Exam 3 Study Guide PDF

Chapter 33: Pharmacology and Preparation for Drug Administration. Check for safety alerts. What to check before medication administration. ○ Safety Alerts Appropriate form of the drug (p. 638) You must administer the appropriate form of each d...

Chapter 33: Pharmacology and Preparation for Drug Administration. Check for safety alerts. What to check before medication administration. ○ Safety Alerts Appropriate form of the drug (p. 638) You must administer the appropriate form of each drug. For example, if the prescriber orders two 325 mg tablets of acetaminophen, you cannot substitute the liquid form without a change in the order. Look-alike, sound-alike drugs (p. 643) Look-alike drugs and packaging and sound-alike names increase the likelihood of mistakenly giving the wrong medication. The Institute for Safe Medication Practices (ISMP) recommends that institutions minimize their stock of these types of drugs. If you identify this problem on your unit, notify the unit manager. Patient identifiers (p. 648) In accordance with National Patient Safety Goals, at least two patient identifiers must be used to ensure that the medication is administered to the correct patient. Say to the patient, “State your name for me, please.” (Do not call the patient by name; some patients who do not hear well will say “yes”; confused patients may answer to any name.) Look at the patient’s identification wristband or number. Some facilities may also require validation of the birth date. Safety alert (p. 653) Some electronic medication administration record (eMAR) fields change to a red color when a medication administration goes beyond the 30 minute window. Do not let the fear of the color change hurry you into making a medication error! It is better to give the correct dose of a medication 5 minutes late than an incorrect dose on time. Watch that decimal point (p. 654) A common dosage error is a mistaken decimal point or a floating zero. For example, the primary care provider writes “0.30 mL of medication.” One nurse says use 3/100 mL, one nurse says use 3/10 mL, one nurse says use 3 mL, and one nurse says 30 mL. Who is correct? Where is the error? Another provider writes “5.0 mg of medication.” One nurse says use 5 mg and another nurse says 50 mg. Who is correct? Where is the error? Inattentional blindness (p. 655) Mental fatigue or overload may contribute to failure to attend to the obvious and result in “inattentional blindness,” the phenomenon of seeing what we expect to see. This sometimes happens when medication labels for different concentrations of the same  medication have similar packaging, and numerous medication errors have been committed because of this. Reducing distractions and placing more focused attention on the task at hand can help combat inattentional blindness. This helps explain why the “no interruption” wear and zone described earlier are critically important when preparing and administering medications. ○ What to check before administering medications Factors affecting drug action (p. 640) The lower the patient body weight, the more concentrated the drug will be in the tissues and, consequently, the more powerful the effect. Most drugs cross the placental barrier and affect the fetus. When liver function is decreased because of disease or aging, a drug may be eliminated more slowly than usual, resulting in an accumulation of the drug that could lead to toxic levels. Adequate fluid intake (50 mL/kg/day) is essential for the patient to eliminate drugs properly. ○ Drug response and pharmacodynamics (p. 641) The length of time the drug exerts a pharmacologic effect is the duration of action. If you know how a drug works, you can usually figure out what its side effects will be. The possibility of adverse drug effects, side effects, allergic reactions, and undesirable interactions with other drugs and foods increase with the number of drugs administered. ○ “Black box” warnings (p. 642) A black box warning is the strongest warning by the FDA that a medication can carry and still remain on the market in the US. The prescription medication must have a warning in a “black box” to alert the patient and health care provider about important safety concerns, such as serious side effects or life-threatening risks. ○ Medication administration and safety (p. 642) You must analyze the order and determine whether the drug, the dose, and the timing of the drug are appropriate for the patient. ○ Considerations for infants and children (p. 643) Doses are based on the child’s age and body weight and are not given