Principles of Drug Administration

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Chapter 3

Responsibilites of the nurse when administering medication

-what drug is ordered
-name (generic and trade) and drug classification
-intended or proposed use
-effects on the body
-contradictions
-special considerations (e.g., how age, weight, body fat distribution, and individual pathophysiologic states affect pharmacotherapeutic response)
-side effects
-why the medication has been prescribed for this particular patient
-how the medication is supplied by the pharmacy
-how the medication is to be administered, including dosage ranges
-what nursing process considerations related to the medication apply to this patient

Allergic Reaction

-an acquired hyperresponse of body defesnes to a foreign substance (allergen)
-signs of allergic reactions vary in severity and include skin rash with or without itching, edema, runny nose, or reddened eyes with tearing

Anaphylaxis

-a sever type of allergic reaction that involves the massive, systemic release of histamine and other chemical mediators of inflammation that can lead to life threatening shock
-symptoms such as acute dyspnea (difficulty breathing), and the sudden appearance of hypotension or tachycardia following drug administration are indicative of anaphylaxis which must recieve immediate treatment

The Five Rights of Drug Administration

-together, they form the operational basis for the safe delivery of medications
-offer simple and practical guidance for nurses to use during drug preparation, delivery, and administration, and focus on individual performance

1. right patient
2. right medication
3. right dose
4. right route of adminitration
5. right time of delivery

can also include:
-right to refuse medication, the right to recieve drug education, the right preparation, and the right documentation

The Three Checks of Drug Administration

-used in conjuction with the five rights help to ensure patient safety and drug effectiveness
1. checking the drug with the MAR or the medication information system when removing it from the medication drawer, refrigerator, or controlled substance locker
2. checking the drug when preparing it, pouring it, taking it out of the unit-dose container, or connecting the IV tubing to the bag
3. checking the drug before administering it to the patient

Compliance

-taking a medication in the manner prescribed by the health care provider, or in the case of OTC drugs, following the instructions on the label
-patient noncompliance ranges from not taking the medication at all to taking it at the wrong time or in the wrong manner

Reasons for noncompliance

-drug may be too expensive
-the drug may not be approved by the patient's health insurance plan
-patients forget doses of medications, especially when they must be taken three or four times per day
-annoying side effects such as; headache, dizziness, nausea, diarrhea, or impotence (erectile dysfunction)
-impair major lifestyle choices

-patients may self-adjust their doses
--some patients believe that if one pill is good, two must be better
-others believe that they will become dependent on the medication if they take it as prescribed so they only take half of the required dose

STAT order

-refers to any medication that is needed immediately and is to be given only once
-often associated with emergency medications that are needed for life-threatening situations
-comes from the latin word "statim" meaning immediately
-should be administered within 5 minues or less of recieving the written order

ASAP order

-not as urgent as STAT
-as soon as possible
-should be avaliable for administration to the patient with 30 minutes of the written order

Single order

-for a drug that is to be given only once, and at a specific time, such as a preoperative order

PRN order

-latin "pro re nata"
-administered as required by the patient's condition
-the nurse makes the judgement, based on patient assessment, as to when such a medication is to be administered

Routine orders

-orders not written as STAT, ASAP, NOW or PRN
-these are usually carried out within 2 hours of the time the order is written by the physician

Standing order

-written in advance of a situation that is to be carried out under specific circumstances
-example: set of postoperative PRN prescriptions that are written for all patients who have undergone a specific surgical procedure "Tylenol elixir 325mg PO every 6 hours PRN sore throat"
-standing orders are no longer permitted in some facilites because of the legal implications of putting all patients into a single treatment category

ac

-before meals

ad lib

-as desired, as directed

AM

-morning

bid

-twice per day

cap

-capsule

gtt

-drops

h or hr

-hours

IM

-intramuscular

IV

-intravenous

no

-number

pc

-after meals, after eating

PO

-by mouth

PM

-afternoon

PRN

-when needed/necessary

qid

-four times per day

q2h, q4h, q6h, q8h, q12h

-every __ hours

STAT

-immediately, at once

tab

-tablet

tid

-three times per day

Enteral Drug Administration

-includes drugs given orally and those administered through the nasogastric or gastrostomy tubes
-take advantage of the vast absorptive surfaces of the oral mucosa, stomach, and small intestine

