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:

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.


4. Right Route – if a prescriber’s order neither does nor designates 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


6. RIGHT DOCUMENTATION –Documentation is an important part of safe medication administration


Client’s Right Related to Medication Administration
A client has the following rights:

1. To be informed of the medication’s name, purpose, action, and potential undesired effects.
2. To refuse a medication regardless of the consequences
3. To have a qualified nurses or physicians assess medication history, including allergies
4. To be properly advised of the experimental nature of medication therapy and to give written consent for its use
5. To received labeled medications safely without discomfort in accordance with the six rights of medication administration
6. To receive appropriate supportive therapy in relation to medication therapy
7. To not receive unnecessary medications

II. Practice Asepsis

• Wash hand before and after preparing the medication to reduce transfer of microorganisms.

III. Nurse who administers the medications is 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. Relabeling of drugs is the responsibility of           the pharmacist.
VII. Return liquid that is 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.

Oral Administration
Advantages

1. The easiest and most desirable way to administer medication
2. Most convenient
3. Safe, does nor break skin barrier
4. Usually less expensive

Disadvantages

1. Inappropriate if client cannot swallow and if GIT has reduced motility
2. Inappropriate for client with nausea and vomiting
3. Drug may have unpleasant taste
4. Drug may discolor the teeth
5. Drug may irritate the gastric mucosa
6. Drug may be aspirated by seriously ill patient.

Drug Forms for Oral Administration

1. Solid- tablet, capsule, pill, powder
2. Liquid- syrup, suspension, emulsion, elixir, milk, or other alkaline substances.
3. Syrup- sugar-based liquid medication
4. Suspension- water-based liquid medication. Shake bottle before use of medication to properly mix it.
5. Emulsion- oil-based liquid medication
6. Elixir- alcohol-based liquid medication. After administration of elixir, allow 30 minutes to elapse before giving water. This allows maximum absorption of the medication.

Sublingual Administration

• A drug that is placed under the tongue, where it dissolves.
• When the medication is in capsule and ordered sublingually, the fluid must be aspirated from the capsule and placed under the tongue.
• A medication given by the sublingual route should not be swallowed, or desire effects will not be achieved

Advantages

1. Same as oral
2. Drug is rapidly absorbed in the bloodstream

Disadvantages

1. If swallowed, drug may be inactivated by gastric juices.
2. Drug must remain under the tongue until dissolved and absorbed

Buccal Administration

• A medication is held in the mouth against the mucous membranes of the cheek until the drug dissolves.
• The medication should not be chewed, swallowed, or placed under the tongue (e.g sustained release nitroglycerine, opiates, antiemetic, tranquilizer, sedatives)
• Client should be taught to alternate the cheeks with each subsequent dose to avoid mucosal irritation

Advantages

1. Same as oral
2. Drug can be administered for local effect
3. Ensures greater potency because drug directly enters the blood and bypass the liver

Disadvantages

• If swallowed, drug may be inactivated by gastric juice

Topical Administration

• Application of medication to a circumscribed area of the body.

1. Dermatologic – includes lotions, liniment and ointments, powder.


2. Ophthalmic - includes instillation and irrigation


3. Otic Instillation – to remove cerumen or pus or to remove foreign body

• 0-3 years old: pull the pinna downward and backward
• Older than 3 years old: pull the pinna upward and backward

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.


5. Inhalation – use of nebulizer, metered-dose inhaler


6. Vaginal – drug forms: tablet liquid (douches), jelly, foam and suppository.

• Vaginal Irrigation – is the washing of the vagina by a liquid at low pressure. It is also called douche.

Rectal Administration

• Can be use when the drug has objectionable taste or odor.

1. Need to be refrigerated so as not to soften.
2. Apply disposable gloves.
3. Have the client lie on left side and ask to take slow deep breaths through mouth and relax anal sphincter.
4. 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.
5. Discard gloves to proper receptacle and perform hand washing.
6. Client must remain on side for 20 minute after insertion to promote adequate absorption of the medication.

Parenteral Administration

• Administration of medication by needle.

Intradermal – under the epidermis.

1. The site are the inner lower arm, upper chest and back, and beneath the scapula.
2. Indicated for allergy and tuberculin testing and for vaccinations.
3. Use the needle gauge 25, 26, 27: needle length 3/8”, 5/8” or ½”
4. Needle at 10–15 degree angle; bevel up.
5. Inject a small amount of drug slowly over 3 to 5 seconds to form a wheal or bleb.
6. 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.

Sites:

• outer aspect of the upper arms
• anterior aspect of the thighs
• Abdomen
• Scapular areas of the upper back
• Ventrogluteal
• Dorsogluteal

1. Only small doses of medication should be injected via SC route.
2. Rotate site of injection to minimize tissue damage.
3. Needle length and gauge are the same as for ID injections

• Use 5/8 needle for adults when the injection is to administer at 45 degree angle; ½ is use at a 90 degree angle.

