Nasal polyps
b. Wheezing
c. Skin rashes
d. Urticaria
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Diagnosis, cont.
4. Allergy testing performed
a. Direct skin testing
•
Skin-prick testing
•
Intradermal testing
b. Radioallergosorbent test (RAST)
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Treatment
5. Treatment
a. Avoidance of allergen (if possible)
b. Drug therapy
•
Antihistamines
•
Decongestants
•
Bronchodilators
•
Inhaled steroids
c. Allergy injections (desensitization
injections)
•
Decreases sensitivity of body to allergen
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Types of Allergy Tests
Types of Allergy Tests
1. Purpose of allergy testing: to determine
allergens causing patient's symptoms
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Direct Skin Testing
1. Extracts of common allergens applied to
skin: observed for reaction
•
Extracts applied topically
– Patch testing
•
Extracts applied into superficial skin layers
– Skin-prick testing
– Intradermal testing
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Direct Skin Testing, cont.
2. Advantage: results obtained immediately
3. Disadvantage: potential to cause
adverse reactions
•
Most serious: anaphylactic reaction
– Alert physician immediately if occurs
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Direct Skin Testing, cont.
4. Guidelines for Direct Skin Testing
a. Instruct patient to discontinue
antihistamines 3 days before testing
•
Otherwise, false-negative results may occur
b. Area of application must be free from:
•
Hair
•
Scar tissue
•
Dermatitis
– Permits good visualization and palpation of
test reactions
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Direct Skin Testing, cont.
– Recommended sites:
1) Intradermal skin testing
a) Anterior forearm
b) Upper arm
2) Patch and skin-prick testing
a) Back
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Direct Skin Testing, cont.
c. Cleanse area with antiseptic and allow to
dry
d. If testing involves a puncture: wear gloves
•
To protect against bloodborne pathogens
e. Space extracts 1 inch apart: provides
enough area for reaction
•
If not enough area: large adjacent reactions may
run together
– Difficult to read results
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Direct Skin Testing, cont.
f. Label test sites:
•
To identify application site when reading results
g. Inform patient: skin testing may cause a
mild allergic reaction
•
Runny nose
•
Sneezing
•
Mild wheezing
h. If more severe reaction occurs:
•
Instruct patient to contact office
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Patch Testing
1. Patch Testing:
a. Identifies allergens that cause contact
dermatitis
b. Allergens applied to skin using a "patch"
•
Patch: Small piece of gauze impregnated with
an allergen
– Applied to skin
– Taped in place with hypoallergenic tape
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Patch Test
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Patch Testing, cont.
c. Allergens commonly applied:
•
Plants
•
Topical drugs
•
Resins
•
Metals
•
Cosmetics
•
Dyes
•
Chemicals
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Patch Testing, cont.
d. Instruct patient to:
•
Leave patch in place
•
Keep dry
•
Return to office in 48 hours to have results read
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Patch Testing, cont.
e. Patches removed: results read 20 minutes
later
•
Allows lessening of redness due to tape removal
f. Positive results: erythema, itching,
induration, vesiculation
•
Graded on a 1+ to 3+ scoring system
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Patch Test Results
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Skin Prick Testing
2. Skin-Prick Testing
a. To diagnose allergies to common allergens
•
Particularly those that are inhaled (house dust,
molds, pollens)
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Skin Prick Testing, cont.
b. Performed by:
•
Applying allergen extracts to skin
– Number ranges from 20 to 30
•
Pricking each with a sterile needle
– Deposits allergen in outer layer of skin
– Allows it to react with body tissues
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Skin Prick Testing
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Skin Prick Testing, cont.
c. Guidelines
•
Place extracts on skin in rows in a specific
pattern
•
Label test sites with felt-tipped pen
– Tracks location of each extract
•
Place a single drop of extract on skin
– More may cause extracts to run together
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Skin Prick Testing, cont.
