Med Admin Notes PDF

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Interventions 2 Medication Administration Ms. Cook  Important task and a legal responsibility to administer medication properly  We are responsible for our actions when we administer medication and practicing correctly  Guided by the Nurse Practice Act  Always know your scope of practice o Pharmacists compound, nurses administer  QSEN Competency Safety o About mixing meds and maintaining sterility when mixing medications together  Work arounds- a way to achieve your goal without going through all of the steps Responsibilities of Health Team Pixus- automated medication-dispensing machine Student nurses cannot administer meds without an instructor or designated staff nurse 1.3 mill are injured, 7k die from improper administration About 1 in 5 misdosages 1. Prescriber—writes orders a. The HCP, a MD, a DO, an NP, or PA b. Can be written or electronic 2. Pharmacist—dispenses medication 3. Nurse—prepares, administers, evaluates effectiveness, and teaches  Assess patient’s ability to self-administer, determine whether patient should receive, administer medication correctly, and closely monitor effect. Cannot be delegated  CANNOT BE DELEGATED

Medication Administration Policy Each facility will have their own policy and procedures GENERAL GUIDELINES 1. Administered as soon as prepared by individual who prepared the dose. 2. Medication Administration Record (MAR) 3. If in doubt, contact MD 4. Patient identification (2)

 The Joint Commission (TJC)- National Patient Safety  Cannot be room # or disease identifier 5. High alert drugs  Controlled substances- must be another nurse present when wasting  Diversion: a growing problem in healthcare where staff are using the patient’s substances 6. Six rights 1. 7. Additional Patient rights  Education of patient  Right to refuse  Right assessment  Right evaluation Procedures Governing the Administration of Medication Healthcare Provider’s Orders 1. Who can write orders? a. Anyone with script privileges 2. What are the seven parts of an order? a. Patient’s name b. The right date and time the order is written c. The right drug d. The right dose e. The right route f. The right frequency g. The person with prescriptive authority must have signature and Rx 3. Where should orders be written? a. On an order sheet, whether patient or electronically 4. What are verbal orders? a. Anything order not written, there are set guidelines on how to take a verbal order b. Get all parts of order, repeat back for confirmation c. Also can take phone orders, must identify if either 5. In what system should orders be written? a. Metric b. Generic names (NCLEX uses both trade and generic names) 6. What abbreviations are acceptable? a. Institute of Safe Medicine Practices have developed a “do not use” list of abbreviations b. Facility will also have their own list Types of Orders 1. Standing a. You can have preprinted orders which can be considered orders b. Something they will receive every day until physician says 2. Stat

a. If a single of that dose is order to given only once and immediately its should be i. Now 3. Single a. Only given once to a patient, not to be repeated 4. PRN a. Must be given in the perimeters for the order 5. Combination a. Having to give two medications at once Medication Administration Guidelines 1. Administer and document only those medications you prepare 2. Check patient identification 3. Remain with the patient 4. Omitted medications 5. Documentation 6. Automatic Stop Orders  When transferred from one service to another  When going in to surgery  Orders for routine meds are good for 30 days or the length of hospital stay  Certain meds are OOD (out of date) automatically (pharmacy will indicate this on MAR and will no longer supply the med): o Antibiotics o Anticoagulants (po, SQ, IV) o 6. Medications Brought by Patient to Hospital  Only persons actively receiving medical care can be given medications

Medication Errors Right patient Right drug Right Dose Right Time Right Route Want to maintain a culture of safety, not a culture of blame Be safe and report near misses Patient safety is top priority when an error occurs Report all med errors HCP Preparation for medication administration Triple check system 1. When you remove the medication from where it is stored.

