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					Medication Storage,
Administration, and Errors

        Ashley Pence
      PharmD. Candidate
   LECOM School of Pharmacy
Objectives
1.   Be familiar with proper medication storage.
2.   Discuss general guidelines for the preparation
     and administration of medications.
3.   Review specific administration procedures for
     the different types of medications.
4.   Know the “five rights” of administration and
     how to use them to prevent errors.
Storage
Med Carts
 Keep med cart locked at all times
 Do not leave medications sitting on top of
  cart
 Make sure all stock bottles are properly
  labeled with the names of all residents
  using that medication
 Watch for expired medications
Refrigerator
 Must be kept between 35 and 46 degrees
  Fahrenheit
 Make sure the door is always tightly shut
 Make sure all opened containers are
  properly labeled with the date they were
  opened as well as expiration date
Medications with Special
Considerations
 Insulin
 Inhalers
 Drops
 Others
Insulin
   Humulin, Humalog, NovoLog, and Lantus
       Vials expire 28 days after opening
   Novolin
     Vials   expire 30 days after opening
   Levemir
     Vials   expire 42 days after opening
Inhalers
   Advair Diskus
     Discardone month after removal from package or
      when dose indicator reads “0”, whichever comes first
   Serevent Diskus
     Discardsix weeks after removal from package or
      when dose indicator reads “0”, whichever comes first
   Xopenex Inhalation Solution
     Once  foil pouch is opened, vials should be used
      within 2 weeks
Miscellaneous
   Nitroquick, Nitrostat
     Keep   in original glass container
     Discard unused tablets 6 months after original
      bottle is opened
   Xalatan
     Storeunopened bottles in refrigerator
     Once opened, may be kept at room temp for 6
      weeks
General Guidelines


Preparation and Administration
Preparation
 Medications are prepared only by licensed
  nursing, medical, pharmacy, or other
  authorized personnel
 Maintain adequate supply of disposable
  containers and equipment on med cart
 Never reuse disposable containers
Crushing Tablets
   Long-acting or enteric-coated dosage forms
    should generally not be crushed
   Each medication preparation area should have a
    device specifically used for crushing meds
   Meds are crushed between two soufflé cups to
    prevent contact with crushing device
   If contact occurs, crushing device should be
    properly cleaned prior to further use
Crushing Tablets
   For residents who can swallow, tablets can be
    ground coarsely and mixed with appropriate
    vehicle (applesauce) so entire dose is received
   For tube-fed residents, medications must be
    crushed finely to prevent clogging
   Best accomplished using mortar and pestle
    which should be cleaned after each use
   If tablets won’t easily crush (due to coating),
    check to see if a liquid form is available
Potent Liquids
 When administering potent liquid
  medications or those requiring precise
  measurement, be sure to use appropriate
  measuring devices
 Use the device provided by the
  manufacturer or obtained from pharmacy
PRN Meds
 When giving PRN meds at times other
  than med pass, prepare the dose at the
  med cart storage area and take med to
  resident
 Leave cart locked and secured
Administration
   Meds must be administered according to written
    order of attending physician
   If a dose seems excessive considering resident
    age or condition, or an order seems unrelated to
    resident’s current diagnosis, contact the
    pharmacy or prescriber for clarification prior to
    administering
   Document this interaction and resulting order
    clarification in nursing notes and in medical
    record as appropriate
Administration
 Administer medications at the time they
  are prepared
 Do not pre-pour!