1. For thin patients: 45 degree angle of needle
2. For obese patient: 90 degree angle of needle
3. For heparin injection: do not aspirate.
4. Do not massage the injection site to prevent hematoma formation
5. For insulin injection: Do not massage to prevent rapid absorption which may result to hypoglycemic reaction.
6. 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.
7. 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

• Needle length is 1”, 1 ½”, 2” to reach the muscle layer
• Clean the injection site with alcoholized cotton ball to reduce microorganisms in the area.
• Inject the medication slowly to allow the tissue to accommodate volume.

Sites:

1. Ventrogluteal site


2. Dorsogluteal site

3. Vastus Lateralis


4. Rectus femoris site –located at the middle third, anterior aspect of thigh.

5. Deltoid site

* IM injection – Z tract injection


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.
• Most rapid route of absorption of medications.
• Predictable, therapeutic blood levels of medication can be obtained.
• The route can be used for clients with compromised gastrointestinal function or peripheral circulation.
• Large dose of medications can be administered by this route.
• The nurse must closely observe the client for symptoms of adverse reactions.
• The nurse should double-check the six rights of safe medication.
• If the medication has an antidote, it must be available during administration.
• When administering potent medications, the nurse assesses vital signs before, during and after infusion.

Nursing Interventions in IV Infusion

1. Verify the doctor’s order
2. Know the type, amount, and indication of IV therapy.
3. Practice strict asepsis.
4. Inform the client and explain the purpose of IV therapy to alleviate client’s anxiety.
5. Prime IV tubing to expel air. This will prevent air embolism.
6. Clean the insertion site of IV needle from center to the periphery with alcoholized cotton ball to prevent infection.
7. Shave the area of needle insertion if hairy.
8. Change the IV tubing every 72 hours. To prevent contamination.
9. Change IV needle insertion site every 72 hours to prevent thrombophlebitis.
10. Regulate IV every 15-20 minutes. To ensure administration of proper volume of IV fluid as ordered.
11. Observe for potential complications.

Types of IV Fluids

1. Isotonic solution – has the same concentration as the body fluid
• D5 W
• Na Cl 0.9%
• Plain Ringer’s lactate
• Plain Normosol M
2. Hypotonic – has lower concentration than the body fluids.
• NaCl 0.3%
3. Hypertonic – has higher concentration than the body fluids.
• D10W
• D50W
• D5LR
• 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 (shortness of breath)
• Coughing
• Tachypnea
• Shock

Nursing Interventions:

• Slow infusion to KVO
• Place patient in high fowler’s 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 back pain
• 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.

General Principles of Parenteral Administration

1. Check doctor’s 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, and 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 with in 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. 

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ENEMA ADMINISTRATION

Definition

The term enema is used to refer to the process of instilling fluid through the anal sphincter into the rectum and lower intestine for a therapeutic purpose. An enema administration is performed using a flexible plastic rectal tube with several large holes in the tip. This is connected to the tubing from a solution bag or container. An enema can also be performed using a prepackaged solution that comes in a soft plastic bottle with a pre-lubricated rectal tip attached. Enema solutions are prepared using plain tap water or saline, soapsuds solutions, oil solutions, or various medication solutions.

Purpose

The most common purpose for administering an enema is to stimulate peristalsis (involuntary contraction) and to evacuate stool from the rectum. A tap water or soapsuds enema dilates the bowel, stimulates peristalsis, and lubricates the stool to encourge a bowel movement. These types of enemas are instilled and held for five to 10 minutes, as tolerated. They are used to treat constipation, to cleanse the bowel before a bowel exam, and to cleanse the bowel before bowel surgery. Another type of enema, the oil retention enema, is prepared in a smaller volume and is retained in the bowel for 300 minutes. The purpose of the oil retention enema is to soften the hardened stool and allow normal elimination. Enemas are also used to deliver medication directly onto the rectal mucous membranes to be absorbed into the bloodstream. Steroid enema solutions can be administered to alleviate bowel inflammation in patients with ulcerative colitis. Antibiotic enema solutions can be administered to treat localized bacterial infections. Medicated hypertonic enema solutions can be used to pull excessive potassium or ammonia from the bloodstream through the rectal wall. These substances are then eliminated with the stool.

Precautions

Enemas should not be used as a first-line treatment for constipation. Frequent use of enemas can lead to fluid overload, bowel irritation, and loss of muscle tone of the bowel and anal sphincter. Never deliver more than three consecutive enemas to treat a patient. A patient with diarrhea may not be able to hold an enema. Enema administration must be used with caution in cardiac patients who have arrhythmias or have had a recent myocardial infarction. Insertion of the enema tube and solution can stimulate the vagus nerve which may trigger an arrhythmia such as bradycardia. Enemas should not be given to patients with undiagnosed abdominal pain because the peristalsis of the bowel can cause an inflamed appendix to rupture. Enemas should be used cautiously in patients who have had recent surgery on the rectum, bowel, or prostate gland. If the patient has rectal bleeding or prolapse of rectal tissue from the rectal opening, cancel the enema and consult with the physician before proceeding. Do not force the enema catheter into the rectum against resistance. This can cause trauma to the rectal tissue. Use only mild castile soap for soapsuds enemas because other soap preparations are too harsh and irritate the rectal tissue.

