Drug Administration - Key Nursing Skills PDF

CHAPTER 6 Drug administration Barbara Workman Aims and learning outcomes This chapter describes the role of the nurse when administering med- ications, and outlines the principles of safe administration of medica- tion by the commonest routes. By the end of this chapter you will be...

CHAPTER 6 Drug administration Barbara Workman Aims and learning outcomes This chapter describes the role of the nurse when administering med- ications, and outlines the principles of safe administration of medica- tion by the commonest routes. By the end of this chapter you will be able to do the following: state and apply the five Rights (5 Rs) of safe drug administration outline the A–F points for safe practice calculate a common drug dose undertake safe administration of oral, rectal, parenteral and eye medications under supervision. Administering medication The administration of medications is controlled by three Acts of Parliament – the Medicines Act (1968), the Misuse of Drugs Act (1971) and the Poisons Act (1972) – and a Statutory Instrument – the Misuse of Drugs Regulations (1985). These provide the framework within which medicines are stored, transported, prescribed, recorded, dispensed and administered. The British National Formulary (BNF) provides a summary of the key legal issues for health care practitioners, which is beyond the scope of this chapter but can be referred to for 93 Key Nursing Skills further guidance. You should also familiarize yourself with local policies and guidelines, which should be available in your workplace for reference. Advances in treatment and drug therapy progress rapidly in nurs- ing and medicine, and as professional research and knowledge expands so must your repertoire of knowledge, to underpin safe practice. The guidelines for safe practice are outlined in this chapter but it is the responsibility of individual practitioners check the product informa- tion of each drug during its administration, in order to verify the dose, route, time, method of administration and contraindications. When administering the drug you must ensure that proper procedures have been followed. Administering drugs by different routes and for various purposes is a common activity in nursing. The UKCC Guidelines for the Administration of Medicines emphasize that ‘in administering any medication, or assisting or overseeing any self administration of med- ication, you must exercise your professional judgement and apply your knowledge and skill in the given situation’ (2000: 4). This means that you should have: knowledge of the drug know its effects and potential side effects know the patient’s condition assess the suitability for that medication at that given time. The five Rights (5 Rs) of drug administration The responsibility for administering medication safely is one which nurses take seriously, and to assist in this procedure the five Rights (5 Rs) of drug administration have been devised: Right patient Right drug Right dose Right time Right route. Right patient Check the identity of the patient with his identification band, using hospital number or date of birth as additional verification. If patients 94  Drug administration are long-stay residents, identification may be by photograph, rather than an impersonal name band (Williams 1996). In the home setting you should satisfy yourself that you have identified the right patient for medication by asking them their full name or date of birth to verify against the prescription. Right drug Drug names can be complex, and have similarities between names. Check for clearly written prescriptions, matching the name on the medication container. In hospital, drugs are prescribed by their gener- ic names, and patients may be confused and think that they are having a new medication. If in doubt, consult the BNF for the generic and trade name of the drug. Check three times during the procedure: when you take the drug from the cupboard or trolley before you pour it into the medication receiver, matching it to the drug name on the prescription sheet as you return it to the cupboard or trolley. Right dose This should be clearly written on the prescription sheet. If the dose is very small, then micrograms should be written out in full (BNF). Calculate the dose carefully (page 99) and check to see if there is a drug with the same name but dispensed in different strengths. TIP! Iftheyou need to calculate the dose, make sure you know what usual dose is likely to be so that if your calculations result in an unusual number, like six tablets rather than two, you are alerted to check it again, preferably with another person. Right time Most drugs are designed to be given with an interval of several hours apart to provide a consistent therapeutic blood level. If given haphaz- ardly, then the medication will be less effective or may cause the patient to develop unwanted side effects. Therefore, it is essential to give doses at prescribed intervals and to record the actual time of administration. 95  Key Nursing Skills Right route Medications are given licences for specific routes of administration. It is possible to give medication by the wrong route, for example, an intramuscular injection may be given intravenously if sited in the wrong place. The A–F of safe practice To ensure safe administration, some other principles can be considered. These are listed below as the A–F of safe practice: Accurate prescription Best information Correct dispensing Deliberation before administration Effective systems Fail-safe policies. Accurate prescription Prescription sheets should be clearly written, and should include the patient’s name and hospital number, weight and allergies – or state ‘no allergies known’. It should include the doctor’s signature, and the date of commencement or discontinuation of medication. The generic name of the prescribed drug should be used. Abbreviations should not be used for micrograms or nanograms. Doses should be in specific met- ric measures rather than number of tablets, for example, paracetamol 1 g rather than paracetamol 2 tabs. Following administration, all docu- mentation should be completed accurately and legibly, and using the accepted local abbreviations, for example if the patient is ‘nil by mouth’ and cannot take his medicine, then that should be recorded on the prescription sheet. TIP! Ifmedical you withhold a drug for any reason, make sure that the staff know. It may need to be given by another route, or its suitability for that patient may need to be reviewed. Best information Your patient has a right to ask you about his medication, and you should be able to explain what the medication is for. The patient may 96 Drug administration not wish to take his medication without knowing how it may affect him. A nurse’s role is to teach the patient about his medications: how and when to take them recognizable effects and side effects when, if ever, to stop the treatment. Understanding medication is more likely to help your patient follow his treatment. When you are administering the medication you should be able to easily access drug information in the clinical area, such as the British National Formulary (BNF) or Data Compendium sheets. If you are unfamiliar with the drug, it is good nursing practice not to administer the drug until you have familiarized yourself with the expected effects and side effects and requisite patient monitoring during the course of treatment. Always consult the pharmacist if you have any uncertain- ties