unit -VIII introduction to clinical pharmacology.pptx

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 . Drug is a any substance that alters physiological function with the potential for affecting health.

Pharmacokinetics - It is the process by which a drug moves through the body and eventually eliminated. It refers to the drug’s activity from the time it enters the body until it leaves. It has four parts- absorption, distribution, metabolism and excretion. Absorption is the process by which a drug enters the blood stream. Distribution is the process by which the medication is delivered to the target organ, cell and tissue. Metabolism is the process of deactivation of the drug in the body. Excretion is the process of removing of drug or its metabolite from the body .

Pharmacodynamics It refers to the physiological and biochemical effect of a drug on the body. Most of the drugs interact with a cellular component to initiate a series of biochemical and physiological effects which can be local or systemic. Effects of the medication administered are monitored by client’s clinical condition and laboratory measurements

The written direction for the preparation and administration of a drug is called a prescription .

Purpose of medication th e se a n y D r u g s can b e adminis t e r ed f or purposes: Diagnostic purpose : to identify disease Prophylaxis : to prevent the of disease. heparin to prevent thrombosis occ u r r ence eg :- or antibiotics to prevent infection. Therapeutic purpose : to cure the disease.

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.

T r eatmen t - 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

Clients Right for medication administration Information Refused Careful assessment Informed consent Safe administration Supportive therapy No unnecessary medication

Special considerations Infant and children – -Based on child’s weight - Special concern for neonate Geriatric patient – -Physiological effect of aging -low dose, misuse Pregnant women

Prescription :- A prescription is a legal order for the preparation and administration of a medication. Certain medications require medical supervision because of dangerous side effect. prescription include medication order as follows- Clients name Identification or medical number Medication name Amount and dosage Route of administration Signature of prescriber Date and time

Legal Aspects of Medication Preparation, dispensing and administration of medications are all covered by laws in every country. Dangerous Drug Act – 1930 and The Narcotic Drugs and Psychotropic Substances Act - 1985. It is an act that governs the procurement and use of some drugs especially the narcotics e.g. morphine, pethedine, cocaine etc. These drugs are prescription only drugs hence cannot be bought or administered without prescription. Dangerous drugs are always kept under lock and key in the Dangerous Drug Cupboard under the care of trusted senior nurses.

It is worth knowing that nurses are responsible for their own actions regardless of the presence of a written order. If a nurse gives an overdose of a drug because it is written by a doctor, the error is accounted to the nurse and not the doctor. The nurse should bear in mind that ALL substances are poisons: there is none that is not a poison. The right dose differentiates a poison from a remedy.

Drug nomenclature I s a term that shows the drug that how can we divide or how can we give a name to a drug and how a drug get a name. This is a process or a method by which we can clarify that, it is the particular drug having a particular name. This technique helps to divide or differentiate between the two similar drug by this we can easily identified the drug with the help of molecular structure, Official name or brand name and other street names. eg . Ethyl alcohol is a chemical name for ethanol(the brand name) some time it is also called as alcohol(street name).

The first is the chemical name, and is the name used by chemists to describe the chemical structure. The second name is the generic , and this is the one used by pharmacologists. The trade name is used by the pharmaceutical companies.

Classification of Medication Medications may be classified according to: The body system that the medicine is targeted to interacts wit; e.g. cardiovascular medications, nervous system medication etc. Therapeutic usages of the medicine; e.g. antihypertensives ,neuroleptics, The diseases the medicine is used for; e. g. anticancer drugs, antimalaria drugs antihelminthics etc.

The action of the medication can also be used to classify the it; e.g. beta-adrenergic blocking agents The overall effect of the medication on the body can also be a criteria for its classification; e.g. sedatives, antianxiety drugs etc.

Storage of Medications Medications are dispensed by the pharmacy to nursing units. Once delivered, proper storage becomes the responsibility of the nurse. All medications must be stored in a cool dry place (usually in cabinets, medicine carts or fridges)

All medications must be stored in a cool dry place (usually in cabinets, medicine carts or fridges)

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.

Cupboard II -contains drugs for internal use only e.g. tablets, 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.

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.

Storage system of medication When the medications are stocked in nursing unit, the nurse has the responsibility to take care of the medication. Certain guidelines for safe medication storage are as follows……………….. Cabinet--- Store all medications according to the classification in a locked, secure cabinet or container. Place the locked cabinet in bright and ventilated place to check and identify easily, but should be free of direct shine and keep it clean, tidy and dry.

A special nurse in charge carries asset of keys for the cabinet. And the nurse checks the quantities and the qualities of the medications regularly Replenish the stock medication following the policies of institution and discard the medication with problems

Placement of medications--- Store and place the medications separately according to their different routes of administration (oral, injection, or topical), toxicity and whether to be used for mental diseases or not, with clear indication. Expensive drugs, narcotics and virulent toxicants must be taken charge of by a special nurse who should lock the cabinet and have the key always with her. On every shift, the nurse going off duty counts all medications, especially narcotics and virulent toxicants, with the nurse coming on duty. Both nurses sign the medication record to indicate that the count is correct

Label the container of medications clearly Different medications should be labeled with different colorful strips. Blue strip labels oral medications, red strip labels external medications and black strip labels virulent toxicants. Keep each medication in its original labeled container, and keep the labels and specifications legible. If the labels are soiled or illegible, discontinue using the medications. In addition, label drug name, concentration and dosage.

Check the medications carefully--- Check the nature of medications carefully. Discontinue using the medications if they become deposited and cloudy, smell abnormal, change color . Store the medications properly according to their different nature .

Nurses responsibility in storage and maintenance of drugs To stock the medicines, each ward should be provided with a medicine cabinet. It should be large enough to accommodate all drugs to be stocked in ward. As far as possible, the medicine cabinet should be kept in a separate room adjacent to the nurse’s room. A washing sink with running water should be provided in that room for hand washing facilities. Adequate lighting should be provided within the cabinet to read the labels clearly. There should be separate compartments for different categories of drugs – for mixtures, tablets, powders etc. drugs used for external use should be kept separate from the drugs used for internal use.

The containers should be arranged alphabetically, so that it is easy to find them. Poisonous drugs should be kept in a separate cupboard which must have separate lock and key. A senior nurse should be responsible for the poisonous medicines in the cupboard. A register should be maintained to keep the account of the poisonous drugs. A daily inventory should be taken to prevent theft of narcotics. All the poisonous drugs should be marked ‘poison’ in red ink.

No drug should be stored without labels, even for a day. All the containers should have labels written neatly and legibly. The labels should contain the name of the drug, the ingredients, the strength, the dose etc. All medicines containers should be kept closed always. The containers keeping the capsules, alcoholic preparations drug should have airtight caps. The tablets and pills tend to disintegrate if exposed to air The drugs that are unusual in color, odor, and consistency should be returned to the pharmacy and replaced with fresh ones. Check the expiry date of every drug and make use of it before its expiry date is over or send it to the dispensary and get it replaced.

The drugs which are destroyed in the room temperature such as vaccines, sera, antibiotics etc., should be kept in the refrigerators. Emergency drugs should be kept in a place where they are readily obtainable for emergency use When indenting for drugs, indent only the required quantity. The request for new supply of medicines should be signed by the ward sister. All medicines should be checked and signed as they are received from the dispensary.

The medicines cabinet should always be kept neat and clean and all equipment's should be kept clean and dry after their use. The medicine cabinet should be kept locked and the key should be kept where only doctors and nurses have access to it. The only medicines should be kept in a separate tray or on a piece of waterproof paper to prevent soiling the shelf. Special oil cups or spoons are used which are helpful in keeping the oily odors away from medicine glasses.

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.

Rights of Medication Administration Medication errors can be detrimental to patients. 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.

2. Right Medication : Beware of same and similar first and surnames to prevent the error of administering one person’s medication to another and vice versa. 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.

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 should also be adhered to because it is important for many drugs that the blood concentration is not allowed to fall below a given level and for others two successive doses closer than prescribed might increase blood concentration to a dangerous level that can harm the patient.

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.

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.

6. Right to information on drug/client education The patient has the right to know the drug he/she is taking, desired and adverse effects and all there is to know about the medication. The charter on patient’s right made this clear.

7. Right to Refuse Medication The patient has the right to refuse any medication. However, the nurse is obliged to explain to patients why the drug is prescribed and the consequences refusing medication.

8. Right Assessment Some medications require specific assessment before their administration e.g. checking of vital signs. Before a medication like Digoxin is administered the pulse must be checked. Some medication orders may contain specific assessments to be done prior to medication

9. Right Documentation a f t er Docum e ntatio n s ho u l d b e done medication and not before.

10. Right Evaluation Conduct assessment to ascertain drug action, both desired an side effect.

Medication order The drug order, written by the physician, should has 7 essential parts for administration of drugs safely. Patients full name. Date and time. Drug name. Dosage. Route of administration. Time and frequency of administration. Signature of physician.

