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Chapter 12 Administering Medication
Medication or drugs are given to exert specific physiologic effects on the body. Since they
play such an important role in preventing, treating, and curing illness, their administration has
become one of the most important, complex, and risk-laden aspects of nursing care. While
medications are administered for an intended therapeutic effect, they can also have side effects,
adverse effects, or even toxic effects. The nurse is responsible for understanding a drug’s expected
and unexpected effects, administering the drug correctly, monitoring the response, and helping the
client self-administer drugs correctly.
In addition to knowing about a specific drugs’ action, the nurse must also understand the
client’s previous and current health problems to determine whether a particular medication is safe
to give. The nurse’s judgment is critical for proper drug administration.
Section 1 Basic Knowledge about
Medication Administration
Drug Forms, Distribution System and Medication Storage
Drug Forms
Medications are available in a variety of forms or preparations. The form of the drug
determines its route of administrations.
The composition of a drug is designed to enhance its absorption and metabolism. Many drugs
are made in several forms such as tablets, capsules, elixirs, and suppositories. When administering
a medication, the nurse must be certain to use the proper form. Table 12-1 lists common forms of
medications.
In addition, medications are classified as the four kinds that are medications to be taken orally,
externally, for injection, and new preparations in terms of routes of administration.
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Table 12-1 Common Forms of Medications
Form
Description
Aerosol spray
Aqueous solution
Aqueous suspension
Capsule
Enteric-coated tablet
Extended/
release
Extract
sustained
Glycerite
Liniment
Lotion
Ointment
Paste
Pill
Powder/granule
Suppository
Syrup
Tablet
Tincture
Transdermal disk or
patch
Troche (lozenge)
Liquid, powder, or foam deposited in a thin layer on the skin or mucous
membrane by air pressure
Liquid preparation that may be used orally, parenterally, or externally;
can also be instilled into body organ and cavity (e.g., bladder irrigations);
contains water with one or more medications dissolved compounds; must
be sterile for parenteral use or when instilled into body cavity
Finely divided drug particles dispersed in liquid medium; when
suspension left standing, particles settle to bottom of container;
commonly is oral medication and is not given parenterally
Solid dosage form for oral use; medication in powder, liquid, or oil form
and encased by gelatin shell
Tablet for oral use coated with materials that do not dissolve in stomach;
coating dissolve in intestine where medication is absorbed
Drugs usually in tablet or capsule form that allow for effect over a longer
period of time
Concentrated drug form made by removing active portion of drug from
its other components (e.g., fluid extract is drug made into solution from
vegetable source)
Solution of drug combined with glycerin for external use; contains at
least 50% glycerin
Preparation usually containing alcohol, oil, or soapy emollient that is
applied to skin
Drug in liquid suspension applied externally to protect skin
Semisolid, externally applied preparation, usually containing one or more
drugs
Semisolid preparation, thicker and stiffer than ointment; absorbed
through skin more slowly than ointment
One or more medications mixed with a cohesive material, in oval, round,
or flattened shapes
Finely ground loose or molded drugs; given with or without liquids
Solid dosage form mixed with gelatin and shaped in the form of pellet for
insertion into a body cavity (rectum or vagina); melts when it reaches
body temperature, releasing the drug for absorption
Medication dissolved in concentrated sugar solution; may contain
flavoring to make drug more palatable
Powdered dosage form compressed into hard disks or cylinders; in
addition to primary drug, contains binders (adhesive to allow powder to
stick together), disintegrators (to promote tablet dissolution), lubricants
(for ease of manufacturing), and fillers (for convenient tablet size)
Alcohol or water-alcohol drug solution
Medication contained within semipermeable membrane disk or patch;
allows medications to be absorbed through skin slowly over a longer
period
Flat, round dose form 34
containing drug, flavoring sugar, and mucilage;
dissolved in mouth to release drug
Distribution Systems
In clinical settings, administering medication includes order management, medication supply
and storing medications. Not only the nurses are responsible for medication administration, but
also are other related people, such as the physician, and pharmacist also help to ensure the right
medication to the right client.
Stock Supply System
Large quantities of medications and multidose containers are in nursing unit. One nurse is
assigned to get and replenish the medications based on physician’s orders. This system is time
consuming because a nurse must dispense each medicine separately for a client every day, and it
has been associated with a high rate of medication errors and is not commonly used today.
Unit-dose System
There is a portable carts to contain a drawer with a 24-hour supply of medications for each
client. The nurse sends the portable cart to center dispensary system, at a designated time each day,
and the pharmacist simplifies medication preparation by packaging and labeling each dosage for
24-hour period. After that, nurses offer the medication for every client at right time. The cart also
contains limited amounts of prn and stock medications for special situations. The unit-dose system
can reduce the number of medication errors and saves steps in dispensing medication. Special
medication rooms, portable locked carts, computerized medication cabinets are some of the
facilities used in nursing unit.
Computer-controlled Dispensing System
These systems are used more and more successfully. They are especially useful for the
delivery and control of narcotics. Each nurse has a security code allowing access to the system.
Then the client’s identification number is entered. In these systems, the nurse is then allowed to
select desired medication, dosage, route. The system delivers the medication to the nurse, records
it, and charges it to the client.
Some special medications, e.g. toxicant, narcotic, and expensive medications, should be
managed by special system.
Medication distribution systems are different in various institution, nurses should follow the
policies of their institution to ensure the supply of medication to the clients.
Store medication
When the medications are stocked in nursing unit, the nurse have responsibility to take care
of the medication. Certain guidelines for safe medication storage are as follows.
Cabinet
Store all medications according to the classification in a locked, secure cabinet or container.
Place the locked cabinet in bright and ventilative place to check and identify easily, but should be
free of direct shine and keep it clean, tidy and dry.
A special nurse in charge carries asset of keys for the cabinet. And the nurse checks the
quantities and the qualities of the medications regularly. Replenish the stock medication following
the policies of institution and discard the medication with problems.
Placement of medications
Store and place the medications separately according to their different routes of
administration (oral, injection, or topical), toxicity or untoxicity and whether to be used for mental
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diseases or not, with clear indication. Expensive drugs, narcotics and virulent toxicants must be
taken charge of by a special nurse who should lock the cabinet and have the key always with her.
On every shift, the nurse going off duty counts all medications, especially narcotics and virulent
toxicants, with the nurse coming on duty. Both nurses sign the medication record to indicate that
the count is correct.
Label the container of medications clearly
Different medications should be labeled with different colorful strips. Blue strip labels oral
medications, red strip labels external medications, and black strip labels virulent toxicants. Keep
each medication in its original labeled container, and keep the labels and specifications legible. If
the labels are soiled or illegible, discontinue using the medications. In addition, label drug name,
concentration and dosage.
Check the medications carefully
Check the nature of medications carefully. Discontinue using the medications if they become
deposited and cloudy, smell abnormal, change color, get deliquescence or mildewy(发霉的).
Store the medications properly according to their different nature.
Medications which tend to volatilize, deliquesce, or effloresce should be kept in airtight
bottles, e.g., ethanol, iodine, sugar-coated tablets.
Medications that will be oxidized if exposed to air and be denatured if exposed to light
should be kept in airtight colored bottles. Cover the container with shade paper box if necessary
and store it in the shady and cool area, e.g., vitamine C.
Biologic products and antibiotics that will be destroyed and decomposed if exposed heat
should be kept in the dry, and shady and cool area (about 20℃) or in refrigerator (about 2～10℃)
according to their nature and desire for storage, e.g., an antitoxic serum, vaccine, placental globin,
penicillin skin test solution.
Medications should be used designedly according to valid periods in case of invalidation, e.g.,
antibiotics and insulin.
Store the inflammable and explosive medications in airtight bottle and place in the shady and
cool area separately and keep them away from fire and electrical appliances.
Principles of Administering Medications
To provide effective and safe administration, the nurses must strictly comply with the
following principles.
Correct Transcription and Communication of Orders
The nurse or a designated unit nurse writes the physician’s complete order on the appropriate
medication forms. The transcribed order includes the client’s name, room, and bed number, drug
name, dosage, frequency, and route of administration. Each time a drug dosage is prepared the
nurse refers to the medication form. When transcribing orders, the nurse should be sure that names,
dosages are legible. The nurse rewrites any smudged or illegible transcriptions.
In some institutions a computer print out lists all currently ordered medications with dosage
information. Orders are entered directly into the computer, preventing the need for transcription of
orders. The same printout may be used to record medications given.
A registered nurse checks all transcribed orders against the original order for accuracy and
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thoroughness. If an order seems incorrect or inappropriate, the nurse should consult the physician
instead of executing the doubtable order blindly or altering it freely. The nurse who gives the
wrong medication or an incorrect dose is legally responsible for the error.
Use the Guidelines of Three Checks and Seven Rights to Ensure Safe
Drug Administration
Preparing and administering medications require accuracy. To ensure safe medication
administration, the nurse uses the guidelines of three checks and seven rights.
Three Checks
Three checks should be implemented when delivering medications. The nurse makes first
check before medication preparation for the client that is called as the check before operation.
Then the nurse makes a second check, or the double check, just before administering medication
to the client that is called as the check during operation. And the nurse makes a third check
immediately after medication administration to the client that is the check after operation. What
the nurse checks three times are what seven rights refer to.
Seven Rights
The seven rights help to ensure accuracy when administering medications. The seven rights
include the right name of the client, right bed number of the client, right name of the medication,
right concentration, right dose, right route, and right time.
Right client: name and bed number
An important step in administering drugs safely is being sure the drug is given to the right
client. It is difficult to remember every client’s name and face. To identify a client correctly, the
nurse checks the medicine card or form against the client’s bed card and asks the client to state his
or her name. If the bed card becomes smudged or illegible, or is missing, the nurse must acquire a
new one for the client. When asking the client’s name and assume that the client’s response
indicates that he or she is the right person. Instead, the nurse asks the client to state his or her full
name. To avoid making the client feel uneasy, the nurse simply states that the question is routine
for giving a drug.
Checking the bed number of the client is to ensure right client again. When two clients have
the same name, the nurse can distinguish them by different bed number.
Right drug: name, concentration and dose
When drugs are first ordered, the nurse compares the medications recording form or
computer orders with the physician’s written orders. When administering drugs, the nurse
compares the label of the drug container with the medication form. The nurse does this three times:
(1) before removing the container from the drawer or shelf, (2) as the amount of drug ordered is
removed from the container, and (3) before returning the container to storage which are before,
during and after dispensing during preparation. If a client questions the medication a nurse
prepares, it is important not to ignore these concerns. With unit-dose prepackaged drugs, the nurse
checks the label with the medicine form a third time even though there is no permanent container.
Unit dose medications may be checked before opening at the client’s bedside.
An alert client will know whether a drug is different from those received before. In most
cases the client’s drug order has been changed; however, the client’s questions might reveal an
error. The nurse should withhold the drug until the preparation can be rechecked against the
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physician’s orders.
Clients who self-administer drugs should keep them in their original labeled containers,
separate from other drugs, to avoid confusion.
The nurse never prepares medications from unmarked containers or containers with illegible
labels. If a client refuses a drug, the nurse should discard it rather than return it to the original
container. Unit-dose packaged drugs can be saved if they are unopened.
Sometimes, one medication has various forms with different concentration. Nurses should
par attention to the concentration of the medication administered. Excessively higher
concentration or lower concentration will influence the client health. When a medication must be
prepared from a high concentration, the nurse should ensure the process of calculation and
implementation correct to make the accurate concentration. When calculating the concentration of
medication and diluting the medication, the nurse should have another qualified nurse check the
results.
The unit-dose system is designed to minimize errors. When a medication must be prepared
from a larger volume or concentration if required or the physician prescribes a medication with a
measurement system different from that of the medication supplied, the chance of error increases.
When calculating or converting the dosage of the medication, the nurse should have another
qualified nurse check the results. After calculation, the nurse prepares the medication using
standard measurement devices. Graduated cups, syringes, and scaled droppers can be used to
measure medications accurately. Some dosages are based on the client’s weight or body surface
area. Always verify calculations of divided or individualized doses with another nurse. Always
check heparin, insulin, and digitalis doses with another nurse.
Right route
If a physician’s order does not designate a route of administration, the nurse consults the
physician. Likewise, if the specified route is not the recommended route, the nurse should alert the
physician immediately. When the nurse administers injections, precautions are necessary to ensure
that the drugs are given correctly. It is also important to prepare injections only from preparations
designed for parenteral use. The injection of a liquid designed for oral use can produce local
complications, such as a sterile abscess, or fatal systemic effects. Drug companies label parenteral
drugs for “injectable use only”.
Right time
The nurse must know why a drug is ordered for certain times of the day and whether the time
schedule can be altered. For example, two drugs are ordered, one q8h (every 8 hours) and the
other t.i.d. (3 times a day). Both medications are to be given 3 times within a 24-hour period. The
physician intends the q8h medication to be given around the lock to maintain therapeutic blood
levels of the drug. In contrast, the t.i.d. medication is given during the waking hours. Each
institution has a recommended time schedule for medications ordered at frequent intervals.
The physician often gives specific instructions about when to administer a medication. A
preoperative medication to be given on call means that the nurse is to administer the drug when
the operating room notifies the nursing division. A drug ordered pc (after meals) is to be given
within half an hour after a meal when the client has a full stomach. A stat medication is to be given
immediately. Absorption of oral drugs is affected by stomach contents as well as the ingestion of
other drugs. Note before-meal and between-meal formulations.
Drugs that must act at certain times are given priority. For example, insulin should be given
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at a precise interval before a meal. All routinely ordered medications should be given within 30
minutes of the times ordered (30 minutes before or after the prescribed time).
Some drugs require the nurse’s clinical judgment in determining the proper time for
administration. A prn sleeping medication should be administered when the client is prepared for
bed or at a time appropriate for maximum benefit. A nurse also uses judgment when administering
prn analgesics. For example, the nurse may need to obtain a stat order from the physician if the
client requires a drug before the prn interval has elapsed.
Administer medication safely and accurately
Nurses should understand the right time, the skill when administering medications. The
prepared drug should be delivered to the patients and taken timely in case of being contaminated
or the invalidation. Explain and demonstrate method for the client so that he can cooperate with us.
Instruct the client to administer drugs correctly. Inquire the client’s history of allergies and
perform the allergy test as ordered before administering medications that can arouse allergies.
Only when the outcome is negative, the medication can be used.
Observe the client’s response to the medication after administration
After administration, observe the therapeutic effect and side effect and record them. After the
digitalis is administered, the nurse should inspect the rate and rhythm of the heart closely. If the
heart rate is lower than 60 times per second or arrhythmia occurs, which means toxic effects,
inform the physicist and discontinue this drug.
