Photo Atlas of Drug Administration



Photo Atlas of Drug Administration


Preparing for Drug Administration


NOTE: This photo atlas is designed to illustrate general aspects of drug administration. For detailed instructions, please refer to a nursing fundamentals or nursing skills book.


When giving medications, remember safety measures and correct administration techniques to avoid errors and to ensure optimal drug actions. Keep in mind the basic “Six Rights”:



Refer to Chapter 1 for additional rights regarding drug administration. Other things to keep in mind when preparing to give medications are as follows:



• Remember to perform hand hygiene before preparing or giving medications (Box 9-1)


• If you are unsure about a drug or dosage calculation, do not hesitate to double-check with a drug reference or with a pharmacist. DO NOT administer a medication if you are unsure about it!


• Be punctual when giving drugs. Some medications must be given at regular intervals to maintain therapeutic blood levels.


• Figure 9-1 shows an example of a computer-controlled drug-dispensing system. To prevent errors, obtain the drugs for one patient at a time.


• Remember to check the drug at least three times before giving it. The nurse is responsible for checking original medication labels against the transcribed medication order. In Figure 9-2, the nurse is checking the drug against the medication administration record after taking it out of the dispenser drawer. The drug must then be checked before opening it and again after opening it but before giving it to the patient. Some drugs (i.e., heparin and insulin) must be checked by two licensed nurses.


• Health care facilities have various means of checking the medication record when a new one is printed, so be sure that you are working from one that has been checked or verified before giving the medication. If the patient’s medication record has a new drug order on it, the best rule of practice is to double-check that order against the original medication order on the patient’s medical record.


• Check the expiration date of all medications. Medications used past the expiration date may be less potent or even harmful.


• Make sure that drugs that are given together are compatible. For example, bile acid sequestrants and antacids (see Chapters 27 and 50) must not be given with other drugs, because they will interfere with drug absorption and action. Check with a pharmacist if unsure. Before administering any medication, check the patient’s identification bracelet (Figure 9-3). The Joint Commission’s standards require two patient identifiers (name and birthday, or name and account number, according to the facility policy). In some facilities, patient information is in a barcode system that is scanned. In addition, assess the patient’s drug allergies before giving any medication.


• Be sure to take time to explain the purpose of each medication, its action, possible adverse effects, and any other pertinent information, especially drug-drug or drug-food interactions, to the patient and/or caregiver.


• Open the medication at the bedside into the patient’s hand or into a medicine cup. Try not to touch the drugs with your hands. Leaving the drugs in their packaging until you get to the patient’s room helps to avoid contamination and waste in case the patient refuses the drug.


• If the patient refuses a drug, the drug may be returned to the automated medication dispenser or to the pharmacy if the package is unopened. Check facility policy. Discard opened drugs per facility protocol. Scheduled drugs that are not given will need a witness if discarded. Note on the patient’s record which drug was refused and the patient’s reason for refusal.


• Discard any medications that fall to the floor or become contaminated by other means.


• Stay with the patient while the patient takes the drugs. Do not leave the drugs on the bedside table or the meal tray for the patient to take later.


• Document the medication given on the medication record (see Figure 9-9) as soon as it is given and before going to the next patient. Be sure also to document therapeutic responses, adverse effects (if any), and other concerns in the nurse’s notes. Some facilities use manual documentation, and others use electronic documentation.


• Return to evaluate the patient’s response to the drug. Remember that the expected response time will vary according to the drug route. For example, responses to sublingual nitroglycerin or intravenous (IV) push medications need to be evaluated within minutes, but it may take an hour or more for a response to be noted after an oral medication is given.


• See the Patient-Centered Care: Lifespan Considerations for the Pediatric Patient box on p. 41 (in Chapter 3) for age-related considerations for medication administration to infants and children.



BOX 9-1


STANDARD PRECAUTIONS


Always adhere to Standard Precautions, including the following:



• Wear clean gloves when exposed to or when there is potential exposure to blood, body fluids, secretions, excretions, and any items that may contain these substances. Always wash hands immediately when there is direct contact with these substances or any item contaminated with blood, body fluids, secretions, or excretions. Gloves must always be worn when giving injections and may be necessary during medication preparation. Be sure to assess the patient for latex allergies and use nonlatex gloves if indicated.


