Routes of drug administration

Routes of Admin

1. Medication Administration: Different Routes Kristine Faith P. Tablizo

2. OUTLINE: Introduction 10 Rights of Medication Administration Types of Drug Preparations Routes of Administration Procedures (IM, ID)

3. PRE-TEST (4 mins )

4. #1-5 5 Basic Rights of Drug Administration # 6-8 Give 3 Sites for IM injection #9 The preferred site for IM injection in infants and younger children. # 10 How do we straighten the ear canal of a 2 year old patient before administering ear drops?

5. 10 R’s of Medication Administration

6. 10 Rs of Medication Administration Right Patient Right Medication Right Dose Right Time Right Route Right Education Right to Refuse Right Assessment Right Evaluation Right Documentation

7. Types of Drug Preparations Some Routes of Medication Administration will be discussed in this section

8. They are classified according to: Route of administration Physical form I) Oral I) Solid II) Topical II) Semisolid III) Rectal III) liquid IV) Parenteral IV) Gaseous V) Vaginal VI) Inhaled VII) Ophthalmic VIII) Otic Types of dosage forms:

9. Oral Dosage Forms NEVER crush sustained release, controlled release or enteric coated pills. Only scored tablets/caplets can be split. Capsules are not split. Suspensions need to be well-shaken every administration. Always check the dosage and the name indicated on the package.

10. Suppositories For Rectal Insertion Don’t forget the GLOVES! Make Sure the medicine is chilled and firm. Position patient left side lying w/ knees bent. Spread buttocks. Insert Suppository. ( 1/2- 1 inch in infants, 1 inch in adults) (Insert upon pt’s exhalation ). Hold buttocks together for a few mins .

11. Transdermal patch Apply to hair-less clean area. Make sure previous dose is removed, before applying new dose. DO NOT touch the medicated side of the path with your bare hands.

12. Opthalmic Preparations Crede’s Prophylaxis for new borns Instruct pt to look up. Expose lower conjunctival sac by pulling skin downward over the bony orbit Hold the tube above the sac and squeeze 1-2cm of ointment from inner canthus to outer canthus . Instruct pt to close eyelids to spread the medication. Instruct pt to look up. Rest hand is on patient forehead to stabilize. With dominant hand, hold eyedropper ½ to ¾ inch above the eyeball. Expose lower conjunctival sac with non-dominant hand. Administer the drops into center of the lower conjunctival sac. If the patient blinks and the drops land on the outer lid or eyelash, repeat the procedure

13. Otic Preparations Make sure the drug to be instilled is not cold . Straighten auditory canal. Pull pinna upward and backward for patients over 3 years . (Downward and backward otherwise.) Pt is to remain side lying for 5 mins after the medication is given.

14. Inhalers Spacer - an add-on device used to increase the ease of administering aerosolized medication from an MDI

15. Nasal Dosage Forms

16. Nebules

17. Topical Preparations CREAM OINTMENT GEL LOTION LINIMENT AEROSOLIZED SPRAY

18. Parenterals

19. Routes of Medication Administration

20. Importance of ROA: The route of administration (ROA) have a profound effect upon the speed and efficiency with which the drug acts.

21. ROUTES OF MEDICATION ADMINISTRATION

22. a. ORAL Route ADVANTAGES DISADVANTAGES Most convenient Can be less ef ficient or less effective - only part of the drug may be absorbed -destruction of drugs by gastric acid and digestive juices Can be self-administered First-pass effect - drugs absorbed orally are initially transported to the liver via the portal vein Pain -free GI irritation - nausea and vomiting Usually less expensive Slower effect- unable to be used for emergencies Can not be administered to an unconscious patient Unpleasant taste

23. b . SUBLINGUAL/ BUCCAL ADVANTAGES DISADVANTAGES EXAMPLES Rapidly absorbed by sublingual mucosa More potent than oral route Drug must remain under the tongue until dissolved and absorbed. Quick Termination May cause irritation to the oral mucosa. No First-Pass effect Can be uncomfortable Economical Works only for certain types of drug preparations Easier to take for people who have problems swallowing Eating, drinking, or smoking, can affect how the drug is absorbed and how well it works. ACE inhibitors CCB’s Nitroglycerin Others: - steroids -clonidine -certain barbiturates -enzymes -vitamins -some medications for mental health conditions

24. c . RECTAL ADVANTAGES DISADVANTAGES EXAMPLES Little or no first-pass effect Discomfort Can be used in a vomiting/unconscious pt. Erratic absorption ; dose absorbed is unpredictable Drug released at a slow steady state Can cause mucosal irritation Can be used to provide local therapeutic effect Limited use Suppositories Enemas Some tablets* when needed

25. *others: Morphine Sulfate tablet Misoprostol ( Cytotek ) tablet

26. Parenteral Route Defined as other than through the alimentary or respiratory tract ; that is, by needle or catheter - generally interpreted as relating to injecting directly into the body, bypassing the skin and mucous membranes.

