chapter 11 administration of medication and intravenous therapy

CHAPTER 11CHAPTER 11ADMINISTRATION OF MEDICATION

AND INTRAVENOUS THERAPY

Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 2

PRETESTPRETEST

True or False1. A drug is a chemical that is used for treatment,

prevention, or diagnosis of disease.

2. The generic name of a drug is assigned by the pharmaceutical manufacturer who develops the drug.

3. The Rx symbol comes from the Latin word recipe and means "take."

4. An anaphylactic reaction can be life threatening.

5. The dorsogluteal site is the most common site for administering injections in infants.


PRETEST, CONT.PRETEST, CONT.

True or False6. A subcutaneous injection is given into muscle

tissue.

7. The purpose of aspirating when administering an injection is to make sure the needle is not in a blood vessel.

8. The Mantoux tuberculin test is administered through a subcutaneous injection.

9. The peripheral veins of the arm and hand are used most often for administering IV therapy.

10. Chemotherapy is the use of chemicals to treat disease.


Content OutlineContent Outline

1. Pharmacology: The study of drugs

a. Includes:• Preparation

• Use

• Action of drugs in the body

2. Drug: A chemical that is used for the treatment, prevention, or diagnosis of disease

Introduction to Administration of Medication


Introduction to Administration of Medication, cont.


3. Most drugs: produced synthetically

a. Can also be obtained from:• Animals

• Plants

• Minerals




4. In the office, medication may be:

a. Administered: given to patient at office

b. Prescribed: Physician provides patient with a handwritten or computer-generated prescription to be filled at a pharmacy• Can also be telephoned or faxed to pharmacy

c. Dispensed: Medication given at office for patient to take at home (e.g., drug samples)




5. Legal Aspects

a. Administer medication only under direction of physician• Unlawful to administer medication without

physician's consent




6. Routes of Administration

a. Oral

b. Sublingual

c. Inhalation

d. Rectal

e. Vaginal




f. Topical

g. Intradermal

h. Subcutaneous

i. Intramuscular

j. Intravenous




7. Route depends on:

a. Type of drug

b. Dosage form

c. Intended action

d. Rapidity of response

desired




1. Most common route of administration in office:a. Parenteral: Refers to

sites located outside gastrointestinal (GI) tract• Most commonly used to

refer to administration of medication by injection




9. Drug References

a. For drugs used in office, MA must be familiar with:• Indications

• Adverse reactions

• Route of administration

• Dosage

• Storage




b. Package insert (PI)• Manufacturer includes with each medication

– Also included with drug samples and injectable medications

• Contains information on the drug




c. Drug References• Contain drug information

• Example: Physician's Desk Reference (PDR)

– Contains information on major prescription pharmaceutical products available in U.S.

– Consists of actual drug PI


Food and Drug AdministrationFood and Drug Administration

1. Federal agency in DHHS (Department of Health and Human Services)

2. Responsible for:

a. Determining if the following are safe before human use:• New food products

• Vaccines

• Medical devices

• Cosmetics


Food and Drug Administration, cont.


3. Determines safety and effectiveness of both prescription and over-the-counter (OTC) drugs

4. Drug manufacturer: must submit application for a new drug to FDA

a. For review and approval

b. Before product can be released for human use




5. FDA also determines if medication will be available with or without a prescription

a. Prescription drugs: must bear following label:• Caution: Federal law prohibits dispensing

without a prescription




b. Nonprescription medication: FDA determines to be safe and effective for use without physician supervision• Has low incidence of adverse reactions when

used properly

• Examples:

– Mild pain relievers

– Topical antibiotics

– Topical corticosteroids

– Cold medicines

– Laxatives


Drug NomenclatureDrug Nomenclature

1. Each drug has four names:

a. Chemical Name: precise description of chemical composition• Used most by manufacturers and pharmacists

b. Generic Name: assigned by manufacturer who developed the drug• Often shortened derivative of chemical name


Drug Nomenclature, cont. Drug Nomenclature, cont.

c. Official Name: name under which drug is listed in official publications• Example: U.S. Pharmacopeia (USP)

• Sets standards for each drug to regulate the following:

• Generic name frequently used for official name

- Strength- Purity- Packaging

- Safety- Labeling- Dosage form


Drug Nomenclature, cont. Drug Nomenclature, cont.

d. Brand Name: name under which pharmaceutical manufacturer markets the drug• A drug may be marketed by more than one company

– Generic drug may have several brand names.

– Example:

1) Generic name: acetaminophen

2) Brand names: Tylenol, Tempra, Apacet


Drug Nomenclature, cont.Drug Nomenclature, cont.

e. MA must be familiar with generic and brand name:• For each drug prescribed or administered in

the office


What Would You Do?What Would You Not Do?



Classification of Drugs Based on Preparation

Classification of Drugs Based on Preparation

1. Forms

a. Liquid

b. Solid


Classification of Drugs Based on Preparation, cont.

Classification of Drugs Based on Preparation, cont.

2. Same medications may be available in both liquid and solid form

a. Permits administration to different types of patients

b. Example: antibiotic• Liquid prep: administered to young children

• Solid prep: administered to older children (tablets, capsules)


Liquid PreparationsLiquid Preparations

1. Elixir

a. Drug dissolved in alcohol and water

b. Sweetened and flavored• Example: Dimetapp Elixir


Liquid Preparations, cont. Liquid Preparations, cont.

2. Emulsion

a. Mixture of fats or oils in water• Example: Soyacol Emulsion



3. Liniment

a. Drug combined with oil, soap, alcohol, or water

b. Applied externally, using friction to produce heat or warmth

c. Example: Heet liniment



4. Lotion

a. Aqueous preparation that contains suspended ingredients

b. Used to treat external skin conditions• Soothes, protects, and moistens skin

• Destroys harmful bacteria

– Example: Caladryl lotion



5. Solution

a. Contains one or more completely dissolved substances• Solute: dissolved substance

• Solvent: liquid in which it is dissolved

b. Example: Polysporin ophthalmic solution



6. Spirit

a. Drug combined with alcohol solution that is volatile: evaporates readily• Example: aromatic spirit of ammonia



7. Spray

a. Fine spray of medicated vapor

b. Often used for throat and nose conditions

c. Example: Dristan nasal spray



8. Suspension

a. Drug that contains solid insoluble drug particles in a liquid

b. Must be shaken before administration• Example: Amoxicillin oral suspension



9. Suspension aerosol

a. Solid or liquid drug particles suspended in a gas

b. Dispensed in a cloud or mist

c. Example: Proventil inhalation aerosol



10.Syrup

a. Drug dissolved in sugar, water, and flavoring (to disguise unpleasant taste)

b. Example: Robitussin cough syrup

11.Tincture

a. Drug dissolved in alcohol or alcohol and water

b. Example: Tincture of iodine


Solid PreparationsSolid Preparations

1. Tablet

a. Powdered drug that has been pressed into a disc

b. Some are scored: marked with indention so can be broken into halves or quarters for proper dosage

c. Example: Tylenol tablets


Solid Preparations, cont. Solid Preparations, cont.

2. Chewable tablet

a. Powdered drug that has been flavored and pressed into a disc

b. Often used for antacids, antiflatulents, children's medications

c. Example: Pepto-Bismol chewable tablets



3. Sublingual tablet

a. Powdered drug that has been pressed into a disc

b. Dissolves under the tongue• Permits rapid absorption into bloodstream

c. Example: nitroglycerin sublingual tablets (Nitrostat)



4. Enteric-coated tablet

a. Coated with substance: Prevents tablet from dissolving until it reaches intestines

b. Purpose of coating:• Prevents drug from being destroyed by gastric

juices

• Prevents drug from irritating stomach

c. Must not be crushed or chewed:• Releases active ingredients prematurely in stomach

• Example: Ecotrin enteric-coated aspirin



5. Capsule

a. Drug contained in a gelatin capsule that is water-soluble

b. Prevents patient from tasting drug

c. Example: Benadryl capsules


Solid Preparations, cont.Solid Preparations, cont.

