***MEDICATION ADMINISTRATION***

Principles of Medication Administration

I. “Six Rights” of drug administration

1. The Right Medication – when administering medications, the nurse compares the label of the medication container with medication            form.

    The nurse does this 3 times: a. Before removing the container from the drawer or shelf b. As the amount of medication ordered is removed from the container c. Before returning the container to the storage

2. Right Dose –when performing medication calculation or conversions, the nurse should have another qualified nurse check the calculated     dose

3. Right Client – an important step in administering medication safely is being sure the medication is given to the right client.

a. To identify the client correctly: b. The nurse checks the medication administration form against the client’s identification bracelet and asks the client to state his or      her name to ensure the client’s identification bracelet has the correct information.

4. Right Route – if a prescriber’s order neither does nor designates a route of administration, the nurse consult the prescriber. Likewise, if     the specified route is not recommended, the nurse should alert the prescriber immediately.

5. Right Time

a. The nurse must know why a medication is ordered for certain times of the day and whether the time schedule can be altered b. Each institution has are commended time schedule for medications ordered at frequent interval

c. Medication that must act at certain times are given priority (e.g insulin should be given at a precise interval before a meal)

6. RIGHT DOCUMENTATION –Documentation is an important part of safe medication administration

a. The documentation for the medication should clearly reflect the client’s name, the name of the ordered medication, the time, dose,     route and frequency b. Sign medication sheet immediately after administration of the drug

Client’s Right Related to Medication Administration

A client has the following rights:

1. To be informed of the medication’s name, purpose, action, and potential undesired effects.

2. To refuse a medication regardless of the consequences 3. To have a qualified nurses or physicians assess medication history, including allergies 4. To be properly advised of the experimental nature of medication therapy and to give

written consent for its use 5. To received labeled medications safely without discomfort in accordance with the six

rights of medication administration 6. To receive appropriate supportive therapy in relation to medication therapy 7. To not receive unnecessary medications

II. Practice Asepsis

Wash hand before and after preparing the medication to reduce transfer of microorganisms.

III. Nurse who administers the medications is responsible for their own action

Question any order that you considered incorrect (may be unclear or appropriate)

IV. Be knowledgeable about the medication that you administer

A fundamental rule of safe drug administration is: “Never administer an unfamiliar medication”

V. Keep the Narcotics in locked place

VI. Use only medications that are in clearly labeled containers. Relabeling of drugs is the responsibility of           the pharmacist.

VII. Return liquid that is cloudy in color to the pharmacy.

VIII. Before administering medication, identify the client correctly

IX. Do not leave the medication at the bedside. Stay with the client until he actually takes the medications.

X. The nurse who prepares the drug administers it. Only the nurse prepares the drug knows what the             drug is. Do not accept endorsement of medication.

XI. If the client vomits after taking the medication, report this to the nurse in charge or physician.

XII. Preoperative medications are usually discontinued during the postoperative period unless ordered to         be continued.

XIII. When a medication is omitted for any reason, record the fact together with the reason.

XIV. When the medication error is made, report it immediately to the nurse in charge or physician

To implement necessary measures immediately. This may prevent any adverse effects of the drug.

Oral Administration

Advantages

1. The easiest and most desirable way to administer medication 2. Most convenient 3. Safe, does nor break skin barrier 4. Usually less expensive

Disadvantages

1. Inappropriate if client cannot swallow and if GIT has reduced motility 2. Inappropriate for client with nausea and vomiting 3. Drug may have unpleasant taste 4. Drug may discolor the teeth 5. Drug may irritate the gastric mucosa 6. Drug may be aspirated by seriously ill patient.

Drug Forms for Oral Administration

1. Solid- tablet, capsule, pill, powder 2. Liquid- syrup, suspension, emulsion, elixir, milk, or other alkaline substances. 3. Syrup- sugar-based liquid medication 4. Suspension- water-based liquid medication. Shake bottle before use of medication to

properly mix it. 5. Emulsion- oil-based liquid medication 6. Elixir- alcohol-based liquid medication. After administration of elixir, allow 30 minutes

to elapse before giving water. This allows maximum absorption of the medication.

“Never crush Enteric-Coated or Sustained Release Tablet”

Crushing enteric-c-coated tablets – allows the irrigating medication to come in contact with the oral or gastric mucosa, resulting in mucositis or gastric irritation.

Crushing sustained-released medication – allows all the medication to be absorbed at the same time, resulting in a higher than expected initial level of medication and a shorter than expected duration of action

Sublingual Administration

A drug that is placed under the tongue, where it dissolves. When the medication is in capsule and ordered sublingually, the fluid must be aspirated

from the capsule and placed under the tongue. A medication given by the sublingual route should not be swallowed, or desire effects

will not be achieved

Advantages

1. Same as oral 2. Drug is rapidly absorbed in the bloodstream

Disadvantages

1. If swallowed, drug may be inactivated by gastric juices. 2. Drug must remain under the tongue until dissolved and absorbed

Buccal Administration

A medication is held in the mouth against the mucous membranes of the cheek until the drug dissolves.

The medication should not be chewed, swallowed, or placed under the tongue (e.g sustained release nitroglycerine, opiates, antiemetic, tranquilizer, sedatives)

Client should be taught to alternate the cheeks with each subsequent dose to avoid mucosal irritation

Advantages

1. Same as oral 2. Drug can be administered for local effect 3. Ensures greater potency because drug directly enters the blood and bypass the liver

Disadvantages

If swallowed, drug may be inactivated by gastric juice

Topical Administration

Application of medication to a circumscribed area of the body.

1. Dermatologic – includes lotions, liniment and ointments, powder.

a. Before application, clean the skin thoroughly by washing the area gently with soap and water, soaking an involved site, or locally                debriding tissue. b. Use surgical asepsis when open wound is present c. Remove previous application before the next application d. Use gloves when applying the medication over a large surface. (e.g. large area of burns) e. Apply only thin layer of medication to prevent systemic absorption.

