workbook chapter16

7/23/2019 Workbook Chapter16

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16

182

3.List four possible causes of this childs seizure.

4. What test should you perform on this infant beforeany medications are administered, and why?

5.What are the possible routes of medication admin-istration for this patient (list in order of your pref-erence and explain).

Active Learning

Some people are great at math, and then there arethe rest of us. There is a certain amount of commonsense that goes into calculating drug dosages, butfor the most part it is based on simple formulas andcalculations.

1. Equivalents

Before you begin calculating drug dosages, thereare several things that you will need to commit tomemory:

a. pound(s) (lb) make up 1 kilogram(kg).

b. 1 kg is equal to gram(s) (g).

Are You Ready?As you arrive on the scene of an unknown medicalemergency, a hysterical woman runs out of her housecarrying an infant who appears blue and is activelyseizing. You yell to your partner, Seizing kid, as youopen the side door of the ambulance and grab thepediatric kit and O2bag. Your partner takes the babyfrom the mother and steps up into the ambulance asyou open the O2 bag.

1.What is your general impression of this patient?

2.What is your first priority?

Medication Administration

and IV


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Chapter 16 Medication Administration and IV 183

c. 1 g is equal to milligram(s) (mg).

d. 1 mg is equal to microgram(s)(mcg).

e. 1 liter (L) is equal to milliliter(s)(mL).

f. 1 cubic centimeter (cc) is equal tomL.

g. 1 teaspoon (tsp) is equal to mL.

h. 1 tablespoon (T) is equal to mL.

i. 1 fluid ounce (fl oz) is equal tomL.

j. 1 grain (gr) is equal to mg.k. 1 deciliter (dL) is equal to L.

l. 1 centimeter (cm) is equal tometer(s) (m).

m. 1 milligram (mg) is equal to g.

n. 1 mcg is equal to g.

2. Calculation Methods

There are several ways to determine how muchof a medication you are supposed to administerto a patient. No matter what method you chooseto use, if performed properly, they should allcome up with the same answer. Following arethree methods for determining the appropriatedose based on information that you have avail-able to you.

Method 1The first method is based on the following for-mula:

Volume to be

administered (X)

Volume on hand

Ordered (or calculated) dose

Concentration (in units

of mg, mcg, g, etc.)

Example:Medical control orders you to adminis-

ter 5 mg of morphine sulfate IV to your 84-year-oldfemale patient who has signs and symptoms of ahip fracture. The morphine in your formularycontains 10 mg in 1 mL. How many milliliters ofmorphine sulfate do you need to administer to thispatient in order to deliver 5 mg?

You have the following information:

Order: 5 mg morphine sulfate IV

On hand: 10 mg/1 mL

Fill in the formula:

X1 mL 5 mg

10 mg

Cancel any common values (volumes or concentra-tions) that exist on the top and on the bottom, andmultiply across the top.

X 1mL 5 m

g10 m

g

1 5 mL

10

5 mL

10

0.5 mL

You need to administer 0.5 mL of morphine sulfateto your patient.

Method 2

This second method involves ratio and proportion.The symbol for proportion is ::, and the symbol forratio is : .

Using the same problem as in method 1, startwith the known ratio on the left side of the pro-portion:

10 mg : 1 mL ::

Place the unknown ratio on the right side of theproportion in the same sequence as the ratioon the left side of the proportion. This ratio isusually the physician order or the dosage thatyou are permitted to administer based on stand-ing orders:

10 mg : 1 mL :: 5 mg : XmL

First, multiply the extremes (the far outsidevalues: 10 mg and X mL) and place the resulton the left side of the equation. Second, multi-ply the means (the numbers on either side ofthe proportion symbol: 1 mL and 5 mg) andplace this value on the right side of the expres-sion:

10X1 5

Multiply:

10X5

Divide both sides by the number in front oftheX:

10X

10

5

10 X 0.5 mL



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184 Part 2 Foundations of Communication, Assessment, and Critical Care

Method 3

The third method is referred to as the crossmultiplication method.This method sets the prob-

lem up using fractions. The first fraction is theconcentration, and the second fraction is the phy-sicians order over the volume of medication beingadministered.

