N212 Week 1 Med Admin Part 2

• a) Anaphylactic Reaction (Anaphylaxis): life threatening allergic reaction that results in respiratory distress, bronchospasm, CV collapse
• b) Antagonistic Effect: in a drug-drug reaction the combined of two or ore drugs acting simultaneously produces an effect less than that of each drug alone
• c) Synergistic Effect: in a drug-drug reaction the combined of two or ore drugs acting simultaneously produces an effect greater than that of each drug alone
• d) Intradermal Injection: are administered into the dermis, just below the epidermis. This route has the longest absorption time of all parenteral routes.
• e) Subcutaneous Injection: administered into the adipose tissue layer just below the epidermis and dermis. This tissue has few blood vessels, thus sustained rate of absorption into the capillaries
• f) Intravenous Route (the most dangerous): most common used route in hospitals especially for fast action requirement.
• g) Piggyback Deliver System: requires the intermittent or additive solution to be placed higher than the primary solution container
• h) Volume-Control System: for intermittent IV infusion. The medication si diluted with a small amount of solution and administered through the patient's IV line
• i) Topical Application: are applied to the skin or mucous membranes, including the eyes, ears, nose, rectum, vagina and lungs. Are usually intended for direct action at a particular site although some may be intended for systemic effects

• a) Medication Orders
• i) a nurse follows only a written or typed order, or an order entered into a computer order-entry system because these types of orders are less likely to result in error.
• ii) under certain circumstances, such as in an emergency, a verbal order from the physician may be given to a registered nurse
• b) CONTROLLED SUBSTANCES ACT OF 1970
• i) 5 DRUG SCHEDULES
• ii) 1. HIGH LEVEL OF DEPENDENCY
• iii) 2. HIGH LEVEL OF DEPENDENCY
• iv) 3. HIGH LEVEL BUT LESS THAN 1&2
• v) 4. LOW LEVEL COMPARED TO 3
• vi) 5. LOW LEVEL COMPARED TO 4
• c) CONTROLLED SUBSTANCES
• i) Nurses may possess these only if:
• (1) They are administering the drugs to the patient for whom they were prescribed
• (2) They themselves are the patient for whom the physician has prescribed the drug
• (3) They have been delegated the responsibility for the unit supply
• (4) It is a crime for the nurse to have a controlled substance UNLESS 1 OF THE 3 ABOVE CONDICTIONS ARE MET.
• ii) NARCOTICS
• (1) MUST COUNT THE NARCOTICS BETWEEN AN ON-COMING AND OFF-GOING STAFF MEMBERS EVERY 8 HOURS
• (2) CHART IN MAR AND NARCOTIC BOOK
• (3) ALL NARCOTICS FOR A DISCHARGED/ DECEASED PATIENT ARE RETURNED TO PHARMACY FOR A COUNT AND DISPOSAL
• (4) WASTED/ USED MEDICATION MUST BE WITNESSED ON DISPOSAL
• (5) NO DRUG SHARING
• iii) REQUIREMENT FOR ORDERS
• (1) PATIENT’S FULL NAME
• (2) DATE WRITTEN
• (3) NAME OF DRUG
• (4) ROUTE, DOSE AND FREQUENCY
• (5) DURATION
• (6) SIGNATURE OF PRESCRIBER
• (7) ADDITIONAL NEEDED DETAILS (ex: take with food, avoid grapefruit)

• a) Developmental
• i) Teratogenic Meds: have the potential to cause developmental defects in the embryo or fetus
• ii) Some drugs cross into breast milk putting breast fed babies at risk
• iii) Small body size, reduced weight, and reduced body water also alter distribution, as do decreases in CO and perfusion
• iv) Drugs are secreted more slowly from the body as result of changes in kidney function
• b) Weight
• i) Blood Surface Area (BSA): the area of the external surface of the body, expressed in square meters (m2). This is considered the most accurate way to calculate the drug dose for children, infants, older adults, patient’s receiving oncologic meds and those with low body weight
• c) Cultural and Genetic Factors
• i) Religious restrictions and beliefs may affect the patient’s acceptance of, response to, and compliance with certain drug therapies
• ii) Genetic difference or variations may determine the response of medication administered
• d) Gender
• i) The difference in the distribution of body fat and fluids in men and women is a minor factor affecting the action of some drugs

