Module four Drug administration Oral medication Sublingual medication

Module four üDrug administration üOral medication üSublingual medication üTopical medications üEye medications üEar medications üRespiratory medications üSuppository medications üParenteral medications 1

Drug administration N Medication or drugs are given to exert specific physiologic effects on the N N N N N body. They play an important role in preventing, treating, and curing illness, their administration has become one of the most important, complex and risk-laden aspects of nursing care. Side effects, adverse effects, toxic effects. Route of administration orally (mouth), topically ( skin, eye, ear), mucosally 9 mouth, lung, nose, rectum, vagina), parenteral injection ( intradermal, SC, IM, IV). Effects: local, systematic. Absorption: movement from the administration site into the bloodstream. Transportation: to the site of action. Metabolism: the drug is converted by enzymes into a less active form that can be excreted. Most drugs are metabolized in the liver. Excretion: elimination from the body. The kidneys are the most important route 2

Drug administration cont’d N Medication are prescribe by physician. N Medication order includes the name of the drug, the dose, the route, frequency. N Most medications have more than one name: the generic name is the patented official name, while the trade name is created by the particular manufacturer and is capitalized. 1. 2. 3. 4. 5. 6. 7. The 7 rights Right Medication Right Dose Right Rout Right Time (b. i. d, t. i. d, q. i. d. q 8 h) Right Client Right information Right Documentation 3

Drug administration cont’d Rationale: n n n To administer medications safely following Dr. ’s orders. To identify potential sources of error. To administer medications following the rights. Assessment: n n n Assess continued validity of order ( renewal order e. g. narcotic). Check the medication sheet is consistent with original Dr’s order. Check interactive effect of medication with other drugs client is receiving. Check compatibility of 2 medications being physically combined in solution. Check that medication is designed for route being used. Check laboratory data, serum drug levels, and client assessment data (VS, WT, Ht, allergy) to ensure safe parameters for drug 4 administration.

Oral medication Most common Safe, convenient, and cost effective. GI provide a large surface area for drug absorption. some drugs cannot be absorbed or are destroyed by enzymes or the acidity ( low PH) of this environment. ü Can be given through a nasogastric or gastrostomy tube. ü ü Rationale: v To provide the most common, easiest, and least expensive route of v v administering medication. To provide sustained drug action and increase absorption time. To provide oral liquid medication to client who has difficulty swallowing pills. To provide oral medication mixed with food for client who is fluid restricted. 5 to provide oral medication via feeding tube.

Oral medication Assessment v Check that client is not NPO for diagnostic or therapeutic purposes. v Assess that client is alert, cooperative, and able to swallow. v Check that medication to be taken with food or on empty stomach. v Assess that volume of fluid required to dilute medication is acceptable considering any fluid restriction. v Check VS, lab data, or other parameters affected by medication to be given. v Make sure that medication and tube feeding scheduling allow for medication to be given on empty stomach. 6

Oral medication Tablets and capsules: Equipment q q q Pill from bottle or in unit dose packaging Cups Water or other liquid for swallowing medication 1. Leave tablet or capsule medication in unit dose packaging. To Maintain identity of the drug, if not taken can be returned to client’s medication box. Procedure: 1. Dispense bottled tablet or capsule into bottle lid, then drop from lid into client’s medication cup. 2. Place client in setting position; assess VS if indicated. Facilitate swallowing. 3. Open unit dose package, place pill in cup, and hand cup to client. Provide water, make sure client swallows medication. 7

Liquids: Oral medication Equipment q q Liquid medication in bottle Calibrated cups 1. Shake bottle if indicated. To suspend medication that has settled. Procedure: 1. 2. Remove bottle lid and place upside down. To prevents contamination of lid. Hold calibrated medication cup at eye level, or place on firm surface with calibrations at eye level. A. Hold bottle so that label will not be soiled if medication drips onto bottle, and pour prescribed amount of medication into calibrated cup. B. Administer medication per skill for administering oral tablets or capsules. C. Provide water following medication, unless topical effect is intended 8

Topical medication v Topical agents are commonly used for a local effect. v Dermal medications (lotions, creams) are applied to rashes, lesions, or burns of the skin for their local anti-inflammatory, antiinfective, or anesthetic effect. v Slow absorption through the skin (transdermally), access the circulation for a systemic effect. v The advantage is that much less drug is lost to metabolism in GI tract or liver before it reach the bloodstream. v Ophthalmic (eye) medications. v Otic (ear) medications. v Nasal drops. 9