in a standardized amount. Check with the child’s parents for the most effective, least traumatic way to give the child a medication. High alerts- Crushing meds, enteric coated ○ Give the right drug by the right route (p. 653)  Look for how the drug is supplied to determine the safety of crushing. For example, sublingual, buccal, enteric-coated, and extended-release products and products with carcinogenic potential should not be crushed. Enteric coated is a tablet with a coating that does not dissolve until it is in the intestine DO NOT CRUSH It can irritate the stomach lining, reduce/eliminate effectiveness of medication Clinical cues and nursing considerations. ○ Dialysis and Medications (p. 640) When your patient is on hemodialysis, many mediations are “dialyzed out” of the system during dialysis and rendered ineffective for the patient. Always check the primary care provider’s preference if a medication should be held or delayed until after dialysis. ○ QSEN Considerations: Alert UAP about possible medication side effects (p. 641) When your patient is taking a medication that may cause secondary effects such as dizziness, inform UAP that the patient may need assistance with ambulation or hygiene. ○ Clinical Cues (p. 642) A patient may be using over-the-counter (OTC) medications, herbal remedies, or illicit substances. He may not report these because “they are not drugs from a doctor.” However, these substances can cause drug-drug interactions. Therefore, question your patients specifically about OTC drugs, herbals, and illicit substances, in a nonjudgmental manner, when taking a drug history. ○ Clinical Cues (p. 643) When giving medication to young children, do not say that the medication is like “candy”; simply say that it will help them get well. After the medication has been given, praise the child and offer a simple reward such as a sticker. ○ Clinical Cues (p. 646) When assessing swallowing ability, put the patient in a high Fowler position. Ask them to swallow as you observe throat movements and their ability to follow instructions. Gently place your thumb and finger over the larynx and ask the patient to swallow again as you feel the swallow movement. Next, try giving the patient 1 teaspoon of water and observe as they swallow. ○ Clinical Cues (p. 648) Get in the habit of asking about allergies to medication every time you give a drug, even if you have already asked the patient about allergies earlier in the day. Later in your career, this habit will be in place when you are caring for multiple patients at a very fast pace.  Make an effort to develop a strong professional relationship with the pharmacist and memorize their telephone number. Pharmacists provide a wealth of clinical information, including drug interactions and compatibilities. When you are at the bedside doing your third and final medication check, ask the patient if they have noticed any ill effects that might be associated with taking the medications—for example, “Sir, this is your antibiotic medication. Does this medication seem to be causing any problems for you?” (e.g., diarrhea, nausea). This is one method of assessing the patient’s subjective response to the medication. Of course, you are also responsible for evaluating relevant laboratory values and observing for effects that the patient may not associate with the medication. ○ Clinical Cues (p. 654) Always double-check if the patient tells you the pill looks different or makes any other comment that causes doubt that the medication is correct. A medication order can be written in the wrong medical record, or you might have made an error when preparing the medication. The prudent nurse will ask another nurse to check the prepared doses of certain drugs before administering them. All insulin is always double-checked in this manner; anticoagulants, injectable digoxin, and other drugs that have a potentially toxic or lethal effect on the patient are double-checked. Many agencies have a list of drugs that require a check by two different nurses before the drug is given. Considerations for the older adult ○ May have chronic medical conditions, or metabolism of drugs may be slowed ○ May be on long-term antiinflammatory drugs for arthritis or may have difficulty swallowing ○ May need a pill organizer to help remember to take pills ○ More likely to have blood pressure fluctuation ○ May become more quickly dehydrated ○ May have decreased kidney function ○ May have limited financial resources ○ May have limited vision ○ May have had a previous stroke ○ May not be able to open childproof bottles ○ May be noncompliant CONSIDERATIONS FOR HOME CARE ○ Be certain that the patient or caregiver can open the medication bottles or dispenser ○ A pill organizer may be needed ○ Written instructions should be left for the patient ○ Verify that patient can obtain needed medications ○ If caregiver is to administer medications, thorough teaching must be performed  Controlled drugs ○ The licensed nurse is responsible for the security of these medications (narcotics) and must account for each dose that is used. (p. 638) ○ Schedule 1 (I): Drugs with no currently accepted medical use in the US, a high potential abuse, and lacking accepted safety measures. Examples: heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), methaqualone, peyote, and 3,4-methylenedioxymethamphetamine (“Ecstasy”) ○ Schedule 2 (II): Drugs with medical use but a high potential for abuse and severe psychological or physical dependence. Examples: cocaine, hydromorphone, methadone, meperidine, oxycodone, fentanyl, codeine, hydrocodone, amphetamine/dextroamphetamine (Adderall), and methylphenidate (Ritalin) ○ Schedule 3 (III): Drugs that are medically useful but with less potential for abuse than the Schedule II drugs, their abuse leading to moderate or low physical and psychological dependence. Examples: butabarbital, acetaminophen with codeine, buprenorphine, ketamine, and testosterone ○ Schedule 4 (IV): Drugs that are medically useful but with less potential for abuse than the Schedule III drugs, their abuse causing limited physical or psychological dependence. Examples: tranquilizers such as chlordiazepoxide, diazepam, temazepam, zolpidem, and tramadol ○ Schedule 5 (V): Drugs with medical use, low potential for abuse, and that produce less physical dependence than the Schedule IV drugs, and cough preparations containing not more than 200 mg of codeine per 100 mL or per 100 g. Examples: mixtures with small amounts of narcotics (e.g., cough syrup containing codeine, such as Phenergan with Codeine; atropine/diphenoxylate [Lomotil]) Classification of drugs NSAID’s-Aspirin ○ Non-narcotics (nonopioids) Action: Relieve mild pain Examples: aspirin, acetaminophen (Tylenol) ○ NSAIDs Action: Reduce inflammation and pain Examples: ibuprofen, naproxen, sulindac ○ Aspirin Relieve mild pain  Antidiuretic, anti inflammatory, anti clotting, analgesic, antipyuretic (reduce fever) Safety guidelines to prevent medication errors Six rights, 3 checks, verifying orders ○ Chapter 34: Administering Oral, Topical, and Inhalant Medications. Lifespan considerations ○ Older Adults 1. Assess your patient’s manual dexterity (ability to use hands). A patients seems shaky or has trouble with fine motor movements, take a clean towel and spread it across their chest before handing over the pills or tablets. If the pt (or you) drops the pill on the clean towel, it can be retrieved, but if the pill falls on the floor or dirty linens, you will have to obtain a new pill from the pharmacy. 2. Overtime, the older adult will experience an increasing number of ailments and illnesses. Older adults frequently receive prescriptions from more than one provider, especially if they are being treated for chronic conditions 3. Older adults (or psychiatric pts) sometimes hold oral medication in the buccal (inner cheek) area rather than swallowing it; check the mouth to be certain that the medication has been swallowed; if in doubt. 4. For older adults with visual acuity deficits, make a chart using large, dark letters on white background. Include the drug’s name, dose, time, and purpose. If the pt cannot read, tape a sample pill to the chart 5. If an older adult patient has difficulty swallowing a pill, instruct them to take a sip of water and swallow it; then place the pill toward the back of the tongue. Have the pt take a large sip of water, place the tongue on top of the roof of the mouth, and with the chin tilted slightly downward, swallow; follow with more water. Consider crushing or cutting the pill unless contraindicated, or ask the provider for a liquid form of the drug. 6. Older adults who see more than one provider sometimes have the same drug prescription with two different brand name drugs. They then end up taking twice as much of the drug as they should be talking and suffer adverse effects or toxicity. Be sure to complete the recommended steps of medication reconciliation. Oral syringes for safety alert ○ Small amounts (less than 30 mL) of oral medications can be measured with a syringe. To increase safety, use an oral syringe to prevent accidental intramuscular (IM), intraveneous (IV), or