6. Sustained-release capsules

a. Contain granules that dissolve at different rates

b. Provides gradual and continuous release of medication

c. Reduces numbers of doses required

d. Example: Contact 12-hour SR capsules



7. Caplet

a. Drug contained in oblong tablet

b. Smooth coating for easier swallowing

c. Example: Advil caplets



8. Lozenge

a. Drug contained in a candy-like base

b. Circular and dissolves on tongue

c. Example: Chloraseptic throat lozenges



9. Cream

a. Drug combined in a nongreasy base

b. Semisolid preparation

c. Applied externally to skin

d. Example: Hydrocortisone topical cream



10.Ointment

a. Drug with an oil base

b. Semisolid preparation

c. Applied externally to skin

d. Usually greasy

e. Example: Cortisporin topical ointment



11.Suppository

a. Drug mixed with a firm base

b. Melts at body temperature

c. Shaped in cylinder or cone for easy insertion into a body cavity• Rectum

• Vagina

d. Example: Preparation H suppositories



12.Transdermal patch

a. Patch with adhesive backing that contains a drug

b. Applied to skin

c. After being absorbed through skin: drug enters circulation• Example: Nictine transdermal patch

(Nicoderm)


Classification of Drugs Based on Action

Classification of Drugs Based on Action

1. Drugs classified according to action they have on body

2. For common drugs administered in office, MA should know:

a. Category to which drug belongs

b. Primary use

c. Major therapeutic effects


Systems of Measurement for Medication

Systems of Measurement for Medication

1. Three systems used in United States for prescribing, administering, and dispensing medication:

a. Metric: used most often because it provides a more exact measurement

b. Apothecary: occasionally used

c. Household: used by patients taking liquid medication at home


Systems of Measurement for Medication, cont.

Systems of Measurement for Medication, cont.

2. Units:

a. Weight: heaviness of an item

b. Volume: amount of space occupied by a substance

c. Length: linear measurement of distance from one point to another• Not used to administer medications

• Used in other aspects of medical office (measure head circumference in centimeters [cm])


Metric SystemMetric System

1. System most often used to administer medications

2. Developed in France in 18th century

3. Pharmaceutical companies: use it to measure and label medications

4. Uniform decimal scale based on units of 10


Metric System, cont. Metric System, cont.

5. Basic units

a. Gram: unit of weight• For measuring solids

b. Liter: unit of volume• For measuring liquids

c. Meter: linear unit• For measuring length and distance



6. Units most often used to administer medication:

a. Milligram (weight)

b. Gram (weight)

c. Milliliter (volume)

d. Cubic centimeter: amount of space occupied by 1 ml (1 ml = 1 cc)• These two units can be used interchangeably



7. Specific guidelines must be followed in notation of metric units and doses to:

a. Read prescriptions and medication orders

b. Record medication administration

c. Avoid medication errors



8. Metric Notation Guidelines

a. Metric unit abbreviations

• Weight

– Microgram: mcg

– Milligram: mg

– Gram: g

– Kilogram: kg


Metric System, cont.Metric System, cont.

• Volume

– Milliliter: ml

– Cubic centimeter: cc

– Liter: L



b. Do not use a period with the abbreviation of metric units• May be mistaken for another letter or symbol

– Correct:

1) mg

2) ml

– Incorrect:

1) mg.

2) ml.



c. Use Arabic numerals• To express the quantity of the dose

– Correct: 4 mg

– Incorrect: mg (MULTIMEDIA: This needs a line added over the numerals and under the period--see page 456 of the 6th ed)

iv



d. Place the numeral that expresses the quantity of the dose in front of the abbreviation• Leave a space between the quantity and the

abbreviation

e. Write a fraction of a dose as a decimal• Correct: 0.5 g

• Incorrect: ½ g



f. If the dose is a fraction of a unit:• Place a zero before the decimal point

– Focuses on the fractional dose

– Reduces possibility of misreading the dose as a whole number

• Example:

– Correct: 0.5 g

– Incorrect: .5 g



g. Do not place a decimal point and a zero after a whole number• Decimal point may be overlooked: results in

tenfold overdose error

– Correct: 1 ml

– Incorrect: 1.0 ml



h. Conversion Equivalents:

• Weight:

– 1000 micrograms = 1 milligram

– 1000 milligrams = 1 gram

– 1000 grams = 1 kilogram


Metric System, cont.Metric System, cont.

• Volume:

– 1000 milliliters = 1 liter

– 1000 liters = 1 kiloliter

– 1 milliliter = 1 cubic centimeter


Apothecary SystemApothecary System

1. Older and less accurate than metric systema. Gradually being phased out for

measurement of medications

2. Developed in England in 18th century

3. Unitsa. Weight

• Grain

• Dram

• Ounce

• Pound


Apothecary System, cont. Apothecary System, cont.

b. Volume• Minim

• Fluid dram

• Fluid ounce

• Pint

• Quart

• Gallon


Apothecary System, cont. Apothecary System, cont.

c. Length• Inch

• Foot

• Yard

• Mile


Household SystemHousehold System

1. Less accurate than metric or apothecary

2. Frequently used in United States

3. May be only system patient can

a. Understand

b. Safely use to take liquid medication at home (e.g., teaspoon)


Household System, cont. Household System, cont.

4. Volume: only household unit used to administer medication

a. Drop (gtt)

b. Teaspoon

c. Tablespoon

d. Ounce

e. Cup

f. Glass


Converting Units of Measurement

Converting Units of Measurement

1. Conversion: changing from one unit of measurement to another

2. Required when medication ordered in a unit different from medication label


Controlled DrugsControlled Drugs

1. Controlled drug: a drug that has restrictions placed on it by the federal government because of its potential for abuse

2. Classified into five categories called schedules

a. Based on abuse potential


Schedule I Schedule I

a. Schedule I• High potential for abuse

• No accepted medical use

• May lead to severe physical or psychological dependence

• Not available for prescribing

• May be used for research with appropriate limitations


Schedule I, cont.Schedule I, cont.

• Examples:

– Heroin

– LSD

– MDMA (Ecstasy)


Schedule II Schedule II

b. Schedule II• High potential for abuse

• Accepted medical use

• Abuse may lead to severe psychological or physical dependence

• Prescription must be in writing

• Emergency telephone order permitted

– Written prescription: must be provided within 7 days


Schedule II, cont.Schedule II, cont.

• No refills allowed

• Manufacturer's label: marked C-II

• Examples:

– Demerol

– OxyContin

– Percocet

– Ritalin


Schedule III Schedule III

c. Schedule III• Intermediate potential for abuse


• Abuse may lead to:

– Low to moderate physical dependence

– Moderate to high psychological dependence

• Telephone and fax orders permitted


Schedule III, cont.Schedule III, cont.

• If authorized by physician:

– Prescription can be refilled:

1) Up to 5 times

2) Within 6 months from issue date


Schedule III, cont. Schedule III, cont.

• Prescription expires 6 months from issue date

• Manufacturer's label: marked C-III

• Examples:

– Tylenol w/ codeine

– Vicodin


Schedule IV Schedule IV

d. Schedule IV• Low potential for abuse


• Abuse may lead to limited physical or psychological dependence

• Telephone and fax orders permitted


Schedule IV, cont. Schedule IV, cont.

• If authorized by physician:

– Prescription can be refilled:

1) Up to 5 times

2) Within 6 months from issue date


Schedule IV, cont. Schedule IV, cont.

• Prescription expires 6 months from issue date

• Manufacturer's label: marked C-IV

• Examples:

– Darvon

– Xanax

– Valium

– Ambien


Schedule V Schedule V

e. Schedule V• Very low potential for abuse


• Abuse may lead to low physical or psychological dependence


Schedule V, cont. Schedule V, cont.

• Prescribing policies determined by state/local regulations

– In most states:

1) Number of refills: determined by physician

2) Prescription expires: 1 year from issue date

3) Some available without prescription to patients >18 years


Schedule V, cont. Schedule V, cont.

• Manufacturer's label: marked C-V

• Examples:

– Cough suppressants with small amounts of codeine

– Antidiarrheals containing paregoric


Controlled Drugs, cont. Controlled Drugs, cont.

3. To administer, prescribe, or dispense controlled drugs:

a. Physician must register annually with Drug Enforcement Administration (DEA)• Assigned a DEA number

• Must put on all prescriptions for controlled drugs


The PrescriptionThe Prescription

1. Physician's order authorizing the dispensing of a drug by a pharmacist

2. Can be authorized in different forms

a. Handwritten

b. Computer-generated

c. Telephoned to pharmacy

d. Faxed to pharmacy


The Prescription, cont. The Prescription, cont.

3. Abbreviations and symbols used to:

a. Write a prescription

b. Record medication info in patient's chart

4. Keep all prescription pads in a safe place

a. Out of reach of individuals who may want to obtain drugs illegally

b. Stock supply should be locked in a drawer


Parts of a PrescriptionParts of a Prescription

1. Date

a. Pharmacist cannot fill prescription without date

b. Prescription expires after a certain length of time after being issued• Usually 1 year except for controlled drugs

c. After prescription expires: cannot be filled (or any refills left on prescription)


Parts of a Prescription, cont. Parts of a Prescription, cont.

