Terms and Definitions a.

Medication administration requires the soldier medic to be familiar with the terms and definitions of medication administration b. Drug effects-mechanism of action (1) Predictable chemical reaction-how the drug works (2) Changes the physiological activity of the body as the drug bonds chemically at a specific site called a receptor site (3) Mechanism of actions of drugs include (a) Drugs that fit the receptor sites well with a good chemical response are called "agonists (b) Drugs that attach at a receptor site and become chemically inactive with no drug response is called an "antagonist (c) Drugs that attach at a receptor site and produce a slight chemical reaction are called "partial agonists c. Drug actions (1) Therapeutic effects (a) Expected positive effect of drug (b) Single medication may have many therapeutic effects such as aspirin which is an analgesic, reduces inflammation, reduces fever and reduces clot formation (c) Some drugs have very specific effects such as antihypertensive medications have a therapeutic effect of controlling high blood pressure. Antibiotics treat bacterial infections. (2) Side effects (a) Unintended secondary effects (b) May or may not be harmful to the patient (c) Side effects of a drug may outweigh the benefits (d) Patients may stop taking a drug because of unpleasant side effects, i.e. codeine prescribed to control coughing but causes constipation. (3) Toxic effects (a) Caused by intake of high doses of medications, ingestion of drugs not intended to be ingested, such as topical medications, or when a drug accumulates in the system due to impaired metabolism or excretion

(b) May be lethal, depending on the action of the drug (c) Usually seen in accidental poisonings and intentional drug overdoses i.e., intentional ingestion or accidental administration of a large amount of a narcotic may cause severe respiratory depression and death. (4) Allergic Reactions (a) Unpredictable response to a drug (b) May be mild or severe (c) Mild allergic reactions include hives, rash, pruritus (itching of the skin), rhinitis (stuffy, runny nose) and wheezing. (d) Severe or anaphylactic reactions are characterized by sudden constriction of the bronchiolar muscles, swelling the throat, severe wheezing and shortness of breath. Without immediate life saving measures, this reaction progresses rapidly and death can occur within minutes. (e) Always ask patient about allergies to medications. Check unconscious patients for a medical alert bracelet or medal indicating a medication allergy prior to administering medications (5) Drug tolerance and dependence (a) Occurs when the patient receives the same drug for long periods of time and requires higher doses to produce the same effect. (b) For example, patients who take pain medications over a long period of time may develop a tolerance for the drug and require higher doses to achieve the same effect. (6) Drug interactions (a) One drug modifies the action of another drug. Drug interactions are common in patients who take many medications (b) A drug may potentiate or diminish the action of other drugs (c) May alter the way a drug is absorbed, metabolized or eliminated from the body (d) Drug interactions may or may not be desirable. For example, combining alcohol with other central nervous system depressants is not desirable. Combining diuretics and vasodilators act together to lower blood pressure in a desirable way.
An adverse drug reaction is defined as an undesirable response associated with use of a drug that either compromises therapeutic efficacy, enhances toxicity, or both.10 ADRs can be manifested as diarrhea or constipation, rash, headache, or other nonspecific symptoms.

Routes of Drug Administration

a. Non-parenteral medication administration (1) Drugs are introduced into the body by different routes, each serving a specific purpose (2) Oral administration of medications is the most common method (a) Advantages 1) Convenience 2) Economy 3) The drug need not be absolutely pure or sterile 4) A wide variety of dosage forms are available (b) Oral medications include tablets, capsules, liquids, and suspensions (c) Disadvantages include 1) Inability of some patients to swallow 2) Slow absorption 3) Partial or complete destruction by the digestive system (d) Other routes associated closely with oral administration 1) Sublingual a) The drug is placed under the tongue and rapidly absorbed directly into the blood stream b) Example - Nitroglycerin sublingual tablets 2) Buccal - The drug is placed between the cheek and gum and is quickly absorbed directly into the blood stream (3) Inhalation (a) The introduction of medications through the respiratory system in the form of a gas, vapor, or powder (b) Divided into three major types 1) Vaporization - the drug is changed from a liquid or solid to a gas or vapor by the use of heat, such as steam inhalation 2) Gas inhalation- almost entirely restricted to anesthesia

3) Nebulization - the drug is nebulized into minute droplets by the use of compressed gas or oxygen (4) Topical ointments (a) Examples of topical preparations 1) Creams 2) Lotions 3) Shampoos (b) Topical application serves two purposes 1) Local effect-the drug is intended to relieve itching, burning, or other skin conditions without being absorbed into the bloodstream and 2) Systemic effect-the drug is absorbed through the skin into the bloodstream. 3) Example - Nitroglycerin paste (5) Suppositories (a) Rectal is preferred to the oral route when patient is 1) Nauseated or vomiting 2) Unconscious, uncooperative, or mentally incapable (b) Vaginal suppositories, creams, or tablets are examples of vaginal preparations that are inserted into the vagina to produce a local effect b. Parenteral medications are those introduced by injection (1) All drugs used by this route must be (a) Pure (b) Sterile (c) Pyrogen-free (pyrogens are products of the growth of microorganisms) (d) Liquid state (2) Several types of parenteral administration (a) Subcutaneous 1) The agent is injected just below the skin's cutaneous layers

