medication administration nursing students

Nursing students, medication administration

1. PANDIARAJAN. K M.Sc , ( Ph.D )

2. A medication is a substance administered for the diagnosis, cure, treatment, or relief of a symptom or for prevention of disease. Pharmacology is the study of the effect of drugs on living organisms.

3. Uses of Drugs Prevention - used as prophylaxis to prevent diseases e.g. vaccines; fluoride-prevents tooth decay. Diagnosis - establishing the patient’s disease or problem e.g. radio contrast dye; tuberculosis (Mantoux) testing. Suppression - suppresses the signs and symptoms and prevents the disease process from progressing e.g. anticancer, antiviral drugs.

4.  Treatment - a l l e via t e t h e s y m p t o m s f or patient s wit h c h r onic disease e.g. Anti- asthmatic drugs. Cure - complete eradication of diseases e.g. anti-biotics, anti-helmintics. Enhancement aspects of health - achieve the best state of health e.g. vitamins, minerals

5. Storage of Medications In less advanced countries, 3 cupboards are usually used for drug storage. Cupboard I -used for drugs for external use only; e.g. calamine lotion, detol, methylated spirit etc. These drugs are contained in distinctive bottles, usually ridged with deep colours (dark green, blue, brown) with red label marked POISON and FOR EXTERNAL USE ONLY .

6. Cupboard II -contains drugs for internal use only e.g. t ablets, suspension, mixtures etc . All drugs must be labelled. Cupboard III -contains the dangerous drug; drugs of addiction. E.g. Morphine, pethedine etc. All drugs should be kept away from direct sunlight and at a temperature suggested by the manufacturer.

7. Another cupboard called the Emergency Cupboard may be stationed at or near the nurses bay for easy access. This cupboard contains drugs for emergency situations e.g. aminophylline (for asthma), hydralazine (for severe hypertension), oxytocin (for maternal bleeding), intravenous infusions (for rehydration) etc.

8. Principles of medication administration Principles include 3 checks and 10 Rights: 3 checks are Check when obtaining the container of medicine. Check when removing the medicine from the container. Check when replacing the container.

9. Rights of Medication Administration To prevent these errors, these guidelines are - the rights- are used in drug administration . 1. Right Patient : correct identification of the client cannot be over emphasized. This can be done by asking the client to mention his/her full name which should be compared with that on the identification bracelet or the patient’s folder and medication/treatment chart for confirmation.

10. 2. Right Medication : Right Medication : before administering any medicine, compare name on medication chart/medication order with that on the medication at least 3 times-checking medication label when removing it from storage unit, compare medication label with that on treatment chart and medication label and name on treatment chart with patient’s name tag.

11. 3. Right Time Right Time : drug timing is very especially with some drugs like antibiotics, antimalaria drugs etc. to achieve cure and prevents resistance. Some drugs must be given on empty stomach e.g. antituberculosis drugs ; and some after meals e.g . NSAIDS -these must be noted and adhered to . The interval of administration of drugs related with blood concentrations.

12. 4. Right Dose This becomes very important when medications at hand are in a larger volume or strength than the prescribed order given or when the unit of measurement in the order is different from that supplied from the pharmacy. Careful and correct calculation is important to prevent over or under dosage of the medication.

13. 5. Right Route An acceptable medication order must specify the route of medication . If this is unclear, the prescriber should be contacted to clarify or specify it. The nurse should never decide on a route without consulting the prescriber.