2. Ophthalmic - includes instillation and irrigation

a. Instillation – to provide an eye medication that the client requires. b. Irrigation – To clear the eye of noxious or other foreign materials. c. Position the client either sitting or lying. d. Use sterile technique e. Clean the eyelid and eyelashes with sterile cotton balls moistened with sterile normal saline from the inner to the outer canthus f. Instill eye drops into lower conjunctival sac. g. Instill a maximum of 2 drops at a time. Wait for 5 minutes if additional drops need to be administered. This is for proper absorption of the     medication. h. Avoid dropping a solution onto the cornea directly, because it causes discomfort. i. Instruct the client to close the eyes gently. Shutting the eyes tightly causes spillage of the medication. j. For liquid eye medication, press firmly on the nasolacrimal duct (inner cantus) for at least 30 seconds to prevent systemic absorption of    the medication.

3. Otic Instillation – to remove cerumen or pus or to remove foreign body

a. Warm the solution at room temperature or body temperature, failure to do so may cause vertigo, dizziness, nausea and pain. b. Have the client assume a side-lying position (if not contraindicated) with ear to be treated facing up. c. Perform hand hygiene. Apply gloves if drainage is present. d. Straighten the ear canal:

0-3 years old: pull the pinna downward and backward Older than 3 years old: pull the pinna upward and backward

e. Instill eardrops on the side of the auditory canal to allow the drops to flow in and continue to adjust to body temperature f. Press gently bur firmly a few times on the tragus of the ear to assist the flow of medication into the ear canal. g. Ask the client to remain in side lying position for about 5 minutes h. At times the MD will order insertion of cotton puff into outermost part of the canal. Do not press cotton into the canal. Remove        cotton after 15 minutes.

4. Nasal – Nasal instillations usually are instilled for their astringent effects (to shrink swollen mucous membrane), to loosen secretions and     facilitate drainage or to treat infections of the nasal cavity or sinuses. Decongestants, steroids, calcitonin.

a. Have the client blow the nose prior to nasal instillation b. Assume a back lying position, or sit up and lean head back. c. Elevate the nares slightly by pressing the thumb against the client’s tip of the nose. While the client inhales, squeeze the bottle. d. Keep head tilted backward for 5 minutes after instillation of nasal drops. e. When the medication is used on a daily basis, alternate nares to prevent irritations

5. Inhalation – use of nebulizer, metered-dose inhaler

a. Semi or high-fowler’s position or standing position. To enhance full chest expansion allowing deeper inhalation of the medication b. Shake the canister several times. To mix the medication and ensure uniform dosage delivery c. Position the mouthpiece 1 to 2 inches from the client’s open mouth. As the client starts inhaling, press the canister down to            release one     dose of the medication. This allows delivery of the medication more accurately into the bronchial tree rather than         being trapped in the        oropharynx then swallowed d. Instruct the client to hold breath for 10 seconds to enhance complete absorption of the medication. e. If bronchodilator, administer a maximum of 2 puffs, for at least 30 second interval. Administer bronchodilator before other inhaled        medication. This opens airway and promotes greater absorption of the medication. f. Wait at least 1 minute before administration of the second dose or inhalation of a different medication by MDI g. Instruct client to rinse mouth, if steroid had been administered. This is to prevent fungal infection.

6. Vaginal – drug forms: tablet liquid (douches), jelly, foam and suppository.

a. Close room or curtain to provide privacy. b. Assist client to lie in dorsal recumbent position to provide easy access and good exposure of vaginal canal, also allows suppository     to dissolve without escaping through orifice. c. Use applicator or sterile gloves for vaginal administration of medications.

Vaginal Irrigation – is the washing of the vagina by a liquid at low pressure. It is also called douche.

i. Empty the bladder before the procedure ii. Position the client on her back with the hips higher than the shoulder (use bedpan) iii. Irrigating container should be 30 cm (12 inches) above iv. Ask the client to remain in bed for 5-10 minute following administration of vaginal suppository, cream, foam, jelly or irrigation

Rectal Administration

Can be use when the drug has objectionable taste or odor.

1. Need to be refrigerated so as not to soften. 2. Apply disposable gloves. 3. Have the client lie on left side and ask to take slow deep breaths through mouth and relax

anal sphincter. 4. Retract buttocks gently through the anus, past internal sphincter and against rectal wall,

10 cm (4 inches) in adults, 5 cm (2 in) in children and infants. May need to apply gentle pressure to hold buttocks together momentarily.

5. Discard gloves to proper receptacle and perform hand washing. 6. Client must remain on side for 20 minute after insertion to promote adequate absorption

of the medication.

Parenteral Administration

Administration of medication by needle.

Intradermal – under the epidermis.

1. The site are the inner lower arm, upper chest and back, and beneath the scapula.

2. Indicated for allergy and tuberculin testing and for vaccinations. 3. Use the needle gauge 25, 26, 27: needle length 3/8”, 5/8” or ½”

4. Needle at 10–15 degree angle; bevel up. 5. Inject a small amount of drug slowly over 3 to 5 seconds to form a wheal or bleb. 6. Do not massage the site of injection. To prevent irritation of the site, and to prevent

absorption of the drug into the subcutaneous.

Subcutaneous- Vaccines, heparin, preoperative medication, insulin, narcotics.

Sites:

outer aspect of the upper arms anterior aspect of the thighs Abdomen Scapular areas of the upper back Ventrogluteal Dorsogluteal

1. Only small doses of medication should be injected via SC route. 2. Rotate site of injection to minimize tissue damage. 3. Needle length and gauge are the same as for ID injections

Use 5/8 needle for adults when the injection is to administer at 45 degree angle; ½ is use at a 90 degree angle.

