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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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 2 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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 3 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 4 Introduction to Administration of Medication, cont. 3. Most drugs: produced synthetically a. Can also be obtained from: • Animals • Plants • Minerals Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 5 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 6 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 7 Introduction to Administration of Medication, cont. 6. Routes of Administration a. Oral b. Sublingual c. Inhalation d. Rectal e. Vaginal Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 8 Introduction to Administration of Medication, cont. f. Topical g. Intradermal h. Subcutaneous i. Intramuscular j. Intravenous Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 9 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 10 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 11 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 12 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 13 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 14 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 15 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 16 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 17 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 18 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 19 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 20 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 21 Drug Nomenclature, cont. e. MA must be familiar with generic and brand name: • For each drug prescribed or administered in the office Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 22 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 23 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 24 Classification of Drugs Based on Preparation 1. Forms a. Liquid b. Solid Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 25 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 26 Liquid Preparations 1. Elixir a. Drug dissolved in alcohol and water b. Sweetened and flavored • Example: Dimetapp Elixir Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 27 Liquid Preparations, cont. 2. Emulsion a. Mixture of fats or oils in water • Example: Soyacol Emulsion Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 28 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 29 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 30 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 31 Liquid Preparations, cont. 6. Spirit a. Drug combined with alcohol solution that is volatile: evaporates readily • Example: aromatic spirit of ammonia Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 32 Liquid Preparations, cont. 7. Spray a. Fine spray of medicated vapor b. Often used for throat and nose conditions c. Example: Dristan nasal spray Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 33 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 34 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 35 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 36 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 37 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 38 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 39 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 40 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 41 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 42 Solid Preparations, cont. 7. Caplet a. Drug contained in oblong tablet b. Smooth coating for easier swallowing c. Example: Advil caplets Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 43 Solid Preparations, cont. 8. Lozenge a. Drug contained in a candy-like base b. Circular and dissolves on tongue c. Example: Chloraseptic throat lozenges Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 44 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 45 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 46 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 47 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 48 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 49 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 50 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]) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 51 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 52 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 53 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 54 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 55 Metric System, cont. 8. Metric Notation Guidelines a. Metric unit abbreviations • Weight – Microgram: mcg – Milligram: mg – Gram: g – Kilogram: kg Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 56 Metric System, cont. • Volume – Milliliter: ml – Cubic centimeter: cc – Liter: L Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 57 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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 58 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 59 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 60 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 61 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 62 Metric System, cont. h. Conversion Equivalents: • Weight: – 1000 micrograms = 1 milligram – 1000 milligrams = – 1000 grams = 1 gram 1 kilogram Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 63 Metric System, cont. • Volume: – 1000 milliliters = 1 liter – 1000 liters = 1 kiloliter – 1 milliliter = 1 cubic centimeter Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 64 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 65 Apothecary System, cont. b. Volume • Minim • Fluid dram • Fluid ounce • Pint • Quart • Gallon Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 66 Apothecary System, cont. c. Length • Inch • Foot • Yard • Mile Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 67 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 68 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 69 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 70 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 71 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 72 Schedule I, cont. • Examples: – Heroin – LSD – MDMA (Ecstasy) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 73 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 74 Schedule II, cont. • No refills allowed • Manufacturer's label: marked C-II • Examples: – Demerol – OxyContin – Percocet – Ritalin Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 75 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 76 Schedule III, cont. • If authorized by physician: – Prescription can be refilled: 1) Up to 5 times 2) Within 6 months from issue date Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 77 Schedule III, cont. • Prescription expires 6 months from issue date • Manufacturer's label: marked C-III • Examples: – Tylenol w/ codeine – Vicodin Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 78 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 79 Schedule IV, cont. • If authorized by physician: – Prescription can be refilled: 1) Up to 5 times 2) Within 6 months from issue date Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 80 Schedule IV, cont. • Prescription expires 6 months from issue date • Manufacturer's label: marked C-IV • Examples: – Darvon – Xanax – Valium – Ambien Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 81 Schedule V e. Schedule V • Very low potential for abuse • Accepted medical use • Abuse may lead to low physical or psychological dependence Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 82 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 83 Schedule V, cont. • Manufacturer's label: marked C-V • Examples: – Cough suppressants with small amounts of codeine – Antidiarrheals containing paregoric Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 84 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 85 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 86 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 87 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 88 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 89 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 90 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 91 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 92 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 93 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 94 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 95 Parts of a Prescription Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 96 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 97 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 98 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 99 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 100 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 101 Medication Record Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 102 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 103 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 104 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 105 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 106 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 107 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: Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 108 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 109 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 110 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 111 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 112 Undesirable Effects of Drugs, cont. Symptoms of Anaphylactic Reaction – If treatment not initiated promptly: 1) Convulsions 2) Loss of consciousness 3) Death Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 113 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 