about a drug. Correct dispensing Pharmacists dispense many medications daily and may occasionally make errors. The nurse should ensure that the dispensed drug is correct against the prescribed drug. This is particularly necessary when the drug has been prepared in the pharmacy and is ready for administration without further preparation in the clinical area. The dose, labelling and prescription should be checked for any peculiarities before admin- istration. If you are unfamiliar with the dose or drug do not assume that it is right. Confirm the dose rather than cause a severe error. Deliberation before administration It is easy to be sidetracked and distracted from tasks in a busy clinical area where there are many interruptions. Medication errors may result because such distractions can prevent busy nurses from recognizing warning signals during the procedure. It is important that drugs are pre- pared in a quiet location if possible, and that the task is completed before another begun. It is also important that nurses should feel able to stop and think, to check when uncertain and to gather additional information to clarify any questions they may have about the drugs that are being prepared (Colleran Cook 1999). 97  Key Nursing Skills Effective systems Studies have demonstrated that if systems and procedures are not fol- lowed, there is an increased likelihood of medication errors (O’Shea 1999). A counter check against error can be provided by the use of a structured routine, such as this: always use the prescription chart, and do not administer from memory always check patient identification – even when the patient is well known never administer something you did not witness being prepared do not leave drugs on lockers to be taken later do not return an unused dose to a stock bottle never leave an open drug cupboard or trolley unattended. Such systems should alert you to danger signals that may lead to an error, thereby adding security to the proceedings. Fail-safe policies The Trust that you work for should have clear policies concerning the mechanisms, supervision and training for drug administration, and for reporting ‘near misses’. These should be followed not only to prevent error and subsequent litigation but also because such policies encour- age good practice. However, there may be changes in knowledge and clinical practice that become accepted practice within the Trust, but are not recorded immediately within Policies (Colleran Cook 1999). You may need to ensure that your Manager is aware of these changes in practice to ensure that the local Policies reflect actual current prac- tice. For example, to reduce errors and spread the workload, your unit may decide that night staff will not give drugs in the morning but wait for the day staff to do it. Local policy may need to take that change into account so that nursing and medical staff are all aware of it. TIP! your To reduce potential errors you should only administer drugs to group of patients, so that you are familiar with their par- ticular needs. Also, consider the timing of doses. If a patient needs to take some medication before and some after his meal, don’t be tempted to give it to him all at once, relying on 98 Drug administration him to remember to take them after eating. He may leave the medicine on his locker and either forget it or another patient may take it by mistake. It takes longer to sort out mistakes than to go to your patient twice! Calculating drug dosages It is important in drug calculations to be able to understand the values of the drug doses and their relationship to one another. The measurement of weight for drugs is expressed in grams (g), milligrams (mg) and micrograms (mcg). Patients are weighed in kilo- grams (kg). The measurement of fluid volumes is usually expressed in litres (l) or millilitres (ml). 1 kilogram = 1 000 grams 1 gram = 1 000 milligrams 1 milligram = 1 000 micrograms 1 litre = 1 000 millilitres Converting measurements To change kilograms to grams, multiply by 1 000: e.g. 5 kg × 1 000 = 5 000 g To change grams to milligrams, multiply by 1 000: e.g. 5 g × 1 000 = 5 000 mg To change milligrams to micrograms, multiply by 1 000: e.g. 0.625 mg × 1 000 = 625 micrograms To change milligrams to grams, divide by 1 000: e.g. 500 mg ÷ 1 000 = 0.5 g To change micrograms to milligrams, divide by 1 000: e.g. 250 mcg ÷ 1 000 = 0.25 mg Calculating drug dosages To calculate drug dosages the following formula may be used: What you want × total volume = dose required What you’ve got 99  Key Nursing Skills Example: a prescription requires 30 mg of a drug that is dispensed as 60 mg in 5 ml What you want: 30 mg 30 × total volume: 5 ml = × 5 = 2.5 ml required What you’ve got: 60 mg 60 It is important to ensure that the units are consistent in the calcula- tion, i.e. either all milligrams or all micrograms. If the numbers are not all converted to the same units, drug errors up to 1 000 times too big or too small may occur. Example: a patient is prescribed Nifedipine 0.06 g. Tablets of Nifedi- pine are 20 mg strength. How many should be given? What you want: 0.06 g × volume: 1 tablet = dose required What you’ve got: 20 mg First the decimal 0.06 g must be converted into a whole number, con- sistent with the drug as dispensed: 0.06 g × 1000 = 60 mg The formula can then be used: 60 mg × 1 = 3 tablets 20 mg NURSING PROBLEM 6.1 Patient history: Mr Jenkins has just been admitted with worsening of Parkinson’s disease. He has come in to have his medication reviewed. He can be very stiff, shaky and slow at times, especially when he has to pick up his pills. 100 Drug administration Problem: Mr Jenkins requires assistance with his oral medication at times. Goal: Mr Jenkins will be assisted to take his oral medication when necessary. Oral medication The oral route is the safest, most convenient and least expensive route for medication delivery. Oral drugs are available in many forms of tablets, capsules or granules, or liquids such as syrups, or suspen- sions. Most are suitable to be swallowed without further preparation, but some may need dissolving or mixing before consumption. If patients cannot swallow their medication because it is in an inappro- priate preparation, such as a large tablet, advice from the pharmacist should be sought to see if an alternative preparation is available. Planning If several patients are to receive their medications at a set time, it is an acceptable practice to use a trolley stocked with all the equipment required (Williams 1996). Ideally this should be the group of patients that you are currently caring for. This equipment should include: stock and specific personal prescription drugs – ensure adequate supplies, within expiry date medicine pots – to dispense individual medication disposable cups – to provide a drink to assist easy swallowing of medication, or to dissolve tablets if necessary water jug, freshly filled, to ensure water is easily available straws – some patients find it easier to take unpalatable medicine through a straw, and a straw may help a patient with swallowing difficulties to wash tablets down more easily teaspoons or medicine spoons – to put tablets into a patient’s mouth without contaminating the medication tissues – to cut up tablets in if necessary pestle and mortar – to crush tablets if necessary (NB: check with pharmacist that a liquid form is not available, and that the tablet is suitable to be crushed) 101 Key Nursing Skills tablet file or cutter or knife – to divide a tablet evenly (NB: check with pharmacist that smaller doses are not available and that the tablet is suitable for cutting) note pad – to keep a record of actions that are to be taken as a result of medication, e.g. re-ordering medication or discharge drugs, or returning to check BP or peak expiratory flow drug reference book, e.g. BNF – to check unfamiliar doses or drugs. Intervention: oral drug administration 1. Wash and dry hands. 