Topical medication Rationale: v v v To reduce inflammationcongestion or itching. To provide local analgesic or anesthesia. To apply agent that stops, slows, or prevents growth of microorganisms To provide appropriate surface for drug absorption. to decrease intraocular pressure. To prepare for diagnostic or therapeutic procedures. Assessment: v Assess that selected area for application( e. g. , chest, buttocks, or v v extremity) is consistent with manufacturer’s recommendation. Check that area for application is clean, dry, hairless, and intact. Assess status of area being treated ( e. g. , rash, character and amount of any drainage). Assess client’s subjective rating of discomfort. Assess potential systematic effect if medication intended for topical 10 effect is absorbed.

Equipment Topical medication q q q Medication tube or patch Permanente paper for past Clean gloves 1. Locate and remove previous medication patch prior to applying new dose. Dispose the used patch in biohazard box. Cleanse selected site if indicated. Clip hair if necessary. 2. 3. Place prescribed medication directly on measuring paper. 4. 5. Remove protective covering from patch. q. Clean plastic wrap q. Tape Procedure: Applying medication to clean , dry, hairless, intact skin. Alternate application sites with each dose of medication (prevent skin irritation). Apply patch immediately after removing protective cover. Label patch with date, time, and your initials. 11

Equipment Ophthalmic drops q. O. S. = left eye q. O. D. = right eye q. O. U. = Both eyes q q q Prescribe ophthalmic (eye) drops Cotton ball or tissue Clean gloves 1. Tilt client’s head slightly backward. Give tissue to client for wiping off excess medication and ask client to look up. The cornea is protected as client looks up. 2. Place ocumeter 0. 5 -1 inch above eyeball with dominant hand. This position reduces risk of dropper touching eyeball and causing injury. 3. Stabilize hand holding ocumeter as necessary. Place nondominant hand on cheekbone and holding ocumeter on top. 4. 5. Expose lower conjunctival sac by pulling down on cheek. Procedure: Without touching client’s lids or lashes, drop prescribed number of drops into center of conjunctival sac. 12

Equipment Ophthalmic drops q q q Prescribe ophthalmic (eye) ointment Tissue Clean gloves 1. Expose lower conjunctival sac by pulling down on cheek. This creates a trough for medication application. 2. Place tube tip 0. 5 -0. 75 inch above eyeball with dominant hand. Without touching client’s lids or lashes, squeeze ribbon ointment along the middle third of the inside edge of the lower 3. Ask client to close eyelids gently to move eyes. It distributes medication over conjunctival surface. Procedure: 13

Equipment q q Otic Medication Prescribe otic (ear) drops Dropper Procedure: 1. Prepare client for instillation of ear medication by positioning on side, with ear to be treated uppermost, as follows: 1. Warm medication bottle in your hand to body temp. Fill medication dropper with prescribe amount of medication. (cold medication cause nausea or vertigo). 2. 3. lift auricle upward and backward. Straightens the ear canal. 4. Instruct client to remain on side for 5 -10 min following instillation Instill medication drops, holding dropper slightly above ear. To protect dropper from contamination. 14

Equipment Nasal Medication q q q Prescribe medication Dropper tissue 1. Fill dropper with prescribe amount of medication and instruct client to tilt head back. To reach the sinuses. 2. Place dropper just inside naris and instill correct medication dosage. 3. 4. 5. Repeat skill in other naris. Procedure: Wipe away any excess medication with tissue. Instruct client not to sneeze or blow nose to keep head tilted for 5 min. 15

Mucosal Medication v Administer for local (topical) or systemic Transmucosal). v The blood vessels in lungs, mouth, nose, rectum, vagina. v Mucosal absorption helps ensure that the drug reaches the bloodstream before it is lost to metabolism in the GI tractor liver. v Sublingual SL ( under the tongue) medications are absorbed rapidly and completely due to the vast network of capillaries in that area. v Nebulizer. v Suppositories: are cone – shape masses of solid medicated substance for introduction into the rectum or vagina either for local or systemic effects. They are usually refrigerated and , when administered , melt at body temp for slow absorption. Best at bed time for retention and absorption. 16

Equipment sublingual Medication q Prescribe tablet q Stethoscope and sphygmomanometer( if indicated) Procedure: 1. 2. Assess preadministration VS. Place or have client place medication under tongue. Explain that client should not swallow drug or eat, smoke, or drink until medication is completely absorbed. 3. Evaluate client for desired drug action including relief of pain, and the side effects 17

