NURS 222 Chapter 3 Notes Chapter 3: Principles of Drug Administration Nurses are accountable for safe administration of medications

s and must know all the components of a drug order and question those orders not complete, unclear, and give a dosage outside recommended range. The Five-Plus-Five Rights of Drug Administration Six rights of nurses: 1. Right to complete and clear order 2. Right to have the correct drug, route (form), and dose dispensed 3. Right to have access to information 4. Right to have policies to guide safe medication administration 5. Right to administer medications safely and to identify system problems 6. Right to stop, think, and be vigilant when administering medications. Rights of drug administration: 1. The right client o Two forms of identification prior to administration of the medication are required (ID bracelet). 2. The right drug o Client must receive drug that was prescribed by either: MD, DDS, DPM (podiatrist), or APRN. o TO (telephone order) or VO (verbal order) must be cosigned by prescribing health care provider within 24 hours. o All components of the drug order must be complete in order for the prescription to be given to the client. o Drug order should be read three times: at the time of contact with the drug bottle container, before pouring the drug, and after pouring the drug. 3. The right dose o Dose is usually within the recommended range for that particular drug. o Before calculating dose, nurse should have general idea based on knowledge of basic formula or ratios and proportions. o Stock drug method- drugs are dispensed to all clients from the same containers. o Unit dose method- drugs are individually wrapped and labeled for single doses. 4. The right time o The time at which the prescribed dose should be administered: o b.i.d. twice a day o t.i.d. three times a day o q.i.d. four times a day o q6h every 6 hours 5. The right route o Necessary for adequate/appropriate absorption.

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Oral (by mouth): liquid, elixir, suspension, pill, tablet, or capsule. Sublingual: under tongue for venous absorption. Buccal: between gum and cheek Feeding tube Topical: applied to the skin Inhalation: aerosol sprays Instillation: in nose, eye, ear. Suppository: rectal, vaginal Parenteral: intradermal, subcutaneous (subQ), intramuscular (IM), and intravenous (IV). 6. The right assessment o Appropriate data must be collected before administration of the drug (measuring heart rate, or serum blood sugar levels). 7. The right documentation o Nurse records the appropriate information about the drug administered: a. Name of drug b. Dose c. Route (injection site if applicable) d. Time and date e. Nurses initials or signature f. Clients response to: narcotics, nonnarcotic analgesics, sedatives, antiemetics, and unexpected reactions to the medication. 8. The clients right to education o Clients must receive accurate and thorough information about the medication and how it relates to their particular situation. o Informed consent- the individual having knowledge necessary to make a decision. 9. The right evaluation o Effectiveness of the medication be determined by the clients response to the medication 10. The clients right to refuse o Client can refuse to take medication at any time; the refusal must be documented immediately 2007 National Patient Safety Goals 1. Improve the accuracy of patient identification o Use two identifiers. 2. Improve the effectiveness of communication among caregivers o Rereading the order or test result. o Standard abbreviations, etc. o Asking and responding to questions. 3. Improve the safety of using medications o Limit drug concentrations used. o Review lists of look-alike and sound-alike drugs. o Label everything.

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4. Accurately and completely reconcile medications across the continuum of care o Communicate between providers. 5. Encourage the patients active involvement in their own care as a patient safety strategy 6. The organization identifies safety risks inherent in the patient population Disposal of Medications Recommended to put kitty litter to drugs and put them in a sealed bag (liquids). Avoid dangerous abbreviations, double-check all calculated doses, use leading zero and never trailing zero (5.0), avoid verbal orders, include the pharmacist on client rounds, think critically, scan bar code at point-of-care, etc. Additional Safety Risks for Safe Medicine Administration For every 100 medication administrations, there are 5 medication errors (administration, documenting, dispensing, prescribing, monitoring, and other). Pill splitting: Small dose changes can cause a big effect on the client. Drug costs cause clients to cut pills in half. Buying drugs on the internet: Can be incorrect drugs that cause serious effects. Counterfeit drugs: Look like the regular drug, but may not have the active ingredient, the wrong active ingredient, or the wrong amount of the active ingredient. Purchase from only licensed pharmacies. When refilling a prescription, always check: color, shape, texture, and taste of the drug. Medication Self-Administration Common practice in the home and many community-based settings (workplace); relatively new in institutional settings. Clients responsible for taking medication according to instructions when they feel they need it. Prepares client to keep them as comfortable as possible at home and manage medications during their hospital stay. Special Considerations: Factors That Modify Drug Response Absorption: Oral takes place as drug particles move from GI tract to body fluids (GI disturbances affect this). Distribution: Protein binding, blood-brain barrier (only allows lipid soluble drugs to enter the brain and CSF), the placental barrier (both lipid-soluble and lipid-insoluble drugs can diffuse across the placenta). Metabolism (Biotransformation): Liver is primary organ for metabolism; infants and neonates have immature liver and kidney function. Excretion via the kidneys normally (also bile, feces, respiration, saliva and sweat).

