MEDICATIONS - any substance used in the diagnosis,

treatment, cure, relief or prevention of symptoms or

diseases

Aka: Drug

Principles of Medication Administration

D-Doctors order verification - FIRST THING TO DO

- Check for the completeness of the order

R-RIGHTS

1. Patient

2. Medication

3. Dosage

4. Time

5. Route

6. Documentation

7. Assessment and evaluation

8. Refuse

9. Approach

10. Education

U-use the principle of aseptic technique (sterile)

G-Go to pharmacy - BEST source of drug information

2nd-drug handbook

A-Accountability and knowledge about the drug

medication error

1st - assess pt (VS)

2nd - notify MD

3rd - Incident report

Knowledge

1. Insomnia - give in the AM

2. Nervousness - give in the AM

3. Sedation - give at HS

4. Nausea - take it with meals; carbonated beverage

5. GI upset - take it with meals

6. Discoloration of the teeth - use straw

7. Unwanted taste - mix with juice; give ice chips - to

numb the tongue

8. Hypogeusia (bitter taste) - spicy foods

9. The drug tastes "FUNNY" - oral care

10. Promote maximum absorption (antibiotics) - give with

meals

D-Do not mix medications unless ordered by the MD; one

at a time

M-medication order error, do not administer and notify the

ordering MD

I-Initiate safety precautions

N-never leave medication at the bed side

S-scalar chain

Safety precaution

1. Do not administer drug you did not prepare

2. Do not give drugs with unreadable labels

3. Electronic infusion pump - TPN and KCl

Types of Medication Order (MO)

1. Standing - MO that must be carried-out continuously

until a specific period of time or until it is discontinued
by another order (eq. Penicillin 500mg PO TID for
 7days)

2. Single/One-time order - MO that must be carried-out

only once and at a specific period of time (eq. Seconal
50mg PO HS before surgery)

3. STAT - immediately/at once/now (eq. Meperidine HCl

50mg TIV STAT)

4. PRN - as necessary/needed (eq. Paracetamol

(Biogesic) 500mg PO q 4hrs for temperature of 37.8C
and above) ***nurse's judgement

5. Ad Lib (libidum) - as desired; ***patient's judgement

Important Terminologies

1. Therapeutic eect - primary eect; intended eect;

reason why the drug was given

A. Curative - cures the disease condition (penicillin for

infection)

B. Palliative - alleviation of the SSx of the disease

(morphine for pain, paracetamol for fever)

C. Substitutive - replaces hormones or enzymes in the

body (insulin for DM, synthroid for hyperthyroidism)

D. Supportive - supports body function until the body

itself or the other treatments can take over (Aspirin
for fever, Norepinephrine bititrate for low BP)

E. Restorative - restores the body back to health

(vitamins and supplements)

F. Chemotherapeutic - destroys malignant cells

2. Side eect - secondary eect; unintended eect;

predictable and usually harmless buy maybe
potentially fatal

3. Adverse eect - potentially FATAL and dangerous

 eect; hepato, nephro, neuro, oto, cyto, ophtho,
cardio, pulmo

4. Teratogenic - "monster producer"; fetal deformities

(NTD, CHD, phocomelia, amelia)

5. Idiosyncratic - unique, individualized, unpredictable

6. Tolerance

7. Withdrawal

8. Cumulative eect - opposite of tolerance; elderly -

decreased kidney and liver function

9. Potentiating eect - giving 2 drugs for more potent

eect

A. Additive - 2 drugs of SAME classification

B. Synergistic - 2 drugs of DIFFERENT classification

(Penicillin plus probenecid)

10. Paradoxical - opposite

ROUTES of Medication Administration

1. Oral - most common form

A. Advantage: convenient, less stress, painless, usually

cheaper, does not require sterile technique

B. Disadvantage: risk for aspiration, not indicated for

pts with nausea and vomiting, decreased GI
function, unconscious; may discolor teeth; may
have unwanted taste and smell