• a) Oral Route
• i) Enteral: administering through NG/G Tube
• ii) Sublingual: placing under the tongue
• iii) Buccal: placing drug between cheek and gum
• b) Parenteral Route
• i) SubQ: into the fat tissue below the epidermis & dermis
• ii) Intramuscular: muscle tissue
• iii) Intradermal: Corium (under epidermis)
• iv) Intravenous: vein
• v) Intra-arterial: artery
• vi) Intracardial: heart tissue
• vii) Intraperitoneal: peritoneal cavity
• viii) Intraspinal: spinal canal
• ix) Intraosseous: bone
• c) Topical Route
• i) Vaginal
• ii) Rectum
• iii) Inunction: rubbing into skin
• iv) Instillation: into direct contact with mucous membranes
• v) Irrigation: flushing with drug solution
• vi) Skin application: applying a transdermal patch
• d) Pulmonary Route: having patient inhale drug

• a) Patient’s name
• i) Date and time order is written
• ii) Name of drug to be administered
• iii) Dosage of drug
• iv) Route by which drug is to be administered
• v) Frequency of administration of the drug
• vi) Signature of person writing the order

• a) Inappropriate prescribing of the drug (ex. Incorrect dose, quantity, or route)
• i) Extra, omitted, or wrong does
• ii) Administration of a medication to a patient that was not ordered for that patient
• iii) Failure to give a medication within the prescribed time interval
• iv) Incorrect preparation of a drug before administration
• v) Improper technique when administering a drug
• vi) Diving a drug that has deteriorated.

• a) A.C. = before meals
• i) A.a = water
• ii) AM= morning ; before noon
• iii) Bid= twice a day
• iv) C with line over it = with
• v) EC = enteric coated
• vi) Fl= fluid
• vii) g = gram
• viii) h, hr = hour
• ix) IM = intramuscular
• x) IV = intravenous
• xi) Kg = kilogram
• xii) L = liter
• xiii) Lb = poung
• xiv) mEq= milliequivalent
• xv) mg= milligram
• xvi) PO= by mouth
• xvii) Oz= ounce
• xviii) p. = after
• xix) p.c. = after meal
• xx) prn = as needed
• xxi) q= every hour
• xxii) q#h = # for hour
• xxiii) Stat. = immediately
• xxiv) Tid= three time a day
• xxv) PR = per rectum
• xxvi) H.s = bedtime

• a) Metric system
• b) Weight
• i) 1 kilogram = 1,000 grams
• ii) 1 gram = 1,000 milligrams
• iii) 1 milligram = 1,000 microgram
• c) Volume
• i) 1 liter = 1,000 milliliters or cubic centimeters
• d) House hold system
• i) 1 teaspoon = 5 mL
• ii) 1 tablespood = 3 teaspoon or 15 mL
• iii) 1 oz = 30 mL

a) IM NOT SURE BUT ILL SPEAK TO THE INSTRUCTOR TOMOOROW !!!!!!!!

a) Right medication is given to, right patient in the, right dosage in the right form, right route at the, right time for the, right reason based on the, right (appropriate) assessment data using the, right documentation and monitoring right response by the patient.

• a) Allow extra time to administer medications their reflexes may be slower
• b) Older adults may have difficulty swallowing medications and may prefer to get the medications crushed or in a liquid form.
• c) Reevaluation of the drug dosage in necessary with the older patient. Weight and age should be used as criteria for determining the dosage.
• d) Assist the older patient to set up a schedule as a reminder to take medications as scheduled at home.
• e) Monitor the patient carefully for adverse effects that may result from the drug regimen. These may be magnified in older adults.
• f) Teach patients the names of dug, rather than distinguishing them by color. Manufactures may vary the colors of generic drugs, and the visual changes associated with aging may make it more difficult to identify medications by their color

• a) Crush the medications (if appropriate for type of medications) and add it to food or a drink so that the patient can swallow it.
• b) Allow the patients to suck on a small piece of ice for a few minutes before taking the medications. The ice numbs the taste buds, and the objectionable taste is less discernible.
• c) Store oily medications in the refrigerator. Cold oil is less aromatic than oil at room temperature.
• d) Place the medications in a syringe, and place the syringe well back to the tongue, being careful not to trigger the patient’s gag reflex.
• e) Use dropper to give infants or every young children liquids
• f) Crush uncoated tablets or empty o soft capsule and mix the medication with soft foods