Routes of Administration
The route prescribed for administering a drug depends on the drug’s properties and desired
effect and on the client’s physical and mental condition. A nurse collaborates with the physician in
determining the best route for a client’s physical and mental condition in determining the best
route for a client’s medication, as in the following hypothetical situations:
The client, Mr. Li, has progressively worsened physically. His temperature is 39.2℃. He
complains of nausea and is unable to tolerate oral fluids. The nurse checks Mr. Li’s order, which
reads,” Aspirin 600mg orally for temperature above 38.5 ℃.” On the basis of the assessment, the
nurse believes that Mr. Li will not be able to tolerate an oral does of aspirin. By consulting the
physician, the nurse acquires an order for a rectal suppository instead.
Oral Routes
Oral administration
The oral route is the easiest and the most commonly used. Medications are given by mouth
and swallowed with fluid. Oral medications have a slower onset of action and a more prolonged
effect than parenteral medications. Clients generally prefer the oral route.
Sublingual Administration
Some drugs are designed to be readily absorbed after being placed under the tongue to
dissolve. A drug given sublingually should not be swallowed or the desired effect will not be
achieved. Nitroglycerin is commonly given sublingually. A drink should not be taken by the client
until the drug is completely dissolved.
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Buccal Administration
Administration of a drug by the buccal route involves placing the solid medication in the
mouth and against the mucous membranes of the cheek until the drug dissolves. Clients should be
taught to alternate cheeks with each subsequent dose to avoid mucosal irritation. Clients are also
warned not to chew or swallow the drug or to take any liquids with it. A buccal medication acts
locally on the mucosa or systemically as it is swallowed in a person’s saliva.
Parenteral Routes
Parenteral administration involves injecting a drug into body tissues. The four major sites
of injection are:
1. Subcutaneous: Injection into tissues just below the dermis of the skin
2. Intramuscular (IM): Injection into a muscle
3. Intravenous( IV): Injection into a vein
4. Intradermal: Injection into the dermis just under the epidermis
A physician may use additional routes for parenteral injections, including the intrathecal or
intraspinal, intracardiac, intrapleural, intraarterial, intraosseous, and intraarticular routes.
Strict sterile technique must be used when preparing medications for parenteral injection.
Contamination of medication solutions, syringe needles, or the syringe itself can lead to infection.
Skin and Mucous Membrane Route
Drugs applied to the skin and mucous membranes generally have local effects. Medications
are applied to the skin by painting or spreading them over an area, applying moist dressings,
soaking body parts in a solution, or giving medicated baths. Systemic effects can occur if a client’s
skin is thin, if the drug concentration is high, or if contact with the skin is prolonged.
Some medications (e.g., nitroglycerin, scopolamine, and estrogens) have systemic effects
because they are applied topically by a transdermal disk or patch. The disk secures the medicated
ointment to the skin. These topical applications may be applied for as little as 8 hours or as long as
7 days.
Mucous membranes differ in their sensitivity to medications. The cornea of the eye and
nasal mucous membranes are very sensitive. The client may complain of a burning sensation when
the nurse administers eye and nose drops. Medications are generally less irritating to vaginal or
rectal mucosa. The nurse uses several methods for applying medications to mucous membranes:
1. Direct application of liquid or ointment (e.g., eye drops, gargling, swabbing the throat)
2. Insertion of drug into a body cavity (e.g., placing a suppository in rectum or vagina or
inserting medicated packing into vagina)
3. Instillation of fluid into body cavity (e.g., ear drops, nose drops, or bladder and rectal
instillation [fluid is retained])
4.Irrigation of body cavity (e.g., flushing eye, ear, vagina, bladder, or rectum with
medicated fluid [fluid is not retained])
5. Spraying (e.g., instillation into nose and throat)
Inhalation Route
The deeper passages of the respiratory tract provide a large surface area for drug absorption.
The vascular alveolar-capillary network readily absorbs gases and mists introduced through the
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airways. Medications introduced into the lung’s airways must not interfere with normal gas
exchange such as constricting bronchioles.
Inhaled medications may have local effects. Drugs such as oxygen and general anesthetics
create general systemic effects. Some medications given by inhalation are designed to produce
local effects. Cocaine, when sniffed or snorted, produces vasoconstriction and
hypertension---physical dangers associated with the abuse of this drug. Administration of
local-acting medications with hand-operated inhalers must be carefully taught to the client by the
nurse.
Except that drugs administered by intraarterial and intravenous injection can directly enter
the blood circulation without absorption process, drugs administered by other routes are absorbed
in blood. They are ranged as the following as declining sequence of absorption: Inhalation Route
＞ Sublingual route ＞ rectal route ＞ intramuscular injection ＞ subcutaneous injection ＞ oral
administration＞skin route
Times and Time of Administration
Maintain effective medication concentration in blood to achieve best therapeutic effect. Thus
the drug is administered at appropriate time and intervals that are determined by the half life of the
drug and the character of the drug and physiological rhythm. The time and times of administration
in hospital are demonstrated in the table 12-2.
Table 12-2. Abbreviations for Common Dosage Used in Medication Administration Schedule
Abbreviation
Explanation
Example of administration time
AC, ac
BID, bid
HS, hs
PC, pc
prn
qm
qd
qod
qh
q2h
q4h
q6h
qid
SOS
Ante cibum/Before meals
Twice a day
At bed time
After meals
As necessary (long term)
Every morning
Every day
Every other day
Every 1 hour
Every 2 hour
Every 4 hour
Every 6 hour
4 times a day
As needed (only onoe time
within 12 hours)
Immediately
3 times a day
discontinue
7:00, 11:00, and 17:00
8:00 and 16:00
St
tid
DC
9:00, 13:00 and 19:00
6:00
8:00
6am, 8am, 10am, and so on
8am, 12n, 4pm, 8pm, 12mn
8am, 2pm, 8pm, 2am
8am, 12n, 4pm, 8pm
8am, 12n, 4pm
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Contributing Factors of Drug Actions
Every medication has its own special nature of drug action. The therapeutic effects of
medications are affected by internal and external factors of the body. The nurse must understand
all factors influencing the action of drugs so that the drug exerts its best therapeutic effect rather
than adverse effect.
Factors about The Drug Itself
Drug Dose Response
After a medication is administered, it undergoes absorption, distribution, metabolism, and
excretion. Except when administered intravenously, medications take time to enter the
bloodstream. The concentration of a medication is changing from high to low with time gradually.
The highest serum concentration, known as peak concentration, of the medication usually occurs
just before the last of the medication is absorbed. After peaking, the serum medication
concentration falls progressively. Serum half-life is the time it takes for excretion processes to
lower the serum medication concentration by half. It indicates the speed of elimination of
medication from blood. For example, if a medication’s serum half-life is 8 hours, then the amount
of medication in the body is as follows: initially 100%; after 8 hours: 50%; after 16 hours; 25%;
after 32 hours: 6.25%. When a medication is ordered, the goal is to reach and keep a constant
blood level within a safe therapeutic range. Repeated doses are required to achieve a constant
therapeutic concentration of a medication because a portion of a medication is always being
excreted. To maintain a therapeutic plateau, the client must receive regular fixed doses. Therefore,
the client and nurse must follow regular dosage schedules are set by the agency in which the nurse
is employed. Table 12- lists common schedules used in acute care settings. When teaching clients
about dosage schedules the nurse uses language that is familiar to the client. For example, when
teaching a client about medication dosing 3 times a day (tid), the nurse instructs the client to take a
medication in the morning, noon, and evening.
Drug Forms
Most drugs, except those applied topically for local effects, must enter the systemic
circulation to exert therapeutic effect. Factors influencing drug absorption include route of
administration, ability of the drug to dissolve, and conditions at the site of absorption. The ability
of an oral medication to dissolve depends largely on its form or preparation. Solutions and
suspensions already in a liquid state are absorbed more readily than tablets or capsules.
Routes and time and interval of Administration
The nurse administers drugs by several routes. Each route has a different influence on drug
absorption, depending on the physical structure of the tissues. Skin absorption is slow. The
mucous membranes and respiratory airways allow quick drug absorption. Orally administered
drugs have a slow absorption rate because they must pass through the gastrointestinal tract.
Intravenous (IV) injection produces more rapid absorption, with direct access to the systemic
circulation. Drugs that are inhaled may produce immediate effects by acting directly on the
“target” site and being rapidly absorbed across the pulmonary capillary network..
In addition, different routes of some medications influence their absorptions, and even lead to
different therapeutic effects. For example, magnesium sulphate administered orally produces
catharsis and cholagogic effects, while it produces sedative and dropping blood tension if
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administered by injection route.
What’s more, whether to arrange the time and interval of administration appropriately affects
the therapeutic effect of medication. Half-life period of medication determines the time and
interval. Thus means the nurse administers the medication at a certain time and interval according
to half-life to maintain effective blood concentration.
Drug interactions
When a client takes several medications at the same time, the medication interaction may
occur. In a medication interaction, the combined effect of two or more medications acting
simultaneously may produce either an effect less than that of each medication alone (antagonist
effect) or greater than that of each medication alone (synergistic effect), and may alter the way in
which another medication is absorbed, metabolized, or eliminated from the body. They may be
beneficial, for example, probenecid, which blocks the excretion of penicillin, can be given with
penicillin to increase blood levels of the penicillin for longer periods; For another example, a
client with hypertension that can not be controlled with one medication, typically receives several
medications such as diuretics and vasodilators that act together to control the blood pressure.
Factors about The Body
Physiological Factors
Age and Weight
Generally, the dose of the medication increases with the increasing weight. However
response to drug therapy of the children and the older adults differ from that of the adults. A
client’s developmental level is a factor in the way nurses administer medications besides the
weight. Children vary in age, weight, surface area, and the ability to absorb, metabolize, and
excrete medications. Children’s drug dosages are lower than those of adults, so special caution is
needed when preparing medications for them. Drugs are usually not prepared and packaged in
standardized dose ranges for children. Preparing an ordered dosage from an available amount
requires careful calculation. Older adults also require special consideration during drug
administration. Age affects the absorption, distribution, metabolism, and excretion of drugs.
Sex
There is no significant difference in response to drug therapy between male and female. What
is paid more attention to is the response to the drug therapy of female in special physiological
periods such as menses, gestation, lactation.
Pathological Factors
The disease the client suffers influence the sensitivity to the drug therapy as well as the
absorption, distribution, metabolism, and excretion of drugs, especially liver and renal function.
Psychological and Behavioral Factors
In addition to physiological factors, behavioral and economic factors influence a client’s use
of drugs, such as the client’s mood, trust to the drug, cooperation to the therapy, and the words and
their hints of the physicist and nurse. For example, supportive care is needed if a child is expected
to cooperate. The nurse explains the procedure to a child, using short words and simple language
appropriate to the child’s level of comprehension. Long explanations may increase a child’s
anxiety, especially for painful procedures such as an injection. The nurse must approach a child
with confidence and act as though the child is expected to cooperate. If it is possible to involve the
child, the nurse may have greater success giving a medication. For example, saying “It’s time to
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take your tablet now. Do you want it with water or juice?” allows a child to make a choice. Never
give the child the option of not taking a medication. After a drug is given, the nurse praises the
child and may even offer a simple reward such as a star or token.
The client’s trust to the drug therapy affect the therapy effect. The client may not cooperate
with the nurse and refuse to take drug or discontinue to use the drug if he doesn’t trust the drug.
By contraries, the inactive drug may exert certain effects in some circumstances if the client trusts
the drug such as conciliative drugs.
Section 2 Oral Administration
Administering oral medications is the most desirable, the most convenient, and relatively safe
way to administer medications. Medications given orally are intended for absorption in the
stomach and small intestine to cure local and systemic diseases. Medication action through this
way has a slower onset and a more prolonged but less potent effect. So that oral medication is not
suitable for client with acute illness. There are certain situations when oral medications would not
be administered, such as when the client has impaired swallowing function, is unconscious, is
fasting, is vomiting, or has gastric or intestinal suction.
Oral medications are available in solid and liquid form. Medication should be prepared with
appropriate measuring device. Medication spoon is used for solid medication, and calibrated cups,
syringe, and drop tube are used for liquid medications. For clients who find it difficult to take
liquids from a cup, the medication can be placed in the mouth directly from a plastic syringe
without a needle. The syringe should be placed between the gum and cheek, and the liquid should
be given to the client slowly to prevent the client from aspiration. To protect the client from
aspiration, the nurse assesses the client’s ability to manage oral medications at first, and then, help
the client has a proper position. The nurse positions the client in a sitting position, side-lying
position when administering oral medications, if not contraindicated by a client’s condition.
For clients with nasogastric feeding tubes or a gastrostomy tube, liquid medications are
preferred, but some tablets can be crushed and capsules opened to mix in a solution for
administration.
The nurse should follow guidelines when administering oral medications.
1.Always administer a drug with warm boiled water of 40~60℃ instead of with tea.
2.Medications that erode teeth such as acid and chalybeate should be sucked with a sucker
and then rinse to protect teeth.
3.Never chew, crush or break sustained release tablets, enteric-coated tablets and capsules
4.Place lozenges under the tongue or between buccal membrane and teeth dissolved slowly
rather than allow clients to chew or swallow.
5.Generally, stomachic medications is appropriately taken before meal, while those irritating
gastric membrane taken after meal. Hypnotics is properly taken before sleep and parasiticides
taken in limosis or half limosis.
6.Antibiotics and sulfonamide should be taken at certain interval to ensure effective drug
blood concentration.
7.Avoid giving fluids immediately after a client swallows medication such as syrup that
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exerts local medicating effects on the oral mucosa
8. Allow the client to drink more water after sulfonamide is taken to prevent the crystal which
the drug produces when excreted through kidney with the less urine volume to block the
nephridium.
9. Observe the heart rate and rhythm closely when cardiotonic is taken. If the heart rate is
lower than 60 times per minute or arrhythmia occurs, discontinue to use the drug and inform the
physicist.
Section 3 Parenteral Administration
Injection is the process that injects a certain volume of sterile solution and/or biological into
human body by using sterile syringe in order to prevent, diagnose and cure disease. Nurses inject
medications by intradermal, subcutaneous, intramuscular, or intravenous injection. Sometimes,
physician injects medications into an artery, the peritoneum, heart tissues, the spinal canal, and
bones, and nurse acts as an assistant. Administering an injection is an invasive procedure that must
be performed using aseptic techniques. After a needle pierces the skin, there is risk of infection.
Each type of injection requires certain skills to ensure that the drug reaches the proper location.
The nurse closely observes the client’s response, depending on the rate of drug absorption.
