Learning Objectives - Jones & Bartlett...

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Chapter 13

Medication Administration

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Learning Objectives

List basic mathematic principles Review mathematic equivalents Differentiate temperature readings

between Celsius, Fahrenheit scales Discuss formulas as basis for performing

drug calculations

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Learning Objectives (Cont’d)

Discuss applying basic principles of mathematics to calculation of problems associated with medication dosages

Discuss legal aspects affecting medication administration

Discuss “6 rights” of drug administration

Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company

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Discuss medical asepsis, differences between clean, sterile techniques

Describe use of standard precautions when giving medication

Describe use of antiseptics, disinfectants

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Describe disposal of contaminated items, sharps

Describe different oral dosage forms, general principles giving oral medications

Describe technique, general principles of rectal medication administration

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Describe technique, general principles of giving medications through gastric tube

Describe technique, general principles of giving medications topically

Describe technique, general principles of giving medications by inhalation route


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Describe technique for withdrawing medication from ampule

Describe technique for withdrawing medication from vial

Describe technique, general principles of giving medications by subcutaneous route

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Describe technique, general principles of giving medications by intramuscular route

Describe indications, equipment needed, technique used, precautions, general principles of peripheral venous access

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Describe indications, equipment needed, technique used, precautions, general principles of intraosseous needle placement, infusion

Describe purpose, equipment needed, techniques used, complications, general principles for obtaining blood sample


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Drug Dosage Calculations

Systems of measurement Apothecary system

• Wheat grain weight, 1 unit• Linear: inches, yards, miles• Volume: minims, fluidrams, ounces, pints, gallons• Quantities < 20, lower case Roman numerals• Quantities >20, Arabic numbers, fractions

Household system• Dropper, teaspoon, tablespoon, cup, glass, pint,

quart, gallon

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Drug Dosage Calculations (Cont’d)

Systems of measurement Metric systems

• Drug calculations, units of 10 Weight (solids, mass): gram (g) Length: meter (m) Volume (liquid, fluid): liter (L)

Pharmacology mathematic equivalents• Centi• Milli• Micro• Kilo

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Systems of measurement Metric conversions


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Systems of measurement Metric conversions

• Temperature conversions

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Systems of measurement Milliliters & cubic centimeters Weight conversions

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Working with formulas Formula 1: single

dose calculations


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Working with formulas Formula 2: drip

(infusion) calculations

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Working with formulas Formula 4: based on weight

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Medical Direction

Legal Considerations Federal, state, local laws governing

purchasing, distribution, dispensing, administering drugs

Medication handling diligence, accounting Medical direction, final word


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Medical Direction (Cont’d)

Protocols: written & online Written, filed with state board of pharmacy Online, radio, cellular phone

• If fails, follow written protocols If event with no protocol, must get medical

direction before proceeding Differ among EMS systems

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Principles of Medication Administration

Safety considerations & procedures Familiar with drug Require physician order Verify physician’s order Concentrate on task Patient properly positioned Assemble, use correct supplies, equipment Handle carefully, avoid dropping, breaking Aseptic technique Carefully calculate drug doses

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Principles of Medication Administration (Cont’d)

Safety considerations & procedures Check drug incompatibility Monitor for overdose signs, take corrective

measures Document drug given, dose, time, route,

patient’s response


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The “six rights” of drug administration Right drug Right patient Right dose

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The “six rights” of drug administration Right time Right route Right documentation

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Medical asepsis Medically clean Source of infections & standard precautions


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Medical asepsis Antiseptics vs. disinfectants

• Disinfection• Antiseptic• Sterilization• Sepsis

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Medical asepsis Proper drug handling Care of site

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Prevention of Injuries & Exposures

Sharps handling Do not recap needle by hand, dispose in

approved container Do not overfill sharps containers No regular trash Retrieve any placed on stretcher Ensure all sharps accounted for before

removing patient from ambulance


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Techniques of Medication Administration

Enteral medication administration Giving oral medications

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Techniques of Medication Administration (Cont’d)

Enteral medication administration Giving sublingual medications

• Place under tongue with gloved fingers• Not swallowed, spit out, or rinsed• Advantages, accessibility, rapid onset• Nitroglycerin most common