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.

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,” which means “as the thing is needed.” 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)

Terminologies and abbreviations used in prescriptions of medications

Abbreviations Meaning STAT order refers to any medication that is needed immediately and is to be given only once often associated with emergency medications that are needed for life-threatening situations comes from the latin word "statim" meaning immediately should be administered within 5 minues or less of recieving the written order ASAP order not as urgent as STAT as soon as possible should be avaliable for administration to the patient with 30 minutes of the written order Single order for a drug that is to be given only once, and at a specific time, such as a preoperative order PRN order latin "pro re nata" administered as required by the patient's condition the nurse makes the judgement, based on patient assessment, as to when such a medication is to be administered

Abbreviations Meaning Routine orders orders not written as STAT, ASAP, NOW or PRN these are usually carried out within 2 hours of the time the order is written by the physician Standing order written in advance of a situation that is to be carried out under specific circumstances. standing orders are no longer permitted in some facilites because of the legal implications of putting all patients into a single treatment category ac before meals AM morning bid twice per day Cap capsule

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

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 ad lib as desired, as directed tab tablet

alt. h. aq. c¯ dil. dist. DS EC fl d g gr alternate hours Water With Dilute Distilled Double strength enteric coated Fluid Gram grain IVP IV push PO By mouth inj. injection oz. Ounce s¯ Without qt. quart SQ Subcutaneous PR rectally, per rectum

stat . -immediately, at once tab. - tablet Tbsp . - tablespoon Tds ., tid . - three times a day Tinct. Tr. -tincture tsp, t – teaspoon

Drug forms Medications a r 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.

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

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.

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.

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.

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)

Transdermal patch : Unit dose of medication applied directly to skin for diffusion through skin and absorption into the bloodstream. Syrup -an aqueous solution of sugar often used to disguise unpleasant taste of drugs. Tincture - an alcoholic or water and alcohol based solution prepared from drugs derived from plants.

Aerosol spray or foam- A liquid, powder or foam deposited in a thin layer on the skin by air pressure. Aqueous solution -one or more drugs dissolved in water. Aqueous suspension -one or more drugs finely divided in a liquid such as water. Caplet -Tablet coated with gelatin that gets dissolved in the stomach. Pill -one or more drugs mixed with cohesive material in oval, round or flattened shapes.

Cream- a non -greasy, semisolid preparation used on the skin. Elixir –a sweetened and aromatic solution of alcohol used as a vehicle for medicinal agents Extract – a concentrated form of a drug made from vegetables or animals . Liniment –a medication mixed with alcohol, oil, or soapy emollient and applied to the skin Paste -a preparation like an ointment but thicker and stiff that penetrates the skin less than an ointment

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

Oral route Oral route : Medications are given by mouth. Sublingual Administration: Some medications are readily absorbed when placed under the tongue to dissolve. Buccal Administration: Administration of a medication by placin g i n th e mout h a g a in s t the muc o u s memb r ane s of th e cheek until it dissolves.

Parenteral Routes P a r en t e r al R ou t e s : P a r e n t e r 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.

in t o b o d y S o m e m edic a ti o n s a r e adminis t e r e d cavities. These additional routes include Epidural Intrathecal Intraosseous Intraperitoneal Intrapleural Intraarterial

Epidural: Epidural medications are administered in the epidural space. Intrathecal : Administration of medications into subarachnoid space or one of the ventricles of the brain.

Int r ao s s eou s : A dminis t r atio n of medication directly into the bone marrow. Int r a peri t one a l : Medic a tion s a d minis t e r ed 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. Int r aa r t eri a l : Int r aar t e r ial med i cations a r e administered directly into the arteries.

Topical Routes Topical: Medications applied to the skin and mucous membranes (eye, ears, nose, mouth, vagina, urethra, rectum) .

Inhalation Route: Administer inhaled medications through the nasal and oral passage s or endot r achea l or t r a c heos t o m y tubes.

Insertion--- Insertion means introducing solid forms of drug into the body orifice e.g., suppositories are introduced into the rectum and vagina Insufflations--- it is the administration of drug in the form in the of powder, vapour or air into a wound or body cavity by blowing with an insufflators Implantation--- It means planting or putting in of solid drug into the body tissues

Route Advantages /Disadvantages Oral-advantage- • Easy • Preferred by patients • “Slow-release” preparations may be available to extend duration of action • Drugs can be formulated in such a way as to protect them from digestive enzymes, acid, etc Oral-disadvantage - Unsuitable in patients who are uncooperative, strictly “nil by mouth”, are vomiting profusely • Most orally administered drugs are absorbed slowly • Unpredictable absorption due to degradation by stomach acid and enzymes

Rectal advantage --- Good absorption Rectal disadvantage – May not be suitable after rectal or anal surgery • Some patients dislike suppositories Subcutaneous or intramuscular- advantage Good absorption, especially for drugs with a low oral bioavailability • Onset is more rapid than the above routes • Depending on formulation can have very long duration of action. eg:antipsychotics and contraceptives

Subcutaneous or intramuscular- disadvantage • Absorption may still be unpredictable if peripheries are poorly perfused • Injections hurt, cause bruises and frighten children and needle phobics Intravenous-advantage • Dependable and reproducible effects Entire administered dose reaches the systemic circulation immediately the dose can be accurately titrated against response . Intravenous-disadvantage Requires a functioning cannula • More expensive and labour intensive than other routes. • Cannulation is distressing to some patients, especially children • Cannula are prone to infection • IV injection of drugs may cause local reactions

Topical –advantage --- • Easy • Non-invasive • High levels of patient satisfaction Topical –disadvantage--- • Most drugs have a high molecular weight and are poorly lipid soluble, so are not absorbed via skin or mucous membranes • Very slow absorption Inhaled-advantage • Very rapid absorption due to the huge surface area of the respiratory endothelium

• Bronchodilators and inhaled steroids can be targeted to lungs with low levels of systemic absorption Inhaled-disadvantage • Bioavailability depends on patient’s inhaler technique and the size of drug particles generated by the delivery technique

Broad classific a ti o n of drugs.

Drugs may be classified according to their chemical composition, clinical action ,therapeutic effects by the symptoms relieved by the drugs

Analgesic s : 🞇 Drug used to relieve pain.

Anestheti c : 🞇 An anaesthetic is a drug used to induce anesthesia - in other words, to result in a temporary loss of sensation or awareness.

Anthel m i n ti c : 🞇 A n tihelminthics are a group of antiparasitic drugs that expel parasitic worms (helminths) and other internal parasites from the body by either stunning or killing them and without causing significant damage to the host.

Antipyretic s : 🞇 Antipyretics are substances that reduce fever.

Antidotes: 🞇 An antidote is a drug, chelating substance, or a chemical that neutralizes the effects of another drug or a poison.

Anti-infective: 🞇 Act either to inhibit, kill or retard the growth of micro-organism.

Ant i -infl a mmatory: 🞇 Ant i -i n f l amma t or y , i s t h e or property of a substance treatment that reduces inflammation or swelling.

Anti coagulant: 🞇 Anticoagulants, commonly referred to as blood thinners, are chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time.

Anti histamine: 🞇 A drug or other compound that inhibits the physiological effects of histamine, used especially in the treatment of allergies.

Antacids: 🞇 An antacid is a substance which neutralizes stomach acidity and is used to relieve heartburn, indigestion or an upset stomach.

Anticonvulsants: 🞇 Anticonvulsants are a diverse group of pharmacological agents used in the treatment of epileptic seizures

Antibiotic 🞇 An antibiotic is a type of antimicrobial substance active against bacteria and is the most important type of antibacterial agent for fighting bacterial infections.

Anti-diarrhetics/ anti-diarrhoeal : 🞇 An ant i diar r hoeal drug i s an y medicat i on which provides symptomatic relief for diarrhoea.

Antitussi v e : 🞇 Antitussives are medicines that suppress coughing, also known as cough suppressants.

Anti asthmatics: 🞇 Drug which provide symptomatic relief of asthmatic attack by relaxing the smooth muscle of the bronchioles.

Androgens: 🞇 An androgen is any natural or synthetic steroid hormone which regulates the development and maintenance of male characteristics

Antipruritics: 🞇 Ant i prur i tics, al s o k n own a s ant i - itch d r ugs, are medications that inhibit the itching.

Antisepti c : 🞇 Antiseptics are antimicrobial substances which inhibits the growth of micro organism.

Anti fungal : 🞇 It is a pharmaceutical fungi static used to treat and prevent growth of fungal infection.

Antispasmo d ic: 🞇 An a n ti s p a s modic is a pharmaceutical drug or o t her a g ent th a t suppresses muscle spasms

Antiem e ti c : 🞇 An antiemetic is a drug that is effective against vomiting and nausea.