10 mg

1 mL

5 mg

XmL

Cross multiply the fractions by multiplying numer-ators by the denominator on the opposite side.

Express the results as an algebraic equation thesame as used in the proportion method.

10X 5 1

5

X 0.5 mL


3. Fluid Volume over Time

To calculate a volume to be infused over a specifictime frame, you need the following information:

The volume to be administered

The delivery of volume of the administrationset (drops [gtt]/mL)

The total time to infuse the fluid (alwaysexpressed in minutes)

Example:The physician orders the administrationof 400 mL of 0.9% sodium chloride solutionover 1 hours using a 10 gtt/mL (macro-drip)administration set. At what drip rate will you setthe infusion?

Volume to be infused: 400 mL

Administration set size: 10 gtt/mL

Total time of infusion: 90 minutes

The following formula should be used when cal-

culating this type of problem:

Drip rate

(gtt>min)

Volume to be infused Drip chamber size

Total time of infusion (minutes)

400 mL 10 gtt/mL

90 min

Simplify:

Drip rate

400 m

L 10 gtt/m

L

90 min

400 gtt

9 min

44.4 gtt/min

This same formula can be used to find out howlong it would take to administer the entire con-tents of an IV bag using a specific drip rate.

Place the drip rate on the left side of the equa-tion.

The total volume of the IV bag multiplied bythe drip chamber size is the numerator on theright side of the equation.

The total time of infusion is the denominatoron the right side of the equation.

Solve the equation for X (the time needed toadminister the entire contents of an IV bag).

Example: You have a 250-mL bag of 5% dextrose inwater (D5W) and have been ordered to infuse it at90 gtt/min using a 60-gtt/mL administration set. Howlong will it take to infuse this amount of fluid?

Volume to be infused: 250 mL

Administration set size: 60 gtt/mL

Total time of infusion: Xminutes

Ordered gtt/min: 90 gtt/min

Set up the formula with the information that youhave on hand:

90 gtt/ min 250 mL 60 gtt/mL

XTime

Multiply each side of the equation byX. Milliliterscancel one another.

X(90 gtt/min)(XTime) 15,000 gtt

Divide each side by 90 gtt/min:

X Time 167 min

It will take 167 minutes, or 2 hours and 47 min-utes, to infuse the 250-mL bag of D5W.

4. IV Infusions

There are also several methods for determiningIV drip rates for patients receiving IV infusions.The following methods are examples of how thiscan be done.

Formula Method

This method finds the ordered dosage over timebased on the patients weight.

Example: You have a resuscitation patient whohas a return of spontaneous circulation (ROSC)after you defibrillate her out of ventricular fibril-lation. You reassess the patient and discover that

she is in a normal sinus rhythm, but she is hypo-tensive. Fluid boluses do not affect the patientsblood pressure, so you decide to start the patienton a dopamine infusion at 10 mcg/kg/min peryour protocols. The patient weighs 132 pounds.


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You have premixed dopamine IV bags that contain200 mg of dopamine in 250 mL of D5W. Your pol-icy for administration of dopamine mandates theuse of a 60-gtt/mL IV tubing. How many drops perminute will need to be delivered in order toachieve the 10 mcg/kg/min dosage?