subcutaneous administration of oral medication. If the facility does not carry oral syringe, discuss this with the charge nurse because errors occur when nurses are forced to use “what’s available”. Skill 34:2 Instilling otic/ophtalmic medications (eye drop, eye ointment)  ○ Preparation of oral controlled substances ○ A controlled dispensing system is used for distributing opiate analgesics and hypnotics ○ Legally controlled substances must be under lock and key ○ Automated controlled substance dispensing machines are often used in the clinical setting to monitor and control narcotic use  ○ When not in a dispensing machine, drugs are supplied in a controlled dispenser or a commercially prepared package Patient education: Metered -Dose Inhaler & table 34:5 Inhalant drugs Patient Education ○ How to Use a Metered-Dose Inhaler With a Spacer When a patient is taking both a corticosteroid and a bron-chodilator, teach them to take the bronchodilator first to open the airways so that the corticosteroid has greater surface area for absorption. Using a spacer with the metered-dose inhaler (MDI) is the preferred method (Vincken et al., 2018). Instruct the patient to use the following steps: Always sit or stand to use the MDI. Attach the medication canister by holding the long end of the mouthpiece and inserting the stemmed top of the canister into it. Shake the canister for 5 seconds to mix medication with propellant, and remove the mouthpiece cap. Insert the MDI into the open end of the spacer (opposite the mouthpiece). Place the mouthpiece of the chamber in the mouth between the teeth and seal the lips around it. Completely exhale from the nose. Depress the canister once to release the medication into the spacer. Breathe in slowly. If you hear a "horn-like" sound while inhaling, slow down your inhalation. After inhalation, hold the breath for 10 seconds and try not to cough. This allows the medication to penetrate the lung mucosa Exhale through the nose and take two or three short breaths to obtain the remaining medication in the spacer. If a second puff is ordered, wait at least 1 minute before repeating the procedure. This allows the first dose to be fully absorbed before the second is given. If using an MDI without a spacer, two possible techniques can be used: 1. “Open mouth" technique: With the bottom of the canister pointing up, place the mouthpiece 1 to 2 inches (2.5 to 5 cm) in front of the mouth. 2. "Closed mouth" technique: Place the mouthpiece directly into your mouth and firmly close the teeth and lips around it. 3. With both the "open mouth" and the "closed mouth" techniques, while starting to inhale, depress the canister to release the medication. Keep inhaling slowly until a full breath is taken; hold the breath for 10 seconds to promote absorption of the medication.  Table 34.5: Inhalant drugs for respiratory problems Drug Example Beta-agonist drugs (stimulants) that open the Metaprotenol, albuterol, terbutaline, small airways levalbuterol Anticholinergics used to decrease Atropine ipratroprium bronchospasm and open the large airways Corticosteroids used to decrease inflmmation Beclomethasone, triamcinolone, flunisolide Leukotriene modifiers for maintenance Montelukast therapy of chronic asthma Antiallergic medications used to decrease Cromolyn sodium mucosal response to allergens Chapter 35: Administering Intradermal, Subcutaneous, and Intramuscular Injections. Routes for parenteral medications & Table 35:2 ○ Intradermal Route Deposits small amounts of drug solution in the dermal layer, for skin testing (tuberculin testing- on inner surface of the foreman) Needle gauge: fine 25-, 27-, or 29- gauge (scale of measurement) Angle: 5- to 15- degree angle of insertion Creates a pool of medication under the thin layer of skin that forms a bleb ○ Subcutaneous Route Injecting medications into the tissues below the dermal of the skin, usually in the upper portion of the upper outer arm, the anterior surface of the thigh, or the abdomen where there are no major vessels or nerves. Small amounts of solution (0.05 to 1.0 mL in volume; see agency policy) are injected subcutaneously with either a tuberculin or a 3 mL syringe. Needle gauges: 27-gauge, 3/8- to ½- inch or a 25 gauge, 5/8-inch needle is used Insertion angle: 45 or 90 degrees, depending on needle length and the patient’s size. Absorption time: slower than with an IM injection because of the lack of blood vessels in this area compared to muscle. Used for medications that require slow absorption for sustained action. ○ Intramuscular Route Injected in the muscular layer. Absorption time: varies, but faster than Sub-Q; aqueous solutions are absorbed more rapidly than those in an oil suspension are. The most frequently used IM sites are the deltoid, ventrogluteal, vastus lateralis, and rectus femoris of the thigh. Insertion angle: 90 degrees, and depending on the patient’s size, a needle from 1 to 3 inches in length is used.  