Anti tubercular: 🞇 Specific drug is used in treatment of Tuberculosis (TB)

Antirheumati c : 🞇 Drug is used to t r eat rheumatism.

Bronchodil a tors: 🞇 A bronchodilator is a substance that dilates the bronchi and bronchioles, decreasing resistance in the respiratory airway and increasing airflow to the lungs.

Coagulan t s: 🞇 An agent that produces coagulation (Coagulation is a complex process by which blood forms clots).

Corticosteroi d s: 🞇 Corticosteroids are used to provide relief for inflamed areas of the body. They lessen swelling, redness, itching, and allergic reactions.

Diaphoretic s : 🞇 Drug which increase the action of sweat gland and induce perspiration.

Diuretic: 🞇 A diur e tic is any substance that promotes diuresis, the increased production of urine.

Emetics: 🞇 a medicine or other substance which causes vomiting.

Oxytoci c s: 🞇 Drug that stimulates uterine co n tractures.

Expectoran t s: 🞇 A medication that helps bring up mucus and other material from the lungs, bronchi, and trachea.

Emollient: applied 🞇 Emollients are moisturising treatments directly to the skin to soothes and hydrate it.

Hypnotic s : 🞇 Hypnotic drugs, commonly known as sleeping pills, are a class of psychoactive drugs whose primary function is to induce sleep and to be used in the treatment of insomnia, or for surgical anesthesia.

Hemos t as i s : 🞇 Hemostasis or haemostasis is a process which causes bleeding to stop.

Hypotensive: 🞇 Any substance capable of lowering blood pressure.

Hypoglyc e mic: 🞇 That lower blood sugar level.

Inotrope s : 🞇 Drug that strengthen cardiac contraction.

Mydriatic s : 🞇 Mydriatics are a type of medicine that make the pupil of the eye dilate (open up)

Myotic s : 🞇 A drug that causes constriction of the pupil of the eye

Sedatives: 🞇 Sedatives are a category of drugs that slow brain activity. Lowering body activity.

Vasodilators: 🞇 Vasodilators are a group of medicines that dilate (open) blood vessels, which allows blood to flow more easily.

Vasoconstriction: 🞇 It causing the constriction of blood vessels, which increases blood pressure.

Types of Medication Action Therapeutic Effects Side Effects/Adverse Effects Toxic Effects Allergic Reactions Idiosyncratic Reactions

Therapeutic Effects: The therapeutic effect is the expected or predicted physiological response that a medication causes. Eg: paracetamol reduces pain, fever and inflammation Side Effects/Adverse Effects: Every medication cause some harm to patient. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic dose. Eg: nausea, loss of appetite, stomach pain Adverse effects are undesirable and unpredictable severe responses to medication.

Toxic Effects: Toxic effects develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. Eg: liver damage or kidney damage Allergic Reactions: unpredictable immunological responses to a medication. Eg: paracetamol produces rash or swelling as allergic reaction.

Idiosyncratic Reactions: a patient overreacts or underreacts to a medication or has a reaction different from normal. For eg : a child who receives Benadryl becomes extremely agitated or excited instead of drowsy . Drug interaction : It occurs when a medication effects are altered by the concurrent presence of other medications or food substances. Drug interactions are changes in a drug’s effects due to recent or concurrent use of another drug or drugs , ingestion of food or ingestion of dietary supplements. Drugs with similar properties are taken at the same time and have additive effects ..

DRUG TOLERANCE It occurs when a client develops decreased response to a drug, requiring increased dosages to achieve the therapeutic effects Drug tolerance is basically the body's ability to adapt to the presence of a drug. Tolerance may be defined as a state of progressively decreased responsiveness to a drug as a result of which a larger dose of the drug is needed to achieve the effect originally obtained by a smaller dose

Systems of drug measurement A system of measurement: A system of measurement is a collection of units of measurement and rules relating them to each other. System of measurement have historically been important regulated and defined for the purpose of science. Medication are measured using three different systems which are :- The Metric System The Apothecary System The Household System Solutions system All three systems have three basic types of measurement in common and they are Weight , Volume , Length. Weight and volume are the two types of measurements you will use most often when administering medication

Metric system : The metric system of measurement is the most widely used system of measurement in the world. It is devised by the French in the latter part of the 18 th century , is the system prescribed by law in most European countries and in Canada. It is the preferred system for administering medication, because it is based on a series of 10 measures or multiples of 10. It is a simple and accurate form of measurement used by health care professionals. In this system, metric units are used. Eg: milligram, gram, milliliter, liter etc . Metric Weight Measures :- 1kilogram (kg, Kg) = 1000grams or 1000g

Household system : Household measures include drops, teaspoons, tablespoons or cups for measuring medications. Their disadvantage is their inaccuracy. Household utensils such as teaspoons and cups vary in size.

E g : Metric system Household system 1 ml 15 drops 5 ml 1 teaspoon 15 ml 1 tablespoon

Apothecary system : The Apothecaries system of measurement is the oldest system of drug measurement. It is brought to the United State from England. In fact, it was the first system used to measure medication amounts. It is infrequently used as a drug measurement. The basic unit of weight in the apothecaries system is the grain likened to a grain of Wheat. The basic unit of volume is the minim , a volume of water equal in weight to a grain of wheat. The word minim means “the least.”

There are a few medication that are still measured in grains (gr). To ensure administration of the correct dose of medication to a patient, it is important to know the conversion of grains to milligrams and how to convert from one system of measurement to another

E g : Metric system Apothecary system 1 mg 1/60 grain 60 mg 1 grain 1 g 15 grains 4 g 1 dram 30 g 1 ounce 500 g 1.1 pound (lb) 1 ml 15-16 minims 5 ml 1 fluid dram 30 ml 1 fluid ounce 500 ml 1 pint 1 L 1 quart 4 L 1 gallon

Solutions : A solution is a given mass of solid substance dissolved in a known volume of fluid or a given volume of liquid dissolved in a known volume of another fluid. For example, a 10% solution is 10 g of solid dissolved in 100 mL of solution.

Converting Measurements Units Sometimes drugs are dispensed from the pharmacy in grams when the orders specifies milligrams, or they are dispensed in milligrams though ordered in grains. Conversion within one system Conversion between systems Dosage Calculation

Conversion within one system To convert measurements within one system simply divide or multiply. Eg: To change milligrams to grams, divide by 1000, moving the decimal 3 points to the left. 1000 mg 350 mg = 1 g = 0.35 g

Conversion Between Systems To convert measurements from one system to another system the nurse should be familiar with the equivalent values of all the systems.

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

The Ratio and Proportion Method: A ratio indicates the relationship between two numbers separated by a colon (:). For example, the ratio 1 : 2 is the same as 1/2. Write a proportion in one of three ways: Example 1: 1:2 = 4:8 Example 2: 1:2 :: 4:8 Example 3: 1/2 = 4/8

In a proportion the first and last numbers are called the extremes , and the second and third numbers are called the means. When multiplying the extremes, the answer is the same when multiplying the means .

Formula methods

Several formulas can be used to calculate drug dosages. One formula uses ratios : mcg/min formula: dose on hand = desired dose quantity in hand quantity desired for eg ; erythromycin 500mg is ordered. It is supplied in a liquid form containing 250 mg in 5 ml. to calculate the dosage, the nurse uses the formula dose on hand (250 mg ) = desired dose (500mg ) quantity on hand (5 ml) quantity desired (x) Then the nurse cross- multiplies: 250x = 5ml×500mg X =5ml ×500mg x= 10 ml 250 mg Therefore, the dose ordered is 10ml.

The nurse can also use this formula to calculate dosages: Amount to administer (x) = desired dose × vehicle = amount to give dose on hand For example, heparin is often distributed in vials in prepared dilutions of 10000 units per milliliter. If the order calls for 5000 units, the nurse can use the formula to calculate x= 5000 × 1 x= ½ ml 10000 therefore, the nurse injects 0.5ml for a 5000 unit dose.

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 = number of tablets on the Stock strength is the amount written drug cover.