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Skill 13-1 Sublingual Med Administration

When giving nitroglycerin spray, do not shake before use; remove plastic canister cover

Hold container upright with index finger on top of grooved button; position close to mouth, without touching

Firmly press button to release spray under patient’s tongue

Release button and ask patient to close mouth and avoid swallowing; replace canister cover


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Enteral medication administration Giving buccal

medications• Placed in pocket

between teeth & cheek

• Glucose for diabetic

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Skill 13-2 Rectal Diazepam (Valium)

Place child on side, facing you; measure for weight

Open package, remove syringe, remove cover, lubricate tip

Bend child’s upper leg forward so knee is close to chest

Expose rectum by separating child’s buttocks

Insert lubricated syringe tip all the way into rectum

Slowly count to 3 while pushing plunger in until it stops

Slowly count to 3 before removing plunger

Slowly count to 3 while holding child’s buttocks together, preventing leakage; monitor child’s respiratory rate and depth; be prepared to assist breathing as necessary

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Enteral medication administration Giving medications by gastric route

• Orgastric tube (OG)• Nasogastric tube (NG)


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Skill 13-3 Nasogastric Tube Insertion

Prep; place patient in sitting position with stretcher head at 45-degree angle or greater; give patient cup of water with straw; measure tube: tip of nose to earlobe, then xiphoid process; mark tube

Prep 1st 2-3 inches of tube with water-soluble lubricant

Have patient tilt head forward and sip water through straw when asked to swallow

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Skill 13-3 Nasogastric Tube Insertion (Cont’d)

Slowly insert tube into nostril; advance tube as patient swallows until premeasured mark is reached; in case of resistance, do not advance tube, withdraw and retry; if resistance continues, attempt other nostril

Verify tube placement by injecting ~20 mL of air into tube while listening over epigastrium with stethoscope; if correct, rush of air will be heard; tape tube in place

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Parenteral medication administration Topical

medications


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Giving inhaled medications Metered-

dose inhalers

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Skill 13-4 MDI Medication Administration

Prep; patient sitting; assemble inhaler, attach spacer if needed; shake inhaler gently before use

Position mouthpiece ~2 finger widths from mouth; if using spacer, patient’s lips close around mouthpiece

Ask patient to inhale deeply and exhale, then inhale slowly while inhaler is activated, hold breath for 10 seconds, and exhale through pursed lips

Observe patient; document procedure

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Giving inhaled medications Nebulizers


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Skill 13-5 Small Volume Nebulizer

Prep; patient sitting; assemble small volume nebulizer; attach mouthpiece to large end of T-shaped piece

Attach extension tubing to small end of T-shaped piece

Unscrew cap Fill base of cup with correct

medication; if a bronchodilator, additional liquid (i.e., normal saline) may be added, if ordered

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Skill 13-5 Small Volume Nebulizer

Attach cap; shake to mix medication and diluent (if used); attach oxygen supply to nebulizer cup, then to oxygen source

Attach cup to bottom of T-shaped piece; adjust oxygen rate 6-10 L/min to create fine mist

Patient sitting; if able, patient may hold mouthpiece alone, if not, hold it for patient; ask patient to inhale slowly, pause 2-3 seconds, exhale through pursed lips; continue until medication is gone; observe patient; document procedure

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Giving inhaled medications Tracheal medications

• Use endotracheal tube• Rapid onset of action• Bag-mask device disperses drug across alveoli• Remove needle from syringe before instilling

medication in ET tube


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Skill 13-6 ET Drug Administration

Prep; ventilate patient’s lungs with several compressions of bag-mask device

Briefly disconnect oxygen source from ET tube (unless ET tube has drug port); briefly discontinue CPR (if applicable); administer medication into ET tube

After administration, give positive-pressure ventilations, resume oxygen/CPR as needed

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Giving intranasal medications

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Injectable medications Equipment

• Needles, syringes


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Syringes Tuberculin Measurement scale

on a 3-mL syringe Needle with

protective sheath

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Injectable medications Parenteral

medication containers

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Skill 13-7 Withdrawing From An Ampule