Oral Drug Administration

-oral dugs administration is the most common, most convienient, and usually the least costly of all routes
-considered the safest route because the skin barrier is not compromised
-avaliable in tablet, capsule, and liquid forms

Tablets and Capsules

-the most common forms of drugs
-patients prefer tablets or capsules over other routes and forms because of their ease of use
-some patients, especially children, have difficulty swallowing tablets and capsules
-crushing tablets or openings capsules and sprinkling the drug over food or mixing it with juice will make it more palatable and easier to swallow
-do not crush tablets or open capsules inless the manufacturer specifically states this is permissable
-some drugs are inavtivated by crushing or opening, whereas others severely irritate the stomach mucosa and cause nausea or vomiting
-some drugs can irritate the oral mucosa, are extremely bitter, or contain dyes that stain the teeth

Enteric Coated Drugs

-the strongly acidic contents within the stomach present a destructive obstacle to the absorption of some medications
-tablets may have hard, waxy coatings that enables them to resist the acidity
-enteric coated tablets are designed to dissolve in the alkaline environment of the small intestine
-do not crush these drugs because the medication would then be directly exposed to the stomach environment

Sustained Release Drugs

-compliance declines as the number of doses per day increases
-sustained release tablets or capsules are designed to dissolve very slowly
-this releases the medication over an extended time and results in longer duration of action for the medication
-also called extended-release (XR), long-acting (LA), or slow-release (SR) medications, these forms allow for convienience of once-or-twice-a-day dosing
-extended release medication must not be crushed ot opened

Disadvantages to Oral Medication

-patient must be conscious and able to swallow properly
-certain drugs, such as proteins, are inactivated by digestive enzymes in the stomach and small intestine
-first pass metabolism=medications absorbed form the stomach and small intestine first travel to the liver, where they may be inactivated before they ever reach their target organs
-the significant variation in the motility of the GI tract and in its abilitt to absorb medications can create differences in bioavaliability
-children and some adults have an aversion to swallowing large tablets and capsules or to taking oral medications that are distasteful

Sublingual and Buccal Drugs

-tablet is not swallowed but kept in the mouth
-the mucosa of the oral cavity contains a rich blood supply that provides an excellent absorptive surface for certain drugs
-medications given by this route are not subjected to destructive digestive enzymes
-do not undergo hepatic first-pass metabolism

Sublingual Route

-the medication is placed under the tongue and allowed to dissolve slowly
-because of the rich blood supply in this region, the sublingual route results in a rapid onset of action
-sublingual dosage forms are most often formulated as rapidly disintegrating tablets or soft gelatin capsules filled with liquid drug
-oral medication should be swallowed before a sublingual medication is administered
-the patient should not move the drug with their tongue
-the patient should not eat or drink anything until the medication is completely dissolved

Buccal Route

-the tablet or capsule is placed in the oral cavity between the gum and the cheek
-the patient must be instructed not to manipulate the medication with the tongue; it could get displaced to the sublingual area where it would be more rapidly absorbed, or to the back of the throat, where it could be swallowed
-the buccal muscosa is less permeable to most medications than the sublingial area, providing for slower absorption
-the buccal route is preferred over the sublingual route for sustained release delivery drugs because of the greater mucosal surface area of the former
-drugs formulated for buccal administration generally do not cause irritation and are small enough to not cause discomfort to the patient
-drugs administered by the buccal route avoid first-pass metabolism by the liver and the enzymatic processes of the stomach and small intestine

Nasogastric and Gastostomy Drug Administration

-patients with a nasogastric tube (NG Tube) or enteral feeding mechanism such as a gastostomy tube (G Tube) may have their medications administered through these devices
-NG tubes are used for short-term treatment
-G tubes are inserted for patient's requiring long-term care
-drugs administered through these tubes are usually in liquid form because a crushed or dissolved solid drug can cause clogging within the tubes
-drugs administered by this route are exposed to the same physiologic processes as those given orally

