Review for NCLEX-RN® - PHARMACOLOGY & PARENTERAL THERAPY

Review for NCLEX-RN® - PHARMACOLOGY & PARENTERAL THERAPY PHARMACOLOGY DRUG ADMINISTRATION Legal aspects of medication administration The Joint Commission requires that two patient identifiers (e.g., name, birthday, account number) be checked prior to administration of any medication. Components of a legal medication order • Date and time • Patient’s name • Patient’s inpatient ID number • Drug Name and strength of dose • Frequency of dose • Physician’s full signature Nurse’s legal responsibility • Interpret each component of the order • Question the order by communicating with the physician if • The nurse cannot read the order • Any component of the order is erroneous or ambiguous • The nurse had any doubt about the appropriateness of the order • Any order which does to make sense, such as large number of tablets or capsule. Or a large volume of solution for injection Controlled Substances All controlled substances must be stored in a locked container requiring a key or computerized access code for entry. An inventory record of all controlled substances used is maintained. If any part of a dose of a controlled substance is discarded, a second nurse witnesses the disposal and the record is signed by both nurses. (Agency policies and procedures are always followed.) Agency policies and procedures are followed with regard to the counting of controlled substances at the end of a shift; any discrepancy in the count is reported immediately. Before Administration Wash your hands. Assess the prescription and compare new medication prescriptions with the current list of medications (reconciliation). Ask the client whether he or she has a history of allergies. Determine the purpose of the medication. Assess the client for existing medical disorders in which the prescribed medication is contraindicated (e.g., many medications are contraindicated in pregnancy and for breastfeeding clients). Check the client’s age (the older client and the neonate are at greater risk for toxicity than is an adult client). Assess the client’s vital signs and significant laboratory results (e.g., the potassium level in a client who has been prescribed a loop diuretic). Assess the client’s understanding of the purpose of the prescribed medication. Identify and address concerns (e.g., social, cultural, religious) that the client has with regard to taking the medication. Use the appropriate resources (e.g., medication formulary, pharmacist) as necessary when preparing the medication. During Administration Assess the six rights: right medication, right dose, right client, right route, right time, and right documentation. Assess the need for conversion or calculation of a dose when preparing medication for administration. Administer the medication within 30 minutes of the prescribed time. Avoid administering medications with antacids, which affect absorption of medication. Also avoid administering medications with grapefruit juice, which contains an enzyme that inhibits absorption of many medications. After Administration Do not recap needles; discard needles in an appropriate container, using the safety device provided with the syringe if one is available. Dispose of any unused medication in accordance with agency policy: Liquid medication may be discarded in a sink or flushed down a toilet; tablets or capsules may be flushed down the toilet. Never discard medication in a trash container. Document administration of the medication given at€” including its name, the dose, the date and time, and your initials at€” immediately after giving the medication. Monitor the client for side effects or adverse effects (e.g., allergic reaction) to the medication and take action if adverse effects occur. Evaluate the client for a therapeutic response to the medication. Administering Oral Medications Pour tablets or capsules into the medication container's cap, not your hand. Medications prepared for unit dosage may be opened at the time of administration in the client's room. Scored tablets (those marked to facilitate division) may be divided into halves or quarters. Enteric-coated tablets and sustained-released capsules must not be crushed. To pour medication accurately using a medicine cup, hold the cup at eye level, then pour to the line designating the desired measure of medication. Volumes of less than 5 mL are measured with the use of a syringe from which the needle has been removed. A calibrated dropper is used to give medicine to a child or to add a small amount of liquid to water or juice. Do not mix liquids with tablets or liquids with liquids in the same container. Sublingual (under the tongue) and Buccal (between the cheek and the gum): Instruct clients to keep the medication in place until it is absorbed. Clients should not eat or drink while the tablet is in place. Liquids, Suspensions, & Elixirs: Follow directions for dilution and shaking. When administering the medication, the base of the meniscus (lowest fluid line) is at the level of the desired dose. Standard precautions require the wearing of gloves when placing a tablet under a patient’s tongue. The patient should not chew a sublingual tablet and should not drink or swallow until the tablet is completely dissolved and absorbed. Nasogastric and Gastrostomy Tubes  Check for proper tube placement.  