First convert the patients weight in pounds intokilograms:

132 lb 2.2 lb/kg 60 kg

Next insert the information that you have on hand intothe formula below, and you will get

the sake of this example, we will say that thepremixed bag contains 800 mcg/mL of fluid. Ifyou are using a 60-gtt/mL administration set(which is typical for the administration of dopa-mine), the clock tells us that for every 60 gtt or

1 mL of fluid, the patient will receive 800 mcgof the solution. The 800 mcg and the 60 gtt/mingo at the top of the clock (at 12:00). To completethe clock, you need to use basic division andaddition. We need to fill in the clock at the 3:00,6:00, and 9:00 positions. In order to do this, weneed to divide both the 800 mcg and the 60 gttby 4: 800 divided by 4 is 200, and 60 divided by4 is 15. The 3:00 position is filled in by 200 mcg/

mL and 15 gtt/mL. Add another 200 mcg/mL and15 gtt/mL, respectively, to these numbers to getthe correct volume and drip rate for the 6:00position (400 mcg/mL and 30 gtt/mL). To com-plete the clock and fill in the 9:00 position, addanother 200 mcg/mL and 15 gtt/mL, respectively,to the 6:00 calculation (obtaining 600 mcg/mLand 45 gtt/mL).

Dosage: 10 mcg/kg/min 10 mcg/60 kg/min 600 mcg/min

Premix IV bag: 200 mg/250 mL 200,000 mcg/250 mL

Concentration: 800 mcg/mL

IV administration set: 60 gtt/mL

You are looking for the drip rate for dopamine indrops per minute. To accomplish this, you needto make sure that you are dealing with like valuesin your clock. For example, the volume that you

are using in your administration set needs tomatch that of your concentration (if the volumeof the administration set is measured in milliliters,then the concentration of the medication needsto be measured in a like volume [mL]). Once this

250 mL

200 mg

10 mcg/kg

1 min

60 gtt

1mL

Because the concentration ordered is weight based,the 10 mcg needs to be multiplied by the patients

weight in kilograms (60 kg):10 60 600 mcg

X250 mL

200 mg

600 mcg

1 min

60 gtt

1 mL

Next convert the amount of drug in the bag frommilligrams to micrograms because the order is inmicrograms:

200 mg 200,000 mcg

X250 mL

200,000 mcg

600 mcg

1 min

60 gtt

1 mL

Simplify the problem (cancel out zeros and units):

X250 mL

200,000 mcg

600 mcg

1 min

60 gtt

1 mL

25

20

6

1 min

6 gtt

1

Now multiply:

X25

20

6

1 min

6 gtt

1

X900 gtt

20 min

Simplify the problem:

X90 gtt

2 min

Reduce the fraction:

45 gtt

1 min 45 gtt/min

Clock MethodDopamine Clock

The clock method is a way in which paramedicscan simplify calculating how many drops per min-

ute they need to infuse once they have determinedthe dosage of the medication that they need toadminister. It helps determine drops per minutebased on the concentration of medication per aspecific volume of fluid and the number of dropsper volume of the administration set.

Example: Dopamine comes in premixed bagswith various concentrations of medication. For

XIV bag volume (mL)

Amount of drug in IV bag

Concentration ordered (mg, mcg, g)

1 min

Administration set (gtt)

1 mL


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has been confirmed, you are ready to set up yourclock:

Apply the information that you have to the equa-tion:

Drops per minute

250 mL 60 gtt/mL 2 mg/min

1,000 mg Simplify: Milliliters cancel one another and milli-grams cancel one another, leaving gtt/min.

Drops per minute 30 gtt/ min

Run the infusion at 30 drops per minute to infuse2 mg of lidocaine per minute (check your work onthe following lidocaine clock).

Clock MethodLidocaine Clock

Lidocaine drips are typically 1 g of lidocainein 250 mL or 2 g of lidocaine in 500 mL of D 5W.These drips are not weight based, but insteadare based on milligrams per minute (mg/min).

The first thing that needs to be done is to convertthe grams of lidocaine to milligrams so that thedrip rate will reflect the established mg/min infu-sion rate.

1 g

1,000 mgNext divide the volume found in the IV bag by theconcentration of the lidocaine to obtain the ratioof mg:mL.

1,000 250 4 mg/mL

2000 mg 500 4 mg/mL

Now simply apply this ratio to a clock:

gtt/min

800 mcg

200 mcg600 mcg

400 mcg

60

30

1545

Since you are going to deliver 600 mcg/min, lookat the clock to determine how many drops per

minute you will need to deliver that amount ofdopamine: 45 gtt/min will give you the desired600 mcg/min.

