Transcript Chapter_035

Administering Medications
Chapter 35
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Safety in Drug Administration
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Safety precautions in the management of
medication administration should be
consistently applied.
MA must clearly understand the medication,
dose, strength, and route of administration for
the drug ordered by the physician.
Once the order is clarified, look up the drug in
the PDR.
A drug should not be given until the MA knows
the purpose, potential side effects, precautions,
and recommended dose.
Patients have the right to refuse medication.
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2
Seven Rights of Drug Administration
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Right patient
Right drug
Right dose
Right route of administration
Right time
Right technique
Right documentation
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3
Drug Label Checks
EACH TIME a medication is dispensed, the
MA MUST do the three label checks.
Compare the physician’s written order with the
label:
1. When removing the drug from the storage site
2. Just before dispensing the medication from
the container
3. When replacing the container or before
discarding it
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4
Additional Safety Steps
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Dispense medications in a quiet, well-lit area.
Consult the physician if there is ANY difference between the
medication ordered and medication available.
Store medications as directed on package.
The person administering the medication is responsible for any
drug errors.
Physician should write every medication order before the
medication is dispensed.
Routinely check medication expiration dates.
Discard drug containers with damaged labels.
Discard medication that has been dispensed but not administered.
Observe all patients for a minimum of 20 minutes after drug
administration.
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5
Patient Assessment Factors
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Before administering any medication the MA
should assess the patient, the drug, and the
environment.
Use the holistic approach to patient assessment:
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Complete an accurate patient history
• Current and past use of prescription and OTC drugs
• Accurate list of drug allergies
Assess the patient’s ability to understand the drug
regimen and afford the treatment.
Record accurate age and weight.
Liver or kidney disease may alter drug orders.
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6
Patient Population Precautions
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Precautions with pregnant and lactating women;
drugs can pass through the placenta into the fetus
and into breast milk.
Pediatric special precautions are necessary
because of alterations in absorption, distribution,
metabolism, and excretion of drugs.
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Explain to the child why medication is needed.
Attempt to gain the child’s cooperation.
Offer choices if possible.
Use diversion during stressful moments.
Encourage parents to help.
Offer a treat at the end of the visit.
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7
Geriatric Precautions
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Aging patients are more sensitive to effects of
drugs because:
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Metabolic rate slows with aging causing susceptibility to
accumulated effects and toxic reactions
Loss of subcutaneous fat may affect parenteral routes of
administration
Accompanying circulatory, liver, and kidney diseases may
affect distribution, metabolism, and excretion of medications
Many aging patients are ordered multiple drugs, which
increases the risk of drug interactions and contraindications
Poor diet may affect drug therapy
May not be able to afford medications
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8
Geriatric Patient Guidelines
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Clearly write instructions for medication therapy.
Monitor patient for swallowing difficulty.
Encourage patient to drink plenty of water.
Reinforce that patient take medication as ordered.
Request that patient bring all medications currently
taking to the office visit and keep accurate records
of each.
Suggest patient use the same pharmacy for all
prescriptions.
Suggest use of daily or weekly pill dispensers.
Encourage patients not to save or share medication.
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9
Assessment of the Patient’s
Environment
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Allergy injections should not be given unless a
physician is present.
Place the patient in a correct and safe position
for injections.
Make sure the patient’s head is elevated
before giving oral medications.
Make sure emergency medications are
accessible to counteract adverse reactions that
might occur.
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10
Suggested Questions for Gathering
Medication Information
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What physician-prescribed drugs are you currently taking?
Do you take any OTC drugs on a regular basis?
What medications have you taken over the past 6 months
to 1 year? Why?
Do you regularly use any alternative or herbal products?
What are they? How much do you use? How frequently?
For what purpose?
What time of day do you take your medicine? Are you
having any side effects? Can you afford to take the
medication? Are you having the desired response?
Where do you store your medications?
Have you checked expiration dates on your containers?
Can you tell me why you are taking the prescribed
medication?
Do you use the same pharmacy to fill all of your
prescriptions?
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11
Drug Forms and Administration
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Oral medications include both solid and liquid
preparations; mucous membrane medications
are absorbed either rectally, vaginally, orally,
nasally, or through the skin topically.
Each form has specific guidelines for
administration, but all require the consistent use
of the three label checks and the seven rights.
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12
Solid Oral Dosage Forms
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The basic forms are tablets, capsules, and
lozenges (troches).
Caplets are oblong, like capsules.
Capsules are gelatin coated and dissolve in the
stomach, or they may be coated to protect
them from the acid action of the stomach.
