Exam 1

Percutaneous Administration

Application of medications to the skin or mucous membranes for absorption

Includes:

• topicals

• inhalation

• instillation of solutions into mouth, ear, eye, nose, vagina

How to document drug administration

• Date, time, drug, dosage, route

• Patient symptoms: Rash, vesicle, etc.

7 Rights

right drug, right indication, right time, right dose, right patient, right route, right documentation

Principles of Oral Drug Administration and Routes

• Give the most important medications first

• Do not touch the medication with your hands

• Encourage liquid intake to ensure swallowing

• Remain with patient while medication is taken; DO NOT leave the medication at bedside unless an order to do so exists

General principles for infants, children, and adults

• Give adults and children the most important medications first

• NEVER dilute medications without specific orders

• DO NOT leave a medication at the bedside without an order to do so

• Check an infant’s ID and be certain the infant is alert

• Provide complete documentation of administration and responses to therapy

Nitroglycerin Oil

• Transdermally (patch) and sublingual 

• Prevent and treat chest pain for a heart attack 

• Vasodilates, lowers BP, causes headaches

• Should take a break from the patch for 10-12 hours to avoid side affects

• Select new site for application each time

• It is important to wear gloves and wash hands to avoid contact with the ointment as the nurse

Transdermal Drug Delivery

• Disk or patch providing controlled release of medication

• Wash hands, put on gloves

• Position the patient

• Apply topical disk or patch

• Application frequency depends on drug

• Wash hands after application

• Label disk with time, date, and nurse initials

sublingual

placed under tongue

buccal

held in the cheek/buccal cavity

eye drops

• All medication for the eye must be labeled ophthalmic

• Inspect the infected eye before putting in the eye drops. 

• Clean any exudate (fluid) from the eye. 

• Expose the lower conjunctival sac and insert the drops. 

• NEVER touch eye with the dropper

• Apply gentle pressure on the inner corner of eyelid for 1-2 minutes after application to avoid systemic absorption (you do not want drops to be absorbed and go to other parts of the body). 

Ear drops

• All medications for the ear must be labeled otic

• Before inserting drops, ensure the ear is clear of any wax

• Medication should be warmed to room temperature

• If the patient is…

1. Younger than 3: pull earlobe DOWN and BACK

2. Older than 3: pull earlobe UP and BACK

Nasal Drops

• patient should blow nose gently

• Position patient lying down with head hanging back

nasal spray

• Have patient blow nose gently

• Patient is upright

•  Block one nostril

•  Shake bottle and insert tip into nostril

•  Spray while patient inhales

Enteral Drug Administration

Via the gastrointestinal tract by the oral, rectal, or nasogastric routes

Enteral Formulas

• Designed to provide basic metabolic requirements and adequate
  nutritional intake

• Prescribed formula should be checked

• Formula should be fully labeled

• Discard unused formula every 24 hours

Administration of Medications by Gastrointestinal Tubes

• Drugs are administered via nasogastric (NG), nasoduodenal (ND), or nasojejunal (NJ) tubes for specific patients, using a liquid form whenever possible

• Gastrostomy or G-tubes: surgically inserted through the abdomen into the stomach

• Percutaneous endoscopic gastrostomy (PEG): procedure during which gastrostomy tube is inserted

• Check the location of the GI tube before administering any liquid

• Always flush the tube before and after administration with 30 mL of water

• Perform premedication assessment

• Assemble equipment before administration

• Flush between each medication with 5 to 10 mL of water

Oral medication routes

• capsule: Small, cylindrical gelatin containers used to administer unpleasant-tasting medications

• lozenges: Flat disks in a flavored base

• tablets: Powdered drugs that have been compressed

• disintegrating tablets: Rapidly dissolve on tongue within seconds

• elixirs: Drugs dissolved in water and alcohol

• emulsions: Dispersions of small droplets of water in oil or small droplets of oil in water

• suspensions: Liquid dose forms that contain solid, insoluble drug particles dispersed in a liquid base

parenteral administration

• Drug administration by any route other than the GI tract

• Route

  • Intradermal

  • Subcutaneous

  • Intramuscular (IM)

  • Intravenous (IV)