2. When you begin to prepare the medication. 3. After you have prepared the medication. Routes of Administration Oral – by the mouth, swallows Sublingual – Under the tongue, readily absorbed. Cannot give anything to drink until absorbed Buccal – Between the outside of the teeth and end of the cheek, ring mouth out, Do not chew or swallow

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Enteral - Medication administration along any portion of the gastrointestinal (GI) tract; includes medications given via tubes: NasogastricGastrostomy- through the nose, in to the stomach o (PEG—Percutaneous Endoscopic Gastrostomy) – shorter, go through the skin, directly in to the stomach, for long term Duodenostomy Jejunostomy- weighted for placement Rectal Topical - medications applied to the skin and mucous membranes. They affect the area to which they are applied. Drug effects are generally local; systemic effects can occur. Applied on TOP Examples: ophthalmic--eye drops or ointment otic--ear drops (never force meds in an included ear) inhalation of drugs through the nose and the mouth into the respiratory tract nose drops vaginal instillation insertion of rectal suppository application of cream to skin Transdermal – the medication is stored in a patch placed on the skin and absorbed through the skin, having a systemic effect.

Administering Oral Medications Absorption of medications along the GI tract: 1. Oral Absorption – very little absorption 2. Sublingual - Absorption is rapid and effects may become apparent within 2 minutes. 3. Buccal – same as sublingual 4. Gastric 5. Small intestine absorption – highly vascular

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Rectal absorption –highly vascular

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Advantages of Oral Medications: 1. Convenient 2. Least expensive 3. Safe 4. Acceptable; causes minimal anxiety

Disadvantages of Oral Medications: 1. Unpleasant taste – can stimulate nausea/vomiting. 2. Patient who has anxiety 3. Cuts and abrasions? 2. Irritating to gastric mucosa 3. Harmful to teeth: Example: liquid iron preparation. a. Mix well with water or other liquid highly dilute. Use drinking straw, follow with water. Rinse mouth with water. 4. Amount of drug absorbed cannot always be determined accurately.

5.

a. Increased peristalsis will decrease absorption b. Some meds are destroyed by GI secretions c. Circulation affects rate of absorption d. If vomiting occurs, amount retained is questionable e. First-pass effect Oral medication administration is limited to those individuals who can swallow.

Contraindications: Oral medication administration is contraindicated for patients with the following types of problems or treatments: - unconscious patient - vomiting - swallowing impairments - gastric suction - NPO- nothing by mouth

Guidelines for Administration of Oral Medications 1. Follow medications with water. 2. Tablets that are not enteric coated or time-released may be crushed

3. 4. 5. 6. 7.

for easier swallowing. Scored tablets may be broken in half. Never crush or break enteric coated or time released medications. Administer effervescent powders and tablets immediately after dissolving in water. Never allow patients to chew or swallow lozenges. Mix powdered drugs with liquids and administer immediately. Avoid giving fluids immediately after a patient swallows a syrup. Some syrup exerts local effects on the mucosa. Protect patients against aspiration by: Giving one tablet or capsule at a time, positioning in a sitting or side-lying position.

Guidelines for Administering Medications Enterally A. B. C. D. E. F. G.

H. I.

Determine the placement of the tube before administering any medications. Administer medications in a liquid form to prevent tube obstruction. Check with the pharmacy for liquid forms of the medication. Read medication labels carefully before crushing a tablet or opening a capsule. Do not administer buccal, sublingual, enteric-coated tablets or sustained action medications through an enteral feeding tube. Do not mix medications with enteral feeding formula. Dissolve crushed tablets, powders, and soft gelatin capsules in warm, sterile water. Flush the tube before and after medications are given with 30-50 mL of warm water or follow agency policy. If more than one medication is being given, give each separately, rinsing the tube with at least 5 mL water between medications. If the tube is obstructed, warm water (Coca-Cola) may be used to flush the tube. Procedure: 1. Auscultate for bowel sounds. 2. Check for residual by aspirating gastric contents. If there is a large volume of aspirate, return aspirate to client and withhold medication 3. Check tube placement: a. Measure pH of aspirate. Gastric fluids have a range of 1-4. b. Inject 5-10 mL of air through the feeding tube while auscultating the left upper abdominal quadrant and listening for a whooshing sound. (not recommended) 4. 5.

Hold syringe 6-18 inches above the head or abdominal area if using NG or PEG tube. Keep HOB elevated when administering the medication and for

20-30 minutes after the procedure unless contraindicated.