27. d . INTRAMUSCULAR- (into a muscle) Can administer larger volume than SQ Drug is rapidly absorbed Can produce pain/anxiety

28. An adult with well-developed muscles : up to 3mL of medication in the gluteus maximus and gluteus medius muscles * Less-developed muscles: 1-2mL Deltoid muscle: 0.5-1.0 mL

29. What syringe to use? Usually 3-5 mL (depends on the amount of medication) Needle: usually 1 ½ inches, #21 or #22 or #23 gauge

30. May vary with different brands/ country Check individual packaging

31. Factors considered in choosing needle length and size: The muscle Deltoid-smaller needle #23-#25; 1 inch long Type of Solution (viscosity) More viscuous - larger gauge (#20 gauge) The amount of adipose tissue covering the muscle Very obese pts - longer than 1 ½ inch may be required Client age

32. Sites for IM injection: Deltoid Site Ventrogluteal Site Vastus Lateralis Rectus Femoris Site Dorsogluteal Site (LOCATING THESE WILL BE INCLUDED IN THE RETDEM)

33. ***Must inject away from BLOOD VESSELS NERVES BONE

34. Contraindications for use of specific site Tissue Injury Presence of nodules , lumps , abscesses , tenderness or other pathology They can interfere with maximal absorption

35. Locating the Deltoid Site Place 4 fingers from the acromion process The top of the axilla marks the lower border of the landmark A triangle within these boundaries indicates the deltoid muscle about 5 cm (2 in.) below the acromion process

36. Tip!

37. Relatively small– No more than 1mL Very close to the radial nerve Often used in adults-rapid absorption

38. Drugs commonly injected at the Deltoid Site Tetanus Toxoid ATS (Anti Tetanus Serum) Rabies vaccine (pre exposure) Flu Vaccine Hep B Vaccine Paracetamol IM HNBB IM Streptomycin IM (for TB)-common though not ideal for this site*

39. Review!

40. Locating the Ventrogluteal Site Assist pt to side-lying position with the knee slightly bent toward the chest. Place the heel of your hand on the greater trochanter with the fingers pointing toward the client’s head. The right hand is used for the left hip and vice-versa. With the index finger on the client’s anterior superior iliac spine, stretch the middle finger dorsally (towards the buttocks), and place it just below the crest of the ilium. The triangle formed by the index finger, the third finger and the crest of the ilium is the injection site.

41. The ventrogluteal site is in the gluteus medius muscle Preferred site of IM injections because the area: Contains no large nerves or blood vessels Provides the greatest thickness of gluteal muscle consisting of both the gluteus medius and gluteus minimus Sealed off by bone Contains consistently less fat than buttock area , thus eliminating the need to determine the depth of subcutaneous fat It is the safest choice for an IM injection of more than 1ml in clients older than 7 months

42. Locating the Dorsogluteal site Find the trochanter. Find the posterior superior iliac spine. Draw an imaginary line between the two bones. After locating the centre of the imaginary line, find a point one inch toward the head. This is where to insert the needle

43. (Alternative way)

44. Risks associated with an IM injection to the dorsogluteal site Contact with sciatic nerve Contact with the superior gluteal artery Too much fatty tissue – poor absorption rates.

45. Drugs commonly administered in the AG and DG sites Large-volume injections (3 mL or greater) MgS04 injection Antibiotics

46. Locating the Vastus Lateralis Site Let the client assume a back-lying or a sitting position for an injection into this site. Divide the area between the greater trochanter of the femur and the lateral femoral condyle into thirds Select the middle third .

47. The vastus lateralis muscle is usually thick and well developed i n both adults and children. Site of choice for intramuscular injections for infants 1 year and younger No major blood vessels or nerves i n the area- desirable for infants whose gluteal muscles are poorly developed. It is situated on the anterior lateral aspect of the infant’s thigh The middle third of the muscle is suggested as the site.

48. Z-track IM injection Method used for tissue irritating drugs Seals medication in the muscle Using the ulnar side of the non-dominant hand, pull the s kin ~2.5 cm to the side. Dart the needle at 90 degree angle.

49. e . INTRADERMAL - Administration of drug into the dermal layer of the skin) -Useful for allergy testing and TB screening -Common site: inner forearm -other sites: upper chest, at the back beneath the scapulae - Inject making ~0.5mm wheal of the drug (diluted if to be tested)

50. Drugs Commonly given ID BCG Vaccine ANTRI RABIES (Post Exposure) PPD (for Mantoux Test)

51. f . SUBCUTANEOUS Common SQ meds: -INSULIN -MEASLES VAX (not MMR)

52. - Assess RBG or CBG before administering insulin. - DO NOT massage the area after insulin injection! -Use dry cotton ball or swab to apply gentle pressure after injection. - Rotate sites to prevent lipodystrophy .

53. g . INTRAVENOUS Appropriate when a rapid effect is required Appropriate when medications are too irritating to tissues to be given thru other routes Avoids discomfort of repeated injection when an IV line is already established. Large-volume administration can be done.