Principles of Injections
Apply Sterile Technique Strictly
Maintain sterile technique throughout the preparation and administration of medications by
injection. Key activities include:
●Preparation of nurses, for example, hand washing, wearing mouth mask, keeping uniform
clean and tidy.
●Sterilize the local skin over injection site as required. The routine method is that using sterile
swabs with aseptic solution to sterilize the skin in a circular motion from the center outward, with
the diameter of about 5cm. Begin to inject the drug after the aseptic solution volatilize and the skin
over injection site is dry.
●Maintain sterility of equipment, for example, sterile swab, sterile tweezers, tip of the syringe,
shaft of plunger, inside of the barrel, tip, shaft of needle, inside of the hub.
Carrying out Check Principles Strictly
When administering medication by injection, the nurse should be aware of nursing standard
called “three checks and seven rights” and adhere to the standard strictly. An important
responsibility is to ensure “seven rights”. In addition, nurse should inspect the package of
medication and sterile equipment to determine their quality. Nurse should pay attention to the
expiration of medication and sterile equipment.
Perform Disinfection and Seclusion Policy
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Arrange equipment in proper site and order to ensure smooth procedure and avoid
contamination of sterile equipment. During an injection, every client individually uses one series
of equipment including syringe, needle, tourniquet(止血带)，小棉枕。All of used equipments are
disposed according to the disinfection and seclusion policy. One-off equipments are disposed in
term of regulation rather than be discarded at random.
Appropriate Syringe and Needle
Nurses should choose appropriate syringe and needle for different route of injection. Besides
the route, other factors should be considered when choosing, including dosage, viscosity, irritation
of medication, and the age, height, and weight of the client, the site of injection as well. Generally,
large diameter needle is appropriate for high viscosity medication, and long shaft needle is for
irritating medication because it requires injection in deep tissues. In addition, the nurse should
check whether the needle is sharp, without crooks, and is connected with tip of syringe tightly;
when using single-use or one-off syringe, the nurse should check the package and the expiration
date.
Appropriate Injection Site
Select appropriate injection site away from nerves, bones, and blood vessels. The skin surface
of the site should be free of inflammation, bruises, itches, tenderness, edema, nodules and scars.
For the client with long period of injection, the nurse should change the site for each injection to
protect tissue. For the client with intravenous injections, the nurse should use a distal site first,
which allows for the use of proximal sites later.
Prepare and Administer Temporarily
The medication solution is prepared and dispensed when administered to prevent from the
lower effect or contamination.
Eject Air thoroughly
Before the medication is injected into the body, the air bubble in syringe should be ejected,
especially for intravenous injection. If air enters the bloodstream, it may arouse air embolism. Do
not eject medication with air.
Note Blood Return
Once the needle inserted into body, the nurse should pull back the plunger to check blood
return. When administering medication by SQ(皮下)，ID, or IM, if blood appears in syringe, the
nurse should remove needle, discard medication and syringe, and repeat the procedure of injection.
Avoid injecting medication into vessels. When administering medication into artery or vein, the
nurse must note blood return into syringe first, and then inject medication.
Insert Needle at Appropriate Angle Degree and Depth
Different types of injection require different angle and depth of needle insertion. Nurses
should perform the injection following standard procedure to ensure the medication injected into
appropriate tissue. Nurses should not insert the whole needle into tissue during IM injection so as
to avoid increased difficulties caused by broken needles.
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Give No-Pain Injection
Nurses should try to minimize the client’s discomfort during injection. There are some
suggestions as follows:
● Explain the procedure and comfort the client to minimize anxiety and promote
understanding and cooperation.
●Assist the client to take a comfortable position to reduce the strain on muscles.
●Divert the client’s attention from the injection through conversation.
●Make skin taut when inserting the needle. Insert and withdraw the needle quickly and
smoothly to minimize tissue pulling. Hold the syringe steady while the needle remains in tissues.
Inject the medication slowly and steadily. That is called “two quicks and one slow”, which means
quick insertion and withdrawal of needles and slow injection of medication.
● When injecting multiple medications, inject less irritating medication first, then more
irritating medications in deep muscle tissues with a sharp-beveled, long shaft needle.
●Follow sterile and isolation techniques strictly. During injection, nurse should use one
syringe for one client, one tourniquet for one client, and one medical sheet for one client. All
equipment used during injection should be disinfected first, and then be disposed.
Equipment
A variety of syringes and needles are available, each designed to deliver a certain volume of a
drug to a specific type of tissue. The nurse uses judgement when determining the syringe or needle
that will be most effective.
Syringes
Syringes consist of a cylindrical barrel on which the scales are printed with a tip designed to
fit the hub of a hypodermic needle and a close-fitting plunger (Figure 12-1). The plunger includes
three parts: body, shaft and handle. The nurse fills a syringe by aspiration, pulling the plunger
outward while the needle tip remains immersed in the prepared solution. The nurse may handle the
outside of the syringe barrel and the handle of the plunger. To maintain sterility, the nurse avoids
letting any unsterile object touch the tip or inside of the barrel, the body of the plunger, or the
needle. Most health care institutions use disposable, single-use plastic syringes, which are
inexpensive and easy to manipulate.
Syringes are various in sizes from 0.5 to 60ml. A syringe whose volume is less than 5ml is
used to administer certain intravenous medications, add medications to intravenous solutions, and
irrigate wounds or drainage tubes. Another type of syringes is called insulin syringes. They are
available in sizes that hold 0.3 to 1 ml and are calibrated in units. Each milliliter of solution
contains 100 units at most. The tuberculin syringe pattern is a long thin barrel with a pre-attached
thin needle. The syringe has 1ml volume and is calibrated in 16ths of a minim and hundredths of a
milliliter. It is used for administration of small amounts of medications. A tuberculin syringe is
also useful when preparing small precise doses for infants or young children. The most common
disposable syringes are various in sizes from 1ml to 50ml. Most of them are calibrated in milliliter.
Needles
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Needles are made of stainless steel, and most are disposable. Usually, needles come packaged
in individual sheaths to allow flexibility in choosing the right needle for a client. Some needles are
preattached to standard-sized syringes. A needle has three discernible parts: the hub, which fits
onto the tip of a syringe; the cannula, or shaft, which is attached to the hub; and the bevel, which
is the slanted part at the tip of the needle. A disposable needle has a plastic hub. The bevel creates
a narrow slit when injected into tissue and quickly closes when the needle is removed to prevent
leakage of medication, blood, or serum. Longer bevels provide the sharpest needles and cause less
discomfort and are commonly used for subcutaneous and intramuscular injections. Short bevels
are used for intradermal and intravenous injections because a long bevel can become occluded if it
rests against the side of a blood vessel. Needles vary in shaft length from 6mm to 75mm. The
adequate needle length is chosen according to the client’s size and weight and the type of tissue
into which the medication is to be injected. For example, a child or slender adult generally
requires a shorter needle. Longer needles are used for intramuscular injections and short needles
are used for subcutaneous injections. The gauge varies from 41/2 to 16. The smaller the needle
gauge is, the smaller the needle diameter. Needles with smaller diameter produce less tissue
trauma, but needles with larger diameter are necessary for vicious medications. The selection of a
gauge depends on the viscosity of fluid to be injected or infused. An intramuscular injection
usually requires a 6 to 7-gauge needle, depending on the viscosity of the medication.
Subcutaneous injections need smaller-diameter needles such as a 5-gauge or 51/2 –needle. A 41/2gauge needle is used for an intradermal injection.
Prefilled Syringes
Disposable, single-dose, prefilled syringes are available for some medications. The nurse
should check the medication and concentration carefully because all prefilled syringes look very
similar. By using these syringes the nurse does not need to prepare medication doses, except
perhaps to expel unneeded portions of medications. In recent years, a new type of injection system
including a plungerlike device in the end of a prefilled vial containing a needle was invented. This
pattern of syringe reduces the risk of needle-stick injuries.
Draw medication
Preparing an Injection from an Ampule
Ampules contain single doses of medication in a liquid. Amplues are available in several
sizes, from 1 ml to 10 ml or more. An ampule is made of glass with a constricted neck that must
be snapped off to allow access to the medication. A colored ring around the neck indicates where
the ampule is prescored to be broken easily. If there is no colored ring, the nurse should use a
small file to file the neck of ampule, and then break it off at that point. Today, using ampule
openers can prevent injury from broken glass. The device consists of a plastic cap that fits over the
top of an ampule and a cutter within the cap that scores the neck of the ampule when rotated.
When broken, the head of the ampule remains inside the cap where it can then be ejected into a
sharp container. Once the ampule is broken, the fluid is aspirated into a syringe. The method is
detailed in skill 12-2.
Preparing an Injection from a Vial
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A vial is a single–dose or multidose glass container with a rubber seal at the top. A metal cap
or plastic cap protects the seal until it is ready for use. Vials contain liquid or powder of
medications. Drugs that are unstable in solution are packaged powder. The vial label specifies the
solvent or diluent used to dissolve the drug and the amount of the diluent needed to prepare a
desired drug concentration. Normal saline and sterile distilled water are solutions commonly used
to dissolve drugs.
Unlike the ampule, the vial is a closed system, and air must be injected into it to permit easy
withdrawal of the solution. Failure to inject air when withdrawing creates a vacuum within the vial
that makes withdrawal difficult.
To prepare a powdered drug, the nurse draws up the amount of diluent or solvent
recommended on the vial’s lable. The nurse injects the diluent into the vial in the same manner as
injecting air into the vial. Most powdered drugs dissolve easily, but it may be necessary to
withdraw the needle to mix the contents thoroughly. Gently shaking or rolling the vial between the
hands will dissolve the powdered drug. The needle is reinserted to draw up the dissolved
medication. After mixing multidose vials the nurse makes a label that includes the date and time of
mixing and the concentration of drug per milliliter. Multidose vials may require refrigeration.
Common Injection Methods
Intradermal Injections
Definition
Intradermal injections involve placing drugs into the tissue between the epidermis and dermis
where blood supply is reduced and drug absorption occurs slowly. A client may have a severe
anaphylactic reaction if the medications enter the circulation too rapidly.
Purpose
Skin test
The nurse typically gives intradermal injections for skin testing (e.g., tuberculin screening
and allergy tests of some antibiotics such as penicillin, narcotics, TAT, etc.).
Vaccine inoculation
Inoculate vaccine to prevent disease, especially the vaccines that need observing the response
to the vaccines. For Example, BCG vaccine ---- A preparation consisting of attenuated human
tubercle bacilli that is used for immunization against tuberculosis.
A prior step to local anesthesia
Site
Skin test: Skin testing requires that the nurse be able to clearly see the injection sites for
changes in color and tissue integrity. Intradermal sites should be lightly pigmented, free of lesions,
and relatively hairless. The inner forearm is ideal location.
And the site of the edge below the deltoid muscle is used for vaccine injection intradermally.
The site for local anesthesia can be injected intradermally.
Equipment and procedure
The nurse uses a tuberculin or small hypodermic syringe for skin testing. The angle of
insertion for an intradermal injection is 5°. As the nurse injects the drug, a small bleb resembling
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a mosquito bite should appear on the skin’s surface. If a bleb does not appear or if the site bleeds
after needle withdrawal, there is a good chance the medication entered subcutaneous tissues. In
this case, test results will not be valid.
Data from an intradermal injection include a description of the precise location and time of
administration. The injection site must be “read” within a prescribed time.
See skill 12-3
Subcutaneous Injections
Definition
Subcutaneous injections involve placing drugs into the loose connective tissue under the
dermis. Because subcutaneous tissue is not as richly supplied with blood as the muscles, drug
absorption is somewhat slower than with intramuscular injections. However, drugs are absorbed
completely if the client’s circulatory status is normal. Because subcutaneous tissue contains pain
receptors, the client may experience some discomfort.
Purpose
Inject small dose of drugs that exert effect in certain time and is inappropriately taken by
mouth.
Vaccine inoculation
Local anaesthesia
Site
Because there are subcutaneous tissues all over the body, various sites are used for
subcutaneous injections. The best subcutaneous injection sites include outer posterior aspect of the
upper arms, the lower abdomen (the abdomen from below the costal margins to the iliac crests),
and the anterior aspects of the thighs. Other sites include the scapular areas of the upper back and
the upper ventral or dorsal gluteal areas. The injection site chosen should be free of skin lesions,
bony prominences, and large underlying muscles or nerves. It is important to rotate injection sites.
Repeated use of the same site causes tissue sloughing and lesions that impair drug absorption.
Common medications
The kinds of medications administered subcutaneously are vaccines, preoperative
medications, narcotics, insulin, and heparin.
Equipment and procedure
Only small doses(0.5 to 2 ml) of water-soluble drugs should be given subcutaneously because
the tissue is sensitive to irritating solutions and large volumes of drugs. Collection of drugs within
the tissues can cause sterile abscesses, which appear as hardened, painful lumps under the skin.
Syringe with volume less than 2ml, and 5-to 6-gauge needles are suitable for a normal-size client.
If the client is obese, the nurse often pinches the tissue and uses a needle long enough to insert
through fatty tissue at the base of skinfold. The preferred needle length is one-half the width of the
skinfold. With this method the angle of insertion may be between 30 and 45 degrees.
Intramuscular Injections
Definition
Intramuscular injection is the method to inject certain medication solutions into muscles. The
intramuscular route provides faster drug absorption than the subcutaneous because of muscle’s
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greater vascularity. There is less danger of causing tissue damage when drugs enter deep muscle,
but the risk of inadvertently injecting drugs directly into blood vessels exist.
Purpose
Inject medications that exert effect quickly and are inappropriately taken by mouth because
they are broken down by the gastric juice.
Inject medications that are inappropriately administered by other routes such as
subcutaneous injection. For example, the medication administered subcutaneously is difficult to be
absorbed for the client with severe edema.
Inject irritating medications. The intramuscular route is often used for irritating
medications since there are few nerve endings in deep muscle tissue.
Site
An important issue in administering an intramuscular injection is the selection of a safe site.
Generally, the site should have well developed muscles, be away from large nerves, bones, and
with no blood vessels under the location, and away from infection, necrosis, bruising, or abrasions
in the surface. Common sites are dorsogluteal, vastus lateralis, ventrogluteal, and deltoid The sites
for injecting intramuscular medications should be rotated when repeated injections are required.
Dorsogluteal muscle site
The dorsogluteal muscle, located in the buttock, is a traditional common site for
intramuscular injections. There are the sciatic nerve and major blood vessels underlying
dorsogluteal muscle. Because of the risk of injury to the sciatic nerve and the presence of major
blood vessels and bone mass near the site, the dorsogluteal muscle is not considered an optimal
site. The site can be located by two method: (a) Cross line method: draw a horizontal line from the
top of gluteal fold to right side or left side, and then draw a vertical line from the crest of ileum.
