Medications: Patient Care Focus PDF

CHAPTER 5 Medications FOCUSING ON PATIENT CARE This chapter will help you develop the skills needed to safely administer medications to the following patients: Cooper Jackson, age 2 years, does not want to take his ordered oral antibiotic. Erika Jenkins, age 20, is extremely afraid of needles and is at the clinic for her birthcontrol injection. Jonah Dinerman, age 63, was recently diagnosed with diabetes and needs to be taught how to give himself insulin injections. LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Prepare medications for administration in a safe manner. 2. Administer oral medications. 3. Administer medications via a gastric tube. 4. Remove medication from an ampule. 16. Administer a piggyback, intermittent intravenous infusion of medication. 17. Administer an intermittent intravenous infusion of medication via a volume-control administration set. 5. Remove medication from a vial. 18. Introduce drugs through a medication or druginfusion lock using the saline flush. 6. Mix medications from two vials in one syringe. 19. Apply a transdermal patch. 7. Identify appropriate needle size and angle of insertion for intradermal, subcutaneous, and intramuscular injections. 20. Instill eye drops. 8. Locate appropriate sites for intradermal injection. 9. Administer an intradermal injection. 10. Locate appropriate sites for a subcutaneous injection. 11. Administer a subcutaneous injection. 12. Locate appropriate sites for an intramuscular injection. 13. Administer an intramuscular injection. 14. Apply an insulin pump. 15. Administer medications by intravenous bolus or push through an intravenous infusion. 21. Administer eye irrigation. 22. Instill ear drops. 23. Administer ear irrigation. 24. Instill nose drops. 25. Administer a vaginal cream. 26. Administer a rectal suppository. 27. Administer medication via a metered-dose inhaler. 28. Administer medication via a small-volume nebulizer. 29. Administer medication via a dry-powder inhaler. 151 LWBK545_C05_p151-276.qxd 8/5/10 4:06 PM Page 152 Aptara Inc 152 UNIT I Actions Basic to Nursing Care KEY TERMS adverse drug effect: undesirable effects other than the intended therapeutic effect in medication administration ampule: a glass flask that contains a single dose of medication for parenteral administration inhalation: route to administer medications directly into the lungs or airway passages intradermal injection: injection placed just below the epidermis; sites commonly used are the inner surface of the forearm, the dorsal aspect of the upper arm, and the upper back intramuscular injection: injection placed into muscular tissue; sites commonly used are the ventrogluteal, vastus lateralis, deltoid, and dorsogluteal muscles intravenous (IV) route: route to administer medications directly into the vein or venous system; the most dangerous route of medication administration metered-dose inhaler (MDI): device to deliver a controlled dose of medication for inhalation nebulizer: instrument that produces a fine spray or mist; in this case, passing air through a liquid medication to produce fine particles for inhalation needle gauge: measurement of the diameter of a needle personal protective equipment (PPE): equipment and supplies necessary to minimize or prevent exposure to infectious material, including gloves, gowns, masks, and protective eye gear subcutaneous injection: injection placed between the epidermis and muscle, into the subcutaneous tissue; sites commonly used are the outer aspect of the upper arm, the abdomen, the anterior aspects of the thigh, the upper back, and the upper ventral or dorsogluteal area suppository: oval or cone-shaped substance that is inserted into a body cavity and melts at body temperature vial: a glass bottle with a self-sealing stopper through which medication is removed Medication administration is a basic nursing function that involves skillful technique and consideration of the patient’s development, health status, and safety. The nurse administering medications needs a knowledge base about drugs, including drug names, preparations, classifications, adverse effects, and physiologic factors that affect drug action (Fundamentals Review 5-1). The nurse observes the Three Checks and the Rights of Medication Administration when administering medications to ensure medications are being administered safely (see Fundamentals Review 5-2 and 5-3 for these important tools). Another way to prevent medication errors is always to clarify a medication order that is: Illegible Incomplete Incorrect route or dosage Not expected for patient’s current diagnosis Nursing responsibilities for drug administration are summarized in Fundamentals Review 5-4. This chapter will cover skills that the nurse needs to safely administer medications via multiple routes. Proper use of equipment and proper technique is imperative. Fundamentals Review 5-5 and Figure 5-1 review important guidelines related to administering parenteral medications. When administering medication, always remember age considerations. Older adults are sensitive to medications because their bodies have experienced physiologic changes associated with the aging process, including decreased gastric motility, muscle mass, acid production, and blood flow, which affect drug absorption. They may also be more susceptible to certain drug side effects. The physiologic changes in older adults that increase drug susceptibility are summarized in Fundamentals Review 5-6. Older adults are more likely to take multiple drugs, so drug interactions in the older adult are a very real and dangerous problem. LWBK545_C05_p151-276.qxd 8/5/10 4:06 PM Page 153 Aptara Inc CHAPTER 5 Medications 153 Fundamentals Review 5-1 KNOW YOUR MEDICATIONS Before administering any unfamiliar medications, know the following: Mode of action and purpose of medication (making sure that this medication is appropriate for the patient’s diagnosis) Side effects of, and contraindications for, medication Antagonist of medication (as appropriate) Safe dosage range for medication Interactions with other medications Precautions to take before administration Proper administration technique Fundamentals Review 5-2 THE THREE CHECKS “Three Checks” denotes that the label on the medication package or container should be checked three times during medication preparation and administration. Read the label: (1) When you reach for the container or unit dose package, (2) After retrieval from the drawer and compared with the Computer-generated Medication Administration Record (CMAR), or compared with the CMAR immediately before pouring from a multidose container, and (3) When replacing the container to the drawer or shelf or before giving the unit dose medication to the patient. Fundamentals Review 5-3 RIGHTS OF MEDICATION ADMINISTRATION The “Rights of Medication Administration” help to ensure accuracy when administering medications. To prevent medication errors, always ensure that the: (1) (2) (3) (4) (5) Right medication is given to the Right patient in the Right dosage through the Right route at the Right time. Additional rights have been suggested to include ensuring (6) the right reason and (7) the right documentation. Validating the right reason requires that the nurse understands the rationale for administration and answers the question, “Does it make sense?” The right documentation refers to accurate and timely documentation of administration. LWBK545_C05_p151-276.qxd 8/5/10 4:06 PM Page 154 Aptara Inc 154 UNIT I Actions Basic to Nursing Care Fundamentals Review 5-4 NURSING RESPONSIBILITIES FOR ADMINISTERING DRUGS Assessing the patient and understanding clearly why the patient is receiving a particular medication Ensuring the rights of medication administration: The (1) right medication is given to the (2) right patient in the (3) right dosage through the (4) right route at the (5) right time, ensuring (6) the right reason, and (7) the right documentation. Preparing the medication to be administered (checking labels, preparing injections, observing proper asepsis techniques with needles and syringes) Calculating accurate dosages Validating medication calculations with another nurse Administering the medication (e.g., proper injection techniques, aids to help swallowing, topical methods, and so on) Documenting the medications given Monitoring the patient’s reaction and evaluating the patient’s response Educating the patient regarding his or her medications and medication regimen Fundamentals Review 5-5 NEEDLE/SYRINGE SELECTION TECHNIQUE When looking at a needle package, the first number is the gauge or diameter of the needle (e.g., 18, 20) and the second number is the length in inches (e.g., 1, 11⁄2). As the gauge number becomes larger, the size of the needle becomes smaller; for instance, a 24-gauge needle is smaller than an 18-gauge needle. When giving an injection, the viscosity of the medication directs the choice of gauge (diameter). A thicker medication, such as a hormone, is given through a needle with a larger gauge, such as a 20 gauge. A thinnerconsistency medication, such as morphine, is given through a needle with a smaller gauge, such as a 24 gauge. Needle package showing first number (gauge or diameter of the needle) and second number (length of the needle in inches). The size of the syringe is directed by the amount of medication to be given. If the amount is less than 1 mL, use a 1-mL syringe to administer the medication. In a 1-mL syringe, the amount of medication may be rounded to the 100th decimal place. In syringes larger than 1 mL, the amount is rounded to the 10th decimal place. If the amount of medication to be administered is less than 3 mL, use a 3-mL syringe. If the amount of medication is equal to the size of the syringe (e.g., 1 mL and using a 1-mL syringe), you may go up to the next size syringe to prevent awkward movements when deploying the plunger. Different needle sizes. An 18-gauge needle (top) and a 24-gauge needle (bottom). LWBK545_C05_p151-276.qxd 08/05/2010 7:36 PM Page 155 Aptara CHAPTER 5 Medications 155 Intramuscular Subcutaneous 90º 90º 72º 45º Intradermal 5 –15º Muscle Subcutaneous tissue Skin FIGURE 5-1. Comparison of the angles of insertion for intramuscular, subcutaneous, and intradermal injections. Fundamentals Review 5-6 ALTERED DRUG RESPONSE IN OLDER PEOPLE Age-Related Changes Implication or Response Nursing Interventions Decreased gastric motility; increased gastric pH Stomach irritation; nausea; vomiting; gastric ulceration Assess for symptoms of gastrointestinal discomfort. Assess stools for blood. Decreased lean body mass; decreased total body water Decreased distribution of watersoluble drugs and higher plasma concentrations, leading to an increased possibility of drug toxicity Assess for signs of drug interactions or toxicity. Monitor blood levels of drugs. Monitor fluid balance; intake and output. Increased adipose tissue Accumulation of fat-soluble drugs; delay in elimination from, and accumulation of, drug in the body, leading to prolonged action and increased possibility of toxicity Assess for signs of drug interactions or toxicity. Monitor blood levels of drugs. Decreased number of protein-binding sites Higher drug plasma concentrations, leading to increased possibility of drug toxicity Assess for signs of drug interactions or toxicity. Monitor blood levels of drugs. Monitor laboratory values—albumin and prealbumin. (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:06 PM Page 156 Aptara Inc 156 UNIT I Actions Basic to Nursing Care Fundamentals Review 5-6 continued ALTERED DRUG RESPONSE IN OLDER PEOPLE Age-Related Changes Implication or Response Nursing Interventions Decreased liver function; decreased enzyme production