14. Types of Medication Orders Four types of medication orders are commonly used: Stat order : A stat order indicates that the medication is to be given immediately and only once . e.g: morphine sulfate 10 milligrams IV stat. Single order: The single order or one-time order indicates that the medication is to be given once at a specified time. e.g: Seconal 100 milligrams at bedtime . (sedative drug)

15. Standing order: Standing order is written in advance carried out under specific circumstances. (e.g: amox twice daily × 2 days ) PRN order: “PRN” is a Latin term that stands for “pro re nata,” A PRN order or as-needed order , permits the nurse to give a medication when the client requires it. (e.g., Amphojel 15 mL prn ) (for indigestion, heartburn, increased stomach acid)

16. Abbreviations Meaning ac before meals AM morning bid twice per day Cap capsule

17. Abbreviations Meaning gtt drops h or hr hours IM intramuscular IV intravenous no number pc after meals, after eating PO by mouth PM afternoon PRN when needed/necessary

18. Abbreviations Meaning qid four times per day q2h, q4h, q6h, q8h, q12h every hours Rx take STAT immediately, at once tid three times per day tab tablet

19. Drug forms Medications ar e a v ai l ab l e i n v a r ie t y of f orm s . Th e f orm of th e med i cation determines its route of administration.

20. Drug forms can be of three types; Solid eg: tablet, capsule Liquid eg: syrup, eye drops Semi solid eg: ointment, lotion

21. Tablet : It is the powdered medication compressed into hard disk or cylinder. Capsule : Medication covered in gelatin shell . Gel or jelly : A clear or translucent semisolid that liquefies when applied to the skin.

22. Lozenge : A flat, round, or oval preparation that dissolves and releases a drug when held in the mouth. Lotion: Drug particles in a solution for topical use. Ointment : Semisolid preparation containing a drug to be applied externally.

23. Powder: Single or mixture of finely ground drugs. Solution: A drug dissolved in another substance. Suspension: Finely divided, undissolved particles in a liquid medium; should be shaken before use . ( Paediatric dose with attractive colour and flavour)

24. Syrup: Medication combined in a water and sugar solution. Suppository: An easily melted medication preparation in a firm base such as gelatin that is inserted into the body (rectum, vagina, urethra)

25. Transdermal patch : Unit dose of medication applied directly to skin for diffusion through skin and absorption into the bloodstream.

26. Route of administration Different route of drug administration are; Oral Parenteral Topical Inhalation

27. Oral route O r a l r ou t e : M e dications a r e g i v en by mouth. Sublingual Administration: Some medications are readily absorbed when placed under the tongue to dissolve. Buccal Administration: Administration of a medication by placing in the mouth against the mucous membranes of the cheek until it dissolves.

28. Parenteral Routes P a r en t e r al R ou t e s : P a r e n t er al administration involves injecting a medication into body tissues. The following are the four major sites of injection: Intradermal (ID): Injection into the dermis just under the epidermis. Subcutaneous (SC): Injection into tissues just below the dermis of the skin. Intramuscular (IM): Injection into a muscle. Intravenous (IV): Injection into a vein.

29. Equipment To administer parenteral medications, nurses use syringes and needles to withdraw medication from (A) ampules and (B) vials . Ampule vial

30. Syringes Syringes have three parts: The tip , which connects with the needle The barrel , or outside part, on which the scales are printed The plunger , which fits inside the barrel

31. Several kinds of syringes are available in differing sizes, shapes, and materials. Syringes range in sizes from 1 to 60 mL . A nurse typically uses a syringe ranging from 1 to 3 mL in size for injections (e.g. subcutaneous or intramuscular).

32. Insulin syringes are available in sizes that hold 0.3 to 1 mL and are calibrated in units. The tuberculin syringe has a capacity of 1 mL. 3 ml syringe 5 ml syringe

33. Needles Most needles are made of stainless steel, and all are disposable. A needle has three parts: The hub , which fits onto the tip of a syringe The shaft , which connects to the hub The bevel , the tip of the needle The gauge varies from 18 to 30 . Use longer needles for IM injections and a shorter needle for subcutaneous injections.

34. Needle size 19 gauge 20 gauge 21 gauge 23 gauge 25 gauge

35. Ca n nula A cannula is a flexible tube that can be inserted into the body . A venous cannula is inserted into a vein, for the administration of intravenous fluids, for obtaining blood samples and for administering medicines. Types of cannula are IV cannula pen-like model. IV cannula with wings model. IV cannula with injection part model. IV cannula y-type model.