2. Consult Mr Jenkins’ prescription sheet. For regular drug adminis- tration times, work systematically from the front page of the pre- scription sheet to identify the following issues: – Has Mr Jenkins any known allergies? – What medication is due, e.g. regular doses? When was it last given? – Once-only prescriptions, such as pre-medications: when are they due, or have they been given? – Variable doses – these may need to be updated as a result of blood tests; therefore, are they current? Check date. – Is analgesia required? If so, when was the last dose and was it effective? If opioids are prescribed, has the patient had all the doses, or should the analgesia needs be reviewed? – Progress of any current intravenous therapy – if a patient has an intravenous infusion in place, then it is an ideal opportunity to check (a) that it is running to time and (b) sufficient is prescribed for the patient’s needs over the next shift (see Chapter 7). 3. Check each medication prescribed for dose, time, date, route and doctor’s signature. 4. Select the medicine bottle, checking the name of the drug with that on the prescription sheet. If Mr Jenkins needs to have a pre- medication check of pulse, blood pressure or peak expiratory flow, now is the time to do that. 5. Calculate the dose. 6. Tip the required number of tablets into the lid of the container (Figure 6.1). If working with another nurse, show the name of the container and the number of tablets to the other person, stating the written dose aloud. 102  Drug administration Figure 6.1 Decanting tablets into container lid. 7. Tip the dose into the pot. If measuring liquid: ensure the lid is on firmly and then shake the bottle to ensure the contents are well mixed. Put the pot on a level surface, pour the liquid into it, turn- ing the bottle label away so that it does not get dripped on and obscured by medicine. Pour to the required level (Figure 6.2). TIP! Ifpatient, medicine needs to be dissolved before you give it to the put it into a disposable cup and let it dissolve whilst you are checking the other medicines and preparing him. 8. Take the medication to Mr Jenkins. 9. Greet Mr Jenkins by name and check identity against the pre- scription sheet label. 10. Assist Mr Jenkins into an upright position to aid swallowing. 11. Ensure he understands the sequential order to take the medica- tion; for example, antacids are taken after other tablets. Provide a Figure 6.2 Measuring liquid dose. 103  Key Nursing Skills drink, and assist him to take the medication, offering tablets on a spoon if required. Ensure all medicines are taken before you leave Mr Jenkins. Do not leave any medicines beside the bed to be taken later. They may get forgotten, knocked over, or consumed accidentally by someone else. 12. Document the drug dose and time. If Mr Jenkins has refused the medication or is nil by mouth, record on the prescription sheet the reasons for withholding the dose according to the local policy code. Report to medical staff. 13. Dispose of waste and used containers. 14. Monitor Mr Jenkins for effects such as degree of pain relief, or side effects such as nausea or rashes, and document as necessary. TIP! Strong-tasting liquids are more palatable if taken through a straw as they do not come into contact with so many taste buds. If patients are reluctant to take their medication, crushing their tablets and putting them into food or drink may change the action of the drug. The UKCC (2001) advises that disguis- ing medication in food or drink may be justified as being in the patient’s best interests if the patient is refusing medication, but not if the patient is sufficiently rational to make an informed consent to treatment. It should not be done as a regular practice but only as a contingency measure, and never for the convenience of health care professionals. Sublingual and buccal medications These are designed to be released slowly by dissolving in the mouth and absorbed through the oral mucosa. The same procedure is followed as above, but for a sublingual medication such as glycerine trinitrate (GTN) the tablet is positioned under the tongue (Figure 6.3). Some patients may place a GTN tablet under the tongue to relieve angina, and when the pain has reduced, may then swallow the tablet to allow it to be absorbed more slowly. Not all sublingual drugs can be taken like this, and swallowing the tablet is usually contraindicated. Patients should therefore not drink until after the drug has dissolved; consequently, if sub- lingual drugs are to be taken, administer them after other medications. Buccal medication is positioned between the gum and the cheek, and can be placed beside either the upper or lower jaw (Figure 6.4). The position should be changed each time to prevent local irritation 104  Drug administration Figure 6.3 Sublingual tablet. Figure 6.4 Buccal tablet. occurring. The patient should not drink until after the tablet has dis- solved. Therefore, all other medication should be taken first. TIP! When checking sublingual or buccal tablets, put them into a separate pot from the other tablets so that they are easily identifiable and are not swallowed by mistake. Evaluation Did Mr Jenkins manage to take his oral medication? Do you need to find alternative preparations? NURSING PROBLEM 6.2 Patient history: Mrs Easton has suffered a stroke and is unable to swallow (dysphagia). She cannot take anything by mouth. Problem: Mrs Easton cannot take medication orally and requires medication via nasogastric (NG) and intramuscular (IM) routes. Goal: Mrs Easton will safely receive medication via NG and IM routes. 105 Key Nursing Skills Nasogastric drug administration This route is effective for patients who cannot swallow, but whose gas- trointestinal tract is functioning. It enables patients to take medication without experiencing unnecessary injections and so reduces the risks associated with intravenous therapy (see Chapter 7). Drug absorption rate is the same as the oral route, but some drugs may be less effective if not prepared correctly. Naysmith and Nicholson (1998) identify four considerations when administering nasogastric drugs: choice of preparation timing drug interaction with enteral feeds administration via the tube. Choice of preparation Ideally, the medication should be in liquid form. Should a liquid pre- paration not be available, some tablets will dissolve or the pharmacy may be able to prepare a suspension. Capsules may be aspirated by needle and syringe or dissolved in water, and the liquid administered. Granular capsules may be opened and mixed with water. Tablets may be crushed in a pestle and mortar or between two spoons. All tablet residues should be mixed with water and drawn up into a syringe for administration to ensure the correct dose is given. ALERT! Enteric-coated medications, modified-release preparations and some hormones and cytotoxic drugs should not be crushed as it changes the chemical actions of the drugs. It is imperative to check with the pharmacist the preferred way of preparing each of these types of medication to ensure that the drug is given correctly. Timing If medication should be taken on an empty stomach, it is advisable to stop the feed for 30 minutes before administration, and resume the feed 30 minutes afterwards. The exception to this is Phenytoin (Naysmith and Nicholson 1998), which requires a break from 106 Drug administration feeding for two hours before and after the feed to allow full absorption of the drug. Interaction with the feed Drugs should not be added directly to the feed and given simultan- eously as a chemical reaction with the feed may occur, blocking the tube. To avoid potential infection from entering the feed, medication and feed should not be mixed together. Administration procedure Equipment Water container (sterile water may be the preferred requirement in some acute Trusts). 