2. Physician's name, address, telephone number, and fax number

a. Preprinted on form

b. Identifies physician issuing prescription

c. Provides info if pharmacist has a question and needs to contact office



3. Patient's name and address

a. Used for insurance billing and to properly dispense medications

4. Patient's age

a. Important in dispensing medications:• Pharmacist double-checks physician's order

• Makes sure proper dose is being dispensed based on age



b. Most common errors in dosage occur with elderly and children• Metabolize drugs differently

• May not require the standard dose

c. Also allows pharmacist to make sure drug is age-appropriate• Some drugs should not be taken by a certain

age group

• Example: ciprofloxacin (Cipro) should not be taken by individuals <18 years (can cause cartilage damage)



5. Superscription

a. Rx symbol: Latin for recipe and means "take"

6. Inscription

a. Name of drug and dosage

b. Example: Amoxil 250 mg



7. Subscription

a. Directions to pharmacist• Generally used to designate number of doses

to be dispensed

b. To prevent prescription from being altered:• Use both numbers and letters to indicate

quantity

• Example: #30 (thirty)



8. Signatura (sig)

a. Latin for write or label

b. Indicates information to be included on medication label• Directions for taking medication at home

• Name of medication



9. Refill

a. Number of times medication can be refilled

10.Physician's signature

a. Prescription cannot be filled without physician's signature

11.DEA number

a. Must appear on prescription for a controlled drug


Parts of a PrescriptionParts of a Prescription


Generic PrescribingGeneric Prescribing

1. Physician writes prescription using generic namea. Pharmacist can fill prescription with drug that

offers best savings to patient

2. Physician writes prescription using brand namea. In most states pharmacist has option of filling

prescription with a generic drug

3. Physician wants prescription to be filled with a specific brand:a. Must indicate Dispense as Written (DAW) on

prescription form


Completing a Prescription Form

Completing a Prescription Form

1. If delegated by physician: MA can complete prescription form

a. Physician must thoroughly review: to make sure info is correct

b. Physician signs form

2. MA must carefully follow prescription writing guidelines


The Medication RecordThe Medication Record

1. Office may use a preprinted form

2. Medications that should be recorded:

a. Prescription

b. Over-the-counter

c. Vitamin supplements

d. Herbal products


The Medication Record, cont.The Medication Record, cont.

3. Detailed information included for each medicationa. Informs physician what patient is taking and how

much

4. Should be part of every patient's medical record

5. MA may be responsible for documenting medication information

6. Medication record includes:a. Patient's name and date of birth

b. Any drug allergies


The Medication Record, cont. The Medication Record, cont.

c. Date medication prescribed (Rx) or date patient started taking (over-the-counter)

d. Name and dosage of medication

e. Frequency of administration

f. Route of administration

g. Whether prescription or over-the-counter

h. Refills (prescription medication only)

i. Date patient stopped taking medication


Medication RecordMedication Record


Factors Affecting Drug ActionFactors Affecting Drug Action

1. Each medication has an intended therapeutic effect

2. Certain factors affect action of drug in the body

a. Causes patients to respond differently to same drug

b. Drug therapy may need to be adjusted to meet variations

Therapeutic Effect


Therapeutic Effect, cont. Therapeutic Effect, cont.

3. Factors affecting drug action

a. Age• Children and elderly: respond more strongly

to drugs than adults

– Smaller dose may be prescribed


Therapeutic Effect, cont Therapeutic Effect, cont

b. Route of Administration• Medication administered by different routes:

absorbed at different rates

• Oral: absorbed slowly

– Must first be digested

• Parenteral: absorbed more quickly than oral

– Injected directly into body


Therapeutic Effect, cont Therapeutic Effect, cont

c. Size• Thin person: may require smaller drug

quantity

• Obese person: may require larger drug quantity

d. Time of Administration• Empty stomach: oral drug absorbed more

rapidly

• After eating: oral drug absorbed slower

• If medication irritating to stomach: take with food


Therapeutic Effect, cont.Therapeutic Effect, cont.

e. Tolerance• Same dose of a drug no longer produces

desired effect

• Patient should notify physician

– Change in drug or dosage may be needed


Undesirable Effects of DrugsUndesirable Effects of Drugs

1. May occur immediately or delayed hours or days

2. Includes:

a. Adverse Reactions• Unintended and undesirable effects that occur

along with therapeutic effects

– May be harmful: warrant discontinuing medication (e.g., allergic reaction)

– May be harmless: referred to as side effects:


Undesirable Effects of Drugs, cont.


• Side effects: adverse reactions that are harmless and often tolerated by patient to obtain therapeutic effect

– Example: dry mouth when taking an antihistamine

b. Drug Interactions• May occur when certain drugs are taken at

same time

• Ask patient what medications he/she is taking

– Record information in chart for review by physician




c. Allergic Drug Reaction• Often mild: rash, rhinitis, pruritus

• Anaphylactic reaction: A serious allergic reaction that requires immediate treatment

– Least common but most serious

– Occurs suddenly




– Symptoms of Anaphylactic Reaction

1) Sneezing

2) Urticaria (hives)

3) Itching

4) Angioedema: a localized urticaria of the deeper tissues of the body

5) Erythema: Reddening of the skin caused by dilation of superficial blood vessel in the skin

6) Disorientation




Symptoms of Anaphylactic Reaction:

– If no treatment, symptoms increase and progress to:

1) Dyspnea

2) Cyanosis

3) Shock

4) Decreased blood pressure

5) Weak and thready pulse




Symptoms of Anaphylactic Reaction

– If treatment not initiated promptly:

1) Convulsions

2) Loss of consciousness

3) Death




– To prevent anaphylactic reaction:

1) Stay with patient after administration of medications

2) Be especially alert after administering:a) Allergy test

b) Penicillin

c) Allergy injections




– Notify physician immediately if anaphylactic reaction occurs

– Treatment

1) One or more injections of epinephrine

2) Once patient is stabilized: antihistamine injection

a) Reverses the life-threatening symptoms

a) Alleviates urticaria, itching, angioedema, erythema




d. Idiosyncratic Reaction• Abnormal or peculiar response to a drug that

is unexplained and unpredictable

• Most often occurs in elderly patients


Guidelines for Preparation and Administration of Medication

Guidelines for Preparation and Administration of Medication

1. Work in quiet, well-lit atmosphere free from distractions

2. Always ask if you have a question about a medication order

3. Know drug to be given


Guidelines for Preparation and Administration of Medication,

cont.


cont.

4. Select proper drug

a. Check label three times• When taking it from storage

• Before preparing medication

• After preparing medication

b. Do not use if label is missing or difficult to read


Check the Drug LabelCheck the Drug Label



cont.


cont.

5. Do not use drug if:

a. Color has changed

b. Precipitate has formed

c. Unusual odor present



cont.


cont.

1. Check expiration date



cont.


cont.

7. Prepare proper dose

a. Dose: the quantity of a drug to be administered at one time• Dose too small: will not produce therapeutic

effect

• Dose too large: could be harmful or fatal

b. Dosage range: range of quantities of the drug that can produce therapeutic effects



cont.


cont.

8. Identify the patient

a. By full name and date of birth

9. Make sure patient not allergic to medication by:

a. Checking patient's record

b. Questioning patient



cont.


cont.

10.If giving injection: determine route and site

a. Determined by the type of injection

b. Examples:• Allergy injection: administered subcutaneously

(SC)

• Antibiotic: administered intramuscularly (IM)



cont.


cont.

c. Site must be free from:• Abrasions

• Lesions

• Bruises

• Edema

11.Use proper technique



cont.


cont.

12.Stay with patient after administration

13.Document information in patient's chart: must be clear and legible

a. Date and time

b. Name of medication and lot number (if required)



cont.


cont.

c. Dose given• If dose contains a fraction of a unit: place a 0

before decimal point

– Example: 0.5 mg (not .5 mg)

• Never place a decimal point and a zero after a whole number

– Example: 20 mg (not 20.0 mg)

– So not misread as 200 mg



cont.


cont.

d. Route of administration

e. Site of administration

f. Any unusual observations or patient reactions

g. Sign record with your name and credentials


Slide TitleSlide Title



cont.


cont.

14.Always follow seven "rights" of preparing and administering medication

a. Right drug

b. Right dose

c. Right time

d. Right patient

e. Right route

f. Right technique

g. Right documentation


Oral AdministrationOral Administration

1. Most convenient and most common method to administer medication

2. Drug is given by mouth (po) in solid or liquid form

3. Absorption of most oral drugs: small intestine


Oral Administration, cont.Oral Administration, cont.

1. Easier for many patients to swallow tablet/capsule with a glass of water

2. Water should not be offered if patient has taken cough syrupa. Water dilutes

beneficial effects


Parenteral AdministrationParenteral Administration

1. Advantages (SC, IM, IV):

a. Absorbed more rapidly and completely than oral route

b. May be only way drug can be given• Unconscious patient

• Gastric disturbance

– Nausea

– Vomiting


Parenteral Administration, cont.