C. Forms:

a. Solid - tablet, caplet, capsule, pill

b. Liquid

1. Suspension - water based

2. Syrup - sugar based

3. Emulsion - fat based

 4. Elixir - alcohol based; ***wait for 30minutes

before giving water to drink

2. Sublingual - under the tongue

A. Advantage: rapid eect; bypasses the liver; direct to

the blood stream

B. Disadvantage: same with oral; may be inactivated

when swallowed

3. Buccal - between the cheeks

A. Advantage: same with sublingual

B. Disadvantage: same with sublingual

4. Vaginal

A. Advantage: produces local therapeutic eect

B. Disadvantage: uncomfortable, limited use

5. Rectal

A. Advantage: Rapid eect, may be considered during

emergency situations; faster than sublingual;
systemic eect

B. Disadvantage: invasive, uncomfortable, risk for

trauma

6. Topical - applied to the skin and mucous membrane

A. Advantage: produces local therapeutic eect

B. Disadvantage: maybe messy; may enter systemic

circulation through cuts and lesions in the skin

7. Patch

A. Advantage: Produces a prolonged, consistent,

systemic eect; gradual

B. Disadvantage: same with topical

C. Applied: hairless, without cuts and lesions, proximal

part, areas not subjected to excessive movements

D. Location: inner aspect of arm, chest, upper back

8. Intradermal - to the skin

A. Advantage: skin test, mantoux test (PTB), very slow

absorption (not used for medication administration)

B. Disadvantage: pain, stress, requires sterile

technique, breaks skin barrier

C. Angle/Degree: 10-15degrees or almost parallel to

the skin with the bevel UP\

D. Needle length: <1 inch

E. Needle gauge: 25 and above

F. Capacity: 0.1ml (bleb/wheal)

G. Sites: inner aspect of forearm, upper chest, thigh,

scapular area

9. Subcutaneous - fats

A. Advantage: INSULIN AND HEPARIN (Do no

ASPIRATE, Do not MASSAGE) - slow absorption

B. Disadvantage: same with ID

C. Angle/Degree: 45-90 degrees = normal; OBESE -

90degrees (perpendicular angle); EMACIATED -
45-60degrees

D. Needle length: <1inch

E. Needle gauge: 25 and above

F. Capacity: 1-2ml

G. Sites: ABDOMEN, upper outer aspect of the arm,

thigh, gluteal area

10. Intramuscular - muscle

A. Advantage: Faster than subQ; can accommodate

irritating and discoloring medications; can handle
larger amount of medications

B. Disadvantage: same with ID

C. Angle/Degree: 90degrees (perpendicular)

D. Needle gauge: 20-24

E. Needle length: at least 1 inch

F. Capacity: 1-4ml

G. Sites:

a. Ventrogluteal - site of choice for IM injection for

patients more than 1 year old and adults; largest
muscle for IM injection; 4ml capacity; no large
nerves and major blood vessels; Landmark: ASIS
- index finger, greater trochanter - palm, iliac crest
- middle finger; position is side lying

b. Vastus lateralis - site of choice for IM injection for

patients 1 year old and below; most developed
muscle; 1-3ml capacity; landmark: middle third of
the lateral thigh between the lateral femoral
condyle and greater trochanter

c. Dorsogluteal - muscle developed by walking; not

used for children less than 3yo unless the child
has been walking already for at least 1 year; small
muscle with 1-3ml capacity; very close to the
sciatic nerve; painful; landmark: upper outer
quadrant of the buttock

d. Rectus femoris - site of the choice for self IM

injection; very painful and aects walking; not
usually used; 1-3ml capacity; landmark: middle
third of anterior thigh

e. Deltoid - NOT usually used; small muscle for

injection with only 1ml capacity; very close to the
brachial nerve and artery; Landmark: 4
fingerbreaths below the acromion process;
***EBP: application of pressure to the site for 10
 seconds before injection minimizes pain

H. Z-Track Technique - modification of IM injection;

DEEP IM; Purpose: To prevent leakage of irritating
and discoloring medication to the subQ

a. Retract (PULL) the skin laterally away from the

site.

b. Inject the needle QUICKLY and smoothly at a

90degree angle to minimize pain.

c. Aspirate first before injecting the drug to know if a

blood vessel was hit.

d. Inject the drug carefully and SLOWLY. (10secs/ml)

e. Wait for another 10seconds before withdrawing

the needle. (To allow the medication to disperse to
the muscle)

f. Withdraw the needle and release the skin

simultaneously.

g. DO NOT MASSAGE!!!