Injection routes and angles. Syringe and needle selection. ○ Intradermal route (ID) Site: Dermal layer of skin (For example: Tuberculin on the inner surface of the forearm) Angle: 5 to 15 degrees ○ Subcutaneous route (Sub-Q) Site: Below dermal layer of skin; upper portion of the upper outer arm, the anterior surface of the thigh, the abdomen where there are no major vessels or nerves (away from the navel) Angle: 45 to 90 degrees ○ Intramuscular route (IM) Site: Muscle layer; deltoid, ventrogluteal, vastus lateralis (children), and rectus femoris of the thigh Angle: 90 degrees ○ Syringe and needle selection (p. 692) ○ The first step is to select the appropriate size and type of needle and syringe for the medication to be given and for the patient’s age and size. ○ For giving IM injections, the 3-mL syringe and a 22-gauge, 1 ½ inch needle are generally used. ○ A tuberculin or 3-mL syringe and a 27-gauge, 3/8 to ½ inch or a 25-gauge, 5/8 inch needle are used to give a subcutaneous injection. Gauge and length  ○ The larger the number of the gauge, the smaller the needle (diameter or bore). ○ Because an ID injection goes under the epidermis (the outer layer of the skin), a 25, 27, or 29 gauge needle works best. ○ The 25 gauge needle is strong enough to puncture the skin and reach below the dermis for subcutaneous injections. ○ Heavier-duty 20, 21, 22, and 23 gauge needles are needed to penetrate the large muscle layers when IM injections are given in those sites. ○ Most often 1 or 1 ½ inch needles are used for parenteral injections. ○ Adult IM injections frequently use 22 and 23 gauge needles, although 20 and 21 gauge needles are preferred for viscous (thick and sticky) solutions or medications in oil suspensions. High alerts medication administration.Mixing insulins/Rotating injections ○ High alerts medication administration When you are giving insulin, heparin, injectable heart medications, or parenteral chemotherapy drugs to a patient, always have another nurse independently double-check for correct medication and correct dose. Show the other nurse the medication vial and ask them to read the amount in the syringe. ○ Mixing insulins (Steps 35.4 – p. 696-697) Use an insulin syringe calibrated in units. Insert the needle into the first vial with the long-acting insulin (cloudy) with air then the short-acting (clear) insulin. Draw short-acting (clear) insulin first then long-acting (cloudy) insulin last. Recap the needle, using the scoop technique if not with the patient. ○ Rotating injections It is best to rotate injection sites, especially with insulin, to promote the best absorption of the medication and to decrease tissue irritation or lipohypertrophy (formation of fatty lumps under the skin caused by insulin injections) Skill 35.1 Intradermal injections. Planning & Implementation (TB) ○ Planning Determine when 48 to 72 hours after the injection will occur (or the proper time for reading the result and whether someone will be available to read the result. Verify that needed supplies are on hand Plan the site at which to place the injection, usually on the inside of the forearm. Select a relatively hairless site. ○ Implementation Check the medication against the MAR or eMAR, following the Six Rights of medication administration. FIRST CHECK to prevent medication errors Perform hand hygiene and draw up the medication. Perform SECOND CHECK per the six rights this time.  Clean the preparation area and take the injection and the MAR or workstation on wheels (WOW) to the patient. Identify the patient by checking the identification band with the MAR. Ask patient to state name and DOB. Perform THIRD CHECK of the medication with the MAR Have the pt extend the elbow and support the forearm. Cleanse the site well with an antiseptic swab using firm, gentle circular motions, or use soap and water. Clean area approximately 2 inches in diameter. Allow the skin to dry. Hold the syring vertically and verify that the exact dose is present in the syringe. Don gloves; stand or sit in front of the pt and turn the pt’s forearm upward, facing you. With the index finger and thumb, pull the skinn taut at the selected site on the forearm. Insert the needle bevel up, at a 5- to 15- degree