• Perform hand hygiene after removing gloves and between patient contacts. According to the Centers for Disease Control and Prevention, the preferred method of hand decontamination is with an alcohol-based hand rub, but washing with an antimicrobial soap and water is an alternative to the alcohol rub. Use soap and water to wash hands when hands are visibly dirty.


• Perform hand hygiene:


• Before direct contact with patients


• After contact with blood, body fluids, excretions, mucous membranes, wound dressings, or nonintact skin


• After contact with a patient’s skin (i.e., when taking a pulse or positioning a patient)


• After removing gloves


• Wear a mask, eye protective gear, and face shield during any procedure or patient care activity with the potential for splashing or spraying of blood, body fluids, secretions, or excretions. Use of a gown may also be indicated for these situations.


• When administering medications, once the exposure or procedure is completed and exposure is no longer a danger, remove soiled protective garments or gear and perform hand hygiene.


• Never remove, recap, cap, bend, or break any used needle or needle system. Be sure to discard any disposable syringes and needles in the appropriate puncture-resistant container.


For detailed information on Standard Precautions, see the guidelines posted on the Centers for Disease Control and Prevention website at http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. Accessed June 11, 2012.





Enteral Drugs


Administering Oral Drugs


Always begin by performing hand hygiene and maintain Standard Precautions (see Box 9-1). When administering oral drugs, keep in mind the following points:


Oral Medications



• Administration of some oral medications (and medications by other routes) requires special assessments. For example, it is recommended that the apical pulse be auscultated for 1 full minute before any digitalis preparation is given (Figure 9-4). Administration of other oral medications may require blood pressure monitoring. Be sure to document all parameters. In addition, do not forget to check the patient’s identification and allergies before giving any oral medication (or medication by any other route).


• If the patient is experiencing difficulty swallowing (dysphagia), some types of tablets can be crushed with a pill-crushing device (Figure 9-5) for easier administration. Crush one type of pill at a time, because if you mix together all of the medications before crushing (instead of crushing them one at a time) and then spill some, there is no way to know which drug has been wasted. Also, if all are mixed together, you cannot check the Six Rights three times before giving the drug. Mix the crushed medication in a small amount of soft food, such as applesauce or pudding. Be sure that the pill-crushing device is clean before and after you use it. See Chapter 2 for more information on medications that are not to be crushed.


• CAUTION: Be sure to verify whether a medication can be crushed by consulting a drug reference book or a pharmacist. Some oral medications, such as capsules, enteric-coated tablets, and sustained-release or long-acting drugs, must not be crushed, broken, or chewed (Figure 9-6). These medications are formulated to protect the gastric lining from irritation or protect the drug from destruction by gastric acids, or are designed to break down gradually and slowly release the medication. If these drugs, designated with labels such as sustained release or extended release, are crushed or opened, then the intended action of the dosage form is destroyed. As a result, gastric irritation may occur, the drug may be inactivated by gastric acids, or the immediate availability of a drug that was supposed to be released slowly may cause toxic effects. Check with the prescriber to see if an alternate form of the drug is needed.


• Be sure to position the patient to a sitting or side-lying position to make it easier for the patient to swallow oral medications and to avoid the risk of aspiration (Figure 9-7). Always provide aspiration prevention measures as needed.


• Offer the patient a full glass of water; 4 to 6 oz of water or other fluid is recommended for the best dissolution and absorption of oral medications. Age-related considerations: Young patients and the elderly may not be able to drink a full glass of water but need to take enough fluid to ensure that the medication reaches the stomach. If the patient prefers another fluid, be sure to check for interactions between the medication and the fluid of choice. If fluid restriction is ordered, be sure to follow the guidelines.


• If the patient requests, you may place the pill or capsule in the patient’s mouth with your gloved hand.


• Lozenges are not be chewed unless specifically instructed/ordered.