11. Intravenous - into the vein

A. Advantage: best during emergency situations; rapid

eect; large amounts of medications

B. Disadvantage: same with ID

C. Needle gauge: 20-24

D. Needle length: at least 1 inch

E. Capacity: IV Push = 10ml, IVF = 4L/day

12. Ophthalmic instillation - eyes

A. Prepare the medications by warming it. Cold meds

may cause squeezing of the eyes.

B. Position: Sitting position with the eyes looking UP

C. Technique: Sterile

D. Instill the medication

 a. Drops - outer third of the lower conjunctival sac

b. Ointment - lower conjunctive from inner to outer

canthus (1-2cms); expel the first bead because it
is contaminated

c. Allow 30 seconds interval in-between the

medications

d. Give the drops first before the ointment

E. Press on the nasolacrimal duct for 30 seconds to

prevent systemic absoprtion of the medication
(1-7% normal systemic absorption)

F. Instruct patient to close the eyes gently.

G. Remain on the same position for 5-10mins.

13. Otic instillation - ear

A. Warm the medication first to prevent pain,

discomfort and vertigo.

B. Position: Side-lying, UNAFFECTED SIDE (if otic

IRRIGATION-AFFECTED side or supine)

C. Straighten the ear canal

a. Adult (3yo and above) - pull the pinna UP and

Back

b. Children (<3yo) - pull the pinna DOWN and BACK

D. Direct the medication to flow the walls of the ear

canal.

E. Press on the tragus gently several times after

administration of the drug to facilitate the downward
flow of the medication.

F. Remain on the same position for 5-10minutes.

14. Nasal Instillation - nasal cavity and sinuses

A. Position

a. Nasal instillation - sitting position with the head

 tilted backwards

b. Sinuses

1. Proetz - supine position with the head directly

hanging over the edge of the bed; ETHMOIDAL
AND SPHENOIDAL

2. Parkinson's - supine position with the head

slightly hanging over the edge of the bed and
turned to the aected side; FRONTAL AND
MAXILLARY

B. Instill the medication during the inhalation phase.

C. Slightly tilt the tip of the nose using the thumb.

D. Remain on the same position for 5-10 minutes.

PRESSURE/BED/DECUBITUS ULCER/SORE

Sore-wound/pain

Ulcer - circumscribed lesion

Decubitus - lying down = side-lying, supine, fowler's,

prone

Causes:

1. ***Pressure - perpendicular (90deg) force acting on the

skin -> ischemia -> tissue damage

ischemia - decreased blood supply to specific part

(localized)

Shock - decreased blood supply to ALL parts of the body

(systemic)

Brain - 3minutes

Heart - 15 minutes

Liver, lungs and kidneys - 30minutes

Non-vital organs = >2hours

Capillary closure pressure - >32mmHg

***#1 cause of bed sore

2. Friction - parallel force (180deg) acting on the skin

Eq. Pushing, pulling, dragging

3. Shearing - combination of the 2

Risk Factors:

1. ***IMMOBILITY - #1

2. Advancing age

3. Poor nutrition

4. Elevated temperature (Fever) -> increased metabolic

activity -> increased oxygen consumption -> more
oxygen will go to vital organs, less oxygen to non-vital
organs

5. Fecal and urinary incontinence -> skin moisture ->

maceration

6. Chronic medical condition eq. DM, Arterial disorders

7. Altered LOC

8. Altered sensory and pain perception

Stages of Bed Sore

1. ***Stage I - NON-BLANCHABLE ERYTHEMA

(hallmark/herald) - "Redness that does NOT go away."

skin is still INTACT; NO lesions/ulcer yet

DO NOT MASSAGE!!!!

