ERT II Unit 3: Medication Administration

Info on drug label

• Brade/Trade name

• Generic name

• Strength

• Total amount or volume in container

• Form of drug

• Manufacturer

• Directions/storage

• Expiration date

• Lot #

• National Drug Code (NDC)

Brand/Trade name

• Name used by manufacturer of drug

• Capitalized & sometimes bold

• Name followed by ® symbol indicating copyright

Generic name

• Name used by all manufacturers who market that drug

• Lower case, smaller font, below brand name

Strength

• Amount of drug contained in identified unit

• Ex: mg/mL, units/mL, mg/tab

Directions/storage

• Directions: “See package insert”

• Storage: is drug heat or light sensitive? does it need to be refrigerated?

Lot #

• Identifies drug by batch

• Needed if recalled

• Required documentation with vaccines

National Drug Code (NDC)

• 10-digit number that identifies each drug (starts with NDC)

• Required by federal law

Decimals

• Tenths (0.1)

• Hundredths (0.01)

• Thousandths (0.001)

Solid medication

• If tablet is scored for easy divisionin halves, you can round to the nearest ½ tablet

  • Ex: 0.4 tab rounded to 0.5 (1/2) tablet

• Never give partial dose unless tablet is scored

Liquid medication

• Usually rounded to the nearest tenth

  • Syringes are calibrated in tenths and/or hundredths

  • Ex: 1.76 mL rounds to 1.8 mL

Systems of measurement

• Metric system (medical setting)

• Household system (usually home setting)

• Systems measure 3 things

  • Weight: mass or heaviness

  • Volume: amount of space occupied

  • Length: linear distance from one point to another

Metric system

• Decimal system

• Based on multiples of 10

• Basic units of measurement

  • Weight (grams)

  • Volume (liters)

  • Length (meters)

Prefixes

• Micro-: 1/1,000,000 (0.000001)

  • One-millionth

• Milli-: 1/1,000 (0.001)

  • One-thousandth

• Centi-: 1/100 (0.01)

  • One-hundredth

• kilo-: 1,000 (1000)

Common uses of metric measurements

• mL: often used to give liquid medication orally or by injection

• mg: is often used to give medications such as tablets, powder, or topical preparations

• cm: is often used to measure a wound, head or chest circumference of an infant, diameter of swollen limb, etc.

• kg: often used to measure infant wieght or to calculate pediatric medication dosage

Household measurements

• Least accurate

• Basic units of measurement

  • Drop/drops (gtt/gtts), teaspoon (t, tsp), tablespoon (T, tbsp, tbs)

  • ounce (oz), pound (lb)

  • quart (qt), pint (pt)

  • cup (c )

• Mostly used for patient use at home to measure medication (drop, tsp, tbsp)

• May be used in healthcare to measure weight (pounds) & hight (ft & in), eye drops, or ear drops

Conversions

• Changing from one unit of measurement to another

• Includes:

  • Converting units within the same measurement system

  • Converting units from one measurement system to another

Syringe

• Plastic disposable part containing medication

• May have safety device

• Separate or combined with needle

• Type used depends on type of injection and amount of medication being administered

• Parts

  • Barrel: holds meds, calibrated in cc/mL or units

  • Flange: rim that stabilizes syringe during injection

  • Plunger: drawns meds, pushes meds

• Types

  • Hypodermic: calibrated in tenths (0.10) of cc/mL, administer IM injections, 1-3 cc/mL capacity

  • Insulin: calibrated in units (U), used to administer insulin, U-50 or U-100 capacity

  • Tuberculin: calibrated in tenths (0.10) and hundredths (0.01) of cc/mL, used to administer small dosages or PPD, 1 cc/mL capacity

Parts of a Needle

• Hub

  • Connects needle to syringe (Leur-Lok)

• Shaft

  • Inserted into tissue

  • Measured in inches (3/8-3 inches)

  • Length varies by type of injection, site, and size of pt

  • Tip is tapered/slanted (bevel)

• Lumen

  • Hollow shaft medication flows through

  • Measured in “gauge”: diameter (width) of lumen

  • As gauge number increases, diameter decreases

Solid drugs

• Tablet: solid formed by compressed powdered medication; may be coated, various sizes & shapes

  • May be chewable or scored for easy splitting

• Caplet: coated, oval tablet

• Capsule: medication contained in gelatin shell

• Enteric coated (protects stomach, dissolves in small intestine rather than stomach), sustained-release SR or extended-release ER or XL (gradual, continuous release)

• Lozenge: disk, possible sweetened, contained medication

Semi-solid drugs

• Cream: medication in non-greasy base

• Ointment: medication in greasy base

• Suppository: medication in oil base like cocoa butter, solid at room temp, but dissolves at body temp; instilled into rectum