50 ml bladder syringe or luer lock syringe depending on type of NG tube. 20 ml luer lock syringe and needles. pH indicator paper. Receiver. Medication pot with prescribed medications. Container for mixing medication. Clamp for NG tube. Cap for NG administration tube. Absorbent pad or towel. Procedure The procedure described above for oral medication (page 102) for administering a drug should be followed, but with the following addi- tional considerations: 1. Wash your hands and take the prescribed medication to Mrs Easton. Check her identity. 2. Position Mrs Easton in a semi-recumbent position to reduce reflux. Explain the procedure to her and provide privacy. Protect the pillow with a towel or absorbent pad to catch any drips. 3. Turn off the feed and clamp the NG tube. Cap the administration tube and put to one side, ensuring that the tube does not get con- taminated from other surfaces. 107  Key Nursing Skills 4. Confirm the position of the NG tube in the stomach by aspirating gastric contents and checking pH (see Chapter 9). Clamp the NG tube. 5. Prepare the medication. After crushing the tablets, mix them with 15–20 ml of water and draw up into the smaller syringe, rinsing the pestle with water to ensure a full dose. TIP! Ifoneusing liquid preparations, pour them into the measuring cup at a time. Do not mix medications in the same container: if some is spilt, you will have no way of determining what drugs have or have not been given. 6. Attach the bladder syringe or the larger luer lock syringe without the piston attachment to the NG tube. This will act as a funnel. Hold the syringe slightly above Mrs Easton’s nose height to pre- vent backflow. TIP! NG tubes can be clamped by kinking the tubing to prevent air from entering the patient’s stomach (Figure 6.5). 7. Slowly pour the medication from the small syringe or cup into the barrel of the larger syringe, ensuring that the large syringe is held upright, and unclamp the NG tube. Raise the tube to speed the flow (Figure 6.6.1) or lower the height of the syringe to slow the flow (Figure 6.6.2). To prevent air from entering the patient’s stomach, add fluid to the larger syringe before it empties com- pletely. If resistance is felt or the tube is blocked, do not force the flow. Check the position of the NG tube by aspiration, and Figure 6.5 Kinking nasogastric tube. 108 Drug administration flushing with additional water in case a drug particle has obstructed the NG tube. 8. Flush with 5–10 ml of water between each drug, and 30–50 ml on completion of administration, now allowing the tube to empty. 9. Clamp the tube and remove syringe. 10. Reconnect to the feeding pump if required, ensuring the cap is removed from the administration set. 11. Position Mrs Easton comfortably before leaving her. 12. Document the drugs given and record the amount of fluid given on the fluid balance chart. 13. Wash equipment and dispose of all waste. Controlled drugs These are drugs whose prescription and use is governed by the Misuse of Drugs Act (1971), as they are potentially addictive. In the hospital setting, controlled drugs (CDs) are ordered by a registered nurse, in a duplicated order book, which must be signed when receiving drugs Figure 6.6.1 Figure 6.6.2 Figure 6.6.1–2 Raising and lowering NG tube. 109 Key Nursing Skills from pharmacy. Each administration of CDs is recorded in a record book kept solely for that purpose. Both the order book and record book must be retained for two years after completion. Security of controlled drugs Controlled drugs are stored in the clinical area in a designated secure locked cupboard, which is used only for CDs and to which access is restricted. The nurse in charge of the area usually holds the keys but may delegate responsibility for them, therefore delegating the security of all medications to another nurse during the shift. It is essential that these keys are kept on a specific person at all times and never left lying around, for example, in a drawer or on a worktop. Routine checks of the CD stock may be made at regular intervals in a clinical area, depending on local policy, to ensure that the stock tallies with the record book. Each page should be a record of only one drug. To check and administer a controlled drug Two people should be involved in the administration procedure of all controlled drugs, and where these two are nurses, one must be a registered nurse. The prescription is checked as for usual medication. In addition, consider the time of the previous dose of controlled drug – is it within the prescribed time period? Has the patient already received his allotted dose? Take the appropriate drug from the locked cupboard and compare it with the prescription sheet. Verify the dose and name of the drug. Check the quantity in the box with the record book and remove the drug from the container. Check that the remaining ampoules or tablets tally with the record book, and return the remainder to the cupboard and lock it. Check the dose required, route, time, and patient’s identity on the prescription. Prepare the appropriate amount of drug required, discarding any excess in the sink. In the controlled drug record book, document (a) the patient details, (b) date and time, (c) dose given, (d) dose discarded, and (e) the amount of remaining stock. 110 Drug administration Both persons should go to the bedside, where the patient’s iden- tity should be confirmed and the prescription dose, time and route should be checked again. Administer the medication by the prescribed route, and document this on the prescription sheet and in the controlled drug record. There should be no cancellation of entries, but if corrected they should be countersigned and cross-referenced if incorrect. Entries should be indelible, and the book should not be used for any other purpose. Intramuscular (IM) injections Injections deliver medication directly into the body and are not retriev- able. It is essential, therefore, to be accurate in identifying safe entry points for injections, and to take the utmost care in administering med- ication by the parenteral route. The intramuscular route delivers injec- tions directly into muscles which have an efficient blood supply and can absorb from 1 ml to 5 ml of medication, depending on the site. Considerations before administration by the IM route The patient’s age: elderly patients may have muscle wasting which may limit the choice of site, and babies who are not yet walking may have underdeveloped muscles, particularly in the buttocks. General physical status: emaciated or cachectic (extremely debil- itated) patients may also have muscle wasting or poor perfusion and skin condition. Oedematous limbs will not absorb medication as effectively as those with good perfusion. The drug therapy: the amount to be given, and the frequency and consistency of medication will influence the choice of location. For example, a depot injection (long-term slow-release action) will require a deep muscle, to allow sufficient slow absorption over a period of time. Assessment of appropriate site There are five sites that may be used for IM injections: deltoid (Figure 6.7); dorso-gluteal (Figure 6.8); ventro-gluteal (Figure 6.9); and the thigh muscles – vastus lateralis and rector femoris (Figures 6.11.1–2). 