•
Pass a sterile needle through each drop
– Point of needle should lightly lift top skin
layer
•
Wipe needle dry with sterile swab between each
prick
– Prevents one extract from mixing with the
next (causes inaccurate test results)
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Skin Prick Testing, cont.
d. Maximum reaction: occurs in 15 to 20
minutes after pricking skin
e. Leave test sites uncovered; instruct patient
not to touch them
f. Do not wipe area: removes extract
•
Results in false-negative results
g. Read results after 15 to 20 minutes
•
Using a millimeter ruler
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Skin Prick Testing, cont.
h. Positive reaction: area of induration
surrounded by redness and itching
i. Measure size of induration in mm (with mm
ruler)
•
Only criteria used in determining a positive
reaction
•
Ignore redness
j. Convert results to a numerical scale (+1,
+2, etc.)
•
Record results
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Skin Prick Results
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Intradermal Skin Testing
3. Intradermal Skin Testing
a. Similar to skin-prick testing but more
specific
b. Number of tests performed: 5 to 30
c. Patients suspected of being highly allergic
•
Greater chance of adverse allergic reaction
occurring
•
Physician usually starts with skin-prick testing
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Intradermal Skin Testing, cont.
d. Small amount of allergen extract (0.02 to
0.05 ml)
•
Injected into skin layers: using a tuberculin
syringe
•
Enough extract must be injected to form a wheal
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Intradermal Skin Testing, cont.
e. Read reaction in 15 to 20 minutes
f. Positive reaction: Induration surrounded by
redness and itching
Copyright and courtesy Hollister-Stier, Spokane, Wash.
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Intradermal Skin Testing, cont.
g. Measure size of induration in mm (with mm
ruler)
•
Only criteria used in determining a positive
reaction
•
Ignore redness
h. Convert to numerical scale based on
amount of induration present
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Intradermal Test Results
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RAST Testing
1. Radioallergosorbent test (RAST):
measures amount of immunoglobulin E
antibodies in blood to common allergens
2. Blood specimen collected and sent to
laboratory
3. Blood exposed to radioactively tagged
allergens
4. Radiation device measures amounts of
immunoglobulin E antibodies to
allergens
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RAST Testing, cont.
5. Advantages
a. Results not affected by medications (e.g.,
antihistamines)
b. No danger of adverse reactions
c. Can be performed on patients with skin
eruptions
•
Unable to undergo direct skin testing
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RAST Testing, cont.
6. Disadvantages
•
Expensive
•
Does not provide immediate results
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Outpatient IV Therapy
1. Intravenous (IV) therapy
a. Administration of a liquid agent directly into
a patient's vein
•
Distributed throughout the body by way of
circulatory system
b. Veins most commonly used
•
Peripheral veins of the arm and hand
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Outpatient IV Therapy, cont.
c. Liquid IV agents:
•
Fluids
•
Medication
•
Nutrients
•
Blood or blood products
d. Infusion: Administration of fluids,
medications or nutrients through the IV
route
e. Transfusion: Administration of whole blood
or blood products through the IV route
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Outpatient IV Therapy, cont.
2. Most IV therapy takes place in a hospital
setting
3. IV therapy is also administered in
outpatient ambulatory settings such as:
a. Medical offices and clinics
b. Urgent care centers
c. Ambulatory infusion clinics
d. Patient's home
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Outpatient IV Therapy, cont.
4. Advantages of Outpatient IV Therapy
a. More convenient for patient
b. Reduces medical costs
•
Earlier Hospital Discharge:
– Example: Hospitalized patient with an
infection needing IV antibiotics
1) No longer needs to be hospitalized
2) Receives the therapy at an infusion
clinic
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Outpatient IV Therapy, cont.
•
Avoidance of Hospitalization
– Patients with acute or chronic illness that
requires IV therapy
– Obtains IV therapy in an outpatient setting
– Can continue daily routine without major
interruptions
– More independence and control over
condition
– Example: Patient with rheumatoid arthritis
needing IV Remicade therapy
1) Receives therapy in rheumatology office
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Outpatient IV Therapy, cont.