 Attempt to administer meds without
  unnecessary interruptions
 The person who prepares the dose for
  administration should be the person who
  administers it
Administration
   Correctly identify residents prior to
    administration
     Check  identification band
     Check picture attached to medical record
     Call resident by name
     If necessary, verify resident identification with
      other personnel
Administration
 Wash hands before and after
  administering topical, opthalmic, otic,
  parenteral, enteral, rectal, and vaginal
  medications
 At least four ounces of water or other
  acceptable liquid are given with oral
  medications
Administration
   Medications should be administered within 60
    minutes of scheduled time, except before or
    after meal orders, which are administered based
    on mealtimes
   Unless otherwise specified by prescriber,
    routine meds can be administered according to
    established med administration schedule for
    facility
   Residents can self-administer meds when
    specifically authorized by attending physician
    and in accordance with procedures
Administration
   Medications supplied for one resident are never
    administered to another resident
   During administration, the med cart is kept
    closed and locked when out of sight of nurse
   It can be kept in the doorway of the resident’s
    room with open drawers facing inward and all
    other sides closed
   No meds should be kept on top of the cart
   The cart must be clearly visible to personnel
    administering medications
   All outward sides must be inaccessible to
    residents passing by
Administration
   For residents not in their room or unavailable on
    med pass, the MAR should be flagged with tags,
    colored plastic strips, drinking straws, or paper
    clips
   After completing the med pass, the nurse should
    return to the missed resident to administer the
    med
   The resident is always observed after
    administration to ensure dose was completely
    ingested
   If only a partial dose is ingested, make a note in
    the MAR
Documentation
   Whoever administers the medication dose
    records the administration on the resident’s MAR
    directly after the medication is given
   At the end of each med pass, the person
    administering meds reviews the MAR to ensure
    necessary doses were administered and
    documented
   In no case should someone who administered a
    medication report off-duty without first recording
    the administration of the med
Documentation
   Current medications, except topicals used for
    treatments, are listed on the MAR
   Topical meds used in treatments are listed on
    the treatment administration record (TAR)
   The resident’s MAR is initialed by the person
    administering the medication in the space
    provided under the date, and on the line for that
    specific medication dose administration
   Initials on each MAR are verified with a full
    signature in the space provided
Documentation
   When PRN medications are administered, the
    following documentation is provided:
     Date  and time of administration, dose, ROA (if other
      than PO), and, if applicable, injection site
     Complaints or symptoms for which med was given
     Results achieved from giving the dose and time
      results were noted
     Signature or initials of person recording administration
      and signature or initials of person recording effects, if
      different from person administering medication
Documentation
   If a dose of regularly scheduled medication is
    withheld, refused, or given at a time other than
    what was scheduled, the space on the front of
    the MAR for that dosage administration is
    initialed and circled
   An explanatory note is entered on the reverse
    side of the record provided for PRN
    documentation
   If two consecutive doses of a vital medication
    are withheld or refused, the physician is notified
Injectables
   Vials and ampules sent from pharmacy in a box or
    container with the label on the outside are kept in that
    box or container
   The date opened and the initials of the first person to use
    the vial are recorded on multidose vials on the vial label
    or an accessory label affixed for that purpose
   Ampules and single-use vials containing no preservative
    are discarded immediately after use
   The solution in multidose vials should be inspected prior
    to each use for unusual cloudiness, precipitation, or
    foreign bodies
   Inspect the rubber stopper for deterioration
Injectables
 If a multidose vial shows visible evidence
  of precipitation or contamination or the
  rubber stopper is deteriorating, do not use
  it and return it to the pharmacy
 A replacement vial will be ordered
 The pharmacy will handle all paperwork
Injectables
   Medication in multidose vials may be used
    until
     The  manufacturer’s expiration date
     For the length of time allowed by state law
     According to facility policy for thirty days

   As long as inspection reveals no problems
    during that time
Infusion Therapy
   Prior to administration of infusion therapy
    products, information about the stability, storage,
    and/or diluent needs to be obtained
   The resident’s medical record is checked for
    known allergies
   Monitor closely for any adverse reactions after
    each dose
   The lack of adverse reaction is charted in the
    resident’s medical record after the first and
    second dose
Infusion Therapy
 All infusion therapy products, including
  piggyback solutions of less than 250 ml,
  are labeled according to state and federal
  requirements and facility policies
 The method of infusion therapy
  administration selected must be consistent
  with resident’s care plan and preferences
  as well as facility policy
Reconstitution for Parenteral
Administration
   Read medication package literature,
    medication label, or other appropriate
    reference to determine correct diluent and
    quantity of diluent to be used
     Note any special steps required such as
      shaking
   Wash hands thoroughly
Reconstitution for Parenteral
Administration
 Break and remove seal from vial of
  medication