• a) Use liquid meds when possible because they are absorbed readily and less likely to cause occlusions
• b) Crush meds into fine powder and mix with 15 ml to 30 ml of water before delivery through the tube
• c) Some capsules may need to be opened, emptied into liquid and administered through the tube, check manufacturer recommendations and/or pharmacist to verify
• d) Bring liquid meds to room temp, cold liquids may cause patient discomfort
• e) Elevate the HOB to prevent reflux
• f) Remove the clamp from the tube and use the recommended procedure for checking tube placement in the stomach or intestine before administration of the drug
• g) Flush tube with 15 to 30 ml (5 to ml, children) before giving the medication and immediately after the medication, flushing helps to maintain tube patency
• h) Give meds separately and flush with water between each drug, some meds may interact with each other or become less effective if mixed with other drugs
• i) If tube is connected to suction, disconnect from suction, keep it disconnected for 20-30 minutes after administration of the med to allow absorption
• j) If the patient is receiving tube feedings, review info about the drugs to be administered
• k) Discontinue a continuous tube feeding and leave the tube clamped for required period of time before and after the med has been given, according to the reference and facility protocol
• l) Document the water intake and liquid medication by tube on the intake and output record
• m) Adjust the amount of water if the patient's fluid intake is restricted

• a) Parenteral - means OUTSIDE OF THE INSTESTINE OR ALIMENTARY CANAL
• b) Needles and syringes
• i) Needles
• (1) Needle length depends on route of administration
• (2) Gauge refers to the diameter of the needle
• (3) Needle gauges numbered 18 through 30
• (4) As the DIAMETER of the needle INCREASES the GAUGE NUMBER DECREASES
• (5) Types
• (a) Some have needle guards to prevent accidental injury
• (b) Retractable needles that locks and seals inside the syringe barrel
• (c) Prefilled syringes w/ retractable needle sheath covers - once needle is contaminated the top slides forward to prevent a needlestick injury
• ii) Syringes
• (1) Most are plastic and disposable
• (2) Various sizes
• (3) Some syringes are supplied with a needle and some are not, which means you should select the appropriate needle
• iii) Equipment must be chose in regards to following criteria
• (1) ROUTE OF ADMINISTRATION - ex: longer needle is needed for IM injections than for intradermal or SQ injections
• (2) VISCOSITY OF THE SOLUTION - some meds are more viscous than others and require a larger lumen needle to inject the drug
• (3) QUANTITY TO BE ADMINISTERED - The larger the amount of the medication to be injected, the greater capacity the syringe
• (4) BODY SIZE - ex: an obese person needs a longer needle to reach muscle tissue than does a thin person
• (5) TYPE OF MEDICATION - there are special syringes for certain uses; ex: insulin syringe used to inject insulin
• c) SAFETY
• i) DO NOT RECAP NEEDLES
• ii) Place needles in puncture-resistant container - "sharps container"
• iii) Most needlestick injuries occur during recapping
• iv) Health care facilities are required to provide needles with needle guards to prevent accidental injury
• v) Use one-handed technique if recapping in absolutely unavoidable
• vi) Maintain surgical asepsis and use strict sterile technique to avoid introducing organism into the body
• vii) PARTS THAT MUST BE KEPT STERILE DURING THE PREP AND ADMIN OF AN INJECTION
• (1) Inside the barrel
• (2) The part of the plunger that enters the barrel
• (3) The tip of the barrel
• (4) The needle - except for the exterior needle hub
• (5) CLEAN THE SKIN FOR AN INJECTION WITH ALCOHOL OR ANOTHER ANTIMICROBIAL IN A CIRCULAR MOTION, WORKING FROM CENTER OF THE DESGINATED SITE OUTWARD
• d) Needleless Systems
• i) Reduces the risk for accidental needlesticks and exposure to blood-borne pathogens
• ii) Available for IV use, including…
• (1) Recessed and shielded IV needles connectors
• (2) Blunt cannulas that are inserted into special receptors sites on tubing or lock setups
• iii) Discard all needleless devices or blunt cannulas in special containers that are puncture proof, leak proof, and labeled clearly

• ii) NPH Insulin
• (1) “cloudy”
• (2) Slower acting
• (3) “contaminated”
• iii) Process
• (1) Gather equipment: correct insulin syringe (U-100 insulin syringe mostly used), correct insulin vials (√ date opened), alcohol swabs, MAR, current fingerstick glucose reading
• (2) Roll the “cloudy” NPH insulin vial
• (3) Clean the top of the vials with an alcohol swab.
• (4) Instill air into the “cloudy” vial equivalent to the “cloudy” dose (NPH) with the vial remaining on the counter surface.
• (5) Instill air into the “clear” insulin vial equivalent to the “clear” dose (Regular).
• (6) Draw up the medication: draw solution from “Clear to Cloudy”
• (7) Invert the “clear” vial and withdraw the desired amount.
• (8) Have this dose checked by another nurse.
• (9) Insert the needle into the “cloudy” vial and withdraw the desired amount.
• (10) Again have the total amount checked by another nurse.