2. MA usually responsible for administering SC, IM, intradermally (ID)

a. Intravenous administration: when immediate effect is needed• Usually administered by physician in

emergency situation




3. Disadvantages

a. Pain• To minimize pain of an injection:

– Insert and withdraw needle quickly and smoothly

– Withdraw needle at same angle as that of insertion

b. Possibility of infection at injection site




4. Injections that are given repeatedly: must rotate sites (e.g., allergy injections):

a. Prevents overuse of one site: • Can cause irritation and tissue damage

b. Allows better absorption of drug




5. Recording administration of medication in patient's chart:

a. Record site of administration • Assists in proper rotation of sites

– For injections given repeatedly

• Provides reference point if problem arises




6. Use medical asepsis when administering medications (Needle and inside syringe must remain sterile)

a. Reduces danger of microorganisms entering patient's body

7. Follow OSHA Bloodborne Pathogens Standard

a. To Protect MA from bloodborne pathogens


Parts of a NeedleParts of a Needle

1. Needle

a. Hub: fits onto top of syringe

b. Shaft: inserted into body tissue

c. Lumen: opening in shaft of needle


Parts of a Needle, cont. Parts of a Needle, cont.

d. Point: located at end of needle shaft• Sharp: to easily penetrate body tissues

e. Bevel: located at top and slanted• Makes narrow, slitlike opening in skin

– Closes quickly to prevent leakage of medication

– Heals quickly


Parts of a Needle and SyringeParts of a Needle and Syringe



f. Gauge• Range: between 18 and 27

• Refers to diameter of lumen

• As size of gauge increases, diameter decreases

• Thick, oily medications: must be given with a large lumen

– Too thick to pass through a smaller one

• Large lumen: makes a larger needle track in tissue

– Use smallest gauge needle possible: to reduce pain and tissue damage



g. Length• Range: between ⅜ and 3 inches

• Based on type of injection given (IM, SC, ID) and size of the patient

-Example: Giving an IM injection to an obese adult: requires a longer need to reach muscle tissue

• Length of needle: must be longer for IM injection

– To penetrate to muscle tissue


Parts of a Syringe Parts of a Syringe

2. Syringe

a. Used for inserting fluids into body

b. Made of plastic

c. Disposable

d. Syringe with attached needle packaged in:• Cellophane wrapper

• Rigid plastic container


Parts of a Syringe, cont. Parts of a Syringe, cont.

e. Printed on wrapper: • Syringe capacity

• Needle length

f. Syringe/needle in separate packages: must attach needle to syringe


Syringe and Needle PackagesSyringe and Needle Packages



g. Parts of a Syringe

• Barrel: holds medication

– Contains calibrated markings to measure proper amount

1) Most syringes calibrated in cubic centimeters (cc)



• Flange: rim at the end of the barrel

– Helps in injecting medication

– Prevents syringe from rolling when placed on flat surface

• Plunger: moveable cylinder that slides back and forth in the barrel

– Used to draw medication into and out of syringe


Parts of a SyringeParts of a Syringe


Hypodermic Syringe Hypodermic Syringe

h. Types of syringes: choice based on type of injection

• Hypodermic syringe

– Calibrated in cc

– Available in 2, 2.5, 3, and 5 cc

1) Commonly used to administer IM injections


Hypodermic SyringeHypodermic Syringe


Insulin Syringe Insulin Syringe

• Insulin syringe

– Designed to administer insulin injections

– Calibrated in units

1) Most common: U-100


Insulin SyringeInsulin Syringe


Tuberculin Syringe Tuberculin Syringe

• Tuberculin syringe

– To administer very small dose of medication (e.g., tuberculin test)

– Capacity of 1 cc

– Calibrations divided into tenths and hundredths of a cc


Tuberculin SyringeTuberculin Syringe


Parts of a SyringeParts of a Syringe

i. Syringes also available in 10, 20, 30, 50, and 60 cc• Not used to administer medication

• Used for medical treatment

– Irrigating wounds

– Drawing fluid from cysts


Safety-Engineered SyringesSafety-Engineered Syringes

1. OSHA stipulates requirements to:

a. Reduce needlesticks and other sharps injuries among health care workers

2. Employers are required to evaluate and implement safer medical devices

3. Safety-engineered syringes: built-in safety feature to reduce risk of needlestick injury


Safety Engineered SyringeSafety Engineered Syringe


Preparation of Parenteral Medication: Vial

Preparation of Parenteral Medication: Vial

1. Vials

a. Closed glass container with a rubber stopper

b. Soft metal or plastic cap• Protects the rubber stopper

• Must be removed first time medication is used


Preparation of Parenteral Medication: Vial, cont.


a. Available• Single-dose

• Multiple-dose




b. Vial may require mixing• Examples:

– Reconstituting a powdered drug

– Mixing vial that separates on standing

• Roll medication between hands

• Do not shake: causes bubbles that may enter syringe


Rolling VialRolling Vial




e. To remove medication from vial:• Inject amount of air equal

to amount of liquid to be removed

– Prevents formation of a partial vacuum: makes it difficult to remove medication




• Inject air above fluid level

– Prevents getting air bubbles into medication




• Remove medication by inserting needle opening below fluid level

– Prevents air bubbles from entering syringe

• Draw up correct amount of medication




• Remove air bubbles from syringe by tapping barrel with fingertips

– Air bubbles take up space medication should take up: prevents patient from receiving full dose of medication


Preparation of Parenteral Medication: Ampule, cont. Preparation of Parenteral Medication: Ampule, cont.

2. Ampule

a. Small, sealed glass container

b. Holds a single dose of medication

c. Constriction in the stem (neck): helps in opening it

d. Make sure no medication in stem: tap it lightly

e. Colored ring around neck: indicates where ampule is prescored• For easy opening



f. Open by holding firmly with gauze and breaking off stem• Use a strong steady

pressure



g. Hazard with ampule• Small glass particles can get into ampule:

when stem broken off

• Prevent this by using filter needle to withdraw medication



h. Remove medication from ampule• Do not let needle touch outside of ampule

– Prevents contamination of needle

• Do not inject air into ampule

– Could force out medication


Preparation of Parenteral Medication: Ampule, cont.Preparation of Parenteral Medication: Ampule, cont.

• Insert needle below fluid level

• Withdraw medication


Preparation of Parenteral Medication, cont.


3. Prefilled syringes and cartridges

a. Disposable

b. Do not have to draw up medication




c. Info printed on syringe/cartridge:• Name of drug

• Dose

• Expiration date

– Example: Tubex injector


Storage of MedicationsStorage of Medications

1. Store properly following info in drug package insert

2. Improper storage may alter effectiveness of medication


Reconstitution of Powdered Drugs

Reconstitution of Powdered Drugs

1. Some medications stable for only short period of time in liquid form

a. Example: measles, mumps, and rubella (MMR) immunization

b. Must be prepared and stored in powdered form


Reconstitution of Powdered Drugs, cont.


2. Liquid added to powder to reconstitute medication

a. Diluent: liquid used to reconstitute• Usually sterile water or

normal saline




3. Powdered drug available in:

a. Single-dose vial

b. Multi-dose vial

4. Instructions provided for reconstituting medication


Subcutaneous InjectionsSubcutaneous Injections

1. Administered into subcutaneous tissue

a. Consists of adipose (fat) tissue• Located just under the skin

b. SC tissue: located all over body• Certain sites more commonly used

– Where bones and blood vessels are not near surface of skin


Subcutaneous Injections, cont. Subcutaneous Injections, cont.

2. SC sites commonly used:

a. Upper lateral part of arms

b. Anterior thigh

c. Upper back

d. Abdomen


Subcutaneous Injection SitesSubcutaneous Injection Sites



1. Angle of insertion: 45 or 90 degrees



4. Medication is absorbed through capillaries

a. Slower absorption rate than IM

5. Do not give SC injection into tissue that is

a. Grossly adipose

b. Hardened


Subcutaneous Injections, cont.Subcutaneous Injections, cont.

c. Inflamed

d. Edematous• May interfere with proper absorption

6. Needle length range: ½ to ⅝ inch

a. Use 45-degree angle of insertion with ⅝-inch needle

b. Use 90-degree angle of insertion with ½-inch needle



7. Needle gauge range: 23 to 25

8. Use proper length needle: to make sure medication is administered into SC tissue

a. Elderly and dehydrated patients: have less SC tissue• Use shorter needle

b. Obese patients: have more SC tissue• Use longer needle



9. SC tissue is sensitive to:

a. Irritating solutions

b. Large volumes of

medication



10.Any medication given SC must be:

a. Isotonic

b. Nonirritating

c. Nonviscous

d. Water soluble

e. Should not exceed 1 cc• More than 1 cc: causes discomfort and pain

– Due to pressure on sensory nerve endings



11.Medications administered SC:

a. Epinephrine

b. Insulin

c. Allergy injections• Following injection: patient must wait 15 to 20

minutes

– To be observed for a reaction

• If patient decides not to wait: must sign a waiver form

– To protect office legally in the event of an allergic reaction


Intramuscular InjectionsIntramuscular Injections

1. Administered into muscular layer of the body

a. Located below skin and SC layer

b. Angle of insertion: 90 degrees to patient’s skin


Angle of InsertionAngle of Insertion


Intramuscular Injections, cont. Intramuscular Injections, cont.