Find the ordered dosage over time:The informa-tion that is needed from the problem is

The ordered dose

The size of the drip chamber

The amount of drug on hand

The total volume on hand (the volume of theIV bag being used)

The physician orders a 2-mg/min maintenanceinfusion of lidocaine for a patient who was expe-riencing ventricular tachycardia. You have apremixed solution of lidocaine that has 1 g oflidocaine in 250 mL of normal saline. You have a60-gtt/mL administration set. At what drip ratewill you set this infusion?

Physicians order: 2 mg/minAdministration set size: 60 gtt/mL

Amount of drug on hand: 1 g

Volume on hand: 250 mL

The following formula should be used when cal-culating these types of problems:

Drops per minute

Volume on hand Drip chamber Ordered dose

Amount of drug on hand

First, convert grams to milligrams to allow for con-sistency between the requested dosage and theconcentration of medication on hand:

1g 1,000 mg

gtt/min

4 mg

1 mg3mg

2 mg

60

30

1545

5. Calculation Problems

Using any of the preceding methods, solve the fol-lowing dosage calculation problems.

a. You have been instructed by medical control to

administer an initial dosage of 0.1 mg/kg of IVadenosine to your 33-lb pediatric patient fol-lowed by a rapid fluid bolus. Based on the avail-able packaging of adenosine (depicted in thephoto at the top of page 187), you will need toadminister mL.


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b. You are working up a patient who is in ventricu-

lar fibrillation. The patient has been defibrillatedfollowing the administration of 1 mg of epineph-rine 1:10,000, CPR is in progress, and the patientis now ready for her first round of lidocaine at1.5 mg/kg. The patient weighs 132 lb. Based onthe order and the lidocaine that you carry in yourformulary (depicted below), you will need toadminister mL of lidocaine.

d. You have a 27-year-old (80 kg) male patientwho has suffered second- and third-degreeburns over 56% of his body. You are transport-ing the patient to the burn center, which is just

under 1 hour away. The patient has receiveda considerable amount of morphine, whichbarely seems to be taking the edge off of thepain. You calculate your fluid infusion for thepatient based on the Parkland formula andrealize that you will need to infuse 1,120 mLper hour for the first 8 hours. You will needto deliver drops per minute inorder to administer 1,120 mL/hour.

e. You are monitoring a 500-mL bag of normalsaline that is dripping at a rate of 120 gtt/minthrough a 10-gtt/mL administration set. Itwill take min for the bag tofinish.

f. You have been given an order to infuse a300-mL fluid bolus to your patient over 45minutes with a 10-gtt/mL administration set.You will need to set the drip rate at

gtt/min in order to accomplishthis goal.

g. The physician orders 3 mcg/kg/min ofdopamine to be administered to your patientin cardiogenic shock. You place 200 mg ofdopamine into a 250-mL bag of D5W to mixthe infusion. You have a 60-gtt/mL administra-tion set, and your patient weighs 165 lb. Youwill run the infusion at the rate of

gtt/min.

h. You have been given an order for dobutaminefor your hypotensive CHF patient. The orderis 15 mcg/kg/min. Your protocol states thatyou are to use a dobutamine infusion consist-ing of 250 mg in 500 mL of normal saline. Thepatient weighs 165 lb. You will need to admin-ister gtt/min if you are usinga 60-gtt/mL administration set.

i. Your preceptor is quizzing you about dosagecalculations, and he states that he wants youto administer dopamine in the alpha range toa hypothetical 65-year-old, 88-lb patient. Youremember that alpha effects are seen at 20 mcg/kg/min, and you have been drilled and drilledthat you are supposed to always use a micro-drip (60 gtt/min) administration set whenadministering IV piggyback medications andthat your local protocols require 200 mg of

dopamine to be mixed into a 250-mL bag ofD5W. Your preceptor wants to know how manydrops per minute you will need to administerto this patient in order to see the desiredeffects. The answer you give isgtt/min.

c. You are treating an infant who is suffering

from a symptomatic bradycardia at a heart rateof 40 beats per minute. The patient has notresponded to oxygen therapy, ventilation, orepinephrine administration. Your base hospi-tal physician has ordered you to administer0.02 mg/kg to this 22-lb child. You shouldadminister mL of atropine(depicted below) to the patient.