1. For thin patients: 45 degree angle of needle 2. For obese patient: 90 degree angle of needle 3. For heparin injection: do not aspirate. 4. Do not massage the injection site to prevent hematoma formation 5. For insulin injection: Do not massage to prevent rapid absorption which may result to

hypoglycemic reaction. 6. Always inject insulin at 90 degrees angle to administer the medication in the pocket

between the subcutaneous and muscle layer. Adjust the length of the needle depending on the size of the client.

7. For other medications, aspirate before injection of medication to check if the blood vessel had been hit. If blood appears on pulling back of the plunger of the syringe, remove the needle and discard the medication and equipment.

Intramuscular

Needle length is 1”, 1 ½”, 2” to reach the muscle layer Clean the injection site with alcoholized cotton ball to reduce microorganisms in the area. Inject the medication slowly to allow the tissue to accommodate volume.

Sites:

1. Ventrogluteal site

a. The area contains no large nerves, or blood vessels and less fat. It is farther from the rectal area, so it less contaminated. b. Position the client in prone or side-lying. c. When in prone position, curl the toes inward. d. When side-lying position, flex the knee and hip. These ensure relaxation of gluteus muscles and minimize discomfort during                 injection. e. To locate the site, place the heel of the hand over the greater trochanter, point the index finger toward the anterior superior iliac     spine, and then abduct the middle (third) finger. The triangle formed by the index finger, the third finger and the crest of the ilium     is the site.

2. Dorsogluteal site

a. Position the client similar to the ventrogluteal site b. The site should not be use in infant under 3 years because the gluteal muscles are not well developed yet. c. To locate the site, the nurse draw an imaginary line from the greater d. trochanter to the posterior superior iliac spine. The injection site id lateral and superior to this line. e. Another method of locating this site is to imaginary divide the buttock into four quadrants. The upper most quadrant is the site of     injection. Palpate the crest of the ilium to ensure that the site is high enough. f. Avoid hitting the sciatic nerve, major blood vessel or bone by locating the site properly.

3. Vastus Lateralis

a. Recommended site of injection for infant b. Located at the middle third of the anterior lateral aspect of the thigh. c. Assume back-lying or sitting position.

4. Rectus femoris site –located at the middle third, anterior aspect of thigh.

5. Deltoid site

a. Not used often for IM injection because it is relatively small muscle and is very close to the radial nerve and radial artery. b. To locate the site, palpate the lower edge of the acromion process and the midpoint on the lateral aspect of the arm that is in line     with the axilla. This is approximately 5 cm (2 in) or 2 to 3 fingerbreadths below the acromion process.

* IM injection – Z tract injection

a. Used for parenteral iron preparation. To seal the drug deep into the muscles and prevent permanent staining of the skin. b. Retract the skin laterally, inject the medication slowly. Hold retraction of skin until the needle is withdrawn c. Do not massage the site of injection to prevent leakage into the subcutaneous.

Intravenous

The nurse administers medication intravenously by the following method: 1. As mixture within large volumes of IV fluids. 2. By injection of a bolus, or small volume, or medication through an existing

intravenous infusion line or intermittent venous access (heparin or saline lock) 3. By “piggyback” infusion of solution containing the prescribed medication and a

small volume of IV fluid through an existing IV line. Most rapid route of absorption of medications. Predictable, therapeutic blood levels of medication can be obtained. The route can be used for clients with compromised gastrointestinal function or

peripheral circulation. Large dose of medications can be administered by this route. The nurse must closely observe the client for symptoms of adverse reactions. The nurse should double-check the six rights of safe medication. If the medication has an antidote, it must be available during administration. When administering potent medications, the nurse assesses vital signs before, during and

after infusion.

Nursing Interventions in IV Infusion

1. Verify the doctor’s order 2. Know the type, amount, and indication of IV therapy. 3. Practice strict asepsis. 4. Inform the client and explain the purpose of IV therapy to alleviate client’s anxiety. 5. Prime IV tubing to expel air. This will prevent air embolism. 6. Clean the insertion site of IV needle from center to the periphery with alcoholized cotton

ball to prevent infection. 7. Shave the area of needle insertion if hairy. 8. Change the IV tubing every 72 hours. To prevent contamination. 9. Change IV needle insertion site every 72 hours to prevent thrombophlebitis. 10. Regulate IV every 15-20 minutes. To ensure administration of proper volume of IV fluid

as ordered. 11. Observe for potential complications.

Types of IV Fluids

1. Isotonic solution – has the same concentration as the body fluid o D5 W o Na Cl 0.9% o Plain Ringer’s lactate o Plain Normosol M

2. Hypotonic – has lower concentration than the body fluids. o NaCl 0.3%

3. Hypertonic – has higher concentration than the body fluids.

o D10W o D50W o D5LR o D5NM

Complication of IV Infusion

1. Infiltration – the needle is out of nein, and fluids accumulate in the subcutaneous tissues.

Assessment:

Pain, swelling, skin is cold at needle site; pallor of the site, flow rate has decreases or stops.

Nursing Intervention:

Change the site of needle Apply warm compress. This will absorb edema fluids and reduce swelling.

2. Circulatory Overload - Results from administration of excessive volume of IV fluids.

Assessment:

Headache Flushed skin Rapid pulse Increase BP Weight gain Syncope and faintness Pulmonary edema Increase volume pressure SOB (shortness of breath) Coughing Tachypnea Shock

Nursing Interventions:

Slow infusion to KVO Place patient in high fowler’s position. To enhance breathing Administer diuretic, bronchodilator as ordered

3. Drug Overload – the patient receives an excessive amount of fluid containing drugs.

Assessment:

Dizziness Shock Fainting

Nursing Intervention:

Slow infusion to KVO. Take vital signs Notify physician

4. Superficial Thrombophlebitis – it is due to o0veruse of a vein, irritating solution or drugs, clot formation, large bore catheters.

