Updated Medication Administration (1).docx

Medication Administration A medication is a substance used in the diagnosis, treatment, cure, relief, or prevention of health problems. Nurses’ roles in medication administration include Safe medication preparation and administration Teaching patients about their medications and side effects Evaluat...

Medication Administration A medication is a substance used in the diagnosis, treatment, cure, relief, or prevention of health problems. Nurses’ roles in medication administration include Safe medication preparation and administration Teaching patients about their medications and side effects Evaluating the effects of medications on patients’ ongoing health status Ensuring adherence to the medication regimen Evaluating the patient’s and family caregiver’s ability to self-administer medications. The Food and Drug Administration (FDA) enforces medication laws to ensure that all medications on the market undergo vigorous testing before they are sold to the public. Nurses are responsible for following legal provisions when administering controlled substances and narcotics, which are federally, and state regulated. Pharmacological concepts: Drug Nomenclature Chemical name- identifies drug’s atomic and molecular structure and provides the exact description of medication’s composition, example N-acetyl-para-aminophenol Generic or official name: assigned by the manufacturer that first develops the drug, example acetaminophen Trade—also known as brand or proprietary name. This is the name under which a manufacturer markets the medication examples Tylenol, Panadol, APAP etc Although NCLEX focuses on generic names, nurses are expected to be familiar with both generic and trade names of drugs. Chemical names are not used in practice and unlike trade or brand names, generic names are usually more complicated and harder to remember. Medications are classified by their effect on body system; chemical composition; clinical indication or therapeutic action. Medications are available in various forms ranging from oral (solid and liquid- capsule, pill, tablet, extended release, elixir, suspension, syrup), topical-lotion, ointment, patches, injectables and forms for instillation into body cavities. The form of the medication determines its route of administration. Some medications can have more than one classification such as aspirin, which can be analgesic, antipyretic, or anti-inflammatory. An elixir is a medication in a clear liquid containing water, alcohol, sweeteners, and flavor. A suspension contains finely divided, undissolved particles in a liquid medium. A solution is a drug dissolved in another substance. A syrup is medication combined in a water and sugar solution. Drug Actions Pharmacokinetics and pharmacodynamics concepts of pharmacology explains action of drugs in the body. Pharmacokinetics refers to as “what the body does to the drug” predicts the rate of drug movement throughout the body characterized by the speed of absorption, distribution, metabolism, and excretion (ADME). In essence, pharmacokinetics is the study of how medications enter the body, are absorbed, and distributed into cells, tissues, or organs site of actions, and after their physiological effects, are metabolized and exit the body. Absorption Passage of medication molecules into the blood from the site of administration. Safe medication administration requires knowledge of factors that alter or impair absorption of prescribed medications and they include: Route of administration: Each route of administration has a different rate of absorption. When applying medications on the skin, absorption is slow because of the physical makeup of the skin. Because orally administered medications pass through the gastrointestinal (GI) tract, the overall rate of absorption is usually slow. Because some medications interact with food, it is often appropriate to administer them before or after meals, with meals, or on an empty stomach. The mucous membrane and the respiratory tract have a quick rate of absorption. Intravenous (IV) administration has the fastest absorption rate. Solubility of the medication in water: Highly soluble medications have rapid absorption (10 to 30 min). Poorly soluble medications have slow absorption. Blood flow to the site of administration: The blood supply to the site of administration will determine how quickly the body can absorb a drug. The richer the blood supply to the site of administration, the faster a medication is absorbed. Body surface area: When a medication encounters a large surface area, it is absorbed at a faster rate. This helps explain why most medications are absorbed in the small intestine rather than the stomach. Lipid solubility: Because the cell membrane has a lipid layer, highly lipid-soluble medications cross cell membranes easily and are absorbed quickly. Distribution After absorption, distribution occurs within the body to tissues, organs, and specific sites of action. The rate and extent of distribution depend on the physical and chemical properties of the medication and the physiology of the patient. Once the medication has entered the bloodstream, it is carried throughout the tissues and organs of the body. The speed of distribution depends on the vascularity of various tissues and organs, permeability of membranes, and the degree to which medication binds to serum proteins will affect medication distribution. Most medications bind to albumin to some extent and then cannot be pharmacologically active. The unbound or “free” medication is its active form. Metabolism Medications are metabolized into a less potent or an inactive form. Biotransformation occurs under the influence of enzymes that detoxify, break down, and remove active chemicals in the liver (major site) as well as Kidneys, blood, intestines, and lungs. The liver is especially important because its specialized structure oxidizes and transforms many toxic substances. The liver degrades many harmful chemicals before they are distributed to the tissues. If a decrease in liver function occurs such as with aging or liver disease, a medication usually is eliminated more slowly, resulting in its accumulation. Patients are at risk for medication toxicity if organs that metabolize medications are not functioning correctly. FACTORS INFLUENCING MEDICATION