• Equipment: syringe and needle (NEVER RECAP NEEDLE)

suppositories

• solid medication designed to dissolve inside a body orifice

• inserted inside rectal

• should not be used for patients who have had recent prostatic or rectal surgery, or
  rectal trauma

intradermal (parenteral administartion)

Any skin surface can be used, but the preferred sites are upper chest, inner aspect of the forearms, and scapular area of the back

ex: PPD test, allergy tes

methods of allergy testing

• Intradermal injection method

• Skin prick test (SPT) method

subcutaneous route (parenteral adminitstartion)

• Medication is deposited in the loose connective tissue between the dermis and
  muscle layer

• Common drugs injected subcutaneously
  include:
   Heparin
   Insulin
   Enoxaparin

• Sites commonly used include upper arm,
  anterior thighs, and abdomen

Intramuscular Route (parenteral administration)

• Injection deep into muscle mass

• Age and muscle mass are factors to consider when giving injections

• Sites include:
   Vastus lateralis muscle (side of the thigh)
   Rectus femoris muscle
   Ventrogluteal area
   Dorsogluteal area
   Deltoid muscle

sites commonly used for IM injections in infants

Vastus lateralis

sites commonly used for Im injections in adults

Gluteal area, deltoid, vastus lateralis

IV administration (parenteral)

Injection of a solution into the vein
 More effective when:
 A large volume of fluid must be quickly administered
 Medications must be absorbed faster
 Requires a written order from the physician
 The physician’s order must include the date, type of solution or medication, dosage, rate,mand frequency

advantages of IV therapy

• Drugs can be administered directly into the vein by syringe injection

• Drugs can be administered intermittently or by continuous infusion through a peripheral or central IV line

• Usually more comfortable drug administration than IM or subcutaneous route

disadvantages of IV therapy

• Requires extended time to administer

• Requires a skilled healthcare provider to administer

• Decreases patient mobility

• Increases the odds of infection

• Increases the possibility of severe adverse drug reaction

Intravascular (IV) compartments

Intravascular (includes blood vessels): Arteries, veins, capillaries
 Intracellular: Inside the cell
 Interstitial: Between the cells

Intravenous Access Devices

• Peripheral access devices: For short-term use in peripheral veins in the hand or forearm

• Midline catheters: For use over 2 to 4 weeks; inserted into intermediate-sized veins and advanced into larger vessels

• Central devices: Inserted into intermediate- sized vessels

• Implantable venous infusion ports: Surgically placed into central veins for long-term therapy

Central Access Devices

• Sites: Subclavian, jugular, or femoral veins

• Tunneled central venous catheters: Surgically placed with proximal end of catheter, exits on chest

• Implantable infusion ports: For long-term therapy in central vein for IV fluids,
  medications, TPN, and chemotherapy; accessed with 90-degree Huber needle

IV solutions

• Consist of water containing one or more dissolved particles (solutes)

• Concentration of dissolved particles is known as the osmolality

• Given to replace body losses of water and electrolytes from a variety of conditions

  • Electrolytes include Na+, Cl-, and K+

• Types: isotonic, hypotonic, hypertonic, total parenteral solutions

Isotonic IV solution

• Similar osmolality as blood

• Used for fluid replacement

• D5/0.2%, and 0.9% sodium chloride are examples

Hypotonic Solution

• Lower osmolality than blood

• Used for conditions of cellular dehydration

• 0.2% and 0.45% sodium chloride are examples

Hypertonic Solution

• Higher concentration of dissolved particles than blood

• Rarely used; tend to pull fluids from extracellular compartment into blood vessels

Total parenteral solutions

Contain all electrolytes needed by the body as well as amino acids, carbohydrates (dextrose), and fatty acids.

ampule

• can have powder

• withdraw with filter needle

Medications for IV administration are available in…

ampules, vials, prefilled syringes, and large-volume IV solution bags

Principles of IV Drug Administration

• Know the purpose of the drug: Use the seven rights

• Determine compatibility issues involved

• Use aseptic technique

• SASH method: used to flush and administer medication through intravenous (IV) or central lines

• Calculate drip rates properly

SASH

• used to flush and administer medication through intravenous (IV) or central lines

• Saline flush, Administer medication, Saline flush, and Heparin flush (to prevent blood clots from forming inside catheter)

Always flush with…

normal saline

In syringes…

Medicine=air (ex: 5 mL of med, 5 mL of air)