Assessment:

Pain along the course of vein Vein may feel hard and cordlike Edema and redness at needle insertion site. Arm feels warmer than the other arm

Nursing Intervention:

Change IV site every 72 hours Use large veins for irritating fluids. Stabilize venipuncture at area of flexion. Apply cold compress immediately to relieve pain and inflammation; later with warm

compress to stimulate circulation and promotion absorption. “Do not irrigate the IV because this could push clot into the systemic circulation’

5. Air Embolism – Air manages to get into the circulatory system; 5 ml of air or more causes air embolism.

Assessment:

Chest, shoulder, or back pain Hypotension Dyspnea Cyanosis Tachycardia Increase venous pressure Loss of consciousness

Nursing Intervention

Do not allow IV bottle to “run dry” “Prime” IV tubing before starting infusion.

Turn patient to left side in the trendelenburg position. To allow air to rise in the right side of the heart. This prevent pulmonary embolism.

6. Nerve Damage – may result from tying the arm too tightly to the splint.

Assessment

Numbness of fingers and hands

Nursing Interventions

Massage the are and move shoulder through its ROM Instruct the patient to open and close hand several times each hour. Physical therapy may be required

     Note: apply splint with the fingers free to move.

7. Speed Shock – may result from administration of IV push medication rapidly.

To avoid speed shock, and possible cardiac arrest, give most IV push medication over 3 to 5 minutes.

General Principles of Parenteral Administration

1. Check doctor’s order. 2. Check the expiration for medication – drug potency may increase or decrease if outdated. 3. Observe verbal and non-verbal responses toward receiving injection. Injection can be

painful; client may have anxiety, which can increase the pain. 4. Practice asepsis to prevent infection. Apply disposable gloves. 5. Use appropriate needle size to minimize tissue injury. 6. Plot the site of injection properly to prevent hitting nerves, blood vessels, and bones. 7. Use separate needles for aspiration and injection of medications to prevent tissue

irritation. 8. Introduce air into the vial before aspiration. To create a positive pressure with in the vial

and allow easy withdrawal of the medication. 9. Allow a small air bubble (0.2 ml) in the syringe to push the medication that may remain. 10. Introduce the needle in quick thrust to lessen discomfort. 11. Either spread or pinch muscle when introducing the medication. Depending on the size of

the client. 12. Minimized discomfort by applying cold compress over the injection site before

introduction of medicati0n to numb nerve endings. 13. Aspirate before the introduction of medication. To check if blood vessel had been hit. 14. Support the tissue with cotton swabs before withdrawal of needle. To prevent discomfort

of pulling tissues as needle is withdrawn. 15. Massage the site of injection to haste absorption. 16. Apply pressure at the site for few minutes. To prevent bleeding.

17. Evaluate effectiveness of the procedure and make relevant documentation.

IV THERAPY

Steel Needles Example: Butterfly catheter. They are named after the wing-like plastic tabs at the base of the needle. They are used to deliver small quantities of medicines, to deliver fluids via the scalp veins in infants, and sometimes to draw blood samples (although not routinely, since the small diameter may damage blood cells). These are small gauge needles (i.e. 23 gauge).

Over the Needle Catheters  

Example: peripheral IV catheter. This is the kind of catheter you will primarily be using.

   

 

 

A Word About Gauges

And now, a word about gauges: Catheters (and needles) are sized by their diameter, which is called the gauge. The smaller the diameter, the larger the gauge. Therefore, a 22-gauge catheter is smaller than a 14-gauge catheter. Obviously, the greater the diameter, the more fluid can be delivered. To deliver large amounts of fluid, you should select a large vein and use a 14 or 16-gauge catheter. To administer medications, an 18 or 20-gauge catheter in a smaller vein will do.

IV Fluid

There are three main types of fluids:

Isotonic fluids 

Close to the same osmolarity as serum. They stay inside the intravascular compartment, thus expanding it. Can be helpful in hypotensive or hypovolemic patients. Can be harmful. There is a risk of fluid overloading, especially in patients with CHF and hypertension. Isotonic fluids contain an approximately equal number of molecules (blue dots) as serum so the fluid stays within the intravascular space. Remember that fluid flows from an area of lower concentration of molecules to an area of high concentration of molecules (osmosis) to achieve equilibrium (fluid balance). In this example, there is no fluid flow into or out of the intravascular space.

Examples: Lactated Ringer's (LR), NS (normal saline, or 0.9% saline in water).

Hypotonic fluids 

Have less osmolarity than serum (i.e., it has less sodium ion concentration than serum). It dilutes the serum, which decreases serum osmolarity. Water is then pulled from the vascular compartment into the interstitial fluid compartment. Then, as the interstitial fluid is diluted, its osmolarity decreases which draws water into the adjacent cells.  Can be helpful when cells are dehydrated such as a dialysis patient on diuretic therapy. May also be used for hyperglycemic conditions like diabetic ketoacidosis, in which high serum glucose levels draw fluid out of the cells and into the vascular and interstitial compartments. Can

be dangerous to use because of the sudden fluid shift from the intravascular space to the cells. This can cause cardiovascular collapse and increased intracranial pressure (ICP) in some patients.

Example: D5NS.45 (5% dextrose in 1/2 normal saline).

Hypotonic fluids Contain a lower number of molecules than serum so the fluid shifts from the intravascular space to the interstitial space (represented by the green arrows). This decreases the interstitial space osmolarity (because of the increase of fluid and constant number of molecules within it) which then causes fluid to move into the cells. Note that the green arrows represent fluid movement, not molecule movement.

Hypertonic fluids 

Have a higher osmolarity than serum. Pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Can help stabilize blood pressure, increase urine output, and reduce edema.  Rarely used in the prehospital setting. Care must be taken with their use. Dangerous in the setting of cell dehydration.

