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  • Copyright © 2023 by Jones & Bartlett Learning, LLC, an Ascend Learning Company and the American Academy of Orthopaedic Surgeons.

Medication Administration Overview

  • Chapter 14: Focuses on various aspects of medication administration critical in medical settings.

Vascular Access

  • Vascular access is crucial for patients in hemodynamically unstable conditions.
  • Various techniques exist for establishing vascular access.
  • The patient's survival relies heavily on the medical personnel's skills and abilities.

Medical Direction

Online Medical Control

  • In instances where medication administration is uncertain:
    • Utilize established protocols, drug formularies, flip guides, smartphone apps, or other resources.
    • Contact online medical control for assistance.

General Medical Control Support

  • Provides:
    • Approval of specific medications.
    • General consultations on treatment modalities.
    • Strong recommendation to contact medical control when in doubt.

Ensuring Safe Medication Administration

Protocols to Follow

  • Utilize standing orders or seek online medical direction when necessary.
  • Avoid human errors during medication administration.
  • Employ tools to cross-verify medication and dosage.
  • Importance of maintaining detailed documentation:
    • Document the dose administered, medication name, route, rate, time of administration, who administered it, who assisted in the verification, and the patient’s response.

Local Drug Distribution System

  • Equipment Check: Ensure all equipment functionality at the start of each shift.
    • Medications must be:
    • Not expired.
    • Not damaged.
    • Readily available in the correct quantities.
  • Responsibility for documentation and security of controlled substances rests with medical personnel.

Medical Asepsis

  • Definition: The practice of preventing contamination of the patient through aseptic techniques.
  • Achieved through:
    • Sterilization of equipment.
    • Use of antiseptics.
    • Application of disinfectants.
  • Clean Technique vs. Sterile Technique:
    • Sterile Technique: Involves destroying all living organisms using heat, gas, or chemicals.
    • Establishing a sterile field includes:
      • Wearing mask and sterile sleeves/gown.
      • Utilizing sterile drapes around the procedural area.
  • Field Considerations:
    • Maintaining a sterile environment may be impractical in field situations. Therefore, medical asepsis should be practiced to limit contamination and infection risk.
    • Key practices include: handwashing, glove use, and maintaining equipment cleanliness.
  • Antiseptics vs. Disinfectants:
    • Antiseptics: Used before invasive procedures.
    • Disinfectants: Toxic to live tissues and must be handled with care.

Standard Precautions

  • Concept: Treat any bodily fluid as if potentially infectious, to avoid cross-contamination.

Disposal of Contaminated Equipment

Sharps Disposal

  • Once an IV catheter or needle has penetrated the skin, it is considered contaminated.
  • Sharps: Items include:
    • Needles/catheters
    • Scalpels
    • Broken ampules/vials
  • Immediate disposal is required in a sharps container, with collection points in ambulances and jump kits for easy access.

Body Fluid Composition

  • The human body primarily consists of water, which serves as a vital environment for life.
  • It maintains a balance of fluid and electrolyte levels.
  • An ill or injured individual may struggle to maintain homeostasis.
  • A healthy person typically loses about 2-2.5 liters of fluid daily through urine, respiration, and skin.

Dehydration

Definition

  • Characterized as inadequate total systemic fluid volume.

Signs and Symptoms

  • Decreased level of consciousness.
  • Postural hypotension.
  • Tachypnea.
  • Dry mucous membranes.
  • Decreased urine output and tachycardia.
  • Poor skin turgor and flushed dry skin.

Causes of Dehydration

  • Contributing factors may include:
    • Diarrhea.
    • Vomiting.
    • Gastrointestinal drainage.
    • Infections.
    • Metabolic disorders.
    • Hemorrhage.
    • Environmental emergencies.
    • High caffeine intake.
    • Insufficient fluid intake.

Overhydration

Definition

  • Occurs when systemic fluid volume increases excessively.

Signs and Symptoms

  • Shortness of breath.
  • Puffy eyelids and edema.
  • Polyuria.
  • Moist crackles (rales).
  • Acute weight gain.