36. Preventing needle stick injuries One of the most potentially hazardous procedures that health care personnel face is using and disposing of needles and sharps . Needlestick injuries present a major risk for infection with hepatitis B virus, human immunodeficiency virus (HIV), and many other pathogens.

37. SCOOP METHOD placing the needle cap and syringe with needle horizontally on a flat surface. inserting the needle into the cap, using one hand. then using your other hand to pick up the cap and tighten it to the needle hub.

38. Epidural: Epidural medications are administered in the epidural space . (spine) Intrathecal : Administration of medications into subarachnoid space or one of the ventricles of the brain. S o m e m edic a ti o n s a r e adminis t e r e d into body cavities. These additional routes include

39. Int r ao s s eou s : A dminis t r atio n of medication directly into the bone marrow . Intraperitoneal: Medications administered into the peritoneal cavity Int r a pleu r a l : A dm i nist r at i on of medications directly into the pleural space . (lung cavities) Intraarterial: Intraarterial medications are administered directly into the arteries .

40. Broad Classification of drugs A drug may be classified by the chemical type of the active ingredient or by the way it is used to treat a particular condition. Eg: Analgesics: to reduce pain Antipyretics: to reduce fever Antibiotics: to treat bacterial infection Anti viral: to treat viral infection Antihypertensive : to treat hypertension Antidiabetic: to treat diabetes

41. Dose Calculations Methods used to calculate medication doses include The ratio and proportion method The formula method Dimensional analysis

42. The Ratio and Proportion Method: A ratio indicates the relationship between two numbers separated by a colon (:). Example 1: 1:2 = 4:8 Example 2: 1:2 :: 4:8 Example 3: 1/2 = 4/8 Metric system Household system 1 ml 15 drops 5 ml 1 teaspoon 15 ml 1 tablespoon

43. Example: The prescriber orders 500 mg of Syp . amoxicillin to be administered in every 8 hours. The bottle of amoxicillin is labeled 400 mg / 5 mL . i.e - 500 * 5 / 400 = 6.25ml

44. Formula method 1. Calculating dose of solid medications First convert the drug amount to the same units and then use the formula. 𝒔𝒕𝒐𝒄𝒌 𝒔𝒕𝒓𝒆𝒏𝒈𝒕𝒉 Dose required = 𝒔𝒕𝒓𝒆𝒏𝒈𝒕𝒉 𝒓𝒆𝒒𝒖𝒊𝒓𝒆𝒅 = n o of tab. Stock strength is the strength of drug written on the cover. E.g -Administer tab.para 250 mg? Eg : paracetamol 250 mg/500 mg= ½ tablet

45. 2. Calculating dose of liquid medications First convert the drug amount to the same units and then use the formula Volume required = 𝑠𝑡𝑟𝑒𝑛𝑔𝑡ℎ 𝑟𝑒𝑞𝑢𝑖𝑟𝑒𝑑×𝑣𝑜𝑙𝑢𝑚𝑒 𝑜𝑓 𝑠𝑡𝑜𝑐𝑘 𝑠𝑜𝑙𝑢𝑡𝑖𝑜𝑛 𝑠𝑡𝑜𝑐𝑘 𝑠𝑡𝑟𝑒𝑛𝑔𝑡ℎ Example: The ordered dose is Ceftriaxone 750 mg IV. the container contain 1g in a 10 ml vial. How to calculate? You should convert first g to mg , then : (D) 750 mg X (V) 10 ml = 7.5 ml (H) 1000 mg

46. What is a drop factor? Drop factor is the number of drops in one milliliter used in IV fluid administration (also called drip factor). A number of different drop factors are available but the Commonest are: 10 drops/ml (blood set) 15 drops / ml (regular set) 60 drops / ml ( microdrop , burette)