for drug metabolism; decreased hepatic perfusion Decreased rate of drug metabolism; higher drug plasma concentrations, leading to prolonged action and increased possibility of drug toxicity Assess for signs of drug interactions or toxicity. Monitor blood levels of drugs. Monitor laboratory values—hepatic enzymes. Decreased kidney function, renal mass, and blood flow Decreased excretion of drugs, leading to possible increased serum levels/toxicity Assess for signs of drug interactions or toxicity. Particularly monitor NSAID use; may decrease renal blood flow and function. Monitor blood levels of drugs. Monitor laboratory values—creatinine clearance, blood urea nitrogen, serum creatinine. Alterations in normal homeostatic responses; altered peripheral venous tone Exacerbated response to cardiovascular drugs; more pronounced hypotensive effects from medications Assess for signs of drug interactions or toxicity. Monitor blood levels of drugs. Monitor vital signs. Orthostatic hypotension precautions Alterations in blood–brain barrier Enhanced central nervous system penetration of fat-soluble drugs; increased possibility for alterations in mental status, dizziness, gait disturbances Assess for signs of drug interactions or toxicity. Assess for dizziness and lightheadedness. Institute fall safety precautions. Decreased central nervous system efficiency Prolonged effect of drugs on the central nervous system; exacerbated response to analgesics and sedatives Assess for signs of drug interactions or toxicity. Assess for alterations in neurologic status. Monitor vital signs and pulse oximetry. Decreased production of oral secretions; dry mouth Difficulty swallowing oral medications Monitor ability to swallow medications, especially tablets and capsules. Discuss changing medications to forms that can be crushed and/or liquid forms with prescribing practitioner. Decreased lipid content in skin Possible decrease in absorption of transdermal medications Monitor effectiveness of transdermal preparations. (Adapted from Aschenbrenner, D., & Venable, S. (2009). Drug therapy in nursing. (3rd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; Porth, C., & Matfin, G. (2009). Pathophysiology: Concepts of altered health states. (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; Smeltzer, S., Bare, B., Hinkle, J., et al. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing. (12th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; and Tabloski, P. (2010). Gerontological nursing: The essential guide to clinical practice. (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall.) CHAPTER 5 Medications 5-1 157 Administering Oral Medications Drugs given orally are intended for absorption in the stomach and small intestine. The oral route is the most commonly used route of administration. It is usually the most convenient and comfortable route for the patient. After oral administration, drug action has a slower onset and a more prolonged, but less potent, effect than other routes. EQUIPMENT ASSESSMENT Assess the appropriateness of the drug for the patient. Review medical history, allergy, assessment, and laboratory data that may influence drug administration. Assess the patient’s ability to swallow medications. If the patient cannot swallow, is NPO, or is experiencing nausea or vomiting, withhold the medication, notify the primary care provider, and complete proper documentation. Assess the patient’s knowledge of the medication. If the patient has a knowledge deficit about the medication, this may be the appropriate time to begin education about the medication. If the medication may affect the patient’s vital signs, assess them before administration. If the medication is for pain relief, assess the patient’s pain level before and after administration. Verify the patient name, dose, route, and time of administration. NURSING DIAGNOSIS Determine related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Impaired Swallowing Risk for Aspiration Deficient Knowledge Anxiety Noncompliance OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when administering an oral medication is that the patient will swallow the medication. Other outcomes that may be appropriate include the following: the patient will experience the desired effect from the medication; the patient will not aspirate; the patient experiences decreased anxiety; the patient does not experience adverse effects; and the patient understands and complies with the medication regimen. Medication in disposable cup or oral syringe Liquid (e.g., water, juice) with straw, if not contraindicated Medication cart or tray Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR) PPE, as indicated IMPLEMENTATION ACTION R AT I O N A L E 1. Gather equipment. Check each medication order against the original in the medical record, according to facility policy. Clarify any inconsistencies. Check the patient’s chart for allergies. This comparison helps to identify errors that may have occurred when orders were transcribed. The primary care provider’s order is the legal record of medication orders for each facility. 2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient. This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient’s disorder and can also be used to educate the patient about the medication. 3. Perform hand hygiene. Hand hygiene prevents the spread of microorganisms. 4. Move the medication cart to the outside of the patient’s room or prepare for administration in the medication area. Organization facilitates error-free administration and saves time. 5. Unlock the medication cart or drawer. Enter pass code into the computer and scan employee identification, if required. Locking the cart or drawer safeguards each patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. Entering pass code and scanning ID allows only authorized users into the computer system and identifies the user for documentation by the computer. (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:06 PM Page 158 Aptara Inc 158 UNIT I 5-1 Actions Basic to Nursing Care Administering Oral Medications ACTION continued R AT I O N A L E 6. Prepare medications for one patient at a time. This prevents errors in medication administration. 7. Read the CMAR/MAR and select the proper medication from the patient’s medication drawer or unit stock. This is the first check of the label. 8. Compare the label with the CMAR/MAR (Figure 1). Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required. This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary. 9. Prepare the required medications: a. Unit dose packages: Place unit dose-packaged medications in a disposable cup. Do not open the wrapper until at the bedside. Keep narcotics and medications that require special nursing assessments in a separate container. Wrapper is kept intact because the label is needed for an additional safety check. Special assessments may be required before giving certain medications. These may include assessing vital signs and checking laboratory test results. b. Multidose containers: When removing tablets or capsules from a multidose bottle, pour the necessary number into the bottle cap and then place the tablets or capsules in a medication cup. Break only scored tablets, if necessary, to obtain the proper dosage. Do not touch tablets or capsules with hands. Pouring medication into the cap allows for easy return of excess medication to the bottle. Pouring tablets or capsules your hand is unsanitary. c. Liquid medication in multidose bottle: When pouring liquid medications out of a multidose bottle, hold the bottle so the label is against the palm. Use the appropriate measuring device when pouring liquids, and read the amount of medication at the bottom of the meniscus at eye level (Figure 2). Wipe the lip of the bottle with a paper towel. Liquid that may drip onto the label makes the label difficult to read. Accuracy is possible when the appropriate measuring device is used and then read accurately. FIGURE 1. Comparing medication label with the CMAR. FIGURE 2. Measuring at eye level. (Photo by B. Proud.) 10. When all medications for one patient have been prepared, recheck the labels with the CMAR/MAR before taking the medications to the patient. Replace any multidose containers in the patient’s drawer or unit stock. Lock the medication cart before leaving it. This is a third check to ensure accuracy and to prevent errors. Locking the cart or drawer safeguards the patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. Some facilities require the third check to occur at the bedside, after identifying the patient and before administration. 11. Transport medications to the patient’s bedside carefully, and keep the medications in sight at all times. Careful handling and close observation prevent accidental or deliberate disarrangement of medications. 12. Ensure that the patient receives the medications at the correct time. Check agency policy, which may allow for administration within a period of 30 minutes before or 30 minutes after the designated time. LWBK545_C05_p151-276.qxd 8/5/10 4:06 PM Page 159 Aptara Inc CHAPTER 5 Medications ACTION 159 R AT I O N A L E 13. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 14. Identify the patient. Usually, the patient should be identified using two methods. Compare the information with the CMAR/MAR. Identifying the patient ensures that the right patient receives the medications and helps prevent errors. a. Check the name and identification number on the patient’s identification band (Figure 3). This is the most reliable method. Replace the identification band if it is missing or inaccurate in any way. b. Ask the patient to state his or her name and birth date, based on facility policy. This requires a response from the patient, but illness and strange surroundings often cause patients to be confused. c. If the patient cannot identify him- or herself, verify the patient’s identification with a staff member who knows the patient, for the second source. This is another way to double check identity. Do not use the name on the door or over the bed, because these signs may be inaccurate. 15. Scan the patient’s bar code on the identification band, if required (Figure 4). The bar code provides an additional check to ensure that the medication is given to the right patient. FIGURE 3. Comparing patient’s name and identification number FIGURE 4. Scanning the bar code on the patient’s identification with the CMAR. bracelet. (Photo by B. Proud.) 16. Complete necessary assessments before administering medications. Check the patient’s allergy bracelet or ask the patient about allergies. Explain the purpose and action of each medication to the patient. Assessment is a prerequisite to administration of medications. 17. Assist the patient to an upright or lateral position. Swallowing is facilitated by proper positioning. An upright or side-lying position protects the patient from aspiration. 18. Administer medications: a. Offer water or other permitted fluids with pills, capsules, tablets, and some liquid medications. Liquids facilitate swallowing of solid drugs. Some liquid drugs are intended to adhere to the pharyngeal area, in which case liquid is not offered with the medication. b. Ask whether the patient prefers to take the medications by hand or in a cup. This encourages the patient’s participation in taking the medications. 19. Remain with the patient until each medication is swallowed. Never leave medication at the patient’s bedside (Figure 5). Unless you have seen the patient swallow the drug, the drug cannot be recorded as administered. The patient’s chart is a legal record. Only with a physician’s order can medications be left at the bedside. (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 160 Aptara Inc 160 UNIT I 5-1 Actions Basic to Nursing Care Administering Oral Medications ACTION continued R AT I O N A L E FIGURE 5. Remaining with the patient until each medication is swallowed. 