Causes of Overhydration

  • Common causes can include:
    • Unmonitored IVs, especially in pediatrics.
    • Kidney failure.
    • Water intoxication during endurance sports.
    • Prolonged hypoventilation.

IV Fluid Composition

Overview of IV Solutions

  • Each IV solution bag is individually sterilized.
  • Altering IV concentration can shift water across fluid compartments.
  • Electrolyte Levels may change due to:
    • Excessive vomiting.
    • Diarrhea.
    • Dietary inadequacies.
    • Medication side effects.
    • Blood loss or other injuries.

Types of IV Solutions

Crystalloid Solutions

  • Composed of dissolved crystals in water.
  • Can cross membranes, thus altering fluid levels.
  • Optimal replacement fluids are as near to whole blood as possible.
  • They do not carry oxygen, but can be used in boluses to maintain perfusion.

Colloid Solutions

  • Contain molecules too large to pass out of capillaries, remaining in the vascular system.
  • Typically high osmolarity and may reduce edema, but cause significant fluid shifts with a short duration of action and low cost-to-benefit ratio.

Tonicity Categories of IV Solutions

  1. Isotonic Solutions:

    • Same sodium concentration as cell fluid.
    • Water does not shift; no change in cell shape.
    • Examples:
      • Lactated Ringer’s (LR) solution
      • D5W (5% dextrose in water)

  2. Hypotonic Solutions:

    • Lower sodium concentration than cellular fluid.
    • Hydrates cells while depleting the vascular compartment, leading to sudden fluid shifts from the intravascular space to inside the cells.
    • Example: 0.45% sodium chloride.

  3. Hypertonic Solutions:

    • Higher sodium concentration than cellular fluid.
    • High osmolarity and ionic concentration pull fluid from intracellular and intestinal compartments to the vascular compartment.
    • Stabilizes blood pressure, increases urine output, and can reduce edema but needs careful monitoring to prevent fluid overload.
    • Example: 3% sodium chloride.

  4. Oxygen-Carrying Solutions:

    • Whole blood serves as the best replacement for blood loss, whereas synthetic blood substitutes are also available.

Techniques and Administration of IVs

IV Therapy Overview

  • Involves cannulation of a vein with a catheter, with peripheral vein cannulation focusing on veins in the extremities.
  • Key prerequisite: Keeping IV equipment sterile.

Assembling Equipment

  • Gather essential items beforehand:
    • Latex-free tourniquet.
    • Cleaning wipes or solution.
    • Gauze pads.
    • Tape or adhesive bandages.
    • Transparent polyurethane dressings.
    • Appropriate size IV catheter.
    • IV extension set.
    • Saline flush.
    • IV fluid and administration set.
    • Sharps container.

Choosing an IV Solution

  • Typically limited to normal saline and lactated Ringer’s solution.
  • Sterility of IV bags is guaranteed, with a 24-hour usability once opened.
  • Standard configurations include:
    • Two ports (injection and access).
    • Removable pigtail.
    • Various fluid volumes.

Choosing an Administration Set

  • Once the piercing spike is exposed, the set must be used.
  • Two common sizes:
    • Microdrip set: 60 gtt/mL.
    • Macrodrip set: 10 or 15 gtt/mL.

Preparing an Administration Set

  • Verify the expiration date of fluids.
  • Ensure that the solution is clear and not expired.
  • Properly spike the IV bag and flush with fluid to eliminate air from the line.

Spiking the Bag

  • Ensure:
    • Solution clarity and expiration.
    • Correct drip rating and un-tangled tubing.
    • Protect covers are present, and flow clamp should be closed.
  • After spiking, fill the drip chamber and monitor levels for proper fluid administration.

Managing IV Sites and Catheters

Choosing an IV Site

  1. Avoid areas with valves and bifurcations.
  2. Look for veins that appear straight, firm, round, and that spring back when palpated.
  3. Limit IV access to distal areas of extremities.
  4. Bulging veins may roll, so keep skin taut.
  5. Consider patient discomfort and opinions when determining the IV site.