 Break and remove seal from vial of diluent
  and wipe rubber stopper with alcohol swab
 Inject into diluent bottle with syringe an
  amount of air equal to the amount of fluid
  to be withdrawn
     Donot allow needle to touch any surface
     other than stopper
Reconstitution for Parenteral
Administration
   Withdraw the appropriate amount of diluent into
    syringe
   Swab rubber stopper on medication vial with
    alcohol wipe
   Inject diluent into medication bottle slowly and
    observe resultant solution or suspension for
    clarity, unusual color, or large particles
   If there appears to be a problem, do not
    administer med without consulting a pharmacist
   Administer medication or add to IV solution as
    directed and complete documentation
Emergency or Unstable Infusion
Therapy Products
   The infusion therapy provider will notify the
    charge nurse about any instability of a product
   Notification is documented and need for nurse to
    prepare the admixture is indicated on the
    infusion therapy record and on the care plan
   Provider supplies complete preparation and
    handling instructions along with products to be
    mixed, and a label to be completed and affixed
    to the infusion therapy product container
   Label should also include the time of infusion
    therapy product preparation
Emergency or Unstable Infusion
Therapy Products
   Date and time of preparation is documented in
    the resident’s medical record as well as the time
    infusion was started
   Products are prepared in accordance with
    infection control standards and with equipment
    and medication manufacturer’s
    recommendations
   Area in which infusion therapy supplies and
    products are stored and prepared for use is kept
    clean and free of clutter
Controlled Medications
   Only authorized personnel have access to
    controlled meds
   Medications are obtained from the locked
    cabinet or safe, or med cart if a Schedule III, IV,
    or V med
   When a controlled medication is administered,
    immediately enter the following information on
    the accountability record and MAR:
     Date and time of administration
     Amount administered
     Signature of the nurse administering the dose,
      completed after the med is actually administered
Controlled Medications
   When a dose of a controlled medication is removed from
    the container for administration but refused by the
    resident or not given for any reason, it is NOT placed
    back in the container
   It must be destroyed according to facility policy and the
    disposal documented on the accountability record on the
    line representing that dose
   The same process applies to the disposal of unused
    partial tablets and unused portions of single dose
    ampules
   Schedule II drugs are reordered when a seven-day
    supply remains to allow time for transmittal of the
    required original written prescription to the pharmacy
Irrigation Solutions
   Labeled with date and time immediately upon
    opening
   Solutions prepared by provider pharmacy, if
    unopened, are disposed of by the expiration
    date indicated
   Solutions without an expiration date are not
    accepted
   Solutions prepared by pharmacy are discarded
    within 72 hours after opening
Irrigation Solutions
   Solutions prepared in facility are disposed of
    within 24 hours
   Solutions without preservatives, in the original
    manufacturer’s container (such as water and
    sodium chloride for irrigation), are disposed of
    within 24 hours after opening
   Aseptic technique is used in the handling and
    application of irrigation solutions
   When expired, unused solutions are poured
    down the drain
   It is not necessary to record disposal of partial
    containers
Enteral Tube Medication
Administration
   Enteral formulas, equipment, ROA, and flow rate
    are selected based on an assessment of
    resident’s condition and need
   Interactions between medications and feeding
    formulas, and interactions of multiple meds must
    be considered before administering meds
    through enteral tube
   Consult manufacturer’s written
    recommendations regarding suggested time
    period for hanging of product when determining
    schedule for feeding
Enteral Tube Medication
Administration
   Meds for enteral administration are obtained in
    easily pulverized or liquid form
   Consult provider pharmacy to determine best
    method for preparing dosage forms for enteral
    tube administration when liquid forms not
    available
   If alternative meds or dosage forms are
    necessary, contact prescriber for a new order
   Enteral tubes are flushed with at least 30
    milliliters of water before administering meds
    and after all meds have been administered
Enteral Tube Medication
Administration
   Prior to crushing tablets for administration through
    enteral tube, nurse should consult the medication
    crushing guidelines to determine if the tablet can be
    crushed
       Mortar and pestle preferred over tablet crusher since tablet can
        be reduced to finer powder
       Crushed meds are not mixed together. The powder from each
        med is mixed with water or other suitable diluent before
        administration. Each med is administered separately to avoid
        interaction and clumping
       Soufflé cup is rinsed with water to get all of med
       Enteral tubing flushed with at least 5 ml of water between each
        med to avoid physical interaction of medications
Enteral Tube Medication
Administration
   Consult pharmacy when changing to a
    different formulation or when initiating
    enteral therapy for necessary dose
    scheduling adjustments
     If on continuous feeding, may have to change
      to intermittent to avoid interaction between
      enteral solution and some meds
     If on intermittent feeding, may need to delay
      feeding up to 2 hours to avoid med interaction
Enteral Tube Medication
Administration
   Medications that are GI irritants (such as
    potassium chloride solution) are diluted as
    recommended for oral administration due
    to high potential for gastric irritation when
    administered directly into stomach through
