NRSG 1302- Parenteral Medications 1 & 2

what are parenteral meds?

enter via any route other than enteral and has a much quicker effect than PO

- IV

- intramuscular injection (IM)

- intraosseous (IO)

- subcutaneous (SC)

what are advantages of parenteral meds?

-avoidance of the first-pass metabolism

-better bioavailability

-reliable dose; has better control over dose and rate

when can you consider using parenteral meds?

-patient is vomiting

-patient cannot swallow safely or unable to at all

-patient is NPO

-rapid onset of a med is needed

why are prefilled syringes effective?

reduce preparation time and error for meds that have standard doses

-ex. heparin or immunizations

why can you only use insulin syringes when administering insulin?

because insulin has very rapid effects and significant effects on the body

-drawn using UNIT measurement

why is needle length important to know?

the length is chosen based on the type of tissue being injected into, injection site, and patients distribution of body fat

what needle lengths are typically used for IM injection?

-23G or 1in

-21G or 1.5in

what needle lengths are typically used for subcut injection?

25G or 5/8in

what does the gauge indicate of the needle?

it is the internal diameter of the needle

-the smaller the gauge, the smaller the needle, and vice versa

-ex. a 25G is smaller than a 21G needle

what is a blunt fill needle?

used for drawing up medication from a vial

-once drawn it is taken off and switched to the correct needle

-helps to keep needles sharp so it is less painful

what is a blunt filter needle?

used for drawing up medication from glass ampules

-reduces the risk of glass particle contamination

-has a one way flow

-switched to appropriate needle once med is drawn

what should you NEVER do to a used needle?

RECAP IT!

-reduces risk of poking and contaminating yourself

glass ampuoles

-usually contain single doses

-remove med from the neck before breaking it open

-cleanse neck with alcohol pad for 15-30secs

-break AWAY from you

-only use a blunt filter needle to draw up the med

vials

-must be equalized before meds are drawn; inject the same amount of air into the vial that you will be drawing up

-can be single or multi dose

-blunt needle or hypodermic needle is used to draw up; but assessment is needed (is the med irritating, viscous, etc.)

what is reconstitution of a med?

powdered forms of meds that are reconstituted using a diluent

-some meds are unstable in solution and must be stored as a powder until its time to administer

-final concentration is always expressed as mg/mL and is used when performing dosage calculations

what is a parenteral drug manual (PDM)?

a manual that provides all information on a medication:

-generic/ trade name

-classification and mechanism of action

-who can administer it

-compatible diluents

-safe daily and single doses

-side effects

-special considerations

-storage/ stability

what are ways to minimize patient discomfort during injections?

-talking, providing a toy, videos, breathing techniques

-cold or vibration to the area

-vapocoolant or topical anesthetic based on policy and procedure of site

how to properly inject meds:

-insert needle at a proper angle, smoothly, and quickly

-inject the med at 1mL/ 10secs

-hold for an extra 10secs to ensure all the med was injected into the tissue/ muscle

what angle of insertion is used for IM?

90*

what angle of insertion is used for subcut?

45-90

-depends on area and amount of patient body fat

what angle of insertion is used for ID?

5-15

what muscle/s can hold the most amount of med?

ventrogluteal and vastus lateralis

-2-3mL is the most effective amount into these muscles for proper absorption

-used these sites all the time if able!!

why are IM injections effective?

-quicker absorption than subcut

-larger amount of med can be injected

-sites are: deltoid, ventrogluteal and vastus lateralis

what are clinical considerations to make for IM injections?

-syringe size (1mL-3mL mostly used)

-needle length or gauge (1in vs 1.5in)

-what site is the best

-technique (angle of insertion, aspiration on VG/ VL dependent on policy)

what is the best site for IM?

ventrogluteal

-less injuries like fibrosis, nerve damage and abscesses

-z tracking is used for this area

how to landmark the ventrogluteal?

patient is laying on side -> find the greater trochanter -> thumb is towards the groin -> find the anterior-superior iliac spine and put pointer finger there -> palpate for iliac crest and put middle finger in the area -> inject into the "fattier" area in between the knuckles of your pointer and middle finger

how to landmark the deltoid muscle?

place pinky finger on acromion process -> go 3 fingers below the acromion process

-make sure muscle/ arm is relaxed

-ensure it is not too low or high so you do not hit a bone or nerve

-good for vaccines

how to landmark vastus lateralis?

patient is supine or sitting -> find the greater trochanter -> other hand by the knee -> move until the middle third of the 2 landmarks is achieved

-site of choice for infants

what are potential complications for IM?

-fibrosis

-nerve damage

-abscess

-tissue necrosis

-muscle contraction

-speed shock (rare)

what is speed shock?

the body's reaction to a substance that is injected into the circulatory system too rapidly

-result of poor landmarking

-symptoms: flushed face, headache, angina, irregular pulse, altered LOC, and cardiac arresrt

how to landmark for an ID injection?