METABOLISM RATE Age: Infants have a limited medication-metabolizing capacity. The aging process also can influence medication metabolism but varies with the individual. In general, hepatic medication metabolism tends to decline with age. Older adults require smaller doses of medications due to the possibility of accumulation in the body. An increase in some medication-metabolizing enzymes: This can metabolize a particular medication sooner, requiring an increase in dosage of that medication to maintain a therapeutic level. It can also cause an increase in the metabolism of other concurrent-use medications. First‑pass effect or presystemic metabolism: The first pass effect is a phenomenon of drug metabolism whereby the concentration of a drug, specifically when administered orally, is greatly reduced before it reaches the systemic circulation. It is the fraction of drug lost during the process of absorption which is generally related to the liver and gut wall. Alternative routes of administration are non-enteral routes such as suppository, intravenous, intramuscular, inhalational aerosol, transdermal, or sublingual, avoid the first-pass effect because they allow drugs to be absorbed directly into the systemic circulation. Similar metabolic pathways: When the same pathway metabolizes two medications, it can alter the metabolism of one or both. In this way, the rate of metabolism can decrease for one or both medications, leading to medication accumulation. Nutritional status: Clients who are malnourished can be deficient in the factors that are necessary to produce specific medication‑metabolizing enzymes, thus impairing medication metabolism. Excretion Chemical makeup of medication determines the organ of excretion. Medications exit the body through the kidney, liver, bowel, lungs, and exocrine glands. The kidneys are the main organs for medication excretion. Following administration of drug, pharmacodynamics referred to “what the drug does to the body describes the interactions between medications and target cells, body systems, and organs to produce effects. It is the process by which drugs alter cell physiology and affect the body. Timing of medication response and Types of medication Actions Safe drug administration requires the nurse to understand both the pharmacokinetics and pharmacodynamics of the drug to enable understanding of timing of drug effects, the actions of the drug, expected responses as well as potential adverse effects and interactions. It involves adherence to prescribed doses and dosage schedules. Agencies set schedules for medication administration. When a medication is prescribed, the goal is to achieve a constant blood level within a safe therapeutic range, which falls between the minimum effective concentration (MEC) and the toxic concentration. When a medication is administered repeatedly, its serum level fluctuates between doses. Therapeutic range: Concentration of drug in the blood serum that produces the desired effect without causing toxicity. It is the expected or predicted physiological response. To maintain a therapeutic plateau the patient must receive regular fixed doses. Adverse effect: Unintended, undesirable, often unpredictable. Adverse drug effects range from mild to severe. Some happen immediately, whereas others develop over time. Adverse effects include: Side effects which are predictable, unavoidable secondary effect. Side effects range from being harmless to causing serious symptoms or injury. Patients often stop taking medications because of side effects. Toxic effect: Accumulation of medication in the bloodstream. Toxic effects often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. Toxic effects often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. Excess amounts of a medication within the body sometimes have lethal effects, depending on its action. For example, toxic levels of morphine, an opioid, cause severe respiratory depression and death. Antidotes are available to treat specific types of medication toxicity. Idiosyncratic reaction: Overreaction or underreaction or different reaction from normal. Medications sometimes cause unpredictable effects, such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction different from normal. Allergic reaction: unpredictable response to a medication. A patient with a known history of an allergy to a medication needs to avoid taking that medication in the future and wear an identification bracelet or medal that alerts nurses and other health care providers to the allergy if the patient is unable to communicate when receiving medical care. Peak: Highest plasma level of a medication when elimination = absorption Trough: The point when the drug is at its lowest concentration, indicating the rate of elimination. Blood sample for trough should be drawn immediately before the next medication dose. Half-life: Amount of time it takes for 50% of blood concentration of a drug to be eliminated from the body. Liver and kidney function affect half‑life. The concept of half-life is useful for determining excretion rates as well as steady-state concentrations for any specific drug and a way for estimation of appropriate dosing interval. Different drugs have different half-lives. A drug is considered to have a negligible therapeutic effect after 4 half-lives. A medication with a short half-life needs to be given more frequently than a medication with a longer half-life Plateau: A plateau is a medication concentration in plasma during a series of doses. Time-critical medications Time-critical medications are medications in which early or delayed administration of maintenance doses (more than 30 minutes before or after the scheduled dose) will most likely result in harm or subtherapeutic responses in a patient. You need to administer time-critical medications at a precise time or within 30 minutes before or after the scheduled time. Non–time-critical medications should be administered within 1 to 2 hours of their scheduled time. Overall, follow the policies of the facility for both time-critical and non-time critical medication administration. Patient teaching. Teaching patients about the indications, what to monitor and side effects of medications is an independent nursing intervention. Follow patient teaching guidelines from simple to complex and mostly from the patient’s