Liquid drugs

• Swallowed, rubbed into skin, or instilled in ears/eyes/nose

• Elixir: medication particle dissolved in liquid containing alcohol

• Syrup: medication particles dissolved in sugar and water

• Suspension: medication particles suspended in liquid; shake before administration

• Aerosol: medication suspended in a gas

• Lotions

• Sprays

Route of administration

• Depends on drug, dosage, intended action, response time desired

• Oral: mouth

• Sublingual (SL): dissolves under tongue; rapid absorption

• Buccal: between gum and cheek; rapid absorption

• Inhalation: lungs; medication reaches alveoli where it is absorbed; Ex: MDIs and nebulizer medications

• Topical: medication applied to skin; local effect; aerosols held 3-6 inches form skin; apply to wounds with sterile swab

• Transdermal: medication applied to skin and absorbed into bloodstream; systemic effect; may use patch to deliver medication; write name and date when patch applied; wear gloves

• Nasal/intranasal: medication breathed in through nose and absorbed in nasal mucosa; blow nose first; sitting position

• Ocular: instilled by liquid drop or ointment into eye; labeled ophthalmic; do not touch eye with applicator tip

• Otic: instilled into ear; treat infection, reduce pain, or soften cerumen

• Rectal: rectum; suppositories; medication absorbed slowly through rectal mucosa; used when pt cannot tolerate oral meds; need water-soluble gel (K-Jelly) to ease insertion; use gloved, lubricated ringer to insert 3-4 inches in adults; use little finger to insert in small children 2 inches

• Vaginal: vagina; local effects; suppositories inserted 3-4 inches with finger; creams, ointments, or foams usually come with applicator; most used at hs when pt is lying flat

• Parenteral: outside GI tract; injection

  • Intradermal (ID): dermis

  • Subcutaneous (Subcut): hypodermis/fat

  • Intramuscular (IM): muscle

  • Intravenous (IV): vein

Rights of drug administration

• Right patient

  • State name and verify DOB

• Right drug

  • Verify three time (when retrieving from storage, when preparing, before administration)

  • Never administer drug prepared by another person

• Right route

• Right time (ex: q2h, TID, @hs)

• Right dose

  • Check label for concentration and compare with provider’s orders

  • Is dosage appropriate range?

• Right documantation

• Right to be educated

  • Explain drug that will be given, verify allergies, discuss possible side effects

• Right to refuse

  • Patient has legal right to refuse but must be informed of consequences of refusal…document!

Oral administration

• Medication is given by mouth in solid or liquid form

• After swallowing, absorption occurs mainly in small intestine (route that takes the longest time to absorb)

• Use medical asepsis to administer

• Most convenient, most common route

• Should not be used if difficulty swallowing or absorption problems

• Oral meds that coat throat should not be followed immediately with water

• Many meds should be swallowed with glass of water, not sip

• Straw should be used with meds that could stain teeth (tetracycline)

• Liquid meds should be measured with plastic med cup or med syringe

• Prescribed dose is gently tapped into lid of med container

• Dose is then placed in med cup

Parenteral administration

• Injectable meds in sterile, liquid form

• After injection, med is absorbed into bloodstream

• Absorption is more rapid than oral route

• Includes:

  • Intradermal

  • IM

  • Subcut

  • IV

• Use sterile technique to administer (invasive)

Prep of parenteral meds

• Available in various dispensing units

  • Ampules

  • Vials

  • Prefilled syringes/cartridges

Ampule

• Small sealed glass container containing single dose of med

• Prep

  • Verify order

  • Perform calculations if necessary

  • Assemble equipment and sanitize hands

  • Compare order with label on vial

  • Check expiration date

  • Tap narrow top of ampule to settle med to bottom of ampule

  • Disinfect neck of ampule with alcohol wipe

  • Place ampule breaker or gauze over top of ampule

  • Hold covered ampule between thumb and fingers

  • Break at neck, away from you, using one quick motion

  • Place broken top in sharps container

  • Using a filter needle, withdraw ordered dose of med

  • Discard ampule in sharps

  • Remove filter needle and place in sharps

  • Place appropriate needle for administration on syringe and recap

Vial

• Closed container with rubber stopper

• Single or multi-dose

• Prep

  • Roll vial between hands if requires mixing

  • Inject equal amount of air into vial to prevent a vacuum from forming in vial

  • When withdrawing, keep needle below fluid level to prevent entrance of air bubbles into syringe