Examples: 9.0% NS, blood products, and albumin.

Hypertonic fluids Contain a higher number of molecules than serum so the fluid shifts from the interstitial space to the intravascular space (represented by the green arrows). This increases the interstitial space osmolarity (because of the loss of fluid and constant number of molecules within it) that then causes fluid to leak out of the cells.

There Are Two Main Groups Of Fluids

Crystalloid Are isotonic and remain isotonic and are therefore, effective volume expanders for a short period of time. However, both the water and the electrolytes in the solution can freely cross the semipermeable membranes of the vessel walls (but not the cell membranes) into the interstitial space, and will achieve equilibrium in two to three hours. They are ideal for patients who need fluid replacement. 

When using an isotonic crystalloid for fluid replacement to support blood

pressure from blood loss, remember that 3 mL of isotonic crystalloid solution are needed to replace 1 mL of patient blood. This is because approximately two thirds of the infused crystalloid solution will leave the vascular spaces by about one hour.

Generally, a good rule of thumb is that initial crystalloid replacement should not exceed three liters before whole blood is instituted. Continued use of crystalloids runs the very real risk that the fluid that has leaked into the interstitial space will result in edema, primarily in the lungs (pulmonary edema).

            Examples: Lactated Ringer's (LR), NS (normal saline).

Colloid These contain molecules (usually proteins) that are too large to pass out of the capillary membranes and therefore remain in the vascular compartment. The large protein molecules give colloid solutions a very high osmolarity. As a result, they draw fluid from the interstitial and intracellular compartments into the vascular compartment. They work well in reducing edema (as in pulmonary or cerebral edema) while expanding the vascular compartment. 

Colloids can produce dramatic fluid shifts and place the patient in considerable danger if they are not administered in a controlled settings.

             Examples: albumin and steroids

Vein Selection

 Veins of the Hand

1. Digital Dorsal veins Veins of the Forearm

2. Dorsal Metacarpal veins3. Dorsal venous network4. Cephalic vein5. Basilic vein

1. Cephalic vein2. Median Cubital vein3. Accessory Cephalic vein4. Basilic vein5. Cephalic vein6. Median antebrachial vein

Generally speaking, it is better to try to cannulate the most distal veins first. If for example, the antecubital veins are ruined as a result of failed cannulation attempts this can cause problems in the event of a successful cannulation further down. Any drugs or fluids put through the cannula may extravasate at the failed cannula site.

The cepahlic vein is one of the best veins available. It tends to be large, and the forearm provides a natural splint (Weinstein, 1997). If you place the cannula too far distally along the vein, you can run into problems with the wrist joint, and are getting close to the radial nerve. Also the tendons that control the thumb can obscure the vein (Hadaway, 1995). These problems can usually be avoided by moving a little further proximally along the vein.

The basilic vein is often overlooked, hiding as it does along the ulnar border of the hand and forearm. On the plus side, it's often fairly large - on the minus side it can roll like a tanker in a rough sea and can have more valves than a submarine.

The dorsal veins are often quite handy (excuse the pun) as the metacarpals splint cannulae well (Weinstein, 1997), but they can be quite small. If the patient is elderly, look elsewhere. The lack of turgor in the skin and loss of subcutaneous tissue make it quite difficult to cannulate these veins in the chronologically gifted (Whitson, 1996).

Cannulation of the antecubital veins can also cause problems as the cannula may occlude as the patient bends their arm. Avoid, if you can, areas where cannulation or venipuncture has previously taken place. Repeated puncture of the vein wall can result and is painful (Ahrens et al., 1991)

In general, locate the vein section with the straightest appearance. Choose a vein that has a firm, round appearance or feel when palpated. Avoid areas where the vein crosses over joints.

If the IV treatment is for a life-threatening illness or injury, your choice may be limited to an area that remains open during hypoperfusion. Otherwise, limit IV access to the more distal areas of the extremities.

Technique

 It is important to point out that starting an IV is an art-form which is learned with experience accumulated after performing many IVs. Some patients are easy but many are difficult.

Preparation It is important to gather all the necessary supplies before you begin. You will need:

Absorbent disposable sheet 1 alcohol prep pad 1 betadine swab Tourniquet IV catheter IV tubing Bag of IV fluid 4 pieces of tape (preferably paper tape or easy to remove tape which has been precut to

approximately 4 inches (10cm) in length and taped conveniently to the table or stretcher. Disposable gloves Gauze (several pieces of 4x4 or 2x2)

Prepare the IV fluid administration set

Inspect the fluid bag to be certain it contains the desired fluid, the fluid is clear, the bag is not leaking, and the bag is not expired.

Select either a mini or macro drip administration set and uncoil the tubing. Do not let the ends of the tubing become contaminated.

Close the flow regulator (roll the wheel away from the end you will attach to the fluid bag). Remove the protective covering from the port of the fluid bag and the protective covering from

the spike of the administration set. Insert the spike of the administration set into the port of the fluid bag with a quick twist. Do this

carefully. Be especially careful to not puncture yourself!

Hold the fluid bag higher than the drip chamber of the administration set. Squeeze the drip chamber once or twice to start the flow. Fill the drip chamber to the marker line (approximately one-third full). If you overfill the chamber, lower the bag below the level of the drip chamber and squeeze some fluid back into the fluid bag.

Open the flow regulator and allow the fluid to flush all the air from the tubing. Let it run into a trash can or even the (now empty) wrapper the fluid bag came in. You may need to loosen or remove the cap at the end of the tubing to get the fluid to flow although most sets now allow flow without removal. Take care not to let the tip of the administration set become contaminated.

Turn off the flow and place the sterile cap back on the end of the administration set (if you've had to remove it). Place this end nearby so you can reach it when you are ready to connect it to the IV catheter in the patient's vein.