2) Example - Insulin (b) Intradermal 1) The drug is injected within the dermis 2) Example - Purified Protein Derivative (PPD) (c) Intramuscular 1) The drug is injected into the muscle 2) Example - Procaine penicillin G (d) Intravenous 1) The drug is introduced directly into the vein 2) Example - Intravenous fluids/antibiotics (e) Intrathecal/intraspinal - The drug is introduced into the subarachnoid space of the spinal column. Bulk and Unit Dose Medications a. Bulk drugs (1) Commonly called floor stock or clinic stock (2) Description - large quantity of drug from which individual medication dose is removed (3) Storage guidelines (a) Once individual dosage is removed, it can NEVER be returned to bulk container (b) Individual dosage drawn from bulk drug container will be disposed of IAW local SOP (c) Some medications require controlled temperature storage ranges b. Unit dose (1) Description - single dose of a drug in a tablet, capsule, liquid, or injectable form that is prepackaged by the pharmaceutical company or pharmacy (2) Storage guidelines (a) Normally found in medication cart (b) If still in original wrapper/unused condition, can be returned to medication cart/storage

c. Internal and topical (external) medications must be stored separately to prevent accidental use of the inappropriate medication. Example - injectable, ointments, and tablets are stored on separate shelves d. Specific medications kept in secured (limited access) area (1) All narcotics (2) All medications with abuse potential, e.g., diazepam (Valium) (3) All pre-filled hypodermic needles and syringes Guidelines and Principles of medication aministration

GUIDELINE #5: GENERAL PROCEDURES FOR MEDICATION ADMINISTRATION

5.1 Principles That Influence Medication Administration Procedures It is important that these principles of medication administration be known and followed by anyone (nursing and non-nursing personnel) who is administering medications. Principle 1: Guarantee that medication administration is a clean procedure by washing hands. Principle 2: Give medication exactly as ordered by the health care provider or indicated on manufacturers instructions. Principle 3: Everything should be done to avoid no-shows, especially for seizure medications and antibiotics. Principle 4: Prevent errors! Do not allow yourself to be distracted. Do not use one students medication for another. Principle 5: Keep individual student information private. Principle 6: Apply child development principles when working with students (e.g., students do not want to be considered unique.) Principle 7: If there is an error or medication incident, it must be reported. Follow district procedure for notifying your school nurse, administration (within 24 hours), the students parent/legal guardian, and physician. Complete documentation. It is important to act as soon as the error is discovered. The school administrator or supervisor should evaluate errors by all persons administering medications. For detailed information about what to do in the case of medication administration errors, see section 9 of the Minnesota Guidelines: Quality Assurance, Monitoring, and Assessment.

5.2 Step-by-Step Procedures When medications are administered by any school personnel, procedures such as the following should be in place: Procedure 1: Wash hands. Administration of medication is a clean (not sterile) procedure, unless otherwise specified. Procedure 2: Verify authorization from parent and/or prescriber; check the label and/or manufacturers instructions. Seek help when questions arise. Procedure 3: Gather necessary items. Procedure 4: Prepare and give medications in a well-lit, dedicated area. Remove medication from locked cabinet. Procedure 5: Check the label for name, time, medication, dose, and route. Use current resources (e.g., medical pharmacopoeia) to verify the accuracy of the physicians order. Procedure 6: Prepare the correct dosage of medication without touching medication, if possible. Procedure 7: Check the label and/or manufacturers instructions for name, time, medication, dose, and route while preparing the correct dose. Procedure 8: Check the label and/or manufacturers instructions for name, time, medication, dose, and route before returning the container to the locked cabinet. Procedure 9: Do not leave medication unattended. Procedure 10: Provide equipment and supplies (e.g., medication cups and alcohol wipes) as needed. Procedure 11: Identify the student. Ask the student to say his or her name. Nonverbal students may need third party assistance with identification. Take measures to maintain data privacy. Procedure 12: Verify the students allergies verbally by asking the student and by checking the student health records. Also verify contraindications to medicine. Watch for typical adverse medication reactions. If an adverse reaction is evident, contact the supervisor, parent/legal guardian, or licensed prescriber, according to school policy.

Procedure 13: If the student questions whether it is the right medication, stop and verify the medication against records, with parent/legal guardian, or with registered pharmacist. Procedure 14: Explain procedure to student. Procedure 15: Position the student properly for medication administration. Procedure 16: Administer medication according to the six rights (right student, right time, right medicine, right dose, right route, and right documentation). Procedure 17: Discuss administration procedure and carefully observe the student as medication is administered. Procedure 18: Record name, time, medication, dose, route, person administering the medication, and any unusual observations. Procedure 19: Ensure accurate documentation of all medications, including the witnessed disposal of medications. Procedure 20: Clean, return, and/or dispose of equipment as appropriate. Procedure 21: Wash hands. This set of medication administration procedures is modified as needed, based on routine or emergency administration and the route of administration: oral, inhaled, topical, rectal, intravenous, pumps, gastrostomy-tube, intramuscular, subcutaneous, or ear and eye. 5.3 The Six Rights of Medication Administration The six rights can be used as a mental checklist to assist those administering medication to remember and clarify the critical elements of the process. They are the:
y y y y y y

Right student. Properly identify the student (e.g., rather than asking the student, Are you Jane Doe? before administering the medication, ask the student to state his or her name). Right time. Administer medication at the prescribed time. This can usually be within 30 minutes earlier or later than the designated time unless otherwise specified by the provider or the pharmacist. Right medicine. Administer the correct medication. Check three times, prior to administration. Right dose. Administer the right amount of medication. Right route. Use the prescribed method of medication administration. Right documentation. Promptly and accurately document the medication administration.