20. Assist the patient to a comfortable position. Remove PPE, if used. Perform hand hygiene. Promotes patient comfort. Proper removal of PPE prevents transmission of microorganisms. Hand hygiene deters the spread of microorganisms. 21. Document the administration of the medication immediately after administration. See Documentation section below. Timely documentation helps to ensure patient safety. 22. Evaluate the patient’s response to medication within appropriate time frame. The patient needs to be evaluated for therapeutic and adverse effects from the medication. EVALUATION The expected outcomes are met when the patient swallows the medication, does not aspirate, verbalizes an understanding of the medication, experiences the desired effect from the medication, and does not experience adverse effects. DOCUMENTATION Guidelines Record each medication administered on the CMAR/MAR or record using the required format immediately after it is administered, including date and time of administration (Figure 6). If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the primary care provider. This verifies the reason medication was omitted and ensures that the primary care provider is aware of the patient’s condition. Recording administration of a narcotic may require additional documentation on a narcotic record, stating drug count and other specific information. A record of fluid intake and output measurement is required. FIGURE 6. Recording each medication administered on the CMAR. LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 161 Aptara Inc CHAPTER 5 Medications Sample Documentation 161 8/6/12 0835 Patient states he is having constant stabbing leg pains. Rates pain as an 8/10. Percocet 2 tabs administered. —K. Sanders, RN 8/6/12 0905 Patient resting comfortably. Rates leg pain as a 1/10. —K. Sanders, RN 8/6/12 1300 Patient states he does not want pain medication, despite return of leg pain. States, “It made me feel woozy last time.” Feelings discussed with patient. Patient agrees to take Percocet 1 tab at this time. —K. Sanders, RN 8/6/12 1320 Percocet, 1 tablet given PO. —K. Sanders, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Patient states that it feels like medication is lodged in throat: Offer patient more fluids to drink. If allowed, offer the patient bread or crackers to help move the medication to the stomach. It is unclear whether the patient swallowed the medication: Check in the patient’s mouth, under tongue, and between cheek and gum. Patients with altered mental status may not be aware that the medication was not swallowed. Also, patients may “cheek” medications to avoid taking the medication or to save it for later use. Watch patients requiring suicide precautions closely to ensure that they are not “cheeking” the medication or hiding it in the mouth. These patients may be trying to accumulate a large amount of medication to take all at once in a suicide attempt. Substance abusers may cheek medication to accumulate a large amount to take all at once so that they may feel a high from medication. Patient vomits immediately or shortly after receiving oral medication: Assess vomit, looking for pills or fragments. Do not readminister medication without notifying primary care provider. If a whole pill is seen and can be identified, the primary care provider may ask that the medication be administered again. If a pill is not seen or medications cannot be identified, do not readminister the medication in order to prevent the patient from receiving too large a dose. Child refuses to take oral medications: Some medications may be mixed in a small amount of food, such as pudding or ice cream. Do not add the medication to liquids because the medication may alter the taste of liquids; if child then refuses to drink the rest of the liquid, you will not know how much of the medication was ingested. Use creativity when devising ways to administer medications to a child. See the section below, Infant and Child Considerations, for suggestions. The capsule or tablet falls to the floor during administration. Discard and obtain a new dose for administration. This prevents contamination and transmission of microorganisms. Patient refuses medication. Explore the reason for the patient’s refusal. Review the rationale for using the drug and any other information that may be appropriate. If you are unable to administer the medication despite education and discussion, document the omission according to facility policy and notify the primary care provider. SPECIAL CONSIDERATIONS General Considerations Some liquid medication preparations, such as suspensions, require agitation to ensure even distribution of medication in the solution. Be familiar with the specific requirements for medications you are administering. Place medications intended for sublingual absorption under the patient’s tongue. Instruct the patient to allow the medication to dissolve completely. Reinforce the importance of not swallowing the medication tablet. Some oral medications are provided in powdered forms. Verify the correct liquid to dissolve the medication in for administration. This information is usually included on the package; verify any unclear instructions with a pharmacist or medication reference. If there is more than one possible liquid to dissolve the medication in, include the patient in the decision process; patients may find one choice more palatable than another. (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 162 Aptara Inc 162 UNIT I 5-1 Actions Basic to Nursing Care Administering Oral Medications continued Ongoing assessment is an important part of nursing care for both evaluation of patient response to administered medications and early detection of adverse effects. If an adverse effect is suspected, withhold further medication doses and notify the patient’s primary care provider. Additional intervention is based on type of reaction and patient assessment. If the patient questions a medication order or states the medication is different from the usual dose, always recheck and clarify with the original order and/or primary care provider before giving the medication. If the patient’s level of consciousness is altered or his or her swallowing is impaired, check with the primary care provider to clarify the route of administration or alternative forms of medication. This may also be a solution for a pediatric or a confused patient who is refusing to take a medication. Patients with poor vision can request large-type labels on medication containers. A magnifying lens also may be helpful. Provide written medication information to reinforce discussion and education in the appropriate language, if the patient is literate. If the patient is unable to read, provide written information to family or significant other, if appropriate. Written information should be at a 5th-grade level to ensure ease of understanding. If the patient has difficulty swallowing tablets, it may be appropriate to crush the medication to facilitate administration. However, not all medications can be crushed or altered; long-acting and slow-release drugs are examples of medications that cannot be crushed. Therefore, it is important to consult a medication reference and/or pharmacist. If the medication can be crushed, use a pillcrusher or mortar and pestle to grind the tablet into a powder. Crush each pill one at a time. Dissolve the powder with water or other recommended liquid in a liquid medication cup, keeping each medication separate from the others. Keep the package label with the medication cup for future comparison of information. Combine the crushed medication with a small amount of soft food, such as applesauce or pudding, to facilitate administration. Infant and Child Considerations Special devices, such as oral syringes and calibrated nipples, are available in a pharmacy to ensure accurate dose calculations for young children and infants. Some creative ways to administer medications to children include the following: have a “tea party” with medicine cups; place oral syringe (without needle) or dropper in the space between the cheek and gum and slowly administer the medication; save a special treat for after the medication administration (e.g., movie, playroom time, or a special food, if allowed). The FDA has received reports of infants choking on the plastic caps that fit on the end of syringes when used to administer oral medications. They recommend the following: remove and dispose of caps before giving syringes to patients or families, caution family caregivers to dispose of caps on syringes they buy over the counter, and report any problems with syringe caps to the FDA. Companies manufacture syringes labeled “oral use” without the caps on them. Older Adult Considerations Elderly patients with arthritis may have difficulty opening childproof caps. On request, the pharmacist can substitute a cap that is easier to open. A rubber band twisted around the cap may provide a more secure grip for older patients. Consider large-print written information, when appropriate. Physiologic changes associated with the aging process, including decreased gastric motility, muscle mass, acid production, and blood flow, can affect patient’s response to medication, including drug absorption and increased risk of adverse effects. Older adults are more likely to take multiple drugs, so drug interactions in the older adult are a very real and dangerous problem. Refer to Fundamentals Review 5-6. Home Care Considerations Encourage the patient to discard expired prescription medications. Discuss safe storage of medications when there are children and pets in the environment. Discuss with parents the difference in over-the-counter medications made for infants and medications made for children. Many times parents do not realize that there are different strengths to the actual medications, leading to under- or overdosing. Encourage patients to carry a card listing all medications, dosage, and frequency in case of an emergency. Discuss the importance of using an appropriate measuring device for liquid medications. Caution patients not to use eating utensils for measuring medications; use a liquid medication cup, oral syringe, or measuring spoon to provide accurate dosing. 163 CHAPTER 5 Medications 5-2 Administering Medications via a Gastric Tube Patients with a gastrointestinal tube (nasogastric, nasointestinal, percutaneous endoscopic gastrostomy [PEG], or jejunostomy [J] tube) often receive medication through the tube. Care of the patient with an enteral feeding tube is described in Chapter 11, Nutrition. Use liquid medications, when possible, because they are readily absorbed and less likely to cause tube occlusions. Certain solid dosage medications can be crushed and combined with liquid. Medications should be crushed to a fine powder and mixed with 15 to 30 mL of water before delivery through the tube. Certain capsules may be opened, emptied into liquid, and administered through the tube (Toedter Williams, 2008). Check manufacturer’s recommendations and/or with a pharmacist to verify. EQUIPMENT ASSESSMENT Research each medication to be given, especially for mode of action, side effects, nursing implications, ability to be crushed, and whether the medication should be given with or without food. Verify patient name, dose, route, and time of administration. Also assess patient’s knowledge of medication and the reason for its administration. Auscultate the abdomen for evidence of bowel sounds. Percuss and palpate the abdomen for tenderness and distention. Ascertain the time of the patient’s last bowel movement and measure abdominal girth, if appropriate. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Possible nursing diagnoses may include: Deficient Knowledge Risk for Injury Impaired Swallowing OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve is that the patient receives the medication via the tube and experiences the intended effect of the medication. In addition, the patient verbalizes knowledge of the medications given; the patient remains free from adverse effect and injury; and the gastrointestinal tube remains patent. Irrigation set (60-mL syringe and irrigation container) Medications Water (gastrostomy tubes) or sterile water (nasogastric tubes), according to facility policy Gloves Additional PPE, as indicated IMPLEMENTATION ACTION R AT I O N A L E 1. Gather equipment. Check each medication order against the original in the medical record, according to facility policy. Clarify any inconsistencies. Check the patient’s chart for allergies. This comparison helps to identify errors that may have occurred when orders were transcribed. The primary care provider’s order is the legal record of medication orders for each facility. 2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient. This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient’s disorder and can also be used to educate the patient about the medication. 3. Perform hand hygiene. Hand hygiene prevents the spread of microorganisms. 4. Move the medication cart to the outside of the patient’s room or prepare for administration in the medication area. Organization facilitates error-free administration and saves time. 5. Unlock the medication cart or drawer. Enter pass code and scan employee identification, if required. Locking the cart or drawer safeguards each patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. Entering pass code and scanning ID allows only authorized users into the system and identifies user for documentation by the computer. 6. Prepare medications for one patient at a time. This prevents errors in medication administration. (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 164 Aptara Inc 164 UNIT I Actions Basic to Nursing Care 5-2 Administering Medications via a Gastric Tube ACTION continued R AT I O N A L E 7. Read the CMAR/MAR and select the proper medication from the patient’s medication drawer or unit stock. This is the first check of the label. 8. Compare the label with the CMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required. This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary. 9. Check to see if medications to be administered come in a liquid form. If pills or capsules are to be given, check with pharmacy or drug reference to verify the ability to crush or open capsules. To prevent the tube from becoming clogged, all medications should be given in liquid form whenever possible. Medications in extended-release formulations should not be crushed before administration. 10. Prepare medication. Pills: Using a pill crusher, crush each pill one at a time. Dissolve the powder with water or other recommended liquid in a liquid medication cup, keeping each medication separate from the others. Keep the package label with the medication cup, for future comparison of information. Some medications require dissolution in liquid other than water. The label is needed for an additional safety check. Some medications require pre-administration assessments. Liquid: When pouring liquid medications from a multidose bottle, hold the bottle with the label against the palm. Use the appropriate measuring device when pouring liquids, and read the amount of medication at the bottom of the meniscus at eye level. Wipe the lip of the bottle with a paper towel. Liquid that may drip onto the label makes the label difficult to read. Accuracy is possible when the appropriate measuring device is used and then read accurately. 11. When all medications for one patient have been prepared, recheck the label with the MAR before taking the medications to the patient. This is a third check to ensure accuracy and to prevent errors. Some facilities require the third check to occur at the bedside, after identifying the patient and before administration. 12. Lock the medication cart before leaving it. Locking the cart or drawer safeguards the patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. 13. Transport medications to the patient’s bedside carefully, and keep the medications in sight at all times. Careful handling and close observation prevent accidental or deliberate disarrangement of medications. 14. Ensure that the patient receives the medications at the correct time. Check agency policy, which may allow for administration within a period of 30 minutes before or 30 minutes after designated time. 15. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 16. Identify the patient. Usually, the patient should be identified using two methods. Compare information with the CMAR/MAR. Identifying the patient ensures the right patient receives the medications and helps prevent errors. a. Check the name and identification number on the patient’s identification band. This is the most reliable method. Replace the identification band if it is missing or inaccurate in any way. b. Ask the patient to state his or her name and birth date, based on facility policy. This requires a response from the patient, but illness and strange surroundings often cause patients to be confused. c. If the patient cannot identify him- or herself, verify the patient’s identification with a staff member who knows the patient for the second source. This is another way to double-check identity. Do not use the name on the door or over the bed, because these signs may be inaccurate. 17. Complete necessary assessments before administering medications. Check the patient’s allergy bracelet or ask the patient about allergies. Explain what you are going to do, and the reason for doing it, to the patient. Assessment is a prerequisite to administration of medications. Explanation relieves anxiety and facilitates cooperation. 18. Scan the patient’s bar code on the identification band, if required. This provides an additional check to ensure that the medication is given to the right patient. LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 165 Aptara Inc CHAPTER 5 Medications ACTION 165 R AT I O N A L E 19. Assist the patient to the high Fowler’s position, unless contraindicated. This reduces the risk of aspiration. 20. Put on gloves. Gloves prevent contact with mucous membranes and body fluids. 21. If patient is receiving continuous tube feedings, pause the tube-feeding pump (Figure 1). If the pump is not stopped, tube feeding will flow out of the tube and onto the patient. 22. Pour the water into the irrigation container. Measure 30 mL of water. Apply clamp on feeding tube, if present. Alternately, pinch gastric tube below port with fingers, or position stopcock to correct direction. Open port on gastric tube delegated to medication administration (Figure 2) or disconnect tubing for feeding from gastric tube and place cap on end of feeding tubing. Fluid is ready for flushing of the tube. Applying clamp, folding the tube over and clamping, or the correct positioning of the stopcock prevents any backflow of gastric drainage. Covering end of feeding tubing prevents contamination. FIGURE 1. Pausing feeding pump. (Photo by B. Proud.) FIGURE 2. Pinching gastric tubing to prevent backflow of gastric drainage and opening medication administration port. (Photo by B. Proud.) 23. Check placement of tube, depending on type of tube and facility policy. (Refer to Chapter 11, Nutrition.) Tube placement must be confirmed before administering anything through the tube to avoid inadvertent instillation in the respiratory tract. 24. Note the amount of any residual. Refer to Chapter 11, Nutrition. Replace residual back into stomach, based on facility policy. Research findings are inconclusive on the benefit of returning gastric volumes to the stomach or intestine to avoid fluid or electrolyte imbalance, which has been accepted practice. Consult agency policy concerning this practice (Bourgault, et al., 2007; Keithley & Swanson, 2004; Metheny, 2008). 25. Apply clamp on feeding tube, if present. Alternately, pinch gastric tube below port with fingers, or position stopcock to correct direction. Remove 60-mL syringe gastric tube. Remove the plunger of the syringe. Reinsert the syringe in the gastric tube without the plunger. Pour 30 mL of water into the syringe (Figure 3). Unclamp the tube and allow the water to enter the stomach via gravity infusion. Folding the tube over and clamping it prevents any backflow of gastric drainage. Flushing the tube ensures all the residual is cleared from tube. 26. Administer the first dose of medication by pouring into the syringe (Figure 4). Follow with a 5- to 10-mL water flush between medication doses. Follow the last dose of medication with 30 to 60 mL of water flush. Flushing between medications prevents any possible interactions between the medications. Flushing at the end maintains patency of the tube, prevents blockage by medication particles, and ensures all doses enter the stomach. (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 166 Aptara Inc 166 UNIT I 5-2 Actions Basic to Nursing Care Administering Medications via a Gastric Tube ACTION continued R AT I O N A L E FIGURE 3. Pouring water into syringe inserted in gastric tube. FIGURE 4. Pouring medication into syringe inserted in gastric (Photo by B. Proud.) tube. (Photo by B. Proud.) 27. Clamp the tube, remove the syringe, and replace the feeding tubing. If stopcock is used, position stopcock to correct direction. If tube medication port was used, cap port. Unclamp gastric tube and restart tube feeding, if appropriate for medications administered. Some medications require the holding of the tube feeding for a certain period of time after administration. Consult a drug reference or a pharmacist. 28. Remove gloves. Assist the patient to a comfortable position. If receiving a tube feeding, the head of the bed must remain elevated at least 30 degrees. Ensures patient comfort. Keeping the head of the bed elevated helps prevent aspiration. 29. Remove additional PPE, if used. Perform hand hygiene. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. 30. Document the administration of the medication immediately after administration. See Documentation section below. Timely documentation helps to ensure patient safety. 31. Evaluate the patient’s response to medication within appropriate time frame. The patient needs to be evaluated for therapeutic and adverse effects from the medication. EVALUATION The expected outcome is met when the patient receives the ordered medications and experiences the intended effects of the medications administered. In addition, the patient demonstrates a patent and functioning gastric tube, verbalizes knowledge of the medications given, and remains free from adverse effect and injury. DOCUMENTATION Guidelines Document the administration of the medication immediately after administration, including date, time, dose, and route of administration on the CMAR/MAR or record using the required format. If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. Record the amount of gastric residual, if appropriate. Record the amount of liquid given on the intake and output record. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the primary care provider. This verifies the reason medication was omitted and ensures that the primary care provider is aware of the patient’s condition. UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Medication enters tube and then tube becomes clogged: Attach a 10-mL syringe onto end of tube. Pull back and then lightly apply pressure to plunger in a repetitive motion. This may dislodge the medication. If the medication does not move through the tube, notify the primary care provider. The tube may have to be replaced. CHAPTER 5 Medications SPECIAL CONSIDERATIONS 5-3 167 If medications are being administered via an NG tube that is attached to suction, the tube should remain clamped, off suction, for a period of time after medication administration. This allows for medication absorption before returning to suction. Check facility policy and drug reference for specific drug requirements. If necessary to use plunger in irrigation syringe to administer medications, instill gently and slowly. Gravity administration is considered best to avoid excess pressure. Give medications separately and flush with water between each drug. Some medications may interact with each other or become less effective if mixed with other drugs. If the patient is receiving tube feedings, review information about the drugs to be administered. Absorption of some drugs, such as phenytoin (Dilantin), is affected by tube feeding formulas. Discontinue a continuous tube feeding and leave the tube clamped for the required period of time before and after the medication has been given, according to the reference and facility protocol. Ongoing assessment is an important part of nursing care for both evaluation of patient response to administered medications and early detection of adverse effects. If an adverse effect is suspected, withhold further medication doses and notify the patient’s primary healthcare provider. Additional intervention is based on type of reaction and patient assessment. Removing Medication from an Ampule An ampule is a glass flask that contains a single dose of medication for parenteral administration. Because there is no way to prevent contamination of any unused portion of medication after the ampule is opened, if not all the medication is used, discard any remaining medication. Remove medication from an ampule after its thin neck is broken. EQUIPMENT ASSESSMENT Assess the medication in the ampule for any particles or discoloration. Assess the ampule for any cracks or chips. Check expiration date before administering the medication. Verify patient name, dose, route, and time of administration. Assess the appropriateness of the drug for the patient. Review assessment and laboratory data that may influence drug administration. NURSING DIAGNOSIS Determine related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Infection Anxiety Deficient Knowledge Risk for Injury OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when removing medication from an ampule is that the medication will be removed in a sterile manner; it will be free from glass shards and the proper dose prepared. Sterile syringe and filter needle Ampule of medication Small gauze pad Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR) IMPLEMENTATION ACTION 1. Gather equipment. Check the medication order against the original order in the medical record, according to facility policy. Clarify any inconsistencies. Check the patient’s chart for allergies. R AT I O N A L E This comparison helps to identify errors that may have occurred when orders were transcribed. The primary care provider’s order is the legal record of medication orders for each facility. (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 168 Aptara Inc 168 UNIT I 5-3 Actions Basic to Nursing Care Removing Medication from an Ampule ACTION 2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient. 3. Perform hand hygiene. continued R AT I O N A L E This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient’s disorder and can also be used to educate the patient about the medication. Hand hygiene deters the spread of microorganisms. 4. Move the medication cart to the outside of the patient’s room or prepare for administration in the medication area. Organization facilitates error-free administration and saves time. 5. Unlock the medication cart or drawer. Enter pass code and scan employee identification, if required. Locking the cart or drawer safeguards each patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. Entering pass code and scanning ID allows only authorized users into the system and identifies user for documentation by the computer. 6. Prepare medications for one patient at a time. This prevents errors in medication administration. 7. Read the CMAR/MAR and select the proper medication from the patient’s medication drawer or unit stock. This is the first check of the label. 8. Compare the label with the CMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required. This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary. 9. Tap the stem of the ampule (Figure 1) or twist your wrist quickly (Figure 2) while holding the ampule vertically. This facilitates movement of medication in the stem to the body of the ampule. FIGURE 1. Tapping stem of the ampule. FIGURE 2. Twisting wrist quickly while holding the ampule vertically. 10. Wrap a small gauze pad around the neck of the ampule. This will protect your fingers from the glass as the ampule is broken. 11. Use a snapping motion to break off the top of the ampule along the scored line at its neck (Figure 3). Always break away from your body. This protects your face and fingers from any shattered glass fragments. LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 169 Aptara Inc CHAPTER 5 Medications ACTION 169 R AT I O N A L E FIGURE 3. Using a snapping motion to break top of the ampule. 12. Attach filter needle to syringe. Remove the cap from the filter needle by pulling it straight off. Use of a filter needle prevents the accidental withdrawing of small glass particles with the medication. Pulling the cap off in a straight manner prevents accidental needlestick. 13. Withdraw medication in the amount ordered plus a small amount more (approximately 30% more). Do not inject air into the solution. Use either of the following methods. While inserting the filter needle into the ampule, be careful not to touch the rim. By withdrawing an additional small amount of medication, any air bubbles in the syringe can be displaced once the syringe is removed and ample medication will still remain in the syringe. The contents of the ampule are not under pressure; therefore, air is unnecessary and will cause the contents to overflow. The rim of the ampule is considered contaminated. a. Insert the tip of the needle into the ampule, which is upright on a flat surface, and withdraw fluid into the syringe (Figure 4). Touch the plunger at the knob only. Handling the plunger at the knob only will keep the shaft of the plunger sterile. b. Insert the tip of the needle into the ampule and invert the ampule. Keep the needle centered and not touching the sides of the ampule. Withdraw fluid into syringe (Figure 5). Touch the plunger at the knob only. Surface tension holds the fluids in the ampule when inverted. If the needle touches the sides or is removed and then reinserted into the ampule, surface tension is broken, and fluid runs out. Handling the plunger at the knob only will keep the shaft of the plunger sterile. 14. Wait until the needle has been withdrawn to tap the syringe and expel the air carefully by pushing on the plunger. Check the amount of medication in the syringe with the medication dose and discard any surplus, according to facility policy. Ejecting air into the solution increases pressure in the ampule and can force the medication to spill out over the ampule. Ampules may have overfill. Careful measurement ensures that the correct dose is withdrawn. 15. Recheck the label with the CMAR/MAR. This is the third check to ensure accuracy and to prevent errors. Some facilities require the third check to occur at the bedside, after identifying the patient and before administration. 16. Engage safety guard on filter needle and remove the needle. Discard the filter needle in a suitable container. Attach appropriate administration device to syringe. The filter needle used to draw up medication should not be used to administer the medication, to prevent any glass shards from entering the patient. (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 170 Aptara Inc 170 UNIT I 5-3 Actions Basic to Nursing Care Removing Medication from an Ampule ACTION continued R AT I O N A L E FIGURE 4. Withdrawing medication from upright ampule. FIGURE 5. Withdrawing medication from inverted ampule. 17. Discard the ampule in a suitable container. Any medication that has not been removed from the ampule must be discarded because there is no way to maintain sterility of contents in an opened ampule. 18. Lock the medication cart before leaving it. Locking the cart or drawer safeguards the patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. 19. Perform hand hygiene. 20. Proceed with administration, based on prescribed route. EVALUATION Hand hygiene deters the spread of microorganisms. See appropriate skill for prescribed route. The expected outcome is met when the medication is removed from the ampule in a sterile manner, free from glass shards, and the proper dose is prepared. DOCUMENTATION Guidelines It is not necessary to record the removal of the medication from the ampule. Record each medication administered on the CMAR/MAR or record using the required format immediately after it is administered, including date and time of administration. If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the primary care provider. This verifies the reason medication was omitted and ensures that the primary care provider is aware of the patient’s condition. Recording administration of a narcotic may require additional documentation on a narcotic record, stating drug count and other specific information. Record fluid intake if intake and output measurement is required. UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS You cut yourself while trying to open ampule: Discard ampule in case contamination has occurred. Bandage wound and obtain a new ampule. Report according to facility policy. All of medication was not removed from the stem and insufficient medication remains in body of ampule for dose: Discard ampule and drawn medication. Obtain a new ampule and start over. Medication in original ampule stem is considered contaminated once neck of ampule has been placed on a nonsterile surface. You inject air into inverted ampule, spraying medication: Wash hands to remove any medication. If any medication has gotten into eyes, perform eye irrigation. Obtain a new ampule for medication dose. Report injury, if appropriate, according to facility policy. CHAPTER 5 Medications 171 Medication is drawn up without using a filter needle: Replace needle with a filter needle. Inject the medication through the filter needle into a new syringe and then administer to patient. Plunger becomes contaminated before inserted into ampule: Discard needle and syringe and start over. If plunger is contaminated after medication is drawn into the syringe, it is not necessary to discard and start over. The contaminated plunger will enter the barrel of the syringe when pushing the medication out and will not contaminate the medication. 