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

Calculating drip rates First convert volume to milliliters and then use this formula d rops per 𝑚𝑖𝑛𝑢𝑡𝑒 = 𝑡𝑜𝑡𝑎𝑙 𝑣𝑜𝑙𝑢𝑚𝑒 𝑡𝑜 𝑏𝑒 𝑔𝑖𝑣𝑒𝑛 ×𝑑𝑟𝑜𝑝 𝑓𝑎𝑐𝑡𝑜𝑟 𝑡𝑖𝑚𝑒 𝑖𝑛 ℎ𝑜𝑢𝑟𝑠 × 60 Drop factor is the drops per millilitre given to the patient. Drop factor for macro set is 15 and micro set is 60

Calculating dose according to body weight Total dose = prescribed dose x patient’s weight Calculating dose according to body surface area Total dose = prescribed dose x patient’s body surface area

To calculate the pediatric dosage Most of the drugs are available in the adult dose. The nurse need to know how to prepare the pediatric dosage: 1. Young’s rule : (for children over 1 year of age) up to 12 years. age of the child (in years ) × adult dose = age of the child (years)+ 12 =child ′ s dose

2 . Clark’s rule : calculated (according to the weight of the child, therefore it can be used for children of all ages). weight of the child in pounds 150 × adult ′ s dose = child ′ s dose

3. Fried’s rule : (for children under 1 year of age) age of the child (months) × adult dose 150 = child ′ s dose

FACTORS AFFECTING DRUG ACTION Body Size Pregnancy Lactation Age – Peadiatric & Geriatric Genetic Factors Disease States – Kidney & Liver Routes of Drug Administration Environmental Factors Psychological Factors Tolerance & Resistance

FACTORS AFFECTING MEDICATION ACTION Various factors affects the action of the medicine. Developmental Factors Pregnancy : Most drugs are contraindicated because of their possible adverse effects on the fetus. Infants usually require small dosages because of their body size and the immaturity of their organs.

In adolescence or adulthood, allergic reactions may occur. Oldage have different responses to medications due to aging. 2. Gender Different action can occur in men and women due to the distribution of body fat and fluid and hormonal differences.

3. Cultural, Ethnic, and Genetic Factors Genetic differences in the production of enzymes that affect drug metabolism. Cultural factors and practices (e.g . values and beliefs) can also affect a drug’s action. 4. Diet Nutrients can affect the action of a medication. For example,vitamin K, found in green leafy vegetables, can counteract the effect of an anticoagulant such as warfarin

5. Environment Environmental temperature may also affect drug activity. When environmental temperature is high, the peripheral blood vessels dilate, thus increase the action of vasodilators. A client who takes a sedative or analgesic in a busy, noisy environment may not benefit as fully as if the environment were quiet and peaceful.

Psychological Factors A client’s expectations about what a drug can do can affect the response to the medication. Illness and Disease Drug action is altered in clients with circulatory, liver, or kidney dysfunction. Time of Administration The time of administration of oral medications affects the speed with which they act.

Safety in Administering medications The safe and accurate administration of medication is one of the major responsibility of a nurse. Read the physician’s orders of the drug. If the order is not clear consult the physician. Consider the age and weight of the patient.

The nurse must have thorough knowledge of drugs that is administered by her. Look for the colour, odour and consistency of the drug before administration. Follow 10 rights and 3 checks in drug administration.

Calculate the drug dosage accurately. Identify the patient correctly. Observe for the symptoms of over dosage of the drugs before it is administered. Give the drugs one by one Stay with the patient until he has taken the medicine completely. Do not leave the medicine with the patient.

The nurse should always assess a client’s health status and obtain a medication history prior to giving any medication. The medication history includes information about the drugs the client is taking currently or has taken recently. And the history of drug allergies. The nurse should clarify with the client any side effects, adverse reactions, or allergic responses due to medications.

The nurse has to identify any problems the client may have in self-administering a medication. For example, a client with poor eyesight, may require special labels for the medication container. The nurse needs to consider socioeconomic factors for all clients. Medication errors must be reported according to the policy of the hospital.

Medication error Medication errors are unintended mistakes in the prescribing, dispensing and administration of a medicine that could cause harm to a patient.

E rror during drug administration are- Which is given not according to the order. Is administered as per the order, but is unsafe or inappropriate for the client. When documentation in a client chart does not reflect that a medication was administered as ordered. Medication was given, but not charted

Medic a tio n er r o rs can oc c u r at al l stages of t he medication administration process. The four main types of medication errors that occur with hospitalized clients: Prescription errors (eg. Wrong drug or dose) T r a nscr i p t i o n / in t erp r e t a tio n e r r o r ( e g . Misinterpretation of abbreviations) Preparation errors (eg. Calculation error) A d mi n ist r atio n er r o rs ( e g. W r o n g dose, w r o n g t i me, omission, or additional dose). Mos t m edic a ti on er r o rs oc c u r duri n g the administration stage.

Administration of I.V. medication in the wrong route. Administering medication in the wrong dose. Administering medication in the wrong time. Administering the wrong medication. Charting medication that was not given. Administering substitution medication. Failure to give medication within the prescribed time interval.

Giving a medication by the wrong route. Incorrect preparation of a drug by an incorrect route. Improper technique when administering a drug Administering medication to the wrong client. Administering drug to a client with known allergy to that drug. Giving a drug that has deteriorated

Rules For Administration of Medication Check the prescription of the drugs in the Medication Order and Drug Administration Form . Note the dose, route, time and frequency of the administration of the medication . c. Do not involve in any conversation during the preparation of the medication. d . Enquire with the patient if he has had his breakfast/ lunch/dinner prior to the preparation of the medication e. The medication will be prepared from a clearly labeled strip f. The medication will be compared THRICE with the medication order and the label on the strip, i.e.………… -Before removing from the medicine box - Before opening the strip or pouring the medication -Before replacing the strip or bottle back into the medicine box, for their generic names, dosage, expiry date and cost of the drug

g. While preparing a syrup…… -Shake the medicine in the bottle before pouring it. -Read the label for instructions on ‘shake before use’. -Use a calibrated measuring cup to pour the medicine from the bottle. - Pour the medicine from the bottle from the side opposite the label. -Hold the measuring cup at your eye level while measuring the dose of the medication from the bottle. -Once the medication is poured out of the bottle, it should not be poured back. -Wipe the mouth of the bottle and turn the cork to close the mouth of the bottle h. The nurse will check for the availability of the medication for the next administration and will document the “got over medicines” in the got over book for purchase from the pharmacy. i . Wash hands prior to medication administration or use hand rub j. The nurse will carry a clean medication tray with a duster, medicine card, containers, got- over medicine book, pen, kidney tray k. While administrating the prepared medicine, the nurse will follow the safety measures in medication administration and will identify the patient prior to the medication administration by using two patient identifiers

l. The nurse should pour the medicines into the patient’s mouth or else give the medicine cup with the prepared medicines to the patient so that he will pour it into his mouth at his convenience (one by one). Do not allow the patient to touch the medicine with his hand. Do not give the medicines in the hand of patient. m . Never give water after giving cough syrup and instruct the patient not to drink water for half hour after taking a fluid medication. n . Do not leave the prepared medicine on the locker or table of the patient. The medicine should be swallowed by the patient in your presence. o . After the medicine is administered to the patient, the nurse should document the drug administration by completing the medication order and drug administration form. p . If the patient refuses a medicine, the nurse will document the same in the medication order and drug administration form as well as inform the treating doctor. The reason for refusal should be documented in the Nurses Daily Assessment and Care Record. q . The nurse will not document the medication administration prior to administration of the medicine . r. The nurse will place a request for the got over medicines or any newly prescribed medicines through the HIS and in emergency cases through the medicine requisition form after the authorization of the treating doctor.

Precautions to be considered while administering different kinds of medicines - Follow the Food and Drug Interaction chart - Syrups should not be diluted. Tonics to be diluted with equal quantity of water. Medicines like Alkaline Citrate, Potassium Chloride liquids should to be diluted with a glass of water . - Anti emetics should be given before half hour of food. - Check vital signs before giving Cardio vascular drugs . - If patient vomits medicine, observe the vomitus and inform the ward in-charge and physician for further action. - If the patient is on a naso -gastric tube, the medicine is powdered using a mortar and pestle, dissolved in little water and administered through the Ryle’s tube. (Do not mix with the feeds).

Reporting of Errors and Adverse drug events All errors related to wrong identification of patient, wrong drug, wrong dose, wrong route, wrong frequency, and wrong documentation, wrong prescription, wrong transcription of medication order, wrongly dispensed medications, wrong dilution in case of injections will be reported in the Medication Error Reporting form and will be submitted to the Medical Superintendent. Any adverse reaction to drugs administered to the patient should be reported in the Suspected Adverse Drug Reaction Reporting Form and submitted to the Medical Superintendent

Oral drug administration: Enteral Drug Administration is : The delivery of any medication that is absorbed through the gastrointestinal tract

Oral route of administration The oral route is the easiest and the most commonly used. Medications are given by mouth and swallowed with fluid. Oral medications have a slower onset of action and a more prolonged effect than parenteral medications. Clients generally prefer the oral route.

Sublingual route of Administration Some drugs are designed to be readily absorbed after being placed under the tongue to dissolve. A drug given sublingually should not be swallowed or the desired effect will not be achieved. Nitroglycerin is commonly given sublingually. A drink should not be taken by the client until the drug is completely dissolved

Buccal Route of Administration Administration of a drug by the buccal route involves placing the solid medication in the mouth and against the mucous membranes of the cheek until the drug dissolves. Clients should be taught to alternate cheeks with each subsequent dose to avoid mucosal irritation. Clients are also warned not to chew or swallow the drug or to take any liquids with it. A buccal medication acts locally on the mucosa or systemically as it is swallowed in a person’s saliva

Oral Medication Oral medication can be by ingestion, sublingual administration (place the pill or direct spray between the underside of the tongue and the floor of the oral cavity ) or buccal (place the medication between the patient’s cheek and gum).