Choosing an IV Catheter

  1. Types:
    • Over-the-needle.
    • Automatic needle retraction.
    • Larger diameter for smaller gauge numbers.
  2. Safety:
    • Ensure the largest-diameter catheter is used where possible, avoiding butterfly catheters in prehospital settings unless necessary.

Inserting the IV Catheter

  1. Position the beveled side of the needle upwards.
  2. Maintain good traction; use a constricting band above the site.
  3. Inspect the needle and prep the site, aiming at a 35 to 45° angle for initial insertion.
  4. Lower angle to 15° after puncturing the vein and advance a few centimeters.
  5. Remove the needle after inserting the catheter and secure the site appropriately.

Securing the IV Line

  • Secure catheter and tubing with tape, covering with sterile gauze. Refer to Skill Drill 14-1 for guidance on obtaining vascular access.

Changing and Discontinuing IV Lines

Changing an IV Bag

  • Close the roller clamp to stop the flow of fluids.
  • Prepare a new IV bag by injecting the spike into it.
  • Ensure the drip chamber is filled and then reopen the roller clamp for continued infusion.

Discontinuing the IV Line

  1. Shut off the flow and peel back the tape.
  2. Stabilize the catheter using pressure above its hub, then smoothly remove the catheter and IV line.
  3. Apply direct pressure and a bandage to the site to prevent bleeding.

Alternative IV Sites and Techniques

Saline Locks

  • Also referred to as intermittent sites, they maintain an active IV site without continuous fluids.
  • Typically use a Luer-lock connector at the end of the IV catheter for administration of saline flush.

External Jugular (EJ) Vein Cannulation

  • Considered after exhausting other IV site options:
    • Requires the correct patient positioning.
    • Use of aseptic technique while identifying and accessing the EJ vein for administration.

Pediatric and Older Adult Considerations in IV Therapy

Pediatric IV Therapy Considerations

  • Best gauges for catheters in children are sizes 20, 22, 24, and 26, while butterfly catheters are preferred due to ease of access.
  • Generally, preferred IV sites remain in the hand veins, with clear explanations provided to children and parents during procedures.

Adult IV Therapy Considerations

  • Use smaller catheters to prevent complications such as hematomas.
  • Monitor for signs of vein damage due to age-related factors, ensuring careful management of existing conditions like varicosities.

Factors Affecting IV Flow Rates

To Ensure Proper Flow

  • After initiating IV administration, monitor:
    • The height of the bag.
    • Catheter type.
    • Constricting band status.
    • Ensure there is no clamping, and check the positioning of the line itself.

Potential Complications of IV Therapy

Local Complications

  1. Infiltration:

    • Caused by catheter dislodgement or puncture of vein wall, often manifested as localized edema.
    • If it occurs, discontinue the IV line and document the condition.

  2. Catheter Occlusion:

    • Resulting in a physical blockage, indicated by a slowing drip rate.
    • Address by replacing the catheter and applying a sterile dressing.

  3. Vein Spasm:

    • Patients may report discomfort; often indicated by changes in infusion rate and localized pain.
    • Slow the rate until resolved, or replace the catheter if spasm persists.

  4. Phlebitis:

    • Inflammation of the vein, potentially caused by irritation chemicals or mechanical factors.
    • If observed, discontinue the IV line and note for analysis.

  5. Thrombophlebitis:

    • Related to long-term IV therapy, IV drug use, or irritants.
    • Respond by stopping infusion immediately and applying warm compress.

  6. Hematoma:

    • Blood accumulates in surrounding tissue; typically seen with improper technique.
    • Monitor the IV flow and manage as per protocol if formation occurs.

  7. Nerve, Tendon, or Ligament Damage:

    • Often results from poor technique or anatomy misidentification.
    • If suspected, discontinue usage and consider alternative sites.

  8. Arterial Puncture:

    • Notable in high-risk areas; bright blood indicates arterial access. Immediate care necessitates direct pressure.