114 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 115 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 116 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 117 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 118 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 119 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 120 Check the Drug Label Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 121 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 122 Guidelines for Preparation and Administration of Medication, cont. 6. Check expiration date Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 123 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 124 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 125 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 126 Guidelines for Preparation and Administration of Medication, cont. c. Site must be free from: • Abrasions • Lesions • Bruises • Edema 11.Use proper technique Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 127 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 128 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 129 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 130 Slide Title Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 131 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 132 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 133 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 134 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 135 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 136 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 137 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 138 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 139 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 140 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 141 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 142 Parts of a Needle and Syringe Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 143 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 144 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 145 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 146 Parts of a Syringe, cont. e. Printed on wrapper: • Syringe capacity • Needle length f. Syringe/needle in separate packages: must attach needle to syringe Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 147 Syringe and Needle Packages Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 148 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 149 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 150 Parts of a Syringe Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 151 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 152 Hypodermic Syringe Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 153 Insulin Syringe • Insulin syringe – Designed to administer insulin injections – Calibrated in units 1) Most common: U-100 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 154 Insulin Syringe Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 155 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 156 Tuberculin Syringe Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 157 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 158 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 159 Safety Engineered Syringe Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 160 Safety Engineered Syringe Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 161 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 162 Preparation of Parenteral Medication: Vial, cont. a. Available • Single-dose • Multiple-dose Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 163 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 164 Rolling Vial Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 165 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 166 Preparation of Parenteral Medication: Vial, cont. • Inject air above fluid level – Prevents getting air bubbles into medication Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 167 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 168 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 169 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 170 Preparation of Parenteral Medication: Ampule, cont. f. Open by holding firmly with gauze and breaking off stem • Use a strong steady pressure Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 171 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 172 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 173 Preparation of Parenteral Medication: Ampule, cont. • Insert needle below fluid level • Withdraw medication Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 174 Preparation of Parenteral Medication, cont. 3. Prefilled syringes and cartridges a. Disposable b. Do not have to draw up medication Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 175 Preparation of Parenteral Medication, cont. c. Info printed on syringe/cartridge: • Name of drug • Dose • Expiration date – Example: Tubex injector Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 176 Storage of Medications 1. Store properly following info in drug package insert 2. Improper storage may alter effectiveness of medication Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 177 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 178 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 179 Reconstitution of Powdered Drugs, cont. 3. Powdered drug available in: a. Single-dose vial b. Multi-dose vial 4. Instructions provided for reconstituting medication Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 180 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 181 Subcutaneous Injections, cont. 2. SC sites commonly used: a. Upper lateral part of arms b. Anterior thigh c. Upper back d. Abdomen Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 182 Subcutaneous Injection Sites Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 183 Subcutaneous Injections, cont. 3. Angle of insertion: 45 or 90 degrees Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 184 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 185 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 186 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 187 Subcutaneous Injections, cont. 9. SC tissue is sensitive to: a. Irritating solutions b. Large volumes of medication Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 188 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 189 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 190 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 191 Angle of Insertion Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 192 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 193 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 194 Intramuscular Injections, cont. 5. Most parenteral medications: administered IM a. Medications administered IM in medical office: • Immunizations • Antibiotics • Injectable contraceptives • Vitamin B12 • Corticosteroids Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 195 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 196 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 197 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 198 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 199 Dorsogluteal Site From Leahy JM, Kizilay PE: Foundations of Nursing Practice: A Nursing Process Approach. Philadelphia, 1988, Saunders. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 200 Deltoid Site d. Deltoid Site • Easily accessible • Patient position: sitting or lying down • Amount: no more than 1 cc should be administered Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 201 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 202 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 203 Deltoid Site From Leahy JM, Kizilay PE: Foundations of Nursing Practice: A Nursing Process Approach. Philadelphia, 1988, Saunders. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 204 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 205 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 206 Vastus Lateralis Site From Leahy JM, Kizilay PE: Foundations of Nursing Practice: A Nursing Process Approach. Philadelphia, 1988, Saunders. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 207 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 208 Ventrogluteal Site From Leahy JM, Kizilay PE: Foundations of Nursing Practice: A Nursing Process Approach. Philadelphia, 1988, Saunders. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 209 Z-Track Method 9. Z-Track Method a. Used for administering medication that: • Irritate SC tissue • Discolor skin – Example: iron dextran injection Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 210 Z-Track Method, cont. b. Sites used • Dorsoglutel • Ventrogluteal • Vastus lateralis Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 211 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 212 Z-Track Method Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 213 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 214 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 215 Intradermal Injections 1. Administered in dermal layer of skin a. Angle of insertion: almost parallel to skin Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 216 Intradermal Injections, cont. 2. Absorption is slow: a. Only small amount of medication can be injected • 0.01 to 0.2 cc Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 217 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 218 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 219 Tuberculin Syringe Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 220 Intradermal Injections, cont. 7. Used to administer skin tests a. Allergy tests b. Tuberculin test Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 221 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 222 Intradermal Injections, cont. b. Results are read and interpreted at proper time • Allergy tests: 15 to 20 minutes • Tuberculin test: 