47. How to calculate IV flow rates ? Example : 1500 ml IV Saline (3 bottles) (1 bottle=5ooml) is ordered over 12 hours. Using a drop factor of 15 drops / ml, how many drops per minute need to be delivered ? (1 pint = 500ml) 1500 (ml) X 15 (drop / ml) -------------------------------------- 12 x 60 (gives us total minutes) = 31 drop/ minute The formula for working out flow rates is: volume (ml) X drop factor (gtts / ml ) = gtts / min --------------------------------------------- time (min )

48. Importance ! Can be life-saving in certain conditions Loss of body water, whether acute or chronic, can cause a range of problems from mild headache to convulsions, coma, and in some cases, death. Though fluid therapy can be a lifesaver, it's never always safe, and can be very harmful. FLUIDTHERPY

49. The fluids used in clinical practice are usefully classified into colloids , crystalloids and blood products 1.Colloid Solutions that contain large molecules that don't pass the cell membranes. When infused, they remain in the intravascular compartment and expand the intravascular volume and they draw fluid from extravascular spaces via their higher oncotic pressure Types of Fluid

50. 2.Crystalloid Solutions that contain small molecules that flow easily across the cell membranes, allowing for transfer from the bloodstream into the cells and body tissues. This will increase fluid volume in both the interstitial and intravascular spaces (Extracellular) It is subdivided into : Isotonic - same like plasma concentration Hypotonic -less than plasma concentration Hypertonic -more than plasma concentration Types of Fluid

51. When to consider a solution isotonic? When the concentration of the particles (solutes) is similar to that of plasma, So it doesn't move into cells and remains within the extracellular compartment thus increasing intravascular volume . Isotonic Fluids

52. Types of isotonic solutions include:  0.9% sodium chloride (0.9% NaCl)  lactated Ringer's solution  5 % dextrose in water (D5W)  Ringer's solution Isotonic Fluids

53. A- 0.9% sodium chloride (Normal Saline)  Simply salt water that contains only water, sodium (154 mEq /L), and chloride (154 mEq /L).  It's called "normal saline solution" because the percentage of sodium chloride in the solution is similar to the concentration of sodium and chloride in the intravascular space. Isotonic Fluids K + Ca 2+ Mg 2+ HCO 3 - Dextrose Solutions Na + 0.9% NaCl 154 Cl - 154 m O s m /L 308

54. 1. Severe vomiting or diarrhoea Shock Mild hyponatremia Metabolic acidosis (such as diabetic ketoacidosis) 5- It’s the fluid of choice for resuscitation efforts . 6- it's the only fluid used with administration of blood products . A- 0.9% sodium chloride (Normal Saline ) When to give?

55. o is the most physiologically adaptable fluid because its electrolyte content is most closely related to the composition of the body's blood serum and plasma. o Another choice for first-line fluid resuscitation for certain patients, such as those with burn injuries. B- Ringer's lactate or Hartmann solution S o l u ti o n s Na + K + Ca 2+ Mg 2+ Cl - HCO 3 - Dextrose m O s m / L L ac t a t e d R i n g e r ’ s 13 4 3 109 28 2 7 3

56. B- Ringer's lactate or Hartmann solution When to be used?  To replace GI tract fluid losses ( Diarrhea or vomiting )  Fluid losses due to burns and trauma  Patients experiencing acute blood loss or hypovolemia Don’t Use -Don't give LR to patients with liver disease as they can't metabolize lactate used cautiously in patients with sever renal impairment because it contains some potassium LR shouldn't be given to a patient whose pH is greater than 7.5

57. C -Ringer's solution Like LR, contains sodium, potassium, calcium and chloride in similar. But it doesn't contain lactate. Ringer's solution is used in a similar fashion as LR, but doesn't have the contraindications related to lactate . (Can given in metabolic acidosis, alkalosis)