-area is free of lesions, discolouration, moles, scars, and hair

-3-4 finger widths below antecubital space and one hand above the wrist

-ensure bevel is up before insertion

-a bleb/ wheel is formed when performed correctly

what are adverse reactions seen during an ID injection?

urticaria, eczema, pruritus, wheezing, and dyspnea

what is diabetes mellitus?

a metabolic disorder characterized by hyperglycemia from impaired insulin secretion, defective insulin action, or both

what is insulin?

-a hormone made by the pancreas

-main function is to facilitate the transport of glucose from the bloodstream into the cells

-also plays a role in protein and fat metabolism

-maintains a blood glucose of 4-7mmol/L

prediabetes

a condition in which the blood glucose level is higher than normal, but not high enough to be classified as type 2 diabetes

gestational diabetes

a form of diabetes mellitus that occurs during some pregnancies

secondary diabetes

a type of diabetes caused by another disease, certain drugs, or chemicals

-ex. cystic fibrosis, schizophrenia, Cushings syndrome, corticosteroids

etiology of diabetes includes...

genetic, autoimmune, viral and environmental factors

-ex. obesity, sedentary lifestyle, stress

those highest at risk are Indigenous, hispanic, asian and african descents

what is normal endogenous insulin secretion?

-insulin levels raise rapidly the first hour or two after meals (peaks at about 1hr)

-after meals, levels decline as carbohydrate absorption from GI tract declines

-levels are fairly low during the night, and slightly increases at dawn

basal bolus release of insulin

basal: released at meals

bolus: maintain levels of insulin

-this is what becomes compromised in diabetes

type 1 diabetes

the pancreas can no longer produce insulin, therefore fats are broken down to get energy (ketone formation), impaired protein synthesis, protein degradation, and excessive glucose production from the liver

-mostly diagnosed under 25yo

-10% of DM cases

-typically thinner

-little to no familial hx

-DKA is very common

what is diabetic ketoacidosis?

insulin deficiency characterized by hyperglycemia, ketosis, acidosis and dehydration

-fats are broken down as a secondary source of fuel producing ketones (byproduct of fat metabolism)

-ketones become serious problems when they accumulate in the blood

-causes the pH balance to be altered (metabolic acidosis)

-3 common manifestations: polyphagia, polyuria, and polydipsia

type 1 diabetes symptoms

polydipsia (extreme thirst), polyuria (frequent urination), polyphagia (extreme hunger), fatigue, and weight loss

what is the treatment of type 1 diabetes?

provide an exogenoud source of insulin

type 2 diabetes

pancreas continues to produce endogenous insulin but not enough for the bodies needs, insulin is poorly utilized by the tissues, and/ or cells become insulin resistant

-causes the pancreas to secrete more insulin to get the cells to respond, but it cannot keep up, and hyperglycemia occurs

-mostly diagnosed over 25yo

-90% of DM cases

-most are overweight

-frequent familial hx

-DKA is rare

type 2 diabetes symptoms

fatigue, recurrent infections, prolonged wound healing,visual changes, foot neuropathy, increased protein in urine, and polydipsia

what is the treatments of type 2 diabetes?

non insulin antihyperglycemic agents are first line

-metformin inhibits glucose secretion from liver and improve sensitivity to insulin, glyburide stimulates insulin secretion, and semaglutide increases insulin release

-exogenous insulin injections are second line

-lifestyle modifications such as diet, exercise, and weight control must be managed

hypoglycemia

low blood sugar due to increased levels of insulin compared to glucose levels in the blood

-causes a BG less than 4mmol/L

hypoglycemia symptoms due to epinephrine release

NE is given to defend against hypoglycemia, but causes:

-diaphoresis

-tremors

-hunger

-nausea

-nervousness

-anxiety

-pallor

-tingling

-heart palpitations

*if untreated can cause death

hypoglycemia symptoms due to decreased BG

-difficulty concentrating

-drowsiness

-irritability

-visual disturbances

-headache

-dizziness

-weakness

-confusion

*mimics alcohol intoxication

what causes hypoglycemia in DM?

-taking diabetic meds or food at the wrong time

-consuming too little food

-not changing meds following weight loss

-high levels of exercise

-drinking alcohol without consuming food

what can cause hypoglycemia in acute settings?

-sudden reduction in PO intake

-discontinuation of parenteral or enteral nutrition

-unexpected transfer from one unit after a rapid action insulin administration

-reduction in corticosteriod dose

hyperglycemia

elevated blood sugar due to:

-corticosteroid use, stress

-illness or infection

-inactivity

-poor absorption or lack of insulin

-too much food

hyperglycemia symptoms

-polyuria

-polyphagia

-polydipsia

-abdo cramping

-nausea and vomiting

--blurred vision

-glycosuria

-headache

-weakness

-fatigue

*in untreated it leads to DKA or HHS

Hyperosmolar Hyperglycemic State (HHS)

HHS is characterized by severe hyperglycemia, severe dehydration, hyperosmolar plasma, and altered LOC, without ketoacidosis

-rare but deadly

nursing interventions of hypoglycemia

if BG is less than 4mmol/L and pt. is alert:

1. give 15g to 20g of carbs PO

-ex. 3/4 glucose tabs, sweet drinks)

2. recheck BG in 15mins

3. if no change, repeat step 1

4. eat snack if meal is over 1hr away

5. recheck BG in 45mins

6. discuss diabetic meds with MD

if pt. has loss consciousness: IM or subcut of glucagon or 50% dextrose IV push

nursing interventions of hyperglycemia

1. check BG

2. determine if OHA or insulin meds are working

3. if meds are not working, talk with MD

4. increase fluid intake

-IV fluids may be necessary

5. if progressed to DKA or HSS, manage in ICU

why is blood glucose monitoring important?