5-4 Removing Medication from a Vial A vial is a glass bottle with a self-sealing stopper through which medication is removed. For safety in transporting and storing, the vial top is usually covered with a soft metal cap that can be removed easily. The self-sealing stopper that is then exposed is the means of entrance into the vial. Singledose vials are used once, and then discarded, regardless of the amount of the drug that is used from the vial. Multidose vials contain several doses of medication and can be used multiple times. The Centers for Disease Control and Prevention (CDC) recommends that medications packaged as multiuse vials be assigned to a single patient whenever possible. In addition, it is recommended that the top of the vial be cleaned before each entry, as well as the use of a new sterile needle and syringe (CDC, 2008a; CDC, 2008b). The medication contained in a vial can be in liquid or powder form. Powdered forms must be dissolved in an appropriate diluent before administration. The following skill reviews removing liquid medication from a vial. Refer to the accompanying Skill Variation for steps to reconstitute a powdered medication. EQUIPMENT Sterile syringe and needle or blunt cannula (size depends on medication being administered and patient) Vial of medication Antimicrobial swab Second needle (optional) Filter needle (optional) Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR) ASSESSMENT Assess the medication in the vial for any discoloration or particles. Check expiration date before administering medication. Verify patient name, dose, route, and time of administration. Assess the appropriateness of the drug for the patient. Review assessment and laboratory data that may influence drug administration. NURSING DIAGNOSIS Determine related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses include: Risk for Infection Risk for Injury Deficient Knowledge Anxiety OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when removing medication from a vial is withdrawal of the medication into a syringe in a sterile manner and that the proper dose is prepared. IMPLEMENTATION ACTION 1. Gather equipment. Check the medication order against the original order in the medical record, according to facility policy. R AT I O N A L E This comparison helps to identify errors that may have occurred when orders were transcribed. The primary care provider’s order is the legal record of medication orders for each facility. (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 172 Aptara Inc 172 UNIT I 5-4 Actions Basic to Nursing Care Removing Medication from a Vial ACTION 2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient. 3. Perform hand hygiene. continued R AT I O N A L E This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient’s disorder and can also be used to educate the patient about the medication. Hand hygiene deters the spread of microorganisms. 4. Move the medication cart to the outside of the patient’s room or prepare for administration in the medication area. Organization facilitates error-free administration and saves time. 5. Unlock the medication cart or drawer. Enter pass code and scan employee identification, if required. Locking the cart or drawer safeguards each patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. Entering pass code and scanning ID allows only authorized users into the system and identifies user for documentation by the computer. 6. Prepare medications for one patient at a time. This prevents errors in medication administration. 7. Read the CMAR/MAR and select the proper medication from the patient’s medication drawer or unit stock. This is the first check of the label. 8. Compare the label with the CMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required. This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary. 9. Remove the metal or plastic cap on the vial that protects the rubber stopper. Cap needs to be removed to access medication in vial. 10. Swab the rubber top with the antimicrobial swab and allow to dry. Antimicrobial swab removes surface bacteria contamination. Allowing the alcohol to dry prevents it from entering the vial on the needle. 11. Remove the cap from the needle or blunt cannula by pulling it straight off. Touch the plunger at the knob only. Draw back an amount of air into the syringe that is equal to the specific dose of medication to be withdrawn. Some facilities require use of a filter needle when withdrawing premixed medication from multidose vials. Pulling the cap off in a straight manner prevents accidental needlestick injury. Handling the plunger at the knob only will keep the shaft of the plunger sterile. Because a vial is a sealed container, before fluid is removed, injection of an equal amount of air is required to prevent the formation of a partial vacuum. If not enough air is injected, the negative pressure makes it difficult to withdraw the medication. Using a filter needle prevents any solid material from being withdrawn through the needle. 12. Hold the vial on a flat surface. Pierce the rubber stopper in the center with the needle tip and inject the measured air into the space above the solution (Figure 1). Do not inject air into the solution. Air bubbled through the solution could result in withdrawal of an inaccurate amount of medication. 13. Invert the vial. Keep the tip of the needle or blunt cannula below the fluid level (Figure 2). This prevents air from being aspirated into the syringe. 14. Hold the vial in one hand and use the other to withdraw the medication. Touch the plunger at the knob only. Draw up the prescribed amount of medication while holding the syringe vertically and at eye level (Figure 3). Handling the plunger at the knob only will keep the shaft of the plunger sterile. Holding the syringe at eye level facilitates accurate reading, and the vertical position makes removal of air bubbles from the syringe easy. 15. If any air bubbles accumulate in the syringe, tap the barrel of the syringe sharply and move the needle past the fluid into the air space to re-inject the air bubble into the vial. Return the needle tip to the solution and continue withdrawal of the medication. Removal of air bubbles is necessary to ensure accurate dose of medication. LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 173 Aptara Inc 173 CHAPTER 5 Medications ACTION R AT I O N A L E FIGURE 1. Injecting air with vial FIGURE 2. Positioning needle tip in FIGURE 3. Withdrawing medication upright. solution. at eye level. 16. After the correct dose is withdrawn, remove the needle from the vial and carefully replace the cap over the needle. If a filter needle has been used to draw up the medication, remove it and attach the appropriate administration device. Some facilities require changing the needle, if one was used to withdraw the medication, before administering the medication. This prevents contamination of the needle and protects against accidental needlesticks. A one-handed recap method may be used as long as care is taken not to contaminate the needle during the process. A filter needle used to draw up medication should not be used to administer the medication to prevent any solid material from entering the patient. Changing the needle may be necessary because passing the needle through the stopper on the vial may dull the needle. 17. Check the amount of medication in the syringe with the medication dose and discard any surplus. Careful measurement ensures that correct dose is withdrawn. 18. Recheck the label with the CMAR/MAR. This is the third check to ensure accuracy and to prevent errors. Some facilities require the third check to occur at the bedside, after identifying the patient and before administration. 19. If a multidose vial is being used, label the vial with the date and time opened, and store the vial containing the remaining medication according to facility policy. Because the vial is sealed, the medication inside remains sterile and can be used for future injections. Labeling the opened vials with a date and time limits its use after a specific time period. 20. Lock the medication cart before leaving it. Locking the cart or drawer safeguards the patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. 21. Perform hand hygiene. 22. Proceed with administration, based on prescribed route. EVALUATION Hand hygiene deters the spread of microorganisms. See appropriate skill for prescribed route. The expected outcome is met when the medication is withdrawn into the syringe in a sterile manner and the proper dose is prepared. (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 174 Aptara Inc 174 UNIT I 5-4 Actions Basic to Nursing Care Removing Medication from a Vial continued DOCUMENTATION Guidelines It is not necessary to record the removal of the medication from the vial. Record each medication administered on the CMAR/MAR or record using the required format immediately after it is administered, including date and time of administration. If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the primary care provider. This verifies the reason medication was omitted and ensures that the primary care provider is aware of the patient’s condition. Recording administration of a narcotic may require additional documentation on a narcotic record, stating drug count and other specific information. Record fluid intake if intake and output measurement is required. UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS A piece of rubber stopper is noticed floating in medication in syringe: Discard the syringe, needle, and vial. Obtain a new vial, syringe, and needle and prepare dose as ordered. As needle attached to syringe filled with air is inserted into vial, the plunger is immediately pulled down: If possible to withdraw medication, continue steps as explained above. If such a vacuum has formed that this is impossible, remove syringe and inject more air into the vial. This is caused by previous withdrawal of medication without the addition of air into the vial. Plunger is contaminated before injecting air into vial: Discard needle and syringe and start over. If plunger is contaminated after medication is drawn into syringe, it is not necessary to discard and start over. The contaminated plunger will enter the barrel of the syringe when pushing the medication out and will not contaminate the medication. Skill Variation Reconstituting Powdered Medication in a Vial Drugs that are unstable in liquid form are often provided in a dry powder form. The powder must be mixed with the correct amount of appropriate solution to prepare medication for administration. Verify the correct amount and correct solution type for the specific medication prescribed. This information is found on the vial label, package insert, in a drug reference, an on-line pharmacy source, or from the pharmacist. To reconstitute powdered medication: 1. Gather equipment. Check the medication order against the original order in the medical record, according to agency policy. 2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient. 3. Perform hand hygiene. 4. Move the medication cart to the outside of the patient’s room or prepare for administration in the medication area. 5. Unlock the medication cart or drawer. Enter pass code and scan employee identification, if required. 6. Prepare medications for one patient at a time. 7. Read the CMAR/MAR and select the proper medication and diluent from the patient’s medication drawer or unit stock. 8. Compare the labels with the CMAR/MAR. Check expiration dates and perform calculations, check medication calculation with another nurse. Scan the bar code on the package, if required. 9. Remove the metal or plastic cap on the medication vial and diluent vial that protects the self-sealing stoppers. 10. Swab the self-sealing tops with the antimicrobial swab and allow to dry. 11. Draw up the appropriate amount of diluent into the syringe. 12. Insert the needle or blunt cannula through the center of the self-sealing stopper on the powdered medication vial. 13. Inject the diluent into the powdered medication vial. 14. Remove the needle or blunt cannula from the vial and replace cap. 15. Gently agitate the vial to mix the powdered medication and the diluent completely. Do not shake the vial. 16. Draw up the prescribed amount of medication while holding the syringe vertically and at eye level. 