58. It is considered an isotonic solution, but when the dextrose is metabolized, the solution actually becomes hypotonic and causes fluid to shift into cells . It provides 170 calories per liter D- Dextrose 5% Solutions Na + K + Ca 2+ Mg 2+ Cl - - HCO 3 Dextrose mOsm/L D5W 50gm/l 278

59. Take Care ! D5W is not good for patients with renal failure or cardiac problems since it could cause fluid overload. patients at risk for intracranial pressure should not receive D5W since it could increase cerebral edema Never mix dextrose with blood as it causes blood to hemolyze. Not used for resuscitation , because the solution won't remain in the intravascular space. Not used in the early postoperative period , because the body's reaction to the surgical stress may cause an increase in antidiuretic hormone secretion D- Dextrose 5 %

60. Indications for GI Intubation To decompress the stomach and remove gas and liquids To lavage (removal) the stomach and remove ingested toxins To administer medications and feeds e.g. Post operative or unconscious patient (gag or swallowing reflex absent) As part of the management of an obstruction i.e Tumor oesophagus, As part of the management of haematemesis i.e oesophgeal variceas . To aspirate gastric contents for analysis

61. Technique continued… Explain procedure to patient and relatives Position the client in a sitting or high Fowler’s position. If comatosed, semi Fowler’s. Examine feeding tube for flaws. Determine the length of tube to be inserted. Measure distance from the tip of the nose to the earlobe and to the xyphoid process of the sternum . Prepare NG tube for insertion.

62. Implementation Wash Hands Put on clean gloves Lubricate the tube Hand the patient a glass of water Gently insert tube through nostril to back of throat (posterior naso pharynx). Have the patient flex the head towards the chest after tube has passed through nasopharynx.

63. Imp le m en t a t ion Con t . Emphasize the need to mouth breathe and swallow during the procedure . Swallowing facilitates the passage of the tube through the oropharynx. When the tip of the tube reaches the carina stop and listen for air exchange from the distal end of the tube. If air is heard remove the tube. Advance tube each time client swallows until desired length has been reached. Do not force tube . If resistance is met or client starts to cough, choke or become cyanotic stop advancing the tube and pull back.

64. Imp le m en t a t ion Con t . Check placement of the tube. Pushing air Testing pH of a spirate X-ray confirmation Secure the tube with tape or commercial device.

65. Enteral Nutrition (GAVAGE) OR Naso Gatric Tube feeding What is it: The administration of nutrients directly into the GI tract . The most desirable and appropriate method of providing nutrition is the oral route, but this is not always possible. Nasogastric feeding is the most common route Nurses are the main healthcare professional responsible for intubation

66. Administering Enteral Feeds Indications: Clients who are unable to maintain adequate oral intake to meet metabolic demands Surgical cases Ventil ator patients Neuromuscular impairment Generally these clients have been referred to the Dietician.

67. Enteral and Parenteral feeding What is enteral and parenteral feeding ? The main difference between enteral and parenteral feeding is that enteral feeding is the delivery of food via the human gastrointestinal tract. In contrast, parenteral feeding is the delivery of food into the bloodstream , bypassing the gut.

68. Total Parenteral Nutrition Intravenous administration of varying combinations of hypertonic or isotonic glucose, lipids, amino acid, electrolytes, vitamins and trace elements through a venous access device (VAD) directly into the vein. .

69. Purposes To provide nutrients required for the normal metabolism, tissue maintenance, repair and energy demands . To bypass the GI tract for patients who are unable to take food orally.

70. Methods of parenteral nutrition Total Parenteral Nutrition ( T PN ) It is indicated for patients requiring parenteral feeding for seven or more days. Given through a central vein often into the superior venacava .

71. Methods of parenteral nutrition Peripheral parenteral nutrition This parenteral formula combines carbohydrates a lesser concentrated glucose solution with amino acids, vitamins, minerals Given through peripheral vein Indicated for patients requiring nutrition for fewer less than 7 days

72. Central venous access devices