Oral Medication A tray or trolley should be set with: Drug to be administ ration cards Water Glass Spoons Mortar and pestle (when necessary) Towel Medication got over book Patient’s folder/treatment chart and pen

Gastric Tube Administration Gastric tubes provide access directly to the GI system.

The nurse should follow guidelines when administering oral medications. Always administer a drug with plain water instead of with tea. Never chew, crush or break sustained release tablets, enteric-coated tablets and capsules. Place lozenges under the tongue or between buccal membrane and teeth dissolved slowly rather than allowing clients to chew or swallow

Generally, stomachic medication is taken before meal, while those irritating gastric membrane taken after meal. Hypnotics is taken just before sleep. Avoid giving fluids immediately after a client swallows medication such as syrup Allow the client to drink more water after sulfonamide is taken to prevent the crystal which the drug produces when excreted through kidney with the less urine volume to block the nephrons. Observe the heart rate and rhythm closely when cardiac medication is taken. If the heart rate is lower than 60 times per minute or arrhythmia occurs, discontinue to use the drug and inform the physician

Parenteral Administration of Medications Parenteral administration of medications is the administration of medications by injection into body tissues. When medications are administered this way, it is an invasive procedure that is performed using aseptic techniques.

INJECTION The term injection is defined as the forcing of fluid into a cavity, a blood vessels, or body tissue through a hollow tube or needles. PURPOSE :- To get rapid or a systemic effect of the drug. e.g . I.V. injections. 2.To give a drug when other routes are undesirable e.g. excessive vomiting or having gastric suction. 3.To obtain local effect at the site of injection e.g . tuberculin test, etc.

GENERAL PRINCIPLES:- Parenteral medications are not without some disadvantages, which should be kept in mind when administering any injection: Aseptic technique must be maintained during the preparation and administration of the drug. The injection may be painful and the tissue damage at the injection site may be a predisposing factor to infection

An irritating or slowly absorbed drug may cause tissue necrosis, and persistent pain. It is possible for the needle to break off in the tissues. Injury to a nerve or other vital tissues may occur if the site of injections incorrectly located. Inadvertent intravenous injection of a solution not suitable for that route can have serious or even fatal consequences. Once the drug has been injected, it is difficult or impossible to recall it or to prevent it from being fully absorbed in the event of an adverse reaction developing to it.

ADVANTAGES OF PARENTERAL ADMINISTRATION An immediate physiological response can be achieved if necessary, which can be of prime consideration in clinical condition such as cardiac arrest, asthma and shock . Parenteral therapy is required for drugs that are not effective orally or that are destroyed by digestive secretions such as insulin other hormones and antibiotics. Drug for uncooperative, unconscious patients must he administered by injection

When desirable, parenteral therapy gives the physician control of the drug since the patient must return for continued treatment, also in some cases the patient cannot be relied upon to take oral administration . In case in which prolonged drug action is wanted, parenteral forms are available, including the long acting penicillin administered deep intra muscularly. Parenteral therapy provides the means of correcting serious disturbances of fluid and electrolyte balances. When food cannot be taken by mouth, total nutritional requirement can be supplied by the parenteral route

DISADVANTAGES OF PARENTERAL ADMINISTION The dosage form must be administered by trained personnel and require more time than those administered by other routes. Parenteral administration requires strict aseptic procedures . The manufacturing and packaging requirements, parenteral dosage forms are more expensive than preparations of given by other routes. Feared by adults and children. Trauma Risk of irritation/pain/necrosis at site, damage to large vessels/nerves/ soreness, and infection. Expensive

Types of parental therapies Parenteral Therapies are medications, nutrients, vitamins and other healing substances administered by injection into the body. The most common types of parenteral therapies are given intravenously, but some are administered into the muscles or under the skin . Parenteral administration of medication means any non-oral means of administration . The common parenteral routes are intramuscular (IM), subcutaneous (SC) and intravenous (IV).

Parenteral Therapies may provide benefits to people who are unable to eat or absorb nutrients from the gastrointestinal tract and those suffering from the following conditions: Infections - viral bacterial, and fungal Immune system illnesses and weakness Autoimmune conditions such as rheumatoid arthritis. Emotional struggles including anxiety, depression, stress Gastrointestinal illnesses Vitamin deficiencies

Cardiovascular illnesses Precancerous conditions Respiratory conditions including asthma and bronchitis Liver disease including hepatitis Addictions Cancer Aging Pain - including migraines and muscle spasms Toxicity Diabetes

Parenteral therapies work by several mechanisms, depending upon the substance administered and the goal of treatment. Parenteral routes of administration allow highly concentrated nutrients and medications to be administered directly into the bloodstream. Some compounds are deactivated by the gastrointestinal system and must be administered parentally in order to be effective .

Types of syringes, needles, cannulas and infusion sets PARENTERAL THERAPY EQUIPMENT AND SUPPLIES There is a multitude of equipment and supplies available for the delivery of parenteral medications. Syringes and needles come in many sizes and are selected according to the route the medication is to be given, the patient’s body size, the thickness of the medication, and the amount of medication to be given.

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

SYRINGES ; Syringes are used today are primarily made of plastic and are completely disposable. Typical syringe sizes range from 1 mL to 5 ml. Larger syringes (10 to 60 mL) are used for irrigating wounds or body cavities, drawing large amounts of blood, and for aspirating fluid from a patient’s joint or body cavity. Syringe selection is primarily based on the amount of medication to be administered. Syringes are packaged in hard plastic containers or peel-apart packages and are sealed to ensure sterility. If a syringe package appears to have already been opened, the syringe should not be used and should be disposed of properly .

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

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).

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. 5 ml syringe 3 ml syringe Tuberculin syringe Insulin syringe

Needles Needles are available in various sizes and lengths and come in disposable and non-disposable forms . Needle selection is determined by the type of medication to be administered, the route of administration, and the size of the patient. Disposable needles are more commonly used and are prepackaged in sterile plastic or paper wrappers. A needle’s gauge (G) refers to the diameter of the needle . Gauge selection is determined by the viscosity or thickness of the medication . Gauge sizes that are typically used in ambulatory care range from 20 to 27 G. The larger the gauge, the smaller the diameter of the needle (for example, a 22-G needle would be smaller in diameter than a 20-G needle).

The length of the needle is determined by the route of administration, the site of the injection, and the amount of adipose tissue over the injection site . Intra-muscular (IM) injections will require a longer needle than a subcutaneous or intradermal injection because muscles are deeper than the other two types of tissue. The location of the injection also plays a role in the selection of needle length. The deltoid and gluteal muscles are two common muscles that are used for intramuscular injections, but each muscle is a different size and at a different depth . The deltoid is smaller and more superficial than the gluteal muscle and, therefore, would take a shorter needle. Finally , the amount of adipose tissue that the patient has in the area in which the injection is being administered will also play a role in the length of the needle that is used . Patients with larger amounts of adipose tissue will require a longer needle to penetrate through the extra layers than patients with little adipose tissue.

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

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

The gauge varies from 18 to 30.Use longer needles for IM injections and a shorter needle for subcutaneous injections.

Protection from needle stick injuries, giving medications with a safety syringe. Needle Safety when Using Parenteral Equipment Needle safety is very important when working with parenteral equipment. Each unit should use safety devices to help prevent accidental needles pricks from contaminated needles. There are a variety of different types of safety devices, including retractable needles and plastic sheaths that slide down over the needle. If a dirty needle stick occurs while performing an injection, the medical assistant should wash the area immediately with soap and water and report the incident to a supervisor . An incident report should be completed and the employee should receive counseling regarding what lab testing should be performed and possible treatment options.

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.

Use appropriate puncture-proof disposal containers to dispose of uncapped needles and sharps. Never throw sharps in wastebaskets. Never recap used needles When recapping a needle, Use a one-handed “scoop” method.

This is performed by 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.

One-handed Needle Recapping Technique One-handed needle recapping is a method that place the cap to needle on clean and safe place such as inside a big tray Purpose: To prevent own finger or another person by needle from pricking accidentally. Procedure: Until giving injection: Before giving the injection, place the needle cover on a solid, immovable object such as the rim of a bedside table or big tray. The open end of the cap should face the nurse and be within reach of the nurse’s dominant, or injection hand. Give the injection.

