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 adv