• Medication Administration: Part I N225 Health Assessment and Nursing Clinical Skills Medication Management System for Patients Automated Dispensing Systems Automated Dispensing Systems for medications are storage areas for patient medications that are located on the unit near the patient’s point of care. Controls, tracks, and documents medication distribution to the patient Example of an Automated Dispensing System “Pyxis” and Scanning a Medication Example of Scanning Device to Check Patient Name Band and Label on Medication Key Aspects to Safe Medication Administration With Administration of any medication you need to check the healthcare provider’s order against medication administration record (MAR). Next you will retrieve the medication from the patient’s drawer and inspect the label. Prepare the medication; any wasted medication are witnessed and scanned by another nurse to validate it. Check the Medication against the patient’s MAR You will need to look up the medication and verbalize the indication, drug classification, contraindication, usual dose range, side effects, and nursing considerations. 3 SAFETY CHECKS! See CLC Skill Validation The 10 Rights Right Right Right Right Right Patient Medication Dose Time Route Right Education Right to Refuse Right Assessment Right Evaluation Right Documentation Medication Orders Standing orders- continue until discontinued. Some automatically discontinued after 7 days One time ordersSTAT- single dose within 30 minutes Now – single dose within 90 minutes prn- as needed, must have reason Order for unfamiliar drug If unfamiliar “look it up” ; “ask the pharmacist” or discuss with MD Would it be NEGLIGENCE if you administered an unfamiliar drug while remaining ignorant of its actions, intended effects & side effects, or adverse reactions? Parts of Medication Orders to Check For 1. Patient’s name and date of birth 2. Date and time medication ordered 3. Name of medication (generic and/or brand) 4. Medication dosage 5. Route of administration 6. Frequency e.g. every 6 hours 7. Duration 8. IF prn medication, needs to include reason 9. Signature of individual ordering the drug Oral Medications Slightly flex head, chin down to prevent aspiration Route of choice- if patient can swallow safely and tolerate medication in the stomach Contraindicated if client is nauseated, vomiting, has gastric or intestinal suction or NPO Class Practice: Oral medications Tablets and capsules Liquid/Elixir Medications If unable to swallow pills Works faster than pills Usually more expensive Use clear plastic medicine cup with measurements Always place med cup on flat surface to measure accurate amount If giving less than 10 mL, draw up liquid with a syringe- LABEL IT! Liquid Amounts Read at the Bottom of the Curved Meniscus Crushing Oral Medications Used for clients who cannot swallow whole pills Need to verify if the med can be crushed Extended release meds and enteric coated meds cannot be crushed Always use a clean mortar and pestle or other crushing utensil Can be mixed with apple sauce, ice cream, jam, etc. (small amount) Capsules can usually be opened & mixed with small amount of food Dispensing oral medications Cannot be delegated Check swallow, gag, cough reflexes Check available labs, e.g. liver function? Do not touch medication Keep meds in wrapper until dispensing Do not split tablet unless scored Stay with patients until pill swallowed Record reasons for refusal or failure to dispense Medications Sublingual (SL)- under tongue and allow to dissolve completely Hold fluids until completely dissolved Caution client against swallowing Buccal- against mucus membranes of cheek until dissolved Powdered- mix with liquids at bedside Lozenges- don’t chew or swallow- avoid oral fluids Sublingual medications are placed under a patient’s tongue for rapid absorption e.g. nitroglycerin for chest pain Topical medications Applied locally to skin Transdermal patch- sustained action medications e.g. nicotine, estrogen Apply to clean, hairless skin in areas without wrinkling & excessive movement Don’t apply heat to patch Don’t massage Remove old patch before applying new one Wear gloves to apply and remove Dispose of properly Document when and where applied. Topical medications Ointments, creams, powders applied to clean, dry skin. Thin layer. Wear gloves or use applicators. May cover with gauze etc. Check orders, Parts of a Syringe Luer-Lock Syringe tip Attach the needle securely to the syringe by twisting to the right firmly. Standard syringe tip Needles Most made of stainless steel Most are disposable 3 parts Hub-fits into the syringe tip Cannula or shaft-attaches to the hub, length varies from 1/4 to 5 inches Bevel-slanted part at needle tip Length – ¼ to 3 inches Choose depending on clients size, weight and location of injection Longer for IM Shorter for subcutaneous Needles Gauge (diameter) varies from #18 to #33 larger the number, the smaller the needle diameter