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Toxicity: First adverse symptoms that occur at a particular dose (more prevalent in persons with liver/renal impairment as well as elderly and infants). Pharmacogenetics: Route of administration Time of administration Emotional factors Preexisting disease state Drug history Tolerance: Ability of a client to respond to a particular dose of a certain drug may diminish after days or weeks of repeated administration. Cumulative effect: Occurs when drug is metabolized or excreted more slowly than the rate at which it is being administered. Drug-drug interaction. Food-drug interaction. Forms and Routes for Drug Administration Many different forms and routes: 1. Tablets and Capsules o P.O. not given to clients who are vomiting, lack a gag reflex, or are comatose o Do not mix with large amount of food. o Enteric-coated and timed-release capsules must be swallowed whole to be effective. o Administer irritating drugs with food to decrease GI discomfort. o Drugs given sublingually (under tongue) or buccallly (between cheek and gum) remain there until fully absorbed. 2. Liquids o Several forms: elixirs (sweetened, hydroalcoholic liquid in preparation of oral liquid meds), emulsions (mixture of 2 liquids not mutually soluble), suspensions (particles mixed with another fluid). o Read labels to determine if mixing or shaking required. o Meniscus must be at line of desired dose. 3. Transdermal o Stored in patch placed on the skin and absorbed through the skin (systemic effect- bypasses liver metabolism). o May be appropriate to cut the patch in half according to instructions given by medical professional. 4. Topical o Applied to clean, dry skin with: glove, tongue blade, or a cottontipped applicator. o Do not double dip; always use clean gloves or applicators.

Age: infants and elderly more sensitive to drugs (elderly hypersensitive to barbiturates and CNS depressants). Body weight: many doses ordered according to body weight.

5. Instillations o Liquid medications usually administered as drops, ointment, or sprays: a) Eyedrops Gently pull down skin below the eye to expose the conjunctival sac. b) Eye ointment Squeeze inch-wide strip of ointment onto the conjunctival sac. c) Eardrops Straighten external ear canal by pulling down the auricle in children; pulling back on auricle in adults. d) Nose drops and sprays Nose drops tilt head back to reach frontal sinus and to affected side to reach ethmoid sinus and place drops in the nasal cavity. Keep head tilted backward for 5 minutes after instillation of drops. Plug one nostril and spray into opened nostril. 6. Inhalations o Handheld nebulizers deliver fine-sized particle spray of meds. o Spaces are devices used to enhance delivery of medications from metered-dose inhalers- hand-held devices that deliver medications to oropharyngeal and lower respiratory tracts. a) Insert medication canister into plastic holder b) Shake well then remove cap c) Breathe out through mouth; open wide and hold mouthpiece 12in from mouth d) Take slow, deep breath through mouth while pushing top of the medication canister once e) Hold breath for 10 sec; exhale slowly through pursed lips f) Wait 1-2min if second dose required o Client position is semi- or high Fowlers. o Teach correct use of equipment; nebulizers change a liquid medication into a fine mist. o Measure amount of medication remaining in an inhaler canister by immersion in water. 7. Nasogastric and Gastrostomy Tubes o Check for proper placement of tube and pour drug into syringe without plunger/bulb, release clamp, and allow medication to flow in properly (by gravity normally). o Flush tubing with 50ml of water or prescribed amount; clamp tube and remove syringe. 8. Suppositories o Rectal- local and systemic absorption. a) Foil around suppository is removed, and suppository may be lubricated before insertion. b) Soften at room temperature (need to be refrigerated).

c) Use glove for insertion, instruct client to lie on left side and breathe through mouth to relax anal sphincter. d) Apply small amount of water-soluble lubricant to tip of unwrapped suppository and gently insert beyond the internal sphincter. o Vaginal- local and systemic absorption. a) Client should be in the lithotomy position. b) After insertion, provide client with sanitary pad. 9. Parenteral o Intradermal a) Action Local effect Small amount injected so volume does not interfere with wheal formation or cause a systemic reaction Used for observation of an inflammatory reaction to foreign proteins b) Sites Locations chosen so that inflammatory reactions can be observed: preferred areas are lightly pigmented, thinly keratinized, and hairless (ventral midforearm, clavicular area of the chest, and scapular area of the back) c) Equipment Needle: 25-27 gauge; 3/8 to 5/8 inches in length Syringe: 1 ml calibrated in 0.01 ml increments (0.01 to 0.1 ml injected) d) Technique Cleanse area (circular motion) Hold skin taught Insert needle, bevel up at a 10-15 degree angle; outline of needle under skin should be visible Inject medication slowly to form a wheal and remove needle; do not recap Mark area with a pen and ask client not to wash it off until read by healthcare provider. o Subcutaneous a) Action Systemic effect Sustained effect; absorbed mainly through capillaries (usually slower in onset than with IM route) Used for small doses of nonirritating, water-soluble drugs b) Sites Locations for subQ injection are chosen for adequate fat-pad size: abdomen, upper hips, upper back, lateral upper arms, and lateral thighs (sites should be rotated with subq injections such as insulin and heparin)