• Effervescent powders and tablets need to be mixed with water and then given immediately after they are dissolved.


• Remain with the patient until all medication has been swallowed. If you are unsure whether a pill has been swallowed, ask the patient to open his or her mouth so that you can inspect to see if it is gone. Assist the patient to a comfortable position after the medication has been taken.


• Document the medication given on the medication record (see Figure 9-9), and monitor the patient for a therapeutic response as well as for adverse reactions.






Sublingual and Buccal Medications


The sublingual and buccal routes prevent destruction of the drugs in the gastrointestinal tract and allow for rapid absorption into the bloodstream through the oral mucous membranes. These routes are not often used. Be sure to provide instruction to the patient before giving these medications.



• Sublingual tablets are placed under the tongue (Figure 9-8). Buccal tablets are placed between the upper or lower molar teeth and the cheek.


• Be sure to wear gloves if you are placing the tablet into the patient’s mouth. Adhere to Standard Precautions (see Box 9-1).


• Instruct the patient to allow the drug to dissolve completely before swallowing.


• These drug forms are not taken with fluids. Instruct the patient not to drink anything until the tablet has dissolved completely.


• Be sure to instruct the patient not to swallow the tablet; saliva should not be swallowed until the drug is dissolved.


• When using the buccal route, alternate sides with each dose to reduce risk of oral mucosa irritation.


• Document the medication given on the medication record (Figure 9-9), and monitor the patient for a therapeutic response as well as for adverse reactions.




Orally Disintegrating Medications


Orally disintegrating medications, either in tablet or medicated strip form, dissolve in the mouth without water within 60 seconds. These medications are placed on the tongue, not under the tongue, as in the sublingual route. The absorption through the oral mucosa is rapid with a faster onset of action than for drugs that are swallowed. The patient must be instructed to allow the medication to dissolve on the tongue and not to chew or swallow the medication.



• Be sure to wear gloves if you are placing the medication on the patient’s tongue. Adhere to Standard Precautions (see Box 9-1).


• Make sure the patient has not eaten or had anything to drink for 5 minutes before and after taking these medications.


• Orally disintegrating medications are often packed in foil blister packs. Do not open the package until just before giving the medication. Carefully open one dose at a time. These medications are fragile and may break if they are pushed through the blister pack. Once a blister or foil pack is opened, the tablet must either be taken or discarded; it cannot be stored for another time.


• Orally disintegrating medications cannot be split, broken, or torn.


• Instruct the patient to hold the medication on the tongue to allow it to dissolve, instead of chewing or swallowing it. This usually takes about a minute. Warn the patient that there may be a sweet or even slightly bitter taste. Remind the patient not to drink water or to eat for 5 minutes after taking the medication.


• Document the medication given on the medication record (see Figure 9-9), and monitor the patient for a therapeutic response as well as for adverse reactions.


Liquid Medications



• Liquid medications may come in a single-dose (unit-dose) package, may be poured into a medicine cup from a multidose bottle, or may be drawn up in an oral-dosing syringe (Figure 9-10).


• When pouring a liquid medication from a container, first shake the bottle gently to mix the contents if indicated. Remove the cap and place it upside down on a paper towel on the counter. Hold the bottle with the label against the palm of your hand to keep any spilled medication from altering the label. Place the medicine cup at eye level, and fill to the proper level on the scale (Figure 9-11). Pour the liquid so that the base of the meniscus is even with the appropriate line measure on the medicine cup.


• If you overfill the medicine cup, discard the excess in the sink. Do not pour it back into the multidose bottle. Before replacing the cap, wipe the rim of the bottle with a paper towel.


• Doses of medications that are less than 5 mL cannot be measured accurately in a calibrated medicine cup. For small volumes, use a calibrated oral syringe. Do not use a hypodermic syringe or a syringe with a needle or syringe cap. If hypodermic syringes are used, the drug may be inadvertently given parenterally, or the syringe cap or needle, if not removed from the syringe, may become dislodged and accidentally aspirated by the patient when the syringe plunger is pressed.