Description

To administer an enema solution, the clinician should have the patient lie down on the left side, knees bent. Lift the upper buttock so that the rectal opening can be visualized. Place the lubricated tip of the enema catheter at the anal opening, and gently advance the catheter through the anal sphincter into the rectum toward the umbilicus (navel), 3 in (7.50 cm) for an adult. Insert the tubing 2 in (5 cm) for a child less than six years and 1 in (2.5 cm) for an infant. After alerting the patient, open the enema tubing to allow the solution to flow or squeeze premixed enema solutions slowly into the rectum. If the patient complains of cramping, slow or stop the enema flow and have the patient breathe slowly through the mouth to encourage relaxation. When giving fluid through an enema bag, start with the bag suspended from an IV pole at the patient's hip level. As the tubing is opened, slowly raise the IV pole to promote fluid flow until the bag is 12 inches (30.5 cm) above the hip for an adult. Continue to hold the rectal tube in place throughout the procedure or it will be expelled from the rectum. If the fluid will not flow in, gently rotate the tubing within the rectum to clear the holes of the tubing from the wall of the bowel or the impacted stool that may be occluding the flow. If ordered to give a high enema, slowly raise the bag no more than 18 inches (46 cm) above the adult patient's hip (12 inches (30.5 cm) above a child's hip and six inches (15 cm) above an infant's hip). This will increase the water pressure to deliver the fluid higher into the bowel. When all of the solution has been administered, clamp the tubing, remove the enema catheter, and release the buttock.

Preparation

Before administering an enema, ensure the patient's privacy by closing the room door. The patient should be encouraged to empty both bladder and bowels before the procedure. Have the patient undress completely from the waist down. Position the patient on the bed on his or her left side with the top knee bent and pulled slightly upward toward the chin. Place a waterproof pad under the patient's hips to protect the bedding and drape a sheet over the patient covering the entire body except the buttocks. Place a bedpan and toilet paper within quick access. Explain the procedure to the patient. Emphasize the importance of breathing slowly through the mouth to encourage relaxation of the rectal sphincter and to avoid oppositional pressure. Let the patient know that while he or she may feel the urge to defecate, most enemas need time to work and he or she should try to hold the fluid for at least five to 10 minutes after instillation (300 minutes for retention enemas and longer for some medicated enema solutions). Check the medication label if it is a medicated solution to avoid medication errors. Be sure it is the right medicine, the right dose (strength), the right time, the right person, and the right method. Verify the expiration date on the label. Do not use outdated medicine.
Wash hands thoroughly and put on gloves. To prepare for premixed disposable enema instillations, follow the directions on the package. Most premixed disposable enemas come with the tip already lubricated. Shake the solution bottle. Remove the cap from the tip and expel excess air from the apparatus before use. To prepare solutions to be administered using an enema bag, heat the solution to 105°F. Adult solutions are generally 750000cc of solution for a non-retention enema and 15000cc of fluid for a retention enema. Children's solutions are 25000cc of solution for a non-retention enema and 7550cc of solution for a retention enema. Infants' solutions are 15050cc of solution for a non-retention enema. If preparing a medicated solution, follow the physician's orders. Select a rectal tube appropriate

Aftercare

After administering an enema, remain near the patient in case he or she needs assistance with the bedpan or to get to the bathroom. Medicated enemas that are expelled immediately may need to be repeated, using fresh solution. Follow the directions or consult with the physician. To assist the patient with retaining an enema after instillation, apply gentle pressure to the rectal opening using a 4 gauze pad or squeeze the buttocks together. Tuck a 4 gauze pad between the buttocks to collect seepage. This maneuver may help the patient feel more secure. Cover the patient after the procedure and instruct him or her to lie still for five to 10 minutes or longer if a medicated solution or retention enema is administered. This will allow time for the solution to take effect. Wash items that might be reused, such as non-disposable enema bags and tubing, in warm soapy water. Rinse and allow them to air dry. Place disposable items, gauze pads, and gloves in a trash bag, then seal and discard it. Assist the patient to the bathroom or with the bedpan after he or she has held the enema solution for the correct amount of time. Hands should be washed after performing the procedure. Note the results of the enema.

Complications

Complications of enema administration are not common but can include irritation, swelling, redness, bleeding, or prolapse of the rectal tissue. If any of these symptoms are apparent, or if the patient complains of pain or burning during enema instillation, stop the procedure and notify the physician.

Results

Most enemas, because of their liquid state, are absorbed quickly and work rapidly. Retention enemas will take 300 minutes to achieve full therapeutic effect. Cleansing enemas usually work within 105 minutes to cleanse the bowel and relieve constipation. They may, however, need to be repeated one or two times to thoroughly cleanse the bowel in preparation for a bowel exam or bowel surgery. Medicated enemas, such as antibiotic or anti-inflammatory solutions, may need to be repeated daily over a period of a week or more for full therapeutic effect.

References
http://www.enotes.com/enema-administration-reference/enema-administration

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