2. Amount that can be injected

a. Gluteal and vastus lateralis sites: • Adults: Up to 3 cc

• Very thin adults and older patients: Up to 2 cc

b. Deltoid site: no more than 1 cc



3. Absorption more rapid than SC

a. More blood vessels in muscle tissue

4. Medication that is irritating to SC tissue: often given through IM route

a. Fewer nerve endings in muscle tissue



5. Most parenteral medications: administered IM

a. Medications administered IM in medical office:• Immunizations

• Antibiotics

• Injectable contraceptives

• Vitamin B12

• Corticosteroids



6. Needle length range: 1 to 3 inches

Must be long enough to reach muscle tissue

a. Average-sized adult: typically use 1½ inches

b. Child or thin adult: 1 inch

c. Obese patient: 2 inches or more depending on amount of SC tissue




a. Depends upon viscosity of medication

8. Intramuscular Injection Sites

a. Located away from large nerves and blood vessels

b. Should be fully exposed• Permits clear visualization of site


Dorsogluteal Site Dorsogluteal Site

c. Dorsogluteal Site• Gluteal muscles are well-developed: can

absorb large amount of medication

• Used for:

– Adults

– Children older than 3 years of age

• Patient position: on abdomen with toes pointed inward (relaxes gluteal muscles)


Dorsogluteal Site, cont. Dorsogluteal Site, cont.

• Inject medication into upper outer quadrant of gluteal area

– Located: above a diagonal line drawn from greater trochanter to posterior superior iliac spine

– Identify landmarks through palpation

• Be extremely careful to maintain proper boundary lines

– To avoid injection into sciatic nerve or superior gluteal artery


Dorsogluteal SiteDorsogluteal Site

From Leahy JM, Kizilay PE: Foundations of Nursing Practice: A Nursing Process Approach. Philadelphia, 1988, Saunders.


Deltoid Site Deltoid Site

d. Deltoid Site• Easily accessible

• Patient position: sitting or lying down

• Amount: no more than 1 cc should be administered


Deltoid Site, cont. Deltoid Site, cont.

• Site is small because major nerves and blood vessels surround it

– Cannot administer large amount of medication

– Cannot administer repeated injections

• Make sure entire arm is exposed

– Completely pull up sleeve

– If cannot pull up sleeve: remove arm from sleeve

1) Tight sleeve constricts arm: causes bleeding from puncture site


Deltoid Site, cont.Deltoid Site, cont.

• To locate site:

– Palpate lower edge of acromion process

– Forms the base of a triangle in line with midpoint of lateral side of arm, opposite the axilla

– Can also be located by placing four fingers horizontally across the deltoid muscle with top finger along acromion process; site located three finger widths below acromion process


Deltoid SiteDeltoid Site



Vastus Lateralis Site Vastus Lateralis Site

e. Vastus Lateralis Site• Thick muscle away from major nerves and

blood vessels

• Recommended for: infants and children younger than 3 years

– Gluteal muscles are not well developed yet


Vastus Lateralis Site, cont. Vastus Lateralis Site, cont.

• To locate site:

– Proximal boundary: hand's breadth below greater trochanter

– Distal boundary: hand's breadth above the knee

– Bounded by midanterior thigh on the front of the leg and midlateral thigh on the side of the leg

• Patient position: Easier to give lying down but patient can be sitting


Vastus Lateralis SiteVastus Lateralis Site



Ventrogluteal Site Ventrogluteal Site

f. Ventrogluteal site• Growing in acceptability because:

– SC layer is small at this site

– Muscle layer is thick

– Located away from major nerves and blood vessels


Ventrogluteal SiteVentrogluteal Site



Z-Track Method Z-Track Method

9. Z-Track Method

a. Used for administering medication that:• Irritate SC tissue

• Discolor skin

– Example: iron dextran injection


Z-Track Method, cont. Z-Track Method, cont.

b. Sites used• Dorsoglutel

• Ventrogluteal

• Vastus lateralis


Z-Track Method, cont. Z-Track Method, cont.

c. To administer injection:• Pull skin and SC tissue to the side

• Administer injection and remove needle

• Release skin: causes a zigzag path through tissue

– Seals off needle track

1) Prevents medication from reaching SC layer or skin surface


Z-Track MethodZ-Track Method


Intradermal InjectionsIntradermal Injections

1. Administered in dermal layer of skin

a. Angle of insertion: almost parallel to skin


Intradermal Injections, cont. Intradermal Injections, cont.

2. Absorption is slow:

a. Only small amount of medication can be injected• 0.01 to 0.2 cc



3. ID injection sites: where skin is thin

a. Anterior forearm

b. Middle of back

c. Upper arm

4. Needle length range: ⅜ to ⅝ inch




6. Tuberculin syringe used

a. Capacity of syringe is small: 1 cc

b. Calibrations divided into tenths and hundredths of a cubic centimeter• Can administer very small amount of

medication

– Required with an ID injection


Tuberculin SyringeTuberculin Syringe



7. Used to administer skin tests

a. Allergy tests

b. Tuberculin test



8. Procedure for skin testing

a. Medication is injected until a wheal forms• Wheal: small raised area because of distention

of skin



b. Results are read and interpreted at proper time• Allergy tests: 15 to 20 minutes

• Tuberculin test: 48 to 72 hours



c. If no reaction occurs• Wheal disappears within a short period of time

• Puncture site: only visible sign left

d. Positive reaction: results in induration and erythema• Only criteria used to assess reaction: extent of

induration (not erythema)


Tuberculin TestingTuberculin Testing

1. Infectious disease that usually attacks lungs

2. Caused by: tubercle bacillus (Mycobacterium tuberculosis)

a. Rod-shaped bacterium

Tuberculosis (TB)


Tuberculosis, cont. Tuberculosis, cont.

3. Symptoms

a. Fatigue

b. Weakness

c. Unexplained weight loss

d. Low-grade fever



e. Night sweats

f. Cough producing mucopurulent sputum

g. Occasional hemoptysis (coughing up blood)

h. Chest pain

4. Not highly contagious



5. Individuals who are infected may not develop disease

a. Body defenses protect them as follows:• Fibrous wall (capsule) builds around TB organisms

• Some bacteria may remain alive in capsule in dormant (inactive) state

• Patient experiences no symptoms

• Cannot spread disease to others

b. Patient is said to have a latent tuberculosis infection (LTBI):• Usually has a positive reaction to TB test



6. LTBI may develop into active TB:

a. Shortly after infection or many years after infection

b. TB bacteria break out of capsule: cause symptoms of active TB

c. Occurs in 10% of patients with LTBI

d. Most likely to occur when body defenses are weakened• During a serious illness

• Patients with immune disorder (e.g., AIDS)


Purpose of Tuberculin TestingPurpose of Tuberculin Testing

1. Detect presence of tuberculin infection

2. Recommended for:

a. Patients who have close day-to-day contact with someone who has active TB

b. Individuals who have symptoms of TB

c. Individuals with lowered immunity (e.g., human immunodeficiency virus [HIV])


Purpose of Tuberculin Testing, cont.


3. Used as screening measure for early detection of TB (before patient becomes symptomatic)

a. Early treatment: helps prevent spread of TB

4. May be:

a. Part of health screen

b. Required for:• Employment

• Entrance into college or military




5. MA responsible for:

a. Administering TB test

b. Interpreting results

6. MA must follow procedure exactly

a. To ensure accurate test results

b. If not performed correctly:• Patient with TB may not react to test


Tuberculin Test ReactionsTuberculin Test Reactions

1. Tuberculin: Consists of purified protein derivative (PPD)

a. Extracted from a culture of tubercle bacilli• Causative agent of TB


Tuberculin Test Reactions, cont.


2. If patient has active or latent TB:

a. Tuberculin causes induration• Induration: abnormally hard spot caused by

accumulation of small sensitized lymphocytes

3. TB test reactions: based on amount of induration present

a. Interpreted according to manufacturer's instructions




4. Positive reaction: indicates presence of TB infection

a. Does not differentiate between active and latent forms

b. Further diagnostic procedures must be done to make a diagnosis• Chest x-ray study

• Microbiologic examination of sputum


Tuberculin Testing MethodsTuberculin Testing Methods

1. Mantoux test

a. Most commonly used

b. Administered using intradermal needle and syringe

c. More specific and accurate test• Uses a known

amount of tuberculin


Tuberculin Testing Methods, cont.


2. Tine test

a. Consists of sterile plastic unit containing four tines• Impregnated with tuberculin

b. Patient inoculated intradermally to a depth of 1 to 2 mm




c. Disc is pressed onto the skin• Causes tuberculin to be deposited in skin

layers

d. Amount of tuberculin cannot be precisely controlled• Rarely used anymore


Mantoux TestMantoux Test

1. Administered through intradermal injection

a. Using a tuberculin syringe• Needle length: ⅜ to ½ inch

• Needle gauge: 26 to 27

2. Dosage: 0.10 ml of PPD containing 5 TU (tuberculin units)


Mantoux Test, cont. Mantoux Test, cont.

