Removing Medication From A Vial PDF

 ͕͔͘         A vial is a glass bottle with a self-sealing stopper through which medi- cation is removed. For safety in transporting and storing, the vial top is usually covered with a soft metal cap that can be removed easily....

 ͕͔͘         A vial is a glass bottle with a self-sealing stopper through which medi- cation is removed. For safety in transporting and storing, the vial top is usually covered with a soft metal cap that can be removed easily. The self-sealing stopper that is then exposed is the means of entrance into the vial. Single-dose vials are used once, and then discarded, regardless of the amount of the drug that is used from the vial. Multidose vials contain several doses of medication and can be used multiple times. The Centers for Disease Control and Prevention (CDC) recommends that medica- tions packaged as multiuse vials be assigned to a single patient when- ever possible (CDC, 2011). In addition, it is recommended that the top of the vial be cleaned before each entry, and that a new sterile needle and syringe are used for each entry. The medication contained in a vial can be in liquid or powder form. Powdered forms must be dissolved in an appropriate diluent before administration. The following skill reviews removing liquid medication from a vial. Refer to the accompanying Skill Variation for steps to reconstitute powdered medication. DELEGATION CONSIDERATIONS The preparation of medication from a vial is not delegated to nursing assistive personnel (NAP) or to unlicensed assistive personnel (UAP). Depending on the state’s nurse practice act and the organization’s poli- cies and procedures, the preparation of medication from a vial may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient’s needs and circumstances, as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A. EQUIPMENT Sterile syringe and needle or Second needle (optional) blunt cannula (size depends Filter needle (optional) on medication being adminis- Computer-generated Medica- tered) tion Administration Record Vial of medication (CMAR) or Medication Antimicrobial swab Administration Record (MAR) ASSESSMENT Assess the medication in the vial for any discoloration or particles. Check expiration date before administering medication. Verify patient name, dose, route, and time of administration. Assess the appropriateness of the drug for the patient. Review assessment and laboratory data that may influence drug administration. 563 564 SKILL 104 NURSING DIAGNOSIS Risk for Infection Deficient Knowledge Risk for Injury OUTCOME IDENTIFICATION AND PLANNING Withdrawal of the medication into a syringe in a sterile manner. Proper dose is prepared. IMPLEMENTATION ACTION RATIONALE 1. Gather equipment. Check the This comparison helps to identify medication order against the errors that may have occurred original order in the medical when orders were transcribed. record, according to facility The primary care provider’s policy. Clarify any inconsis- order is the legal record of medi- tencies. Check the patient’s cation orders for each facility. chart for allergies. 2. Know the actions, special This knowledge aids the nurse nursing considerations, safe in evaluating the therapeutic dose ranges, purpose of effect of the medication in rela- administration, and adverse tion to the patient’s disorder and effects of the medications to can also be used to educate the be administered. Consider patient about the medication. the appropriateness of the medication for this patient. 3. Perform hand hygiene. Hand hygiene deters the spread of microorganisms. 4. Move the medication cart to Organization facilitates error-free the outside of the patient’s administration and saves time. room or prepare for admin- istration in the medication area. 5. Unlock the medication cart Locking the cart or drawer safe- or drawer. Enter pass code guards each patient’s medication and scan employee identifi- supply. Hospital accrediting cation, if required. organizations require medication carts to be locked when not in use. Entering pass code and scan- ning ID allows only authorized  ‡†‹ ƒ–‹‘ǣ‡‘˜‹‰ˆ”‘ƒ‹ƒŽ ǦǦǦ 565 ACTION RATIONALE users into the system and identi- fies the user for documentation by the computer. 6. Prepare medications for This prevents errors in medica- one patient at a time. tion administration. 7. Read the CMAR/MAR and This is the first check of the select the proper medica- label. tion from unit stock or the patient’s medication drawer. 8. Compare the label with the This is the second check of the CMAR/MAR. Check expira- label. Verify calculations with tion dates and perform cal- another nurse to ensure safety, culations, if necessary. Scan if necessary. the bar code on the package, if required. 9. Remove the metal or plastic Cap needs to be removed to cap on the vial that protects access medication in the vial. the rubber stopper. 10. Swab the rubber top with Antimicrobial swab removes the antimicrobial swab and surface bacteria contamination. allow to dry. Allowing the alcohol to dry pre- vents it from entering the vial on the needle. 11. Remove the cap from the Pulling the cap off in a straight needle or blunt cannula by manner prevents accidental pulling it straight off. Touch needlestick injury. Handling the the plunger only at the knob. plunger only at the knob will Draw back an amount of keep the shaft of the plunger air into the syringe that is sterile. Because a vial is a sealed equal to the specific dose of container, injection of an equal medication to be withdrawn. amount of air (before fluid is Some facilities require use removed) is required to prevent of a filter needle when with- the formation of a partial vacuum. drawing premixed medica- If not enough air is injected, the tion from multidose vials. negative pressure makes it dif- ficult to withdraw the medication. Using a filter needle prevents any solid material from being with- drawn through the needle. 