Principles of Medication Administration Lecture Notes

Monday
1/11/16

Learning Objectives

Identify types of medication orders and how to read them

Describe safety measures in preparing drugs

Describe principles used to prepare and administer oral, parenteral, topical, and inhalation
medications.

Describe measures for safe administration of medications

Understand and Implement guidelines for nursing actions to assess and administer
medications to patients.

Understand and demonstrate interventions to enhance patient care for patients with a
tracheostomy, to include daily care and suctioning.

Understand and demonstrate interventions to maintain fluid balance, to include assessment

and initiation of an IV, administering IV fluids, maintaining IV lines using sterile technique.

Understand and demonstrate interventions to obtain blood samples.

Nurses
always responsible for their own actions
must know state laws regarding nursing practice and medication administration

Never re-cap used needle

Remember Standard Precautions

Drug Information

not possible to know or memorize all drug info

best way to know how to administer the medication is to READ the package insert
read nursing implications Drug Handbook / PDR / Hospital Pharmacy websites

Mechanism of Drug Action

Absorption:
from site of entry to bloodstream

Metabolism:
changing drug to different form

Distribution:
blood flow to the tissues

Excretion:

 lungs, kidneys, GI

Pharmacodynamics:
achieving desired effects

Adverse Drug Effects

NKMA
Allergic Reaction
Drug Tolerance
build up immunity

Toxic effect
e.g. Tylenol over 4000 mg extremely toxic to kidneys
Side effects
Drug Interactions

Drug Action and the Patient

weight
gender
cultural
religious
e.g. birth control pharmacist doesnt believe in can refuse to fill prescription
genetic factors
pyschological factors ( placebos)
timing of medications

Medication Orders ( NEED TO KNOW )

Stat order now

Single order or One-time order: needed for that time period
e.g. flu shot
Standing order
PRN order:
as needed you and or patient make that decision
e. g. pain medication

Parts of Medication Order Must Have ALL Parts

Name of Patient
Date & Time order is written
Name of Drug
Dose & Frequency
Route
Signature of Provider

******If Something is Missing from Prescription Call and Ask!**********

Example of an Order: Hospital

Jane Doe

February 14, 2016

0900
Fluconazole 150mg PO one-time only
This AM please
John Smith MD

What is wrong with the above order?

Prescriptions

must have Date of Birth

Prescription Example
Jane Doe
DOB: 4-9-1987
January 10th, 2016
Fluconazole 150mg PO one-time only
Dispense #1
No refills
John Smith MD
MAR or EMAR

Patient Identity

must have 2 identifiers

JCAHO's National Patient Safety Goals Required by Joint Commission
Name
ID Number often on ID Hand
Photo ID
e.g. patient isnt awake picture
Or other person-specific ID
NOT room number

Rights of Medication Administration [MUST KNOW]

Checking the medication orders for transcription errors, allergies, interactions

e.g. if you see med listed patient is allergic to make sure to call doctor and have it
removed

After preparing medications NEVER leave the medications in the room for the patient to
take later

You MUST WITNESS the patient taking the medications to document they were given

Do NOT give medication I have not pulled myself

3 Checks Before Giving a Medication

1. When reaching/picking up medication
2. Compare to the EMAR be sure it is right!
3. Before giving to the patient- be sure it is right

SIX Rights of Medications [ KNOW ]

1.
2.
3.
4.
5.
6.
7.

Right Medication
Right Patient
Right Dosage
Right Route
Right time
Right Reason
Right Documentation

Oral Medications
1. Assess:

Allergies
Swallowing
Vital Signs, lab results
e.g. Blood Pressure Medicine
always check blood pressure before giving and if on the edge and I am
worried wait
and hour and recheck blood pressure again
2. Patient knowledge and needed education
3. Equipment: cups, spoons, pill cutters, water to drink, crushing tool

Special Situations

Crushing:
only way to know if you can crush look it up
slip into pudding

Syringe or Dropper:
make certain the syringe is oral syringe and not IV syringe

Children:
tiny amounts

Buccal:

 putting medication in the cheek

Sublingual:
give medication under the tongue

Feeding Tubes and Medications

Liquid Medication
1. Look to see if you can crush medication and if you cant call pharmacy and see if can get
liquid
2. Check Placement of the Tube
pull back on syringe and see if patient is gagging and if so it may be in patient's
lungs
3. Crush Medicine and Mix it with Water
4. Flush:
adult=15-30 ml
child=5-10 ml
5. Give meds separately & Flush between
Topical Medications
Dermatologic:
lotions use cotton balls
patches
do not put estrogen patches on someone's breast not cause it but trigger it
take old patch off
new patch put a sharpie dot on it if patient is in hospital
spray
powder
use caution to not shake and inhale
dont shake in front of patient's face they may breathe it
transdermal

Eye Administration

wear gloves and make sure eye med

place in lower conjunctival sac
place pressure over inner canthus to prevent systematic absorption
allow to absorb before rubbing
Eye Irrigation: flushing w/ water