To Recap : Place the tip of the needle at the entrance of the cap. Gently slide the needle into the needle cover. This method can allow time. Once the needle is inside the cover, use the object’s resistance to completely cover the needle. Confirm that the needle is covered by the cap. This can reduce the risk of needle-sticking. Dispose of the needle at the first opportunity. To prevent the spread of infection Perform hand hygiene. This procedure should be used only when a disposal box for sharps is unavailable and the nurse cannot leave the client’s room

Using a Medication Cartridge or an Injector Device Some medications come in sealed, prefilled glass cartridges that hold a single dose of medication. penicillin , Phenergan, are examples of medications that are available in cartridges. The prefilled cartridge–needle units require no mixing, no special calculations, and are easily administered to the patient. The cartridge needle units are designed to fit into a cartridge unit syringe, referred to as an injector device.

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.

Pen-like model

With wings model

With injection part model

Y-type model

Size of cannula

Routes of parenteral therapies Intra-dermal Subcutaneous Intramuscular Intra Venous Advanced techniques: Epidural Intra-thecal Intra-osseous Intra-peritonial Intra-plural Intra-arterial

Intradermal: The term intradermal means pertaining to within the skin. The epidermis (outer layer of the skin) is the layer of skin that is used for intradermal injections. In order for the needle to stay within this layer, the needle should be positioned at a 10° to 15° angle.

Intradermal Injections An intradermal (ID) injection is the administration of a drug into the dermal layer of the skin just beneath the epidermis. Usually only a small amount of liquid is used, for example 0.1ml. This method of administration is frequently used for allergy testing and tuberculosis (TB) screening.

Use a tuberculin or small hypodermic syringe for skin testing. The angle of insertion for an intradermal injection is 5 to 15 degrees

After injecting the medication, a small bleb resembling a mosquito bite appears on the surface of the skin.

SUBCUTANEOUS INJECTION

D e fini t ion A subcutaneous injection is an invasive method used to administer medications into a loose connective tissue just below the dermis of the skin.

Hypodermal Or Subcutaneous Injections : The term subcutaneous is a medical term that means pertaining to under the dermis (or true layer of the skin). Subcutaneous tissue is made up of fatty and connective tissue

INDICATIONS Medications that need not be absorbed quickly. Heparin administration. Diabetes mellitus. Insulin administration.

CONTRAINDICATIONS EMERGENCY CASES MALNOURISHED BURNS OPEN WOUND S LARGE VOLUME OF DR UGS

Kinds of drugs commonly administered: vaccines preoperative medications narcotics insulin heparin Only small volumes (0.5 to 1.5 mL) of medications are given subcutaneously. The angle of insertion for a subcutaneous injection is 45 degrees

Subcutaneous Injections The subcutaneous injection sites include : The outer posterior aspect of the upper arms The abdomen The anterior aspects of the thighs The scapular areas of the upper back The upper ventral or dorsal gluteal areas.

Kinds of drugs commonly administered: vaccines preoperative medications narcotics insulin heparin Only small volumes (0.5 to 1.5 mL) of medications are given subcutaneously. The angle of insertion for a subcutaneous injection is 45 degrees

Sites and Angle There are 4 sites where subcutaneous injections can be administered. they are as follows: Outer aspect of upper arm. Abdomen 4 cm away from the umbilicus. Anterior aspect of thighs Buttocks. “Subcutaneous injection is administered at an angle of 45 to 90 degree’’.

Preparation 1.Articles A clean tray containing: Clean, disposable gloves. Medication card. Paper bag. Kidney tray. Puncture proof container. Dry and wet cotton. Medication vial or ampoule . A syringe tray containing Insulin syringe .

2.PATIENT Explain the procedure to the patient. Assess the condition of the client and monitor blood glucose levels. Assess the site for the injection. Position the client in a comfortable position. Educate the client not to take the meal before the administration of medication. Provide psychological support.

3.Nurse Check with the physicians order. Check the rights of medication. Perform hand hygiene.

3.Environment Provide privacy. Ensure proper lighting and ventilation.

P r o c edu r e Wash hands with soap and warm water. Check for doctors order. Prepare the syringe with medication. Go to the clients bed side and perform checks. Don gloves before starting the procedure. Clean the site in circular motion with an alcohol swab Pinch the skin between thumb and index finger and inject the needle at 90 degree in a slow push method. Remove the syringe after 10 seconds and let go the pinched skin Discard the syringe in a sharp container .

Complications Severe pain Infection Allergic reaction Swelling Warmth

SPECIAL CONSIDERATION PER FORM THE MEDICATION ADMINISTRATION RIGHTS CHECK T HE MANUFACTURE AND EXPIRY DATE OF MEDICATION CHECK THE C OAGULATION FACTORS IF INSULIN PROVIDED , THE CHECK THE BLOOD SUGAR LEVEL DO NOT MASSAGE

Intramuscular Injections The angle of insertion for an IM injection is 90 degrees. 2 to 5 ml of medication can be administered into a larger muscle for an adult.

INDICATIONS Muscles have more blood supply ,so quicker action of drugs. More amount of drug can be administered than the intradermal and subcutaneous tissue.

CONTRA-INDICATIONS Avoid sites of lesions, lumps, tissue injury,presence of nodules other pathology. Avoid sites near to large blood vessels, nerves and bones.

Sites for IM injections are Ventrogluteal Dorsogluteal Vastus Lateralis Deltoid Rectus Femoris

Ventrogluteal site Injection is given to gluteus medius muscle. Position client in prone or side lying position with the knee bent and raised slightly toward the chest. The nurse places the heel of the hand on the client’s greater trochanter, with the fingers pointing towards the client head.

Point the thumb toward the patient’s groin and the index finger toward the anterior superior iliac spine; extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle; the injection site is the center of the triangle.

ADVANTAGES OF VENTROGLUTEAL SITE 1.No large nerves or blood vessels in this area. 2.Provides greatest thickness of gluteal muscles. 3.It is sealed off by bone. Contains less consistency fat than buttock area. Most suitable for adults and children over 1 yr

PROCEDURE-VENTRO GLUTEAL Place patient on side-lying position, bent the knees and raise it slightly to chest.(use alternate hands for hips). Place the nurses heel of hand over the greater trochanter of patient with fingers pointing towards head of patient. Index finger should rest on anterior superior iliac spine, middle finger stretched dorsally. Midpoint of triangle formed between index finger ,middle finger and iliac crest is the site.

Dorsogluteal site Injection is given to the gluteus maximus muscle. Position the client in prone position. Draw an imaginary line to divide the buttocks into 4 equal quadrants. The injection site is upper outer quadrant.

PROCEDURE FOR DORSOGLUTEAL Injection is given to the gluteus maximus muscle. Position the client in prone position. Draw an imaginary line to divide the buttocks into 4 equal quadrants. The injection site is upper outer quadrant.

Vastus Lateralis The muscle is located on the anterior lateral aspect of the thigh.

The land- mark is established by dividing the area between the greater trochanter of the femur & the lateral femoral into thirds & selecting the middle third.

Deltoid Site Found on the lateral aspect of the upper arm. Locate the site by placing four fingers across the deltoid muscle, with the top finger along the acromion process. The injection site is then three finger widths below the acromion process.

PROCEDURE FOR DELTOID SITE Place 4 fingers over the deltoid muscle,first finger over the acromion process. Top of axilla is the line that marks the lower border. Triangle formed between these boundaries is the site for injection.

Rectus Femoris it is used occasionally for IM injections. Situated on the anterior aspect of the thigh.

RECTUS FEMORIS

Z-Track Method in Intramuscular Injections When administering IM injections, the Z-track method be used to minimize local skin irritation by sealing the medication in muscle tissue. The Z-track method has been found to be a less painful technique, and it decreases leakage of irritating medications into the subcutaneous tissue

For administering in Z-track method pull the overlying skin and subcutaneous tissues approximately 2.5 to 3.5 cm laterally or downward.

Hold th e skin i n th i s positio n unt i l y ou administer the injection. With the needle at a 90-degree angle to the site administer the medicine.

STEPS OF IM INJECTION ASSESSMENT 1.Assess any drug allergy Specific drug’s action, side-effects and adverse reactions Client knowledge about the medication. 4.Client’s age and weight to determine the site and needle size.

PLANNING 1. PATIENT FILE WITH PHYSICIAN’S ORDER

2. STERILE MEDICATION ( AMPULE,VIAL,PREFILLED SYRINGE).

3.SYRINGE AND NEEDLE OF APPROPRIATE SIZE

4.ANTISEPTIC SWABS AND CLEAN GLOVES

IMPLEMENTATION-preparation PEFORM THE 3 CHECKS:- Read the label 1.When medicine is taken from cart or cupboard. 2.Before withdrawing the medicine . 3.After withdrawing and before giving the medicine.

Confirm the correct dose and organize the equipment near the patient. Also check the expiry date of the drug.