point of view. Use teach back method where feasible to evaluate outcomes. When teaching medication schedules, use familiar language. For example, instruct a patient who needs to take a medication twice a day to take it in the morning and again in the evening. Medication interactions: occurs when one medication modifies the action of another. Medication interactions are common when individuals take several medications. Some medications increase or diminish the action of others or alter the way another medication is absorbed, metabolized, or eliminated from the body. When two medications have a synergistic effect, their combined effect is greater than the effect of the medications when given separately. Route of medication administration The route prescribed for administering a medication depends on the properties and desired effect of the medication and the patient’s physical and mental condition. Oral and enteral routes The oral route is the easiest and the most used route of medication administration. 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. Patients generally prefer the oral route. Nursing considerations Protect a patient from aspiration by assessing his or her ability to swallow. Use a liquid form of the medication to facilitate swallowing whenever possible. When administering crushed, ensure that the medication can be crushed (Do not open capsules, and do not crush time released or enteric coated medications). Ensure that patients swallow enteric-coated or time-release medications whole not chewed or crushed. Do not mix with large amounts of food or beverages in case clients cannot consume the entire quantity. Avoid administration with interacting foods or beverages (grapefruit juice). Administer oral medications as prescribed and follow directions for whether medication is to be taken on an empty stomach (30 min to 1 hr before meals, 2 hr after meals) or with food. Give oral medications on an empty stomach if absorption is decreased or with meals if absorption is enhanced by food. Follow the manufacturer’s directions for crushing, cutting, and diluting medications. Break or cut scored tablets only. Enteral (tube) route Before giving a medication by this route, verify tube placement Use liquid forms of medications; if not available, consider crushing medications if appropriate guidelines allow. Do not administer sublingual medications through the tube. Administer each medication separately. The risk for drug-drug interactions is high when two or more medications are given in this route because they can interact together as soon as they are administered. Do not mix medications with enteral feedings. Determine if medications need to be given on an empty stomach or if they are compatible with the patient’s enteral feeding. If a medication needs to be given on an empty stomach or is not compatible with the feeding, hold the feeding for at least 30 minutes before or 30 minutes after medication administration. Some of medications may need up to 120 minutes to absorb Completely dissolve crushed tablets and hard gelatin capsules in 15 to 30 mL of room temperature water prior to administration. To prevent clogging, flush the tubing with 15 to 30 mLs water before medication administration, 5 mLs between each medication and another 15 to 30 mLs after instilling all the medications. Instill the medications by gravity or lightly use the plunger if needed. Sublingual and Buccal Administration Directly enters the bloodstream and bypasses the liver Sublingual: under the tongue Buccal: between the cheek and the gum Nursing consideration Keep the medication in place until complete absorption occurs. Do not eat or drink while the tablet is in place or until it has completely dissolved. Parenteral routes Parenteral administration involves injecting a medication into body tissues. The following are the four major sites of injection: 1. Intradermal (ID): Injection into the dermis just under the epidermis 2. Subcutaneous: Injection into tissues just below the dermis of the skin 3. Intramuscular (IM): Injection into a muscle 4. IV: Injection into a vein Each type of syringe for parenteral routes is designed to deliver a certain volume of a medication to a specific type of tissue. Use nursing judgment when determining the syringe size or needle length and gauge that will be most effective. Syringes come in several sizes, from 0.5 to 60 mL. Most needles vary in length from 1/4 to 3 inches. Choose the needle length according to a patient’s size and weight and the type of tissue into which the medication is to be injected. Use the correct syringe when preparing insulin. Use a 100-unit insulin syringe or an insulin pen to prepare U-100 insulin. Verify dose with another nurse before administering it to the patient. Ampule Ampules contain single doses of medication in a liquid. 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 for easy breaking. Tap the neck of the ampule to avoid wasting the medications around the neck. Correct method of breaking the glass is to break it away from your face. Carefully aspirate the medication into a syringe with a filter needle. The use of a filter needle prevents particulate matter such as small glass fragments from entering the syringe. Replace the filter needle with an appropriate-size needle or a needleless access device before administering the injection. Vial A vial is a single-dose or multidose container with a rubber seal at the top. A metal cap protects the seal until it is ready for use. Vials contain liquid or dry forms of medications. Medications that are unstable in solution are packaged dry. The vial label specifies the solvent or diluent used to dissolve the medication and the amount of diluent needed to prepare a desired medication concentration. Normal saline and sterile distilled water are commonly used to dissolve medications. Unlike the ampule, the vial is a closed system, and air needs to 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. ****Mixing medications (Not currently done in practice) If two medications are compatible, it is possible to mix them in one injection syringe if the total dose is within accepted limits. This prevents a patient from having to receive more than one injection at a time. When mixing medications from both a vial and ampule, prepare medication from the vial first. Using the