angle for approximately ⅛ inch (3 mm). You should be able to see the outline of the point of the needle. If you are in the dermis, you will feel resistance of the needle; if you can move the needle freely, you are in the subcutaneous tissue and you must start over. Lift the needle’s point slightly and inject the solution slowly; a bleb, or bump, of 6 to 10 mm in diameter should form Carefully withdraw the needle and activate the safety guard over the used needle; do not recap. Wipe the skin very gently with the antiseptic swab after you remove the needle; DO NOT APPLY PRESSURE. Drop the needle and syring in the sharps container. Remove gloves; perform hand hygiene. Circle the injection site with a skin pencil. (Facilitates in locating the site when it is time to read the reaction.) Box 35.2 Reading the Tuberculin Skin Test Results ○ Locate the injection site indicated on the patient record and marked with a skin pencil. Inspect the injection site under a good light, noting any erythema. Palpate the margin of the induration. With a millimeter ruler, measure the transverse diameter of the indurated area across the point at which the needle entered. The reading is recorded in millimeters of induration (quality of being hard). Induration, not erythema, is the key to the positive reaction. The result is read between 48 and 72 hours after injection. ○ POSITIVE REACTION The test is positive when the swelling at the site of injection is more than 5 mm in diameter in people who have a history of contact with infectious tuberculosis or in immunocompromised patients. Induration of more than 10 mm in diameter is positive in recent immigrants from countries where tuberculosis is prev-alent, in medically underserved groups, and in the homeless. For those people at low risk, induration of more than 15 mm is considered positive (deWit, Stromberg, & Dalled, 2017).  NEGATIVE REACTION ○ The induration measures less than 5 mm. Subcutaneous injections/Special Considerations/Safety Alert Box ○ The needle angle used depends on the length of the needle and the amount of subcutaneous tissue at the site. If 2 inches (5 cm) of tissue can be grasped, insert the needle at a 90 degree angle; if only 1 inch of tissue can be grasped, use a 45 degree angle for the injection. ○ Allergy injection sites should be rotated from one side of the body to the other. ○ Heparin injections are given in the abdomen on both sides of and below the umbilicus from the lower costal margins to the iliac crests. Wait at least 15 minutes to 30 seconds before removing the needle from the injection site. ▪ If bruising occurs after a heparin injection, ice the area chosen for the next injection. ○ Keep a record of where each insulin injection is given. Insulin is absorbed more quickly and uniformly when injected into the abdominal sites. 35.3 Subcutaneous Administration of Heparin ○ When heparin is administered subcutaneously. it requires additional precautions during administration. Because of its anticoagulant properties, it can stimulate bleeding into the tissues. Always have another nurse double-check your syringe for the correct amount and the vial for the correct strength and dose. Sites on the abdomen from below the costal margins to the iliac crests are used because this area is not involved in muscular activity, whereas the arms and legs are. Sites should be rotated within the abdominal area, alternating from one side to another; avoid giving a subsequent injection too close to a previous one. Do not massage the site after the drug has been iniected because this may cause bruising of the tissue, bleeding, and severe ecchymosis (purplish area under the skin caused by bleeding). Patient education-Injection disposal ○ Home Care Considerations (p. 698) In the home care setting, the patient may be self-administering heparin or insulin injections. Regulations for sharps disposal from home vary according to state and local jurisdiction, so it is important to know the local laws. Some counties require home “sharps containers” to be rigid and no larger than 2 L. Most communities offer drop boxes outside of hospitals or pharmacies for used sharps. ○ Patient Education – Injection, Disposal, and Storage (Insulin Pen) (p. 704) Replace the outer needle shield. Unscrew the capped needle and appropriately dispose of it as instructed. (Used needles are a biohazard) Discard the pen 28 days after initial use, even if there is insulin remaining.  ○ Home Care Considerations (p. 704) Be certain that used syringes and needles are being disposed of safely. Remind patients and families that reusing needles is not recommended even in home settings because of the risk of infection and increased pain, bleeding, or even breakage of reused needles. Intramuscular injections-Special considerations/Clinical cues ○ Improper site selection can result in damaged nerves, abscesses, necrosis, sloughing of skin, and pain. ○ If more than 3 mL of medication must be given at one time to an adult, the dose should be divided in half and given in two different large muscle sites. ○ The dorsogluteal site is no longer recommended as an IM injection site because of the high potential for injury to the sciatic nerve and the blood vessels. ○ The ventrogluteal area is the preferred IM injection site. The site can be used for both adults and children and is especially helpful if patients are only able to lie on their back or turn to one side or the other. The center of the “V” bounded by the index and middle fingers is the precise injection site to be used. ○ Special Considerations (p. 707) Many older adults have muscle wasting (atrophy). A shorter needle may be necessary. The vastus lateralis and ventrogluteal sites are the preferred sites in older adults. Apply pressure to the injection site in the older adult for longer than for a younger person, to prevent bleeding and hematoma formation. Clotting time is often decreased in adults. When the patient is receiving a series of injections, check the former sites for induration at the time of choosing a site for the next injection. If a medication causes excessive discomfort when injected, place ice over the site for 3 to 5 minutes before injecting. ○ Clinical Cues (p. 707) One milliliter of medication can be safely injected into the mid-deltoid sites for adults. Check agency policy before injecting a larger amount. The ventrogluteal area is considered the safest intramuscular injection site in adults to avoid damage to nerves or blood vessels. However, rather than leaving your hand in the “V” position, after identifying the correct injection site, place an alcohol swab on the patient’s skin to mark the site (e.g., develop a routine of always placing an alcohol swab directly adjacent to the injection site, “pointing” toward it). This is especially important if you suspect that the patient might move during the procedure (e.g., if the patient is confused or unable to follow instructions). ○ Clinical Cues (p. 708) Intramuscular (IM) injections are less painful when the muscle is relaxed. Because the gluteal muscles are tense when the hip is extended or the  leg is externally rotated, ask the patient to lie in a prone position with the toes turned inward or to lie in the Sims position. ○ Clinical Cues (p. 709) The vastus lateralis is the site of choice for infants younger than 12 months through 2 years of age. For children older than 13 months of age, you can also use the deltoid muscles if it is developed. Playacting is a helpful way of explaining procedures to children in the preschoolage group. You can demonstrate the entire procedure on a doll, indicating the reasons for the injection and the way the doll responds to it, so that the child has an idea of what will happen and how to behave. Give the child an opportunity to look at or handle empty vials or syringes. Explain that the medicine will help them get well and that then they will be able to play. ○ When giving a deltoid injection to a child, give the injection in the thickest part of the muscle; the needle should point at a slight angle toward the shoulder. Ways to decrease injection discomfort Box 35.4 ○ For a child, EMLA cream a mixture of lidocaine and prilocaine, available by prescription) can be applied to the site where the injection wil be administered to numb the area. The cream is applied 1 hour before injection time. ○ Apply an ice pack for 3 to 5 minutes to numb the skin. ○ Use the smallest gauge needle that is appropriate. ○ Select a site without signs of infammation, lesions, or bony prominences and without large underlying vessels or nerves. ○ Ask the patient to assume a prone position with the feet turned inward, or the Sims position, to relax the muscles. ○ Press down with your thumb over the injection site for 10 seconds to numb it. ○ When using alcohol to clean the area, allow it to dry before inserting the needle, to decrease the stinging sensation. ○ Ask the patient to deep breathe and try to relax. ○ Use the Z-track method for all irritating medications. ○ Instruct the patient to look away while the injection is given. ○ Insert the needle smoothly and remove it quickly while applying pressure to the skin. ○ Inject the medication slowly and steadily. ○ Apply light pressure to the site with a gauze pad after withdrawing the needle. Never massage an injection given via Z-track method. ○ Encourage active use of the muscle after the injection. Giving a Z track injection ○ With the nondominant hand, press the side of the hand down and retract the skin and tissue laterally. Cleanse the site. Insert needle at a 90-degree angle. Maintain this hand position, with traction on the skin until after medication is injected. (Retracting skin and tissue provides a slanted needle track when the  needle enters the tissue; layers of tissue block the needle track after the needle is removed and tissue returns to normal position.) ○ Slowly inject medication. Wait for 10 seconds before withdrawing the needle. (Injecting medication slowly allows tissue to absorb the medication and prevents untoward bruising. Waiting allows time for the medication to disperse into tissue; this helps prevent medication from traveling back up the needle track.) ○ Withdraw the needle with a slow movement while releasing the tissue. Gently wipe the injection site with an alcohol swab. Do not massage site. Use alternate sites for subsequent injections. (Releasing tissue while withdrawing the needle disrupts the needle track, preventing medication from traveling to the skin surface. Massage might force the medication out into the subcutaneous tissue.) ○ Document that the injection was given, including site used and technique. (The right documentation verifies that the patient received the medication and notes site in case of local reaction. Anaphylactic shock. Safety Alert ○ Symptoms of anaphylactic shock (circulatory failure from an allergic reaction) include urticaria (a reaction characterized by reddened, slightly elevated patches known as wheals); bronchiolar constriction that manifests as wheezing or difficulty breathing; edema, and, finally, circulatory collapse. ○ Some allergic reactions may occur for up to 2 weeks after the medication was administered. ○ Allergic reactions are more common the second or successive times the medication is received. ○ Safety Alert Critical nursing responsibilities when administering a parenteral drug are to check for allergy to the drug before administration and to observe the patient for 30 minutes after the drug has been given for the first time. Other: Returning to the room to offer medication. Orthostatic hypotension nursing interventions. ○ Pg. 836 Move older adults slowly out of bed to prevent possible orthostatic hypotension. Elastic support stockings may help prevent or lessen such hypotension. Patients should use appropriate footwear. Use a gait belt until independent ambulation is established. Use assistance devices, such as a cane or walker, to provide a wider base of support and increase stability when needed. ○ Lifespan Considerations (p. 372) Placing special elastic stockings on the lower extremities may lessen the problem. ○ Box 21.5 – Technique for Determining Orthostatic Hypotension (p. 376) When the patient is experiencing fatigue, light-headedness, falls, visual blurring, or syncope, check for orthostate hypotension. Measure the pulse rate. Then, with the patient supine and the brachial artery at the level of the heart, measure the blood pressure. While measuring, support the patient's arm and back; the patient should have legs uncrossed. Record the measurements. Assist the patient to a standing position. Immediately measure the pulse. Again, with the brachial artery at the level of the heart, measure the blood pressure at and 3 minutes after standing. Determine the difference between the supine and standing systolic blood pressures and the difference between the supine and standing diastolic blood pressures. If there is a 20 mm Hg decrease in the systolic blood pressure or a 10 mm Hg decrease in the diastolic blood pres: sure when standing, the patient has orthostatic hypoten. sion. Variations in heart rate are helpful in determining the cause of the orthostatic hypotension. A tachycardio response (increase in heart rate over 20 beats per minute indicates dehydration or volume depletion. If the patient has both a decrease in blood pressure of 20 mm Hg and an increase in heart rate of 20 beats per minute it is "dou-bly" significant (KeithRN, 2016)- the patient could be in serious trouble!  Legal-late entry Communication ○ Better to document late than not to document at all. o May lead to the next shift nurse to administer an extra dose of medication to a patient who just received that medication on your shift.