PERF O RMANCE. 1.Perform hand hygiene and wear a clean glove. 2.Prepare medication from the ampule or vial . 3.Change the needle after drug withdrawal. 4.Invert syringe to upside and expel the air . 5.Provide client privacy 6.Introduce yourself and explain procedure

Continued……… 7.Position the patient according to the site. 8.Locate and clean the site –clean site in a circular movement- start from centre and move outward about 5 cm . 9.Transfer and hold the swab between the third and fourth finger of your non-dominant hand .

Remove needle cover without contaminating needle. Use the Z track method- use ulnar side of non dominant hand to pull skin approximately to the side (2.5 cm).

Holding the syringe between thumb and forefinger pierce the skin to muscles quickly and smoothly at 90* angle. Aspirate by holding barrel of syringe with non- dominant hand(for 5 to 10 sec) If blood doesn’t appear inject the medicine.

After injection wait for 10 sec to permit the drug to disperse and remove the needle at the same angle. Apply gentle pressure with dry sterile gauze/cotton. 17.Discard all items as per protocol 18.Document in drug chart and nurses notes. 19.Look for effectiveness of medication.

Intravenous Administration

Intravenous Administration Needle is injected into the vein. Direct IV or IV push, IV infusion. This is the most rapid route of absorption of medications. Angle of insertion is 25 degree.

P U R POSE • Obtaining blood samples. • Administration of fluid, medication, parenteral nutrition, chemotherapy and blood products. • Blood donation and dialysis.

REQUIREMENTS Tegaderm Plaster Alcohol swab Gloves Tourniquet IV stopper or tubing set Splint (if necessary) Heparin saline or drip

For adults, the veins on the arm are: Basilic vein Median cubital vein Dorsal veins Median vein Radial vein Cephalic vein On the foot, the veins are; Great saphenous vein Dorsal plexus

Parts of an IV infusion set

PRE PROCEDURES Check for doctor’s order. Greet and explain procedures to patient. Assess patient’s level of conciuousness and anxiety. Provide privacy.

DURING PROCEDURES

POST PROCEDURES

Basics for IV Administration Sets Each IV administration set has following components, including: Piercing pin: A hollow spike that is inserted into the administration port of the IV bag. It is important this remains sterile when inserted. Drip chamber: This is where the solution flows prior to its entry into the tubing; it acts as a pressurizing chamber for non-vented bags. Roller clamp: This is used to regulate the flow of fluids through the IV tubing. IV cannula or catheter : A flexible tube that is used to insert medication within a body cavity or blood vessel. It has a sharp-pointed needle attached to it that punctures the skin to get the catheter within the vein. Slide clamp: This is used to restrict fluid flow and act as a quick on/off control of the IV tubing. The tubing ends in a sterile-capped adapter, which is attached to the cannula

Complications to observe for during IV therapy: Infiltration escape of fluid into subcutaneous tissue due to dislodgement of the needle causing swelling and pain. Gross infiltration may result in nerve compression injury which can result in permanent loss of function of extremity or in case of irritating medications , significant tissue loss, permanent loss of function may result. When there is infiltration, the site should be changed.

Phlebitis is the inflammation of the vein. This may result from mechanical trauma due to the insertion too big a needle (for small vein) or leaving a device in place for a long time. Chemical trauma result s from irritation from solutions or infusing too rapidly. This manifests as pain or burning sensation along the vein. On observation, there may be redness, increased temperature over the course of the vein. The site should be changed and warm compress should be applied.

Circulatory Overload ; the intravascular fluid compartment contains more fluid than normal. This occurs when infusion is too rapid or excess volume is infused. This manifests as dyspnoea, cough, frothy sputum and gurgling sounds on aspiration. Embolism ; obstruction of the blood vessels by travelling air emboli or clot of the blood.

Duties of the Nurse during IV Therapy Explain the need for the IV therapy, what to expect, duration of the therapy, activities permitted during the procedure and observations to be made. Help patient to maintain activities of daily living; bathing and grooming, feeding etc. Observation should be made on the flow rate, patency of the tubing, infusion site, level of fluid in the infusion bag/bottle, patient’s comfort and reaction to therapy. Change dressing on the IV line as may be necessary.

Advanced techniques Epidural Intrathecal Intraosseous Intraperitonial Intraplural Intra arterial

Epidural administration Epidural administration is a medical route of administration in which a drug or contrast agent is injected into the epidural space of the spinal cord . Techniques such as epidural analgesia and epidural anaesthesia employ this route of administration. The epidural route is frequently employed by certain physicians and nurse anesthetists to administer diagnostic (e.g. radio contrast agents ) and therapeutic steroids chemical substances, as well as certain analgesic and local anaesthetics agents. Epidural techniques frequently i nvo l ve injection of drugs thro u gh a catheter placed into the epidural space . The injection can result in a loss of sensation — including the sensation of pain —by blocking the transmission of signals through nerve fibers in or near the spinal cord. lumbar epidural injections carry a low risk of injuring the spinal cord. Insertion of an epidural needle involves threading a needle between the bones, through the ligaments and into the epidural potential space taking great care to avoid puncturing the layer immediately below containing CSF under pressure

Intraperitoneal administration : Intraperitoneal administration is the injection of a substance into the peritoneum (body cavity). It is more often applied to animals than to hum a ns. Liquid injection, usually of antibacterial agent, rarely anesthetic administered to obtain systemic blood levels of the agent faster than subcutaneous or intramuscular injection and used when veins not accessible . The needle is introduced into the upper flank and the syringe plunger withdrawn to ensure that intestine has not been penetrated. The injected solution should run freely.

Intrapleural Administration: Administration of a drug within the pleural cavity. The intrapleural drug administration usually results in both local and systemic drug action.

Intraosseous administration (IO Intraosseous administration (IO) is the process of injecting directly into the marrow of a bone. This technique is used to provide fluids and medication when intravenous access is not available or not feasible. The needle is injected through the bone's hard cortex and into the soft marrow interior which allows immediate access to the vascular system . An IO infusion can be used on adult or pediatric patients when traditional methods of vascular access are difficult or impossible. In most cases, the antero-medial aspect of the upper tibia is used as it lies just under the skin and can easily be palpated and located . The anterior aspect of the femur , the superior iliac crest and the head of the humorous are other sites that can be used.

Intrathecal administration Intrathecal administration is a route of administration for drugs via an injection into the spinal canal , or into the subarachnoid space so that it reaches the cerebrospinal fluid (CSF) and is useful in spinal anesthesia , chemotherapy , or pain management applications. This route is also used t o introduce drugs that fight certain infections, particularly post-neurosurgical. The drug needs to be given this way to avoid the blood brain barrier . The same drug given orally must enter the blood stream and may not be able to pass out and into the brain. Analgesic and Chemotherapy agents are commonly administered through Intrathecal route.

Intra arterial administration: This method is used for chemotherapy in cases of malignant tumors and in angiography Definition Arterial injection and blood sampling is the nursing skill to inject medications into artery and collect arterial blood as specimen.

Common sites The sites of injection commonly used are radial artery, brachial artery, and femoral artery. When administering the medication for chemotherapy, select common carotid artery for the illness in head and face, sub clavian artery or brachial artery for illness in superior limb and chest, and femoral artery for illness in inferior limb and abdomen. Purposes To get arterial blood sample. To prepare for some special test, for example, cerebral angiography. To give some medications for treatment. To make arterial blood transfusion.

Equipment used for intra arterial Injection Equipment Medical tray Antiseptic solution Medication Medication card Sterile swab Sterile gauze Adhesive plaster Sterile glove (if necessary ) a syringe based on the volume of medication, 6- to 9-gauge needle File and vial opener Container for blood specimens Sterile cork Tourniquet Small pad Sandbag Gloves Sterile dressing

Topical Medication Applications DEFINITION Topical administration is the application of a drug directly to the surface of the skin. It includes administration of drugs to any mucous membrane of eye, nose, ears, lungs, vagina, urethra, and colon PURPOSES To provide safe protecting covering to skin surface. For treating localized infection or inflammation. For relieving local irritation For obtaining desired therapeutic effect

Drugs are applied topically to the skin or mucous membranes, mainly for local action. Skin Applications Nasal Instillation Eye Instillation Ear Instillation Rectal Instillation Vaginal instillation

EQUIPMENT USED IN TOPICAL DRUG ADMINISTRATION : Medical tray ,Medication order card, prescription slip, Ordered topical medicine(cream, lotion, powder, etc.) Small sterile gauge ,dressings tape, plastic wrap etc. Cotton tipped applicators/tongue blade/spatula, towel, soap and Gloves .

PROCEDURE Always wash hands and put on gloves Review the 10 rights: right person, right medication, right time, right dose, right route. Expose the area where the topical medication will be placed. If a patch is being placed, ensure area is clean and dry. Firmly attach patch. If topical cream or lotion is rub thoroughly into affected area. Remove and dispose of gloves. Dispose of solid supplies Wash hands.