    enteral tubes
Self-Administering Medications
 Document in resident’s medical record
 Bedside medication record is reviewed on
  each nursing shit and administration
  information is transferred to MAR
 Notation is made by placing a check mark
  in the appropriate space and noting in
  nursing comments initials of nurse
  documenting resident’s report of self-
  administration
Self-Administering Medications
 All nurses and aides are required to report
  to the charge nurse on duty any meds
  found at the bedside not authorized for
  bedside storage
 Give all unauthorized meds to charge
  nurse for return to family or responsible
  party
Self-Administering Medications
 Medications stored at bedside are
  reordered in the same manner as other
  meds
 The nursing staff is responsible for proper
  rotation of bedside stock and removal of
  expired, discontinued, or recalled
  medications
Self-Administering Medications
   When it’s determined that bedside or in-room
    storage of meds is a safety risk to other
    residents, the meds of the resident allowed to
    self-administer are kept in the med cart or med
    room
   The resident requests each dose from the med
    nurse, who provides the med to the resident in
    the unopened package for resident self-
    administration
   Nurse then records self-administration on MAR
Specific Medication
Administration
Procedures
Procedures for All Medications
   Medication cart is locked at all times unless in
    use and under direct observation of medication
    nurse/aide
   Provide privacy for resident if appropriate
   Secure all records containing protected health
    information
   Note any allergies or contraindications the
    resident may have prior to drug administration
Procedures for All Medications
   Check expiration date on package
   When opening a multi-dose container, place the
    date on the container
   Read medication label three times before
    pouring
     Some meds may be labeled “use as directed.” Refer
      to MAR for instruction details
   Identify resident before administering medication
Procedures for All Medications
   Cleanse hands before handling medication and
    before contact with resident
   When applicable, explain to resident the type of
    medication being administered
   Obtain and record any vital signs necessary
    prior to med administration
   After administration, return to cart and document
    administration in MAR
   If resident refuses medication, document refusal
    on MAR
Procedures for All Medications
   When administering PRN meds, observe for
    medication actions/reactions and record on the
    PRN effectiveness sheet/nurse’s notes
   Once removed from the package, unused doses
    should be disposed of in accordance with
    medication destruction policy
     Followthe appropriate policy for controlled
      medications
Oral Medications
 Refer to crushing guidelines prior to
  crushing any medication for assurance
  that it can be pulverized
 Refer to medication reference text for
  administration of any medication when
  added to any substance such as
  applesauce, juice, milk, etc.
 Mortar and pestle/tablet crusher/tablet
  splitter should be cleaned after each use
Oral Medications
 Pour correct number of tablets or capsules
  into the soufflé cup
 Crush medications, if indicated for this
  resident, only after checking med crushing
  guidelines. Crush in tablet crusher or
  mortar and pestle or with other appropriate
  device and clean immediately after use
Oral Medications
   For liquid medications:
     Pour  correct amount directly into a graduated
      medication cup or measuring device or pull up
      correct amount into oral syringe
     Wipe rim and sides of bottle with tissue or
      towelette and replace cap after pouring
     Dilute in any fluid indicated by prescriber’s
      orders. Liquid potassium supplements, bulk
      laxatives, and liquid stool softener may be
      diluted in juice at nurse’s discretion
Oral Medications
 Administer medication and remain with
  resident while medication is swallowed
 If resident is in bed, head of bed should be
  elevated to greater than 45 degrees prior
  to administration and for at least two
  minutes after
 Follow all medication with 4 to 8 ounces of
  water
Sublingual and Buccal Medications

 Pour proper number of sublingual/buccal
  tablets/capsules into soufflé cup
 Have resident take sip of water to moisten
  mouth, and instruct resident to swallow
  water
 Place medication in the resident’s mouth
  or help resident to do so if capable
Sublingual and Buccal Medications
   Place buccal tablet in the pouch between cheek
    and upper or lower gum
   Place sublingual tablet under the tongue
   Instruct resident to close mouth and to not
    swallow or chew until tablet has completely
    dissolved
     Eating, drinking, and smoking should be avoided
      while tablet is dissolving
   Instruct resident to avoid rinsing mouth for
    several minutes after tablet has dissolved
   Wash your hands
Nasal Inhaler, Spray, and Pump
   Determine that an adequate amount of
    medication is remaining in the aerosol canister
    or pump
   Have resident blow nose gently to clear nostrils
   Shake medication container. Remove cap and
    place it on clean dry surface
   If needed, prime the pump by holding bottle
    upright and away from patient while spraying
    into air
Nasal Inhaler, Spray, and Pump
   Administer medication to resident or help
    resident to do so
     Hold   pump bottle with thumb on bottom and index
      and middle finger on either side of spray tip
     Instruct resident to keep head upright and slightly
      tilted forward
     Use finger of other hand to close nostril that’s not
      receiving medication by gently pressing side of nostril
     Keep bottle upright and insert spray tip into nostril not
      more than ¼ inch. Point tip to back and outer side of
      nose
Nasal Inhaler, Spray, and Pump
  Spray  firmly and quickly while resident
   breathes in through nose and out through
   mouth
  After removing spray bottle from nostril, have
   resident tilt head back for several seconds to
   aid penetration of drug
  Wipe any excess drainage immediately.