• a) Intradermal:
• i) -Administered into the dermis, which has the longest absorption time of all the parenteral routes
• ii) -They are used for tuberculin skin testing and for allergy.
• iii) -Sites commonly used are the inner surface of the forearm (one hand’s breath above wrist), upper back and upper chest
• b) Subcutaneous:
• i) -Administered into the adipose tissue layer just below the epidermis and dermis where this tissue has few blood vessels, thus drugs administered here have a slow, sustained rate of absorption into the capillaries. This route is to administer drugs such as insulin and heparin.
• ii) -Sites commonly used are outer aspect of upper arm, abdomen (from below the costal margin to the iliac crests), anterior aspects of the thigh, the upper back, and the upper ventral gluteal area
• iii) -Injection in the abdomen is absorbed most rapidly as opposed to ventral or dorsogluteal areas, which have the slowest absorption.
• iv) -Avoid sites that are bruised, tender, hard, swollen, inflamed or scarred which can affect absorption or cause discomfort and injury
• c) Intramuscular:
• i) -Administers medication through the skin and subcutaneous tissues into certain muscle. Allows faster onset of action because muscles have larger and a greater number of blood vessels. It has some longer duration of effect.
• ii) This route is used such as antibiotics, hormones and vaccines such as the pneumococcal and hepatitis vaccines.
• iii) Site: Deltoid, Ventrogluteal, Vastus Lateralis, Gluteal (not recommended because of sciatic nerve)

• (3) Middle finger extended toward iliac tubercle
• (4) Injection site lies within the triangle formed by the index and middle fingers
• (5) (adults; use for irritating, viscous, oily solutions 1 ½ inch needle)
• iv) Deltoid
• (1) NOT RECOMMENDED FOR USE
• (2) Locate the posterior iliac spine.
• (3) Locate the greater trochanter
• (4) Draw an imaginary line between these two landmarks.
• (5) Injection site is above and lateral to the line.
• (6) (Most dangerous site because of sciatic nerve location)
• d) Intravenous route: Most dangerous route of administration because the drug is placed directly into the bloodstream, it cannot be recalled and its actions cannot be slowed. Use in most emergency situations when immediate onset of action is required. There are also many nonemergency clinical situations in which drugs are administered intravenously.
• i) Administering medications by intravenous bolus or push through an intravenous solution
• (1) Prepare medications
• (2) Identify patient
• (3) Assess IV site for presence of inflammation or infiltration
• (4) Put clean gloves
• (5) Select injection port on the tubing that is closest to the venipunture site
• (6) Clean porn with an antimicrobial swab
• (7) Uncap the syringe
• (8) Steady the port with non-dominant hand when inserting the syringe with an antimicrobial swab
• (9) Uncap the syringe
• (10) Move non-dominant hand to section of IV tubing just above the injection port
• (11) Fold tubing between your fingers
• (12) Pull back slightly on the plunger just until blood appears in the tubing
• (13) Inject medication at recommended rate
• (14) Release tubing
• (15) Remove syringe
• (16) DO NOT RECAP
• (17) Check IV fluid infusion rate
• (18) Remove gloves
• (19) Document
• (20) Evaluate patient’s response to medication in appropriate time frame
• ii) Administering a piggyback intermittent intravenous infusion of medication
• (1) Prepare medications
• (2) Identify patient
• (3) Assess IV site for presence of inflammation or infiltration
• (4) Close clamp on the short secondary infusion tubing
• (5) Use aseptic technique, remove the cap on tubing spike and the cap on the port of medication container, taking care to avoid contaminating either end
• (6) Attach infusion tubing to the medication container by inserting the tubing spike into the port with a firm push and twisting motion
• (7) Hang piggyback container on IV pole (positioning it higher than the primary IV according to manufacturer’s recommendations)
• (8) Place label on tubing with date
• (9) Squeeze the drip chamber on tubing and release. Fill to the line or about half full. Open the clamp and prime the tubing. Close the clamp. Place the needleless connector on the end of the tubing using sterile technique
• (10) Use antimicrobial swab to clean access port or stopcock above or stop clamp on primary IV infusion tubing
• (11) Connect piggyback setup to the access port or stockcock
• (12) Open clamp on secondary tubing. Set the rate for the secondary infusion on the infusion pump and begin the infusion
• (13) If using gravity infusion, use the roller clamp on the primary infusion tubing to regulate flow at the prescribed delivery rate
• (14) Monitor medication infusion at periodic intervals
• (15) Clamp tubing on the piggyback when solution is infused
• (16) Raise primary IV fluid container to its original height. Check the primary infusion rate on the infusion pump. If using gravity infusion, read just the flow rate of primary IV
• (17) Document
• (18) Evaluate pt response to medication in appropriate time frame