Phlebitis

• on IV site

• an inflammation of the veins, typically caused by a blood clot

• red, streaky, painful

Teratogens

Drugs (including alcohol) that cause abnormal development of fetal tissues (cause birth defects, usually occur in the first trimester)

ex: ACE inhibitors, chemo, warfarin

Nursing Process

Assessment, diagnosis, outcome, planning, implementation, evaluation & documentation

Assessment

First step in the nursing process
 Comprehensive collection of data, including:
 Physical examination
 Nursing history
 Medication history: obtain current and past meds, including OTC and herbal
 Professional observation
An ongoing process that starts with admission and continues until the patient
is discharged from care

Diagnosis

• A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes (NANDA-I)

• Consists of a three-part statement that:
   Uses a NANDA-I diagnostic label
   Has contributing factors
   Defines characteristics

• Types: actual, risk, health promotion & wellness, syndrome

actual diagnosis

Based on human responses and supported by defining characteristics

risk diagnosis

Patient may be more susceptible to a particular problem

health promotion and wellness diagnosis

• only has a one part label

• clinical judgment of a person's, family's, or community's motivation and readiness to increase well-being and actualize their health potential. It identifies opportunities to enhance health behaviors, not current or potential problems, and is supported by signs of willingness and desire to improve health

Syndrome Diagnosis

Clusters signs and symptoms to predict certain circumstances or events

Outcomes

• Therapeutic outcomes are developed to evaluate the effectiveness of the care given

• Goals of care plan

  • must be individualized and based on patient’s abilities

Planning

Four phases of a nursing care plan include:
 Setting priorities
 Developing measurable goal/outcome statements
 Formulating nursing interventions
 Formulating anticipated therapeutic outcomes

Implementation

• Meeting the physical needs of the patient, providing for patient safety, monitoring for potential complications, assessing and evaluating to identify changes in the patient’s needs

• Actual process of carrying out the established plan of care

• Nursing actions are suggested:

  • Dependent actions: Performed by a nurse based on health care provider’s orders

  • Interdependent actions: Implemented with the cooperation of a team

  • Independent actions: Provided by nurse by virtue of education and license

Evaluation

• Involves patient, family, and significant others who provide feedback and help determine goals

• Involves nurse determining whether the expected outcomes were met

• Recognizes the successful completion of previously established goals

• Provides a means for the input of new significant data that indicate the development of additional problems or lack of therapeutic responsiveness

Who to treat first

• use MASLOW’s Hierarchy

• ABC’s

Teaching strategies for medication education

affective, cognitive, psychomotor domain

affective domain

involves feelings, beliefs, needs, values, opionions

cognitive domain

involves learning, storing knowledge

psychomotor domain

• visual

• learning new skills

Teaching older adults/elderly

• talk loud and slow with the elderly

• Slow pace of the presentation, allow time to process new information

Medication reconcilliation

• Comparing patient’s current medication orders with the medications the patient is actually taking; performed during patient transfers, changes in practitioner

• Develop list of current medications and compare with list of medications prescribed

• Make clinical decisions based on the comparisons, and communicate new list to
  appropriate caregivers

Medication Errors

• Prescribing errors

• Transcription errors

• Dispensing errors

• Administration errors

• Monitoring errors

• Adverse drug events (ADEs): Costly errors

polypharmacy

patients on multiple medications

anaphylaxis

a life-threatening allergic reaction (throat swells up, throat closes, hives, increased heart rate, hard to breath)

idiosyncratic reaction

occurs when something unusual happens when the drug is first administered

desired affect

what you want the medication to do

agonist

drug binds to receptors and activates it, mimicking the natural chemical

ex: Morphine activates opioid receptors for pain relief.

antagonist

binds to the receptor but blocks it, preventing activation

displacement

a type of drug-drug interaction where one drug dislodges another from its binding site, which can include plasma proteins or receptors. When a drug is displaced, the concentration of the unbound, active drug in the body increases

synergistic effect

occurs when the combined effect of two or more drugs is greater than the sum of their individual effects; the drugs work together to produce a significantly enhanced therapeutic outcome that could not be achieved by a higher dose of a single agent. 

interpreter

if available at hospital request an actual interpreter; look at patient when talking, not the interpreter; do not use a family member

peak level

the highest concentration it reaches in a person's bloodstream after a dose is administered.

trough level

the lowest concentration of a drug in the bloodstream, measured immediately before the next dose is administered.