   Instruct resident to avoid blowing nose for 15
   minutes, if possible
  Repeat for other nostril if indicated
Nasal Inhaler, Spray, and Pump
 Rinse the pump, spray, or inhaler tip with
  hot water keeping the tip pointed
  downward to prevent water from getting
  into container
 Replace protective cap
 Wash your hands
Nose Drop Administration
   Have resident gently blow his/her nose to clear
    the nostrils
   Have resident lie on bed with head tilted back
    and neck supported
   Shake the nose drops container if needed
   Insert dropper tip into nostril no more than ¼
    inch, and place prescribed dose or number of
    drops in nostril. Direct flow of drops towards
    floor of nasal cavity
Nose Drop Administration
 Instruct resident to remain in same
  position for at least five minutes
 Repeat with other nostril if indicated
 Rinse dropper tip with hot water and
  replace cap on container
 Wash your hands
Eye Drop Administration
   Shake eye drop container if needed
   Remove cap, taking care to avoid touching
    dropper tip. Place cap on clean, dry surface.
   Have resident tip head back slightly
   If bottle has separate dropper, draw required
    amount of solution into dropper, holding bottle
    upright. If self-contained unit, invert bottle
   Pull lower eyelid down and away from eyeball to
    form a pocket
Eye Drop Administration
   Hold dropper tip directly over eye, taking care to
    avoid touching eye or eyelid
   Instruct resident to look upward, and place one
    drop into pocket, continuing to hold eyelid for a
    moment to allow medication to distribute
   Release eyelid and instruct resident to close eye
    slowly and keep it closed for 1-2 minutes. Do
    not allow resident to squeeze eye shut or rub
    eye. If stinging or burning occurs, reassure
    resident that this is temporary
Eye Drop Administration
 Use gauze to remove any excess drops on
  resident’s face
 Replace cap on container
 Wait at least five minutes before applying
  additional medication to the eye
 Always administer drops before ointments
 Wash your hands
Eye Ointment and Gel
   Remove cap from medication tube, taking care
    to avoid touching tip of tube. Place cap on
    clean, dry surface
   Have resident tilt head back slightly
   Pull lower eyelid down and away from eyeball to
    form a pocket
   Squeeze tube and apply prescribed amount of
    ointment or gel to inner surface of lower eyelid.
    Do not touch tip of medication to eye or eyelid
Eye Ointment and Gel
   Release eyelid and instruct resident to gently
    close eye, and keep it closed for 1-2 minutes.
    While the eye is closed, it may be gently rotated
    to distribute medication
   Instruct resident to avoid squeezing eye shut or
    rubbing eye
   Replace cap on medication tube
   Wipe off any excess gel or ointment with gauze
    pad
   Inform resident that eye ointments/gels can
    temporarily blur the vision
   Wash hands
Ear Drop Administration
   Warm the ear drops, if cold, by holding the
    container if your hand for a few minutes
     Don’twarm in hot water because that can cause pain,
      nausea, and dizziness upon instillation
   Shake container if needed
   Have resident tilt head to one side, or lie down
    with affected ear facing up
   Open container and position dropper tip near,
    but not inside, ear canal opening to avoid
    contamination
Ear Drop Administration
   Gently pull the resident’s ear backward and
    upward to open the ear canal
   Place the proper number of drops into ear canal.
    Do not touch tip of dropper to any surface,
    including ear
   Replace cap on container. Don’t rinse dropper
    after use. Keep container tightly closed
   Gently press small, flat skin flap over ear canal
    to force out air bubbles and encourage drops
    down ear canal
Ear Drop Administration
   Instruct resident to stay in the same position for
    at least five minutes. If resident unlikely to
    comply with this requirement, place clean piece
    of cotton ball into ear canal opening to prevent
    medication from draining out
   Repeat procedure for other ear if indicated
   Gently wipe any excess medication off outside of
    ear
   Wash your hands
Oral Inhalation Administration
   Determine that an adequate amount of
    medication is remaining in aerosol canister
   Warm canister to hand temperature
   Examine holding chamber or spacer and remove
    any foreign objects
   Remove caps from inhaler and holding chamber
    or spacer
   Shake inhaler. Don’t shake dry powder inhalers
Oral Inhalation Administration
   Attach the holding chamber or spacer device to
    inhaler
   Instruct resident to tilt head back slightly, stand
    or sit up as straight as possible, and breathe out
    through mouth
   Place holding chamber or spacer with inhaler
    attached into resident’s mouth
   Instruct resident to inhale slowly as you depress
    canister to release medication
   Breathe in and out normally through holding
    chamber or spacer for three breaths
Oral Inhalation Administration
   Repeat doses as prescribed. Short acting
    beta agonists should be administered
    before other medications to help open
    airways for better medication distribution
     Wait one minute between “puffs” for multiple
      inhalations of the same medication
     Wait 1-2 minutes before administering next
      inhaled medication
Oral Inhalation Administration
 Have resident rinse mouth and spit out the
  rinse water
 Remove inhaler from holding chamber or
  spacer. Rinse and dry inhaler mouthpiece
  and holding chamber or spacer
 Replace caps on inhaler and holding
  chamber or spacer
 Wash your hands
Rectal Suppository Administration

 Assist resident in turning to left side with
  knees bent
 Remove wrapper from suppository
 Wear gloves
 Lubricate index finger and suppository
 Separate buttocks
Rectal Suppository Administration

   Insert suppository gently
     Ask  resident to take a deep breath to relax
      anal sphincter
     Insert suppository about 3 inches beyond
      sphincter
     Apply pressure with tissue over anus briefly
      until desire to expel suppository has passed
     Instruct resident to retain suppository for 10-
      15 minutes if possible
Rectal Suppository Administration
   Place tissue and glove in paper towel
   If suppository was for bowel evacuation, assist
    resident onto a bedpan, commode, or toilet.