Perform the venipuncture

Be sure you have introduced yourself to your patient and explained the procedure. Apply a tourniquet high on the upper arm. It should be tight enough to visibly indent the skin, but

not cause the patient discomfort. Have the patient make a fist several times in order to maximize venous engorgement. Lower the arm to increase vein engorgement.

Select the appropriate vein. If you cannot easily see a suitable vein, you can sometimes feel them by palpating the arm using your fingers (not your thumb) The vein will feel like an elastic tube that "gives" under pressure. Tapping on the veins, by gently "slapping" them with the pads of two or three fingers may help dilate them. If you still cannot find any veins, then it might be helpful to cover the arm in a warm, moist compress to help with peripheral vasodilatation. If after a meticulous search no veins are found, then release the tourniquet from above the elbow and place it around the forearm and search in the distal forearm, wrist and hand. If still no suitable veins are found, then you will have to move to the other arm. Be careful to stay away from arteries, which are pulsatile.

Don disposable gloves. Clean the entry site carefully with the alcohol prep pad. Allow it to dry. Then use a betadine swab. Allow it to dry. Use both in a circular motion starting with the entry site and extending outward about 2 inches. (Using alcohol after betadine will negate the effect of the betadine) Note that some facilities may require an alcohol prep without betadine.

To puncture the vein, hold the catheter in your dominant hand. With the bevel up, enter the skin at about a 30 to 45 degree angle and in the direction of the vein. Use a quick, short, jabbing motion. After entering the skin, reduce the angle of the catheter until it is nearly parallel to the skin. If the vein appears to "roll" (move around freely under the skin), begin your venipuncture by apply counter tension against the skin just below the entry site using your nondominant hand. Many people use their thumb for this. Pull the skin distally toward the wrist in the opposite direction the needle will be advancing. Be carefully not to press too hard which will compress

blood flow in the vein and cause the vein to collapse. Then pierce the skin and enter the vein as above.

Advance the catheter to enter the vein until blood is seen in the "flash chamber" of the catheter. 

If not successful If you are unsuccessful in entering the vein and there is no flashback, then slowly withdraw the catheter, without pulling all the way out, and carefully watch for the flashback to occur. If you are still not within the vein, then advance it again in a 2nd attempt to enter the vein. While withdrawing always stop before pulling all the way out to avoid repeating the painful initial skin puncture. If after several manipulations the vein is not entered, then release the tourniquet, place gauze over the skin puncture site, withdraw the catheter and tape down the gauze. Try again in the other arm.

Otherwise, After entering the vein, advance the plastic catheter (which is over the needle) on into the vein while leaving the needle stationary. The hub of the catheter should be all the way to the skin puncture site. The plastic catheter should slide forward easily. Do not force it!!

Release the tourniquet.

Apply gentle pressure over the vein just proximal to the entry site to prevent blood flow. Remove the needle from within the plastic catheter. Dispose of the needle in an appropriate sharps container. NEVER reinsert the needle into the plastic catheter while it is in the patient's arm! Reinserting the needle can shear off the tip of the plastic catheter causing an embolus. Remove the protective cap from the end of the administration set and connect it to the plastic catheter. Adjust the flow rate as desired.

Tape the catheter in place using the strips of tape and/or a clear dressing. It is advisable not to use the "chevron" taping technique.

Label the IV site with the date, time, and your initials. Monitor the infusion for proper flow into the vein (in other words, watch for infiltration).

Occasionally, you may inadvertently enter an artery. You'll recognize this because bright red blood is quickly seen in the IV tubing and the IV bag because of the high pressure that exists. If this occurs, stop the fluid flow, remove the catheter, and put pressure on the site for at least 5 minutes.

It is sometimes helpful to draw blood after you have entered the vein and before you have connected the IV tubing and bag. You can easily withdraw blood into a 15 or 20 mL syringe and then inject it into blood vials. Be sure to fill the vials to at least three quarters full. To recall the order of the blood tubes, remember the pneumonic Red Blood Gives Life for red, blue, green, lavender top tubes. Gently rock the tubes back and forth a few times to mix the blood with the additives. There is no need to rock the red top tube, however, the blood in this tube will clot quickly because it contains no additives. It should not be shaken because this will destroy the sample.

To discontinue an IV

 Remember to observe universal precautions. Start by clamping off the flow of fluids. Then gently peel the tape back toward the IV site. As you get closer to the site and the catheter, stabilize the catheter and remove the rest of the tape from the patient's skin. Then place a 4 x 4 gauze over the site and gently slide the plastic catheter out of the patient's arm. Use direct pressure for a few minutes to control any bleeding. Finally, place a band aide over the site.

Some of this text was modified and the pictures borrowed from an unknown nursing website.

How to correctly apply a warm, moist compress Put a bath towel under hot water and wring it out.  Then fold it in half (by width not length) and enclose the arm from fingertips to elbow in the towel.  Now place the towel-wrapped arm into a plastic bag and seal the open end of the bag near the elbow.  While the pack is working (using heat to cause venous dilation), you can be setting up your supplies and be ready to perform the venipuncture as soon as you remove the pack.  It works wonders!  Many professional, experienced IV Therapy nurses would not even consider performing a venipuncture on patient with limited venous access without using a pack first

The Five Rights

Remember the five rights: The minimum standard of practice for medication administration is checking the “five rights” (right drug, right patient, right dose, right time and right route) to provide patient safety.

Do I have the right drug?

Do I have the right patient?

Do I have the right dose?

Do I have the right time?

Do I have the right route?

Now add to this:

Do I have the right solution?