Equipment Metered dose inhaler q Prescribe medication q Metered dose inhaler (MDI) dispenser q Tissues n 1. Procedure: Insert medication canister (stem down) into longer part of metered dose dispenser. 2. Hold canister upright and shake to mix medication with propellant before each MDI puff. If not, little or no medication will be delivered. 3. Instruct client to remove mouthpiece and hold inhaler 2 inches away from mouth, while he is setting or standing. Why? When inhaler is held in mouth , medication droplets are swallowed rather than mist being inhaled into airway. 18

Metered dose inhaler n 4. Procedure cont’d: Instruct client to exhale through pursed lips. This will increase exhaled volume, allowing room for a greater inspiratory volume. 5. Instruct client to depress inhalation device, releasing a puff of medication, while inhalation slowly 3 -5 sec and deeply through mouth. with deep , slow inhalation, medication goes to lower respiratory tract. 6. Instruct client to hold breath for 10 sec and slowly exhale through pursed lips 7. Provide tissues. Medication may stimulate coughing. 19

Rectal suppositories n Equipment n Procedure : Ø Ø 1. 2. 3. 4. Prescribed suppository Water- soluble lubricant Paper towel Clean gloves Squeeze dollop of lubricant onto paper towel. Remove foil wrapper from suppository. Moisten suppository tip with warm water or lubricant place client in Sims’ position ( lying on left side with top leg flexed. 5. Instruct client to bear down in order to identify anal opening and insert suppository into rectal canal beyond anal sphincter (4 inc). 6. Instruct client to lie quietly for 15 min, to promote drug absorption 20

n. Injections= IM, SC, ID 21

n n Administration of medication by the parenteral route or injection exposes the body to 2 foreign objects: the hypodermic needles and medication being injected. Require sterile technique, need special skills Faulty technique and misdirected injection can hamper the medication’s effectiveness and cause permanent injury to the client. Parenterally administration medications enter the blood stream readily, have a more rapid onset of action when compared to the oral route, and have a potential for serious local or systemic complication. 22

n n The intradermal site is used to determine a client’s immune Response to small quantity of injected antigen. Subcutaneous injections are administered into fatty tissue where there are few blood vessels, slowing absorption. The abdominal site offers the quickest absorption, followed by the arm, then the leg. Intramuscular injections. Intravenous are injected directly into the circulation, bypassing all barriers to absorption, therefore effects are immediate. 23

n Parenteral medication come in vials, ampules. n Not all medication are appropriate for all injection routes. n Powder drugs n n n Injection preparation Syringes and needles are available in a variety of sizes; appropriate equipment is selected depending on client factors, medication type, and the desired site of administration. Some medication ( heparin & insulin) need special syringes. Needles vary in diameter ( gauge): the large the number, the smaller the gauge. Smaller- gauge needles are used for ID & SC injection. While large gauge used for deep penetration to inject medication into muscle. disposing needles. 24

Withdrawing medication from a vial Rationale: n To achieve rapid onset of drug action. n To ensure adequate drug absorption and predictable results. n To provide medication to clients who are NPO. n To prepare medication for injection using sterile technique. Assessment: n Check type and volume of medication ordered. n Assess appropriate site for administering medication. n n Check the total volume to be administered is close to capacity of selected syringe. Check that needle length and gauge are appropriated for the client’s size and selected site for injection. 25

Withdrawing medication from a vial Equipment: n Medication in vial n Syringe of closest capacity to hold medication. n Appropriate size needle Procedure: 1. Select appropriate syringe size: capacity should closed accommodate volume to be administered. Facilitates handling and accuracy in preparation. – Assemble syringe and needle, maintaining sterility. Infection/abscess – Remove vial cap and cleanse rubber top of vial with alcohol swab. – Remove needle guard. Pull back on plunger of syringe to fill with an amount of air equal to amount of solution to be withdrawn. 26

Withdrawing medication from a vial Procedure cont’d: 2. Insert needle into upright vial and inject air into vacant area of vial, keeping needle bevel above surface of medication. If air is injected into the medication, bubbles may form, making drug withdrawal more difficult. Air creates positive pressure in the vial, allowing withdrawal of medication. 3. Invert vial and pull on the plunger tip to extract desired amount of medication. Expel any air from syringe at this time, tapping side of syringe below air bubble. Tapping below bubble makes it rise to needle hub area. expelling air facilitates validation of dose withdrawn. 27