5. Medical Office-Based IV Therapy
a. Some medical offices provide outpatient IV
therapy
•
Oncology offices: may administer IV
chemotherapy
•
Rheumatology offices: may administer IV
rheumatology medications
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Outpatient IV Therapy, cont.
b. Advantages
•
Closer monitoring of:
– Patients response to IV therapy
– Adverse reactions
From Potter PA, Perry AG: Basic nursing: essentials for practice, ed 5, St. Louis, 2002, Mosby.
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Outpatient IV Therapy, cont.
c. Medical assists must acquire basic
knowledge in IV therapy
•
MA often responsible for:
– Scheduling IV therapy
– Providing patient instructions
– Answering questions
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Outpatient IV Therapy, cont.
d. Requirements for MA to perform IV therapy:
•
Check the laws of his or her state
– Determine if legally permissible for MA to
perform this procedure
•
Acquire proper training (theory and skills)
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Indications for Outpatient IV
Therapy
1. Physician assesses need for outpatient
IV therapy:
a. Patients condition warrants the use of IV
therapy
b. No alternate routes are feasible or
appropriate
c. Patient does not need to be hospitalized to
receive IV therapy
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Indications for Outpatient IV
Therapy, cont.
2. Physician is responsible for:
a. Prescribing IV medication/fluid and
treatment plan
b. Ordering laboratory tests to monitor
patients progress
c. Assessing patient following IV therapy
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Indications for Outpatient IV
Therapy, cont.
3. IV therapy administered at an outpatient
site other than medical office (e.g.,
infusion clinic)
a. MA responsibilities:
•
Scheduling the necessary services
•
Providing patient with IV therapy instructions
– Length of time required for the therapy
– Any dietary restrictions
– Advising the patient to wear loose-fitting
comfortable clothing
– Whether or not someone needs to transport
patient to/from appointment
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Indications for Outpatient IV
Therapy, cont.
4. IV therapy administered at the medical
office
a. Special room to deliver the therapy
•
Lounge chair for patient comfort
b. Entry-level MA responsibilities:
•
Scheduling IV therapy
•
Providing IV therapy instructions
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Indications for Outpatient IV
Therapy, cont.
c. IV practitioner (e.g., nurse or speciallytrained medical assistant)
•
Initiates, maintains and discontinues the IV
therapy
Photo by Margaret Hartshorn; Courtesy of the Arizona Arthritis Center
(www.arthritis.arizona.edu)
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Indications for Outpatient IV
Therapy, cont.
• Must be completely familiar with IV
therapy including:
– Indications and uses
– Actions
– Dosage and rate of infusion
– Incompatibilities
– Contraindications and precautions
– Antidote
– Adverse effects
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Indications for Outpatient IV
Therapy, cont.
• During the IV therapy:
– Monitor patient response to therapy
– Be alert for adverse or allergic reactions
• After the therapy:
– Provide follow-up instructions
1) Normal side effects once patient returns
home
2) Adverse reactions to report to medical
office
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Indications for Outpatient IV
Therapy, cont.
5. Indications for IV therapy in an
outpatient setting:
a. Administration of IV medication
b. Replacement of fluids and electrolytes
c. Administration of nutritional supplements
d. Administration of blood products
e. Emergency administration of IV
medications and fluids
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Administration of IV Medication
1. Process of delivering medication directly
into a vein
a. Rapid and effective
b. Provides more accurate dosing than other
routes
•
Medication enters the body directly from
circulatory system
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Administration of IV Medication,
cont.
– Bypasses barriers to drug absorption
1) Digestive tract: from oral administration
2) Muscle tissue: from IM administration
– Easier to control actual amount of drug
delivered to the body
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Administration of IV Medication,
cont.