12. Hold the vial on a flat sur- Air bubbled through the solution face. Pierce the rubber stop- could result in withdrawal of an per in the center with the inaccurate amount of medication. needle tip and inject the 566 SKILL 104 ACTION RATIONALE measured air into the space above the solution. Do not inject air into the solution. 13. Invert the vial. Keep the tip This prevents air from being of the needle or blunt can- aspirated into the syringe. nula below the fluid level. 14. Hold the vial in one hand Handling the plunger only at and use the other to with- the knob will keep the shaft of draw the medication. Touch the plunger sterile. Holding the the plunger only at the syringe at eye level facilitates knob. Draw up the pre- accurate reading, and the vertical scribed amount of medi- position makes removal of air cation while holding the bubbles from the syringe easy. syringe vertically and at eye level. 15. If any air bubbles accumu- Removal of air bubbles is neces- late in the syringe, tap the sary to ensure an accurate dose barrel of the syringe sharply of medication. and move the needle past the fluid into the air space to re- inject the air bubble into the vial. Return the needle tip to the solution and continue withdrawal of the medica- tion. 16. After the correct dose is This prevents contamination of withdrawn, remove the nee- the needle and protects against dle from the vial and care- accidental needlesticks. A one- fully replace the cap over handed recap method may be the needle. If a filter needle used as long as care is taken not has been used to draw up to contaminate the needle dur- the medication, remove it ing the process. A filter needle and attach the appropri- used to draw up medication ate administration device. should not be used to administer Some facilities require the medication to prevent any changing the needle, if one solid material from entering the was used to withdraw the patient. Changing the needle may medication, before adminis- be necessary because passing the tering the medication. needle through the stopper on the vial may dull the needle. In addition, it ensures the tip of the needle is free from medication residue, significantly reducing pain intensity associated with the injection (Ağaç & Güneş, 2010).  ‡†‹ ƒ–‹‘ǣ‡‘˜‹‰ˆ”‘ƒ‹ƒŽ 567 ACTION RATIONALE 17. Check the amount of medi- Careful measurement ensures cation in the syringe with that the correct dose is with- the medication dose and drawn. discard any surplus. 18. Depending on facility This third check ensures accu- policy, the third check racy and helps to prevent errors. of the label may occur at Note: Many facilities require the this point. If so, when all third check to occur at the bed- medications for one patient side, after identifying the patient have been prepared, and before administration. recheck the labels with the CMAR/MAR before taking the medications to the patient. 19. If a multidose vial is being Because the vial is sealed, the used, label the vial with the medication inside remains date and time opened, and sterile and can be used for future store the vial containing injections. Labeling the opened the remaining medication vials with a date and time limits according to facility policy. its use after a specific time period. 20. Lock the medication cart Locking the cart or drawer before leaving it. safeguards the patient’s medica- tion supply. Hospital accrediting organizations require medication carts to be locked when not in use. 21. Perform hand hygiene. Hand hygiene deters the spread of microorganisms. 22. Proceed with administration, See appropriate skill for pre- based on prescribed route. scribed route. EVALUATION Medication is withdrawn into the syringe in a sterile manner and the proper dose is prepared. DOCUMENTATION It is not necessary to record the removal of the medication from the ampule. Prompt recording of administration of the medication is required immediately after it is administered. 568 SKILL 104     ‡ ‘•–‹–—–‹‰‘™†‡”‡†‡†‹ ƒ–‹‘ ‹ƒ‹ƒŽ Drugs that are unstable in liquid 7. Read the CMAR/MAR and form are often provided in a select the proper medica- dry powder form. The powder tion and diluent from unit must be mixed with the correct stock or from the patient’s amount of appropriate solution medication drawer. This is to prepare the medication for the first check of the medi- administration. Verify the cor- cation label. rect amount and correct solution 8. Compare the labels with type for the specific medication the CMAR/MAR. This is prescribed. This information is the second check of the found on the vial label, pack- medication label. Check age insert, in a drug reference, expiration dates and per- an on-line pharmacy source, or form calculations, check from the pharmacist. To recon- medication calculation with stitute powdered medication: another nurse. Scan the 1. Gather equipment. Check bar code on the package, if the medication order required. against the original order in 9. Remove the metal or plas- the medical record, accord- tic cap on the medication ing to agency policy. vial and diluent vial that 2. Know the actions, special protects the self-sealing nursing considerations, safe stoppers. dose ranges, purpose of 10. Swab the self-sealing tops administration, and adverse with the antimicrobial swab effects of the medications and allow to dry. to be administered. Con- 11. Draw up the appropriate sider the appropriateness amount of diluent into the of the medication for this syringe. patient. 12. Insert the needle or blunt 3. Perform hand hygiene. cannula through the center of the self-sealing stopper on the powdered medica- tion vial. 13. Inject the diluent into the 4. Move the medication powdered medication vial. cart to the outside of the 14. Remove the needle or blunt patient’s room or prepare cannula from the vial and for administration in the replace cap. medication area. 15. Gently agitate the vial to 5. Unlock the medication cart mix the powdered medi- or drawer. Enter pass code cation and the diluent and scan employee identifi- completely. Do not shake cation, if required. the vial. 6. Prepare medications for 16. Draw up the prescribed one patient at a time. amount of medication