Prep: medical director’s orders, PPE, six rights

Check medication clarity; verify drug not expired; check concentration

Clear contents from top by holding upright and gently tapping container’s top with finger or gently swirl ampule to displace medication from container’s top


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Skill 13-7 Withdrawing From An Ampule (Cont’d)

Wrap ampule neck/top Snap off top away from body Replace syringe’s sterile needle with

filter needle to keep out glass particles Place needle into ampule solution,

withdraw dose of medication; if needle is not long enough to reach bottom of ampule, invert to withdraw desired dose; do not touch ampule outer surface/rim; do not inject air in ampule

Tap syringe to remove air bubble, push plunger to expel air; replace sterile needle; properly dispose sharps

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Skill 13-8 Withdrawing From A Vial

Prep: medical director’s orders, PPE, six rights; check medication clarity; verify drug not expired; check concentration

Remove protective cover on vial’s stopper, if present; cleanse rubber stopper with alcohol; let dry

Hold vial with thumb/forefinger, insert needle into vial; with needle tip above solution, push syringe plunger to inject air equal to desired dose to prevent vacuum

Invert vial/syringe; hold at eye level with needle below level of solution in vial; if syringe does not fill automatically, pull down plunger to desired dose

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Skill 13-8 Withdrawing From A Vial (Cont’d)

Tap syringe to remove air bubble, push plunger to expel air; adjust plunger for desired dose

Remove needle from vial; reverify dose; properly dispose sharps


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Injectable medications Intralingual injections

• Injected into underside of tongue• 25-gauge, 5/8-inch needle

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Injection routes A, intramuscular (IM) B, subcutaneous (Sub-Q) C, intradermal (ID) D, intravenous (IV)

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Injectable medications Subcutaneous

injections


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Skill 13-9 Subcutaneous Injection

Prep; prepare correct medication dose; select injection site; cleanse site with alcohol wipe using circular motion from center out; allow to dry

Gently pinch skin and lift subcutaneous tissue away from muscle

Insert needle at 45-degree angle with quick, darting motion

Release skin; pull back plunger, check for blood; if blood present, remove needle; if no blood, press plunger, inject medication; withdraw needle; massage area; apply bandage if bleeding; observe patient; properly dispose sharps; document

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Injectable medications Intramuscular injections

• Into muscle layer• Rapid onset• Complications• Deltoid site• Dorsogluteal site• Ventrogluteal site• Vastus lateralis, rectus femoris sites

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Deltoid Site


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Dorsogluteal Site

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Ventrogluteal Site

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Vasrus Lateralis & Rectus Femoris Sites


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Skill 13-10 Intramuscular Injection

Prep; prepare correct medication dose; select injection site; cleanse site with alcohol wipe using circular motion from center out; allow to dry

Spread skin at site; hold skin taut, insert needle at 90-degree angle with quick, darting motion

Pull back plunger slightly, check for blood; if blood present, remove needle; if no blood, inject medication with slow, continuous motion, withdraw needle; massage area; apply pressure with gauze if bleeding, apply bandage if needed; observe patient; properly dispose sharps; document

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Vascular access Venous access

• Intravenous cannulation• Venipuncture• Intravenous therapy

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Vascular access Peripheral venous

access• Intravenous

catheters Saline lock Over-the needle Through-the-

needle Hollow needle


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Vascular access Peripheral venous access

• Factors in selection• Purpose of infusion• Amount, type of fluid, medication to be infused• Accessibility, size, condition of vein• Patient’s age, size, general health, hand dominance,

mobility• Presence of disease, injury, prior surgery• Presence of shunt, graft• Experience, skill at venipuncture

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Peripheral intravenous sites

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Vascular access Peripheral venous access

• Peripheral intravenous insertion

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Skill 13-11 Peripheral Venous Access

PPE; assemble supplies; use appropriate fluid; check expiration date; check solution clarity; check bag for leaks; select appropriate select catheter length/gauge/microdrip/ macrodrip as appropriate; clamp tubing