111 Key Nursing Skills Prior to injection, the proposed site should be inspected for signs of inflammation, swelling or infection; areas of skin damage should be avoided. If a course of injections are to be given then a record of each site should be documented to avoid using the same area too frequent- ly, as complications such as muscle atrophy or a sterile abscess may occur (Springhouse 1993). Locating deltoid site The densest part of the muscle can be located on the mid-lateral aspect of the arm in line with the axilla, and about 2.5 cm below the acrom- ial process (Figure 6.7). This avoids the radial nerve and brachial artery. Positioning the hand on the hip causes the muscle to relax and makes it easier to access (Workman 1999). The typical absorption volume is no greater than 1–2 ml. Dorso-gluteal site The patient should lie either on their side with knees slightly bent, or prone with toes pointing inwards (Figure 6.8). An imaginary line is drawn across from the cleft of the buttock to the greater trochanter of the femur. Then a vertical line is drawn midway across the first line, and the outer quadrant is identified. This quadrant is then divided into four quadrants: the desired location is the upper outer quadrant (Campbell 1995). The aim is to access the gluteus maximus muscle, and to avoid the sciatic nerve and gluteal artery. The typical absorp- tion volume is 2–4 ml. Figure 6.7 Deltoid site. 112 Drug administration Figure 6.8 Dorso-gluteal site. Ventro-gluteal site The patient can lie on either side with knees slightly flexed. Place the palm of your right hand onto the left greater trochanter (or right hand onto left hip), and extend the index finger towards the superior iliac crest. If you have small hands, start with the palm of the hand on the greater trochanter, and slide the hand up until the tip of the index finger touches the iliac crest (Covington and Trattler 1997). Stretch out middle finger to form a V and the injection should be located into the centre of the V. This will enter the gluteus medius and minimus muscles (Figure 6.9). There have been very few complications docu- mented from the accurate use of this site (Beyea and Nicholl 1995). The typical absorption volume is 2–4 ml. Figure 6.9 Ventro-gluteal site. 113 Key Nursing Skills Figure 6.10 shows the proximity of the dorso-gluteal site to the ventro-gluteal site. Figure 6.10 Proximity of DG and VG sites to each other. Vastus lateralis and rector femoris These quadriceps muscles (Figures 6.11.1–2) are particularly good for toddlers or patients who have wasted muscles as they can be ‘bunched up’ before injecting (Figure 6.12; Springfield 2000). They can be locat- ed by measuring a hand’s breadth down from the greater trochanter, and a hand’s breadth up from the knee, identifying the middle third of the muscle as the safe location. The vastus lateralis is located on the side of the leg, and the rector femoris is at the front of the thigh. The typical absorption volume is 1–4 ml. Figure 6.11.1 Vastus lateralis site. Figure 6.11.2 Rector femoris site. Figure 6.11.1–2 Locating vastus lateralis and rector femoris sites. 114 Drug administration Figure 6.12 Bunched-up muscle. Intervention: intramuscular (IM) injection Equipment 2 ml or 5 ml syringe (depending on amount for injection). 2 × 21 (green) or 23 (blue) gauge needle. Note: a large needle should be used for adults to ensure that it reaches the muscle layer. Short needles may result in the injection going into the adipose tissue, resulting in reduced effectiveness (Cockshott et al. 1982). Alcohol wipe – if required by Trust policy. Gauze swab. Receiver. Prescribed drug and prescription sheet. Gloves – to protect from drug spillage and body fluids. Apron – if required by Trust policy for protection as above. Preparing the injection This is an aseptic procedure (see Chapter 11) and therefore all equip- ment should be sterile. Every effort should be made to prevent con- tamination of equipment during the procedure. Check all equipment to ensure it is sealed and used within expiry date. Wash hands and put on gloves. Prepare drug vial. Carry out the same checks as described in the procedure for oral drug administration (page 102). If a glass ampoule is used, flick the top of the ampoule to encourage all fluid to drain into the reservoir. Use a tissue or piece of gauze to pro- tect your fingers from glass cuts when breaking the top off the 115  Key Nursing Skills ampoule. If a vial with a rubber bung is being used, remove the cover using scissors or forceps to prevent injury to your fingers; clean the rubber bung with an alcohol wipe. Assemble needle and syringe, taking care not to touch the needle, except for the barrel when connected to the syringe. Uncap the needle. It is best practice never to resheath an un- capped needle, even if unused, to prevent needlestick injuries. To dilute a drug – if the drug requires mixing with a diluent, or if you are drawing fluid from a closed vial – draw up the equivalent amount of air into the syringe, steady the vial on a flat surface with one hand, and insert the syringe into the vial and inject the vial with the air (Figure 6.13). This will make it easier to withdraw. The vial can be gently rolled on the palm of the hand to aid mixing. Ensure drug is dis- solved before aspirating the medication into the syringe. Figure 6.13 Inserting air into vial. TIP! When drawing up a drug keep the needle bevel under the fluid level at all times to reduce the amount of air drawn up in the syringe. Adjust the angle of needle and syringe to a V shape (Figure 6.14) while drawing up. Withdraw required amount into the syringe. Remove the vial, and holding the syringe with the needle uppermost, tap the syringe firmly to encourage air bubbles to rise to the top to be expelled. Larger syringes may have the connection on the side, rather than the middle of the syringe. To aid the air to rise to the top, tip the syringe to a slight angle so that the air collects under the connection, and keep it at that angle until all the air is expelled (Figure 6.15). This ensures an accurate dose. 116  Drug administration Figure 6.14 V-shape to draw up injection. Figure 6.15 Expelling air from syringe. Change the needle. This ensures that the injection is given with a clean, dry, sharp needle thus reducing pain (Beyea and Nicholl 1995), and prevents a possible sharps injury resulting from transporting the injection to the patient. TIP! Recheck the amount of dose in the syringe after you have expelled the air to make sure that you still have the right amount in the syringe and did not lose any when changing the needle. If the dose is very small do not expel the air until after you have changed the needle so that there is minimum wastage. Administering the injection The reason for the injection should be explained to Mrs Easton, so that she can give her verbal consent. This may be done prior to preparing the injection in case Mrs Easton would like to prepare herself, for example, by visiting the toilet or warning her visitors. 