Urinary Tract Infection (UTI)

• more common in women because their urethra is shorter

• Gram-negative aerobic bacilli from the GI tract: Escherichia coli

• Avoid indwelling urinary catheter

chronic urinary incontinence

• Decreasing the amount of fluids causes the urine to become more concentrated, which irritates the bladder wall, thus increasing the incidence of bladder spasm and urinary incontinence.

• It is more effective to increase the intake of fluids, especially water. Intake of water may be decreased in the late evening to reduce the incidence of nighttime urinary incontinence.

Patient education for UTI’s

• wipe front to back

• wash perineal area

• adequate fluids

Antibiotics

• called antimicrobial

• the purpose is to treat an infection through antiseptic abilities. 

• you can build a resistance because the more you take the same _______, the bacteria can build a resistance to it and cause infection.

• Classified according to type of pathogen they are effective against

  • Antibacterial: Bacteria

  • Antifungal: Fungi

  • Antiviral: Viruses

• Based on sensitivity of the pathogen and possible toxicity to the patient

Treatment of UTI

Until the UTI test and antibiotic test comes back, the doctor prescribes a general (broad spectrum/empiric) antibiotic to start the process. When the cultures come back, the appropriate, specific antibiotic is prescribed. 

Get the cultures before you prescribe an antibiotic so the culture is not nullified.

Overactive Bladder Syndrome

• Urgency, with or without urge incontinence, usually with frequency and nocturia (waking up in the middle of the night with the urge to urinate)

• Can decrease quality of life

• Tell client to space out liquids (do not drink water before bed)

Glaucoma

characterized by elevated intraocular pressure (IOP); caused by an increased production of aqueous humor or an outflow obstruction

cancer

Disorder of cellular growth (abnormal/uncontrolled cell growth)

Treatment for cancer…

requires combination of surgery, radiation, chemotherapy, and immunotherapy

Chemotherapy

• Targets normal cells too, especially fast growing cells (hair)

• People can experience mouth sores, nausea, hair loss, vomiting

• Immunocompromised (wear masks, be careful of fresh fruit/veggies, flowers)

Goal of Palliation (cancer is uncontrolled)

alleviation of symptoms

How to diagnose cancer

Biopsy, imaging, screenings, pap smear

Pathology

result of a biopsy is called

serious adverse reactions of alkylating agents (cancer drug)

Bone marrow depression, nephrotoxicity

adverse affects of antimetabolites (cancer drug)

bone marrow depression, petechiae (bleeding underneath the skin), hepatotoxicity, dermatitis, stomatitis (mouth sores)

adverse affects of natural products for cancer

Bone marrow depression, peripheral neuropathy, hepatotoxicity

adverse affects of hormones (for cancer)

Gynecomastia (large breasts in males), hot flashes, diarrhea, pelvic pain, edema, hepatitis, thrombosis, hyperglycemia

amifosine

• chemoprotective agent

• protects kidneys from toxicity

bone marrow stimulants

Trigger recovery of bone marrow cells to make RBC

Nursing assessment for cancer

• History of risk factors

• Dietary habits

• Pre-existing health problems

• Understanding of and adaptation to diagnosis

• Psychomotor functions

• Safety

• Symptoms of pharmacologic adverse effects

• Physical and sexual assessment

• Smoking

• Pain

Nursing interventions (cancer)

• Plan care based on assessment data and individual needs of patient; monitor VS (temp)

• Examine lab tests

• Monitor for development of emergencies

• Monitor hydration status

• Report early signs of infection

• Nausea and vomiting are common

• Pre-administer antiemetic (anti-nausea); report poor control, monitor hydration and electrolyte status

• Meticulous oral hygiene for stomatitis (mouth sores)

• nutritional needs (protein intake)

• Vascular access devices (ports to give chemo)

neutropenia

low neutrophil count, causing risk for infection

Thrombocytopenia

low platelets, causes risk for bleeding, which can cause anemia

anemia

space activities and rest

common musculoskeletal disorders

RA and osteoarthritis, gout

how to assess for musculoskeletal disorders

lab work and x-rays