• Document the medication given on the medication record (see Figure 9-9), and monitor the patient for a therapeutic response as well as for adverse reactions.




Oral Medications for Infants and Children



• Liquids are usually ordered for infants and young children because they cannot swallow pills or capsules.


• A plastic disposable oral-dosing syringe is recommended for measuring small doses of liquid medications. Use of an oral-dosing syringe prevents the inadvertent parenteral administration of a drug once it is drawn up into the syringe.


• Position the infant so that the head is slightly elevated to prevent aspiration. Not all infants will be cooperative, and many need to be partially restrained (Figure 9-12).


• Place the plastic dropper or syringe inside the infant’s mouth, beside the tongue, and administer the liquid in small amounts while allowing the infant to swallow each time.


• A clean empty nipple may be used to administer the medication. Place the liquid inside the empty nipple and allow the infant to suck the nipple. Add a few milliliters of water to rinse any remaining medication into the infant’s mouth, unless contraindicated.


• Take great care to prevent aspiration. A crying infant can easily aspirate medication. If the infant is crying, wait until the infant is calmer before trying again to give the medication.


• Do not add medication to a bottle of formula; the infant may refuse the feeding or may not drink all of it. Make sure that all of the oral medication has been taken, and then return the infant to a safe, comfortable position.


• A child will reject oral medications that taste bitter. The drug may be mixed with a teaspoon of a sweet-tasting food such as jelly, applesauce, ice cream, or sherbet. Using honey in infants is not recommended because of the risk of botulism. Do not mix the medication in an essential food item, such as formula, milk, or orange juice, because the child may reject that food later. After the medication is taken, offer the child juice, a flavored frozen ice pop, or water.



Administering Drugs through a Nasogastric or Gastrostomy Tube


Always begin by performing hand hygiene and maintain Standard Precautions (see Box 9-1). Gloves must be worn. When administering drugs via these routes, keep in mind the following points:



• Before giving drugs via these routes, position the patient in a semi-Fowler’s or Fowler’s position and leave the head of the bed elevated for at least 30 minutes afterward to reduce the risk of aspiration (Figure 9-13).


• Assess whether fluid restriction or fluid overload is a concern. It will be necessary to give water along with the medications to flush the tubing.


• Check to see if it is recommended for the drug to be given on an empty or full stomach. In addition, some drugs are incompatible with enteral feedings. If the drug is to be given on an empty stomach, or if incompatibility exists, the feeding may need to be stopped before and/or after giving the medication. Follow the guidelines for the specific drug if this is necessary. Examples of drugs that are not compatible with enteral feedings are phenytoin and carbidopa-levodopa. Whenever possible, give liquid forms of drugs to prevent clogging the tube.


• If tablets must be given, crush the tablets individually into a fine powder. Administer the drugs separately (Figure 9-14). Keeping the drugs separate allows for accurate identification if a dose is spilled. Be sure to check whether the medication can be crushed; enteric-coated and sustained-release tablets or capsules are not to be crushed (see Chapter 2). Check with a pharmacist if you are unsure.


• Before administering the drugs, follow the institution’s policy for verifying tube placement and checking gastric residual. Reinstill gastric residual per institutional policy, and then clamp the tube.


• Dilute a crushed tablet or liquid medication in 15 to 30 mL of warm water. Some capsules may be opened and dissolved in 30 mL of warm water; check with a pharmacist.


• Remove the piston from an adaptable-tip syringe and attach it to the end of the tube. Unclamp the tube and pinch the tubing to close it again. Add 30 mL of warm water and release the pinched tubing. Allow the water to flow in by gravity to flush the tube, and then pinch the tubing closed again before all the water is gone to prevent excessive air from entering the stomach. If a stopcock valve device is present on the enteral tube, then open and close the stopcock instead of pinching the tubing to clamp it.


• Pour the diluted medication into the syringe and release the tubing to allow it to flow in by gravity (Figure 9-15). Flush between each drug with 10 mL of warm water. Be careful not to spill the medication mixture. Adjust fluid amounts if fluid restrictions are ordered, but sufficient fluid must be used to dilute the medications and to flush the tubing.