a. General guidelines (1) Check the physician's/PA orders

(2) Wash hands prior to touching any medication (3) Five patient rights (a) Right patient - verify patient's identity by comparing the patient's medical record, provider's orders, and the medical bracelet (hospital) or ask patient to state full name (b) Right medication - compare provider's orders, medication sheet, and medication label (c) Right dose - ensure amount of medication ordered by the provider is measured correctly (i.e., graduated medicine cup, syringe, number of tablets, number of milligrams, etc.) (d) Right time - administer medications at the prescribed time as per provider's orders (e) Right route - administer medication via the route specified in the provider's order (i.e., PO, IM, IV, etc.) (4) Check medical records, allergy bands, medic-alert tags and ask patient for medication allergies b. Principles of Medication Administration (1) Only administer medication that you have prepared or received from the pharmacy as unit dose (2) Be familiar with all potential medication effects, both therapeutic and non-therapeutic. This information can be found in the (a) Manufacturer's medication insert that accompanies prepackaged medications (b) Local SOP (c) If available, Physicians Desk Reference (PDR) or RN's Drug Book CAUTION: If there is any doubt about administering a medication, check with supervisor, nurse, physician, PA, or pharmacist. (3) Administration route and time will be followed IAW provider's orders WARNING: NEVER alter medication dosage ordered by physician/PA! (4) If in doubt about medication dose, time, administration route, or if a medication is missing, check with supervisor, nurse, physician, PA or pharmacist (a) MD/PA's order and medication label DO NOT match exactly (b) Illegible medication label; return to pharmacy or follow local SOP (5) Check all medications label 3 times to ensure that the correct medication is being prepared for administration

(a) When removing the medication or container from the storage area (b) When preparing the medication dose (c) When returning the container to the storage area (6) Check the expiration date of the medication (7) Handle only one medication at a time (8) While administering medication, do not perform other duties (i.e., obtain vital signs, dressing changes) (9) Prepare the prescribed dose of medication (a) Tablet or capsules - transfer the prescribed dose of tablets or capsules to the medicine cup or if unit dose- open the package and give directly to the patient (b) Liquids - pour the prescribed dose of liquid medication into the medicine cup. Small amounts of liquid medication should be drawn up in a syringe (c) Powders - pour the correct dose of powdered or granulated medication into the medicine cup 1) Pour the required amount of water or juice into a paper cup 2) Reconstitute the medication at the patient's bedside WARNING: Never directly touch oral medications. Some medications can be absorbed through the skin, also the medication will become contaminated.

3) The medic may assist the patient in taking the medication if the patient is physically unable WARNING: DO NOT administer oral medications to patients with a decreased level of consciousness. Check with supervisor for instructions. CAUTION: prior to administering medication. (10) Patient Identification (a) Patient identification (Hospital) 1) Be sure the patient has received and wears an identification band 2) Check the information on the band to see that it is correct 3) Check the tag on the bed or wall and door, and make sure the patient is properly identified Positive patient ID required

4) Ask the patient to state his/her name 5) Check patient ID band for medication allergies and other pertinent information 6) In a hospital environment, have patients return to their bedside to receive medication (b) Patient identification (Clinic) 1) Have patient state name 2) Ask patient if he/she has any allergies to medications Dosage a. Systems of drug measurement (definitions) (1) Metric system (a) Decimal system, each basic unit of measure is organized into units of 10 (b) Basic units of measure are the meter (length), the liter (volume), and the gram (weight) (c) Small or large letters are used to designate the basic units 1) Gram = g or GM 2) Liter = l or L (d) Small letters are abbreviations for subdivisions of major units 1) Milligram = mg 2) Milliliter = ml (2) Household measurements (a) Familiar to most people (b) Used when more accurate systems of measure are unnecessary (c) Basic units of measure include drops, teaspoons, tablespoons, cups, and glass for volume; and ounces and pounds for weight b. Dosage (1) A dose is the amount of medication to be administered (2) Dosology is the study of dosage and the criteria that influence it (3) United States Pharmacopeia and National Formulary (USP-NF) states the doses given are the average therapeutic doses or "usual adult doses"

(4) The following terms are used in connection with doses (a) Therapeutic dose 1) Amount needed to produce the desired therapeutic effect 2) Also referred to as "usual adult dose" 3) Calculated on an average adult about 24 years old, weighing approximately 150 pounds (b) Dosage range 1) The range between the MINIMUM amount of drug and the MAXIMUM amount of drug required to produce the desired effect 2) Many drugs, such as antibiotics, require large initial doses that are later tapered to smaller amounts 3) MINIMUM dose, the least amount of drug required to produce a therapeutic effect 4) MAXIMUM dose, the largest amount of drug that can be given without reaching the toxic effect 5) TOXIC dose, the least amount of drug that will produce symptoms of poisoning 6) Minimum lethal dose - The least amount of drug than can produce death c. Factors affecting dosage (1) Many factors that affect the dose, method of administration, and frequency of the dose (2) Although a physician prescribes the amount to be given, you need to know how and why these quantities are determined (3) Two primary factors that determine or influence the dose are age and weight (4) Age is the most common factor that influences the amount of drug to be given (a) An infant would require much less than an adult (b) Elderly patients may require more or less than the average dose, depending upon the action of the drug and the condition of the patient (5) Weight has a more direct bearing on the dose than any other factor, especially in the calculation of pediatric doses (6) Other factors that influence dosage are (a) Genetic make-up - The genetic structure of the individual may cause peculiar reactions to medications in some patients