Use a syringe and allow the medication to flow in by gravity, or push in with the plunger of the syringe. General guidelines Use liquid forms of medications. Do not give sublingual medications. Do not crush specially prepared oral medications (extended/time-release, fluid-filled, enteric coated). Check the compatibility of medications before mixing. Do not mix medications with enteral feedings. To prevent clogging, flush the tubing before and after each medication with 5 to 30 mL of warm water. When administration of medications is complete, flush with 30 to 60 mL of warm water. Keeping the drugs separate allows for accurate identification if a dose is spilled. The patient should be positioned in a semi-Fowler’s or Fowler’s position during and after administration of medications via a nasogastric tube to reduce the risk of aspiration. Parenteral Medications Parenteral medications are administered by way of subcutaneous, intramuscular, or intradermal injection or the intravenous route. These medications are packaged in ampules, vials, and premeasured syringes and cartridges. General Considerations: The vastus lateralis site is usually the recommended site for infants and children < 2 years of age. After age 2, the ventral gluteal site can be used. Both of these sites can accommodate fluid up to 2 mL. The deltoid site has a smaller muscle mass and only can accommodate up to 1 mL of fluid. Use a needle size and length appropriate to the type of injection and client size. Syringe size should approximate the volume of medication. Use a tuberculin syringe for solution volume < 0.5 mL. Rotate injection sites to enhance medication absorption, and document each site used. Do not use injection sites that are edematous, inflamed, or have moles, birthmarks, or scars. If medication is given intravenously, immediately monitor the client for therapeutic and side/adverse effects. Discard all sharps (broken ampule bottles, needle) in designated containers. Containers should be leak- and puncture-proof. Intradermal: This route is usually used for tuberculin testing or checking for medication/allergy sensitivities. It may be used for some cancer immunotherapy. Use small amounts of solution (0.01 to 0.1 mL) in a tuberculin syringe with a fine-gauge needle (26 to 27) In lightly pigmented, thin-skinned, hairless sites (inner surface of midforearm or scapular area of back) at a 10 to 15o angle. Tuberculin Syringe The tuberculin syringe, holding 1 mL, is used to measure small or critical amounts of medication (e.g., an allergen extract or vaccine or a child's medication). It may also be used to inject medication intradermally for diagnostic testing (e.g., tuberculin testing). This syringe is calibrated in hundredths (0.01) of a milliliter. In general, 3 to 4 finger widths below the antecubital space and 1 hand width above the wrist is the preferred location on the forearm. Subcutaneous: This route is appropriate for small doses of nonirritating, water-soluble medications and is commonly used for insulin and heparin. Use a 3/8- to 5/8-inch, 25- to 27-gauge needle, or an insulin syringe of 28- to 31-gauge. Inject no more than 1.5 mL solution. For an average-size client, pinch up skin and inject at a 45 to 90o angle. For an obese client, use a 90o angle. Sites are selected for adequate fat-pad size (abdomen, upper hips, lateral upper arms, thighs). Insulin Syringe The standard U-100 insulin syringe is used to measure U-100 insulin only; it is calibrated for a total of 100 units, or 1 mL. Insulin should not be measured in any other type of syringe. When a prescription indicates that regular and NPH insulin are to be combined, remember RN: Draw up the regular insulin first, then the NPH insulin. The proper technique for subcutaneous injections involves the use of a 1/2- to 5/8-inch needle, 25- gauge, at a 45- or 90-degree angle of insertion dependent on patient size, and aspiration is not done with anticoagulants and insulin. The landmark for the vastus lateralis is one handbreadth below the greater trochanter and above the knee on the outer aspect of the thigh. Intramuscular: This route is appropriate for irritating medications, solutions in oils, and aqueous suspensions. Most common sites include ventrogluteal, dorsogluteal, deltoid, and vastus lateralis (pediatric). Use needle size 18 to 27 (usually 22- to 25-gauge), 1 to 1 1/2 inches long, and inject at a 90o angle. Volume injected is usually 1 to 3 mL. If a greater amount is required, divide into two syringes