• If water or medication does not flow freely, you may apply gentle pressure with the plunger or bulb of the syringe. Do not try to force the medicine through the tubing.


• After the last drug dose, flush the tubing with 30 mL of warm water, and then clamp the tube. Resume the tube feeding when appropriate.


• Have the patient remain in a high Fowler’s or slightly elevated right-side-lying position to reduce the risk of aspiration.


• Document the medications given on the medication record (see Figure 9-9), the amount of fluid given on the patient’s intake and output record, and the patient’s response in the patient’s record.





Administering Rectal Drugs


Always begin by performing hand hygiene and maintain Standard Precautions (see Box 9-1). Gloves must be worn. When administering rectal drugs, keep in mind the following points:



• Assess the patient for the presence of active rectal bleeding or diarrhea, which generally are contraindications for the use of rectal suppositories.


• Suppositories should not be divided to provide a smaller dose. The active drug may not be evenly distributed within the suppository base.


• Position the patient on his or her left side, unless contraindicated. The uppermost leg needs to be flexed toward the waist (Sims’ position). Provide privacy and drape.


• Do not insert the suppository into stool. Gently palpate the rectal wall for the presence of feces. If possible, have the patient defecate. DO NOT palpate the patient’s rectum if the patient has had rectal surgery.


• Remove the wrapping from the suppository and lubricate the rounded tip with water-soluble gel (Figure 9-16).


• Insert the tip of the suppository into the rectum while having the patient take a deep breath and exhale through the mouth. With your gloved finger, quickly and gently insert the suppository into the rectum, alongside the rectal wall, at least 1 inch beyond the internal sphincter (Figure 9-17).


• Have the patient remain lying on his or her left side for 15 to 20 minutes to allow absorption of the medication.


• Age-related considerations: With children it may be necessary to gently but firmly hold the buttocks in place for 5 to 10 minutes until the urge to expel the suppository has passed. Older adults with loss of sphincter control may not be able to retain the suppository.


• If the patient prefers to self-administer the suppository, give specific instructions on the purpose and correct procedure. Be sure to tell the patient to remove the wrapper.


• Use the same procedure for medications administered by a retention enema, such as sodium polystyrene sulfonate (see Chapter 29). Drugs given by enemas are diluted in the smallest amount of solution possible. Retention enemas need to be held for 30 minutes to 1 hour before expulsion, if possible, for maximum absorption.


• Document the medication given on the medication record (see Figure 9-9), and monitor the patient for a therapeutic response as well as for adverse reactions.






imageimage
FIGURES 9-20 and 9-21 There are several types of needlestick prevention syringes. This example (Figure 9-20) has a guard over the unused syringe. After the injection, the nurse pulls the guard up over the needle until it locks into place (Figure 9-21).





imageimage
FIGURES 9-26 and 9-27 Some medications come in prefilled sterile medication cartridges. Figures 9-26 and 9-27 show the Carpuject prefilled cartridge and syringe system. Follow the manufacturer’s instructions for assembling prefilled syringes. After use, dispose of the syringe in a sharps container; the cartridge is reusable. Some prefilled syringes come with an air bubble in the syringe; do not expel the bubble before administration.





Parenteral Drugs


Preparing for Parenteral Drug Administration


Removing Medications from Ampules


Always begin by performing hand hygiene and maintain Standard Precautions (see Box 9-1). Gloves may be worn. When performing these procedures, keep in mind the following points:



• When removing medication from an ampule, use a sterile filter needle (Figure 9-29). These needles are designed to filter out glass particles that may be present inside the ampule after it is broken. The filter needle IS NOT intended for administration of the drug to the patient.


• Medication often rests in the top part of the ampule. Tap the top of the ampule lightly and quickly with your finger until all fluid moves to the bottom portion of the ampule (Figure 9-30).


• Place a small gauze pad or dry alcohol swab around the neck of the ampule to protect your hand. Snap the neck quickly and firmly, and break the ampule away from your body (Figures 9-31 and 9-32).