• (1) Inadvertent contact may cause patient to sneeze and contaminate dropper
• e) Vaginal
• i) Ask patient to void before inserting medication
• ii) Position patient so that she is lying on her back with knees flexed
• iii) Provide adequate light to visualize vaginal opening
• f) Rectal
• i) Used primarily for their local action
• (1) Laxatives and fecal softeners
• (2) Relieve N/V
• (3) Don’t administer who’s had recent rectal or prostate surgery
• (4) Assess WBC and platelet counts
• (5) Thrombocytopenic or neutropenic patient’s should not receive suppositories
• (6) Don’t administer to patient’s at risk for cardiac arrhythmias
• (7) After suppository is inserted, patient should remain in position for 5 minutes
• (8) For laxative purposes, 35-45 minutes or until patient feels urge to defecate
• g) Respiratory Inhalation
• i) Inhalation are aerosolized, delivered in small particles, and breathed in by the patient
• ii) May be used to administer several different classes of drugs
• iii) Disadvantage because it’s difficult to establish
• iv) Bronchodilators act to decrease resistance to airflow by enlarging airways
• (1) Promotes relaxation of musculature in trachebronial tree
• v) May be administered by a hand atomizer or nebulizer
• (1) They break up medication into mist for more efficient inhalation
• vi) Metered-Dose Inhaler (MDI) are used incorrect and deliver incorrect dose
• (1) Use a spacer when delivering medication via MDI
• vii) Dry Powder Inhalers (DPI) are breath activated
• (1) Supplied in powder form, or disk, inserted into DPI or in a compartment inside DPI
• (2) II. Drug output or size distribution of aerosol is more or less dependent on flow rate
• (3) Must be able to take powerful, deep inspiration
• viii) Neubilization
• (1) May result from force of oxygen stream or compressed air passed through fluid in nebulizer or an atomizer
• (2) II. Good for patients who require inhalation of drug several times a day when hand is fatigue
• (3) III. Use of oxygen mask, children can receive meds with minimal interruptions

• a) Intradermal:
• i) -Volume 0.01-0.05 ml
• ii) -Angle: 10-15 degrees
• b) Subcutaneous:
• i) -Volume: up to 1ml
• ii) -Angle: 45-90 degrees
• c) Intramuscular:
• i) -Volume: up to 4ml
• ii) -Angle: 90 degrees

• a) Z-Track Method: is recommended for all intramuscular injections to ensure that medication does not leak back along the needle track and in the subcutaneous tissue. This reduces pain and discomfort for patients receiving injections over an extended period. This is recommended for older adults who have decreased muscle mass.
• b) -Methods used with irritating medications such as vistaril and iron
• c) -Used to “trap” medication in muscle and prevent “tracking” of solution through tissues
• i) Attach new appropriate sized sterile needle to syringe
• ii) Put on don gloves
• iii) Pull skin 1 to 1 ½ laterally away from injection site
• iv) Clean site with antimicrobial wipe
• v) Maintain displacement, insert needle in 90 degree angle
• vi) Aspirate to see if needle is in blood vessel
• vii) If so, discard and prepare a new injection
• viii) Inject medication and wait 10 seconds keeping skin taut
• ix) With draw needle and least retracted skin apply light pressure in swab at the injection site without massaging
• x) Activate needle safety feature
• xi) Dispose of needle in puncture proof container
• xii) Return client to a position of comfort and safety
• xiii) Discard gloves
• xiv) Wash hands
• xv) Document administration of medications in medication record

• a) Select a needle of the smallest gauge & correct length that is appropriate for the site and solution to be injected
• b) Be sure the needle is free of medication that may irritate superficial tissues as the needle is inserted. Recommended Procedure—use two needles , one to remove the medication form the vial and a second to inject the medication. If medication is in a pre filled syringe with a non removable needle and has dripped back on the needle during preparation, gently tap the barrel to remove the excess solution
• c) Use the Z-Track technique for IM injections to prevent leakage of medication into the needle track,
• d) Inject into a relaxed muscle
• e) Do Not inject to areas that feel hard or tender to the patient.
• f) Do not administer more solution in one injection than is recommended of the site. Creates excess pressure
• g) Inject the solution slowly so that it may be dispersed more easily into the surround tissue (10 seconds per 1 ml)
• h) Apply gentle pressure after injection, unless contraindicated
• i) Allow fearful patients talk about their fears and answer any questions
• j) Rotate sites when the patient is to receive repeated injections. Same site injections may cause irritation, pain, discomfort