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j. You have achieved a return of spontaneouscirculation on a ventricular fibrillation cardiacarrest patient following your second defibrilla-tion. Your partner boluses the patient with

lidocaine and asks that you prepare a lido-caine drip. Your protocols require that youbegin a lidocaine infusion at 2 mg/min. Youcarry premixed lidocaine (2 g in 500 mL).Using a 60-gtt/mL administration set, you willset the lidocaine infusion at a drip rate of

gtt/min to deliver 2 mg/min.

You Are There: Reality-Based Cases

Case 1

As you are inspecting your ambulance at the begin-ning of your shift, an elderly man shuffles up to theback of the ambulance and says, Excuse me youngman, may I have some help? I am having chest painand I really dont feel well. You pull out the gurney

from the back of the ambulance and ask the gentlemanto sit down so that you can check him out. The patientcomplies, and as you are about to begin your assess-ment, your partner walks up to the ambulance. Thetwo of you immediately go to work.

You assess the patient as your partner hooks himup to the ECG monitor and the pulse oximeter (hisoxygen saturation is 92% on room air) and thenplaces the patient on O2 at 10 L by non-rebreather

mask. The patients vital signs are BP of 188/96, HRof 112, and irregular and slightly labored respira-tions of 28. The ECG shows the rhythm in Fig-ure 16-1. The patient presents with cool, pale, moistskin and speaks in five- to six-word sentences. He isalert and oriented and follows basic commands. Hestates that he is having a heavy sensation in hischest, very similar to the pressure that he felt whenhe had an MI 2 months ago. The pressure (6 on ascale of 10) is nonradiating and is associated with

nausea. The onset of this episode was 30 minutesago while walking.

The patient states that he had a stent placed, buthe doesnt know which artery it was placed in. He

takes digoxin, atenolol, Coumadin, Glucophage, andLipitor. He has no allergies to medications.

You discover that the patient has jugular venousdistention (JVD), slight supraclavicular retractionswith his ventilations, trace pedal edema, and faintcrackles in the bilateral bases of his lungs. He has hadno recent illnesses and has had no sputum produc-tion. He states that he has had trouble breathing whenhe sleeps at night, so he has been sleeping in a recliner

in his living room. He also states that he has troublebreathing when he walks.As you establish an IV, your partner administers

one metered dose of sublingual nitroglycerin and325 mg of aspirin. Your partner states that he wouldlike to complete the MONA algorithm and asks if youwould like to contact medical control to get an orderfor morphine sulfate or if you would like him to makethe call.

1. What is your general impression of the patient?

2. What is your first priority in the treatment of thispatient?

3. Describe your basic treatment of the patient priorto administration of medications.

FIGURE 16-1


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4. What do you need to know about the patient beforeyou can administer medications?

5. What do you need to know about a medicationprior to administering that medication?

6. What are the five rights of medication adminis-tration?

7. What is likely the single most important thing thata paramedic can do following medication admin-

istration to prevent unnecessary exposure to con-taminated items?

8. Explain why your partner was able to administernitroglycerin and aspirin but needed to contactmedical control in order to administer morphinesulfate.

9. During the process of obtaining a history, what isan important question to ask the patient regardingmedicationsother than the names of the medica-

tions and any known allergies that the patient mayhave to medicationsthat can have a dramaticimpact on the patients current condition?