Parenteral - A medication is administered by injection. Common routes for parenteral administration are: 1. Subcutaneous - into the subcutaneous tissue (just below the skin). 2. Intramuscular - into a muscle. 3. Intradermal - under the epidermis. (into the dermis) 4. Intravenous - into a vein. 5. Less commonly used routes: These routes are usually used by physicians. Examples: a. Intrathecal or Intraspinal - into the spinal canal. b. Intra-arterial - into an artery. c. Epidural – into the epidural space. Common parenteral routes (These routes have systemic effects.) A.

B. C. D.

Subcutaneous (SC) - approximately 1-2 mL drug diffused into capillary per hour; sustained effect; slower in onset than IM; used for non-irritating drugs. Intramuscular (IM) - absorption rate varies with injection site; more rapid effect than sc; used for irritating drugs. Intravenous (IV) - into vein; medication acts immediately when it enters the blood. Intradermal – under the epidermis

Reasons for Administering Parenteral Medications 1. Precise dosage 2. Rapid absorption 3. Rapid drug action 4. Nature of medication Example: - insulin (destroyed by gastric secretions) thus, given SC, IV route. Advantages of parenteral drug administration 1. Accurately measure amount absorbed. 2. Complete absorption. 3. Can be administered to patient with altered level of consciousness (LOC). 4. Medication not affected by gastric disturbances.

5. 6 7. 8. 9.

Administered to patients with difficulty swallowing. Administered to patients with vomiting/diarrhea, gastric suction, NPO. Medication irritating to SC can be given IM as there are fewer pain receptors. Larger volume of medication can be given IM. IM route has faster rate of absorption than SC.

Disadvantages of parenteral drug administration 1. Potential for infection (skin broken) 2. Potential of damaging major nerves and blood vessels 3. Pain/discomfort 4. Sterile abscess (collection of undissolved medication) – caused by medication injected too fast. 5. Hypertrophy - (thickening of skin) – caused by multiple injections 6. Lipodystrophy – (atrophy of tissue) – caused by multiple injections in the same site. 7. Periostitis – inflammation of periosteum (membrane covering bone) – caused by the needle hitting the bone during an IM injection. Guidelines for Intradermal Injections Use recording to find these

Characteristics of subcutaneous injection sites: 1. Abdomen 2. Anterior thigh 3. Flank 4. Scapular 5. Buttocks 6. Outer aspect of the upper arm

Characteristics of intramuscular injection sites 1.

Ventrogluteal - can use Z-track method of administration. A deep site, situated away from major nerves and blood vessels. Considered the preferred IM site. Less chance of contamination in incontinent patients. Easily identified by prominent bony landmarks. Suitable for immobilized patients with muscle atrophy. Some health professionals are unfamiliar with the site. Blood flow slower than deltoid and thigh.

2.

Vastus Lateralis - lacks major nerves and blood vessels; rapid drug absorption; large muscle mass; it may be more painful. Deltoid - easily accessible but muscle not well developed in most

3.

patients. Used for small amounts of drugs; potential for injury to radial and ulnar nerves or brachial artery; fastest absorption; acceptable to patients.

Preparation of Parenteral Medication 1. Syringe Sterile parts-tip, plunger, inside barrel; shaft and bevel of needle Nonsterile parts-outside of barrel and flange; outside of the hub of the needle 2. Types of syringes Needle sizes and maximum volumes of medication  

Needle Gauge

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Needle Length

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Angle of Insertion Maximum Volume of Medication

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Subcutaneous (S.C.) 24-30 range 25, average adult 3/8” – 5/8” range 5/8”, average adult 45o to 90o

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Intramuscular (I.M.) 20-23 range 22, average adult 1” – 3” range 1½” average adult 90o

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1 mL maximum

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Deltoid: 1 mL is the maximum amount. Other sites-_ mL is maximum amount

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NOTE: Nurse must determine whether the size of the muscle is appropriate to the volume of the drug. 1. Vial Single dose Multiple dose 2. Ampule Withdrawal of medication from a vial

Withdrawal of medication from an ampule

Guidelines for changing the needle on a syringe

A.