17. After the correct dose is withdrawn, remove the needle from the vial and carefully replace the cap over the needle. If a filter needle has been used to draw up the medication, remove it and attach the appropriate administration device. Some facilities require changing the needle, if one was used to withdraw the medication, before administering the medication. 18. Check the amount of medication in the syringe with the medication dose and discard any surplus. 19. Recheck the label with the CMAR/MAR. 20. Lock the medication cart before leaving it. 21. Perform hand hygiene. 22. Proceed with administration, based on prescribed route. CHAPTER 5 Medications 5-5 175 Mixing Medications From Two Vials in One Syringe Preparation of medications in one syringe depends on how the medication is supplied. When using a single-dose vial and a multidose vial, air is injected into both vials and the medication in the multidose vial is drawn into the syringe first. This prevents the contents of the multidose vial from being contaminated with the medication in the single-dose vial. The CDC recommends that medications packaged as multiuse vials be assigned to a single patient whenever possible. In addition, it is recommended that the top of the vial be cleaned before each entry, as well as the use of a new sterile needle and syringe (CDC, 2008a; CDC, 2008b). When considering mixing two medications in one syringe, you must ensure that the two drugs are compatible. Be aware of drug incompatibilities when preparing medications in one syringe. Certain medications, such as diazepam (Valium), are incompatible with other drugs in the same syringe. Other drugs have limited compatibility and should be administered within 15 minutes of preparation. Incompatible drugs may become cloudy or form a precipitate in the syringe. Such medications are discarded and prepared again in separate syringes. Mixing more than two drugs in one syringe is not recommended. If it must be done, contact the pharmacist to determine the compatibility of the three drugs, as well as the compatibility of their pH values and the preservatives that may be present in each drug. A drug-compatibility table should be available to nurses who are preparing medications. Insulins, with many types available for use, are an example of medications that may be combined together in one syringe for injection. Insulins vary in their onset and duration of action and are classified as rapid acting, short acting, intermediate acting, and long acting. Before administering any insulin, be aware of the onset time, peak, and duration of effects, and ensure that proper food is available. Be aware that some insulins, such as Lantus and Levemir, cannot be mixed with other insulins. Refer to a drug reference for a listing of the different types of insulin and action specific to each type. Insulin dosages are calculated in units. The scale commonly used is U100, which is based on 100 units of insulin contained in 1 mL of solution. The preparation of two types of insulin in one syringe is used as the example in the following procedure. EQUIPMENT ASSESSMENT Determine the compatibility of the two medications. Not all insulins can be mixed together. For example, Lantus and Levemir cannot be mixed with other insulins. Assess the contents of each vial of insulin. It is very important to be familiar with the particular drug’s properties to be able to assess the quality of the medication in the vial before withdrawal. Unmodified preparations typically appear as clear substances, so they should be without particles or foreign matter. Modified preparations are typically suspensions, so they do not appear as clear substances. Keep in mind that it is no longer safe to use the terms “clear” and “cloudy” to designate types of insulin preparation. Insulin Glargine (Lantus) is a clear, long-acting insulin (24-hour duration). Check the expiration date before administering the medication. Assess the appropriateness of the drug for the patient. Review the assessment and laboratory data that may influence drug administration. Check the patient’s blood glucose level, if appropriate, before administering the insulin. Verify patient name, dose, route, and time of administration. NURSING DIAGNOSIS Determine related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses include: Risk for Infection Risk for Injury Deficient Knowledge Anxiety OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when mixing two different types of medication in one syringe is the accurate withdrawal of the medication into a syringe in a sterile manner and that the proper dose is prepared. Two vials of medication (insulin in this example) Sterile syringe (insulin syringe in this example) Antimicrobial swabs Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR) (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 176 Aptara Inc 176 UNIT I 5-5 Actions Basic to Nursing Care Mixing Medications From Two Vials in One Syringe continued IMPLEMENTATION ACTION R AT I O N A L E 1. Gather equipment. Check medication order against the original order in the medical record, according to facility policy. This comparison helps to identify errors that may have occurred when orders were transcribed. The primary care provider’s order is the legal record of medication orders for each facility. 2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient. This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient’s disorder and can also be used to educate the patient about the medication. 3. Perform hand hygiene. Hand hygiene deters the spread of microorganisms. 4. Move the medication cart to the outside of the patient’s room or prepare for administration in the medication area. Organization facilitates error-free administration and saves time. 5. Unlock the medication cart or drawer. Enter pass code and scan employee identification, if required. Locking the cart or drawer safeguards each patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. Entering pass code and scanning ID allows only authorized users into the system and identifies user for documentation by the computer. 6. Prepare medications for one patient at a time. This prevents errors in medication administration. 7. Read the CMAR/MAR and select the proper medications from the patient’s medication drawer or unit stock. This is the first check of the labels. 8. Compare the labels with the CMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required. This is the second check of the labels. Verify calculations with another nurse to ensure safety, if necessary. 9. If necessary, remove the cap that protects the rubber stopper on each vial. The cap protects the rubber top. 10. If medication is a suspension (e.g., NPH insulin), roll and agitate the vial to mix it well. There is controversy regarding how to mix insulins in suspension. Some sources advise rolling the vial; others advise shaking the vial. Consult facility policy. Regardless of the method used, it is essential that the suspension be mixed well to avoid administering an inconsistent dose. Regular insulin, which is clear, does not need to be mixed before withdrawal. 11. Cleanse the rubber tops with antimicrobial swabs. Antimicrobial swab removes surface contamination. Some sources question whether cleaning with alcohol actually disinfects or instead transfers resident bacteria from the hands to another surface. 12. Remove cap from needle by pulling it straight off. Touch the plunger at the knob only. Draw back an amount of air into the syringe that is equal to the dose of modified insulin to be withdrawn. Pulling cap off in a straight manner prevents accidental needlestick. Handling the plunger by the knob only ensures sterility of the shaft of the plunger. Before fluid is removed, injection of an equal amount of air is required to prevent the formation of a partial vacuum, because a vial is a sealed container. If not enough air is injected, the negative pressure makes it difficult to withdraw the medication. 13. Hold the modified vial on a flat surface. Pierce the rubber stopper in the center with the needle tip and inject the measured air into the space above the solution (Figure 1). Do not inject air into the solution. Withdraw the needle. Unmodified insulin should never be contaminated with modified insulin. Placing air in the modified insulin first without allowing the needle to contact the insulin ensures that the second vialentered (unmodified) insulin is not contaminated by the medication in the other vial. Air bubbled through the solution could result in withdrawal of an inaccurate amount of medication. LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 177 Aptara Inc 177 CHAPTER 5 Medications ACTION R AT I O N A L E 14. Draw back an amount of air into the syringe that is equal to the dose of unmodified insulin to be withdrawn. Before fluid is removed, injection of an equal amount of air is required to prevent the formation of a partial vacuum, because a vial is a sealed container. If not enough air is injected, the negative pressure makes it difficult to withdraw the medication. 15. Hold the unmodified vial on a flat surface. Pierce the rubber stopper in the center with the needle tip and inject the measured air into the space above the solution (Figure 2). Do not inject air into the solution. Keep the needle in the vial. Air bubbled through the solution could result in withdrawal of an inaccurate amount of medication. FIGURE 1. Injecting air into modified insulin preparation. FIGURE 2. Injecting air into the unmodified insulin vial. 16. Invert vial of unmodified insulin. Hold the vial in one hand and use the other to withdraw the medication. Touch the plunger at the knob only. Draw up the prescribed amount of medication while holding the syringe at eye level and vertically (Figure 3). Turn the vial over and then remove needle from vial. Holding the syringe at eye level facilitates accurate reading, and the vertical position makes removal of air bubbles from the syringe easy. First dose is prepared and is not contaminated by insulin that contains modifiers. 17. Check that there are no air bubbles in the syringe. The presence of air in the syringe would result in an inaccurate dose of medication. 18. Check the amount of medication in the syringe with the medication dose and discard any surplus. Careful measurement ensures that correct dose is withdrawn. 19. Recheck the vial label with the CMAR/MAR. This is the third check to ensure accuracy and to prevent errors. Some facilities require the third check to occur at the bedside, after identifying the patient and before administration. 20. Calculate the endpoint on the syringe for the combined insulin amount by adding the number of units for each dose together. Allows for accurate withdrawal of second dose. (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 178 Aptara Inc 178 UNIT I 5-5 Actions Basic to Nursing Care Mixing Medications From Two Vials in One Syringe ACTION continued R AT I O N A L E 21. Insert the needle into the modified vial and invert it, taking care not to push the plunger and inject medication from the syringe into the vial. Invert vial of modified insulin. Hold the vial in one hand and use the other to withdraw the medication. Touch the plunger at the knob only. Draw up the prescribed amount of medication while holding the syringe at eye level and vertically (Figure 4). Take care to withdraw only the prescribed amount. Turn the vial over and then remove needle from vial. Carefully recap the needle. Carefully replace the cap over the needle. Previous addition of air eliminates need to create positive pressure. Holding the syringe at eye level facilitates accurate reading. Capping the needle prevents contamination and protects the nurse against accidental needlesticks. A one-handed recap method may be used as long as care is taken to ensure that the needle remains sterile. FIGURE 3. Withdrawing the prescribed amount of unmodified FIGURE 4. Withdrawing modified insulin. insulin. 