Prefilled disposable syringes or cartridges

• Used with reusable Tubex injector

• Drug info printed on cartridge

Reconstitution of powdered drugs

• Adding liquid (usually normal saline-NS or sterile water) to a powdered drug

• Prolongs shelf-life

• Prep

  • Read label to determine correct amount of diluent to add to create dose ordered by provider

  • Disinfect top of each vial with alcohol wipe

  • Draw up correct amount of air to inject into diluent

  • Insert needle into center of rubber stopper and inject air

  • Invert diluent vial and withdraw correct amount of diluent

  • Remove needle from diluent

  • Inject needle into center of rubber stopper of drug vial and inject diluent

  • Remove needle from vial and discard into sharps

  • Roll vial between palms to mix thoroughly

  • Place air into new syringe equal to amount of med to be administered

  • Inject air into vial, invert vial, and withdraw ordered amount of med

  • Mark with reconstitution date if multi-dose vial

Intradermal injection (ID)

• Given just under the epidermis

  • Almost parallel angle (10-15º)

• Small amount of med only (0.01-0.1 mL)

• Nerves exist here, so may cause burning sensation when med is dispersed

• Common ID injections include

  • Mantoux tuberculin skin test (TST)

  • Intradermal flu vaccine (Fluzone)

  • Allergy testing

Tuberculosis (TB) ID injection

• TB is an infectious, bacterial disease caused by tubercle bacillus

• Usually affects lungs

• S&S: fatigue, weight loss, fever, night sweats, productive cough, chest pain

• Latent TB

  • No active disease, no s/s, not contagious, but TB test will be positive

  • Latent TB can become active TB when immune system is weakened

  • Will need tx antibiotics (INH) six months to one year

• Why do we do screening? To identify pts who:

  • are infected with TB

  • might develop TB

  • would benefit from treatment of latent TB

• Two types of tests have been approved by FDA to screen tuberculosis

  • Skin test (TST)

  • Blood test called QuantiFERON-TB Gold In-Tube test (GFT-GIT)

  • T-SPOT TB Test (T-Spot)

TST (TB skin test)

• MA responsibilities

  • Administer TST

  • Read results

• Can be given to

  • Pts with prior BCG vaccination (notify provider, may want blood test instead)

  • Pts with mild illness

  • Female pts who are pregnant or breastfeeding

  • Pts immunized with any vaccine ON THE SAME DAY as TST

  • Pts immunized with inactivated vaccines

• Contraindications

  • Prior, documented positive TST

  • Prior, severe reaction/allergy to TST

  • Prior, documented treatment for active TB

  • Pts under 6 months who have received vaccination with live virus such as MMR vaccine within past month (can interfere with cell mediated response to PPD)

• Procedure

  • Screen: can pt have TST?

  • Use 1 mL syringe with 1/4-5/8 inch, 25-27-gauge needle

  • Draw up 0.1 mL of PPD (purified protein derivative of tuberculin) from vial (Tubersol 5 TU/0.1 mL)

  • Have pt extend forearm, palm up

  • Identify site on mid-anterior forearm (2-4 inches below elbow)

  • Disinfect skin at site with alcohol and allow to dry

  • Remove cover from syringe/needle and hold it with dominant hand using thumb and index finger

  • Ensure that bevel is pointing upward

  • Hold skin taught at site with non-dominant hand

  • At 5-15º angle (almost parallel to skin), slowly insert needle until bevel is covered with skin

  • Lower needle to be parallel with skin and anchor it in place with dominant hand

  • Move non-dominant hand to slowly inject all of PPD (0.1 mL) until 6-10 mm wheal is created

    • No wheal, withdraw needle & administer new injection in new location

  • Withdraw needle and activate safety device using one hand

  • Discard syringe/needle into sharps

  • Document (include lot # and exp date)

• Reading results

  • Use inspection & palpation to read results

  • Results are read 48-72 hours after administration

  • Use mm ruler to read at diameter horizontally (induration only, redness is not significant)

  • If person was infected with TB, immune system has developed antibodies that will react to injection by causing swelling (induration)

  • Will cause induration in person with latent or active TB (does not differentiate between two types)

  • Induration ≥ 15 mm in patient with no known risk factors is considered positive

  • Induration of ≥ 5-15 mm in patient with certain risk factors is considered positive

  • Positive TB is followed with chest x-ray

TST (two step-TB)

• Who needs two-step TST?