    Make the resident comfortable
     Leave  call signal with resident or check back at
      intervals
     Elevate head of bed to Fowler’s position if resident
      remains in bed
   Remove soiled articles. Place in covered,
    plastic-lined container in utility room
   Wash your hands
   Document effect of suppository if for bowel
    evacuation
Rectal Enema Administration
 Assist resident in turning to left side with
  knees bent
 Prepare enema for administration
 Put gloves on
 Separate buttocks
 Insert enema tip gently
     Ask resident to take deep breath to relax anal
      sphincter
     Insert enema tip into rectum about 3 inches
      beyond sphincter
Rectal Enema Administration
   Slowly empty contents of enema into colon
     Instruct resident to resist urge to expel colon
      contents while enema is being administered,
      and afterward for as long as possible
     If resident is uncomfortable, enema flow rate
      may be too fast
     Enema solution should be retained until
      definite lower abdominal cramping is felt
Rectal Enema Administration
   Remove gloves and discard appropriately
   If enema was for bowel evacuation, assist resident
    onto bedpan, commode, or toilet. Make the
    resident comfortable
       Leave call signal with resident or check back at intervals
       Elevate head of bed to Fowler’s position if resident
        remains in bed
   Remove soiled articles. Place in covered, plastic-
    lined container in utility room
   Wash your hands
   Document effect of enema if for bowel evacuation
Vaginal Administration
 Place tablet/suppository in applicator or
  draw cream/gel into applicator
 Have resident lie on back with knees
  flexed and legs spread apart, or on left
  side with knees bent
 Wearing sterile gloves, examine perineum
     Clean   area if discharge is noted
Vaginal Administration
   With one hand, spread out labia
       Place applicator into vagina and advance plunger to instill gel
        or cream or to release tablet or suppository
       If without applicator, insert lubricated tablet or suppository
        approximately 3-4 inches into vaginal area
   Wipe lubricant from vaginal area with tissue
   Advise resident to remain lying down for about 30
    minutes
   Place tissue and glove in paper towel
   Place wrapped, soiled articles in covered, plastic-lined
    container in utility room
   Wash your hands
Enteral Tube Administration
   If resident is in bed, elevate head of bed to 30-
    45 degree angle
   Turn off pump to stop continuous feeding 1-2
    hours prior to medication administration if med
    is associated with an incompatibility or 30
    minutes if medication should be given on an
    empty stomach
   Wash hands and wear gloves
   Establish the privacy of the resident and explain
    the procedure
Enteral Tube Administration
 Inflate trach cuff if necessary
 Verify tube placement
     Unclamp tube and use either of following
      procedures:
        Insert small amount of air into tube with syringe and
         listen to stomach with stethoscope or gurgling
         sounds
        Aspirate stomach contents with syringe

   Reclamp tube to maintain closed system.