117 Key Nursing Skills Procedure Take the prepared injection and prescription sheet to Mrs Easton’s bedside. Call Mrs Easton by name, and confirm her identity and consent. Close the curtains to provide privacy, and assist Mrs Easton into an appropriate position depending on the chosen injection site, draping the bed and her nightclothes to protect her dignity but allowing access to the site. Locate the site by identifying the anatomical landmarks and encourage the patient to relax. If local policy dictates, the skin should be cleaned with an alcohol swab for 30 seconds and allowed to dry for 30 seconds (Simmonds 1983). If the patient is physically clean and the nurse maintains hand hygiene and asepsis during the procedure, additional skin preparation may not be necessary. Remove the needle cap, stretch the skin taut with thumb and index finger of your non-dominant hand. Position the needle just above the skin at a 90° angle, holding the syringe barrel like a dart. Warn Mrs Easton that she will feel a sharp prick. Insert the needle three-quarters of its length in, using a dart-like action. Aspirate to allow any blood to surface. Should any blood appear, remove the needle and discard the injection. The procedure will have to be recommenced. Continuing with the injection could result in the injection being given intravenously. If no blood is aspirated, proceed with the injection, injecting slowly at a rate of approximately 1 ml in 10 seconds. On com- pletion, allow about 10 seconds before removing the needle to allow the muscle to accommodate the fluid (Beyea and Nicholl 1995). Remove the needle at a 90° angle and place in the receiver. Apply gentle pressure to the site with gauze. Make Mrs Easton comfortable. Ensure she can reach the call bell should she require any assistance, and that she has all she needs at hand. Draw the curtains. Remove all equipment and dispose of sharps safely. Discard apron and gloves. 118  Drug administration Record the dose on the prescription chart. Document additional information, such as choice of site and effect of medication in the nursing notes. Z track technique The Z track technique was originally used for drugs that stain the skin or are particularly irritant. Beyea and Nicholl (1995) recommend it as a method to reduce pain and leakage from intramuscular sites. Following location of site use the thumb to pull the skin about 3 cm to one side (Figure 6.16). Insert the needle at 90°, release the thumb. Administer the injection as above. Return the thumb to retract the skin, and then remove the needle. Remove thumb and allow skin to return to usual position. TIP! Twelve steps towards a painless injection (Workman 1999): 1. Prepare patients with appropriate information before the procedure, to aid their compliance and cooperation. 2. Change the needle after preparation and before adminis- tration to ensure it is clean, dry and sharp and the correct length to enter muscle layer. 3. Make the ventro-gluteal site the preferred choice to ensure the medication reaches the muscle layer. 4. Position the patient so that the chosen muscle is flexed. Figure 6.16 Z track technique. 119  Key Nursing Skills 5. If cleaning the skin before injecting, ensure it is dry before injecting as alcohol can cause stinging. 6. Consider using ice or freezing spray to numb the skin before injecting, particularly for needle-phobic patients or children. 7. Use the Z track technique. 8. Rotate injection sites and document so that no one site is overused. 9. Enter the skin firmly with a controlled thrust, positioning the needle at an angle of 90° to prevent shearing and tis- sue displacement (Katsma and Smith 1997). 10. Inject medication steadily and slowly – about 1 ml per 10 seconds – to allow the muscle to accommodate the fluid. 11. Wait 10 seconds after completion of the injection to allow diffusion through the muscle. Then remove the needle at the same angle as it entered. 12. Apply gentle pressure but to prevent local tissue irritation do not massage the site afterwards. Evaluation Did Mrs Easton receive her medication by the most effective route? NURSING PROBLEM 6.3 Patient history: Mrs Bell is a young woman who has just been diag- nosed with Type 1 insulin-dependent diabetes mellitus. Problem: Mrs Bell needs to learn how to administer her insulin subcutaneously. Goal: Mrs Bell will be able to safely administer her insulin sub- cutaneously. Subcutaneous (SC) injections Small amounts of medication (0.2–2 ml) are given into the sub- cutaneous tissue to allow a slow, sustained absorption of medication. It 120 Drug administration is an ideal route for insulin, which requires frequent injections, but is also used regularly for heparin. Preferred sites for self-administered SC injections are the outer upper arms, the upper thighs, and the lower abdomen around the umbilicus (Figure 6.17). Nurses can also use the back of the upper arms, outer thighs and upper buttocks but these are not accessible for self-administration. Figure 6.17 Subcutaneous injection sites. If SC medications are administered into the muscle, it will increase the absorption rate of the drug and in the case of insulin may result in hypoglycaemia: it is important, therefore, to ensure the injec- tion does not go too deep. Intervention: administering subcutaneous injections Equipment Insulin syringe or 1 ml syringe. If injecting insulin use an insulin syringe with a 25 or 27 gauge needle. (Patients may prefer to use an insulin pen of which there are several types.) 2 × 25 or 27 gauge needles (orange). Gauze swab. Receiver. Prescribed drug and prescription sheet. 121 Key Nursing Skills Preparing an insulin drug dose Preparing an insulin dose may require drawing up from more than one multi-dose vial. The following procedure explains how to do this, and allows you to draw up from an ampoule that has a vacuum in it. If the air were not injected first, it would be very difficult to withdraw insulin as the vacuum within the ampoule would draw in the contents of the syringe and cause mixing of the two different types. To prepare an injection from two multi-dose vials (Figure 6.18): Figure 6.18 Drawing up from a multi-dose vial. Clean the rubber bung on both vials with an alcohol wipe. Draw air into the syringe to equal the volume of drug to be with- drawn from the first vial. With the first vial on a flat surface, insert the needle into the first vial. Do not touch the liquid with the needle, but inject the air and remove the needle. Draw air into the syringe to equal the volume of drug to be with- drawn from the second vial, insert into the second vial, and inject the air. Then invert the vial and withdraw the required dose, tap to remove air bubbles and expel, and remove needle from vial. Return to first vial, clean rubber bung, insert needle, invert vial and withdraw required amount carefully. Remove needle and expel air, taking care not to lose any of the first drug. If necessary change the needle before administration. Some dis- posable insulin syringes have an integral needle which cannot be changed. This is the only time that you would resheath the needle 122 Drug administration to prevent (a) needlestick injury during transportation to the patient, and (b) contamination of sterile equipment (Figure 6.19). Figure 6.19 One-handed resheathing of needle. Procedure The first stages of the procedure are the same as those described for oral drug administration (page 102). Take equipment to Mrs Bell and confirm her identity. Provide privacy. Locate site. Do not use if there is swelling, redness, bruising or lumps. Patients that use insulin should be taught to systematically rotate within an anatomical area, as absorption rate varies dep- ending on anatomical location (Peragallo-Dittko 1997). Other medications given subcutaneously such as heparin should also be rotated within an area to reduce bruising. Pinch up a fold of skin to lift the adipose tissue away from the muscle, and insert insulin needle at 90°. WARNING! If not using insulin equipment for SC injection the needle is longer and therefore needle entry should be at 45°. Release the skin fold and inject slowly and steadily. 