54. Methods to administer medications thru an IV line Large volume infusion Intermittent intravenous infusion ( piggyback) Volume-controlled infusion ( Soluset ) Intermittent injection port ( Heplock )

55. Any questions?

56. PROCEDURES # dizizitpansit ID IM

57. Speed tip! “UNIVERSAL” STEPS that must be constantly observed in every procedure: HANDWASHING ASEPTIC TECHNIQUE PREPARATION OF MATERIALS and SUPPLIES needed SELF INTRODUCTION AND PATIENT IDENTIFICATION EXPLAINING THE PROCEDURE TO THE PATIENT/ GUARDIAN AFTER CARE

58. ADMINISTERING ID INJECTION Check and confirm drug to be administered and the Basic 5 Rs . Wash and dry hands thoroughly. 3. Gather all the necessary articles: Sterile medication (ampule or vial) Syringe and needle appropriate of size for the amount of solution to be administered Aspirating needle(s) 1 cc syringe Sterile water for dilution Alcohol/ cotton Clean gloves Micropore , bandage scissors

59. 4. Prepare the drug to be tested by dissolving the solute with its corresponding solvent. 5. Aspirate 0.9 cc of distilled water using another aspirating needle into the 1cc syringe. 6. Remove excess solution or air bubbles from the prepared 0.9cc distilled water. 7. Aspirate 0.1cc of the drug to be tested without pushing the plunger and introducing distilled water into the ampule. 8. Make sure that the medicine is evenly distributed by pulling down the plunger and carefully tilting the tuberculin syringe upwards and downwards.

60. 9. Change the aspirating needle with gauge 25 needle , carefully setting aside the used aspirating needle by returning its cover. 10 . Remove excess air bubbles from the syringe of the prepared mixture for testing. 11. Identify the client using the appropriate technique 12. Explain/inform the client about the procedure to be done. 13. Cleanse the site with wet cotton balls using circular motion ; observes aseptic technique. 14. Hold the skin taut. 15. Insert needle, bevel up at a 10-15 degree angle, outline of needle under skin should be visible. 16. Inject medication slowly to form a wheal(at least 0.01ml)

61. 17. Remove needle slowly and do not recap the needle (or by fishing technique) and disposes to sharps container 18 . Do not massage the area; instruct patient not to do so. 19. Encircle wheal using black or blue ink. 20. Instruct client about signs and symptoms to be observed within 30 mins from injection. Instruct to avoid scratching the area. 21. Return materials and discards used disposable materials properly . 14. Return after 30 minutes to evaluate result and record it.

62. ADMINISTERING IM INJECTION Check and confirm drug to be administered and the Basic 5 Rs . Wash and dry hands thoroughly. 3. Gather all the necessary articles: Sterile medication (ampule or vial) Syringe and needle appropriate of size for the amount of solution to be administered Aspirating needle 3 cc syringe (for Deltoid site) Sterile water for dilution (if necessary) Alcohol/ cotton Clean gloves Micropore , bandage scissors

63. 4. Disinfect the top vial with the cotton ball with alcohol. 5. Attach the aspirating needle to the syringe and set aside the needle for injection on the tray. 6. Remove needle cap and pull back plunger up to the level of desired amount of the drug . 7. Insert needle into the vial and inject air equal to the amount of the solution to be injected. 8. Extract or aspirate the desired amount of solution. 9. Change the aspirating needle with the appropriate injecting needle.

64. 10. Expel remaining b ubbles from the syringe. 11. If medication is not entirely used, return vial to storage with proper labels (date patient name, time, dilution and remaining medication) or discard if used completely 12. Take prepared medication together with wet and dry cotton balls and the syringe to the patient. 13. Correctly identify the patient. 14. Explain medication’s action and the procedure to be done 15. Cleanse the injection site with a wet cotton ball in a circular motion from inner to outer. Prepare dry cotton ball in hand.

65. 17. Withdraws the needle immediately presses the injected area with dry CB 18. Grasp (deltoid) muscle with free hand (usually non-dominant hand). 19. Inject needle at a right angle. 20. Release grasp on muscle and support the needle hub. 21. Aspirate by slightly pulling back plunger to check if there’s no vein or by blood vessel that is hit. 22. Inject the drug slowly by pushing the plunger (if there is no blood aspirated). If blood appears in the barrel, withdraw syringe/needle immediately. 23. D o the a fter- care. Document.

66. TIPS!!! Facilitate muscle relaxation by positioning client correctly. Do not use the syringe used in aspirating from vial for injecting. Avoid injecting into sensitive or hardened skin. Use needle long enough to reach muscle (determine length according to bulk of adipose tissue)

67. TIPS!!! “Dart” needle quickly into muscle Use smallest gauge possible (unless a very viscous drug is injected) Inject medication slowly Do not move needle once inserted. Withdraw needle quickly at the same angle.

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