    Check that breathing tube is not clamped
Enteral Tube Administration
   Prepare meds for administration
       Mortar and pestle are preferable to tablet crusher for
        preparing tablets for enteral administration to allow smaller
        particle size
       Consult guidelines before crushing tablets
       Crush tablets and dissolve in 30 ml of warm water or other
        appropriate liquid
       Empty capsule contents into 30 ml of warm water or other
        appropriate liquid
       Dilute liquid medications with 10-30 ml of warm water or
        enteral formula if liquid medication is hyperosmolar and
        compatible with enteral formulas
       Dilute gastric irritants in water for highly concentrated
        solutions
Enteral Tube Administration
 Check gastric contents for residual feeding
 Remove plunger from the 60 ml syringe
  and connect syringe to clamped tubing
 Flush tube with 15-30 ml of water prior to
  administration. Clamp tubing after syringe
  is empty, allowing water to remain in tube
Enteral Tube Administration
   Administer each medication separately,
    flushing tube with five ml of water after each
    dose
     Administer  liquid meds first, then those that need
      to be diluted. Reserve thick medications
      (antacids) for last
     Allow medication to flow down tube via gravity
     Give gentle boosts with the plunger
      (approximately 1 inch down) if the medication will
      not flow by gravity. Repeat if necessary. Do not
      push meds through tube
Enteral Tube Administration
 Flush tube with 15-30 ml of water and
  clamp for 30 minutes before reattaching
 Leave head of bed elevated for 30 minutes
  to prevent aspiration of stomach contents
 Leave trach cuff inflated for 30 minutes
 Clean feeding syringe and return to
  bedside stand
 Wash your hands
Transdermal Drug Delivery System
   Identify the location on the body for patch
    placement
   Remove old patch from body
   Cleanse area of old patch with alcohol wipe
   Remove new patch from package and envelope
   Label patch with date and nurse’s initials
   Apply new patch firmly against skin
   Wash your hands
Transdermal Drug Delivery System
   Document placement site on MAR as follows:

SITE                CODE
Left upper arm      LA
Right upper arm     RA
                           For transdermal scopolamine:
Left upper thigh    LT
Right upper thigh   RT       SITE              CODE
Left chest          LC       Behind left ear   LE
Right chest         RC       Behind right      RE
Left upper back     LB       ear
Right upper back    RB
Intramuscular Administration
   Sites for administration:
     Ventriogluteal   (front of hip area)
     Deltoid(arms)
     Dorsogluteal (back buttock)
     Vastus lateralis (upper lateral area of leg)
     Rectus femoris (medial upper leg)
Intramuscular Administration
   Prepare medication as follows:
     Calculatecorrect amount of medication
     Shake well if required
     Prepare syringe and needle
        Swab rubber cap with alcohol sponge
        Pull back plunger to draw volume of air into
         syringe equal to volume of medication to be
         given. Inject air into vial.
        Withdraw correct amount of medication

        Create air lock in syringe

        Recap needle
Intramuscular Administration
   Select an appropriate site for injection
   Adjust resident’s position
   Cleanse skin with alcohol sponge using circular
    motion from center of chosen site until area about
    3 inches in diameter has been prepared
   Expel air from syringe
   Expose site to be injected
   Gently tap the area to stimulate nerve endings
    and minimize initial pain
Intramuscular Administration
   Stretch the skin so that it’s taut to ease needle
    insertion
   Using other hand to hold the syringe, insert the
    needle at a 90-degree angle; use a quick, dart-
    like thrust
   Pull back on plunger to see if needle is in blood
    vessel. If so, withdraw needle, secure new
    equipment and medication, and repeat
    procedures
   Hold the needle steady and inject the
    medication at a slow, even rate
Intramuscular Administration
 Withdraw needle rapidly
 Swab the area with an alcohol wipe in a
  circular motion
 Discard syringe and needle in designated
  area. Do not recap needle.
 Wash hands
Intramuscular Administration
Document the injection on the MAR along with site used,
                        as follows:


                SITE            CODE
                Left buttock    LB
                Right buttock   RB
                Left arm        LA
                Right arm       RA
                Left thigh      LT
                Right thigh     RT
Subcutaneous Administration
   Prepare medication as follows:
     Calculatecorrect amount of medication
     Shake well if required
     Prepare syringe and needle
        Swab rubber cap with alcohol sponge
        Pull back plunger to draw a volume of air into the
         syringe equal to volume of medication to be
         given. Inject air into vial
        Withdraw correct amount of medication

        Create air lock in syringe

        Recap needle
Subcutaneous Administration
 Select an appropriate site for injection
 Adjust resident’s position
 Cleanse skin with alcohol sponge, using
  circular motion from center of chosen site
  until an area about 3 inches in diameter
  has been prepared
 Expel air from syringe
 Expose site to be injected
Subcutaneous Administration
   Gently tap area to stimulate nerve endings and
    minimize initial pain
   Grasp and pinch a cushion of flesh
   Hold needle with bevel side up and insert at a
    45-degree angle
   Insert needle quickly
   Pull back on plunger to see if needle is in a
    blood vessel. If so, withdraw needle, secure
    new equipment and medication, and repeat
    procedure
Subcutaneous Administration
 Inject medication slowly
 Remove needle quickly
 Wipe area with alcohol sponge. Apply
  pressure over the injection site for two
  minutes
 Discard syringe and needle in designated
  area. Do not recap needle
 Wash hands
Subcutaneous Administration
Document the injection on the MAR along with site used,
                        as follows:

              SITE            CODE
              Left buttock    LB
              Right buttock   RB
              Left arm        LA
              Right arm       RA
              Left thigh      LT
              Right thigh     RT
              Left abdomen    LS
              Right abdomen   RS
Infusion Therapy
   Obtain infusion therapy medication
   Draw required amount of medication into syringe
   Complete “Infusion Therapy Solution/Additive”
    label and place on IV bag or bottle
   Clamp tubing
   Wipe rubber topper of infusion therapy solution
    container with alcohol swab
   Follow procedures for adding med directly to
    solution or via piggyback according to type of
    system in use
Infusion Therapy
   Unclamp tubing and allow fluid to flow through
   Regulate flow of medication infusion as
    prescribed
   Discard syringe and needle in designated area.