Test Yourself

1. You are called to an apartment building by lawenforcement officials who have discovered a man

whom they believe to be delusional. The patienttells you that he has been hearing people talkingall day long, like a radio playing in my head. Inthe kitchen you find several bottles of Abilify, an

antipsychotic medication; all the bottles are full,and the prescriptions were filled several monthsago. You should suspect

a. a medication overdose.

b. a manic depressive disorder.

c. a traumatic head injury.

d. a medication underdose.

2. In regard to medication administration, what is a

contraindication?

3. When administering a medication, you shouldcheck the patients vital signs

a. after administering the medication.

b. before and after administering the medica-

tion.c. every 10 minutes after administering the med-

ication.

d. before administering the medication.

4.Next to a patients bathroom sink, you find a pre-scription sleep aid, an over-the-counter (OTC) painreliever, an herbal remedy, and a toothpaste thatcontains fluoride. Which of the following must bedocumented in your report?

a. The prescription and OTC medications

b. The prescription medication only

c. The prescription, OTC medication, and herbalremedy

d. The prescription, OTC medication, herbal rem-edy, and toothpaste

5. Like medications, IV catheters and tubing haveexpiration dates.

True

False

6. Your patient is in hypovolemic shock and requiresimmediate fluid replacement therapy. While pre-paring to administer the IV, you drop the needleand it falls to the ground. What should you do?

a. Retrieve a new needle.

b. Wipe off the needle with a clean, dry piece ofgauze.

c. Wipe the needle with an antiseptic.

d. Use your breath to steam the surface of theneedle.


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7.Sharps should be disposed of in

a. a plastic bag clearly marked Caution.

b. any public trash receptacle.

c. a jar containing alcohol.d. a biohazard receptacle.

8. _________ drugs need to be accounted for at thebeginning and end of your shift, should be keptsecure throughout your shift, and require detailedcustody logs.

9. In accordance with your local protocols, you shouldfrequently inspect your ambulances medicationsupply. List three specific factors you should notewhen performing this task.

10.Although needle-less systems do not require nee-dles, they are compatible with traditional nee-dles.

True

False11.Your partner has been experiencing chronic bumps

and raised, red areas on her hands. When she wenton vacation for 2 weeks, the symptoms graduallydisappeared, but a week after returning to work,the symptoms have returned. She is always verycareful to wear gloves when handling medicationsand during any patient contact. You should sus-pect

a. a reaction to handling a medication.b. contact dermatitis contracted from a patient.

c. a fungal infection.

d. a latex allergy.

12.Which of the following statements regarding inject-able medications is true?

a. Most injectable medications should not be fro-zen.

b. Most injectable medications have a very shortshelf life.

c. Most injectable medications can only be storedin glass bottles.

d. Most injectable medications cannot be exposedto light.

13.List the three acceptable methods for sterilizationof medical equipment.

14. EMS providers can emulate pharmacies by usinga three-step system to confirm that the correct

medication is being administered. Briefly describethese three steps.

15. You have responded to a remote location for apatient in hemorrhagic shock. En route to the hos-pital you are attempting to obtain IV access to beginfluid resuscitation, but the road that you are travel-ing on is bumpy, and you are unable to safely per-form the procedure. To minimize the possibility ofan accidental needle stick, you would likely

a. wait until you reach the main highway beforereattempting to obtain IV access.

b. have the driver pull over, and obtain IV accesswhile the ambulance is stopped.

c. concentrate on alternative forms of treatmentuntil you reach the hospital.

d. continue to carefully attempt to obtain IVaccess until you are successful.

16. A drug in your supply expires December 2012.

What is the last date that you can administer thedrug?

a. December 1, 2012

b. November 1, 2012

c. December 31, 2012

d. November 31, 2012

17.How are the majority of health-care workers acci-dentally exposed to blood during their occupa-

tional training? a. Eye splashes

b. Non-intact skin exposure

c. Mucous membrane exposure

d. Needle sticks

18.Most patients who regularly take prescriptionmedication are compliant with their prescribeddosing regimen.