• To draw up the medication, either set the open ampule on a flat surface or hold the ampule upside down. Insert the filter needle (attached to a syringe) into the center of the ampule opening. Do not allow the needle tip or shaft to touch the rim of the ampule (Figure 9-33).


• Gently pull back on the plunger to draw up the medication. Keep the needle tip below the fluid within the vial; tip the ampule to bring all of the fluid within reach of the needle.


• If air bubbles are aspirated, do not expel them into the ampule. Remove the needle from the ampule, hold the syringe with the needle pointing up, and tap the side of the syringe with your finger to cause the bubbles to rise toward the needle. Draw back slightly on the plunger, and slowly push the plunger upward to eject the air. Do not eject fluid.


• Excess medication is disposed of into a sink. Hold the syringe vertically with the needle tip up and slanted toward the sink. Slowly eject the excess fluid into the sink, and then recheck the fluid level by holding the syringe vertically.


• Remove the filter needle and replace with the appropriate needle for administration. NEVER use a filter needle to administer medications to a patient!


• Be sure to ensure the sterility of the injection needle throughout the process. Do not touch the open end of the needle hub, or the tip of the syringe, when attaching a needle to a syringe.


• Dispose of the glass ampule pieces and the used filter needle in the appropriate sharps container.



Removing Medications from Vials


Always begin by performing hand hygiene and maintain Standard Precautions (see Box 9-1). Gloves may be worn. When performing these procedures, keep in mind the following points:



• Vials can contain either a single dose or multiple doses of medication. Follow the institution’s policy for using opened multidose vials, such as vials of insulin. Mark multidose vials with the date and time of opening and the discard date (per facility policy). If you are unsure about the age of an opened vial of medication, discard it and obtain a new one.


• Check institutional policies regarding which type of needle to use to withdraw fluid from a vial. With the exception of insulin, which must be withdrawn using an insulin syringe, fluid may be withdrawn from a vial using a blunt fill needle or a filter needle. Using a blunt fill needle reduces the chance of injury with a sharp needle (Figure 9-34).


• If the vial is unused, remove the cap from the top of the vial.


• If the vial has been previously opened and used, wipe the top of the vial vigorously with an alcohol swab.


• Air must first be injected into a vial before fluid can be withdrawn. The amount of air injected into a vial needs to equal the amount of fluid that needs to be withdrawn.


• Determine the volume of fluid to be withdrawn from the vial. Pull back on the syringe’s plunger to draw an amount of air into the syringe that is equivalent to the volume of medication to be removed from the vial. Insert the syringe into the vial, preferably using a needleless system. Figure 9-35 shows a needleless system for vial access. Inject the air into the vial.


• While holding onto the plunger, invert the vial and remove the desired amount of medication (Figure 9-36).


• Gently but firmly tap the syringe to remove air bubbles. Excess fluid, if present, must then be discarded into a sink.


• Some vials are not compatible with needleless systems and therefore require a needle for fluid withdrawals (Figure 9-37). Use a blunt fill needle if available (see Figure 9-34).


• When an injection requires two medications from two different vials, begin by injecting air into the first vial (without touching the fluid in the first vial), and then inject air into the second vial. Immediately remove the desired dose from the second vial. Change needles (if possible), and then remove the exact prescribed dose of drug from the first vial. Take great care not to contaminate the drug in one vial with the drug from the other vial. Check with a pharmacist to make sure the two drugs are compatible for mixing in the same syringe.


• For injections, if a needle has been used to remove medication from a vial, always change the needle before administering the dose. Changing needles ensures that a clean and sharp needle is used for the injection. Medication that remains on the outside of the needle may cause irritation to the patient’s tissues. In addition, the needle may become dull if used to puncture a rubber stopper. However, some syringes, such as insulin syringes, have needles that are fixed onto the syringe and cannot be removed.


• Ensure the sterility of the injection needle throughout the process. Do not touch the open end of the needle hub, or the tip of the syringe, when attaching a needle to a syringe.



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May 9, 2017 | Posted by in NURSING | Comments Off on Photo Atlas of Drug Administration

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