Flow Rates

You will often need to calculate IV flow rates. The administration sets come in two basic sizes: 

Microdrip sets   Allow 60 drops (gtts) / mL through a small needle into the drip chamber. Good for medication administration or pediatric fluid delivery

Macrodrip sets   Allow 10 to 15 drops / mL into the drip chamber. Great for rapid fluid delivery. Also used for routine fluid delivery and KVO

Fluid may be ordered at a KVO rate. This means to Keep the Vein Open, or run in fluids very slowly, enough to keep the vein open, but not really deliver much volume. At times, you may desire a faster flow rate. This is usually expressed in mLs / hour. In other words, how much fluid do you want your patient to receive each hour? A common "maintenance" amount, for instance, would be "run it in at 125 an hour". Your patient would receive 125 mL of fluid every hour. Unless you are using an electronic pump to deliver the fluid at precise amounts, you will need to learn how to set a flow rate yourself. This is usually done by counting the number of drops that fall into the clear drip chamber on the IV administration set in one minute. To do this, you must know what size administration set you are using (micro or macrodrip). Plug the numbers into the following formula and you've got it!

(Volume in mL) x (drip set) 

gtts

------------------------------------

= ------

(Time in minutes)  min

Let's say you want your patient to receive 250 mL of normal saline (NS) over a 90 minute time period. You decide to use a macrodrip (10gtt / mL) administration set. The formula will now look like this:

(250 mL) x (10 gtts/min)  gtts-----------------------------------

-= ------

(90 min)  1 min

Which becomes: 

2500  gtts-----------------------------------

-= ------

90  1

Then solving for gtts:

gtts27.7 = ------

1

Or, gtts = 28

Sometimes you will need to know how many milligrams of a medication to give a patient based on their weight. Let's say you need to give the patient some D50. You look up the medication and see that it should be given in a concentration of 0.5 mg / kg. The patient weighs 220 pounds. The first thing to do is convert the weight to kilograms. Then we can express all of this as simple ratios. We now have:

0.5 mg  ? mg--------- = ------1 kg  100 kg

Solving for? Give us 50 mg     ((0.5 mg x 100) kg / 1 kg) Fortunately for you; 50 mg is exactly what is in one amp of D50.

Want to try this yourself? Let's say you want your patient to have 500 mL of NS given over a two-hour period using a microdrip administration set. Use the first formula above.

Here's how it's done. First, the formula...

(Volume in mL) x (drip set) gtts-----------------------------------

-= ------

(Time in minutes) min

Plug the numbers in...

(500 mL) x (60 gtts/min) gtts-----------------------------------

-= ------

(120 min) 1 min

Which becomes:

30000 gtts-----------------------------------

-= ------

120 1

Which becomes:

gtts250 = ------

min

Perioperative Nusring is the care of a client or patient before, during and after and operation. It is a specialized nursing area wherein a registered nurse works as a team member of other surgical health care professionals. Perioperative nursing entails a lot of responsibilities and here are some of them:

Preoperative Phase

Preadmission Testing

1. Initiates initial preoperative assessment.2. Initiates teaching appropriate to patients to patients needs.3. Verifies completion of preoperative testing.4. Verifies understanding of surgeon-specific preoperative orders (e.g. bowel preparation,

preoperative shower)5. Assess patient’s need for postoperative transportation and care.

Admission to Surgical Center or Unit

1. Completes preoperative assessment.2. Assess for risk for postoperative complications.3. Reports unexpected findings or any deviation from normal.4. Verifies that operative consent has been signed.5. Reinforce previous teaching.

6. Explain phase in perioperative period and expectation.7. Develop a plan of care.

In Holding Area

1. Assess patient’s status, baseline pain and nutritional status.2. Review chart.3. Identifies patient.4. Verifies surgical site and marks site per institutional policy.5. Establishes intravenous line.6. Administers medication if prescribed.7. Takes measures to ensure patient’s comfort.8. Provides psychological support.9. Communicates patient’s emotional status to other appropriate members of the health care

team.

Intraoperative Phase

Maintenance of Safety

1. Maintains aseptic, controlled environment.2. Effectively manages human resources, equipment, and supplies for individualized patient care.3. Transfer patient to operating room bed or table.4. Position the patient: function alignment, exposure of surgical site.5. Applies grounding device to patient.6. Ensure that the sponge, needle, and instrument counts are correct.7. Completes intraoperative documentation.

Physiologic Monitoring

1. Calculates effect on patient of excessive fluid loss or gain.2. Distinguishes normal from abnormal cardiopulmonary data.3. Reports changes in patient’s vital signs.

Post Operative Phase

Transfer of Patient to Postanesthesia Care Unit

Communicates intraoperative information:

1. Identifies patient by name.2. States type of surgery performed.3. Identifies type of anesthetic used.

4. Reports patient’s response to surgical procedure and anesthesia.5. Describes intraoperative factors (e.g., insertion of drains or catheters, administration of blood,

analgesic agents, or other medications during surgery, occurrence of unexpected events.6. Describes physical limitation.7. Reports patient’s preoperative level of consciousness.

Postoperative Assessment Recovery Area

1. Determines patient’s immediate response to surgical intervention.2. Monitor patient’s physiologic status.3. Assess patient’s pain level and administers appropriate pain relief measures.4. Maintains patient’s safety(airway, circulation, prevention of injury)5. Administer medication, fluid and blood component therapy, if prescribed.6. Assess patient’s readiness for transfer to inhospital unit or for discharge home based on

institutional policy.

Surgical Unit/Ward

1. Continues monitoring of patient’s physical and psychological response to surgical intervention.2. Provides teaching to patient during immediate recovery period.3. Assist patient in recovery and preparation for discharge home.4. Determines patient’s psychological status.5. Assist with discharge planning.

Home or Clinic

1. Provides follow-up care during office or clinic visit or by telephone contact.2. Reinforce previous teaching and answer patients and family questions about surgery and follow-

up care.3. Assess patient’s response to surgery and anesthesia and their effects on body image and

function.