Withdrawing medication from a vial Procedure cont’d: n Recheck amount of medication in syringe; turn vial upright and remove needle. n Replace needle guard using the scoop method. The scoop method is not necessary when recapping a sterile needle, but encourages development of a safe habit. n Recheck medication label and dosage against medication record any dose calculation. n Dispose of or replace equipment appropriately. 28

Withdrawing medication from an ampule Equipment: n Medication in ampule n Syringe of closest capacity to hold medication. n Appropriate size needle Procedure : 1. Tap stem of the ampule, or, holding stem tip, briskly flick wrist to move all medication to ampule base. 2. Using alcohol swab or dry gauze square, grasp and snap off stem of ampule, breaking away from you. (prevent injury) 3. Remove syringe needle guard and insert needle into ampule without touching side of ampule neck. Prevent contamination. 4. If needle is long enough, withdraw appropriate amount of medication. Tilt or invert ampule if needle is short. Then return ampule to upright position and remove syringe. 29

Intradermal injection n ID route, just under the top layers of the skin. n Used to inject a very small ( e. g. 0. 1 ml) volume of a substance ( antigen) to elicit a client’s immune or sensitivity response. n Inner aspect of the forearm is typically used for this type of testing. n Alternate sites include the upper arm, upper chest, and shoulder blade areas. n The client’s reaction to the substance indicating immune or allergic response is monitored at the injection site ( e. g. noting induration indicating immune response to tuberculin PPD). n ID also use to administer a local anesthetic prior to a venipuncture procedure. 30

Rationale: n Intradermal injection Immune, diagnostic, anesthetic. Assessment: n n Assess for previous exposure to TB, previous positive skin test, or previous BCG vaccination ( PPD is contraindicated in these situation). assess that site is free of dermatitis. Assess that skin dry at planned injection site. Assess that client is not allergic to local anesthetic (e. g. lidocaine) Equipment: n n n Unit dose (1 ml) tuberculin syringe with ¼-in to 5/8 - in – long needle ( small 25 -27 gauge). Medication( 0. 1 ml Purified Protein Derivative antigen- PPD) Dry gauze square Pen Clean gloves 31

Procedure: Intradermal injection 1. Select lesion- free injection site on hairless undersurface, upper third of forearm ( for skin testing) or site selected for venipuncture. Use alcohol swab to cleanse area with circular motion, moving from inside outward, and allow alcohol to dry. Prevent contamination. 2. Remove needle guard. 3. Grasp client’s outer forearm to gently pull skin tight on undersurface for skin testing. 4. Hold syringe almost parallel to skin and, with bevel facing up, insert needle tip ( about 1/8 in). rationale: bevel up facilitates visualization of injected substance. 32

Intradermal injection Procedure cont’d: 5. Do not aspirate. There is no risk of intravascular injection with correct intradermal technique. 6. Slowly inject medication, observing for wheal ( blister) formation and blanching at site. Rationale: wheal formation indicates proper injection. If no wheal develop, injection was given too deeply. 7. Withdraw needle at same angle as inserted. Do not recap. 8. Pat site with dry gauze. Do not massage area. Massage could disperse medication. 9. Use pen to mark injection site for future assessment; if more than one test is being performed, number injection site and record number and corresponding antigen in client’s record. 33

Subcutaneous Injection=SC n n n Administered into the fatty tissue under the skin, where there are few blood vessels and nerves. This site can be used only for medications that are not irritating to tissue. Drugs absorption is slower than when administered into muscle. The most common sites used are the outer surface of upper arm, the anterior thigh, and the abdomen ( avoiding the area 1. 5 in around umbilicus). Alternate site include the ventrodorsal gluteal area and scapular areas of the upper back. Typically a small amount ( less than 2 ml) of 34 medication is injected.