2. Medication may have to be administered
through the IV route because:
a. Rapid systemic response to medication is desired
b. Therapeutic blood levels need to be maintained
c. Medication is destroyed by stomach acids and/or
digestive enzymes
d. Medication cannot be absorbed into body through GI
tract
e. Medication is toxic and could damage to lining of GI
tract
f.
Medication is painful or irritating when given by
other parenteral routes (IM or SC)
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Direct IV Injection
3. IV Administration Methods
a. Direct IV Injection (IV push)
•
Administration of medication as a single dose
into the vein over a short period of time (usually
less than 10 minutes)
– Administered through a vascular access
device already in place
•
Immediate and predictable results
•
Good way to administer life-saving medications
in an emergency
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Intermittent IV Administration
b. Intermittent IV Administration
•
Administration of a medication over a specific
amount of time (termed the rate of infusion) and
at specified intervals
•
Frequently employed in outpatient settings
•
Before administering
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Intermittent IV Administration, cont.
– Dilute medication in a moderate amount of
IV fluid (25 to 250 ml)
– Amount and type of IV fluid: indicated in
drug insert
1) Example: Intermittent IV administration
of ceftriaxone (an antibiotic)
a) Reconstitute medication
b) Dilute in 50 to 100 ml of an IV
fluid (e.g., sterile water, 0.9%
sodium chloride)
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Intermittent IV Administration, cont.
• Rate of infusion: Depends on medication
being administered
– Typically ranges from 15 minutes to several
hours
– Specified in drug insert
1) Examples:
a) Rate of infusion for ceftriaxone
(Rocephin): Between 15 to 30
minutes
b) Rate of infusion for IV infliximab
(Remicade): At least 2 hours
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Intermittent IV Administration, cont.
• Interval of time between doses depends
on:
– Medication being administered
– Patient condition
1) Example: Outpatient treatment plan for a
patient with Lyme disease
a) IV ceftriaxone intermittently
once a day for a period of
14 days
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Continuous IV Administration
c. Continuous IV Administration
•
Infusion of medication over a continuous period
of time (between 4 to 24 hours)
•
Also known as an IV drip
•
Most often used in hospital or home setting
•
Used to maintain a constant therapeutic blood
level of the medication
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Continuous IV Administration, cont.
•
Medication is diluted in a large quantity (250 to
1000 ml) of an IV fluid such as:
– 0.9% sodium chloride (known as normal
saline)
– 5% dextrose in water (known as D5W)
•
Not generally used to administer IV medications
in medical office
– Because of amount of time required
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IV Medication: Antibiotics
4. Intravenous Medications Administered in
an Outpatient Setting
a. IV Antibiotics
•
May be prescribed to treat a serious infection
– To prevent the infection from spreading
– To avoid the development of serious
complications
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IV Medication: Antibiotics, cont.
•
Quickly achieves high blood concentrations
– Works on the infection immediately.
•
IV antibiotic therapy may be prescribed in an
outpatient setting for:
– Osteomyelitis, cellulitis endocarditis,
bacterial meningitis, Lyme disease,
bacterial pneumonia, bacterial septicemia,
pyelonephritis, pelvic inflammatory disease,
AIDS-related infections, severe urinary tract
infections, and non-healing wound
infections
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IV Medication: Chemotherapy
b. IV Chemotherapy
• Chemotherapy: the use of chemicals to treat
disease.
– More specifically: the use of antineoplastic
medications to treat different types of
cancer
•
Works by interfering with the ability of cancer
cells to grow or reproduce
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IV Medication: Chemotherapy, cont.
•
IV route commonly used to administer
chemotherapy
– Most antineoplastic medications are toxic
and irritating
– Must be delivered to the body through a vein
– Cause pain and trauma to tissues if
administered by other parenteral routes
(i.e.; IM or SC)
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IV Medication: Chemotherapy, cont.