Administering Eye Med into Conjunctival Sac

Ear Medicines

ear drops:
make certain to have right temperature
submerge into warm water to get it room temperature
don't put hot or cold into ear
Wait 5 minutes before changing sides * important*
Massage tragus to encourage movement of medicine
Cotton ball used to keep medicine from rolling down neck
Irrigation

Nasal Medications

gloves
kleenex
Fowlers, sitting with head up and slightly tilted back
depress bottle/ dropper to administer
hold position for a few minutes
provide kleenex

Vaginal Application

gloves and hand hygiene

creams, foams, tablets
vaginal applicator
remain supine for 5-10 minutes to absorb
peri pad

Rectal Application

suppositories and enema

use index finger to insert 3-4 inches
lubrication
encourage to remain on side for 5 or greater minutes may have to tell patient to hold the
medicine in
retain as directed

Asthma Medications

read instructions for appliance

add spacer, prn
shake med if needed

WANT to INHALE not swallow **** IMPORTANT****

Administer with intake of breath
place 1-2 inches from open mouth
If steriod rinse mouth after medication

Parenteral Medications ( shots )

IM intramuscular
into muscles
90- degree angle

SQ- subcutaneous
into fat of the body
45-degree angle

Intradermal
into skin
10-15 degree angle

IV going into the vein

Wear clean gloves when administering the medication

Clean site with alcohol
Length of My Needle is NURSING Decision ****
look at patient and assess

Shots

first apply gloves and clean site

use a swift dart like motion
do not bounce or hesitate

inject the medicine and remove the needle

use safety features of needle/syringe
dispose of in sharps

Syringes & Needles

Parts of the syringe
tip
barrel
plunger
luer lock ( screw on) or non-luer lock
prefilled syringe e.g. flu shot
insulin syringe *** measured in units
only use syringes with units on side for insulin
*****Needles are classified by GAUGE #18-#30
the larger the # ( 30) the smaller the needle diameter
E.G.
gauge # 30 is so tiny it used for NICU not strong enough to go into muscle the needle
would bend if used on adult

Drawing Up Medications

Ampule:
glass be careful
Need a Filter Needle which will be changed BEFORE injecting the patient
Vial: clean the top with alcohol
Check Order and inject air ( in the amount of medication you will take out) into the vial

Subcutaneous Shot Picture super skinny patient

e.g.
Bunching

SQ Sites

back of arm
side of the arm
within the stomach 2 inches from umbilicus

thighs last resort

Insulin

given in very small amounts

usually given SQ
can be given IV or inhaled or SQ with a pump
oral medication- dont worry about this however

Insulin 2 Nurses Verify

different types of insulin mixed in one syringe

Clear before Cloudy *****
Regular Insulin= clear
NPH= cloudy due to added proteins ( proteins added to slow down absorption long acting)
Order:
6 units Regular 6 units NPH
Start with NPH Add Air Go to R add air
Draw up R then add NPH

Intradermal

administer medication into the dermal layer of the skin just below the epidermis
15 degrees, bevel up
the hole of the needle aka bevel
forms a wheal or bleb ( looks like a blister)
e.g. allergy shots , TB shots

Intramuscular: IM

injection into the muscle

need a needle that will reach the muscle
** MUSCLE, NOT vein, so aspirate

aspirate
pull back the plunger to make certain needle not in vein
if you see blood in syringe take the needle out

Sites Used for Intramuscular Injections

Ventrogluteal adults right on hip not on butt find top of trochanter and find top
of hip
bone it is in triangle ** preferred site of IM shots**
** DO NOT USE DORSOGLUTUEL DO NOT GO BACK THERE**

Vastus Lateralis in pediatrics give most of the time the muscle running up thigh

Deltoid in patients arm

Z-track

purpose is to keep medicine inside the skin so it will not come out
certain medications
can stain the skin

REMEMBER

Safety
Do not Recap
Use Sharps Container

Intravenous Therapy
Solutions
IV tubing: drop factor and length
Drop Factor

how many drops = ml

different droppings have different factors read the package
REASONS TO HAVE VENOUS ACCESS
To balance fluids in the body
To administer medications
To have access to the circulatory system

Prepare the Solution

1.
2.
3.
4.
5.
6.
7.

Check orders to verify solution

Obtain bag if IV fluids, compare to order
Check contents for expiration date
Obtain correct IV tubing, note drip factor and length of tubing
Remove caps ( sterile) off bag and tubing
Spike the bag, Prime the line and let fluid run through tubing
Clamp

If giving blood use big enough for cells to get through 18 gauge
Who decides needle size and how long? - Nurse

IV Catheters

PICC
peripherally inserted central catheter
medication goes directly into the heart
everything push through goes into the heart
big deal
PICC Lines
e.g. picture of Power PICC
on used for drawing labs
one for pushing meds
nurse practioners and doctors insert PICC lines
PICC line changes are sterile procedure and done using sterile technique
Removal of a PICC line requires special care to limit air embolism
***NEVER USE PICC LINE WITHOUT PROFESSOR PRESENT**
IV Site Preparation
-clean the skin
Finding an IV Site
locate vein put tournaqit
lower extremity
apply warmth circulation and dilation
tap vein
open and close fist
use of vein finder