2. Stage II - skin involvement -> epidermis and dermis

actual appearance of the lesion

Blister formation, weeping appearance, painful

3. Stage III - epidermis, dermis, subQ

sparring the fascia

4. Stage IV - epidermis, dermis, subQ, muscle, bones,

(osteomyelitis), nerves, fistula

Management: "PRESSURE"

P-Precaution

DO NOT MASSAGE!!!

Maintain low body temperature (36C)

***R-Reposition the client every 2 hours (alleviates the

pressure); best way to manage and prevent pressure

E - Ensure turning schedule (HOB - time and position)

S - Sucient nutrition

CHON - tissue growth and repair

Vit C - collagen formation - first stage of healing

CHO - CHON sparring

Vit A - skin cell regeneration (epithelial) fibrous=scarring

Zinc - speed-up the healing process and increases the

immune system

S-Special bed = promotes equal distribution of the weight

of the patient

water bed, air bed, egg crate/mattress

Alternating pressure mattress - low air loss bed

U-use appropriate dressings

Prevention/Stage I - TRANSPARENT GAUZE or dry

sterile gauze (Protection=Friction)

Stage II-IV - ***HYDROCOLLOID DRESSING

Advantages:

Lasts for 3-7 days

Absorbent of mild to moderate drainage

It can FIT to uneven wound edges

Artificial skin -> water proof = bathe, shower

It can contain wound odor

Disadvantage: OPAQUE DRESSING -> no wound

visibility

R-RYB Color Coding

Red - Granulation tissue formation - late stage of healing

-> epithelial tissue formation

***Do NOT interrupt/disturb the wound

***PROTECTION

YELLOW - acute, present or previous infection

Purulent (Pus) exudate

***CLEANSING = Dakin's solution - HOSPITAL POLICY

Eq. Alcohol, betadine, hydrogen peroxide, PNSS, Sterile

water, Na Hypochlorite (Zonrox = 1:10)

Black - necrotic tissue = eschar

***DEBRIDEMENT

Mechanical - surgery; scalpel

Chemical - proteolytic enzyme

Biologic - maggot therapy

Whirlpool - cross contamination

E-eliminate friction and shearing

Eq. LIFT rather than push, pull, drag

Braden Scale Tool - assessment tool used to determine

the patient's risk to develop bed sore

INTERPRETATION:

19-23 = NO RISK

NI: Reassess patient in 24 hours

15-18 = Mild Risk

NI: Initiate turning schedule

13-14 = Moderate Risk

NI: Apply a transparent wound barrier

10-12 = High Risk

NI: Close monitoring

6-9 = Very high/Severe Risk

NI: Special bed

BASIC HUMAN NEEDS: REST AND SLEEP

Sleep - a universal, biologic need for all people

a human beings spends 1/3 of his lifetime sleeping

S-stress coping

L-let the mind (psychological) and body (physical) to

recover

E-energy conservation

E-enjoy LIFE (pleasure)

P-prevents fatigue

FACTS:

1. Brain center for sleep: Reticular Activating System

(RAS) - regulates the sleep-wake cycle or circadian
rhythm

A. Nocturnal

B. Diurnal

2. Main hormone for sleep: MELATONIN (Pineal gland;

tryptophan)

A. Light -> decreased melatonin -> wakefulness

B. Dark -> increased melatonin -> sleep

3. Main neurotransmitters for sleep

A. Serotonin (Raphe of nuclei; tryptophan) - it

decreases response to external sensory stimuli ->
"deep sleep"

B. GABA (Locus ceruleus; gamma amino acid) - it

shuts out the activity in the RAS

C. Dopamine (Midbrain; tyrosine)

D. Norepinephrine (Pons; epinephrine)

E. Acetylcholine (Reticular formation; choline)

4. Diagnostic Test for Sleep: POLYSOMNOGRAPHY

 A. EEG - brain = Delta wave - sleep wave

B. EMG - muscle

C. EOG - inner and outer canthus -> NREM or REM

5. New Concept of Sleep: Sleep is a state of altered

consciousness (OLD: Sleep is a state of
unconsciousness)

6. 24 hours of straight wakefulness is equivalent to a

BAL (Blood Alcohol Level) of 0.1% (10ml of alcohol for
every 1000ml of blood.