Some situations which require a needle change include the following: 1. When the medication is known to be an irritant to subcutaneous tissue or stains the skin. 2. After puncturing the rubber stopper of the vial multiple times, as this may dull the needle. 3. If the needle becomes contaminated. 4. Anticoagulants 5. Other situations as recommended in the literature

B.

The procedure for changing the needle when necessary (PPCP) a. Prepare the injection. b. Pull plunger down to draw the medication out of the needle. c. Change the needle. d. Push the plunger up to remove the air and replace the medication in the needle.

Injection Procedure

Ways to Prevent Medication Tracking (depositing of medication along the needle tract) A. B.

Change the needle (when medication can discolor or irritate the skin) Use Z-track technique

Z Track Technique (to be used for all IM injections except deltoid) Locate the site using correct landmarks. Using the ulnar side of the nondominate hand, pull the skin to the side. Insert the needle into the identified site. Use the thumb and index finger of the nondominate hand to steady the syringe while aspirating with the dominate hand. Inject the medication. Wait ten seconds. Withdraw the syringe while leaving the skin return to its normal position at the same time. Put pressure on the injection site-do not massage. Ways to Reduce Injection Pain A. Talk to patient to decrease the patient’s anxiety. B. Change the needle after withdrawing medication from a vial. C. Avoid sensitive areas. D. Avoid tracking. E. Position properly/inject into relaxed muscle.

F.

Unless otherwise advised, allow refrigerated meds to warm to room temperature. G. Allow alcohol to dry. H. Do not give more (volume) than allowed. I. Insert and remove needle quickly and smoothly. J. Hold skin firmly when removing; needle will not pull as much on tissue. K. Insert medication slowly. L. Apply firm pressure to site-don’t massage M. Rotate sites. Guidelines for administering medication to older adults A. Allow time for assessment, explanation and administration. B. Observe for drug toxicity even when the suggested medication dosage is taken, as many physiologic changes associated with aging enhance the possibility of cumulative effects and toxicity. C. Position the patient upright to reduce the chance of aspiration when oral preparations are administered and provide ample fluids as permitted to assist with swallowing. D. Obtain liquid forms of medications if the patient has difficulty swallowing. E. Select an injection site that has sufficient muscle mass. F. Determine if the patient can obtain medication when discharged. Some older patients have limited transportation and finances.

Home Care Considerations A. To determine if special teaching or administration strategies are require, assess patient’s or family member’s: 1. knowledge of drug therapy 2. sensory function 3. ability to read medication labels B.

Instruct patient or family members regarding: purpose of medications dosage schedule common side effects who should be called about problems what to do about missed doses drug safety (discard outdated drugs and keep drugs out of the reach of children)

C.

Devise learning aids if needed. Examples: - Egg cartons with color-coded sections for medications to take at specific times - Commercially prepared divided containers to provide one week of medication at a time.

The "Don'ts" of Medication Administration Do NOT be distracted when preparing medications. Do NOT give drugs poured by others. Do NOT pour drugs from containers with labels that are difficult to read, or whose labels are partially removed or have fallen off. Do NOT transfer drugs from one container to another. Do NOT pour drugs into your hand. Do NOT give medications for which the expiration date has passed. Do NOT guess about drugs and drug doses. Ask when in doubt. Do NOT use drugs that have sediment, are discolored, or are cloudy (and should not be). Do NOT leave medications by the bedside or with visitors. Do NOT leave prepared medications out of sight. Do NOT give drugs if the patient says he or she has allergies to the drug or drug group. Do NOT call the patient's name as the sole means of identification. Do NOT give the drug if the patient states the drug is different from the drug he or she has been receiving. Check the order. Do NOT re-cap contaminated needles. Use standard precautions. Do NOT mix with large amount of food (pudding, ice cream or applesauce, etc.) Do NOT give with foods that are contraindicated.

CGC 2/19...