True

False

19.Who can authorize the administration of medica-tion?

a. The team leader

b. The patient

c. The online physician

d. The most senior paramedic

20. You are called to a man down in a supermarket.When you arrive, the adult male patient is unrespon-sive and apneic. The ECG monitor reveals that thepatient is in cardiac arrest. You need to administerepinephrine, but you cannot confirm the patients


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medical history or allergies because none of theimmediate bystanders know the man. You should

a. administer the epinephrine immediately.

b. provide care without administering any medi-cations.

c. use the mans cell phone to contact a familymember.

d. use the stores public address system to askany friends or family to come forward.

Need to KnowThe following represent the Key Objectives of Chap-ter 16:

1. Describe the safe and appropriate administration ofmedications based upon the selected route.

With administration of medications comes a greatdeal of responsibility. The process of administeringmedications needs to be methodical, well thoughtout, and based on sound judgment. There is noroom for complacency in medication administra-tion, for when the paramedic becomes complacent,

mistakes are made, and when it comes to medica-tion administration, mistakes can be lethal.

All medication administration decisions needto be based on the results of assessments thatinclude past medical history, any known aller-gies to medications (specific medications [e.g.,morphine] or general classifications of medica-tions [sulfa-based medications]), physical exami-nation, and vital signs (e.g., heart rate, blood

pressure, respiratory rate, temperature, ECG trac-ing, pulse oximetry). Paramedics must have abasic knowledge of any medications that theymay administer, including indications, contrain-dications (absolute or relative), potential side

effects or complications, precautions, any possi-ble interactions with other medications, and theexpected therapeutic effects, based on their scopeof practice and the formulary of their provider.

Is the paramedic able to administer the medica-tion based on standing orders, or does the medi-cation administration require consultation withmedical control?

Because most medication dosages are basedon a patients weight, the paramedic must be ableto perform drug calculations so that the patientdoes not receive an overdose or an underdose ofa medication. Since some medications do not

come packaged as ready to administer, paramedicsneed to know how to prepare medications foradministration. For example, glucagon comes intwo vials. One of the vials contains a powder, andthe other vial contains a liquid. The powder needsto be combined with the liquid and thoroughlydissolved before it can be administered. Simi-larly, some medications need to be mixed withan IV solution in an IV bag before they can beadministered as an IV drip (infusion). If given

such a medication undiluted as an IV bolus, thepatient could experience undesired effects.

Standard medication administration mustfollow safe administration techniques via theappropriate administration route while maintain-ing asepsis. Contaminated disposable medicationadministration equipment needs to be disposed ofin the appropriate disposal container, and reusablemedication administration equipment needs to be

cleaned and maintained per the manufacturersinstructions.Any preexisting medication administration

device that is used by paramedics must be approvedby the EMS agency and the EMS provider that theparamedic works for. Any medication administra-tion device that the paramedic is not familiar withor specifically trained how to use should not beused by the paramedic.

Other than ensuring that the five rights of

medication administration are followed and thepatient is not allergic to the medication that youare administering, perhaps the most importantstep in medication administration is to reassessthe patient following the administration of a med-ication to see if it had the desired or any undesiredeffects. Make sure that the medication administra-tion is clearly and accurately documented on yourpatient care report. This report is a part of the

patients medical record and may be referred to bymedical personnel to direct them in further treat-ment of the patient.


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Skill NameSkill Sheet Numberand Location