3. Brand names for Mantoux test:

a. Tubersol

b. Aplisol

4. Draw up proper amount of tuberculin solution

a. Too much: may elicit reaction not caused by a TB injection

b. Too little: may be insufficient solution to elicit a reaction


Mantoux Test, cont. Mantoux Test, cont.

5. Inject solution into superficial skin layers to form wheal

a. If injected into SC layer: wheal will not form

b. If injection too shallow: leakage of solution onto skin• If patient has TB: results in false-negative test

• Repeat test: at a site at least 2 inches away


Mantoux TestMantoux Test


Mantoux Test, cont.Mantoux Test, cont.

6. Do not apply pressure after injecting solution

a. Solution not intended to be absorbed into tissues

b. May cause leakage of solution

7. Do not cover site with adhesive bandage

8. Wheal disappears on its own in a few minutes


Guidelines for Administering a Mantoux Test

Guidelines for Administering a Mantoux Test

1. Use anterior forearm: 4 inches below bend in elbow

a. Areas to avoid• Hairy areas

• Areas with visible veins


Guidelines for Administering a Mantoux Test, cont.


• Scar tissue

• Red, swollen areas

• Bruised areas

• Dermatitis or other skin irritations




2. Cleanse site with antiseptic and allow to dry

3. Inject tuberculin into superficial layers of skin

a. Blood at puncture site: will not affect results

4. Read results 48 to 72 hours following administration


Guidelines for Reading Mantoux Test Results

Guidelines for Reading Mantoux Test Results

1. Read in good lighting

2. Use both inspection and palpation to read results

3. If induration is present:• Rub finger lightly from area of normal skin to

indurated area

– To assess size of induration


Guidelines for Reading Mantoux Test Results, cont


• Measure induration in millimeters

4. Induration: only criteria used to determine a positive reaction

a. If erythema present without induration: results are negative




5. Record reaction in mm

a. No induration present: record as 0 mm

6. Never record results as positive or negative




7. Interpretation of test results depends on:

a. Measurement of the induration (in mm)

b. Individual's risk of being infected with TB

c. Individual's risk of progression to disease if infected




8. Mantoux results interpreted as follows:

a. Positive reaction

• Vesiculation -Strongly positive reaction

– Vesiculation: formation of vesicles that are fluid-containing lesions

• Induration of 10 mm or more: Positive reaction

– Further diagnostic tests required to determine if active TB is present




• Induration of 5 mm: Positive for:

– Individual who lives in close contact with person infected with TB

– HIV-infected individual

– Individual at risk for HIV

• Doubtful reaction: Induration of 5 to 9 mm

– Retesting recommended using a different site

• Negative reaction: induration of less than 5mm


Tuberculosis Test Record CardTuberculosis Test Record Card


AllergyAllergy

1. Abnormal hypersensitivity of body to substances that are ordinarily harmless (allergens)a. Allergen: A substance that is capable of

causing an allergic reaction

2. Allergens enter body by:a. Being inhaled

b. Being swallowed

c. Being injected

d. Coming into contact with skin


Allergy, cont. Allergy, cont.

3. Common allergens

a. Plant pollens

b. Molds

c. House dust

d. Animal dander

e. Feather pillows



f. Dyes

g. Soaps

h. Detergents

i. Cosmetics

j. Certain foods

k. Medications

l. Insect stings



4. Exact cause of allergies: not fully understood

a. May be inherited

5. Allergies can develop at any age

a. Most likely to develop in children


Allergic ReactionAllergic Reaction

1. First time allergen enters body:

a. Stimulates body to produce antibodies (immunoglobulin E antibodies) to the allergen

2. Antibodies combine with allergen: results in allergen-antibody reaction

a. Histamine released in significant amounts• Causes allergic symptoms

b. Respiratory and integumentary systems: most frequently affected


Allergic Reaction, cont. Allergic Reaction, cont.

3. Allergic symptoms

a. Can range from mild to very severe (anaphylactic reaction)

4. Allergies appear in different forms: depends on allergen and body system affected


DiagnosisDiagnosis

1. Best way to prevent allergic reaction:

a. Identify and avoid allergens

2. Detailed medical history: obtained by physician

a. Most important: • Home and work environment

• Diet

• Living habits


Diagnosis, cont. Diagnosis, cont.

3. PE performed to detect conditions resulting from allergies:

a. Nasal polyps

b. Wheezing

c. Skin rashes

d. Urticaria


Diagnosis, cont. Diagnosis, cont.

4. Allergy testing performed

a. Direct skin testing• Skin-prick testing

• Intradermal testing

b. Radioallergosorbent test (RAST)


TreatmentTreatment

5. Treatment

a. Avoidance of allergen (if possible)

b. Drug therapy• Antihistamines

• Decongestants

• Bronchodilators

• Inhaled steroids

c. Allergy injections (desensitization injections)• Decreases sensitivity of body to allergen


Types of Allergy TestsTypes of Allergy Tests

Types of Allergy Tests

1. Purpose of allergy testing: to determine allergens causing patient's symptoms


Direct Skin TestingDirect Skin Testing

1. Extracts of common allergens applied to skin: observed for reaction

• Extracts applied topically

– Patch testing

• Extracts applied into superficial skin layers

– Skin-prick testing

– Intradermal testing


Direct Skin Testing, cont. Direct Skin Testing, cont.

2. Advantage: results obtained immediately

3. Disadvantage: potential to cause adverse reactions

• Most serious: anaphylactic reaction

– Alert physician immediately if occurs



4. Guidelines for Direct Skin Testing

a. Instruct patient to discontinue antihistamines 3 days before testing• Otherwise, false-negative results may occur

b. Area of application must be free from:• Hair

• Scar tissue

• Dermatitis

– Permits good visualization and palpation of test reactions



– Recommended sites:

1)Intradermal skin testing

2)Patch and skin-prick testing

a) Anterior forearm

b) Upper arm

a) Back



c. Cleanse area with antiseptic and allow to dry

d. If testing involves a puncture: wear gloves• To protect against bloodborne pathogens

e. Space extracts 1 inch apart: provides enough area for reaction• If not enough area: large adjacent reactions

may run together

– Difficult to read results



f. Label test sites: • To identify application site when reading

results

g. Inform patient: skin testing may cause a mild allergic reaction• Runny nose

• Sneezing

• Mild wheezing

h. If more severe reaction occurs:• Instruct patient to contact office


Patch TestingPatch Testing

1. Patch Testing:

a. Identifies allergens that cause contact dermatitis

b. Allergens applied to skin using a "patch"• Patch: Small piece of gauze impregnated with

an allergen

– Applied to skin

– Taped in place with hypoallergenic tape


Patch TestPatch Test


Patch Testing, cont. Patch Testing, cont.

c. Allergens commonly applied:• Plants

• Topical drugs

• Resins

• Metals

• Cosmetics

• Dyes

• Chemicals


Patch Testing, cont.Patch Testing, cont.

d. Instruct patient to:• Leave patch in place

• Keep dry

• Return to office in 48 hours to have results read


Patch Testing, cont.Patch Testing, cont.

e. Patches removed: results read 20 minutes later• Allows lessening of redness due to tape

removal

f. Positive results: erythema, itching, induration, vesiculation• Graded on a 1+ to 3+ scoring system


Patch Test ResultsPatch Test Results


Skin Prick Testing Skin Prick Testing

2. Skin-Prick Testing

a. To diagnose allergies to common allergens• Particularly those that are inhaled (house

dust, molds, pollens)


Skin Prick Testing, cont. Skin Prick Testing, cont.

b. Performed by:• Applying allergen extracts to skin

– Number ranges from 20 to 30

• Pricking each with a sterile needle

– Deposits allergen in outer layer of skin

– Allows it to react with body tissues


Skin Prick TestingSkin Prick Testing



c. Guidelines• Place extracts on skin in rows in a specific

pattern

• Label test sites with felt-tipped pen

– Tracks location of each extract

• Place a single drop of extract on skin

– More may cause extracts to run together


Skin Prick Testing, cont.Skin Prick Testing, cont.