Topical Drug Administration

-those applied locally to the skin or the membranous linings of the eye, ear, nose, respiratory tract, urinary tract, vagina, and rectum
-some drugs are applied topically to produce a local effect
---example: antibiotics applied to the skin to treat skin infections
-local, topical delivery produces fewer side effects compared with oral or parenteral administration of the same drug
--this is because topically applied drugs are absorbed very slowly, and amounts reaching the general circulation are minimal
-some drugs are given topically to provide for slow release and absorption of the drug in the general circulation
---these agents are administered for their systemic effects
---example: nitroglycerin patch applied to the skin not to treat a local skin condition but to treat a systemic condition, coronary artery disease

Dermatologic Preparations

-drugs applied to the skin
-the most common topical route
-includes creams, lotions, gels, powders, and sprays

Instillations and Irrigations

-drugs applied into the body cavitied or orifices
-includes the eyes, ears, nose, urinary bladder, rectum and vagina

Inhalations

-drugs applied to the respiratory tract by inhalers, nebulizers, or positive-pressure breathing apparatuses
-most common indication for inhaled drugs is bronchoconstriction due to bronchitis or asthma
-illegal, abused drugs are taken by thise route because it provides a very rapid onset of drug action

Transdermal Delivery System

-provides an effective means of delivering certain medications
---examples: nitroglycerin for angina pectoris and scopolamine for motion sickness
-although transdermal patches contain a specific amount of the drug, the rate of delivery and the actual dose may be variable
-patches are changed on a regular basis, using a site rotation routine, which should be documented in the MAR
-drugs administered this way avoid the first pass metabolism in the liver and bypass digestive enzymes

Ophthalmic Administration

-used to treat local conditions of the eye and surrounding structures
-common indications include excessive dryness, infections, glaucoma, and dilation of the pupil during eye examinations
-avaliable in the form of eye irrigations, drops, ointments, and medicated disks

Otic Administration

-used to treat local conditions of the ear, including infections and soft blockages of the auditory canal
-otic medications include eardrops and irrigations which are usually ordered for cleaning purposes

Nasal Administration

-used for both local and systemic drug administratio
-nasal muscosa provides an excellent absorptive surface for certain medications
-advantages include ease of use and avoidance of the first-pass metabolism and digestive enzymes
-nasal sprays formulations of corticosteroids have revolutionized the treatment of allergic rhinitis owing to their hish safety margin when administered by this route
-althougth the nasal mucosa provides an excellent surface for drug delivery, there is potential for damage to the cilia within the nasal cavity
-mucosal irritation is common
-unpredictable mucus secretion among some individuals may affect drug absorption from this site
-drops or sprays are often used for their local astringent effect= they shrink swollen mucous membranes or loosen secretions and facilitate drainage
---this brings immediate relief from the nasal congestion cause by the common cold

Vaginal Administration

-used to deliver medications for treating local infections and to relieve vaginal pain and itching
-vaginal medications are inserted as suppositories, creams, jellies, or foams
-provide for privacy and patient dignity
-offer a perineal pad following administration

Rectal Administration

-the rectal route may be used for either local or systemic drug administration
-it is a safe and effective means of delivering drugs to patients who are comatose or who are experiencing nausea or vomiting
-normally in suppository form, although a few laxatives and diagnostic agents are given via enema
-although absorption is slower than by other routed, it is steady and reliable provided the medication can be retained by the patient
-venous blood from the rectum is not transported by way of the lover so first-pass metabolism is avoided as are the digestive enzymes of the upper GI tract

Parenteral Drug Administration

-refers to the dispensing of medications by routes other than oral or topical
-delivers drugs via a needle into the skin layers, subcutaneous tissue, muscles, or veins
-can also include administration into arteries, body cavities (such as intrathecal), and organs (such as intracardica)
-much more invasive than topical or enteral
-because of the potential for introduction of pathogenic microbes directly into the blood or body tissues, aseptic techniques must be strictly applied

Intradermal and Subcutaneous Administration

-injection into the skin delivers drugs to the blood vessels that supply the various layers of the skin
-the major difference between intradermal and subcutaneous methods is the depth of injection
-advantages:
---they offer a means of administering drugs to patients who are unable to take them orally
---avoid the hepatic first-pass effect and digestive enzymes
-disadvantages:
---only small volumes can be administered
---injection can cause pain and swelling at the injection site