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13
Caplets and Capsules
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Some tablets are coated with a volatile liquid that
dissolves in the mouth, such as an antacid tablet.
Tablets are compressed powders or granules that,
when wet, break apart in the stomach, or in the
mouth if they are not swallowed quickly.
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Should not crush:
• Enteric-coated tabs—coating that resists gastric secretions;
protects stomach mucosa
• Buffered tabs—prevent stomach irritation by combining
drug with buffering agent
• Timed or sustained release (SR) capsules or spansules—
dissolve at different rates over a period of time
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14
Caplets, Capsules, and Tablets
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15
Scored Tablets
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Only those tablets
that are scored can
be cut in half.
This is accomplished
with a pill cutter.
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16
Liquid Oral Dosage Forms
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Liquid forms differ mainly in the type of
substance used to dissolve the drug: water,
oils, or alcohol.
Solutions are drug substances contained in
a homogeneous mixture with a liquid.
There are multiple forms of liquid preparations.
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17
Liquid Medications
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Solutions: Mixture of liquid (usually water) and
a powdered drug product; will separate if left
standing so you must shake the container
before administering the medication
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Syrups: Solutions of sugar and water, usually
containing flavoring and medicinal substances.
Cough syrups are the most common.
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18
Suspensions
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Suspensions are insoluble drug substances
contained in a liquid.
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Emulsions: Mixtures of oil and water that improve
the taste of otherwise distasteful products such as
cod liver oil.
Gels and magmas: Minerals suspended in water.
Minerals settle, so products containing minerals must
be shaken before use (Milk of Magnesia).
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19
Alcohol Mixes
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Fluid extracts: Combinations of alcohol and vegetable
products that are more potent than tinctures
Tinctures: Alcoholic preparation of a soluble drug or
chemical substance, usually from plant sources
Extracts: Concentrated combinations of vegetable
products and alcohol or ether that are evaporated until a
syrupy liquid, solid mass, or powder is formed; many
times stronger than the crude drug
Elixirs: Aromatic, alcoholic, sweetened preparation;
differ from tinctures in that they are sweetened; some
pediatric medications retain the name elixir, although
they no longer contain alcohol
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20
Oral Administration
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Taken with plenty of water unless designed to coat
the mouth or throat (such as cough syrup).
Make sure patient is able to swallow.
Liquid medications best type of administration for
children.
Oral syringes can be used for pediatric
administration.
N/V requires alternative route of administration.
Always remain with the patient until the medication
is swallowed.
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21
Oral Syringes
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22
Mucous Membrane Forms
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Rectal administration:
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Rapid absorption without irritation to gastric mucosa.
 Suppositories melt and release the medication.
 Administer after bowel movement.
 Patient remains lying down for 20 to 30 minutes.
 Insert suppository 2 inches above rectal sphincter.
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Vaginal administration:
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Suppositories, tabs, creams, fluid solutions.
Treat local infections; creams and foams for
contraception.
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23
Rectal Suppositories
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24
Mucous Membrane Forms
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Oral administration:
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Sl tabs: placed under the tongue and rapidly absorbed
into the bloodstream; systemic absorption that bypasses
gastric mucosa (nitroglycerin)
 Buccal: placed between cheek and upper molars; quickly
absorbed
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Nasal administration:
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Nose drops and nasal sprays for localized action
 May cause systemic reactions including tachycardia,
hypertension, CNS stimulation
 Treatment of nasal congestion, nose bleeds; instillation
of medications
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25
Topical Forms
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Lotions: relieve pruritus, treat localized
infection
Liniments: emulsion; protect skin
Ointments (ung): have a petroleum and
lanolin base
Transdermal patches: absorbed slowly for a
time-released systemic effect (nitro, hormone
patches)
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26
Transdermal Patch Recommendations
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Write application date on patch and document
on patient chart.
Patient may shower with patch intact.
If ordered to apply every 24 hours, apply new
patch at same time every day.
Keep old patch on for 30 minutes after applying
new one.
Rotate application sites to prevent irritation.
Avoid areas with scars or large amount of body
hair.
Use caution when disposing of used patch.
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27
Transdermal Patch
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28
Parenteral Administration
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Parenteral medications must be sterile and in liquid
form.
Are manufactured in ampules, single-dose or multidose
vials, prefilled syringes, or cartridge systems.
Before dispensing, check expiration date and examine
solution for possible deterioration.
Drug characteristics and individual patient factors
determine the correct gauge and length of the needle
needed.
Must use Standard Precautions when disposing of
needles and wear gloves when administering.