So, the buttock is divided into four quadrants. The injection is given in the upper outer quadrant
and keeps away from inner corner. (b) Line method: draws an imaginary line from anterior
superior iliac spine to coccyx. The injection site is lateral and superior to 1/3 point of the line.
Another line is drawn between the posterior superior iliac spine and the greater trochanter. The
injection site is lateral and slightly superior to the midpoint of the line. The gluteal muscles are
developed through walking. Therefore, the dorsogluteal site is not to be used for children under
age 3 years because their gluteal muscles are too small.
Ventrogluteal muscle site
The ventrogluceal muscle involves the gluteus medium and minimum in the hip area deep
under the dorsogluteal muscle, where there are no major nerves and blood vessels. The
ventrogluteal site is recommended for both adults and children. The nurse locates the muscle by
the following methods: (a) Triangle locating method: placing palm of the hand over the greater
trochanter of the client’s hip with the wrist perpendicular to the femur. The nurse points the index
finger to the anterior superior iliac spine, and extends the middle finger back along the iliac crest
toward the buttock. The index finger, the middle finger, and the iliac crest form a triangle shape,
and the injection site is the center of the triangle. The right hand is used for the client’s left hip and
the left hand is used for the right hip to identify landmarks. (b) Three-fingers’ width method: the
site is in lateral to three fingers’ width away from the client’s anterior superior iliac spine.
It is recommended that the client be in a prone position with the toes pointed inward, or in
the side-lying position with upper knee flexed and the upper leg in front of the lower leg, or sit at a
higher seat and move the center of gravity to the opposite site, or a spine position for crisis client.
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No matter what position the client have, it should help to promote maximum muscle relaxation
and minimum discomfort. When the client is in a standing position, the gluteus muscle usually is
tense and this position should not be used.
Vastus lateralis muscle site
The vastus lateralis muscle is another injection site recommended more frequently for adult
clients. It is located on the anterior lateral aspect of the thighs. It is thick and well developed.
There are no large nerves or vessels in proximity, and it does not cover a joint. The vastus lateralis
site is particularly desirable for infants and children, whose gluteal muscles are poorly developed.
To locate the site of injection, following methods can be used: (a) Thirds method: the area from a
handbreadth (approximate 10cm) above the knee to a handbreadth (approximate 10cm) below the
greater trochanter of the femur is divided into three equal parts. The middle third is the suggested
site for injection. (b) Ninths method: The area of the front of thigh is divided into thirds
horizontally and vertically and outer middle third is selected for injection site. To help relax the
muscle, the nurse asks the client to lie flat with the knee slightly flexed or in a sitting position.
Deltoid muscle site
The deltoid muscle is located in the lateral aspect of the upper arm. It is not often used
because the muscle is not well developed in many adults. The radial and ulnar nerves and brachial
artery lie within the upper arm along the humerus. The nurse should use this site only for small
medication volumes, generally limited to 1ml of solution, or when other sites are inaccessible
because of dressings or casts. To locate the deltoid muscle, the client may sit, stand, or lie down.
The nurse fully exposes the client’s upper arm and shoulder, then selects injection site by using
following methods: (a) The nurse palpates the lower edge of the acromion process, which forms
the base of a triangle, which is at the midpoint in line with the axilla and the lateral aspect of the
upper arm. The injection site is in the center of the triangle, about 2.5 to 5cm below the acromion
process. (b) Place four fingers across the deltoid muscle, with the top finger along the acromion
process. The injection site is then 2 to 3 finger widths below the acromion process.
Equipment and procedure
The angle of insertion for an intramuscluar injection is 90 degrees. Muscle is less sensitive to
irritating and viscous drugs. A normal, well-developed client can tolerate 3ml of medication into a
larger muscle without severe muscle discomfort. A larger volume of medication is unlikely to be
absorbed properly. Children, older adults, and thin clients can tolerate only 2ml of an
intramuscular injection.
The nurses assess the integrity of a muscle before giving an injection. The muscle should be
free of tenderness. Repeated injections in the same muscle can cause severe discomfort. With the
client relaxed, the nurse can palpate the muscle to rule out any hardened lesions. The nurse can
minimize discomfort during an injection by helping the client assume a position that will help
reduce muscle strain.
Intravenous Injections
Definition
Intravenous injection is the method to administer medications into vein directly. It is a
relatively common form of therapy. Both central veins and peripheral veins may be used for this
injection. Compared with other methods of injection routes, the IV injection has the advantage of
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providing the most rapid and complete absorption of medication. However, because medications
administered by this route cause an immediate and critical response, they must be prepared and
given with even greater knowledge, skill, and caution than is necessary for medications delivered
through the other routes.
Purpose
To inject medication which are not suitable for other routes
It commonly used for the client who is in life-threatening situations or in emergencies when a
fat-acting drug must be delivered quickly, unable to take medication by mouth, by subcutaneous
injection or by intramuscular injection, needs mediations that would be destroyed by the digestive
juices or not be absorbed by the gastrointestinal tract. Furthermore, drugs with large dose, high
concentration and intense irritation can be injected intravenously because they can be diluted
rapidly after infusing the blood flow.
To inject drugs or dyestuffs to diagnose diseases.
To get desired effect rapidly, especially for the client with critical illness
To get blood sampling
Site
The sites chosen for venipuncture varies with the client’s age, the condition of vein, and the
purposes of injection. For adult, veins in the hand, arm, leg and foot are commonly used; for
infants veins in the scalp and dorsal foot vein are often used. Veins in the scalp are common used
for children because of their rich distribution, accessibility, rare movement, easy securing the
needle and relative ease of preventing dislocation of the needle. Large veins include temporal
superficial vein, frontal vein, occipital vein, and posterior ear vein. Sometimes larger veins are
preferred for getting desirable effect rapidly. The median cubital, basilic, and cephalic veins in the
antecubital space are commonly used for drawing blood, bolus injections of medication. In
addition, the saphena magna vein, saphena parva vein in leg and veins in dorsal foot are common
sites of injection too, but they are not the best site, because of the danger of thrombosis caused by
the vein valve. Veins in dorsal foot are commonly used for children, but are avoided in adults
because of the danger of thrombophlebitis. Clinical guidelines for vein selection are as follow: (a)
Use vein from distal limb to proximal limbs gradually; (b) Use the client’s nondominant arm as far
as possible; (c) Select a vein that is easily palpated and feels soft, naturally splinted by bone, large
enough to accommodate the needle to be used; (d) Avoid usage of veins that are in areas of flex,
highly moving, damaged by previous use, phlebitis, infiltration, or sclerosis; (e) Keep the vein
away from joint and vein valve.
Equipment and procedure
Arterial Injection and blood sampling
Definition
Arterial injection and blood sampling is the nursing skill to inject medications into artery and
collect arterial blood as specimen.
Common sites
The sites of injection commonly used are radial artery, brachial artery, and femoral artery.
When administering the medication for chemotherapy, select common carotid artery for the illness
in head and face, subclavian artery or brachial artery for illness in superior limb and chest, and
53
femoral artery for illness in inferior limb and abdomen.
Section 4 Inhalation Administration
Inhalation is the process that medications administered with inhalers are dispersed through an
aerosol spray, mist, or powder that penetrates lung airways. The alveolarcapillary(肺泡毛细血管)
network absorbs medications rapidly. The purposes of inhalation are to decrease resistance of
airflow by using bronchodilators（支气管扩张剂）, expectorants（祛痰剂）and decongestants（解
除充血剂）to enlarge the passageway, to treat and prevent infection of respiratory system, to
increase humidity of airway and to treat lung cancer. This route of medication administration is
used for clients who have chronic respiratory diseases such as chronic asthma ( 哮喘 )，
emphysema (肺气肿), or bronchitis (支气管炎). Medications given by inhalation relieve of
airway obstruction caused by spasm (痉挛) of airway, and because these clients depend on
medications for disease control, they must learn the method of administering them safely.
Inhalation is often administered by using of nebulizers (喷雾器). There are three types of
nebulizations (雾化) in accordance with different nebulizers. Common types are handheld
nebulization, oxygen nebulization and ultrasonic nebulization. A handheld nebulizer (HHN) is a
metered–dose inhalers (MDIs) that can be used by clients to self-administer measured doses of an
aerosol(气雾) medication. It is usually designed to produce local effects. However, some
medications can create serious systemic side effects. Oxygen nebulization is accomplished by
using the force of an oxygen stream or compressed air passed through the fluid in a nebulizer or an
atomizer (喷雾器). This method is valuable for clients who require inhalation of a medication
several times a day. The oxygen stream is also useful in the production of vapors when high
humidity is needed continuously for long periods. Ultrasonic nebulization creates aerosol spray or
mist of medication through high frequency vibration of ultrasonic production film. Aerosol spray
or mist can reach terminal bronchiole（细支气管） and alveolus (肺泡). This equipment also can
regulate the amount of spray and warm the medication solution.
Section 5 Medication Anaphylaxis Test
Some clients get anaphylactic reactions when taking some medications, which may lead to
discomfort, allergic shock and even death. To prevent anaphylactic reactions, nurses should
inquire the patient’s allergic history, read the medications instruction, know the chemical structure
of the medication and even do the allergic test of some special medications. The nurses should be
able to handle the dispensing of allergic reagent of some special medications, the testing method,
the determination of testing result and emergency treatment of the allergy.
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Skin test of medication is a common clinical method to monitor whether the patients get
immediate or delayed anaphylactic reaction after the small dosage medication came into the body
through some approaches. Immediate anaphylactic test is usually used to detect human reaction to
foreign antigen such as medication, heterogenous protein (异体蛋白) etc. in order to determine
whether the medication can be used and prevent severe anaphylactic reaction. Intradermal test is
usually used. The test result is checked after 15 to 20 minutes and the nurse should determine
whether the patient is allergic to the medication according to criteria, but sometimes the result is
false negative because of insufficient dosage or anti-allergic medication taken before the test.
There are still other methods such as conjunctiva method (眼结膜试验法), skin scarification
method（皮肤划痕试验法）, and intravenous injection method.
Medications prone to provoke anaphylaxis include antibiotics, such as penicillin,
streptomycin, cephalothin; biological products, such as TAT, narcotics, such as procaine, contrast
medium, such as Iodide.
Characteristics of Anaphylactic Reaction to Medications
Medications anaphylactic reaction is also called allergy, which is kind of antigen-antibody
reaction when human body contacts the same reagent that came into the body before as antigen.
This pathological reaction may cause tissue damage or physiological disturbance. It has common
characteristics as follows:
●Anaphylaxis does not usually happen to patients who take the medication for the first time，
unless the patient might take it before but there is no record or the patient himself has no idea
whether he has used the similar kind of medication or medication with crossing anaphylactic
reaction. There is a sensitized course before anaphylactic response occurs, meanwhile, this means
there is a latent period in the reaction after the patient was exposed to the medication as the
antigen.
●Anaphylaxis only happens to a few persons with allergic habitus, with no relation to dosage.
But the dosage influences the serious degree of the allergic reaction.
●The different medications with similar chemical structure may lead to full or part cross
reactions.
Penicillin Anaphylactic Test
Penicillin is widely used in clinic settings, which has few side effects. But penicillin is easy
to cause anaphylactic reaction with the incidence of 5% to 6%. The reaction is not affected by the
patient’s age, sex, medication dosage, and the way it is administered. Therefore, anaphylactic test
must be done before the patient takes every form of penicillin. The medication can be
administered only if the result of the anaphylactic test is negative.
Mechanism of penicillin anaphylaxis
Anaphylactic is a kind of tissue damage and physical disturbance when antibody-antigen
reaction happens in anaphylactic cells. Penicillin G and its compounds of high molecular polymer,
such as 6-aminopenicilalkyl acid, degradation products of penicillin such as penicillin-thiazole,
and some moulds act as haptens. After entering the human body, they combine protein and
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polypeptide to form antigen which causes the body to produce specific IgE. The IgE with affinity
to tissue cells fixed on the surface of mast cells and white blood cells leads to an anaphylactic
condition. When the patient contacts the same antigen again, antigen combines the specific IgE
and anaphylaxis occurs. The anaphylaxis leads to cell rupture and then the releasing of histamine,
bradykinin, 5-HT, etc. These vasoactive substances act on target organs and cause smooth muscle
constriction, capillary dilation and increased capillary permeability, increased secretions of
mucous. Different patients have different clinical manifestation due to individual difference.
The Clinical Manifestations of Penicillin Anaphylaxis
Anaphylactic shock
It often occurs several seconds or minutes, sometimes half an hour after intradermal skin test
or medication administration. Only a few patients have anaphylactic shocks during continual
medication administration.
Respiratory failure symptoms
Symptoms due to hypoxia (缺氧) and asphyxia(窒息)，the patient feels chest tightness,
obstruction in the throat, even dying. Nurses can find that patient has shortness of breath,
cyanosis(紫绀) and foam at the mouth.
Cardiovascular failure symptoms
Facial paleness, cold sweat, rapid and weak pulse, and decreased blood pressure are always
presented.
Central nervous system symptoms
Due to cerebral anoxia( 缺 氧 症 ) ， dysphoria( 烦 躁 不 安 ), feeling of dizziness,
quadriplegia(四肢瘫痪)，loss of consciousness, tic(痉挛), and excrement(大便) and urine
incontinence would be presented.
Cutaneous allergic symptoms
There are pruritus(搔痒), urticaria（风疹，寻麻疹）, and other skin eruption.
Serum sickness reaction
It usually happens within 7 to 12 days after exposure. The clinical manifestations are similar
to serum sickness such as fever, edema and pain in arthrosis (关节)，pruritus, urticaria, swelling of
lymph nodes, and abdomen pain.
Anaphylaxis of organ and tissue
Cutaneous anaphylaxis
Skin eruption (urticaria) often occurs in severe cases, and exfoliative dermatitis(剥脱性皮
炎) may occur.
Respiratory anaphylaxis
It may cause asthma or trigger original asthma(哮喘).
Digestive system anaphylaxis
It may lead to anaphylactic purpura (紫癜) with symptoms of abdominal pain and
hematochezia (便血).
Symptoms as above may occur alone or simultaneously, or many symptoms and signs may
occur at the same time. Respiratory symptoms and pruritus may occur first. Nurses should pay
attention to the patient’s complaint.
The treatment of penicillin allergic shock
56
Emergency treatment on site
Stop medication immediately. Let the patient lie on the back, keep warm, and give puncture
on the philtrum (人中).