same syringe and filter needle, next withdraw medication from the ampule. Nurses prepare the combination in this order because it is not necessary to add air to withdraw medication from an ampule. Maintain aseptic technique and do not contaminate one medication with another. Steps for mixing medications Use only one syringe with a needle or needleless access device attached to mix medications from two vials. Aspirate the volume of air equivalent to the dose of the first medication (vial A). Inject the air into vial A, making sure that the needle does not touch the solution. Withdraw the needle and aspirate air equivalent to the dose of the second medication (vial B). Inject the volume of air into vial B. Immediately withdraw the medication from vial B into the syringe and insert the needle back into vial A, being careful not to push the plunger and expel the medication within the syringe into the vial. Withdraw the desired amount of medication from vial A into the syringe. ****Note that mixing medications in one syringe is currently not practiced anymore in hospitals*** Administering injections Failure to select an injection site in relation to anatomical landmarks results in nerve or bone damage during needle insertion. Select the proper injection site, using anatomical landmarks. Inability to maintain stability of the needle and syringe unit can result in pain and tissue damage. Injecting too large a volume of medication for the site selected causes extreme pain and results in local tissue damage. Subcutaneous injections Subcutaneous injections involve placing medications into the loose connective tissue under the dermis. Because subcutaneous tissue is not as richly supplied with blood as the muscles, medication absorption is somewhat slower than with IM injections. The best subcutaneous injection sites include the outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs. The site most frequently recommended for heparin injections is the abdomen. Alternative subcutaneous sites for other medications include the scapular areas of the upper back and the upper ventral or dorsal gluteal areas. The injection site chosen needs to be free of skin lesions, bony prominences, and large underlying muscles or nerves. The administration of low-molecular-weight heparin (LMWH) (e.g., enoxaparin) requires special considerations. When injecting the medication, use the right or left side of the abdomen at least 2 inches from the umbilicus (the patient’s “love handles”) and pinch the injection site as you insert the needle. Administer LMWH in its prefilled syringe with the attached needle and do not expel the air bubble in the syringe before giving the medication. Recommended sites for insulin injections include the upper arm and the anterior and lateral parts of the thigh, buttocks, and abdomen. Rotating injections within the same body part (intrasite rotation) provides more consistency in the absorption of the insulin. The injections are to be given at least 2.5 cm (1 inch) away from the previous site. The rate of insulin absorption varies based on the site; the abdomen has the quickest absorption, followed by the arms, thighs, and buttocks. Subcutaneous tissue is sensitive to irritating solutions and large volumes of medications. Thus, only administer small volumes (0.5 to 1.5 mL) of water-soluble medications subcutaneously to adults and give smaller volumes, up to 0.5 mL to children. Hardened, painful lumps, called sterile abscesses, occur under the skin if medication collects within the tissues. A patient’s body weight indicates the depth of the subcutaneous layer. Therefore, choose the needle length and angle of insertion based on a patient’s weight and an estimation of the amount of subcutaneous tissue. Use a 3⁄8- to 5⁄8-inch, 25-gauge, 5/8-inch (16-mm) needle inserted at a 45-degree angle or a 1/2-inch (12-mm) needle inserted at a 90-degree angle to administer subcutaneous medications to a normal-size adult patient. Some children require only a 1/2-inch needle. If the patient is obese, pinch the tissue and use a needle long enough to insert through fatty tissue at the base of the skinfold. Thin patients often do not have sufficient tissue for subcutaneous injections; the upper abdomen is usually the best site in this case. To ensure that a subcutaneous medication reaches the subcutaneous tissue, follow this rule: If you can grasp 2 inches (5 cm) of tissue, insert the needle at a 90-degree angle; if you can grasp 2.5 cm (1 inch) of tissue, insert the needle at a 45-degree angle. Intramuscular injections The IM route provides faster medication absorption than the subcutaneous route because of the greater vascularity of muscle. However, IM injections are associated with many risks. Use a needle size 18- to 27-gauge (usually 22- to 25-gauge), 1- to 1.5-inch long, and inject at a 90° angle. Solution volume is usually 1 to 3 mL. Divide larger volumes into two syringes and use two different sites. Do not give more than 1 mL to small children and older infants, and do not give more than 0.5 mL to smaller infants. Assess the muscle before giving an injection. Properly identify the site for the IM injection by palpating bony landmarks and be aware of the potential complications associated with each site. The site needs to be free of tenderness. Minimize discomfort during an injection by helping a patient assume a position that helps to reduce muscle strain. The ventrogluteal muscle is the preferred and safest site for all adults for medications that have larger volumes and are more viscous and irritating. The ventrogluteal site is recommended for volumes greater than 2 mL. Locate the ventrogluteal muscle by positioning the patient in a supine or lateral position. Flexing the knee and hip helps to relax this muscle. Place the palm of your hand over the greater trochanter of the patient’s hip with the wrist perpendicular to the femur. Use the right hand for the left hip and the left hand for the right hip. Point the thumb toward the patient’s groin and the index finger toward the anterior superior iliac spine; extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle; the injection site is the center of the triangle. The vastus lateralis muscle is another injection site for adults and children. The muscle is thick and well developed, is located on the anterior lateral aspect