Intravenous Sites for Adult

Arm
Always Towards the Heart

IV Site on Infant

into skull

Starting an IV
!!!!!!ALWAYS start an IV in the direction of the heart!!!!
1. Apply tourniquet
2. Clean skin at site for 30 seconds or according to policy. Allow to dry
3. Hold skin taught below sight with non-dominant hand
4. Insert IV catheter at a 10-15 degree angle
5. Look for blood return in the flash-back chamber

Medications can be added to an IV line

******MUST use 10cc syringe ******
IV medications are administered IV piggyback or direct IV push
ALWAYS must know the rate the medication is to be infused over
make certain medication does not stay in line
NEVER guess the IV rate on a medication, look it up.!!!ALWAYS!!!

Make sure medications are compatible

Flushing an IV Line
Flushing an IV line provides access and assesses patency of the line and vein
Use a 10 cc syringe and normal saline
Some hospitals use pre-filled syringes
Valves on lines MUST be cleaned before use

Setting and IV Rate

Using roller clamp, you will adjust the rate
The rate will be in the doctors orders
The rate is usually set on the IV pump machine
Can be hand calculated, using the DROP factor
Will practice in lab

Piggy back meds

IV meds that will be added to regular lines
the HIGHEST bag will flow first

Changing a dressing on an IV site

wear gloves
keep IV stable
remove old dressing and apply new
requires a mask for all in room
PICC requires special kit and sterile technique

Removing an IV
Assessing an IV Site *** MUST KNOW****

Infiltration
needles has wiggled out of skin
cannot save it
remove IV

-can be swollen or pale

Phlebitis see red line, redness

remove IV
Tissue trauma at site it is torn or ripped
Infection: indication of any pus on the scene if you see this let doctor
know so pt can go on
antibiotic . Start new IV somewhere else
Septic- same as infection in the bloodstream patient is sick pull it out
and call M.D

Caution for Nurses

always wear gloves when starting an IV
always dispose of needles in sharp box
always check patients allergies
remember the medication is going into the patients heart you can get it back
be accurate

Tracheostomy

parts

obturator
inner cannula

outer cannula

The obturator fits into the inner cannula which fits into the outer cannula
only time you use this it is for insertion
Tracheostomy
temporary or permanent
cuffed or uncuffed
placed in OR or ICU under sterile technique
local anesthesia
*** always over head of bed***
if it comes back out put back in
GRU always have emergency trach box
so will have one of same size and one smaller size because it can close up before your eyes
Cuffed or Cuffless
how it is held into patient
depends on patients neck
cuffed trach on ventilator patients
will downsize to cuffless before decanulate patient

Tracheostomy ties or velcro fastener

change gauze
change ties

Goal: Maintain Airway

suction equipment
oxgygen
spare tracheostomy and obturator ( insertion piece)
call bell
always get someone in there sooner than later
this is 911 situation

Suctioning
done with sterile technique

Tracheostomy Care

Always Sterile Technique

when sucking secretions also sucking air out****

talk to patient

let them know

tell patient if it gets too much communicate with me
set up communication system so you know patient needs to catch breath
provide safety
provide airway
provide sterile technique
provide communication to patient

We will be checking of

Trach Care
IV starts
Hanging IV bags

Robillard LRC Check Of

-giving medications

Adult Health 1
1

Reading and Skills Modules

Week

Readings in: Yoost, Crawford ( 2014). Fundamentals of Nursing

Please read the following information by LRC dates. Thank

you.

Chapter 35 Medication Administration

Chapter 38 Oxygenation and Tissue Perfusion (Tracheostomy cleaning and suctioning)
Chapter 39 Fluid, Electrolyte and Acid-Base Balance (IV starting and fluid administration)
Elsevier Essential skills on Elsevier/Evolve site:
Evolve Skills Modules

Medication Administration

Administering Ear Medications

Administering Eye Medications

Administering Intradermal Injections

Administering Intramuscular Injections

Administering Oral Medications

Administering SQ Injections

Applying an Estrogen Patch and Nitroglycerin

Ointment

Applying Topical Medications

Documenting Medication Administration

Drawing up more than One Type of Insulin

Ensuring the Six Rights of Medication

Administration

Handling Medication Variations

Inserting a Rectal Suppository

Preparing and Administering Insulin

Preparing Injections from a Vial

Preparing Injections from an Ampule

Using a dry Powder Inhaler

Using a Metered Dose Inhaler

IV Therapy

Administering IV Medications by Mini-Infusion

Pump

Administering Medications by Piggyback

Administering Medications By Intravenous

Bolus (Push)

Drawing blood and administering Fluid

Dressing the Infusion Site

Performing Venipuncture

Preparing an Infusion Site

Regulating an Intravenous Infusion

Troubleshooting Intravenous Infusions

Providing Tracheostomy Care