Administering epinephrine（肾上腺素）immediately
Inject 0.1% epinephrine 1ml subcutaneously right away. If the patient is a child , the dosage
should be reduced. If the symptoms are not relieved, inject 0.5ml every half an hour repeatedly
until the patient gets out of the crisis. Epinephrine is the first choice for allergic shock. It can
constrict blood vessels, increase peripheral resistance, excite myocardium(心肌), increase cardiac
output and relax bronchial smooth muscle.
Correct Hypoxia and improving respiratory
Oxygen is administered immediately, mouth-to-mouth artificial respiration is indicated if the
patient’s respiration is depressed, and respiratory stimulants such as nikethamide and lobeline are
injected. Prepare for incision of trachea or intubation of trachea if laryngeal edema which
influences respiration occurs.
Treating allergic shock
Dexamethasone 5 to10mg is administered by intravenous injection, or hydrocortisone 200 to
400mg in500ml 5%~10% glucose solution is given by IV infusion. Administer anti-histamine
medications such as 异丙嗪、苯海拉明.
Improve cardiovascular function（correct shock）
：
Increase peripheral blood capacity by intravenous infusion of 10% glucose solution or
balanced solution. If the blood pressure is not up, administer dopamine(多巴胺) or metaraminol
（间羟胺）by intravenous infusion. If cardiac arrest occurs, implement cardiac compression.
Observe the patient intensively and record information：
Assess the client’s temperature, pulse, respiration, blood pressure, urine volume, and other
clinical manifestation. Make nursing record of the patient’s condition. Do not move the client
when he or she is still in critical situation.
The Method of Penicillin Anaphylactic Test
The following patients need skin test to detect whether they are allergic to penicillin. First
take medication (首次用药者), stop penicillin three days ago and reuse（停药 3 天以上再用者）,
the batch of the medication is changed (更换批号者).
The anaphylactic test reagent and its dispensing method
Skin test reagent is isotonic saline with 200u to 500u penicillin G per milliliter. Inject 0.1 ml
(include penicillin G 20 to 50u) intradermally. There are different standards for injection dosage in
different places. The standard in shanghai is 20u while 50u in Beijing and Shandong province. The
diluting method is as follows:
(1) Inject 4ml isotonic saline into vial with P 80,0000u, so there is 20,0000u per milliliter.
(2) Dilute the 0.1ml P solution in (1) with isotonic saline to 1ml, that is 2,0000 per milliliter.
(3) Dilute the 0.1ml P solution in (2) to 1ml, that is 2000u per milliliter.
(4) Dilute 0.25ml P solution in (3) to 1ml, that is 500u per milliliter which is the anaphylactic
testing reagent. Mix completely when diluting every time.
Method of anaphylactic test
Inject 0.1ml reagent containing 50u penicillin intradermally at the patient’s medial forearm,
and observe the result after 20minutes.
57
Result determination
Negative result:
There is no skin redness, swelling, blush and the patient has no uncomfortable feeling.
Positive result:
•The wheal becomes large.
•There is skin redness and swelling.
•The diameter of the wheal is more than 1cm, or there is pseudopodium.
•The patient has pruritus feeling.
•Dizziness, fluster, nausea may occur in severe cases, even anaphylactic shock.
Cautions of penicillin administration
•Inquire the patient’s medication history, allergic history and family allergic history before
test.
•Normal/isotonic saline is always used as menstruum to dissolve and dilute penicillin.
medications.
•Use fresh allergic test reagent. The dosage and concentration of reagent is accurate.
－histamine medications is banned in 24h before test in case of false negative .
•Be ready for aids before, keep epinephrine on hand .
•Keep close watch on the patient. The nurse should watch on the patient with first skin test
for 20miniutes and then can leave .
•If positive, penicillin should be banned, and the nurse should report to the doctor. Record
penicillin positive result on the doctor’s order sheet, medical record，injection card and bedside
card, and inform the patient and his family of the result.
•If you doubt false positive，control experiment is made to exclude allergy induced by
disinfector.
Streptomycin Anaphylactic Test
Clinical Manifestation of Anaphylactic Reaction
Streptomycin itself has severe toxic effects that include the damage to renal function, deaf,
numbness and twitch due to deficient calcium etc.. Furthermore, it will lead to anaphylaxis
similar to penicillin approximately.
Treatment
The treatment of anaphylaxis of streptomycin is similar to that of penicillin by and large. In
addition, 10%葡萄糖酸钙、5％氯化钙 can be administered to relieve the toxic effects of
streptomycin because the streptomycin can joint with the calcium.
The Reagent of Streptomycin and its Dispensing Method
Skin test reagent is isotonic saline with 2500u streptomycin per milliliter. Inject 0.1 ml
(include streptomycin 250u) intradermally. The diluting method is as follows:
58
(1) Inject 3.5ml isotonic saline into vial with streptomycin 100,0000u, so there is 25,0000u
per milliliter.
(2) Dilute the 0.1ml S solution in (1) with isotonic saline to 1ml, that is 2,5000 per milliliter.
(3) Dilute the 0.1ml s solution in (2) to 1ml, that is 2500u per milliliter that is the
anaphylactic testing reagent. Mix completely when diluting every time.
Method of anaphylactic test
Inject 0.1ml reagent containing 250u streptomycin intradermally at the patient’s medial
forearm, and check the result after 20minutes.
Result Determination
Result determination is similar to penicillin.
TAT (tetanus antitoxin) anaphylactic test
The cause of anaphylaxis
Tetanus antitoxin is made from the immune serum of equine, which can neutralize tetanus
toxin in the client’s body fluid. It is used to prevent and cure tetanus. It can control the progress of
the illness or can be used as passive immune antitoxin. TAT is a kind of heterogenous protein to
human body that may cause anaphylaxis. Its clinical manifestations include fever, immediate or
delayed serum sickness. Generally, the reaction is not serious, but occasionally, there may be
allergic shock or even death in some severe cases. So nurses should perform anaphylactic test
before using TAT. The patients who have used TAT more than 1 week before should take the test
again if they want to reuse it. Only the patients with negative result can use TAT with injection
dosage for one time. Patients with positive result may use desensitized injection of TAT because
TAT is a specific antibody to tetanus without replacement. When applying desensitized injection,
the nurse should observe the client’s reactions intensively. If finding some abnormal condition, the
nurse should give effective first aid immediately.
The method of TAT anaphylactic test
The anaphylactic test reagent and its dispensing method
Dilute the original TAT fluid (1500u per milliliter) 0.1ml to 1ml, which is 150u per milliliter.
This solution is the reagent.
Method of anaphylactic test
Inject 0.1ml reagent solution (TAT 15u) at client’s forearm intradermally, and check the
result in 20 minutes.
Result determination
Negative result:
No local skin redness and swelling. No abnormal systemic reaction.
Positive result:
59
•The wheal is red and swelling.
•Induration with diameter larger than 1.5cm, and blushing with diameter larger than
4cm.
•Sometimes there is pseudopodium.
•The patient has pruritus feeling.
•The systemic reaction is similar to that of penicillin and serum sickness is the most
common.
TAT desensitized injection
Mechanism of desensitized injection
If the test result is positive and there is no substitute, nurses should divide the dosage into
several smaller dosages and inject them separately and continuously in a short period time.
Several smaller dosages come into the human body consequently, combine the IgE on the mast
cells and basophils and release the active substance, such as histamine, gradually. There is enzyme
of histamine released from human body, which could decompose histamine with no harm to the
body. So the client has no clinical manifestation. After continuous injection with small dosage in a
short period of time, most of the IgE on cells will be almost or totally consumed, and no
anaphylaxis will occur even exposed to a large amount of TAT. But this kind of desensitization is
temporary and IgE will be produced in a period of time and anaphylaxis will happen again. That
could explain why the anaphylactic test should be done again if the TAT is reused later.
Desensitized injection method
According to table 12-, the nurse makes an intramuscular injection at the interval of 20
minutes until the total dosage is accomplished and observes the client’s reactions intensively
during desensitized injection. The nurse should stop injection immediately and help the physician
to start first aid if the client has facial paleness, shortness of breath, cyanosis, urticaria, dizziness,
palpitation or even allergic shock. If the anaphylactic reaction is not severe, each dose can be
decreased and injection times can be increased base on the client’s condition until desensitized
injection is finished under intensive observation.
Table 12- Desensitized injection method of TAT
Times
TAT(ml)
Normal Saline
Administration Route
1
2
3
4
0.1ml
0.2ml
0.3ml
remainder
0.9
0.8
0.7
Dilute to 1ml
IM
IM
IM
IM
Procaine (Novocaine) Anaphylactic Test
Procaine is akind of local anesthetic, which can be used in infiltrationanesthesia, conduction
anesthesia, lumbar anesthesia and epidural anesthesia. Anaphylaxis from slight to severe may
occur occasionally. Skin anaphylactic test should be done before it is used for the first time if
procaine is needed in operation or special exam. Application is permitted if the result is negative.
Procaine anaphylactic test method: inject 0.25% procaine solution 0.1ml intradermally, and
60
check the result in 20 minutes.
Other details can be referred to the penicillin anaphylactic test.
Cytochrome C anaphylactic test
Cytochrome C is an activator of cell respiration that is a kind of assisted medication used in
tissue hypoxia. Anaphylaxis may occur occasionally. Anaphylactic test should be done before
using. There are 3 general methods for anaphylactic test:
Intradermal test
Dilute 0.1ml of Cytochrome C solution (15mg per 2ml) to 1ml, which is 0.75mg per
milliliter solution. This is the test reagent. Administer 0.1ml (containing cytochrome C 0.075mg)
by intradermal injection, and check the result in 20minutes. The result is positive if there is local
redness and swelling，with the diameter of wheal larger than 1cm，and papular appears.
Skin scarification test
Choose the medial side of forearm, and sterilize the local site with 70% alcohol solution. Put
one drip of original Cytochrome C solution on the forearm, and make two scarifications with the
length of 0.5cm and depth of little bleeding. Check the result in 20minutes. The result
determination can be referred to intradermal test.
The eye drop method has also been reported, which is to put one drip of original Cytochrome
C on the conjunctiva, and check the result after 20 minutes. If there are congestion, edema, or itch
in conjunctiva, the result is positive.
Cephalosporin anaphylactic test
The mechanism of Anaphylaxis
Anaphylaxis of cephalosporin is also a kind of antigen-antibody reaction, which is similar to
that of penicillin. Some believe that their antigens are different duo to different chemical structure,
which is why some patients who are allergic to penicillin are tolerant to Cephalosporin. Others
believe that Cephalosporin and penicillin have the same β-lactam structure. After entering
human body, the medication will combine with protein and become antigen in human body. So,
there is partial cross anaphylaxis between these two medications. 3% to 4% of the patients who
are allergic to penicillin are alleric to Cephalosporin, while less than 5% of children have allergies
to it.
The Method of Cephalosporin Anaphylactic Test
The Anaphylactic Test Reagent
(1) Take0.5g Cephalosporin and put it into 2ml normal saline. That is 250mg Cephalosporin
per milliliter.
(2)Dilute 0.2ml of solution (1) into 1ml to make a new solution containing 50mg
Cephalosporin per milliliter.
(3) Dilute 0.1ml of solution (2) into 1ml to make a new solution containing 5mg
Cephalosporin per milliliter.
61
(4) Dilute 0.1ml of solution (3) into 1ml to make a new solution containing 500μg
Cephalosporin per milliliter. This is the skin test reagent.
Method of Anaphylactic Test
Inject 0.1ml test reagent intradermally at the client’s forearm, and check the result in 20
minutes.
Result Determination
It is similar to penicillin.
Iodic Preparation AnaphylacticTest
Clinically iodide contrast medium are commonly used in renal angiography, cholecystography,
cystic radiography, bronchial radiography, cardiovascular radiography and cerebral angiography.
These medications can trigger allergic reaction. So if it is the first time to use them, anaphylactic
test should be done 1 or 2 days before graphs with iodode. If the result is negative, angiography
can be done. For few clients, the result is negative, but anaphylactic reactions still may occur. So
when the angiography is applied, emergency treatment must be prepared. Treatment of
anaphylactic reaction is the same as that of penicillin.
Method of Anaphylactic Test
Methods of test commonly used are as follows:
Oral Administration
If the symptoms of paralysis of mouth, dizziness, palpitation, nausea, and vomiting, or/and
urticaria are present, the result is positive.
Intradermal Injection
If local skin becomes red and swelling or sclerosis appears, with the diameter more than 1cm,
the result is positive.
Intravenous Injection
If the blood pressure, pulse, respiration and face color of the client have changed, if the client
has palpitation, mucous edema, nausea and vomiting, uritcaria and other discomforts, the result is
positive.
The conjunctiva test method has also been reported, which is to put one or two drips of
iodide contrast medium into unilateral conjunctiva sac, and observe the result in 1 minute. If there
are congestion and vasodilatation or varicosity in conjunctiva and sclera, the result is positive.
For some medications, such as asparaginase, purified antivenin, refined anthrax antitoxin
serum, and refined rabies antitoxin serum, anaphylactic test and desensitization, therapy are also
required.
Section 6 Topical Administration
Topical medications applications are the methods that the medications are applied locally to
the skin or to the affected mucous membranes in such areas as the eye, external ear canal, nose,
vagina, and rectum. Medications can be prepared with lotion, paste, ointment, powder, aerosol
spray, or transdermal patches. Topical applications usually are intended for direct action on a
62
particular site, although some systemic effect may also occur. The action depends on the type of
tissue and the nature of the medication. Most topical applications used therapeutically are not
absorbed well and completely when applied to intact skin because the skin’s thick outer layer
serves as a natural barrier to medication diffusion.
Skin Application
Because many locally applied drugs such as lotions, pastes, and ointments can create
systemic and local effects, the nurse should apply these drugs using gloves and applicators. Sterile
technique is used if the client has an open wound.
Skin encrustations and dead tissues harbor microorganisms and block contact of medications
with the tissues to be treated. Simply applying new medications over previously applied drugs
does little to prevent infection or offer therapeutic benefit. Before applying medications, the nurse
cleans the skin thoroughly by washing the area gently with soap and water, soaking an involved
site, or locally debriding (清除) tissue.
When applying ointments or pastes, the nurse spreads the medication evenly over the
involved surface and covers the area well without applying an overly thick layer. Opaque（不透明
的） ointments prevent visualization of underlying skin. Physicians may order a gauze (纱布)
dressing to be applied over the medication to prevent soiling of clothes and wiping away of the
drug. Each type of medication, whether an ointment, lotion, powder, or other type, should be
applied a specific way to ensure proper penetration and absorption. The nurse applies lotions and
creams by smearing them lightly onto the skin’s surface; rubbing may cause irritation. A liniment
is applied by rubbing it gently but firmly into the skin. A powder is dusted lightly to cover the
affected area with a thin layer. During any application the nurse should assess the skin thoroughly.