of the thigh and extends in an adult from a hand breadth above the knee to a hand breadth below the greater trochanter of the femur. Use the middle third of the muscle for injection. The vastus lateralis site is preferred site for IM injections often used for infants and toddlers. The deltoid site is easily accessible and used for only for small medication volumes (2 mL or less), when giving immunizations, or when other sites are inaccessible because of dressings or casts. Locate the injection site using anatomical landmarks (acromion process and the axilla). To locate the muscle, fully expose the patient’s upper arm and shoulder. Do not roll up a tight-fitting sleeve. Have the patient relax the arm at the side and flex the elbow. Locate the site by placing four fingers across the deltoid muscle, with the top finger along the acromion process. The injection site is then three finger widths below the acromion process. Use the Z-track technique for IM injections of irritating fluids or fluids that can stain the skin (iron preparations). This method prevents medication from leaking back into subcutaneous tissue. To use the Z-track method, put a new needle on the syringe after preparing the medication so no solution remains on the outside needle shaft. Place the ulnar side of the nondominant hand just below the site and pull the overlying skin and subcutaneous tissues approximately 2 to 3 cm (1 to 1.2 inches) laterally or downward. Hold the skin in this position until you administer the injection. The needle remains inserted for 10 seconds to allow the medication to disperse evenly rather than channeling back up the track of the needle. Release the skin after withdrawing the needle. This leaves a zigzag path that seals the needle track where tissue planes slide across one another. The medication cannot escape from the muscle tissue. The dorsoglutea site is no longer recommended as a common injection site due to its proximity to the sciatic nerve. Intradermal (ID) ID injections typically are used for skin testing (e.g., tuberculin screening and allergy tests). Because these medications are potent, they are injected into the dermis, where blood supply is reduced, and medication absorption occurs slowly. Choose skin-testing sites that allow easy access for changes in color and tissue integrity, lightly pigmented, free of lesions, and relatively hairless. The inner forearm and upper back are ideal locations. Use small amounts of solution (0.01 to 0.1 mL) in a tuberculin syringe with a fine‑gauge needle (26‑ to 27-gauge). The angle of insertion for an ID injection is 5 to 15 degrees, and the bevel of the needle is pointed up. As you inject the medication, a small bleb resembling a mosquito bite appears on the surface of the skin. If a bleb does not appear or if the site bleeds after needle withdrawal, there is a good chance that the medication entered subcutaneous tissues. In this case test results will not be valid. Do not massage the site after injection. Needle stick safety Occupational exposure often occurs through accidental needlesticks and sharps injuries. Needlestick injuries commonly occur when health care workers recap needles, mishandle IV lines and needles, or leave needles at a patient’s bedside. Exposure to bloodborne pathogens is one of the deadliest hazards to which nurses are exposed daily. Most needlestick injuries are preventable with the implementation of safe needle devices. The Needlestick Safety and Prevention Act mandates the use of special needle safety devices to reduce the frequency of needlestick injuries. Safety syringes have a sheath or guard that covers a needle immediately after it is withdrawn from the skin. This eliminates the chance for a needlestick injury. The syringe and sheath are disposed of together in a receptacle. Use needleless devices whenever possible to reduce the risk of needlestick and sharps injuries. Always dispose of needles and other instruments considered sharps into clearly marked, appropriate containers. Containers need to be puncture proof and leak proof. Never force a needle into a full needle disposal receptacle. Never place used needles and syringes in a wastebasket, in your pocket, on a patient’s meal tray, or at the patient’s bedside. Intravenous (IV) therapy IV therapy is used for administering medications, fluid, and blood products. Onset is rapid, and absorption into the blood is immediate, which provides an immediate response. There is an increased risk for infection or embolism with IV injections. Other IV complications are Phlebitis (warm, red streak, swollen, and tender) and infiltration (cold and swollen). Remove the IV and apply warm compress when any of these occur. Vascular access devices can be for short-term use (catheters) or long-term use (infusion ports). Use 16-gauge devices for clients who have trauma and 18-20 gauge during surgery and blood administration. Use 22- to 24-gauge for children, older adults, and clients who have medical issues or are stable postoperatively. Standard color codes for the routinely used 18-24 gauges are green-18, pink-20, blue 22, and yellow-24) Nurses administer medications intravenously by the following methods: 1. As mixtures within large volumes of IV fluids 2. By injection of a bolus or small volume of medication (IV push-IVP) through an existing IV infusion line or intermittent venous access (heparin or saline lock). The IV bolus, or “push,” is the most dangerous method for administering medications because there is no time to correct errors. In addition, a bolus may cause direct irritation to the lining of blood vessels. Students do not give IVP medications. 