  • Residents in long-term care facilities

  • Healthcare providers

• First TST

  • May be negative if immune system did not immediately identify bacteria

  • False-negative

• Second TST

  • Done 1-3 weeks after first test was read

  • Helps trigger immune response to identify those people who have been previously exposed to TB

  • Booster effect/booster phenomenon

ID flu vaccine

• Only ID vaccine

• Fluzone contains less antigen than IM flu vaccines

• Approved for adults 18-64 years

• Administered in deltoid area, but not into muscle

• Comes in pre-filled syringe

• Insert at 90-degree angle

Subcutaneous injection (Subcut)

• Subcut injection is given into adipose (fat) tissue (under epidermis & dermis)

  • SC, SQ, subQ no longer recommended as abbreviations

• Medication is absorbed into capillaries (slower than into muscle) which is beneficial when slow, continuous absorption is needed

• Nerves exist here, so may cause discomfort when medication is dispersed

• Amount of medication (0.5-1.5 mL); 0.5 mL in children

• Common subcut injections include:

  • Some vaccines (MMR)

  • Many drugs that must be taken daily, or injected at home, are designed for subcutaneous injection

  • Examples

    • Enoxaparin (Lovenox)

    • Heparin

    • Insulin (measured in units)

    • Allergy injections (NOT TESTING)

    • Some fertility drugs

    • Epinephrine

    • Drugs such as Enbrel for autoimmune diseases

    • Drugs such as Ozempic for DM

• Angle of insertion

  • Depends upon length of needle

  • Inserted at 45-degree angle if using 5/8 inch needle

  • Inserted at 90-degree angle is using ½ inch needle

• Sites

  • Upper, lateral-posterior arm for most adults (not into deltoid muscle)

    • Hand width above elbow, 3 fingers below acromion process

  • Anterior thigh

    • One hand above knee, one hand width below greater trochanter

    • Most often used for infants less than one year or when pt needs to self-administer

  • Upper back

  • Abdomen

    • Two inches away from/around umbilicus

    • Most often used when pt needs to self-administer (ex: insulin)

• Injection

  • Use 1-3 mL syringe, 5/8 or ½ needle, approx. 25 gauge

  • Identify site

  • Disinfect skin at site with alcohol and allow to dry

  • Remove cover from syringe/needle and hold it with dominant hand using thumb, index finger, and middle finger

  • Grasp and pinch up tissue with non-dominant hand (lift subcutaneous layer away from underlying muscle)

  • Insert entire needle at 45- or 90-degree angle, depending on needle length

  • Using one-handed or two-handed technique, inject medication slowly using plunger

  • Follow facility/provider recommendation for aspiration (no aspiration for pediatric vaccines, insulin, or heparin)

  • Release skin

  • Withdraw needle in same path it entered

  • Activate safety device with one hand

  • Discard syringe/needle into sharps (needle first)

  • Apply gentle pressure to injection site (do not rub)

  • Monitor pt for adverse reactions

  • Document

• Site rotation

  • Used for multiple or frequent injections

  • Easiest to give subsequent injections in circular pattern

  • One inch apart

  • Reduces risk of abscesses for pts who require frequent injections

Subcut: Enoxaparin (Lovenox)

• Enoxaparin is an anticoagulant that helps prevent blood clots (may teach pts how to self administer at home)

• When administering subcut enoxaparin, follow these guidelines

  • Drug should be clear and colorless to pale yellow

  • Do not push air out of syringe unless you are instructed to do so

  • Using finger and thumb, pinch skin 1-2 inches away form umbilicus

  • Push entire needle into skin and inject med while still holding pinched skin

  • Remove needle

  • Do not rub or massage

Subcut: Mixing insulin

• Insulin is prescribed to type I diabetics, and sometime type II diabetics that require treatment beyond oral hypoglycemic meds

• Must be injected (destroyed by stomach)

• Comes dissolved or suspended in liquid

• Ordered in units

• Diabetics sometimes have to take two types of insulin at the same time

  • Two types can come already combined in premixed solution

  • Two types may need to be correctly mixed in the same syringe

  • Make sure syringe chosen is greter than total dosage required (30, 50, or 100 unit syringe?)

  • Air into cloudy, air into clear…withdraw clear, withdraw cloudy

Intramuscular injection (IM)

• Injection into muscle tissue

• More rapid absorption than subcutaneous

• Used when administering drugs that would irritate or damage subcutaneous tissue

• Larger gauge needle used for oil-based medication

• Needle length 1-3 inches (1-1 ½ average adult)

• Gauge varies with viscosity of med

• 90-degree angle of insertion always!

• 3 mL syringe

• Inject with moderate speed

• Apple pressure, do not massage

• Skin is flattened over site with non-dominant hand

• Used for: most immunizations, antibiotics, contraceptives (Depo-Provera), vitamin B12, corticosteroids

• Aspiration

• Air lock technique

Aspiration

Air lock technique

IM injection procedure