Systemic Complications

  1. Allergic Reactions:

    • Possible reactions to IV solutions or medications, requiring immediate cessation of the infusion.

  2. Pyrogenic Reactions:

    • May occur due to foreign proteins within the solution, manifesting swiftly.
    • Requires monitoring and sometimes replacement of the IV site.

  3. Circulatory Overload:

    • Resulting from excessive fluid intake leading to pulmonary edema; necessitates immediate intervention monitoring.

  4. Speed Shock:

    • Rapid infusion causing adverse effects; halt the infusion and monitor closely.

  5. Air Embolus:

    • Introducing air into the bloodstream causes complications, usually managed by positioning and supplemental oxygen.

  6. Vasovagal Reactions:

    • Patient anxiety around needles resulting in faintness; manage by positioning and monitoring.

  7. Catheter Shear:

    • Potential complication where the catheter is damaged, requiring immediate alternative access management.

Obtaining Blood Samples

  • Blood samples may be collected simultaneously with IV insertion, utilizing specific syringes and needles.
  • Follow standard protocols for occluding and attaching syringes correctly to obtain the requisite sample volume, ensuring proper handling afterwards.

Blood Transfusions

Procedures

  • Confirm necessary details: Type and cross-match, patient identification (name, medical record number), transfusion product details, ABO, Rh types, and expiration date.
  • Type O blood is generally available; however, it must be utilized within four hours after opening.
  • For monitoring transfusions, vital signs should be assessed frequently, and protocols for addressing reactions must be understood.

Intraosseous (IO) Infusion

Overview

  • IO infusion is indicated for rapid access in situations where IV access proves difficult. Common sites include:
    • Proximal tibia.
    • Humeral head.
    • Sternum.
  • The technique allows for quick absorption and can be life-saving in emergencies.

Equipment for IO Infusion

  • Manually inserted IO needles or advanced devices (e.g., EZ-IO, FAST) streamline the insertion process, particularly during emergencies.

Potential Complications

  • Include:
    • Infiltration, osteomyelitis, and other issues which arise from improper anatomy recognition.

Contraindications for IO Infusion

  • Presence of a functional IV line or fragility of targeted bones (e.g., osteoporosis) precludes IO use.

Medication Administration

Ground Rules

  • Familiarity with medication mechanics is essential, especially concerning their actions, effects, contraindications, dosage, and antidotes.

Mathematical Principles in Pharmacology

Key Concepts

  • Understanding fractions, decimals, and percentages is critical for proper calculations.
  • The metric system aids in universal communication of weights and volumes.
  • Volume and weight conversion methods should be practiced for accurate dosing and administration details.

Computing Medication Doses

  1. Determine the desired dose, relative to what is on hand in terms of concentration on a per-mL basis.
  2. Follow established formulas for continuous drug infusion and dosage based on patient weight when appropriate.

Administration Routes of Medications

Enteral and Parenteral Medication Administration

  • Ensure adherence to proper routes—oral, intramuscular (IM), subcutaneous (SC), intravenous (IV), or IO— to align with specific therapeutic requirements.
  • Each method's administration process varies from preparation all the way to post-administration monitoring and documentation.

Ocular and Aural Medication Administration

  • Utilizing techniques tailored to target these sensitive areas requires specific precautions and an understanding of the anatomical features involved.

Percutaneous Medications

  • Dermal application for sustained drug release highlights the significant need for proper technique and vigilance, especially in sensitive patient populations.

Long-Term Vascular Access Devices

Types of VADs

  • Non-tunneling devices (e.g., PICC, midlines) favor short-term access and require strict aseptic protocols during access and management.
  • Implanted VADs are suited for patients needing prolonged therapy requiring specialized access techniques.

Key Management Practices

  • Consistently follow the access and maintenance protocols to safeguard against infection and ensure efficacy over the short- and long-term.

Rates of Medication Absorption

  • Absorption rates are significantly affected by the route of delivery, with IV injections entering the bloodstream fastest, while oral medications take longer for effective uptake.