3. By “piggyback” infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line In all three methods, a patient has either an existing IV infusion running continuously or an IV access site for intermittent infusions. IV fluid therapy is used primarily for fluid replacement in patients unable to take oral fluids and as a means of supplying electrolytes and nutrients. When using any method of IV medication administration, observe patients closely for symptoms of adverse reactions. After a medication enters the bloodstream, it begins to act immediately, and there is no way to stop its action. When administering potent medications, assess vital signs before, during, and after infusion. Never give a medication intravenously if the insertion site appears swollen or edematous or the IV fluid cannot flow at the proper rate. Medications that carry a risk of adverse effects if administered too quickly should be diluted and administered as a piggyback or via an infusion pump. A piggyback is a small (25 to 250 mL) IV bag or bottle connected to a short tubing line (secondary line) that connects to the upper Y-port of a primary infusion line or to an intermittent venous access. The set is called a piggyback because the small bag or bottle is higher than the primary infusion bag or bottle. In the piggyback setup the main line does not infuse when the piggybacked medication is infusing. The port of the primary IV line contains a back-check valve that automatically stops flow of the primary infusion once the piggyback infusion flows. After the piggyback solution infuses and the solution within the tubing falls below the level of the primary infusion drip chamber, the back-check valve opens, and the primary infusion again flows. Heparin lock (H/L) or Saline lock (S/L) An intermittent venous access (commonly called a saline lock) is an IV catheter capped off on the end with a small chamber covered by a rubber diaphragm or a specially designed cap. Special rubber-seal injection caps usually accept needle safety devices. Before administering an IV bolus or piggyback medication, assess the patency and placement of the IV site. After the medication has been administered through an intermittent venous access, the access must be flushed with a solution to keep it patent. Generally, normal saline is an effective flush solution for peripheral catheters. When using a H/L or S/L, remember SAS (Saline, action, saline). Some agencies require the use of heparin flush after saline for central lines. Follow institution policies regarding care and maintenance of the IV site. Topical administration These are medications directly applied to the mucous membranes or skin. Includes powders, sprays, creams, ointments, pastes, oil-and suspension-based lotions. Medications applied to the skin and mucous membranes generally have local effects. Apply with a glove, tongue blade, or cotton-tipped applicator. Do not apply with a bare hand. For skin applications, wash the skin with soap and water. Pat dry before application. Use surgical asepsis to apply topical medications to open wounds. Follow directions for each type of medication. Transdermal patches Medication in a skin patch for absorption through the skin, producing systemic effects. Use gloves for application. Remove old patch before applying new. Place the patch on a hairless area and rotate sites to prevent skin irritation. Document the location of the new patch. Ask about patches during the medication history. Apply a label to the patch if it is difficult to see. Document removal of the patch as well. Inhaled medications Administered through metered-dose inhalers (MDI) or dry-powder inhalers (DPI). MDIs and DPIs use a chemical propellant to push the medication out of the inhaler and require the patient to apply approximately 5 to 10 lbs of pressure to the top of the canister to administer the medication. Children or older adults with chronic respiratory diseases often use MDIs. Patients who receive medications by inhalation frequently suffer chronic respiratory disease such as chronic asthma, emphysema, or bronchitis. Different respiratory problems require different inhaled medication. To ensure that the patient does not run out of medication, teach him or her to refill it at least 7 to 10 days before it runs out. Some patients use a spacer with the MDI. The spacer is a 10- to 20-cm (4- to 8-inch) long tube that attaches to the MDI and allows the particles of medication to slow down and break into smaller pieces, which improves drug absorption in a patient’s airway. ***See details on patient teaching for MDIs with spacer and DPIs in your ATI book*** Instillation (drops, ointments, sprays) Generally used for eyes, ears, and nose Eye Instillations Position patient and using medical asepsis, access and drop the medication into the conjunctival sac, avoid placing it directly on the cornea, and have the patient close the eye gently. If the patient blinks during installation, repeat the procedure. Apply gentle pressure with your finger and a clean facial tissue on the nasolacrimal duct for 30 to 60 seconds to prevent systemic absorption of the medication. If instilling more than one medication in the same eye, wait at least 5 min between them. For eye ointment, apply a thin ribbon to the edge of the lower eyelid from the inner to the outer canthus. Ear Instillations Position patient and straighten the ear canal by pulling the auricle upward and outward for adults or down and back for children less than 3 years of age. Hold the dropper 1 cm above the ear canal, instill the medication, and then gently apply pressure with your finger to the tragus of the ear unless it is too painful. Do not press a cotton ball deep into the ear canal. If necessary, gently place it into the outermost part of the ear canal. Have clients remain in the side-lying position if possible, for 2 to 3 min after installation of ear drops. Nasal Instillations Use medical aseptic technique when administering medications into the nose. Have client lie supine with the head positioned to allow the medication to enter the appropriate nasal passage. Use your dominant hand to instill the drops, supporting the head with your nondominant hand. Instruct client to breathe through the mouth, stay in a supine position, and not to blow the nose for 5 min after drop instillation. For nasal spray, prime the spray if indicated, insert tip into nare, and point nozzle away from the center of the nose. Spray into nose while the client inhales and instruct the client not to blow nose for several minutes. Vaginal Instillations Vaginal medications are available as suppositories, foam, jellies, or creams. Position client supine with the knees bent and feet flat on the bed and close to the hips (modified lithotomy or dorsal recumbent position). Provide perineal care, if needed. Lubricate the suppository or fill the applicator, depending on the formulation. Insert the medication along the posterior wall of the vagina (7.5 to 10 cm [3 to 4 in] for suppositories; 5 to 7.6 cm [2 to 3 in] for