Intradermal (ID) Injection

- administered into the dermis layer of the skin
-because the dermis contains more blood vessels than the deeper subcutaneous layer, drugs are more easily absorbed
-usually employed for allergy and disease screening or for local anesthetic delivery prior to venous cannulation
-limited to very small volumes of drugs, usually only 0.1 to 0.2mL
-usual sites for ID injections are the nonhairy skin surfaces of the upper back, over the scapulae, the high upper chest, and the inner forearm

Subcutaneous Injection

-delivered to the deepest layers of the skin
-insulin, heparin, vitamins, some vaccines, and other medications are given in this areas because the sites are easily accessible and provide rapid absorption
-body sites that are ideal for subcutaneous injections:
---outer aspect of the upper arms, above the triceps muscle
---middle 2/3rds of the anterior thigh area
---subscapular areas of the upper back
---upper dorsogluteal and ventrogluteal areas
---abdominal areas, above the iliac crest and below the diaphragm, 1.5 to 2 inches out from the umbilicus
-small in volume, usually ranging from 0.5 to 1 mL
-the needle size varies with the patient's quantity of body fat
-the length is usually the size of a pinched/bunched skinfold that can be grasped between the thumb and forefinger
-rotate injection sites to promote absorption, minimize tissue damage, and alliviate discomfort

Intramuscular Administration

-delivers medication into specific muscles
-because muscle tissue has a rich blood supply, medication moves quickly into blood vessels to produce a more rapid onset of action than with oral, intradermal, or subcutaneous administration
-the anatomical structure of muscle permits this tissue to recieve a larger volume of medication than the subcutaneous region
-adults can safely tolerate up to 3mL of medication in a large muscle, although only 2mL is recommended
-injection sites must be away from bone, large blood vessels, and nerves
-the size and length of needle are determined by body size and muscle mass, the type of drug to be administered, the amount of adipose tissue overlying the muscle and the age of the patient

Four Commone sites for intramuscular injections

1. ventrogluteal site
---this is the preferred site for IM injections
---provides the greatest thickness of gluteal muscle, contains no large blood vessels or nerves, is sealed off by bone, and contains less fat than the buttock area thus eliminating the need to determine the depth of subcutaneous fat
-suitable site for children and infancts over 7 months of age
2. deltoid site
---this site is used in well-delevoped teens and adults for volumes of medication not to exceed 1mL
---because the radial nerve lies in close proximity, the deltoid is not generally used, except for small volume vaccines, such as hepatitis B in adults
3. dorsogluteal site
---this site is used for adults and for children who have been walking for at least 6 months
---the site is safe as long as the nurse appropriately locates the injection landmarks to avoid puncture or irritation of the sciatic nerve and blood vessels
4. vastus lateralis site
---usually thick and well developed in both adults and children
---the middle third of the muscle is the site for the IM injection

Intravenous (IV)Administration

-medications and fluids are administered directly into the bloodstream and are immediately avaliable for use by the body
-the IV route is used when a very rapid onset of action is desired
-IV medications bypass the enzymatic process of the digestive system and the first-pass effect of the liver
-disadvantages
---although the IV route offers the fastest onset of drug action, it is also the most dangerous
---once injected, the medication cannot be retrieved
---if the drug solution or the needle is contaminated, pathogens have adirect route to the bloodstream and body tissues
-patients who are recieving IV injections must be closely monitored for adverse reactions

The 3 basic types of IV administration

1. Large volume infusion
2. Intermittent infusion
3. IV bolus (push) administration

Large volume infusion

-this type of IV administration of for fluid maitenance, replacement, or supplementation
-compatible drugs may be mixed into a large-volume IV container with fluids such as normal saline or Ringer's lactate

Intermittent infusion

-this is a small amount of IV solution that is arranged tandem with or piggybacked to the primary large-volume infusion
-used to instill adjunct medications, such as antibiotics or analgesics over a short period of time

IV bolus (push) administration

-this is a concentrated dose delivered directly to the circulation via syringe to administer single-dose medications
-bolus injections may be given through an intermittent injection port or a direct IV push

First pass metabolism

=medications absorbed form the stomach and small intestine first travel to the liver, where they may be inactivated before they ever reach their target organs

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