7. 7 days of without sleep -> sudden cardiac arrest

Sleep Architecture - pertains to the basic organization of

normal sleep

2 types: alternates in cycle

1. NREM

2. REM 5-10mins -> 20-30%

1. NREM - consists the 75-80% of normal sleep; 4

stages

A. Stage I/Very light sleep

a. ***transition from wakefulness to sleep

(hypnagogia) - hypnapompia-> waking-up

b. It lasts for 5-10mins

c. VS decreases = 5-10%

d. Muscle twitching and sensation of falling (hypneic

jerk)

e. The sleeper is very drowsy and relaxed, eyes roll

from side to side

f. The sleeper is easily aroused and may deny that

he/she is asleep

 B. Stage II/Light sleep

a. Lasts for 10-15minutes

b. VS decreases = 10-20%

c. Absence of hypneic jerk and eyes are generally

still

C. Stage III/Deep sleep

D. Stage IV/Very deep sleep

a. Stage 3 and 4 are very identical in terms of

manifestations

b. Diers only on the percentage of delta/sleep wave

present on a 30secs EEG strip (stage 4 has 20%
higher delta wave)

c. VS decreases = 20-30%

d. Skeletal muscles are relaxed, reflexes are

diminished and snoring may occur

e. Swallowing and saliva production decreases

f. Sudden Unexpected Nocturnal Death Syndrome

(SUNDS)

2. REM - it occurs every 90minutes and usually lasts for

5-30minutes

A. Stage of PARADOXICAL SLEEP - brain in highly

active; EEG activity resembles wakefulness

B. Dreaming occurs -> the body will initiate LARGE

MUSCLE (EXTREMITIES) immobility -> REM
paralysis or Sleep paralysis = to prevent your body
from acting out your dreams

Notes:

1. NREM sleep is necessary for the recovery of important

HORMONES especially GH

2. Lack of NREM sleep leads to PHYSIOLOGIC

problems such as decreased immune system,
increased susceptibility to infection, triggers profound
fatigue, slows down wound healing, decreases pain
tolerance

3. REM sleep is necessary for the recovery of important

neurotransmitters

4. Lack of REM sleep leads to PSYCHOLOGIC problems

such as irritability, confusion, disorientation, apathy,
depression, hallucinations, paranoia, anger, memory
lapses, prone to error.

PASSPORT USA

Sleep Hygiene - pertains to NI that promotes sleep

1. Sleep pattern

A. ***Establish a regular sleeping and waking-up time

to regulate the sleep-wake cycle/circadian rhythm.

B. Establish a regular relaxing routine. (Eq. Warm bath,

light reading =200-300words, count
backwards=100, ***soft music)

C. Avoid heavy activities 3 hours before sleeping.

D. Avoid thinking about school, work or family related

problems. (Rumination)

E. Avoid using your bed for eating, watching TV,

telephoning, surfing the net and studying.

F. Use your bed for only 2 things: SLEEP and SEX

G. If sleep wont come within 30minutes, leave the bed

and engage in relaxing activities.

H. Allow for the use of comfortable sleeping articles

and decrease environmental stimulation.

2. Diet

A. Avoid heavy meals 2-3hours before sleeping.

B. Avoid coee and alcohol before sleeping. ->

DIURETICS -> NOCTURIA

C. If meals are required before sleeping, consume light

CHO and a glass of milk. -> amino acid =
tryptophan

3. Medications

A. Consider sleep medications as a last resort.

B. Consult with the doctor first before stopping the

drug to prevent withdrawal.

C. Sleep medications are used for short term period

 only (1-2 weeks).

***prolonged use may aect quality of sleep

Tony Stark - 1 1 1 1 1 1 = 6

Steve Rogers - 4 2 3 3 3 3 = 18

Thor Odinson = 2 2 2 2 2 3 = 13

Bruce Banner = 3 3 3 3 3 2 = 17

Natasha Romano = 4 4 4 4 4 3 = 23