c) Equipment Needle: 25-27 gauge; to 5/8 inches in length Syringe: 1 to 3 ml (usually 0.5 to 1.5 ml injected) Insulin syringe measured in units for use with insulin only d) Technique Cleanse area (circular motion) Pinch skin Insert needle at 45-90 degree angle Release skin Aspirate except heparin, LMWH, and insulin Inject medication slowly then remove needle quickly (do not recap) Gently massage area unless contraindicated (heparin and LMWH) Apply gentle pressure to site to prevent bleeding or oozing Apply bandage if needed o Intramuscular a) Action Systemic effect Usually more rapid effect of drug than with the subQ route Used for irritating drugs, aqueous suspensions, and solutions in oils b) Sites Locations chosen for adequate muscle size and minimal major nerves and blood vessels in the area: ventrogluteal, dorsogluteal, deltoid, and vastus lateralis (peds). c) Equipment Needle: 20-23 gauge; 18 gauge for blood products; 1 to 1.5 in. in length d) Technique Same as subQ except flatten the skin area using the thumb and index finger and inject between them 90 degree angle into the muscle Syringe: 1 to 3ml (usually 0.5 to 1.5 ml injected) e) Preferred IM Injection Sites i. Ventrogluteal 1 to 3 ml, 20-23 gauge, 1.25 to 2.5 inch needle Slightly angle the needle toward the iliac crest. ii. Dorsogluteal 1 to 3 ml, 5ml gamma globulin with 18-24 gauge, 1.25 to 3 inch needle

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Place needle at 90 degree angle to skin with the client prone

Deltoid 0.5 to 1 ml, 23-25 gauge, 5/8 to 1.5 inch needle Place needle at a 90 degree angle to the skin toward acromion iv. Vastus lateralis Less than 0.5 ml in infants (max 1 ml), 1ml peds, 1 to 1.5 ml adults (max 2 ml) Direct needle at the knee at 45-60 degree angle to the frontal, sagittal and horizontal planes of the thigh o Z-track technique a) Action Prevents medication from leaking back into subQ tissue Frequently advised for medications that cause visible and permanent skin discolorations b) Sites Gluteal preferred c) Technique Pull skin to one side and hold; insert the needle Holding skin to side, inject the medication Withdraw the needle and release skin o Intravenous a) Action Systemic effect More rapid than IM or subQ routes b) Sites Accessible peripheral veins (cephalic or cubital vein of arm; dorsal vein of hand) In newborns, veins of feet, lower legs, and head mau also be used after previous sites have been exhausted c) Equipment Needle Adults: 20-21 gauge; 1 to 1.5 inches Infants: 24 gauge; 1 inch Children: 22 gauge; 1 inch Larger bore for viscous drugs, whole blood or fractions; large volume for rapid infusion Electronic IV delivery device, an infusion controller, or pump Patient-controlled analgesia (PCA) system, if ordered Eutectic mixture of local anesthetics (EMLA) if appropriate

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d) Technique Apply tourniquet and cleanse area using aseptic technique Insert butterfly or catheter and feed up into the vein until blood returns; remove tourniquet Stabilize needle and dress site Monitor the flow rate, distal pulses, skin color and temperature, and insertion site Consult agent policy regarding addition of medications to bottle or bag, piggyback technique, and IV push; be alert that all tubing is connected correctly. Developmental Needs of Pediatric Clients Stranger anxiety (infant): maintain nonthreatening environment and move slowly. Hospitalization, illness, or injury may be viewed as punishment (3-6 years): allow control where appropriate and obtain childs view of situation; encourage positive relationships; include family. Fear of mutilation (3-6 years): explain procedures carefully, use less intrusive routes whenever possible; allow children to give play injections to a doll or stuffed animal. Technologic Advances Robotic medication dispensing systems Pain-free delivery of insulin through patch PCA infusion machine that scans Abbott drugs Data from MAR displayed on handheld devices updated with each prescribers medication entry Infusion pump with a scanner used so that after reading the IV bag label, the nurse scans the medication; then nurse and client ID band programmed into the pump.