(b) Habitual use - Some patients must take medications chronically, causing their bodies to build up tolerance to the drug. This tolerance may require larger doses than their initial doses to obtain the same therapeutic effect. (c) Time of administration - Therapeutic effect may be altered depending upon time of administration. Example - Before or after meals. (d) Mode of administration - This has a definite impact on the dose. Example - Injections

Medication Administration
PRINCIPLES OF MEDICATION ADMINISTRATION I - Six Rights of drug administration 1. The Right Medication when administering medications, the nurse compares the label of the medication container with medication form. The nurse does this 3 times: a. Before removing the container from the drawer or shelf b. As the amount of medication ordered is removed from the container c. Before returning the container to the storage 2. Right Dose when performing medication calculation or conversions, the nurse should have another qualified nurse check the calculated dose 3. Right Client an important step in administering medication safely is being sure the medication is given to the right client. a. To identify the client correctly: b. The nurse check the medication administration form against the clients identification bracelet and asks the client to state his or her name to ensure the clients identification bracelet has the correct information. 4. RIGHT ROUTE if a prescribers order does nor designate a route of administration, the nurse consult the prescriber. Likewise, if the specified route is not recommended, the nurse should alert the prescriber immediately. 5. RIGHT TIME a. the nurse must know why a medication is ordered for certain times of the day and whether the time schedule can be altered b. each institution has are commended time schedule for medications ordered at frequent interval c. Medication that must act at certain times are given priority (e.g insulin should be given at a precise interval before a meal ) 6. RIGHT DOCUMENTATION Documentation is an important part of safe medication administration a. The documentation for the medication should clearly reflect the clients name, the name of the ordered medication,the time, dose, route and frequency b. Sign medication sheet immediately after administration of the drug CLIENTS RIGHT RELATED TO MEDICATION ADMINISTRATION A client has the following rights: a. To be informed of the medications name, purpose, action, and potential undesired effects. b. To refuse a medication regardless of the consequences c. To have a qualified nurses or physicians assess medication history, including allergies d. To be properly advised of the experimental nature of medication therapy and to give written consent for its use e. To received labeled medications safely without discomfort in accordance with the six rights of medication administration f. To receive appropriate supportive therapy in relation to medication therapy g. To not receive unnecessary medications II Practice Asepsis wash hand before and after preparing the medication to reduce transfer of microorganisms. III Nurse who administer the medications are responsible for their own action. Question any order that you considered incorrect (may be unclear or appropriate) IV Be knowledgeable about the medication that you administer

A FUNDAMENTAL RULE OF SAFE DRUG ADMINISTRATION IS: NEVER ADMINISTER AN UNFAMILIAR MEDICATION V Keep the Narcotics in locked place. VI Use only medications that are in clearly labeled containers. Relabelling of drugs are the responsibility of the pharmacist. VII Return liquid that are cloudy in color to the pharmacy. VIII Before administering medication, identify the client correctly IX Do not leave the medication at the bedside. Stay with the client until he actually takes the medications. X The nurse who prepares the drug administers it.. Only the nurse prepares the drug knows what the drug is. Do not accept endorsement of medication. XI If the client vomits after taking the medication, report this to the nurse in-charge or physician. XII Preoperative medications are usually discontinued during the postoperative period unless ordered to be continued. XIII- When a medication is omitted for any reason, record the fact together with the reason. XIV When the medication error is made, report it immediately to the nurse in-charge or physician. To implement necessary measures immediately. This may prevent any adverse effects of the drug. Medication Administration 1. Oral administration Advantages a. The easiest and most desirable way to administer medication b. Most convenient c. Safe, does nor break skin barrier d. Usually less expensive Disadvantages a. Inappropriate if client cannot swallow and if GIT has reduced motility b. Inappropriate for client with nausea and vomiting c. Drug may have unpleasant taste d. Drug may discolor the teeth e. Drug may irritate the gastric mucosa f. Drug may be aspirated by seriously ill patient. Drug Forms for Oral Administration a. Solid: tablet, capsule, pill, powder b. Liquid: syrup, suspension, emulsion, elixir, milk, or other alkaline substances. c. Syrup: sugar-based liquid medication d. Suspension: water-based liquid medication. Shake bottle before use of medication to properly mix it. e. Emulsion: oil-based liquid medication f. Elixir: alcohol-based liquid medication. After administration of elixir, allow 30 minutes to elapse before giving water. This allows maximum absorption of the medication. NEVER CRUSH ENTERIC-COATED OR SUSTAINED RELEASE TABLET Crushing enteric-coated tablets allows the irrigating medication to come in contact with the oral or gastric mucosa, resulting in mucositis or gastric irritation. Crushing sustained-released medication allows all the medication to be absorbed at the same time, resulting in a higher than expected initial level of medication and a shorter than expected duration of action 2. SUBLINGUAL a. A drug that is placed under the tongue, where it dissolves. b. When the medication is in capsule and ordered sublingually, the fluid must be aspirated from the capsule and placed under the tongue. c. A medication given by the sublingual route should not be swallowed, or desire effects will not be achieved Advantages: a. Same as oral b. Drug is rapidly absorbed in the bloodstream Disadvantages a. If swallowed, drug may be inactivated by gastric juices.