Insert spiked end of tubing into bag Squeeze drip chamber until chamber

fills halfway; loosen protective cap over needle adapter to allow air to escape; open clamp slowly; flush air from tubing; flick tubing with finger to remove air bubbles; close clamp; retighten cap


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Skill 13-11 Peripheral Venous Access (Cont’d)

Apply tourniquet ~4 inches above injection site, tight enough to restrict venous blood flow without restricting arterial circulation; if vein not distended, ask patient to open and close fist several times; cross ends of tourniquet and apply tension

Fold middle of one end of tourniquet under opposite end to form loop; leave distal portion of folded end free to allow one-handed release of tourniquet

Cleanse site; allow to dry

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With nondominant hand, anchor vein by pressing thumb ~2 inches directly below insertion site; hold skin taut

Puncture vein (direct or indirect method); use dominant hand to hold IV catheter; once punctured, quickly lower IV catheter until hub is nearly parallel to skin

When blood is seen, advance catheter 2-3 mm more to be sure of vein, then advance catheter over the needle to catheter hub

Apply light pressure to vein proximal to catheter tip to slow blood escape

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Remove needle portion of cannula with dominant hand; properly dispose needle

Attach syringe to IV catheter; withdraw blood if samples needed

Release tourniquet; connect administration set to catheter; check connection is secure

Slowly open clamp on tubing; look for swelling or fluid leakage at site; if patent, adjust flow of infusion to prescribed rate

Secure catheter in place


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External jugular vein cannulation

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Vascular access Central venous access

• Into vena cava from subclavian, EJ, femoral vein• Need for long-term IV therapy• Large volumes of fluid• Blood products, hypertonic solutions, caustic

medications, parenteral feeding solutions• Placement of transvenous pacemaker electrodes• Central venous pressure monitoring, central venous

sampling

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Parenteral medication administration Complications

• Local• Systemic


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Vascular access Intravenous medications

• Bolus• Piggyback• Infusion pumps

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Skill 13-12 IV Bolus Medication

Six rights; ask patient about allergies; check medication concentration, clarity, expiration date; calculate, prep dose, fill syringe with correct dose

Check site for infiltration; once certain that catheter is in vein, cleanse injection port closest to patient with alcohol swab; recheck medication, dose

Connect syringe to injection port; pinch tubing above port; give correct dose at proper push rate

Remove syringe; release tubing; allow IV solution to flow at prescribed rate; properly dispose sharps; observe patient; document

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Skill 13-13 IVPB Medication

Six rights; check allergies; select correct medication; check clarity, expiration dates of medication and IV solution

Calculate, draw up, medication into syringe; calculate flow rate of piggyback medication in drops per minute; cleanse port on bag with alcohol swab; inject correct dose into solution; gently shake bag

Connect secondary admin set to medication solution; fill drip chamber and flush air from tubing; connect secondary admin set to primary solution tubing


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Skill 13-13 IVPB Medication (Cont’d)

Check site for infiltration; raise piggyback solution until higher than primary solution; tape connection

Recheck medication dose; open clamp on piggyback tubing; adjust flow rate to calculated desired dose; properly dispose sharps; observe patient; label piggyback solution (date, time, name, amount of medication added to bag, preparer’s initials); document

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Vascular access Intraosseus infusion

• Indications

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Vascular access Intraosseus

infusion• Sites

Anterior tibial approach

Distal femur approach


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Vascular access Intraosseus

infusion• Sites

Distal tibia approach

Anterior superior illiac spinal approach

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Skill 13-14 Pediatric IO Infusion

Select IV fluid; prep; PPE; place infant/child supine; support popliteal fossa; optimize positioning

Identify needle insertion landmarks Cleanse site; stabilize leg; angle

needle away from joint; insert needle with firm pressure

Advance needle with twisting motion; angle 60-90 degrees, toward toes

Advance needle until pop, or decrease in resistance is felt

Unscrew cap; remove stylet; attach 10-mL saline-filled syringe; attempt to aspirate bone marrow into syringe; if successful, slowly inject 10-20 mL saline to clear needle

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Skill 13-14 Pediatric IO Infusion (Cont’d)

Observe for swelling; if aspiration unsuccessful, consider other indicators of correct needle position