Pick gauge depending on size of client and how viscous medication is. Examples : Adult needing a subcutaneous injection - use #24 to #26 gauge needle that is 3/8 to 5/8” long For an obese adult – subcutaneous -use 1 inch #24 to #26 gauge needle For children and thin elderly clients – subcutaneous use a #24 to #26 gauge shorter needle Safety Needles for Safety Healthcare facilities do have safety needles for use to promote and safety and prevent needle injuries Ampule Medications Some medications are solutions that are packaged in glass ampules Before opening ampule flick the top so the medication moves down to the main portion Use an ampule opener or alcohol swab to break the neck to remove the top portion Breaking the Ampule Neck Scored for easy opening, usually this band is colored at the neck band Snap neck AWAY from you Don’t inject air into vial Ampule Medications To withdraw the medication invert the ampule and use a syringe with a filter needle to withdraw fluid or place the ampule at a 45 degree angle. Discard syringe in Biohazard Container Vials Vial Small bottle with rubber seal Seal needs to be pierced & air injected equal to what you are withdrawing Single dose and multi-dose vials available. Date multi dose vials May use a filter needle to aspirate- then change needles Class activity: Snap cap off, do not handle rubber seal, alcohol top- wait for the ETOH to dry (some agencies policies are to not alcohol rubber seal with 1st dose removed) Withdraw 0.8 mL of fluid- which syringe would you use? Now, try to withdraw 2 mL without injecting air first Vials Tuberculin syringe (1 mL capacity) Measurement is in hundreds of a mL on one side of the syringe (and may have minims (apothecary system) on the other side). Compare this syringe to the insulin syringe in your bag. Insulin Syringe Measurement is in units. Most syringes are U100 per mL (BE CAREFUL!) Come in different sizes never more than one mL. Can NOT substitute tuberculin syringes! Take out a 1 ml syringe and compare to the insulin syringes in your bag. Mixing Meds in One Syringe: Example Mixing Two Types of Insulin Example of mixing meds: Intermediate acting NPH insulin—cloudy Fast acting Regular insulin—clear REMEMBERcloudy (NPH)-clear (Regular)-clear (Regular)-cloudy (NPH) Air goes first in cloudy, then air in clear. Withdraw medication from clear and then cloudy Injected Parenteral Medications Intradermal (ID): this injection places the medication into the dermis under the epidermis. Subcutaneous (SC): this injection places the medication into the loose connective tissue under the dermis Intramuscular (IM): this injection places the medication into the body of a muscle Intravenous (IV): this injection places the medication/solution into a vein through an existing IV line or a short venous access device (saline lock). Intravenous route medications may be ordered as an IV bolus, an intermittent (piggyback) medication, or in a large volume continuous infusion (IV bag). Safety Considerations Always wash your hands Keep sterile parts of the needle and syringe sterile Use new, sterile equipment with each injection Needle Length Correct needle length allows for correct delivery of medication into the correct site and can reduce complications such as abscesses, pain, and bruising. Needle selection should be based on size of patient, gender, injection site, and amount of medication injected Needles of varying length, with and without retractable caps extended. Injection Tips With all injections, the needle should be inserted all the way up to the hub For injections, use a sharp, beveled needle and place bevel side up Enter the skin smoothly and quickly to help reduce pain during injection. Hold the syringe steady once the needle is in the tissue to prevent tissue damage. Withdraw the needle at the same angle used for insertion. Rules of Thumb for SQ or IM Parenteral Medications Wash your hands- before and after procedure. Wear gloves. Check medication vial at least 3 times- when removing from drug cart, when drawing up, before administering Clean injection site in a circular motion, start at center and move out~ 2 inches. Insert needle quickly and smoothly. Hold needle still when in tissue Inject medication slowly to allow time for medication to disperse through the tissue Hold needle in place for 10 seconds to prevent leak back Massage site after injecting to aid in absorption Subcutaneous Injection Injected into the loose connective tissue under dermis. Less vascular, absorbs slower than IM Some vaccines, insulin, heparin 45 to 90 degree angle to the skin (depends on patient size; book states 90 degree, and you will do this on your CLC skill validation) Needle length 1.25-1.5 cm (1/2-5/8 in.) 25-27 gauge 1 mL or less is injected Subcutaneous Injection continued Sites: usually inject into fatty tissue Outer posterior aspect of the upper arm Abdomen, below the costal margins to the ileac crest Anterior aspect of the thighs