Type of injection degree: 35

Sc injection site 36

deltoid muscle-2 fingers widths down from the acromion process; the bottom edge is at an imaginary line drawn from the axilla 37

ventro gluteal muscle - With thumb toward the umbilicus, place palm of hand on the greater trocanter, index finger on the anterior superior iliac spine, and the middle finger on the iliac crest. 38

Vastus lateralis-Place one hand below the greater trocanter and one hand above the lateral femoral condyle; mid-lateral thigh. 39

DORSAL GLUTEAL-Draw an imaginary line between the greater trochanter and the posterior superior iliac spine; at the middle of the imaginary line, go up about one inch 40

Subcutaneous Injection=SC Rationale: n n To deliver small amount of a nonirritant medication. To avoid hematoma formation. Assessment: n n n Check that the volume of drug to be administered is less than 2 ml Check that the drug to be administered is nonirritating. Check results of lab. Tests ( PTT) for specific medication. Equipment: n n syringe 3 ml with 5/8 in needle ( small 25 -29 gauge). Medication vial or ampule Alcohol swabs Clean gloves 41

Subcutaneous Injection=SC Procedure: n n n Select site for injection, alternating sites for each injection. This prevents repeated trauma to tissue. Avoid area around umbilicus. With selected site fully exposed, cleanse area with alcohol swab using circular motion moving from inside outward. Allow alcohol to dry. This prevent alcohol from tracking into tissue with injection. Remove needle guard Use thumb and forefinger to gently grasp SC tissue ( pinch and inch) on posterior- lateral aspect, mid-upper arm ( or other appropriate site). Holding syringe like a dart or between thumb and force finger , insert needle at 45 -90 degree angle. Angle varies with amount of SC tissue, selected site, nd needle length. 42

Subcutaneous Injection=SC Procedure cont’d: n n Hold syringe barrel with dominant hand, with same hand, aspirate by pulling back on plunger. If no blood appears, administer injection. If blood appears, withdraw syringe, discard, and prepare new injection. Inject medication slowly. Wait 10 sec, then withdraw needle quickly ( prevent medication leakage). Do not recap. Release tissue and gently massage injection site with alcohol swab( Aids absorption) 43

Intramuscular Injection=IM n n n n Given deeply into muscle, which is rich with blood vessels, for rapid drug absorption. May be more painful than others because nerves are more plentiful in muscle. Because of blood vessels and nerves it needs skills. Well- defined anatomic landmarks are used for individual injection site selection to avoid accidental intravascular deposition of drug and to prevent nerve injury. Injection less than 4 ml for a large muscle. Needle length and gauge selection is based on the drug, the client’s size, and the selected site for injection. Muscles used for injection include the ventrogluteal, 44 vastus lateralis, dorsogluteal, and deltoid.

Intramuscular Injection=IM n n Ventrogluteal site is preferred for injection because its relative lack of large nerves, blood vessels, and fat. Suitable for most age groups. Vastus lateralis of the thigh, thick and well developed, lack of large nerves, blood vessels. The injection site should be confined to the middle third of the muscle. Common in pediatric clients. dorsogluteal site is the more difficult to locate and the least desirable of all IM injection sites because major blood vessels and the sciatic nerve are located there. Deltoid is a small muscle mass located in the upper arm near the shoulder, close to major vessels and the radial 45 nerve.

Intramuscular Injection=IM Rationale: n For rabid absorption n To administer medication that are too irritating to be given SC n To provide medication to client who are NPO, nauseated, or vomiting. Assessment: n n n Check type and volume of drug to be given. Assess client’s size and age. Assess status of previous injection site. Assess relevant VS, lab Check that selected site is free of local tissue damage. Check that selected site is clearly visible for identification of landmarks and safety of administration. 46

Intramuscular Injection=IM Equipment: n n Syringe 3 ml with 1. 5 in needle ( small 21 -23 gauge). Medication vial or ampule Alcohol swabs Clean gloves Procedure: 1. Fully expose area to select site for injection, alternating site for 2. 3. 4. each injection. Rationale: facilitates visualization and palpitation of landmarks. Cleanse area with alcohol swab using circular motion, moving from inside outward. Allow alcohol to dry. Rationale: prevent tracking of alcohol into the tissue. Remove needle guard. Use thumb and forefinger to spread skin taut, or grasp muscle in a small client to increase mass. Rationale: to ensure needle placement 47 in the muscle belly.

Intramuscular Injection=IM Procedure cont’d: 5. Insert needle at 90 degree angle into muscle belly, using a quick darting motion. Rationale: this angle facilitates medication reaching muscle. 6. Pull back on plunger to aspirate for presence of blood. If blood returns, discard and prepare a new injection. 7. Inject medication slowly. 8. Withdraw needle at same angle as inserted. Retract needle if using safety syringe or do not recap needle. 9. Press site with gauze. 48