• Pass a sterile needle through each drop

– Point of needle should lightly lift top skin layer

• Wipe needle dry with sterile swab between each prick

– Prevents one extract from mixing with the next (causes inaccurate test results)



d. Maximum reaction: occurs in 15 to 20 minutes after pricking skin

e. Leave test sites uncovered; instruct patient not to touch them

f. Do not wipe area: removes extract• Results in false-negative results

g. Read results after 15 to 20 minutes• Using a millimeter ruler



h. Positive reaction: area of induration surrounded by redness and itching

i. Measure size of induration in mm (with mm ruler)• Only criteria used in determining a positive

reaction

• Ignore redness

j. Convert results to a numerical scale (+1, +2, etc.)• Record results


Skin Prick ResultsSkin Prick Results


Intradermal Skin Testing Intradermal Skin Testing

3. Intradermal Skin Testing

a. Similar to skin-prick testing but more specific

b. Number of tests performed: 5 to 30

c. Patients suspected of being highly allergic• Greater chance of adverse allergic reaction

occurring

• Physician usually starts with skin-prick testing


Intradermal Skin Testing, cont. Intradermal Skin Testing, cont.

d. Small amount of allergen extract (0.02 to 0.05 ml)• Injected into skin layers: using a tuberculin

syringe

• Enough extract must be injected to form a wheal


Intradermal Skin Testing, cont. Intradermal Skin Testing, cont.

e. Read reaction in 15 to 20 minutes

f. Positive reaction: Induration surrounded by redness and itching

Copyright and courtesy Hollister-Stier, Spokane, Wash.


Intradermal Skin Testing, cont.Intradermal Skin Testing, cont.

g. Measure size of induration in mm (with mm ruler)• Only criteria used in determining a positive

reaction

• Ignore redness

h. Convert to numerical scale based on amount of induration present


Intradermal Test ResultsIntradermal Test Results


RAST TestingRAST Testing

1. Radioallergosorbent test (RAST): measures amount of immunoglobulin E antibodies in blood to common allergens

2. Blood specimen collected and sent to laboratory

3. Blood exposed to radioactively tagged allergens

4. Radiation device measures amounts of immunoglobulin E antibodies to allergens


RAST Testing, cont.RAST Testing, cont.

5. Advantages

a. Results not affected by medications (e.g., antihistamines)

b. No danger of adverse reactions

c. Can be performed on patients with skin eruptions • Unable to undergo direct skin testing


RAST Testing, cont.RAST Testing, cont.

6. Disadvantages• Expensive

• Does not provide immediate results


Outpatient IV TherapyOutpatient IV Therapy

1. Intravenous (IV) therapy

a. Administration of a liquid agent directly into a patient's vein• Distributed throughout the body by way of

circulatory system

b. Veins most commonly used• Peripheral veins of the arm and hand


Outpatient IV Therapy, cont. Outpatient IV Therapy, cont.

c. Liquid IV agents:• Fluids

• Medication

• Nutrients

• Blood or blood products

d. Infusion: Administration of fluids, medications or nutrients through the IV route

e. Transfusion: Administration of whole blood or blood products through the IV route


Outpatient IV Therapy, cont.Outpatient IV Therapy, cont.

2. Most IV therapy takes place in a hospital setting

3. IV therapy is also administered in outpatient ambulatory settings such as:

a. Medical offices and clinics

b. Urgent care centers

c. Ambulatory infusion clinics

d. Patient's home



4. Advantages of Outpatient IV Therapy

a. More convenient for patient

b. Reduces medical costs • Earlier Hospital Discharge:

– Example: Hospitalized patient with an infection needing IV antibiotics

1) No longer needs to be hospitalized

2) Receives the therapy at an infusion clinic



• Avoidance of Hospitalization

– Patients with acute or chronic illness that requires IV therapy

– Obtains IV therapy in an outpatient setting

– Can continue daily routine without major interruptions

– More independence and control over condition

– Example: Patient with rheumatoid arthritis needing IV Remicade therapy

1) Receives therapy in rheumatology office



5. Medical Office-Based IV Therapy

a. Some medical offices provide outpatient IV therapy• Oncology offices: may administer IV

chemotherapy

• Rheumatology offices: may administer IV rheumatology medications



b. Advantages• Closer monitoring of:

– Patients response to IV therapy

– Adverse reactions

From Potter PA, Perry AG: Basic nursing: essentials for practice, ed 5, St. Louis, 2002, Mosby.



c. Medical assists must acquire basic knowledge in IV therapy• MA often responsible for:

– Scheduling IV therapy

– Providing patient instructions

– Answering questions



d. Requirements for MA to perform IV therapy:• Check the laws of his or her state

– Determine if legally permissible for MA to perform this procedure

• Acquire proper training (theory and skills)


Indications for Outpatient IV Therapy

Indications for Outpatient IV Therapy

1. Physician assesses need for outpatient IV therapy:

a. Patients condition warrants the use of IV therapy

b. No alternate routes are feasible or appropriate

c. Patient does not need to be hospitalized to receive IV therapy


Indications for Outpatient IV Therapy, cont.


2. Physician is responsible for:

a. Prescribing IV medication/fluid and treatment plan

b. Ordering laboratory tests to monitor patients progress

c. Assessing patient following IV therapy




3. IV therapy administered at an outpatient site other than medical office (e.g., infusion clinic)a. MA responsibilities:

• Scheduling the necessary services

• Providing patient with IV therapy instructions

– Length of time required for the therapy

– Any dietary restrictions

– Advising the patient to wear loose-fitting comfortable clothing

– Whether or not someone needs to transport patient to/from appointment




4. IV therapy administered at the medical office

a. Special room to deliver the therapy• Lounge chair for patient comfort

b. Entry-level MA responsibilities:• Scheduling IV therapy

• Providing IV therapy instructions




c. IV practitioner (e.g., nurse or specially-trained medical assistant)• Initiates, maintains and discontinues the IV

therapy

Photo by Margaret Hartshorn; Courtesy of the Arizona Arthritis Center(www.arthritis.arizona.edu)




• Must be completely familiar with IV therapy including:

– Indications and uses

– Actions

– Dosage and rate of infusion

– Incompatibilities

– Contraindications and precautions

– Antidote

– Adverse effects




• During the IV therapy:

– Monitor patient response to therapy

– Be alert for adverse or allergic reactions

• After the therapy:

– Provide follow-up instructions

1) Normal side effects once patient returns home

2) Adverse reactions to report to medical office




5. Indications for IV therapy in an outpatient setting:

a. Administration of IV medication

b. Replacement of fluids and electrolytes

c. Administration of nutritional supplements

d. Administration of blood products

e. Emergency administration of IV medications and fluids


Administration of IV Medication

Administration of IV Medication

1. Process of delivering medication directly into a vein

a. Rapid and effective

b. Provides more accurate dosing than other routes• Medication enters the body directly from

circulatory system


Administration of IV Medication, cont.


– Bypasses barriers to drug absorption

1) Digestive tract: from oral administration

2) Muscle tissue: from IM administration

– Easier to control actual amount of drug delivered to the body




2. Medication may have to be administered through the IV route because:

a. Rapid systemic response to medication is desired

b. Therapeutic blood levels need to be maintained

c. Medication is destroyed by stomach acids and/or digestive enzymes

d. Medication cannot be absorbed into body through GI tract

e. Medication is toxic and could damage to lining of GI tract

f. Medication is painful or irritating when given by other parenteral routes (IM or SC)


Direct IV InjectionDirect IV Injection

3. IV Administration Methods

a. Direct IV Injection (IV push)• Administration of medication as a single dose

into the vein over a short period of time (usually less than 10 minutes)

– Administered through a vascular access device already in place

• Immediate and predictable results

• Good way to administer life-saving medications in an emergency


Intermittent IV AdministrationIntermittent IV Administration

b. Intermittent IV Administration• Administration of a medication over a specific

amount of time (termed the rate of infusion) and at specified intervals

• Frequently employed in outpatient settings

• Before administering


Intermittent IV Administration, cont.


– Dilute medication in a moderate amount of IV fluid (25 to 250 ml)

– Amount and type of IV fluid: indicated in drug insert

1) Example: Intermittent IV administration of ceftriaxone (an antibiotic) a) Reconstitute medication

b) Dilute in 50 to 100 ml of an IV fluid (e.g., sterile water, 0.9% sodium chloride)




• Rate of infusion: Depends on medication being administered

– Typically ranges from 15 minutes to several hours

– Specified in drug insert

1) Examples: a) Rate of infusion for

ceftriaxone (Rocephin): Between 15 to 30 minutes

b) Rate of infusion for IV infliximab (Remicade): At least 2 hours




• Interval of time between doses depends on:

– Medication being administered

– Patient condition

1) Example: Outpatient treatment plan for a patient with Lyme disease

a) IV ceftriaxone intermittently once a day for a period of 14 days


Continuous IV AdministrationContinuous IV Administration

c. Continuous IV Administration• Infusion of medication over a continuous

period of time (between 4 to 24 hours)

• Also known as an IV drip

• Most often used in hospital or home setting

• Used to maintain a constant therapeutic blood level of the medication


Continuous IV Administration, cont.

Continuous IV Administration, cont.