b. Drug must remain under the tongue until dissolved and absorbed 3. BUCCAL a. A medication is held in the mouth against the mucous membranes of the cheek until the drug dissolves. b. The medication should not be chewed, swallowed, or placed under the tongue (e.g sustained release nitroglycerine, opiates,antiemetics, tranquilizer, sedatives) c. Client should be taught to alternate the cheeks with each subsequent dose to avoid mucosal irritation Advantages: a. Same as oral b. Drug can be administered for local effect c. Ensures greater potency because drug directly enters the blood and bypass the liver Disadvantages: If swallowed, drug may be inactivated by gastric juice 4. TOPICAL Application of medication to a circumscribed area of the body. 1. Dermatologic includes lotions, liniment and ointments, powder. a. Before application, clean the skin thoroughly by washing the area gently with soap and water, soaking an involved site, or locally debriding tissue. b. Use surgical asepsis when open wound is present c. Remove previous application before the next application d. Use gloves when applying the medication over a large surface. (e.g large area of burns) e. Apply only thin layer of medication to prevent systemic absorption. 2. Opthalmic - includes instillation and irrigation a. Instillation to provide an eye medication that the client requires. b. Irrigation To clear the eye of noxious or other foreign materials. c. Position the client either sitting or lying. d. Use sterile technique e. Clean the eyelid and eyelashes with sterile cotton balls moistened with sterile normal saline from the inner to the outer canthus f. Instill eye drops into lower conjunctival sac. g. Instill a maximum of 2 drops at a time. Wait for 5 minutes if additional drops need to be administered. This is for proper absorption of the medication. h. Avoid dropping a solution onto the cornea directly, because it causes discomfort. i. Instruct the client to close the eyes gently. Shutting the eyes tightly causes spillage of the medication. j. For liquid eye medication, press firmly on the nasolacrimal duct (inner cantus) for at least 30 seconds to prevent systemic absorption of the medication. 3. Otic Instillation to remove cerumen or pus or to remove foreign body a. Warm the solution at room temperature or body temperature, failure to do so may cause vertigo, dizziness, nausea and pain. b. Have the client assume a side-lying position ( if not contraindicated) with ear to be treated facing up. c. Perform hand hygiene. Apply gloves if drainage is present. d. Straighten the ear canal: 0-3 years old: pull the pinna downward and backward Older than 3 years old: pull the pinna upward and backward e. Instill eardrops on the side of the auditory canal to allow the drops to flow in and continue to adjust to body temperature f. Press gently bur firmly a few times on the tragus of the ear to assist the flow of medication into the ear canal. g. Ask the client to remain in side lying position for about 5 minutes h. At times the MD will order insertion of cotton puff into outermost part of the canal.Do not press cotton into the canal. Remove cotton after 15 minutes. 4. Nasal Nasal instillations usually are instilled for their astringent effects (to shrink swollen mucous membrane), to loosen secretions and facilitate drainage or to treat infections of the nasal cavity or sinuses. Decongestants, steroids, calcitonin. a. Have the client blow the nose prior to nasal instillation b. Assume a back lying position, or sit up and lean head back. c. Elevate the nares slightly by pressing the thumb against the clients tip of the nose. While the client inhales, squeeze the bottle.

d. Keep head tilted backward for 5 minutes after instillation of nasal drops. e. When the medication is used on a daily basis, alternate nares to prevent irritations 5. Inhalation use of nebulizer, metered-dose inhaler a. Simi or high-fowlers position or standing position. To enhance full chest expansion allowing deeper inhalation of the medication b. Shake the canister several times. To mix the medication and ensure uniform dosage delivery c. Position the mouthpiece 1 to 2 inches from the clients open mouth. As the client starts inhaling, press the canister down to release one dose of the medication. This allows delivery of the medication more accurately into the bronchial tree rather than being trapped in the oropharynx then swallowed d. Instruct the client to hold breath for 10 seconds. To enhance complete absorption of the medication. e. If bronchodilator, administer a maximum of 2 puffs, for at least 30 second interval. Administer bronchodilator before other inhaled medication. This opens airway and promotes greater absorption of the medication. f. Wait at least 1 minute before administration of the second dose or inhalation of a different medication by MDI g. Instruct client to rinse mouth, if steroid had been administered. This is to prevent fungal infection. 6. Vaginal drug forms: tablet liquid (douches). Jelly, foam and suppository. a. Close room or curtain to provide privacy. b. Assist client to lie in dorsal recumbent position to provide easy access and good exposure of vaginal canal, also allows suppository to dissolve without escaping through orifice. c. Use applicator or sterile gloves for vaginal administration of medications. Vaginal Irrigation is the washing of the vagina by a liquid at low pressure. It is also called douche. a. Empty the bladder before the procedure b. Position the client on her back with the hips higher than the shoulder (use bedpan) c. Irrigating container should be 30 cm (12 inches) above d. Ask the client to remain in bed for 5-10 minute following administration of vaginal suppository, cream, foam, jelly or irrigation. 7. RECTAL can be use when the drug has objectionable taste or odor. a. Need to be refrigerated so as not to soften. b. Apply disposable gloves. c. Have the client lie on left side and ask to take slow deep breaths through mouth and relax anal sphincter. d. Retract buttocks gently through the anus, past internal sphincter and against rectal wall, 10 cm (4 inches) in adults, 5 cm (2 in) in children and infants. May need to apply gentle pressure to hold buttocks together momentarily. e. Discard gloves to proper receptacle and perform hand washing. f. Client must remain on side for 20 minute after insertion to promote adequate absorption of the medication. 8. PARENTERAL- administration of medication by needle. Intradermal under the epidermis. a. The site are the inner lower arm, upper chest and back, and beneath the scapula. b. Indicated for allergy and tuberculin testing and for vaccinations. c. Use the needle gauge 25, 26, 27: needle length 3/8, 5/8 or d. Needle at 1015 degree angle; bevel up. e. Inject a small amount of drug slowly over 3 to 5 seconds to form a wheal or bleb. f. Do not massage the site of injection. To prevent irritation of the site, and to prevent absorption of the drug into the subcutaneous. Subcutaneous vaccines, heparin, preoperative medication, insulin, narcotics. The site: outer aspect of the upper arms anterior aspect of the thighs Abdomen Scapular areas of the upper back Ventrogluteal Dorsogluteal a. Only small doses of medication should be injected via SC route. b. Rotate site of injection to minimize tissue damage. c. Needle length and gauge are the same as for ID injections d. Use 5/8 needle for adults when the injection is to administer at 45 degree angle; is use at a 90 degree angle. e. For thin patients: 45 degree angle of needle f. For obese patient: 90 degree angle of needle