To record administration, the area applied, name of medication, and condition of skin should be
noted. The following are typical preparations applied to skin areas, their primary purposes, and
specific nursing interventions:
●Powders are used to promote drying of the skin and prevent friction between the skins. Use
cautions during application to prevent inhalation of the medical powder.
●Ointments provide prolonged contact of a medication on the skin and soften the skin. Massage
can help the medication penetrate the skin.
●Creams and oils lubricate and soften the skin and prevent drying of the skin. To prevent
chilling, the preparation should be warmed in the hands or fingers, if a large part of the body is to
be covered.
●Lotions protect and soothe (舒缓) the skin. Shake lotions thoroughly before using and apply
with cotton balls or gauze.
Nasal Instillations
Eye Instillations
Ear Instillations
Vaginal Instillations
Vaginal medications or instillations are inserted into vaginal to treat infection or to relieve vaginal
63
discomfort. The common forms are suppositories(栓剂), foam（泡腾）, jellies (凝胶), or cream (霜
剂). Suppositories come individually packaged in foil wrappers. Storage in a refrigerator prevents
the solid, oval-shaped suppositories from melting. After a suppository is inserted into the vaginal
cavity, body temperature causes it to melt and be distributed and absorbed. Foam, jellies, and
creams are administered with an inserter or applicator. A suppository is given with a gloved hand
in accordance with Universal Precaution. Clients often prefer administering their own vaginal
medications and should be given privacy. After instillation of the drug, a client may wish to wear a
perineal pad to collect drainage. Because vaginal medications are often given to treat infection,
discharge may be foul-smelling. Aseptic technique should be followed, and the client should be
offered frequent opportunities to maintain perineal hygiene.
Rectal Instillations
Insertion of medication into the rectum in the form of suppositories is a frequent pratice in
clinical setting. Rectal suppositories are thinner and more bullet-shaped than vaginal suppositories.
The rounded end prevents anal(肛门) trauma during insertion. Rectal suppositories are used
primarily for their local action, such as laxative promoting defecation and a fecal softener, or
systemic effects, such as reducing nausea, lowering fever. Rectal suppositories are stored in the
refrigerator until administered against melting.
During administration, the nurse must place the suppository past the internal anal sphincter
(肛门内括约肌) and against the rectal mucosa. Otherwise the suppository may be expelled before
it can dissolve and be absorbed into the mucosa. With practice a nurse learns to recognize the
sensation of the sphincter relaxing around the finger. The suppository should not be forced into a
mass of fecal material. It may be necessary to clear the rectum with a small cleansing enema
before a suppository can be inserted.
64
Skill 12-1 Administering Oral Medication
Purpose
To provide a medication that has systemic effects or local effects.
Indications
Clients who are able to swallow solid and liquid
Contraindications
1.Clients with impaired swallowing function
2.Unconscious clients
3.clients who refuse to take medications orally
4.clients with vomiting or/and nausea
5.clients with gastric or intestinal suction
6.clients with bowel inflammation or reduced peristalsis
7.clients with recent GI surgery
Equipment
Medication cards, sheets, or records
● Medication cups, measuring cup, drop tube
● Pill-crushing or pillating device(研钵)
● Paper towels
Medication cart or tray
●Drinking straws
●Kettle with warm water
●
●
Procedures and Key Points
Steps
Rationale and Key Points
1.Wash hands, wear mouth mask and assemble
the equipment
2.Medication preparation
(1) Follow the three checks and seven rights
principle. Assess for any contraindications to
client receiving oral medications. Assess
client’s history of allergies.
To avoid giving medications to client with
contraindications
● The physician’s order is the most reliable
source and the only legal record of medications
clients to receive
●Prepare medications for one client at a time
●
(2) Prepare medications with appropriate
method based on different forms of medication
Solid medication
① Hold the medication bottle in one hand with
the label facing to the nurse
② Remove the bottle cap from the container
and place the cup upside down
65
Steps
Rationale and Key Points
③ Remove required number of tablets or
capsules from a bottle by using medication
spoon, and then transfer them to the medication
cup. Do not touch medication with fingers.
④If needed, the medications can be broken
using a gloved hand, or cut with a pill crushing
device.
All medications to be given to one client at the
same time may be placed in one medicine cup.
●
Tablets that are to be broken in half must be
prescored
●Keep unused portions of divided tablets and
give clear indication of the medication name
and dose for next use.
●
Keep
medications
that
require
preadministration assessments and special
medications separate from others.
●If the client has difficulty in swallowing, ask
the physician to prescribe a liquid substitute. If
liquid medications are not an option, use
pill-crushing device such as a mortar or pestle
or grind pills. Mix the grinded tablet in water.
●
⑤ To prepare unit-dose tablets or capsules,
place packaged tablet or capsule directly into
medicine cup. Do not open wrapper until at
client’s bedside.
Liquid medication
①check the quality of liquid
Change the medication if it has a changed
color or turned cloudy.
●To prevent an incorrect concentration
●To prevent contamination of the inside of the
cap
●Spilled liquid will not soil or fade label
●
②Shake the container
③Remove the cap from the container and place
it upside down
④Hold the bottle in one hand with the label
against the palm of hand while pouring
⑤Hold the measuring cup in the other hand at
the eye level, and fill it to the needed level on
scale, where the thumbnail is pointed to.
⑥Pour the medication into the medication cup
To ensure accuracy of measurement
●Scale should be even with the fluid level at its
base of meniscus
●Different liquid medication should be poured
into different medication cup.
●Measuring cup should be cleaned every time
after a type of liquid is measured.
●
⑦Wipe tip and neck of bottle with paper towel
⑧Draw up the medication in a syringe without
needle, if the needed volume is less than 10ml
⑨If the needed volume of medication is less
than 1ml, use drop tube to draw up the liquid,
and then keep drop tube at 45 angle with
horizontal level, drip them into a cup with
certain water or bread.
To prevent liquid from adhering to the cup
wall and interfering with the dose.
●When the medication cannot be diluted, it can
be dropped on bread.
●
66
Steps
Rationale and Key Points
(3) When all medications of one client have
been prepared, return the unused medications to
drawer, and recheck once again with the
medication order before taking them to client
3. Administering medications
(1) Gather equipment and medication and take
them to the client at correct time
(2) Identify the client. Ask client to state his or
her name, assess any factors influencing the
client’s taking oral medications
(3) Explain the purpose and action of each
medication. Allow the client to ask any
question about medications
(4) Assist the client to have a proper position
Prepare solid medication at first, and then
prepare liquid medication
●
To ensure smooth procedure
●
Ensure the medication given to the right client
●
To improve client’s cooperation and reduce
the doubts and anxieties
●
Proper position can help the client to swallow
and prevent aspiration
●Take out the medications for one client at one
time, don’t take out the medications for two
clients at the same time to avoid confusing .
●If the client has questions, the nurse should
recheck again
●If the client cannot take medications for some
reasons, the nurse should return the medications
to the cart
●Do not leave medication unattended
●Medication is absorbed through blood vessels
of undersurface of tongue. If swallowed,
medication is destroyed by gastric juices or
detoxified so rapidly by liver that therapeutic
blood levels are not attained.
●Buccal medications act locally on mucosa or
systemically as they are swallowed in saliva
● If
prepared in advanced, powdered
medications may thicken and even harden,
making swallowing difficult
●Medications acts through slow absorption by
oral mucosa, not gastric mucosa
●
(5) Offer medications and water
① For sublingual or buccal administration,
ask the client place the medication at the
proper site. Remind the client not to drink
liquids or swallow the medication until it
has been dissolved.
② Mix powdered medications with liquids at
bedside and give to client to drink
③ Remind the client not to chew or swallow
lozenges
④If the client is unable to hold medication cup,
the nurse should help him to place the cup to
the lips and gently introduce the medication
into the mouth slowly.
67
Steps
Rationale and Key Points
⑹Stay with the client until every medication is
swallowed. Ask the client to open mouth if
uncertain whether medications have been
swallowed
⑺Assist client in returning to a comfortable
position
⑻Return the cup to the cart. Wash hands
⑼Dispose of equipment
⑽Evaluate the client’s response to medication
at all times. Always notify the physician when
any abnormal response occurs
Nurse is responsible for ensuring receives
ordered dosage
●
Evaluation
1.Whether the nurse has followed three checks and seven rights principles.
2.The client’s response to the medications. If the client exhibits a toxic effect or allergic reaction,
or some side effects, the nurse should notify the physician on time and discontinue administration
of medications
3.Dirired effect
4.The client’s knowledge about oral medication administration and compliance with medication
therapy
Skill12-2 Preparing Medication Injection
Purposes
To prepare medication for an injection
Equipment
Ampule, vial and diluent
Antiseptic solution
● MAR or computer printout
Syringes and needles
Antiseptic swab
● Vial opener, and file
●
●
●
●
Procedures and Key Points
Steps
Rationale and Key Points
1. Wash hands, wear mouth mask
2. Check the physician’s order
3. Prepare medication
To reduce transmission of microorganisms
● To ensure the right medication preparation
●
68
Steps
Rationale and Key Points
Draw medication from an ampule
⑴Tap the upper stem of the ampule lightly with
finger while holding the ampule vertically
⑵File the neck of the ampule. Sterilize the neck
of ampule as routine
⑶Snap the neck of the ampule to break off its top
along the prescored line at its neck. Always break
away from your body. Place small sterile gauze
pad around neck of ampule if necessary
⑷ Hold small ampule with thumb and index
finger of nondominant hand. Remove the cap
from the needle by pulling it straight off. Insert
the needle into the center of ampule opening.
Maintain the bevel of the needle downward and
below the surface of medication fluid. Firm the
hub of needle with thumb and the fourth finger of
nondominant hand, pulling back the plunger by
dominant hand to withdraw medication into
syringe. Touch plunger at knob only .
If the ampule is larger, hold it with thumb and
index finger of nondominant hand, firm the
syringe with thenal (大鱼际肌) muscle and other
fingers. Keep the bevel downward and under
surface of medication fluid, pull back plunger to
withdraw medication with prescribed amount.
Touch plunger at knob only.
Draw medication from a vial containing a
solution
⑴Remove the metal or plastic cap on the vial
that protects the rubber stopper. Sterilize the
rubber seal routinely and allow it to dry
⑵Remove needle cap and pull back plunger to
draw the amount of air into syringe equivalent to
the volume of medication to be withdrawn from
the vial
⑶Insert tip of needle with beveled tip entering
first through center of rubber seal
⑷Inject air into the airspace and keep the bevel
of needle above the solution in the vial
69
This facilitates the movement of medication
in the stem to the body of the ampule
●
Using small gauze can protect the nurse’s
finger from being hurt by glass if the ampule
is broken
●
Bevel down makes it easy to withdraw
medication
● Do not allow needle tip or shaft to touch
rim of ampule because broken rim of ampule
is considered contaminated
●
Center of seal is thinner and easier to
penetrate
●
Inject air to prevent buildup of negative
pressure in vial when aspirating medication
●
Inject air above the solution prevents
formation of bubbles and inaccuracy in dose
●
Steps
Rationale and Key Points
⑸ Invert vial while keeping firm hold on syringe
and plunger. Hold vial between index finger and
middle finger and grasp the barrel with thumb,
fourth finger and little finger of nondominant
hand. Grasp knob of plunger with thumb and
index finger of dominant hand to counteract
pressure in vial. Keep bevel of needle within
fluid.
⑹Allow air pressure from the vial to fill syringe
gradually with medication. If necessary, pull back
slightly on plunger to obtain needed amount of
solution
⑺ When desired volume has been obtained,
position needle into vial’s airspace. Remove
needle from vial by pulling back the barrel of
syringe
Draw medication from vial containing a
powder
⑴Remove cap covering the vial of powdered
medication and cap covering the vial of proper
diluent. Sterilize the rubber seals as routine
⑵Draw up diluent into syringe following steps as
described above about drawing medications from
a vial with a solution
⑶Insert the tip of needle through the center of
rubber seal of the vial containing powdered
medication. Inject diluent into it. Remove needle
⑷Mix medication thoroughly. Roll in palms. Do
not shake
⑸Withdraw the medication follow the steps as
described above about drawing medications from
a vial with a solution
4.Hold syringe vertically with needle up, and pull
back the plunger. Tap barrel to dislodge any air
bubbles. Push plunger upward to eject air
For multidose vial, make a label that includes
date of mixing, concentration of medication per
milliliter, and nurse’s initials
5.Recheck fluid level ensures proper dose
70
Keeping bevel of needle below fluid level
can prevent air frome being drawn into the
syringe
●The scales should face to the nurse
●
Positive pressure within vial forces fluid
into syringe (unless vial has been used
several times)
●
Avoid shaking because shaking produces
bubbles and influences the accuracy of dose
●Roll the vial to improve the disperse of the
medication throughout the solution
●
Pulling back plunger allows fluid within
needle to enter barrel
●Holding syringe vertically allows air at top
of barrel
●Don’t eject fluid with air
●To ensure that future doses will be prepared
correctly
●
6.Cover needle with its safety cap. Check again.
Reserving the empty ampule and vial to
check
●
Evaluation
1.Accuracy of the medication name and dose
2.Whether the powder medication is dissolved thoroughly
3.Whether the nurse used sterile techniques and maintained the equipment sterile during the whole
procedure
Skill 12-3 Administering an Intradermal Injection
Purposes
1.To use for diagnostic skin tests and medication allergy tests
2.To inject vaccine
3.A prior step to local anesthesia
Equipment
Medication tray
●70% alcohol solution
●medication
Sterile tweezers and vat
●1-3cml syringe, 41/2-needle or OT needle
●File and vial opener
●
●
71
MAR
●Sterile swab
Washcloth
●Contamination container
●
●
Procedure and Key Points
Steps
Rationale and Key Points
1.Wash hands and wear mouth mask
2.Assemble equipment and check the
physician’s order. If necessary, draw medication
from an ampule or a vial at preparation room
3.Take the equipment to the bedside of the
client. Identify the client. Explain procedure to
the client
4.Select appropriate site
5.Sterilize the skin with an alcohol swab while
wiping with a firm, circular motion and moving
outward from the injection site. Allow the skin
to dry.
Follow sterile principles strictly
●To ensure correct medication administration
●
To encourage client’s cooperation and reduce
anxiety
●Ask the client’s allergic history
●
Pathogens on the skin can be forced into the
tissues by the needle
● Introducing alcohol into tissues irritates the
tissues and is uncomfortable for the client if
skin doesn’t dry
●The antiseptic solution containing iodine can
not be used, which will interfere with the test
results
●
6.Check again, and eject air in syringe
thoroughly.