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29
Parenteral Administration: Prefilled
Cartridge Systems
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30
Needle Parts
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Bevel—angled tip of a needle
Gauge—diameter or lumen size of a needle
The larger the gauge number, the smaller the
diameter of the needle
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Smallest gauges are 27 to 28 for ID injections
Gauges 25 to 26 for SC injections
Gauges 20 to 23 for IM—viscous drugs and deeper
injections
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31
Needle Length
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Length depends on two factors
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Area of body for injection
 Depth of administration (SC versus IM)
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Lengths vary from 3/8 inch to 4 inches
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ID: 3/8 inch; bevel only part of needle injected
SC: 1/2 to 5/8 inch
IM: 1 to 3 inches; length depends on the muscle
being used and patient size
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32
Syringes
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Parts of syringe—barrel, calibrated scale,
plunger, tip
3-cc syringe—calibrated with cc and minims
Tuberculin syringe—holds 1 ml
Insulin syringe—calibrated in units, 50 U or 100 U
The appropriate syringe is determined by the type
of medication and the amount of drug. Specialty
syringe units, such as the Nova Pen and the
EpiPen, are designed for quick administration of
certain medications in public or in an emergency.
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33
Parts of the Syringe
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34
Retractable Needle Cover
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35
EpiPen
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Automatic injector systems that contain a
dose of epinephrine
Carried as a safety precaution by individuals
who have anaphylactic reactions to allergens
such as bee stings or certain types of foods
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36
Anaphylactic Signs and Symptoms
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Hypotension resulting from systemic
vasodilation
Urticaria
Dyspnea caused by bronchoconstriction
Vomiting and diarrhea
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37
EpiPen Injection
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EpiPen can be injected through clothing.
Firmly press tip of injector on outer aspect of
thigh and hold in place for 10 seconds.
Remove EpiPen and massage to promote
absorption.
Notify physician or go to ER for follow up.
Periodically check unit expiration date.
Store in a readily available location.
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38
Routes of Administration
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Parenteral routes of administration include intradermal
(ID), subcutaneous (SC), and multiple intramuscular (IM)
sites.
Route and site of administration are determined by type
of medication, physician order, and unique characteristics
of patient. Avoid scar tissue, moles or warts, bones, blood
vessels, and nerves.
Site must be able to hold the amount being injected.
Must use sterile technique while dispensing, transporting,
and administering injections.
Do not combine medications unless approved by
physician.
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39
Parenteral Guidelines
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OSHA guidelines include using syringe units
with retractable needle covers and wearing
disposable nonsterile gloves.
Never recap a contaminated needle, and
immediately discard it into a sharps container.
Dispose of contaminated nonsharp materials in
biohazard containers.
Disinfect contaminated work areas.
Sanitize hands before and after procedures.
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40
Intradermal Injections
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Drug administered within the skin layers just
under the epidermis.
Many nerves present, so injection causes burning
and stinging.
Inject minute amount of solution.
Insert only the bevel point of the needle.
Proper administration causes a wheal to rise at
the injection site.
Used for allergy testing and tuberculin screening.
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41
Tuberculosis Screening
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Mantoux test
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Injects 0.1 ml of PPD in center of anterior forearm.
 Angle of injection 15 degrees, almost parallel to skin
surface.
 Monitor site 48 to 72 hours later for induration.
 Patient must return to have the test read.
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42
Positive TB Skin Test
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Induration of 5 mm or greater – HIV+ patients; anyone
in close contact with a newly diagnosed patient; and
patients who have undergone recent organ transplants
or are taking immunosuppressant medications.
Induration of 10 mm or greater – recent immigrants
from countries in which TB is prevalent; IV drug users;
residents and employees of correctional institutions,
homeless shelters, and healthcare facilities; and
children under 4 years of age.
Regardless of risk factors, anyone with an induration of
15 mm or greater in diameter is considered positive.
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43
Intradermal Injection
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The intradermal injection is administered just
under the epidermis.
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44
Recommended Sites for Intradermal
Injections
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45
Subcutaneous Injections
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Given under the skin in adipose tissue.
Insertion angle of 45 degrees; insulin and
heparin administered at a 90-degree angle.
Posterior upper arm is the typical injection site;
abdomen, thigh, upper back also SC sites.
Sites must be rotated to prevent trauma and
aid absorption.
Patients should keep rotation site record.
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46
Subcutaneous Injection
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47
Subcutaneous Injection Sites
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48
Insulin Administration
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Follow policy for mixing types of insulin in the
same syringe.
Always ordered in unit doses.