22. Check the amount of medication in the syringe with the medication dose. Careful measurement ensures that correct dose is withdrawn. 23. Recheck the vial label with the CMAR/MAR. This is the third check to ensure accuracy and to prevent errors. Some facilities require the third check to occur at the bedside, after identifying the patient and before administration. 24. Label the vials with the date and time opened, and store the vials containing the remaining medication according to facility policy. Because the vial is sealed, the medication inside remains sterile and can be used for future injections. Labeling the opened vials with a date and time limits its use after a specific time period. The CDC recommends that medications packaged as multiuse vials be assigned to a single patient whenever possible (CDC, 2008a; CDC, 2008b). 25. Lock medication cart before leaving it. Locking the cart or drawer safeguards the patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. 26. Perform hand hygiene. 27. Proceed with administration, based on prescribed route. Hand hygiene deters the spread of microorganisms. See appropriate skill for prescribed route. CHAPTER 5 Medications EVALUATION 179 The expected outcome is met when the medication is withdrawn into a syringe in a sterile manner, and the proper dose is prepared. DOCUMENTATION Guidelines It is not necessary to record the removal of the medication from the vials. Record each medication administered on the CMAR/MAR or record using the required format immediately after it is administered, including date and time of administration. If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the primary care provider. This verifies the reason medication was omitted and ensures that the primary care provider is aware of the patient’s condition. Recording administration of a narcotic may require additional documentation on a narcotic record, stating drug count and other specific information. UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS You contaminate plunger before injecting air into insulin vial: Discard needle and syringe and start over. If plunger is contaminated after medication is drawn into the syringe, it is not necessary to discard and start over. The contaminated plunger will enter the barrel of the syringe when pushing the medication out and will not contaminate the medication. You allow modified insulin to come in contact with the needle before entering the unmodified insulin vial: Discard needle and syringe and start over. You notice that the combined amount is not the ordered amount (e.g., you have less or more units in combined syringe than ordered): Discard syringe and start over. There is no way to know for sure which dosage is wrong or which medication should be expelled. You inject medication from first vial (in syringe) into second vial: Discard vial and syringe and start over. SPECIAL CONSIDERATIONS General Considerations A patient with diabetes who is visually impaired may find it helpful to use a magnifying apparatus that fits around the syringe. Before attempting to explain or demonstrate devices that help low-vision diabetic patients to prepare their medication, attempt to use the device yourself under similar circumstances. To detect any difficulties the patient may experience, practice using the aid with your eyes closed or in a poorly lit room. Infant and Child Considerations School-age children are generally able to prepare and administer their own injections, such as insulin, with supervision (Kyle, 2008). Parents/significant others and the child should be involved in teaching. 5-6 Administering an Intradermal Injection Intradermal injections are administered into the dermis, just below the epidermis. The intradermal route has the longest absorption time of all parenteral routes. For this reason, intradermal injections are used for sensitivity tests, such as tuberculin and allergy tests, and local anesthesia. The advantage of the intradermal route for these tests is that the body’s reaction to substances is easily visible, and degrees of reaction are discernible by comparative study. Sites commonly used are the inner surface of the forearm and the upper back, under the scapula. Equipment used for an intradermal injection includes a tuberculin syringe calibrated in tenths and hundredths of a milliliter and a 1⁄4- to 1⁄2-inch, 26- or 27-gauge needle. The dosage given intradermally is small, usually less than 0.5 mL. The angle of administration for an intradermal injection is 5 to 15 degrees (see Figure 5-1 in the chapter opener). (continued) LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 180 Aptara Inc 180 UNIT I Actions Basic to Nursing Care 5-6 Administering an Intradermal Injection continued EQUIPMENT Prescribed medication Sterile syringe, usually a tuberculin syringe calibrated in tenths and hundredths, and needle, 1⁄4- to 1 ⁄2-inch, 26- or 27-gauge Antimicrobial swab Disposable gloves Small gauze square Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR) PPE, as indicated ASSESSMENT Assess the patient for any allergies. Check expiration date before administering medication. Assess the appropriateness of the drug for the patient. Review assessment and laboratory data that may influence drug administration. Assess the site on the patient where the injection is to be given. Avoid areas of broken or open skin. Avoid areas that are highly pigmented, and those that have lesions, bruises, or scars and are hairy. Assess the patient’s knowledge of the medication. This may provide an opportune time for patient education. Verify the patient’s name, dose, route, and time of administration. NURSING DIAGNOSIS Determine related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Deficient Knowledge Risk for Allergy Response Risk for Infection Risk for Injury Anxiety OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when administering an intradermal injection is the appearance of a wheal at the site of injection. Other outcomes that may be appropriate include the following: the patient refrains from rubbing the site; the patient’s anxiety is decreased; the patient does not experience adverse effects; and the patient understands and complies with the medication regimen. IMPLEMENTATION ACTION R AT I O N A L E 1. Gather equipment. Check each medication order against the original order in the medical record according to facility policy. Clarify any inconsistencies. Check the patient’s chart for allergies. This comparison helps to identify errors that may have occurred when orders were transcribed. The primary care provider’s order is the legal record of medication orders for each facility. 2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient. This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient’s disorder and can also be used to educate the patient about the medication. 3. Perform hand hygiene. Hand hygiene prevents the spread of microorganisms. 4. Move the medication cart to the outside of the patient’s room or prepare for administration in the medication area. Organization facilitates error-free administration and saves time. 5. Unlock the medication cart or drawer. Enter pass code and scan employee identification, if required. Locking the cart or drawer safeguards each patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. Entering pass code and scanning ID allows only authorized users into the system and identifies user for documentation by the computer. 6. Prepare medications for one patient at a time. This prevents errors in medication administration. 7. Read the CMAR/MAR and select the proper medication from the patient’s medication drawer or unit stock. This is the first check of the label. LWBK545_C05_p151-276.qxd 8/5/10 4:07 PM Page 181 Aptara Inc 181 CHAPTER 5 Medications ACTION 8. Compare the label with the CMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required. R AT I O N A L E This is the second check of the label. Verify calculations with another nurse to ensure safety. 9. If necessary, withdraw medication from an ampule or vial as described in Skills 5-3 and 5-4. 10. When all medications for one patient have been prepared, recheck the label with the CMAR/MAR before taking the medications to the patient. This is a third check to ensure accuracy and to prevent errors. Some facilities require the third check to occur at the bedside, after identifying the patient and before administration. 11. Lock the medication cart before leaving it. Locking the cart or drawer safeguards the patient’s medication supply. Hospital accrediting organizations require medication carts to be locked when not in use. 12. Transport medications to the patient’s bedside carefully, and keep the medications in sight at all times. Careful handling and close observation prevent accidental or deliberate disarrangement of medications. 13. Ensure that the patient receives the medications at the correct time. Check agency policy, which may allow for administration within a period of 30 minutes before or 30 minutes after the designated time. 14. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 15. Identify the patient. Usually, the patient should be identified using two methods. Compare information with the CMAR/MAR. Identifying the patient ensures the right patient receives the medications and helps prevent errors. a. Check the name and identification number on the patient’s identification band. This is the most reliable method. Replace the identification band if it is missing or inaccurate in any way. b. Ask the patient to state his or her name and birth date, based on facility policy. This requires a response from the patient, but illness and strange surroundings often cause patients to be confused. c. If the patient cannot identify him- or herself, verify the patient’s identification with a staff member who knows the patient for the second source. This is another way to double-check identity. Do not use the name on the door or over the bed, because these signs may be inaccurate. 16. Close the door to the room or pull the bedside curtain. This provides patient privacy. 17. Complete necessary assessments before administering medications. Check allergy bracelet or ask the patient about allergies. Explain the purpose and action of the medication to the patient. Assessment is a prerequisite to administration of medications. Explanation provides rationale, increases knowledge, and reduces anxiety. 18. Scan the patient’s bar code on the identification band, if required. Provides an additional check to ensure that the medication is given to the right patient. 19. Put on clean gloves. Gloves help prevent exposure to contaminants. 20. Select an appropriate administration site. Assist the patient to the appropriate position for the site chosen. Drape as needed to expose only area of site to be used. Appropriate site prevents injury and allows for accurate reading of the test site at the appropriate time. Draping provides privacy and warmth. 21. Cleanse the site with an antimicrobial swab while wiping with a firm, circular motion and moving outward from the injection site. Allow the skin to dry. Pathogens on the skin can be forced into the tissues by the needle. Moving from the center outward prevents contamination of t

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