7.Use the nondominant hand to spread the skin
taut over the injection site. Place the needle
against the client’s skin at 5-degree angle, with
the bevel up, and insert the needle into the skin
until the bevel inserts into the skin completely.
Place the syringe flat against the skin. Firm the
hub with thumb of the nondominant hand.
Slowly inject the medication about 0.1ml with
the dominant hand while watching for a small
wheat to appear
Taut skin provides an easy entrance into
intradermal tissue
●Holding the needle as nearly parallel to the
client’s skin as possible when inserting. If the
angle of inserting is lager, the needle may insert
into subcutaneous tissue
● Inserting the bevel of needle into the skin
completely to avoid leaking of medication
● If a small bleb appears, the reagent is in
intradermal tissue
●
8.Withdraw the needle quickly at the same
angle that it was inserted
Don’t massage the area after removing the
needle and instruct the client not to massage the
area because medication may disperse into
deeper tissue or out through the needle insertion
site
●
9.Check again. Dispose of equipment properly
10. Assist the client to take a comfortable
position. Wash hands.
72
Steps
Rationale and Key Points
11.observe response of the client. Make
judgment and record the result.
Generally, observe the result in 15 to 20
minutes after the injection
● If necessary, inject 0.1ml of 0.9% normal
saline solution at the same site of the other
forearm for comparative study
●
Evaluation
1.Whether the nurse has followed the principle of the threechecks and seven rights and the sterile
techniques. Observe the size of the wheal in the site of injection. Whether there is bleeding,
infiltration or discomfort in the injection site.
2.The client’s systemic reaction to the medications
3.The client’s knowledge about medication and methods of administration
Skill12-4 Administering a Subcutaneous Injection
Purposes
1. To inject medications that need to produce effect within given time but cannot be administered
orally
2. To inject vaccine
3.To give local anesthesia
Equipment
Medical tray
● Antiseptic solution
● Medication
● Medication card
● Sterile swab
Sterile tweezers and vat
● File and vial opener
● 1 to 3ml syringe, 5 to 6-gauge
needle
● Contamination container
●
●
Procedures and Key Points
73
Steps
Steps 1 to 4 are the same as described in 12-3
5.Close door and windows.
6.Assist client to comfortable position
appropriate for the site selected
(1) If the outer aspect of upper arm is selected,
the client may have a sitting or lying position,
the arm should be relaxed at the site of the
body.
(2) If the anterior thighs are selected, the client
may sit or lie with the leg relaxed
(3) If the abdomen is selected, the client may
lie in a semirecumbent position or supine
position with the knees flexed
(4) If the scapular area is selected, the client
may be prone, on side, or assume a sitting
position
7. Sterilize the area as routine and allow the
skin to dry
8. Inject medication
(1) Remove the needle cap with the
nondominant hand
(2) Grasp and bunch the area surrounding the
injection site or spread the skin at the site
(3) Hold the syringe flat in the dominant hand
and keep bevel side up. Insert the needle
quickly at an angle of 30- to 40-degree and
stop at the 1/2 or 2/3 length of the needle
(4) After the needle is in place, release the
grasp on the tissue and immediately move your
nondominant hand to steady the hub of the
needle. Slide your dominant hand to the end of
the plunger.
(5) Aspirate by pulling back gently on the
plunger of the syringe to determine whether
the needle is in a blood vessel
(6) If no blood appears, inject the solution
slowly
Rationale and Key Points
To provide privacy
Proper position will make the local tissue
relax and reduce the discomfort of the client
● It is necessary to rotate sites if the client is to
receive frequent injection for a long time
●
●
This provide for easy, less painful entry into
the subcutaneous tissue
● If the client is thin, skin needs to be pinched
to prevent too deep insertion
● If the client is thin, the angle of inserting
should be smaller
●
If blood appears, the needle should be
withdrawn and discarded, and a new syringe
with new medication prepared
● It is not suggested that nurses aspirate when
injecting heparin, an anticoagulant, in order to
prevent bleeding
● Irritating
medications should not be
administered subcutaneously
● Rapid injection of the solution creates
pressure in the tissues, resulting in discomfort
●
74
Steps
Rationale and Key points
(7) After medication injection, withdraw the
needle quickly. Massage the area gently with
dry sterile swab
Slow withdrawal of the needle pulls the
tissues and causes discomfort
● Massage helps distribute the solution and
hastens its absorption
●
9.Check again
10.Assist the client to a comfortable position.
Dispose of equipment. Wash hand. Record the
relevant data if necessary
Evaluation
1.Whether the nurse has followed the three checks principle and antiseptic techniques
2.Observe the size of the wheal in site of injection, and whether there is bleeding, infiltration,
discomfort in the injection site, and the client’s systemic reactions to the medications.
3.The client’s knowledge about medication and methods of administration.
Skill12-5 Administering an Intramuscular Injection
Purposes
1.To inject medications that need to produce effect within a period of time and cannot be
administered orally
2.To produce rapid effects, but the medication cannot be administered by intravenous injection
3.To inject irritating medication or a large volume of medication
Equipment
Sterile tweezers and vat
● File and vial opener
● 2 to 5ml syringe, 51/2 to
7-gauge needle
● Contamination container
●
Medical tray
● Antiseptic solution
● Medication
● Medication card
● Sterile swab
●
Procedures and Key Points
75
Steps
Rationale and Key Points
Steps 1 to 4 are the same as described in 12-3
5.Using screen to provide for privacy
6.Assist client to comfortable position
appropriate for the site selected
(1) If the dorsogluteal is selected, the client
may lie prone with toes pointing inward or on
the side with the upper leg straight and relaxed
and the lower leg flexed
(2) If the ventrogluteal are selected, the client
may lie on the back or on the side with upper
leg straight and lower leg flexed
(3) If the vastus lateralis is selected, the client
may lie in a supine position or sit
(4) If the deltoid is selected, the client may sit
or lie with arm relaxed
7. Select the injection site
To ensure the local muscle relax
●
Good visualization is necessary to establish
the correct location of the site and assess the
local condition
●Locate the site of choice correctly and ensure
that the area is not tender and is free of lumps
or nodules
●
8.Sterilize the site as routine. Allow it to dry
9.Injecting medication
(1) Hold dry sterile swab between the third and
fourth fingers of nondominant hand. Remove
the needle cap by pulling it straight off.
(2) Spread the skin at the site using thumb and
forefinger or nondominant hand
(3) Hold the syringe in a dart-like manner.
Quickly dart the needle into the tissue at a
90-degree angle in 2/3 length of needle shaft
Swab remains readily accessible when needle
is withdrawn
●
Taut tissue makes it easy for the needle to
enter the tissue and minimize discomfort
●Fix the hub with middle finger when holding
syringe
●Determine the depth of injection according to
the age and weight of client
●Once the needle is broken, the nurse should
ask the client keep the position, steady the local
tissue, take out the needle by using sterile
forceps or ask a surgical doctor for help
●A quick injection is less painful
●To reduce pain
●
(4) As soon as the needle is in place, move your
nondominant hand to hold the hub of the needle
and the syringe, slide your dominant hand to
the knob of the plunger
76
Steps
Rationale and Key Points
(5) Aspirate by slowly pulling back on the
plunger to determine whether the needle is in a
blood vessel. If blood is aspirated, discard the
needle, syringe, and medication, prepare a new
sterile set, and choose another site
(6) If no blood is aspirated, inject the solution
slowly. Observe the client’s responses
Discomfort and possibly a serious reaction
may occur if a medication for intramuscular use
is injected into a vein
●
Injecting slowly helps reduce discomfort
When injecting oily medication, firm hub to
prevent separation of hub from tip of syringe by
great force
● When
injecting suspension, shake the
medication first, and then, inject the medication
quickly to prevent sediment
●Slow removal of the needle pulls tissues and
may cause discomfort
● Massaging helps distribute the solution and
hastens its absorption by increasing blood flow
to the area
●
(7) Remove the needle quickly while applying a
swab gently over the site. Massage the injection
site with the sterile swab using gentle pressure
10.Check again
11.Assist the client to have a comfortable
position. Dispose of equipment. Wash hands.
Record the relevant data if necessary
Tenderness caused by long-term repeated
injecting at the same muscle site can be treated
by not compress or physiotherapy
●
Evaluation
1. Whether the nurse has carried out the principle of the three checks and seven rights and the
principle of sterilization. Observe whether there is bleeding, infiltration, or discomfort in the
injection site, assess mobility of limbs
2.The client’s systemic reactions to the medications
3.The client’s knowledge and skills about medication and methods of administration
77
Skill 12-6 Administering an Intravenous Injection
Purposes
1. To inject medication which are not suitable for other routes
2.To get desired effect rapidly, especially for the client with critical illness
3.To use for diagnosis test, for example, X-ray examinations of liver, kidney, or gallbladder
4.To get blood sampling
Equipment
Medical tray
●
Antiseptic solution
(Povidone-iodine)
● Medication
● Medication card
●Sterile swab
● Sterile tweezers and vat
● a syringe based on the volume
of medication, 6- to 9-gauge
needle
File and vial opener
●Container of speicimen
●Tourniquet
●Small pad
● Contamination container
●Gloves (if necessary)
●Sterile dressing (if necessary)
●
●
Procedures and Key Points
Steps
Rationale and Key Points
Peripheral intravenous injection
Steps 1 to 4 are the same as described in 12-3
5.Select an appropriate site and palpate
accessible veins
6.Dilate the vein
(1) Apply tourniquet approximately 6cm above
site chosen. Direct the ends of the tourniquet
away from the site of entry. Check to be sure
that radial pulse is still present
(2) If using arm, have client clench the hand.
Palpate vein. If a vein cannot be felt, release the
tourniquet and have the client lower his arm
below the level of the heart to fill the veins.
Reapply tourniquet and gently tap over the
intended vein to help it distend or remove
tourniquet and place warm compresses over the
intended vein for 10 to 15 minutes
Shave the needle insertion area if too hairy
●
Interrupting the blood flow to the heart causes
the vein to distend. Interruption of the arterial
flow will impede venous filling
●The end of the tourniquet directed away could
prevent contamination of the injection area
●
78
Steps
Rationale and Key Points
7. Sterilize the site as routine. Permit the
solution to dry. Reuse tourniquet.
8. Injecting medication or collecting blood
specimen
(1) Check again, eject air in syringe
(2) Place the nondominant hand about 5cm
below the entry point. Hold the skin taut against
the vein
(3) Hold syringe in the dominant hand. The
needle, with the bevel side up, is directed to
proximal limb. Enter the skin gently at a 15- to
30-degree angle in upper to side of vein, and
when the needle is through the skin. Lower the
needle until it is nearly parallel to the skin,
while following the course of the vein, advance
the needle into the vein.
(4) When blood returns, it indicates that the
needle is inserted into the vein. Decrease needle
angle and prepare to thread needle
approximately from 0.5 to 1cm into vein
(5) Release the tourniquet and unclench the
hand
Nurses should be cautious not to contaminate
the aseptic area
●
To anchor the vein by placing thumb over vein
and stretching skin against direction of
insertion 5cm distal to site
●A sensation of “give” can be felt when the
needle enters the vein
●Inserting angle should not be larger in order to
avoid piercing through vein. Once infiltration
appears, remove needle immediately, and press
the site with sterile swab. Change site to insert
again
●
Because pressure is greater in the vein than in
the needle, blood will flow into the needle
when the vein is entered
●
When collecting blood specimen, the
tourniquet will not be released until the needed
volume of specimen is collected
●When injecting irritating medication, normal
saline should be used to inject at first to test the
needle is in the vein. Then change the syringe
with medication for injection to prevent
medication irritating tissue once the insertion
fails
● Control the speed of injection according to
age of client and nature of medication
●Maintain pressure to aid in hemostasis
●
(6) Inject medication slowly or collect blood
specimen. Observe responses of the client
(7) Remove needle quickly and apply gentle
pressure over the site with a sterile swab
immediately for 2 to 3 minutes
(8) Once bleeding has stopped, apply a sterile
adhesive dressing. Ask client crook the arm
9. Check again. Assist the client to a
comfortable position. Dispose of equipment.
Wash hands. Record the administration of the
medication if necessary
Femoral intravenous injection
Step 1 to 5 are the same as peripheral
intravenous injection described above
Using sterile dressing
contamination of injecting site
●
79
can
prevent
Steps
Rationale and Key Points
6.Help the client a supine position. Straight legs
and abduct slightly
7.Touch the most distinct pump of femoral
artery in femoral triangle area or select the
middle point of line between superior anterior
and public tubercle for injection. Then mark the
site
8. Sterile the area of injection
9. Sterilize the index finger and third finger of
the manipulator’s nondominant hand
10.Injection
(1) Check again
(2) Palpate the clearest pump of femoral artery
by using index figure of nondominant and
steady it there
(3) Hold the syringe by the dominant band and
insert the needle into the femoral vein at 0.5cm
of its medial side in a 90-degree angle or
45-degree angle
(4) If there is dull red blood aspirated into the
barrel, it indicates the needle is inserted into the
vein
To expose the site of injection completely
●
Palpating the femoral artery pump to locate
the site of injection
●
Controlling the depth of insertion to avoid
transfixing through vein
●
The nurse should pay attention to the color of
blood. If the color is bright red, it indicates that
the needle insert into the artery. Withdraw the
needle immediately. Press the site with sterile
gauze for 5 to 10 minutes until no bleeding
●
(5) Steady the syringe by the dominant hand.
Inject the medications or collect blood sample
by pulling the plunger of syringe
(6) Withdraw the needle quickly while applying
sterile swab or gauze gently over the site and
press 3 to 5 minutes to stop bleeding
(7) Once the bleeding has been stopped, apply a
sterile adhesive dressing
11. Check again. Assist the client to a
comfortable position. Dispose of equipment.
Wash hands. Record the relevant information
Withdrawing needle quickly can decrease the
client’s discomfort
● Pressing local site to prevent bleeding or
hematoma
●Protect the site of injection from infection
●
Evaluation
1. Whether the nurse has followed the principle of the three checks and seven rights and the
principle of sterilization. Observe whether there is bleeding, seepage, or discomfort of the
80
injection site, and access the mobility of limbs.