and use two sites. Z-Track Technique: Z-track is a type of IM injection that prevents medication from leaking back into subcutaneous tissue. It is often used for medications that cause visible and/or permanent skin stains such as certain iron preparations. The Z-track method prevents medication from leaking into subcutaneous tissues where it can be irritating and/or painful. This method should be used with medications that are particularly irritating to the tissue. Some institutional policies require the use of the Z-track method with all intramuscular injections. The standard 3-mL syringe: This is calibrated in tenths of a milliliter.Standard medication doses for adults are to be rounded to the nearest tenth (0.1) of a milliliter. The nurse should not administer more than 3 mL per intramuscular or subcutaneous injection site; when a volume greater than 3 mL is required, a 5-mL syringe, calibrated in fifths, may be used. The dorsogluteal injection site is no longer recommended for injections because of the close proximity to the sciatic nerve and major blood vessels. Injury to the sciatic nerve from an injection may cause partial paralysis of the leg. The dorsogluteal site is not to be used for intramuscular injections. 0.2 mL of air should be withdrawn into the syringe to provide an airlock and prevent the leakage of medication back into the subcutaneous tissue. Intravenous: This route is appropriate for administration of medications, fluid, and blood products. Vascular access devices can be for short-term use (catheters) or long-term use (infusion ports). Use 16-gauge for trauma clients, 18-gauge for surgical clients, and 22- to 24-gauge for children, older adults, medical clients, and stable postoperative clients. Preferred sites are peripheral veins in the arm or hand. Ask the client which site he or she prefers. In neonates, veins of the head, lower legs, and feet may be used. After administration, immediately monitor for therapeutic and side/adverse effects. Epidural: Administration of intravenous opioid analgesia (morphine [Duramorph] or fentanyl [Sublimaze]). A catheter is advanced through a needle that is inserted into the epidural space at the level of the fourth or fifth vertebrae. Infusion pumps are necessary to administer medication. Injectable Medications in Powder Form Some medications become unstable when stored in solution and are therefore packaged in powder form. Powders must be dissolved with sterile diluent, or reconstituted, before use; usually sterile water or normal saline solution is used. Certain steps must be followed when a medication is reconstituted: 1. First locate the instructions on the label or in the vial's package insert. Read and follow the directions carefully. 2. The instructions will state the volume and type of diluent to be used and the resulting volume of the reconstituted medication. 3. Often the powdered medication adds volume to the solution in addition to the amount of diluent that is required. 4. When reconstituting a multiple-dose vial, label the vial with the date and time of preparation, your initials, and the date of expiration. It is also important to label the strength per volume. Eye drops, Ointments, & Eardrops Drops: Place medication in the lower conjunctival sac and instruct the client to blink one or two times, then keep the eyes closed for several minutes. Ointment: Squeeze a strip about a quarter-inch long (unless otherwise indicated) into the lower conjunctival sac and instruct the client to gently close his or her eyes and keep them closed for 2 to 3 minutes. Eardrops: Instruct the client to lie on the unaffected side or to tilt the head toward the unaffected side and to remain in this position for 2 minutes after administration. Next, pull back the pinna: In an adult client or older child, pull the pinna up and back; in an infant or child younger than 3 years, pull the pinna down and back. The eyedropper is held 1 to 2 cm above the conjunctival sac. The nurse should drop the prescribed number of drops into the conjunctival sac. Never apply eye drops to the cornea. If the drops land on the outer lid margins (e.g., if the patient moved or blinked), the procedure should be repeated. Antianginal Transdermal Patch or Ointment Remove the old patch or ointment and cleanse the skin. Avoid touching the inside of the patch or the ointment (wear gloves). Avoid applying the patch or ointment to skin with hair. When using ointment, measure out the correct amount on the appropriate paper applicator and tape the paper in place on the skin. Do not rub the ointment into the client's skin. Respiratory Inhaler 1. Shake inhaler well and remove the mouthpiece cover. 2. Breathe out through the mouth, expelling air. 3. Place the lips securely around the mouthpiece and inhale, pushing the top of the medication inhaler once while inhaling. 4. Hold the breath for a few seconds, then exhale slowly. 