48 to 72 hours Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 223 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 224 Tuberculin Testing Tuberculosis (TB) 1. Infectious disease that usually attacks lungs 2. Caused by: tubercle bacillus (Mycobacterium tuberculosis) a. Rod-shaped bacterium Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 225 Tuberculosis, cont. 3. Symptoms a. Fatigue b. Weakness c. Unexplained weight loss d. Low-grade fever Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 226 Tuberculosis, cont. e. Night sweats f. Cough producing mucopurulent sputum g. Occasional hemoptysis (coughing up blood) h. Chest pain 4. Not highly contagious Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 227 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 228 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 229 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]) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 230 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 231 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 232 Tuberculin Test Reactions 1. Tuberculin: Consists of purified protein derivative (PPD) a. Extracted from a culture of tubercle bacilli • Causative agent of TB Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 233 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 234 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 235 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 236 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 237 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 238 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 239 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 240 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 241 Mantoux Test Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 242 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 243 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 244 Guidelines for Administering a Mantoux Test, cont. • Scar tissue • Red, swollen areas • Bruised areas • Dermatitis or other skin irritations Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 245 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 246 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 247 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 248 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 249 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 250 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 251 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 252 Tuberculosis Test Record Card Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 253 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 254 Allergy, cont. 3. Common allergens a. Plant pollens b. Molds c. House dust d. Animal dander e. Feather pillows Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 255 Allergy, cont. f. Dyes g. Soaps h. Detergents i. Cosmetics j. Certain foods k. Medications l. Insect stings Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 256 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 257 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 258 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 259 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 260 Diagnosis, cont. 3. PE performed to detect conditions resulting from allergies: a. Nasal polyps b. Wheezing c. Skin rashes d. Urticaria Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 261 Diagnosis, cont. 4. Allergy testing performed a. Direct skin testing • Skin-prick testing • Intradermal testing b. Radioallergosorbent test (RAST) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 262 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 263 Types of Allergy Tests Types of Allergy Tests 1. Purpose of allergy testing: to determine allergens causing patient's symptoms Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 264 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 265 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 266 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 267 Direct Skin Testing, cont. – Recommended sites: 1) Intradermal skin testing a) Anterior forearm b) Upper arm 2) Patch and skin-prick testing a) Back Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 268 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 269 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 270 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 271 Patch Test Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 272 Patch Testing, cont. c. Allergens commonly applied: • Plants • Topical drugs • Resins • Metals • Cosmetics • Dyes • Chemicals Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 273 Patch Testing, cont. d. Instruct patient to: • Leave patch in place • Keep dry • Return to office in 48 hours to have results read Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 274 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 275 Patch Test Results Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 276 Skin Prick Testing 2. Skin-Prick Testing a. To diagnose allergies to common allergens • Particularly those that are inhaled (house dust, molds, pollens) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 277 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 278 Skin Prick Testing Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 279 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 280 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 281 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 282 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 283 Skin Prick Results Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 284 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 285 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 286 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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 287 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 288 Intradermal Test Results Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 289 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 290 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 291 RAST Testing, cont. 6. Disadvantages • Expensive • Does not provide immediate results Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 292 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 293 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 294 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 295 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 296 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 297 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 298 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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 299 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 300 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 301 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 302 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 303 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 304 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 305 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 306 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 307 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 308 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 309 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 310 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 311 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 312 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 313 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 314 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 315 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 316 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 317 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 318 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 319 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 320 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 321 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 322 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 323 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 324 IV Medication: Chemotherapy, cont. • Often administered in an outpatient setting such as: – Oncology medical office – Infusion clinic Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 325 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 326 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 327 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 328 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 329 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 330 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 331 PCA Pump From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, ed 3, St. Louis, 2004, Mosby. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 332 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 333 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 334 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 335 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 336 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 337 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 338 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 339 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 340 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 341 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 342 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 343 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 344 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 345 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 346 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 347 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 348 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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 349 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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 350