123  Key Nursing Skills Withdraw needle, and if bleeding occurs apply light pressure with gauze swab. Discard equipment. Document which site has been used and record administration of the drug. TIP! SC injections do not require skin cleansing beforehand, pro- vided the patient is physically clean. Also, you don’t need to aspirate before injecting as the risk of puncturing a blood ves- sel is remote (Peragallo-Dittko 1997). Evaluation Mrs Bell is able to administer subcutaneous insulin correctly. NURSING PROBLEM 6.4 Problem: Mr Elland requires rectal medication to treat an inflamed colon. Goal: Mr Elland will safely receive rectal medication to relieve dis- comfort. Rectal medication Rectal medication bypasses the upper gastro-intestinal tract, avoiding liver metabolism and therefore working quickly. It is suitable for patients who are unconscious, unable to swallow or are vomiting. Drugs given by suppository or enema can produce a local effect – e.g. to relieve constipation or treat local inflammation – or can work sys- temically – e.g. to provide pain relief. Before administering medications rectally you should check the anal area to ensure there are no signs of rectal bleeding, skin tags, recent anorectal surgery, undiagnosed abdominal pain or paralytic ileus (Addison et al. 2000), as the procedure may aggravate these condi- tions. An unhurried and gentle approach should be taken to adminis- tering medication rectally, because the procedure can induce vagal 124 Drug administration stimulation resulting in bradycardia and vasodilation (Campbell 1994), and on rare occasions may cause the patient to collapse. Intervention: administering suppositories Equipment Tray. Prescribed suppositories – as per prescription or by group protocol. Disposable gloves and apron. Lubricant: either water for glycerine suppositories, or water-based lubricant. Tissues or gauze swabs. Protective bed cover such as incontinence pad. Waste disposal bag. Easy access to toilet, bedpan or commode. Procedure Prepare to administer medications as described for oral adminis- tration of drugs (page 102). Wash hands and prepare equipment. Prepare Mr Elland. Ask Mr Elland to empty his bladder to reduce pelvic discomfort. If the medication is for systemic effect, ask him to empty his bowel if he is able. This will ensure an empty rectum and facilitate absorption. He should give his verbal consent to treatment. Encourage Mr Elland to relax as much as possible by providing privacy and ensuring that interruptions are prevented. Position Mr Elland on his left side, so allowing the direction of the suppository to follow the natural direction of the GI tract. Bend his knees slightly to aid comfort and ease access to the anus. Cover him with a blanket to maintain dignity and warmth. Protect the bed by placing the incontinence pad under his but- tocks. This will reduce Mr Elland’s embarrassment if there is any discharge or leakage. Put on gloves. Open suppositories and place on gauze or tissue. Lubricate as advised on pack. Glycerine suppositories may be lubricated with water. With your left hand, lift the upper buttock and observe the anal area for evidence of local tissue damage. Encourage deep slow 125 Key Nursing Skills breaths during the procedure should Mr Elland begin to feel uncomfortable, and warn him that he will feel the suppository inserted. Insert suppository. If it is to treat constipation it should be in- serted with the pointed end first (Figure 6.20.1), pushing the sup- pository in with the index finger along the rectal wall until it pass- es the internal sphincter (Springhouse 2000). It should rest next to the rectal mucosa and not in faecal matter or it will be ineffec- tive (Campbell 1994). If the medication is for systemic effect, inserting it blunt end first (Figure 6.20.2) will reduce the patient’s urge to defaecate, and aid absorption (Addison et al. 2000). If more than one suppository is ordered, repeat procedure. Figure 6.20.1 Constipation is treated by inserting suppositories pointed end first. Figure 6.20.2 Blunt end of suppository inserted first for systemic effect Figure 6.20.1–2 Insertion of suppository. 126  Drug administration Gentle pressure on the anal area with a gauze or tissue pad will reduce the desire for immediate defaecation. Encourage Mr Elland to retain the suppository for as long as possible (at least 20 min- utes) for it to be effective, and to rest on his side for at least five minutes to aid retention. Clean perineal area with tissues. Dispose of all waste, removing gloves by turning inside out to prevent cross-contamination. Wash hands. Record administration on the prescription sheet and document the outcome. TIP! Suppositories are easier to administer if kept in the fridge until required unless otherwise stated on the drug information sheet. Intervention: administering enemas Equipment Disposable gloves and apron. Prescribed enema and prescription sheet. Lubrication. Bowl/receiver of warm water. Gauze swabs or tissues. Waste bag. Protective bed cover or incontinence pad. Easy access to toilet, bedpan or commode. Procedure Prepare to administer medications as described for oral adminis- tration of drugs (page 102). Wash hands and prepare equipment. At the bedside remove outer packaging from the enema if neces- sary and place in warm water to raise it to room temperature to reduce shock and bowel spasms. Retention enemas are usually 200 ml or less to promote retention (Addison et al. 2000). Prepare Mr Elland. Ask Mr Elland to empty his bladder to reduce pelvic discomfort. If the medication is for systemic effect, ask him to empty his bowel if he is able, to ensure an empty rectum and 127 Key Nursing Skills facilitate absorption (Heywood Jones 1995). He should give his verbal consent to treatment. Encourage Mr Elland to relax as much as possible by providing privacy and ensuring interruptions are prevented. Position him on his left side, so allowing the enema to flow in the natural direction of the GI tract. Bend his knees slightly to aid comfort and ease access to the anus. Cover him with a blanket to maintain dignity and warmth. If administering a steroid enema, the patient’s bed should have the bottom raised to a 45˚ angle to help retention. Patients receiving steroid retention enemas are likely to have them administered at bedtime to enable the medication to be absorbed overnight whilst resting (Addison et al. 2000). Protect the bed by placing the incontinence pad under his but- tocks. This will reduce Mr Elland’s embarrassment if there is any discharge or leakage. Put on gloves. Ensure enemas are mixed by gentle shaking before administration. Place lubricant on clean gauze and apply to the enema tube. Using fluid from the enema to lubricate the tube may cause local irrita- tion to the anus. Remove the plastic tip from the nozzle of the enema. Expel air through the tube by rolling up the enema bag from the base. Warn Mr Elland that you are about to give the enema and that he will feel the tube and gentle pressure in the rectum. Suggest that he takes deep breaths and tries to relax during the procedure. Lift the upper buttock and gently insert the enema tube into the anus as far along the tube as possible, and allow the fluid to flow into the rectum by gravity (Addison et al. 2000). Roll up the bag as the fluid flows in, to prevent backflow. Tube extensions are available for self-administration (Heywood Jones 1995). Gentle pressure on the anal area with a gauze or tissue pad will reduce the desire for immediate defaecation. Encourage Mr Elland to retain the enema for as long as possible (5–15 minutes for evac- uant enemas) for it to be effective, and to rest on his side for at least five minutes to aid retention. Retention medicated enemas should be retained for at least 30–60 minutes or as long as the patient can hold onto them (Springhouse 2000). 