Classification of OR team

There are two types of OR team according to the functions of its members.

Sterile team members

1. Surgeon2. Assistants to the surgeon3. Scrub person (either a registered nurse or surgical technologist)

Unsterile team members

1. Anesthesiologist2. Circulator3. Biomedical technicians, radiology technicians or other staff that might be needed to set

up and operate specialized equipment or devices essential in monitoring the patient during a surgical operation

Operating Room Team: Sterile Personnel

The members of the OR sterile team will do the following things:

1. Perform surgical hand washing (arms are included).2. Don sterile gowns and gloves.3. Enter the sterile field.4. Handles sterile items only.5. Functions only within a limited area (sterile field).6. Wear mask.

Operating Surgeon

The surgeon is a licensed physician (MD), osteopath (DO), oral surgeon (DDS or DMD), or podiatrist (DPM). This professional is especially trained and is qualified by knowledge and experience for the performance of a surgical operation.

Responsibilities of a surgeon:

1. Preoperative diagnosis and care of the patient2. Performance of the surgical procedure3. Postoperative management of care

Assistants to surgeon

During a surgical procedure, the operating surgeon can have one or two assistants to perform specific tasks under his/her (operating surgeon) direction. The responsibilities of a surgeon’s assistant:

1. Help maintain the visibility of the surgical site2. Control bleeding3. Close wounds4. Apply dressings5. Handles tissues6. Uses instruments

Types of Assistants to Surgeon:

First Assistants could either be:

1. A qualified surgeon or resident in an accredited surgical education program. The first assistant should be capable of assuming the operating surgeon’s responsibility in cases of incapacitation or accidents.

2. Registered Nurse and surgical technologists that have a written hospital policy permitting the action.

Second Assistant could be a registered nurse or surgical technologist. These staff should be trained and they mar retract tissues and suction body fluids to help provide exposure of the surgical site.

Scrub Person

A scrub person could be the following:

Registered Nurse Surgical technologist Licensed practical/vocational nurse

The responsibility of a scrub person is to maintain the integrity, safety and efficiency of the sterile field throughout the surgical procedure.

DUTIES & RESPONSIBILITIES

SCRUB NURSE

Before an operation

Ensures that the circulating nurse has checked the equipment Ensures that the theater has been cleaned before the trolley is set Prepares the instruments and equipment needed in the operation Uses sterile technique for scrubbing, gowning and gloving Receives sterile equipment via circulating nurse using sterile technique Performs initial sponges, instruments and needle count, checks with circulating nurse

When surgeon arrives after scrubbing

Perform assisted gowning and gloving to the surgeon and assistant surgeon as soon as they enter the operation suite

Assemble the drapes according to use. Start with towel, towel clips, draw sheet and then lap sheet. Then, assist in draping the patient aseptically according to routine procedure

Place blade on the knife handle using needle holder, assemble suction tip and suction tube

Bring mayo stand and back table near the draped patient after draping is completed Secure suction tube and cautery cord with towel clips or allis Prepares sutures and needles according to use

During an operation

Maintain sterility throughout the procedure Awareness of the patient’s safety Adhere to the policy regarding sponge/ instruments count/ surgical needles Arrange the instrument on the mayo table and on the back table

Before the Incision Begins

Provide 2 sponges on the operative site prior to incision Passes the 1st knife for the skin to the surgeon with blade facing downward and a

hemostat to the assistant surgeon Hand the retractor to the assistant surgeon Watch the field/ procedure and anticipate the surgeon’s needs Pass the instrument in a decisive and positive manner Watch out for hand signals to ask for instruments and keep instrument as clean as

possible by wiping instrument with moist sponge Always remove charred tissue from the cautery tip Notify circulating nurse if you need additional instruments as clear as possible Keep 2 sponges on the field Save and care for tissue specimen according to the hospital policy Remove excess instrument from the sterile field Adhere and maintain sterile technique and watch for any breaks

End of Operation

Undertake count of sponges and instruments with circulating nurse Informs the surgeon of count result Clears away instrument and equipment After operation: helps to apply dressing Removes and siposes of drapes De-gown Prepares the patient for recovery room Completes documentation Hand patient over to recover room

CIRCULATING NURSE

Before an operation

Checks all equipment for proper functioning such as cautery machine, suction machine, OR light and OR table

Make sure theater is clean Arrange furniture according to use Place a clean sheet, arm board (arm strap) and a pillow on the OR table Provide a clean kick bucket and pail Collect necessary stock and equipment Turn on aircon unit Help scrub nurse with setting up the theater Assist with counts and records

During the Induction of Anesthesia

Turn on OR light Assist the anesthesiologist in positioning the patient Assist the patient in assuming the position for anesthesia Anticipate the anesthesiologist’s needs If spinal anesthesia is contemplated:

Place the patient in quasi fetal position and provide pillowPerform lumbar preparation asepticallyAnticipate anesthesiologist’s needs

After the patient is anesthetized

Reposition the patient per anesthesiologist’s instruction Attached anesthesia screen and place the patient’s arm on the arm boards Apply restraints on the patient Expose the area for skin preparation Catheterize the patient as indicated by the anesthesiologist Perform skin preparation

During Operation

Remain in theater throughout operation Focus the OR light every now and then Connect diatherapy, suction, etc. Position kick buckets on the operating side Replenishes and records sponge/ sutures Ensure the theater door remain closed and patient’ s dignity is upheld Watch out for any break in aseptic technique

End of Operation

Assist with final sponge and instruments count Signs the theater register Ensures specimen are properly labeled and signed

After an Operation

Hands dressing to the scrub nurse Helps remove and dispose of drapes Helps to prepare the patient for the recovery room Assist the scrub nurse, taking the instrumentations to the service (washroom) Ensures that the theater is ready for the next case