If infiltration present, remove IO needle, attempt another site; if no infiltration signs, attach standard IV tubing; syringe, pressure infuser, or IV infusion pump may be needed to infuse fluids

Secure needle/tubing with bulky sterile dressing and tape; observe site every 5-10 minutes; monitor for infiltration; assess distal pulse; tape admin set to foot


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Fast1 IO system

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EZ-IO device

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Vascular access Intraosseus infusion

• Precautions for FAST1 use, not recommended• Precautions of EZ-IO device, not recommended


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Parenteral medication administration Vascular access

• Intraosseus infusion Contraindications Possible complications

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Vascular access Unbilical vein access

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Fibrinolytic Initiation & Monitoring

Dissolve clots Acute myocardial infarction, stroke Must be given before clot disrupts blood

flow, cause tissue necrosis Thorough history, rate monitoring


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Blood Infusions

Implications & reactions Reaction possible

• Headache• Change in consciousness level• Skin flushing• Nausea, vomiting• Breathing difficulty• Chills• Weak, thready pulse with tachycardia• Hypotension• Fever

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Blood Infusions (Cont’d)

Reaction Immediately discontinue blood infusion Open primary IV line Rapidly infuse normal saline High-flow oxygen Continually monitor patient for changes Contact medical direction for orders Save blood bag, tubing, must be returned to

lab for analysis

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Obtaining Blood Sample

Purpose Baseline evaluation

Safety precautions Label tube with patient name, date, time, your

initials Tape sample to bag, give to ER receiving party


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Chapter Summary

Medication administration Drugs originally measured to apothecary

system, based on grain of wheat Household system, dropper, teaspoon,

tablespoon, cup, glass, pint, quart, gallon, expressed in Arabic numbers, fractions, decimals not used

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Chapter Summary (Cont’d)

Metric system used for drug calculations, based on unit of 10

Basic units in metric system Weight, gram Length, meter Volume, liter

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Four commonly used units in drug calculations: centi, milli, micro, kilo

Calculating drug dosages, must be able to convert milligrams to grams, grams to milligrams, milligrams to micrograms, micrograms to milligrams

Body temperature, Celsius, Fahrenheit


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Formulas necessary to calculate dosages Formula 1: single dose calculations

• DD x V divided by DH Formula 2: drip(infusion) calculations

• Total volume to be infused divided by total time of infusion in minutes, multiplied by drops divided by mL

Formula 3: drip not based on weight• DD x V divided by DH, multiplied by gtt divided by

mL

Formula 4: drip based on weight• Calculate patient’s weight in lbs by 2.2• Multiply patient’s weight in kg by desired dose/kg

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Formulas necessary to calculate dosages Formula 4: drip based on weight

• Prepare infusion, calculate dose on hand• Cross out like terms that appear in numerator &

denominator, 1 for 1

Paramedic authorized to give medications under direction of physician Federal, state, local laws govern purchasing,

distribution, dispensing, administration of drugs Must know local policies, procedures

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Protocols, written form of medical direction Must be signed by medical director Medical direction given by cell phone, radio If no communication, written protocols followed

Safety protocols, procedures with medication Be familiar with drug given Convey important information about patient to

online physician


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Safety protocols, procedures with medication Verify physician’s order Concentrate on task at hand Patient properly positioned Assemble, use correct supplies, equipment Handle drugs carefully, avoid dropping,

breaking Always use aseptic technique Carefully calculate dosages Monitor for overdose signs Carefully document

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Six rights of drug administration Right drug Right patient Right dose Right time Right route Right documentation

Standard precautions, must do every time in contact with patient

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Disinfection involves cleaning emergency vehicle, stretcher, equipment with disinfectants, toxic to body tissues

Antisepsis, cleanse local skin areas before needle puncture, alcohol-based/iodine-based products used


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Sterilization makes object free of all life forms, uses extreme heat, certain chemicals

Proper precautions when handling sharps Medications given orally, rectally, gastric

tube, topically, inhalation, injection, through vascular access, intraosseous infusion

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Blood sample needed before starting any IV lines, giving medications

Questions?

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