g. For heparin injection: h. do not aspirate. i. Do not massage the injection site to prevent hematoma formation j. For insulin injection: k. Do not massage to prevent rapid absorption which may result to hypoglycemic reaction. l. Always inject insulin at 90 degrees angle to administer the medication in the pocket between the subcutaneous and muscle layer. Adjust the length of the needle depending on the size of the client.

m. For other medications, aspirate before injection of medication to check if the blood vessel had been hit. If blood appears on pulling back of the plunger of the syringe, remove the needle and discard the medication and equipment. Intramuscular a. Needle length is 1, 1 , 2 to reach the muscle layer b. Clean the injection site with alcoholized cotton ball to reduce microorganisms in the area. c. Inject the medication slowly to allow the tissue to accommodate volume. Sites: Ventrogluteal site a. The area contains no large nerves, or blood vessels and less fat. It is farther from the rectal area, so it less contaminated. b. Position the client in prone or side-lying. c. When in prone position, curl the toes inward. d. When side-lying position, flex the knee and hip. These ensure relaxation of gluteus muscles and minimize discomfort during injection. e. To locate the site, place the heel of the hand over the greater trochanter, point the index finger toward the anterior superior iliac spine, then abduct the middle (third) finger. The triangle formed by the index finger, the third finger and the crest of the ilium is the site. Dorsogluteal site a. Position the client similar to the ventrogluteal site b. The site should not be use in infant under 3 years because the gluteal muscles are not well developed yet. c. To locate the site, the nursedraw an imaginary line from the greater trochanter to the posterior superior iliac spine. The injection site id lateral and superior to this line. d. Another method of locating this site is to imaginary divide the buttock into four quadrants. The upper most quadrant is the site of injection. Palpate the crest of the ilium to ensure that the site is high enough. e. Avoid hitting the sciatic nerve, major blood vessel or bone by locating the site properly. Vastus Lateralis a. Recommended site of injection for infant b. Located at the middle third of the anterior lateral aspect of the thigh. c. Assume back-lying or sitting position. Rectus femoris site located at the middle third, anterior aspect of thigh. Deltoid site a. Not used often for IM injection because it is relatively small muscle and is very close to the radial nerve and radial artery. b. To locate the site, palpate the lower edge of the acromion process and the midpoint on the lateral aspect of the arm that is in line with the axilla. This is approximately 5 cm (2 in) or 2 to 3 fingerbreadths below the acromion process. IM injection Z tract injection a. Used for parenteral iron preparation. To seal the drug deep into the muscles and prevent permanent staining of the skin. b. Retract the skin laterally, inject the medication slowly. Hold retraction of skin until the needle is withdrawn c. Do not massage the site of injection to prevent leakage into the subcutaneous. GENERAL PRINCIPLES IN PARENTERAL ADMINISTRATION OF MEDICATIONS 1. Check doctors order. 2. Check the expiration for medication drug potency may increase or decrease if outdated. 3. Observe verbal and non-verbal responses toward receiving injection. Injection can be painful.client may have anxiety, which can increase the pain. 4. Practice asepsis to prevent infection. Apply disposable gloves. 5. Use appropriate needle size. To minimize tissue injury. 6. Plot the site of injection properly. To prevent hitting nerves, blood vessels, bones.

7. Use separate needles for aspiration and injection of medications to prevent tissue irritation. 8. Introduce air into the vial before aspiration. To create a positive pressure within the vial and allow easy withdrawal of the medication. 9. Allow a small air bubble (0.2 ml) in the syringe to push the medication that may remain. 10. Introduce the needle in quick thrust to lessen discomfort. 11. Either spread or pinch muscle when introducing the medication. Depending on the size of the client. 12. Minimized discomfort by applying cold compress over the injection site before introduction of medicati0n to numb nerve endings. 13. Aspirate before the introduction of medication. To check if blood vessel had been hit. 14. Support the tissue with cotton swabs before withdrawal of needle. To prevent discomfort of pulling tissues as needle is withdrawn. 15. Massage the site of injection to haste absorption. 16. Apply pressure at the site for few minutes. To prevent bleeding. 17. Evaluate effectiveness of the procedure and make relevant documentation. Intravenous The nurse administers medication intravenously by the following method: 1. As mixture within large volumes of IV fluids. 2. By injection of a bolus, or small volume, or medication through an existing intravenous infusion line or intermittent venous access (heparin or saline lock) 3. By piggyback infusion of solution containing the prescribed medication and a small volume of IV fluid through an existing IV line. a. Most rapid route of absorption of medications. b. Predictable, therapeutic blood levels of medication can be obtained. c. The route can be used for clients with compromised gastrointestinal function or peripheral circulation. d. Large dose of medications can be administered by this route. e. The nurse must closely observe the client for symptoms of adverse reactions. f. The nurse should double-check the six rights of safe medication. g. If the medication has an antidote, it must be available during administration. h. When administering potent medications, the nurse assesses vital signs before, during and after infusion. Nursing Interventions in IV Infusion a. Verify the doctors order b. Know the type, amount, and indication of IV therapy. c. Practice strict asepsis. d. Inform the client and explain the purpose of IV therapy to alleviate clients anxiety. e. Prime IV tubing to expel air. This will prevent air embolism. f. Clean the insertion site of IV needle from center to the periphery with alcoholized cotton ball to prevent infection. g. Shave the area of needle insertion if hairy. h. Change the IV tubing every 72 hours. To prevent contamination. i. Change IV needle insertion site every 72 hours to prevent thrombophlebitis. j. Regulate IV every 15-20 minutes. To ensure administration of proper volume of IV fluid as ordered. k. Observe for potential complications. Types of IV Fluids Isotonic solution has the same concentration as the body fluid a. D5 W b. Na Cl 0.9% c. plainRingers lactate d. Plain Normosol M Hypotonic has lower concentration than the body fluids. a. NaCl 0.3% Hypertonic has higher concentration than the body fluids. a. D10W b. D50W c. D5LR d. D5NM