    Do not recap needle.
   Wash hands
   Document in nursing progress notes:
     Type of solution and medication
     Duration of medication infusion
     Any adverse reactions
Medication Errors
Background
   Estimated to cause at least one death every day
   Error rate in drug administration is about 19%
   Most common error is delayed drug
    administration as a result of a missed dose
Definition
   “Any preventable event that may cause or lead
    to inappropriate medication use or patient harm
    while the medication is under the control of the
    health care professional, patient or consumer.
    Such events may be related to professional
    practice, health care products, procedures, and
    systems, including prescribing; order
    communication; product labeling, packaging and
    nomenclature; compounding; dispensing;
    distribution; administration; education;
    monitoring and use.”
Reducing Medication Error
   Person-centered approach
     Focuses on the individual who made error
     May receive education, training, or discipline
     Doomed to failure
Reducing Medication Error
   System-centered approach
     Erroris unavoidable
     Processes can be designed to reduce the
      possibility of error
     Processes can be designed so that errors are
      detected and corrected before harm occurs
The Five Rights
1.   Right Drug
2.   Right Dose
3.   Right Time
4.   Right Route
5.   Right Patient
Right Drug
 Most common error
 Similar labeling and packaging of products
 Medications with similar names being
  stored together
 Poor communication
Ways to Avoid Error
   Always repeat verbal orders
   Avoid using dosage and product abbreviations
   Never use trailing zeros, but always use leading
    zeros (25 vs 25.0; 0.25 vs .25)
   Never try to decipher illegible orders
   When in doubt, always check with prescriber,
    pharmacist, or literature
   Always check label and dose against order
    three times prior to administration
   Don’t administer any drug if you’re unsure of it’s
    intended use
   Never assume anything
Right Dose
 Recheck all math
 Have someone else verify final dosage
 Consider patient’s age, weight, and vital
  signs
 Especially important in newborns,
  pediatric, and elderly patients
Right Time
 Meds should ideally be given within 30
  minutes before or after scheduled time
 Consider drug-drug and drug-food
  interactions when scheduling
 Appropriate spacing of doses
 Meds may need to be skipped or delayed
  prior to diagnostic studies
Right Route
 Route depends on patient’s condition and
  speed with which therapeutic effect
  desired
 Prescribed dosage based on route
 Oral dosages generally > than IV doses
     30
       mg of morphine sulfate given IV instead of
     PO could lead to respiratory arrest
Right Route
 Special caution with IV
 Many drugs can cause severe soft tissue
  injury if IV becomes infiltrated
 Check for blood return prior to
  administration of any IV medication
 Rapid onset of action
     Staywith patient for a few minutes to assess
     for adverse reaction
Right Patient
 Hectic environment with nurses floating
  between units and seeing large numbers
  of patients
 Always check patients ID bracelet prior to
  giving medication
 Confirm patient’s name, age, and allergies
 Ask patient to state their name
Conclusion
   Always follow proper administration guidelines
    and techniques
   Make sure medications are stored appropriately
    and discarded at the correct time
   Document, document, document
   By always checking the five rights of
    administration, we can decrease the chance of
    having an error
References
 “Policies and Procedures: Pharmacy
  Services for Nursing Facilities.” American
  Society of Consultant Pharmacists
 “Preventing Medication Errors.” East
  Liverpool City Hospital Education
  Department
 Etchells E, Juurlink D, et al. Medication
  errors: the human factor. CMAJ. 2008
  January 1; 178(1): 63–64.
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