creams, jellies, or foams) or instill irrigation as indicated. Instruct client to remain supine for at least 5 min after insertion to retain the suppository. If using a reusable applicator, wash it with soap and water. If it is disposable, discard it. Rectal instillations Rectal suppositories are thinner and more bullet-shaped than vaginal suppositories. The rounded end prevents anal trauma during insertion. They contain medications that exert local effects such as promoting defecation, or systemic effects, such as reducing nausea. Position clients in the left lateral or Sims’ position. Insert the suppository (use lubricant if needed) just beyond the internal sphincter. Instruct client to remain flat or in the left lateral position for at least 5 min after insertion to retain the suppository. Systems of medication measurements/dosage calculations Medications are not always dispensed in the unit of measure in which they are ordered. Medication companies package and bottle medications in standard dosages. Nurses frequently convert available units of volume and weight to desired doses. The need to understand the different roles that members of the health care team play in prescribing and administering medications as well as how to calculate medication doses accurately cannot be over emphasized. To calculate medications accurately, nurses also need to know common equivalents of metric and household units. Household measures include drops, teaspoons, tablespoons, and cups for volume and pints and quarts for weight. Encourage patients to never use household measuring devices to give liquid medicines. The devices are inaccurate and may deliver more or less than prescribed. Today’s over the counter (OTC) liquid medicines almost always have their own measuring devices. Dosage calculation Methods Calculations are needed for: Solid oral medication Liquid oral medication Injectable medication Correct doses by weight IV infusion rates. Three different methods for dosage calculation are ratio and proportion, formula (desired over have), and dimensional analysis. ***See standard conversion factors, rounding guidelines and examples of the different types of calculations with each of the 3 methods in ATI chapter 48*** According to the nursing handbook, “Students must pass a medication administration dosage exam prior to start of clinical in the junior and senior year nursing courses.” Health care provider’s roles Prescriber can be physician, nurse practitioner, or physician’s assistant. Orders can be written (hand or electronic), verbal, or given by telephone. The use of abbreviations can cause errors; use caution and only approved abbreviations. See ATI chapter 47 table 47.1 Error-prone abbreviation list. Medication orders are given by writing an order on a form in the patient’s medical record or on a legal prescription pad. If the order is given verbally to the nurse, it is called a verbal order. When a verbal or telephone order is received, the nurse who took the order writes the complete order or enters it into a computer, reads it back, and receives confirmation from the prescriber to confirm accuracy. The prescriber countersigns the order later, usually within 24 hours after giving it. Nursing students cannot take medication orders of any kind. They only give newly ordered medications after a registered nurse has written and verified the order. Many hospitals are implementing computerized physician order entry (CPOE) to handle medication orders to decrease medication errors. In using this system, the prescriber completes all computerized fields before the order for the medication is filled to include date and time order is written, name of drug to be administered, dosage, route, and frequency thus avoiding incomplete or illegible orders. Types of medication orders Types of medication orders depend on the urgency, or how frequently they are needed. A standing order is carried out until the prescriber cancels it by another order, or the prescribed number of days elapses. It often indicates a final date or number of treatments or doses. Such orders are known as routine or scheduled medications. A prn order indicates that the prescriber ordered a medication to be given only when a patient requires it. Sometimes a health care provider orders a medication to be given once at a specified time. This is common for preoperative medications or medications given before diagnostic examinations. A STAT order signifies that a single dose of a medication is to be given immediately and only once. A now order is more specific than a one-time order and is used when a patient needs a medication quickly but not right away, as in a STAT order. When receiving a now order, the nurse has up to 90 minutes to administer the medication. Only administer now medications one time. The health care provider writes prescriptions for patients who are to take medications outside of the hospital. The pharmacist prepares and distributes prescribed medications. Pharmacists work with nurses, physicians, and other health care providers to evaluate the effectiveness of patients’ medications. They are responsible for filling prescriptions accurately and being sure that prescriptions are valid. Dispensing the correct medication, in the proper dosage and amount, with an accurate label is the pharmacist’s main task. Pharmacists also provide information about medication side effects, toxicity, interactions, and incompatibilities. Medication Distribution Systems Health care agencies have a special area for stocking and dispensing medications. Medication storage areas need to be locked when unattended. The most common medication administration systems include unit dose and automated medication dispensing systems (AMDSs). Medication reconciliation Nurses play an essential role in medication reconciliation to prevent polypharmacy. The Joint Commission requires policies and procedures for medication reconciliation. Nurses compile a list of each client’s current medications, including all medications with correct dosages and frequency. They compare the list with new medication prescriptions and reconcile it to resolve any discrepancies. This process takes place at admission, when transferring clients between units or facilities, and at discharge. Accurate medication reconciliation requires consulting with the patient, family