2.The client’s systemic reactions to the medications
3. The client’s knowledge and skills about medication and methods of administration
Skill 12-7 Arterial Injection and Blood Sampling
Purposes
1. To get arterial blood sample
2. To prepare for some special test, for example, cerebral angiography
3. To give some medications for treatment
4. To make arterial blood transfusion
Equipment
Medical tray
● Antiseptic solution
● Medication
● Medication card
●Sterile swab
●Sterile gauze
●Adhesive plaster
●Medical tissue
●Sterile glove (if necessary)
● Sterile tweezers and vat
a syringe based on the volume
of medication, 6- to 9-gauge
needle
●File and vial opener
●Container for blood specimens
●Sterile cork
●Tourniquet
●Alcohol lighter (if necessary)
●Small pad
●Sandbag
● Contamination container
●Gloves
●Sterile dressing (if necessary)
●
●
Procedures and Key Points
81
Steps
1. Wash hands and wear mask, check and
prepare the medication according to the
physician’s order
2. Take the equipment to the bedside of the
client. Identify the client. Explain the
procedure to the client
3. Provide privacy
4. Have the client assume a position
appropriate for the site selected
(1) For carotid artery, the client lies on
back, and turn head to the opposite side of
injection slightly
(2) For radial artery, the client lies on
back, and stretch and relax the arm with
the inner side upward
(3) For femoral artery, the client lies on
back, flex and abduct the knees, expose
the inguinal region
5. Sterilize the injection site. The area
sterilized should be at least 5cm in
diameter with the injection site as its
center. Allow it to dry
6. Applying disposable gloves or sterilize
the manipulator’s index finger and the
middle finger of non-dominant hand
7. Inject medication or collect blood
sample
(1) Check again
(2) Palpate the pump of artery and place
the most clear pump site between two
fingers
(3) Hold the syringe by dominant hand and
insert the needle into artery at the most
clear pump site in a 90-degree angle or
40-degree angle
(4) If there are bright red blood aspirated
into the barrel, it indicates the needle is
inserted into the artery
(5) Steady the syringe by the dominant
hand. Inject the medications or collect
blood sample by the non-dominant hand
Rationale and Key Points
● Follow sterile principles strictly
● To ensure correct medication administration
●
To encourage cooperation and reduces anxiety
The appropriate positions make it easy to access to
the artery
●
Follow sterile principles to prevent infection
The diameter of cleaning area should be larger
than 5cm
●
●
Pump of vessel indicates that the palpated vessel is
artery
● The nurse should pay attention to the depth and the
angle of insertion when inserting into the artery to
avoid transfixing the artery and bleeding. Once
bleeding, withdraw the needle immediately and
press the site with sterile gauze to stop bleeding.
● If the color is dull red, it indicates that the needle
is inserted into the vein. Once bleeding, withdraw
the needle immediately and press the site with sterile
gauze until bleeding stops. Change the equipment
and injection site, restart the insertion process
● Steadying the syringe is to prevent from damaging
the artery.
● Before collecting blood sample, the nurse should
aspirate 0.5ml of heparin (1:500), and spread it
evenly on the inside wall of barrel, then eject
residual solution, to prevent blood agglutination
● The volume of blood specimen for ABGs is 0.5 to
1ml
●
82
Steps
(6) Withdraw the needle quickly while
applying sterile swab or gauze gently over
the site to press 5 to 10 minutes to stop
bleeding. If necessary, use sandbag to
press the site of injection
8.Check again
9.If blood sample is used for Arterial
Blood Gases (ABGs), as soon as the
needle is withdrawn, it should insert into a
sterile cork immediately. Roll the syringe
in palms.
10. Once bleeding has stopped, apply a
sterile adhesive dressing
11. Help the client have a comfortable
position. Dispose of equipment. Wash
hands or remove gloves. Record the
relevant information. Send blood sample
to laboratory as soon as possible
Rationale and Key Points
●
To prevent bleeding
Inserting the needle into sterile cork is to isolate
the blood from the air to prevent the mistake of test
result
● Rolling the syringe makes the blood confuse with
the antiagglutinin completely
● Don’t shake the syringe
● To prevent infection
● Instruct the client not to massage the injection site
or move the limb immediately
●
Evaluation
1. Whether the nurse has followed the principle of check and sterilization. Observe whether there
is bleeding, infiltration, or discomfort of the injection site, and access the mobility of limbs.
2. The client’s systemic reactions to the medications
3. The client’s knowledge and skills about medication and methods of administration
Skill 12-8 Administering Vaginal Instillations
Purposes
1. To treat or prevent vaginal infection
2. To reduce vaginal inflammation
3. To relieve vaginal inflammation
Indications
1. Clients with vaginal infection
2. Clients with vaginal discomfort, for example, itch or pain
Equipment
Vaginal medication
Applicators
● Disposable gloves
● Tissue
● Paper tower
Perineal pad
Screen
● Lubricants
● Bedpan
● MAR or computer
●
●
●
●
83
Procedures and Key Points
Steps
Rationale and Key Points
1. Follow check principles
To ensure safe and correct administration of
medication
● To reduce transfer of microorganisms
● To ensure that the correct client receives
medication
● To indicate the level of assistance needed
from nurse
●
2. Wash hands
3. Identify the client; ask the client to state her
name
4. Assess the client’s ability to use applicator or
suppository and to insert the medication by
himself
5. Explain techniques to the client, especially
for the client who wants to self-administer
medication
6. Arrange supplies for convenient use
7. Draw room curtain or close door
8. Ask the client to void
●
To promote understanding
To ensure smooth procedure
● To provide privacy
● If the bladder is empty, the client will have
less discomfort during the treatment, and the
possibility of injuring the vaginal lining is
decreased
● To provide easy access to and good exposure
of vaginal canal. Also allow suppository to
dissolve without escaping through orifice
● Provide warmth for the client
●
9. Help client to take a back-lying position with
the knees flexed and the hips rotated laterally
10.Spread a medical cloth under the buttock of
the client
11. Drape the client appropriately so that only
the perineal area is exposed
12.Apply disposable gloves
●
To minimize embarrassment
To prevent transmission of microorganism
between nurse and client
● Proper insertion requires visualization of
external genitalia
●
To reduce the chance of transfer of
microorganisms into the vagina
●
13. Be sure vaginal orifice is well illuminated
by room light or gooseneck lamp
14. Provide perineal care
15. Administer medication
Insert suppository
(1) Check again
(2) Remove suppository from foil wrapper and
lubricate the rounded end of the suppository
Lubrication reduces friction against mucosal
surfaces during insertion
●
84
Steps
Rationale and Key Points
(3) Lubricate gloved index finger of dominant
hand
(4) Expose the vaginal orifice by separating the
labia with nondominant hand
(5) Insert the rounded end of suppository along
the posterior wall of the vaginal canal about 5
to 8cm deep
(6) Withdraw the finger and wipe away the
remaining lubricant from a round orifice and
labia
Apply cream or foam
(1) Check the client and medication
(2) Fill cream or foam applicator following
package directions
(3) With the gloved nondominant hand, gently
retract labial folds
(4) Insert applicator approximately 5 to 8cm by
the dominant gloved hand
(5) Slowly push the plunger to deposit
medication into vagina until the applicator is
empty
(6) Withdraw applicator and place on the towel.
Wipe off the residual cream from labia or
vaginal orifice
(7) Discard the applicator if disposable or clean
it according to the manufacturer’s directions
16. Check again
17. Remove gloves by pulling them inside out
and discard in appropriate receptacle. Wash
hands
18.Ask client to remain on back for at least 10
minutes
19. Offer perineal pad to the client when she
resumes ambulation
To avoid inserting suppository into urethra
●
Proper placement ensures equal distribution of
medication along the wall of vaginal cavity
●To maintain comfort
●
To expose vaginal orifice
●
To allow even distribution of medication
along vaginal walls
●
Residual cream on applicator may contain
microorganisms
●
To reduce transmission of microorganism
●
It helps medication to be distributed and
absorbed
●To prevent vaginal discharge from spreading
to clothing and ensure client comfort
●To evaluate medication effects
●
20. Assess the client’s response, conditions of
vagina secretion and vulva
Evaluation
1. Relief of complaints
2. Amount, character, and odor of discharge
3. Appearance of vaginal orifice to compare to baseline data
4. Adverse reactions or side effects of medication
85
Skill 12-9 Administering Rectal Suppository
Purpose
1. To use for local actions, for example, to soften feces and alleviate constipation
2. To exert systemic effect, for example, to reduce fever or to relieve nausea and vomiting
Indications
1. Clients with constipation
2. Clients with infection in rectum
3. Clients with recent rectal surgery
Equipment
Rectal suppository
●Lubricants
●Disposable gloves
●
Medical cloth
●Screen
●MAR or computer printout
●
Procedures and Key Points
86
Steps
Rationale and Key Points
1.Follow three checks and seven rights
principles
2.Wash hands, wear mouth mask, and assemble
equipment
3.Take the equipment to the bedside of the
client
4.Identify the client
To ensure safe and correct administration of
medication
●
To ensure that the correct client receives
medication
●To promote understanding and cooperation
●
To maintain privacy and minimize
embarrassment
●Provide warmth for the client
●To prevent contamination with infected fecal
material
●To help the client relax external anal sphincter
●
5.Explain procedure to the client
6.Close room curtain or door, and provide
screen if necessary
7.Apply disposable gloves
8.Assist the client to a side-lying position with
Knees flexed. Keep client draped with only
anal area exposed
9.Spread a medial cloth under the buttock of the
client
10.Examine the condition of anus externally
and palpate rectal walls as needed. If gloves
become soiled, dispose of them by turning
inside out and placing in proper receptacle
11.Apply another pair of disposable gloves
12.Remove suppository from its wrapper and
lubricate its rounded end. Lubricate index
finger of dominant hand with a water-soluble
lubricant
13.Ask the client to take slow deep breaths
through mouth and relax anal sphincter
14.Retract buttocks with nondominant hand,
insert suppository gently through anus, past
internal sphincter and against rectal wall, 10cm
in adults, 5cm in children and infants. Gentle
pressure may be needed to apply to hold
buttocks together momentarily
15.Withdraw finger and wipe anal area with
tissue
16.Disacard gloves by turning them inside out,
and dispose of them in appropriate receptacle
17.Check again
18.Ask the client to remain flat or on side for 5
minutes
To determine presence of active rectal
bleeding. Palpation determines whether the
rectum is filled with feces, which may interfere
with suppository placement
●
Lubrication reduces friction as suppository
enters rectal canal
●
Forcing suppository through constricted
sphincter causes pain
● Suppository must be placed against rectal
mucosa for eventual absorption and therapeutic
action
●
To provide comfort
●
Ask the client to control over the urge to
defecate so as to prevent expulsion of
suppository
●
87
Steps
Rationale and Key Points
19.If suppository contains laxative or fecal
softener, place call light within reach
5 minutes
20.Return within 5 minutes to determine
whether the suppository was expelled
21.Observe effects of the suppository 30
minutes after administration
Call light allows client to obtain assistance to
bedpan or toilet
●
Reinsertion may be necessary
●
Evaluate effectiveness of the medication
●
Evaluation
1. Conditions of bowel elimination
2.Relief of symptoms
3.Adverse reactions or side effects of medication
Skill 12-10 Using Metered-Dose Inhalers
Purposes
To decrease resistance to airflow by using bronchodilators, expectorants and decongestants
Indications
Clients with chronic respiratory disease such as chronic asthma, emphysema, or bronchitis
Equipment
Facial tissues (optional)
●MAR or computer printout
●
MDI with medication canister
●Kidney tray
●
Procedures and Key Points
Steps
Rationale and Key Points
1.Follow three checks and seven rights
principle
2.Wash hands. Assemble equipment
3.Take the equipment to the bedside of client.
Check the client
4.Explain and demonstrate how to inhaler and
give the client opportunity to manipulate
inhaler. Explain what metered dose is, and warn
client about overuse of inhaler, including side
effects of medication
5. Medication administration
To ensure correct medication administration
●
Nurses should simplify the procedure, explain
in detail, and allow the client to ask questions at
any time in order to help the client know how
to use
●
88
Steps
Rationale and Key Points
No Aerochamber
(1) Remove mouthpiece cover from inhaler
(2) Shake inhaler well
(3) Have the client take a deep breath and
exhale
(4) Instruct the client to position the inhaler in
one of the two ways: ①open lips and place
inhaler in mouth with opening toward the back
of throat; ②position the device 2.5 to 5 cm
from the mouth
(5) Ask the client hold inhaler with thumb at the
mouthpiece and the index finger and middle
finger at the top, keep the inhaler in proper
position
(6) Teach the client to tilt his/her head back
slightly, inhale slowly and deeply through
his/her mouth, and depress medication canister
fully
(7) Hold breath for approximately 10 seconds
after every deep breath
(8) Exhale through pursed lips
With Areochamber
(1) Remove mouthpiece cover from MDI and
open mouthpiece of Aerochamber
(2) Insert MDI into the end of Aerochamber
To ensure fine particles are aerosolized
● Prepare the client’s airway to receive the
medication
●Directing aerosol spray toward airway
●Positioning the mouthpiece 2.5 to 5cm from
the mouth is considered as the best way to
deliver the medication
●
Medication is distributed to airways during
inhalation. Inhalation through mouth draws
medication more effectively into airways
●
Allow tiny drops of aerosol spray to reach
deeper branches of airways
●Keep small airways open during exhalation
●
Aerochamber is a spacer that traps medication
released from the MDI; the client then inhales
the drug from the device. These devices deposit
up to 80% of the medication in the lungs rather
than in the oropharynx
●To ensure fine particles be aerosolized
●Teach the client not to insert beyond the raised
edge of the mouthpiece. Avoid covering small
exhaltiomn slots with the lips to prevent
medication escapiing through mouth
● Allow
client to relax before delivering
medication
●Emit spray that allows finer particles to be
inhaled. Large droplets are retained in
areochamber
● To
ensure particles of medication are
distributed to deeper airways
●To ensure full medication distribution
●
(3) Shake inhaler well
(4)Place the mouthpiece of areochamber in
mouth and close lips
(5)Breathe normally through the aerochamber’s
mouthpiece
(6)Depress the medication canister, spraying
one puff into areochamber
(7)Breathe in slowly and fully for 5 seconds
(8)Hold breath for 5 to 10 seconds
89
Steps
Rationale and Key Points
6. Instruct client to wait 2 to 5 minutes between
inhalations or as ordered by physician
Medication must be inhaled sequentlyially.
First inhalation opens airways and reduces
inflammation. Second or third inhalation
penetrates deeper airways
● Accumulation of spray around mouthpiece
can interfere with proper distribution during use
●To evaluate the effects of medication
●
7.After
medication
inhalation,
remove
medication canister and clean inhaler in warm
water
8.Assess client’s respirations and auscultate
lungs
Evaluation
1. Conditions of breathing
2. Relief of symptoms
3. Adverse reactions or side effects of medication
4. Client’s knowledge about medication and skill of inhalation
90