Scapular areas of upper back Upper ventral or dorsal gluteal area Rotate sites Abdominal site preferred for insulin injection because the absorption is more predictable Sites for SQ Injections SQ Administration Heparin (LMWH) Injections (SQ) Select site on abdomen at least 2 inches from umbilicus & above iliac crests Needle length depends on client #25 gauge needle or smaller 90 degree angle or if very thin 45 degree angle with >3/8 needle length SQ Heparin Injection To prevent tissue damage and bruising, do not aspirate or massage anticoagulant injections Heparin and low molecular weight heparin, Lovenox (LMWH) does come in a prefilled syringe Pre-filled syringe and Carpuject holder Intradermal Injections Usually for skin testing- allergy, TB tests (Manitou test), lidocaine injections Administered into the dermal layer of the epidermis- (decreased blood supplydecreased med absorption). In area free of rashes, hair, etc. Small amount of solution is used (0.01 to 0.1 mL) Used frequently for allergy or TB testing 1mL syringe with a #25, #26 or #27 gauge needle that is 3/8 to 1/2 inch long INTRADERMAL INJECTION Syringe—1mL (or a tuberculin [TB] syringe) Needle Short ¼ – ½ inch Fine gauge (#26#27) Amount injected 0.01 – 0.1 mL Insert needle at 15 degree angle, bevel up, and inject solution to form a wheal on the skin (if no wheal, you probably went too deeply Intradermal Wheal Intramuscular Injections Faster absorptiongreater blood supply Syringe 3 mL syringe most common Needle – Length 1.5 -3.8 cm (1 – 1½ inch) Gauge #19 – #25 gauge depends on the muscle and fat at the site Intramuscular Injections 3 mL syringe Note syringe is marked to measure tenths of a mL (CLC may have syringe that measures Note you cannot measure medication in this syringe to more than tenths) IM injections Clean site using a circular motion- start at center and move out ~ 2 inches. Wait till alcohol dries (less burning, more effective) Muscle relaxed, area free of rash etc. Insert quickly but inject steadily & slowly (10 seconds/ml) Wait 10 seconds then withdraw smoothly at same angle as injection Z-Track Method of IM Injection Preferred method for all IM’s but not used much in practice, best for meds that irritate or discolor tissue, e.g. iron injections, progesterone injections Less painful –seals medication in muscle tissue New needle on syringe Pull skin to the side (1-1 ½ inches) Z-Track Insert needle at 90 degrees deep into muscle Aspirate, if no blood return, inject med After 10 seconds-withdraw needle and let skin go back to natural position When the skin returns, it forms a natural seal over the site, preventing the seepage of the med. into the subcutaneous tissue Z-track Ventrogluteal Site Deep in the gluteus muscles (gluteus medius) of the lateral hip ** Preferred site- No large nerves or blood vessels Side lying easiest to find landmarks Right hand/left hip Left hand/right hip Heel of hand rests on Greater Trochanter Index finger- Anterior Superior Iliac Spine Middle finger –below Posterior Iliac Crest to form V (triangle) inject into middle of triangle Ventrogluteal Site Ventrogluteal Injection Site Locate greater trochanter and anterior superior iliac spine. Place palm at trochanter and index finger at anterior superior iliac spine; fan remaining fingers posteriorly. Vastus Lateralis Infants, children & adults Anterior lateral aspect of thigh Use middle third of muscle Divide into 1/3 area between the top and bottom of femur, select middle Vastus Lateralis Injection Site Select site 1 hand-breadth below greater trochanter and 1 hand-breadth above knee for vastus lateralis injection. Site is middle third and anterior lateral aspect of thigh. Inject medications at 90-degree angle directly into muscle. Deltoid IM Injection Site Needle Length – 5/8 – 1 1/2 inch Gauge 19-25 Use 3 ml syringe 3-5 cm (1-2 inches) below acromion process Relax & flex elbow Rapid absorption HepB, flu shots Apply pressure for 10 seconds before injecting to decrease pain Deltoid IM Injection Site Reconstitution of Medication Reconstituting vial- powdered med Label will tell you what to mix with the powderusually 0.9 NS or sterile water (diluent) Draw up amount needed of diluent and inject into bottle. Mix by gently rotating (rolling) vial until all powder dissolved Remove needed amount Label with date/time/diluent/concentration Syringe with Attached Needle and Safety Shield Review of Injection Types What we hope to avoid when administering medications!!! Use this to Practice in the CLC Open a patient chart in the EHRgo (Practice Patient only) Open the Physician order and verify the order against the MAR for any of the oral medications Look up the medication in your drug book Do your first and second check of the medication at the medication cart Scan the medication/ or hit the pencil icon Follow prompts for giving the medication Make sure to hit the blue save icon when finished Document date, time, site, patient’s tolerance.