caregivers, other clinicians, pharmacists, and other members of the health care team. Medication errors A medication error can cause or lead to inappropriate medication use or patient harm. Errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, or failing to administer a medication. When an error occurs, the patient’s safety and well-being are the top priorities. First assess and examine the patient’s condition and notify the health care provider of the incident as soon as possible. Once the patient is stable, report the incident to the appropriate person in the agency. The nurse is responsible for preparing and filing an occurrence or incident report as soon as possible after the error occurs to include an accurate, factual description of what occurred and what was done. The occurrence report is not a permanent part of the medical record and is not referred to anywhere in a patient’s medical record to legally protect the nurse and health care agency. Report all medication errors that reach the patient, including those that do not cause harm as well as near misses. All health care workers, including nurses, need to feel comfortable in reporting an error and not fear repercussions from managers or administrators. Even when a patient suffers no harm from a medication error, the agency can still learn why the mistake occurred and what can be done to avoid similar errors in the future. Rights of safe medication administration To prevent medication errors, every step of safe medication administration requires a disciplined attitude and a comprehensive, systematic approach. The attitude nurses need to possess when administering medications to patients includes responsibility and accountability to the rights of medication administration which include: Rights of medication administration Right medication Right patient Right dosage Right route Right time Right reason Right assessment data Right documentation Right response Right to education Right to refuse ***See PPT for explanation of these rights*** Follow the rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these rights. Patient’s Rights In accordance with The Patient Care Partnership (American Hospital Association, 2003) and because of the potential risks related to medication administration, a patient has the following rights: To be informed of the name, purpose, action, and potential undesired effects of a medication To refuse a medication regardless of the consequences To have qualified nurses or physicians assess a medication history, including allergies and use of herbals To be properly advised of the experimental nature of medication therapy and to give written consent for its use To receive labeled medications safely without discomfort in accordance with the six rights of medication administration To receive appropriate supportive therapy in relation to medication therapy To not receive unnecessary medications To be informed if medications are part of a research study Know these rights and handle all inquiries by patients and families courteously and professionally. Do not become defensive if a patient refuses medication therapy, recognizing that every person of consenting age has a right to refusal. Assessment The ongoing physical or mental status of a patient affects whether a medication is given and how it is administered. Assess a patient carefully before giving any medication. During the assessment process thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care. Before you administer medications, review a patient’s medical history to help you understand the indications or contraindications for medication therapy. Some illnesses place patients at risk for adverse medication effects. Ask your patients questions to find out about each medication they take. In addition, review the action, purpose, normal dosage, routes, side effects, and nursing implications for administering and monitoring each medication. Nursing Diagnoses Anxiety Ineffective Health Maintenance Deficient Knowledge (Medication Self-Administration) Noncompliance (Medications) Impaired Swallowing Impaired Memory Caregiver Role Strain (Caregiving Activities) Planning It is important to minimize distractions or interruptions when preparing and administering medications. No-interruption zones (NIZs) have been recommended to reduce distractions and interruptions during medication administration. Prioritize care when administering medications. Use patient assessment data to determine which medications to give first, whether it is time to evaluate a patient’s response to a medication, or if it is appropriate to administer prn medications. Implementation A medication order is required for every medication that nurses administer to a patient. Follow all agency policies when documenting medication administration. Never document that you have given a medication until given and never administer any medication you did not prepare or witness the preparation. *****Three checks of medication administration following reading the order: Compare order in the electronic medication administration record (eMAR) to the Pyxis After retrieval from the drawer and compared eMAR At the bedside, scan patient’s armband and the barcodes on the medication. Ensure the check mark beside the medication in the eMAR. Teach patients and family about the benefit of all medications, the knowledge needed to take it correctly, side effects of medications. It is essential to verify the accuracy of every medication you give to your patients with the provider’s orders. If the medication order is incomplete, incorrect, or inappropriate, vague, questionable or if there is a discrepancy between the original order and the information on the medication administration record (MAR), consult with the health care provider. Carefully monitor a patient’s response to a medication, especially when the first dose of a new medication is administered. Evaluation The goal of safe and effective medication administration is met when a patient responds appropriately to medication therapy and assumes responsibility for self-care. When patients do not experience expected outcomes of medication therapy, investigate possible reasons, and determine appropriate revisions to the plan of care. ***Summary notes contents adapted from course textbook, ATI, other books, and online literature***