5. If a second inhalation is prescribed, wait 1 to 2 minutes before administering it. 6. A spacer may be used to keep the medication in the device longer thereby increasing the amount of medication delivered to the lungs and decreasing the amount of the medication in the oropharynx. Rectal Suppository: To administer a suppository rectally, place the client in the Sims position. Lubricate the suppository and insert it, pointed end first, through the anal sphincter at€” about 4 inches in an adult, 2 inches in a child. Instruct the client to remain supine for 5 to 10 minutes. Vaginal Suppository: To administer a suppository vaginally, first place the client in the lithotomy position. Lubricate the suppository and insert it 2 to 3 inches, toward the sacrum. Instruct the client to remain in the supine position for 5 to 10 minutes (offer a perineal pad). INTRAVENOUS THERAPY General Guidelines Check the prescription; if the nurse has questions, he or she must contact the physician to verify the accuracy of the prescription. Determine the purpose of the solution (e.g., to remedy dehydration). Determine the client’s understanding of the purpose of the IV infusion. Identify and address concerns (e.g., social, cultural, religious) that the client may have about IV therapy. Ask the client whether he or she has a history of allergies (e.g., latex). Caution is required in the administration of IV fluids to certain clients. Assess vital signs and the pertinent laboratory results. Document the IV solution (the name of the solution, the date and time when the infusion was initiated, the flow rate, the site and appearance of the infusion, and your initials) immediately after initiation of the infusion and after assessment. Monitor the client for adverse effects of the therapy (e.g., infiltration, phlebitis). Evaluate the client for a therapeutic response to the treatment. Commonly Used IV Solutions Isotonic Solutions: Concentration of solute is similar to plasma. The osmotic pressure is constant inside and outside the cells, therefore, fluid in each compartment remains, no shift occurs. Cells neither shrink nor swell because fluid is distributed between intravascular and interstitial (extracellular). Hypotonic Solutions: Lower concentration of solutes than plasma. It causes fluid to shift from intravascular space to intracellular and interstitial spaces. Cells swell, but may deplete intravascular fluid (plasma, circulatory system). Hypertonic Solutions: Rarely used. Higher concentration of solute than plasma. It causes fluid to shift from intracellular space to extracellular (intravascular and interstitial) spaces. Used as volume expanders, hyponatremia, and cerebral edema. Solution Type Uses 0.9% NaCl (Sodium Chloride) (Normal Saline) (NS) Isotonic Composition: Water Na: 154 mEq/l Cl: 154 mEq/L  Use to increase fluid volume in extracellular spaces. Examples are: Hemorrhage, sever e vomiting or diarrhea, heavy drainage from GI suction, fistulas or wounds.  Also mild hyponatremia, hypercalcemia, and metabolic acidosis. Fluid of choice for resuscitation efforts (patient in shock). Lactated Ringer’s (LR) (Hartmann Solution) Isotonic Composition: Na:130 mEq/l K: 4 mEq/l Ca: 3 mEq/l Cl: 103 mEq/l  Its electrolyte content is most closely related to blood serum and plasma. Therefore, it is more beneficial for patients who require electrolyte replace.  Alkalinizing Solution: The lactate is metabolized into bicarbonate by the liver, so LR is often used to correct metabolic acidosis.  Another choice for resuscitation efforts, especially for fluid loss in burns and trauma. Also for patient with acute blood loss (hypovolemia) 0.9% NaCl (Sodium Chloride) (Normal Saline) (NS) Isotonic Use to increase fluid volume in extracellular spaces. Examples are: Hemorrhage, sever e vomiting or diarrhea, heavy drainage from GI suction, fistulas or wounds. Also mild hyponatremia, hypercalcemia, and metabolic acidosis. Fluid of choice for resuscitation efforts (patient in shock). Lactated Ringer’s (LR) (Hartmann Solution) Isotonic Used to remedy extracellular fluid deficits (e.g., fluid loss from burns, bleeding, or dehydration resulting from loss of bile or diarrhea). 5% dextrose in water (D5W): isotonic Replaces deficits of total body water. Not generally used alone to expand extracellular fluid volume because dilution of electrolytes may occur. 5% dextrose in 0.225% saline (5% D and 1/4 NS): isotonic 5% dextrose in 0.45% saline (5% D and 1/2 NS): hypertonic Used as initial fluid for hydration because it provides more water than sodium. Commonly used as maintenance fluid. Inserting an IV Catheter Prepare the client for the insertion procedure (i.e., the procedure and what to expect in terms of discomfort). Use sterile technique when inserting the IV and whenever working with an IV. Determine the client's dominant side and select the opposite side for venipuncture. Once a side has been selected, carefully choose a site.