128  Drug administration Clean perineal area with tissues. Ensure easy access to toileting facilities. Dispose of all waste, removing gloves by turning inside out to prevent cross-contamination. Wash hands. Record administration on the prescription sheet and document the outcome. Record any additional observations such as the con- sistency, appearance and quantity of stools. TIP! Caution should be taken with administering phosphate en- emas to elderly or debilitated patients as complications such as trauma to local tissue can occur, causing bleeding. There may be local irritation, or on rare occasions a systemic reaction (Addison et al. 2000). Evaluation Did Mr Elland receive his suppository or enema without discomfort? What was the effect of the medication? NURSING PROBLEM 6.5 Patient history: Mrs Paur is an elderly lady with many medical problems, one of which is glaucoma. Problem: Mrs Paur requires eye drops to treat glaucoma. Goal: Mrs Paur will have her eye drops administered safely. Ophthalmic medication Ophthalmic medication is usually applied topically, the most common methods being eye drops or ointment. These may be used for diag- nostic purposes such as dilating the pupil prior to examination; anaes- thetizing the eye prior to treatment, or for treatment of eye conditions such as glaucoma or infection. Heywood Jones (1995) recommends that administration of oph- thalmic medication follows these principles: 129 Key Nursing Skills Always use separately labelled drug containers for each eye to prevent cross-infection. If eye drops and ointment are prescribed to be administered at the same time, give the drops first, then administer ointment several minutes later, as the ointment can prevent absorption of the drops. Medication should not be directed onto the cornea of the eye as this may damage the cornea, but directed into the area in the lower eyelid (Figure 6.21). Figure 6.21 Eye drops directed into lower eyelid. When clearing discharge from the eye or wiping away excess med- ication, do not use dry cotton-wool balls as fibres may get into the eye and damage the cornea. Always work from the inner canthus (nose side) outwards to edge of eye when applying ointment or swabbing eye to reduce infec- tion risk. Medication containers should not touch the eye during adminis- tration as they may become contaminated or damage the eye. Once an eye medication has been opened, record the starting date on the container and discard after two weeks. If both eyes are to be treated but only one is discharging, treat the cleaner eye first to prevent cross-infection. Wash hands between eyes. 130  Drug administration TIP! Avisual patient who is receiving eye medication may have some impairment. Always introduce yourself to him as you approach, so that you can be identified by your voice even if his sight is limited. Intervention: administering eye medication Equipment Prescribed medication and prescription. Tissues or gauze swabs. Sterile saline solution and sterile eye dressing pack containing gallipot and sterile gauze (if eye requires cleansing prior to drug administration). Procedure Following the standard procedure for drug administration (page 102), check the prescribed medication and identify Mrs Paur, explaining the procedure and gaining her consent. Sometimes patients require different medications in each eye, so ensure you clearly identify the correct eye to receive each medication. Prepare equipment. Wash hands. Prepare Mrs Paur. She may prefer sitting upright in the chair, or lying on the bed with her head supported comfortably. Confirm which eye is to be treated. Give her a tissue to use after the pro- cedure to soak up any moisture. If discharge is present, wash your hands, and then clean the eye using a sterile eye care pack. Swab the discharge with sterile swabs moistened with sterile saline, working from the inner canthus to the outer edge, cleaning first the upper lid, then the lower lid. Use a single swab once for each wipe to reduce potential cross- infection. Dry the eye with a gauze swab. Position yourself behind Mrs Paur, or to one side, so that you can place your dominant hand on her forehead, holding the medica- tion downwards ready for application; place your other hand below the eye to pull the lower lid down gently with your index finger (Figure 6.22). 131 Key Nursing Skills Figure 6.22 Hand positions to administer eye drops. Tell Mrs Paur to look upwards, so that the cornea is raised away from the site of medication delivery. Deliver the required number of drops into the lower lid area – nearer the outer edge to reduce drainage from the nasal tear duct. If more than one type of drug is to be administered, allow several minutes to elapse between different medications. If administering ointment, squeeze a length of ointment along the lower lid from the inner canthus to the outer, squeezing out addi- tional ointment as required. To break the flow of ointment, twist the tube upwards, and stop pressing the tube. Be careful not to touch any part of the eye or eyelid as it will cause Mrs Paur to blink and interrupt the application flow. Remove hands and allow Mrs Paur to blink gently two or three times to disperse the medication, but do not let her squeeze her eyes. Dry excess moisture with tissue or sterile gauze. Leave Mrs Paur in a comfortable position. Advise her that her vision may be briefly impaired while her eyes respond to the medication. Wash hands and dispose of all waste. Document on the prescription sheet. Record in the nursing notes any observations regarding the state of the treated eye, such as redness, inflammation or amount of discharge. 132 Drug administration Evaluation Were Mrs Paur’s eye drops given effectively? Further reading Beyea SC, Nicholl LH (1995) Administration of medications via the intramuscular route: an integrative review of the literature and research-based protocol for the procedure. Applied Nursing Research 5(1): 23–33. British National Formulary. London: British Medical Association and British Pharmaceutical Society. Covington TP, Trattler MR (1997) Learn how to zero in on the safest site for an IM injection. Nursing (January): 62–63. Naysmith MR, Nicholson J (1998) Nasogastric drug administration. Professional Nurse 13(7): 424–27. Rodger MA, King L (2000) Drawing up and administering intramuscular injections: a review of the literature. Journal of Advanced Nursing 31(3): 574–82. Workman BA (1999) Safe injection techniques. Nursing Standard 13(39): 47–53. UKCC (2000) Guidelines for the Administration of Medications. London: UKCC. 133