Use appropriate syringe (30 U, 50 U, or 100 U)
for total amount of insulin ordered.
Insulin should be stored in a refrigerator.
Gently rotate insulin vial between hands to
warm before dispensing.
Do not aspirate or massage after injection.
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49
Insulin Rotation Sites
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50
Intramuscular Injections
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Based on patient size, choose needle long
enough to reach muscle.
Angle of insertion 90 degrees.
IM sites include the deltoid, vastus lateralis,
gluteus medius, and ventrogluteal muscles.
Muscular site used for three reasons:
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Irritating drug for SC tissues
Requires more rapid absorption
Large volume of medication needed
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51
Intramuscular Injection
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52
Intramuscular Injection Sites
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53
Deltoid Site
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Muscular cap of shoulder located at top of upper arm.
Injection site located 2 fingerbreadths below the
acromial process.
Avoid the acromion and humerus.
Can hold up to 2 cc of medication.
Acceptable site for adults and older children.
Should not be used if the muscle is small or
underdeveloped.
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Small arm: 25-gauge, 5/8-inch needle
 Average arm: 23-gauge, 1-inch needle
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54
Deltoid Site
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55
Vastus Lateralis
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Part of the quadriceps group of the thigh
Developed at birth, so is safest IM site for infants and
young children
Fewer major nerves and blood vessels, so excellent site
for adults
Located at the midpoint of the upper, outer thigh
Adult location: 1 handwidth below the greater trochanter
and above the patella; inject at a 90-degree angle
Pediatric location: below greater trochanter but within the
upper lateral quadrant of the muscle; inject at a
45-degree angle with needle pointing toward feet
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56
Dorsogluteal Site
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Traditional site for deep IM injections in adults
High risk of sciatic nerve damage
Must take great care in locating the exact site
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Patient should be in Sims’ position
Palm on greater trochanter of femur with finger
pointed toward posterior iliac spine
Inject into the gluteus medius muscle above the
imaginary line drawn between the two anatomic
markings
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57
Dorsogluteal Site
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58
Ventrogluteal Site
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Safe IM site that uses the gluteus medius
muscle
Good alternative to the dorsogluteal site
Free from major nerves and blood vessels and
safe for children and adults
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Position adult patient in Sims’ position
Palm of hand on greater trochanter
Point index finger toward anterior iliac spine
Spread fingers to form a triangular injection site
1-inch needle for child; as long as 2½-inch needle
for obese patient
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59
Ventrogluteal Site
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60
Z-Track Injection
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Used when medication irritates skin and SC
tissues
Displace upper tissue before inserting needle
to prevent leakage of medication from deep
muscle to upper SC tissues
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Change needle after dispensing medication
 Skin pushed aside and held, site cleansed
 Needle inserted and medication slowly injected into
deep muscle
 After needle is withdrawn, release skin
 Do not massage after injection
 Rotate sites to prevent tissue damage
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61
Principles of Intravenous Therapy
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IV therapy is often the route of choice when
the physician wants to speed up the action of
a drug.
The medical assistant must be familiar with
both legal restrictions and employer policies
before having anything to do with IV therapy.
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62
Intravenous Terminology and Practices
Three types of IV fluids
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Isotonic
 Hypotonic
 Hypertonic
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63
Dangers of Intravenous Treatment
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Infection or inflammation
Localized phlebitis
Infiltration
Fluid overload
Medication error
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64
Intravenous Administration Set
From deWit S:
Fundamental
concepts and skills
for nursing, ed 3,
St Louis, 2009,
Saunders.
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65
Role of the Medical Assistant in
Assisting with Intravenous Therapy
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Follow state practice acts.
Gather a comprehensive health history to determine
indications for IV therapy.
Weigh the patient before and monitor vital signs during
infusion to alert the physician of possible complications;
do not take blood pressure in arm with IV.
Be alert for signs of infiltration and phlebitis.
Monitor equipment for problems.
Watch for the too-rapid infusion of fluids, which might
lead to circulatory overload.
Document all pertinent information in the patient record.
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66
Drug Treatment
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The more the patient knows and understands
about how to take the medication and why it is
prescribed, the greater the chances that the
drug treatment will
be successful.
Patient education is absolutely crucial to the
correct administration of medication at home.
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67
Patient Education
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The patient should understand:
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Purpose of the drug
 Time, frequency, and amount of the dose
 Storage requirements
 Typical side effects
 Take medicine as prescribed
 Discard all expired drugs
 Keep medicine away from light, heat, air, moisture
 Do not combine different drugs in the same container
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