-provides real time results

-can be done wherever

-detects hypo/ hyperglycemia

-track variations of BG levels

when should BGM be done for pts. with diabetes in hospital?

-before meals

-at HS

-q4-6h for NPO or receiving enteral feedings

-q1-2h for continous IV insulin or critically ill

how to obtain a BGM

-clean site with alcohol pad

-use side of finger, ensuring its not over bone

-rotate sites and ask for pt. preference

-notify immediately if BG is abnormal

subcut injections

-has a slower absorption rate than IM

-contains pain receptors, so pt. may feel discomfort

-limit to 1.5mL in adults and 0.5mL in pediatrics

subcut sites should be:

free of tenderness, hardness, swelling, scarring, itching, burning, bones, or inflammation

always assess the site prior to administration

-abdo is common site for insulin and heparin

how to determine whether to pinch or spread skin for a subcut injection?

-if someone has a smaller amount of adipose tissue, it is recommended to pinch to ensure the needle is not injected into muscle or circulatory system

-if someone has a larger amount of adipose tissue, it is recommended to spread to ensure the needle is in the subcut tissue

what is important to remember for insulin pen/ needle injections?

no skin pinch is needed and always insert at 90*

-failure to do this may cause the pt. to not receive their full dose

-ALWAYS use an insulin syringe if you need to draw and mix meds from vials

-give 5cm away from umbilicus and away from costal margins

-give in 1 site, but rotate area of injection

where are the best subcut injection sites?

outer area of upper arms, abdomen below costal margins, anterior aspect of thighs

abdomen is absolute best and choice for most pts.

what are rapid-acting insulins?

lispro, aspart, glulisine

-give 15 mins before meals

-rapid onset but short duration

what are short-acting insulins?

Humulin R, Novolin R

-give 30-45 mins before meals

-slower onset compared to rapid but longer duration

what are intermediate-acting insulins?

NPH (Humulin N, Novolin N)

-combination of Humulin R & N to maintain basal bolus regime

-given at HS or BID, before breakfast and before dinner

-often given in combination with a short-acting insulin

-longer duration compared to short

what are long-acting insulins?

glargine (Lantus), detemir (Levemir)

-must be given once or twice a day at the SAME time

-should not be mixed with any other insulins because it may change the time or action profile and cause precipitation

-has the longest duration

what is premixed insulin?

30% Humulin R and 70% Humulin N

-a basal bolus already mixed in a fixed ratio

how much should each type of insulin be administered?

-intermediate or long acting once or twice a day

-rapid or short acting before meals (TID or QID)

what does a supplemental or "sliding scale" of insulin do?

allows an increase in BG to be treated quickly to maintain better glycemic control

-recommended to be used in addition to a basal routine

what is the correct sequence when mixing insulin?

"cloudy, clear, clear, cloudy"

1. add correct amount of air into cloudy

2. remove needle, inject correct amount of air into clear

3. invert vial and draw up correct dose of clear

4. remove needle, draw up correct dose of cloudy

as a student in a clinical setting, how do you mix insulin?

1. first check on clear, draw up meds, last two checks are completed, then without removing the needle, grab your second nurse and instructor

2. first check on cloudy, draw up cloudy portion, last two checks are completed, then without removing needle, grab your second nurse and instructor

3. remove needle from vial and recap

what do you have to remember about insulin pens?

-each pen is pt. specific and must be stored in their specific bin

-an expiration sticker must be applied once opened

-use a new needle for each injection

-prime 2 units on the pen before going to ordered dose

why is heparin ordered?

for pts. with thrombotic conditions like a-fib, venous thromboembolism, embolic stroke, and post-op to reduce the risk of forming a thromboembolism

what are pts. receiving heparin at risk for?

bleeding gums, hematemesis, hematuria, or melena

-bleeding secondary to unintentional OD

-clot formation secondary to unintentional underdosing

-heparin induced thrombocytopenia secondary to an immune response

*always monitor lab results for changes that indicate one of the 3 major risks*

what conditions increase the risk of hemorrhage for pts. on heparin?

-renal and/or liver disease

-CVA

-aortic aneurysms

-severe HTN

-blood dyscrasias

-active ulcers or lesions in the GI, GU or respiratory tract

what meds interact with heparin?

antiplatelets, anticoagulants like ASA or NSAIDS