Complication of IV Infusion 1. Infiltration the needle is out of nein, and fluids accumulate in the subcutaneous tissues. Assessment: Pain, swelling, skin is cold at needle site, pallor of the site, flow rate has decreases or stops. Nursing Intervention: Change the site of needle Apply warm compress. This will absorb edema fluids and reduce swelling. 2. Circulatory Overload -Results from administration of excessive volume of IV fluids. Assessment: Headache Flushed skin Rapid pulse Increase BP Weight gain Syncope and faintness Pulmonary edema Increase volume pressure SOB Coughing Tachypnea shock Nursing Interventions: Slow infusion to KVO Place patient in high fowlers position. To enhance breathing Administer diuretic, bronchodilator as ordered 3. Drug Overload the patient receives an excessive amount of fluid containing drugs. Assessment: Dizziness Shock Fainting Nursing Intervention Slow infusion to KVO. Take vital signs Notify physician 4. Superficial Thrombophlebitis it is due to o0veruse of a vein, irritating solution or drugs, clot formation, large bore catheters. Assessment: Pain along the course of vein Vein may feel hard and cordlike Edema and redness at needle insertion site. Arm feels warmer than the other arm Nursing Intervention: Change IV site every 72 hours Use large veins for irritating fluids. Stabilize venipuncture at area of flexion. Apply cold compress immediately to relieve pain and inflammation; later with warm compress to stimulate circulation and promotion absorption. Do not irrigate the IV because this could push clot into the systemic circulation 5. Air Embolism Air manages to get into the circulatory system; 5 ml of air or more causes air embolism. Assessment: Chest, shoulder, or backpain Hypotension

Dyspnea Cyanosis Tachycardia Increase venous pressure Loss of consciousness Nursing Intervention Do not allow IV bottle to run dry Prime IV tubing before starting infusion. Turn patient to left side in the trendelenburg position. To allow air to rise in the right side of the heart. This prevent pulmonary embolism. 6. Nerve Damage may result from tying the arm too tightly to the splint. Assessment Numbness of fingers and hands Nursing Interventions Massage the are and move shoulder through its ROM Instruct the patient to open and close hand several times each hour. Physical therapy may be required Note: apply splint with the fingers free to move. 7. Speed Shock may result from administration of IV push medication rapidly. To avoid speed shock, and possible cardiac arrest, give most IV push medication over 3 to 5 minutes. BLOOD TRANSFUSION THERAPY Objectives: 1. To increase circulating blood volume after surgery, trauma, or hemorrhage 2. To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia 3. To provide selected cellular components as replacements therapy (e.g clotting factors, platelets, albumin) Nursing Interventions: a. Verify doctors order. Inform the client and explain the purpose of the procedure. b. Check for cross matching and typing. To ensure compatibility c. Obtain and record baseline vital signs d. Practice strict Asepsis e. At least 2 licensed nurse check the label of the blood transfusion Check the following: Serial number Blood component Blood type Rh factor Expiration date Screening test (VDRL, HBsAg, malarial smear) - this is to ensure that the blood is free from blood-carried diseases and therefore, safe from transfusion. f. Warm blood at room temperature before transfusion to prevent chills. g. Identify client properly. Two Nurses check the clients identification. h. Use needle gauge 18 to 19. This allows easy flow of blood. j.Use BT set with special micron mesh filter. To prevent administration of blood clots and particles. k. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occurs during the first 15 to 20 minutes. l. Monitor vital signs. Altered vital signs indicate adverse reaction. Do not mixed medications with blood transfusion. To prevent adverse effects Do not incorporate medication into the blood transfusion Do not use blood transfusion line for IV push of medication. m. Administer 0.9% NaCl before, during or after BT. Never administer IV fluids with dextrose. Dextrose causes hemolysis. n. Administer BT for 4 hours (whole blood, packed rbc). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed. Complications of Blood Transfusion 1. Allergic Reaction it is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient antigen.