•
May take only a few minutes to administer or as
long as several hours
•
May be given on a daily, weekly or monthly basis
•
Frequency and length of treatment depends on:
– Type of cancer
– Antineoplastic medications being
administered
– Patient’s overall health
– Patients to tolerate the antineoplastic
medications
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IV Medication: Chemotherapy, cont.
•
Often administered in an outpatient setting such
as:
– Oncology medical office
– Infusion clinic
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IV Medication: Monoclonal
Antibodies
c. Monoclonal Antibodies
•
Used to treat inflammatory diseases
•
Individuals with certain inflammatory diseases
– Have too much of a normally-occurring
protein (tumor necrosis factor [TNF])
1) Causes inflammation
2) In too large of amounts: attacks healthy
tissues
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IV Medication: Monoclonal
Antibodies, cont.
•
Remicade (infliximab) is a monoclonal antibody
which works by:
– Binding with TNF and blocking its action
1) Reduces the inflammatory response of
the body
2) Disadvantage: Also lowers ability of
body to fight infection
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IV Medication: Monoclonal
Antibodies, cont.
•
IV Remicade administered in an outpatient
setting for treatment of:
– Crohn's disease
– Rheumatoid arthritis
– Ulcerative colitis
– Ankylosing spondylitis
– Psoriatic arthritis
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IV Medication: Monoclonal
Antibodies, cont.
•
Remicade works to:
– Reduce the symptoms
– Initiate and maintain remission of the
disorder
•
IV Remicade only administered after an
inadequate response to conventional therapy
– Has some undesirable side effects
– Expensive
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IV Medication: Analgesics
d. IV Analgesics
•
May be prescribed if patient is unable to manage
pain using oral pain medications
•
IV analgesic therapy may be prescribed in an
outpatient setting for:
– Migraine headaches
– Cancer-related pain
– Pain associated with AIDs conditions
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IV Medication: Analgesics, cont.
•
Patient-controlled analgesia (PCA) pump
– Used to administer IV narcotic analgesics
– Delivery of the medication controlled by
patient
– When patient experiences pain
1) Presses a button on PCA pump
2) Predetermined dose delivered IV to
patient
– Pump is preset: to prevent overmedication
– Includes a locking device for security of the
medication
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PCA Pump
From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, ed 3, St. Louis, 2004, Mosby.
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Replacement of Fluids and
Electrolytes
1. To remain healthy: Body must maintain
adequate fluid and electrolyte balance
2. Depletion of fluids and electrolytes may
be caused by:
a. Vomiting
b. Diarrhea
c. Excessive perspiration (e.g., fever breaking
or hot weather)
d. Starvation
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Replacement of Fluids and
Electrolytes, cont.
3. Excessive loss of fluids or electrolytes
a. Must be replaced as soon as possible to
prevent dehydration
•
Infants and children: Especially vulnerable to
dehydration
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Replacement of Fluids and
Electrolytes, cont.
4. Best way to replace fluids and
electrolytes: oral consumption
a. May not be possible (e.g., excessive
vomiting)
•
IV fluid therapy may be prescribed
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Replacement of Fluids and
Electrolytes, cont.
5. Physician determines the IV fluid/amount
using the following information:
a. Patient's diagnosis (e.g., prolonged
diarrhea)
b. Other existing medical conditions
c. Length of the current illness
d. Body size and weight
e. Physician's findings from physical
examination
f. Laboratory test results
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Replacement of Fluids and
Electrolytes, cont.
6. Examples of IV fluids used to replace
fluids/electrolytes:
a. 0.9% sodium chloride
b. Ringer's solution
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Replacement of Fluids and
Electrolytes, cont.
7. Administered by continuous IV
administration in following outpatient
settings:
a. Urgent care centers
b. Infusion clinics
c. Patient's home
8. Medical office does not typically
administer IV fluids/electrolytes except in
an emergency
a. Because of length of time required for
continuous IV administration
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Administration of Nutritional
Supplements
1. IV therapy used to administer nutritional
supplements in an outpatient setting
a. Indications:
•
Patient unable to eat
•
Conditions causing poor absorption of nutrients
from GI tract
b. Only used when patient has a condition that
prevents other routes of administration
(e.g., oral or enteral route)
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Administration of Nutritional
Supplements, cont.