• Medication is diluted in a large quantity (250 to 1000 ml) of an IV fluid such as:

– 0.9% sodium chloride (known as normal saline)

– 5% dextrose in water (known as D5W)

• Not generally used to administer IV medications in medical office

– Because of amount of time required


IV Medication: AntibioticsIV Medication: Antibiotics

4. Intravenous Medications Administered in an Outpatient Setting

a. IV Antibiotics• May be prescribed to treat a serious infection

– To prevent the infection from spreading

– To avoid the development of serious complications


IV Medication: Antibiotics, cont.

IV Medication: Antibiotics, cont.

• Quickly achieves high blood concentrations

– Works on the infection immediately.

• IV antibiotic therapy may be prescribed in an outpatient setting for:

– Osteomyelitis, cellulitis endocarditis, bacterial meningitis, Lyme disease, bacterial pneumonia, bacterial septicemia, pyelonephritis, pelvic inflammatory disease, AIDS-related infections, severe urinary tract infections, and non-healing wound infections


IV Medication: ChemotherapyIV Medication: Chemotherapy

b. IV Chemotherapy

• Chemotherapy: the use of chemicals to treat disease.

– More specifically: the use of antineoplastic medications to treat different types of cancer

• Works by interfering with the ability of cancer cells to grow or reproduce


IV Medication: Chemotherapy, cont.


• IV route commonly used to administer chemotherapy

– Most antineoplastic medications are toxic and irritating

– Must be delivered to the body through a vein

– Cause pain and trauma to tissues if administered by other parenteral routes (i.e.; IM or SC)




• May take only a few minutes to administer or as long as several hours

• May be given on a daily, weekly or monthly basis

• Frequency and length of treatment depends on:

– Type of cancer

– Antineoplastic medications being administered

– Patient’s overall health

– Patients to tolerate the antineoplastic medications




• Often administered in an outpatient setting such as:

– Oncology medical office

– Infusion clinic


IV Medication: Monoclonal Antibodies

IV Medication: Monoclonal Antibodies

c. Monoclonal Antibodies• Used to treat inflammatory diseases

• Individuals with certain inflammatory diseases

– Have too much of a normally-occurring protein (tumor necrosis factor [TNF])

1) Causes inflammation

2) In too large of amounts: attacks healthy tissues


IV Medication: Monoclonal Antibodies, cont.


• Remicade (infliximab) is a monoclonal antibody which works by:

– Binding with TNF and blocking its action

1) Reduces the inflammatory response of the body

2) Disadvantage: Also lowers ability of body to fight infection




• IV Remicade administered in an outpatient setting for treatment of:

– Crohn's disease

– Rheumatoid arthritis

– Ulcerative colitis

– Ankylosing spondylitis

– Psoriatic arthritis




• Remicade works to:

– Reduce the symptoms

– Initiate and maintain remission of the disorder

• IV Remicade only administered after an inadequate response to conventional therapy

– Has some undesirable side effects

– Expensive


IV Medication: AnalgesicsIV Medication: Analgesics

d. IV Analgesics• May be prescribed if patient is unable to

manage pain using oral pain medications

• IV analgesic therapy may be prescribed in an outpatient setting for:

– Migraine headaches

– Cancer-related pain

– Pain associated with AIDs conditions


IV Medication: Analgesics, cont.

IV Medication: Analgesics, cont.

• Patient-controlled analgesia (PCA) pump

– Used to administer IV narcotic analgesics

– Delivery of the medication controlled by patient

– When patient experiences pain

1) Presses a button on PCA pump

2) Predetermined dose delivered IV to patient

– Pump is preset: to prevent overmedication

– Includes a locking device for security of the medication


PCA PumpPCA Pump

From Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, ed 3, St. Louis, 2004, Mosby.


Replacement of Fluids and Electrolytes

Replacement of Fluids and Electrolytes

1. To remain healthy: Body must maintain adequate fluid and electrolyte balance

2. Depletion of fluids and electrolytes may be caused by:

a. Vomiting

b. Diarrhea

c. Excessive perspiration (e.g., fever breaking or hot weather)

d. Starvation


Replacement of Fluids and Electrolytes, cont.


3. Excessive loss of fluids or electrolytes

a. Must be replaced as soon as possible to prevent dehydration• Infants and children: Especially vulnerable to

dehydration




4. Best way to replace fluids and electrolytes: oral consumption

a. May not be possible (e.g., excessive vomiting)• IV fluid therapy may be prescribed




5. Physician determines the IV fluid/amount using the following information:

a. Patient's diagnosis (e.g., prolonged diarrhea)

b. Other existing medical conditions

c. Length of the current illness

d. Body size and weight

e. Physician's findings from physical examination

f. Laboratory test results




6. Examples of IV fluids used to replace fluids/electrolytes:

a. 0.9% sodium chloride

b. Ringer's solution




7. Administered by continuous IV administration in following outpatient settings: a. Urgent care centers

b. Infusion clinics

c. Patient's home

8. Medical office does not typically administer IV fluids/electrolytes except in an emergencya. Because of length of time required for

continuous IV administration


Administration of Nutritional Supplements

Administration of Nutritional Supplements

1. IV therapy used to administer nutritional supplements in an outpatient setting

a. Indications:• Patient unable to eat

• Conditions causing poor absorption of nutrients from GI tract

b. Only used when patient has a condition that prevents other routes of administration (e.g., oral or enteral route)


Administration of Nutritional Supplements, cont.

Administration of Nutritional Supplements, cont.

• Enteral nutrition: The delivery of nutrients through a tube inserted into the GI tract.

2. May require IV administration of nutritional supplements:

a. Ulcerative colitis, Crohn’s disease, short bowel syndrome, celiac disease, pancreatitis, esophageal cancer, AIDS-related malnutrition, and malnutrition related to an eating disorder

3. Parenteral IV nutrition is often administered in outpatient settings (e.g., infusion clinics and the patient's home)


Administration of Blood Products

Administration of Blood Products

1. Immune Globulin

a. Consists of pooled human plasma containing antibodies• Has been tested

– Found to be safe and free of bloodborne pathogens

• Must be given through IV route

b. Intravenous immune globulin (IVIG) therapy


Administration of Blood Products, cont.


• Used to treat:

– Immune deficiencies who are unable to produce their own antibodies

1) Chronic inflammatory demyelinating polyneuropathy (CIDP)

a) Autoimmune disease: A condition in which, for some unknown reason, the body's immune system attacks the body's own cells such as:o Multiple sclerosis

o Myasthenia gravis

o Lupus




c. IVIG treatment plan• Dose is based on patient's weight

• Medication is infused slowly over a number of hours

• Number and frequency of treatment depends on patient condition.

– Patient who cannot produce antibodies: IVIG treatment once a month

– Patient with autoimmune disease: may only require a treatment when there is a flare-up (to boost immune system)




2. Hemophilia Factorsa. Hemophilia: An inherited bleeding

disorder characterized by a deficiency of a clotting factor needed for proper coagulation of the blood;

b. Without this factor• Hemophiliac may bleed:

– Spontaneously

– Following trauma to any tissues or organs of the body

• Most common sites of bleeds: Joints and muscles




c. Missing blood clotting factor: must periodically be administered IV

d. If treatment delayed: • Irreversible damage to affected tissues

• Death

e. Many patients receive IV clotting factors at home• More convenient

• Easier to manage condition


Emergency Administration of IV Medication and Fluids

Emergency Administration of IV Medication and Fluids

1. Capability to initiate an IV line is important in an emergency

a. Provides an access route for IV administration of:• Life-saving medications

• Fluids


Emergency Administration of IV Medication and Fluids, cont. Emergency Administration of

IV Medication and Fluids, cont.

2. Emergency situations sometimes arise in medical office

a. While waiting for squad to transport patient to hospital• IV line may be established to administer

medications and fluids as soon as possible


Emergency Administration of IV Medication and Fluids, cont.Emergency Administration of

IV Medication and Fluids, cont.

b. Emergency situations which may benefit from establishing IV access: • Myocardial infarction

• Stroke

• Anaphylactic reaction

• Diabetic emergencies

• Heat-related injuries (e.g., heat stroke)


POSTTESTPOSTTEST

True or False1. OSHA is responsible for determining if drugs are

safe before release for human use.

2. An enteric-coated tablet does not dissolve until it reaches the intestines.

3. The apothecary system is most often used to administer medication in the medical office.

4. The parenteral route of administering medications is used when the patient is allergic to the oral form of the drug.

5. Hypodermic syringes are calibrated in cubic centimeters.


POSTTEST, CONT.POSTTEST, CONT.

True or False6. The maximum amount of medication that can be

administered through the subcutaneous route is 2 cc.

7. A patient with latent tuberculosis infection has a negative reaction to a TB test.

8. A tuberculin skin test result should be read 15 to 20 minutes after administering.

9. Intermittent IV administration involves the administration of IV medication over a specific amount of time at specified intervals.

10. Immune globulin consists of pooled human plasma that contains clotting factors.

chapter 11 administration of medication and intravenous therapy

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