Assessments Flushing Rush, hives Pruritus Laryngeal edema, difficulty of breathing 2. Febrile, Non-Hemolytic it is caused by hypersensitivity to donor white cells, platelets or plasma proteins. This is the most symptomatic complication of blood transfusion Assessments: Sudden chills and fever Flushing Headache Anxiety 3. Septic Reaction it is caused by the transfusion of blood or components contaminated with bacteria. Assessment: Rapid onset of chills Vomiting Marked Hypotension High fever 4. Circulatory Overload it is caused by administration of blood volume at a rate greater than the circulatory system can accommodate. Assessment Rise in venous pressure Dyspnea Crackles or rales Distended neck vein Cough Elevated BP 5. Hemolytic reaction. It is caused by infusion of incompatible blood products. Assessment Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood. Chills Feeling of fullness Tachycardia Flushing Tachypnea Hypotension Bleeding Vascular collapse Acute renal failure Nursing Interventions when complications occurs in Blood transfusion 1. If blood transfusion reaction occurs. STOP THE TRANSFUSION. 2. Start IV line (0.9% Na Cl) 3. Place the client in fowlers position if with SOB and administer O2 therapy. 4. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. 5. Notify the physician immediately. 6. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as per physicians order or protocol. 7. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RBC hemolysis. 8. Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for analysis.

Principles of Patient Observation and Medication Documentation a. Patient observation

(1) Remain with patient until medication is swallowed completely, injected, or applied topically (2) If patient refuses medication (a) Remove medication from the patient's room (b) Report the patient refusal to the nurse/supervisor (c) Offer the medication again in five minutes (d) If refused a second time, record the omission per SOP and document the reason for the omission in the nursing notes. Report patient refusal to direct supervisor. CAUTION: DO NOT leave medications in the patient's possession without a specific physician's order to do so. (3) Observe for medication effects and/or side effects (a) Medical history 1) Before administering medications, review the patients medical history for possible indications or contraindications for medication therapy 2) Disease or illness may place patient at risk for adverse medication effects 3) Long-term health problems or surgical history may require medications (b) History of allergies 1) Allergic to medication 2) Food allergies should be documented 3) If patient is allergic to shellfish, they may be sensitive to any product containing iodine such as Betadine or dyes used in radiological testing (c) Medication history 1) Length of time drug has been taken 2) Current dosage schedule 3) Any ill effects experienced 4) Drug data - action, purpose, normal dosage, routes, side effects and nursing implications for administration and monitoring (4) If the patient has an adverse reaction. (Rash, itching, and nausea/vomiting/diarrhea are common examples of adverse reactions.) WARNING: Anaphylaxis is the most severe form of adverse reaction to a medication.

(a) Stop dosage immediately (b) Assess patient's airway, breathing, circulation (c) Inform nurse/physician on duty immediately b. Medical documentation (1) Record administration of medication IAW SOP. Minimum information needed is (a) Name of medication given (b) Dosage of medication (c) Time given (d) Route of administration (e) Patient's reaction (effects/side effects) (f) Name of person who administered medication (2) Record the omission of a medication on the appropriate medical forms whenever a scheduled medication is not administered IAW local SOP Medication Errors a. Any event that causes the patient to receive inappropriate drug therapy (medications) or failing to receive appropriate drug therapy (medications) b. Can be made by anyone involved in the prescribing (MD/PA), transcribing of the order, preparing and dispensing (pharmacist, RN, 91W) or administering the medication (RN, LPN, 91W) c. Strict adherence to the five "rights of medication administration helps to prevent errors d. Errors should be acknowledged as soon as they are discovered or known to have happened and reported immediately to the appropriate people for patient follow-up e. Professional and ethical obligations to your patients mandate that you report all medication errors
Some of the factors associated with medication errors include the following: y y y Medications with similar names or similar packaging Medications that are not commonly used or prescribed Commonly used medications to which many patients are allergic (e.g., antibiotics, opiates, and nonsteroidal anti-inflammatory drugs)

Medications that require testing to ensure proper (i.e., nontoxic) therapeutic levels are maintained (e.g., lithium, warfarin, theophylline, and digoxin)

Look-alike/sound-alike medication names can result in medication errors. Misreading medication names that look similar is a common mistake. These look-alike medication names may also sound alike and can lead to errors associated with verbal prescriptions. The Joint Commission publishes a list of look-alike/sound-alike drugs that are considered the most problematic medication names across settings. (This list is available at www.jointcommission.org/NR/rdonlyres/C92AAB3F-A9BD-431C-8628-11DD2D1D53CC/0/lasa.pdf.) Medication errors occur in all settings5 and may or may not cause an adverse drug event (ADE). Medications with complex dosing regimens and those given in specialty areas (e.g., intensive care units, emergency departments, and diagnostic and interventional areas) are associated with increased risk of ADEs.6 Phillips and colleagues7 found that deaths (the most severe ADE) associated with medication errors involved central nervous system agents, antineoplastics, and cardiovascular drugs. Most of the common types of errors resulting in patient death involved the wrong dose (40.9 percent), the wrong drug (16 percent), and the wrong route of administration (9.5 percent). The causes of these deaths were categorized as oral and written miscommunication, name confusion (e.g., names that look or sound alike), similar or misleading container labeling, performance or knowledge deficits, and inappropriate packaging or device design.

Types of Medication Errors Leape and colleagues27 reported more than 15 types of medication errors: wrong dose, wrong choice, wrong drug, known allergy, missed dose, wrong time, wrong frequency, wrong technique, drug-drug interaction, wrong route, extra dose, failure to act on test, equipment failure, inadequate monitoring, preparation error, and other. Of the 130 errors for physicians, the majority were wrong dose, wrong choice of drug, and known allergy. Among the 126 nursing administration errors, the majority were associated with wrong dose, wrong technique, and wrong drug. Each type of error was found to occur at various stages, though some more often during the ordering and administration stages.