•
Enteral nutrition: The delivery of nutrients through a
tube inserted into the GI tract.
2. May require IV administration of nutritional
supplements:
a. Ulcerative colitis, Crohn’s disease, short bowel
syndrome, celiac disease, pancreatitis,
esophageal cancer, AIDS-related malnutrition,
and malnutrition related to an eating disorder
3. Parenteral IV nutrition is often administered
in outpatient settings (e.g., infusion clinics
and the patient's home)
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Administration of Blood Products
1. Immune Globulin
a. Consists of pooled human plasma
containing antibodies
•
Has been tested
– Found to be safe and free of bloodborne
pathogens
•
Must be given through IV route
b. Intravenous immune globulin (IVIG) therapy
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Administration of Blood Products,
cont.
•
Used to treat:
– Immune deficiencies who are unable to
produce their own antibodies
1) Chronic inflammatory demyelinating
polyneuropathy (CIDP)
a) Autoimmune disease: A condition
in which, for some unknown
reason, the body's immune system
attacks the body's own cells such
as:
o
Multiple sclerosis
o
Myasthenia gravis
o
Lupus
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Administration of Blood Products,
cont.
c. IVIG treatment plan
•
Dose is based on patient's weight
•
Medication is infused slowly over a number of
hours
•
Number and frequency of treatment depends on
patient condition.
– Patient who cannot produce antibodies:
IVIG treatment once a month
– Patient with autoimmune disease: may only
require a treatment when there is a flare-up
(to boost immune system)
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Administration of Blood Products,
cont.
2. Hemophilia Factors
a. Hemophilia: An inherited bleeding disorder
characterized by a deficiency of a clotting
factor needed for proper coagulation of the
blood;
b. Without this factor
•
Hemophiliac may bleed:
– Spontaneously
– Following trauma to any tissues or organs of
the body
•
Most common sites of bleeds: Joints and
muscles
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Administration of Blood Products,
cont.
c. Missing blood clotting factor: must
periodically be administered IV
d. If treatment delayed:
•
Irreversible damage to affected tissues
•
Death
e. Many patients receive IV clotting factors at
home
•
More convenient
•
Easier to manage condition
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Emergency Administration of IV
Medication and Fluids
1. Capability to initiate an IV line is
important in an emergency
a. Provides an access route for IV
administration of:
•
Life-saving medications
•
Fluids
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Emergency Administration of IV
Medication and Fluids, cont.
2. Emergency situations sometimes arise
in medical office
a. While waiting for squad to transport patient
to hospital
•
IV line may be established to administer
medications and fluids as soon as possible
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Emergency Administration of IV
Medication and Fluids, cont.
b. Emergency situations which may benefit
from establishing IV access:
•
Myocardial infarction
•
Stroke
•
Anaphylactic reaction
•
Diabetic emergencies
•
Heat-related injuries (e.g., heat stroke)
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POSTTEST
True or False
1. OSHA is responsible for determining if drugs are safe
before release for human use.
2. An enteric-coated tablet does not dissolve until it
reaches the intestines.
3. The apothecary system is most often used to
administer medication in the medical office.
4. The parenteral route of administering medications is
used when the patient is allergic to the oral form of
the drug.
5. Hypodermic syringes are calibrated in cubic
centimeters.
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POSTTEST, CONT.
True or False
6. The maximum amount of medication that can be
administered through the subcutaneous route is 2 cc.
7. A patient with latent tuberculosis infection has a
negative reaction to a TB test.
8. A tuberculin skin test result should be read 15 to 20
minutes after administering.
9. Intermittent IV administration involves the
administration of IV medication over a specific
amount of time at specified intervals.
10. Immune globulin consists of pooled human plasma
that contains clotting factors.
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