Skin applicants are applied using gloves. Before applying medications, clean the skin thoroughly. When applying skin applicants, spread the medication evenly over the involved surface and cover the area well. Topical skin or dermatologic preparations include ointments, pastes, creams, lotions, powders, sprays, and patches.

Procedure for Applying Skin Preparations POWDER Make sure the skin surface is dry. Spread apart any skinfolds, and sprinkle the powder until the area is covered with a fine thin layer of powder. Cover the site with a dressing if ordered.

LOTION Shake the container before use. Put a little lotion on a small gauze dressing or gauze pad, and apply the lotion to the skin by stroking it evenly in the direction of the hair growth.

CREAMS, OINTMENTS, PASTES Take the medicine in gloved hands. Spread it evenly over the skin using long strokes in the direction of the hair growth. Apply a sterile dressing if ordered by the physician.

AEROSOL SPRAY Shake the container well to mix the contents. Hold the spray container at the recommended distance from the area (usually about 15 to 30 cm. Cover the client’s face with a towel if the upper chest or neck is to be sprayed. Spray the medication over the specified area.

TRANSDERMAL PATCHES Select a clean, dry area that is free of hair. Remove the patch from its protective covering, holding it without touching the adhesive edges, and apply it by pressing firmly with the palm of the hand for about 10 seconds. Advise the client to avoid using a heating pad over the area to prevent an increase in circulation and the rate of absorption. Remove the patch at the appropriate time, folding the medicated side to the inside so it is covered.

SPECIAL CONSIDERATION Impaired skin integrity is observed. Use of sterile technique is essential. Avoid rubbing the skin when applying cream/ Oit ./ lotion cause skin irritation. To prevent accidental exposure or absorption the nurse must use gloves or applicator. Check patients BP before vasodilator patches. Always be alert about systemic side effects or topical medication. Follow the guidelines for medication safety.

Advantages : 1) Local therapeutic effects. 2) Lower risk of side effects. 3) Relatively Cheaper than parenteral products. 4 ) The drug can be self administered.

di sadvantages : 1) Absorption is slow. 2) Effect is slow. 3) Skin irritation or necrosis may occur. 4 ) Irritation 5) The dosage is difficult to control.

Direct application of liquids- Gargle Gargling is the act of bubbling a liquid in mouth to reduce the sore throat. The head is tilted back, allowing a mouthful of liquid to sit in the upper throat.

Insertion of drug into body cavity- suppository A suppository is a medicated solid dosage form used in the rectum, vagina and urethra. Vaginal suppositories are called pessaries. Urethra suppositories are called bougies.

Rectal suppository Rectal suppository: Insertion of medications into the rectum in the form of suppositories. Procedure: Give left lateral position, with the upper leg flexed. Expose the buttocks. Wear gloves. Unwrap the suppository and lubricate the suppository. Lubricate the gloved index finger.

Encourage the client to relax. Insert the suppository gently into the anal canal, rounded end first along the rectal wall using the gloved index finger. Press the client’s buttocks together for a few minutes. Ask the client to remain in the left lateral or supine position for at least 5 minutes to help retain the suppository.

Instillation of drug In s ti l lat i on i s t h e ad m i n ist r atio n of li q u i d form of drug drop by drop. Different drug instillations are; Nasal Instillation Eye Instillation Ear Instillation

Nasal Instillation Administration of medicine drop by drop into nose. Articles Tray Dropper Gloves Medicine

Perform hand washing. Instruct the patient to clear or blow nose gently. Position the patient. Supine position with head backward. Take the medicine in dropper. Administer the nasal drops. Have patient remain in supine position 5 minutes. Replace the articles and document the procedure.

Eye Instillation Administration of medicine drop by drop into eyes. Articles T r a y B o w l Cotton swabs Dropper Gloves Medicine Kidney tray

Perform hand washing. Position the patient. Ask patient to lie supine or sit back in chair with head slightly hyperextended. Wipe the eyes with cotton balls from inner canthus to outer canthus. Take the medicine. Expose the lower conjunctival sac by placing the thumb or fingers of nondominant hand on the client’s cheekbone just below the eye and gently drawing down the skin on the cheek.

Administer the medication drops into conjunctival sac. After instilling drops, ask patient to close eye gently. Replace the articles and document the procedure.

Ear Instillation Administration of medicine drop by drop into ear. Articles Tray Dropper Gloves Medicine

Perform hand washing. Place p a t i e n t in sid e - l yi n g position. Straighten ear canal by pulling auricle down and back (children younger than 3 years) or upward and outward (children 4 years of age and older and adults). Instill prescribed drops holding dropper 1 cm above ear canal Ask patient to remain in side-lying position 2 to 3 minutes. Replace the articles and document the procedure.

Irrigation Some medications are used to irrigate or wash out a body cavity. Commonly used irrigating solutions are sterile water, saline, or antiseptic solutions on the eye, ear and bladder. Irrigations cleanse an area.

Eye irrigation An eye irrigation is administered to wash out the conjunctival sac to remove secretions or foreign bodies or to remove chemicals that may injure the eye.

Articles Sterile irrigating solution warmed to 37⁰ C (98.6 F) Disposable gloves Cotton balls Sterile irrigating set (sterile container and irrigating tube or irrigating syringe) Emesis basin or kidney tray Mackintosh Towel

Procedure Explain procedure to the client. Arrange all articles. Wash hands. Have the client sit or lie with the head tilted toward the side of the affected eye. Protect the client and the bed with mackintosh. Clean the lids and the lashes with a cotton ball moistened with normal saline or the solution ordered for the irrigation. Wipe from the inner canthus to the outer canthus. Discard the cotton ball after each wipe. Place the emesis basin at the cheek on the side of the affected eye to receive the irrigating solution.

Expose the lower conjunctival sac. Hold the irrigator about 2.5cm(1 inch) from the eye. Direct the flow of the solution from the inner canthus to the outer canthus along the conjunctival sac. Irrigate until the solution is clear or all of the solution has been used. Dry the area after the irrigation with cotton balls or a gauze sponge. Offer a towel to the client if the face and neck are wet. Wash hands. Replace all articles and document the procedure.

Different types of irrigating syringe Asepto syringe Rubber bulb

Piston syringe P ome r o y

Ear irrigation An ear irrigation is administered to wash the external ear canal to remove secretions or foreign bodies that may obstruct the ear.

Articles Sterile irrigating solution warmed to 37⁰ C (98.6 F) Disposable gloves Cotton balls Sterile irrigating set (sterile container and irrigating tube or irrigating syringe) Emesis basin or kidney tray Mackintosh Towel

Procedure Explain procedure to the client. Arrange all articles. Wash hands. Protect the client and the bed with mackintosh. Explain that the client may experience a feeling of fullness, warmth, and, occasionally, discomfort when the fluid comes in contact with the tympanic membrane. Assist the client to a sitting or lying position with head tilted toward the affected ear.

Place the emesis basin under the ear to be irrigated. Fill the syringe with solution.

Straighten the ear canal. Administer the fluid. Continue instilling the fluid until all the solution is used or until the canal is cleaned. Assist the client to a side-lying position on the affected side for the complete drainage of the fluid. Dry the area after the irrigation with cotton balls or towel. Wash hands. Replace all articles and document the procedure.

Bladder irrigation Bladder irrigation is done to wash out the bladder and sometimes to apply a medication to the bladder lining. Two method; Open method Closed method

Closed bladder irrigation Arrange all articles. Wash hands. Apply clean gloves and cleanse the port with antiseptic swabs. Connect the irrigation tubing to the input port of the three way catheter. Irrigate the bladder by allowing the irrigating fluid into bladder. Adjust the flow rate. The irrigated fluid back from the bladder is collected in urinary bag. Wash hands. Replace all articles and document the procedure.

Open bladder irrigation Arrange all articles. Wash hands. Apply clean gloves and cleanse the port with antiseptic swabs. Disconnect catheter from drainage tubing and place the catheter end in the sterile basin. Place sterile protective cap over end of drainage tubing. Draw the prescribed amount of irrigating solution into the syringe.

Insert the tip of the syringe into the catheter opening. Gently and slowly inject the solution into the catheter. Remove the syringe and allow the solution to drain back into the basin. Continue to irrigate the client’s bladder until the total amount to be instilled has been injected or when fluid returns are clear. Remove the protective cap from the drainage tube and wipe with antiseptic swab. Reconnect the catheter to drainage tubing. Remove and discard gloves. Perform hand hygiene. Replace all articles and document the procedure.

Inhalation medications Nebulizers deliver most medications administered through the inhaled route. A nebulizer is used to deliver a fine spray of medication or moisture to a client.

The metered-dose inhaler (MDI) is a pressurized container of medication that can be used by the client to release the medication through a mouthpiece.

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