Step-by-Step Numberand Location

Intravenous Access 42 Appendix A and DVD 42 This chapter and DVD

Intravenous Access Using Saline Lock 43 DVD 43 DVD

Phlebotomy 44 DVD N/A

Intraosseous Access and DrugAdministration

45 Appendix A and DVD 45 This chapter and DVD

Umbilical Vein Cannulation 46 DVD N/A

Central Line Access for Fluids and DrugAdministration

47 DVD N/A

Intravenous Drug Bolus 48 Appendix A and DVD 48 This chapter and DVD

Intravenous Drug Infusion 49 Appendix A and DVD 49 This chapter and DVD

Intramuscular Drug Administration 50 Appendix A and DVD 50 This chapter and DVD

Intranasal Drug Administration 51 DVD N/A

Nebulized Drug Administration 52 Appendix A and DVD 52 This chapter and DVD

Subcutaneous Drug Administration 53 Appendix A and DVD 53 This chapter and DVD

Sublingual Drug Administration 54 DVD N/A

Endotracheal Drug Administration 55 DVD N/A

Eye Drop Drug Administration 56 DVD N/A

Oral Drug Administration 57 DVD N/A

Rectal Drug Administration 58 Appendix A and DVD 58 This chapter and DVD

Autoinjector Drug Administration Device 59 DVD N/A

NREMT Intravenous Therapy 89 DVD N/A

NREMT Pediatric Intraosseous Infusion 91 DVD N/A

Need to Do

The following medication administration skills are explained and illustrated in a step-by-step manner, via skillsheets and/or Step-by-Steps in this text and on the accompanying DVD:


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Intravenous Access

Conditions:The candidate should perform this skill on a simulated patient under existing indoor,ambulance, or outdoor lighting, temperature, and weather conditions. Establish a patent IV line within6 minutes.

Indications: Patients who require or may potentially require administration of fluids or intravenousmedications.

Red Flags: Prep the site with aseptic or medically clean technique as field conditions permit. Avoid startingan IV on the same arm as a dialysis shunt. IV infiltration, especially when medications are being administered,can cause serious and irreversible tissue damage. Avoid using areas of burned skin or heavy vein scarring.

Step-by-Step 42

Steps:

1.Use appropriate standard precautions.

2. Select proper fluid and check its expiration dateand clarity.

3.Select proper IV tubing.

4.Close roller clamp.

5. Remove tab from IV bag and cap from spikeend of IV tubing. Insert spike into IV bagadministration port (Figure SBS 42-1).

6. Squeeze the drip chamber until IV solutionreaches fluid line or the drip chamber is half full.

7.Run fluid through the tubing until fluid fillstubing and air bubbles are removed.

8.Gather equipment (IV needle, tourniquet, tape,

gauze, alcohol prep, etc.).

9.Apply tourniquet proximal to desired site.

10.Select site (Figure SBS 42-2). (Possible sitesinclude between knuckles, dorsal thumb, back ofhands, forearms, or antecubital fossa.)

11.Cleanse area with alcohol prep.

12.Control site by pulling skin firmly, taking care tokeep your fingers out of the needle path.

13. Insert needle at less than a 45-degree angle withthe bevel up (Figure SBS 42-3).

14.Advance needle in a smooth motion.

SBS 42-1

SBS 42-2

SBS 42-3

193

Continued


13/27


15.Monitor for flashback, and verbalize whenflashback is visualized.

16.Advance catheter into vein while retracting

needle until it locks.17.Avoid catheter shear by not reinserting needle

into catheter.

18.Remove tourniquet if blood sample is not required.

19.Hold hub, and tamponade vein to preventbleeding (Figure SBS 42-4).

20.Remove needle from hub and place in a sharpscontainer.

21.Connect administration set to catheter hub.

22.Open roller clamp and observe for free flowthrough drip chamber (Figure SBS 42-5).

23. Inspect and palpate for infiltration at IV site.

24.Secure site and tubing with tape or a commercialdevice (Figure SBS 42-6).

Critical Criteria:

Use appropriate standard precautions.

Maintain aseptic or medically clean techniquethroughout procedure.

Avoid catheter shear by not reinserting needleinto catheter.

Observe for infiltration.

Establish a patent IV line within 6 minutes.

Dispose of sharps in an appropriate container.

SBS 42-4

SBS 42-5

SBS 42-6


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Intraosseous Access and Drug Administration

Conditions: The candidate should perform this skill on a simulated patient under existing indoor,ambulance, or outdoor lighting, temperature, and weather conditions.

Indications: A patient who requires intravascular access for medication administration and/or volumeresuscitation and for whom IV access is not readily available.

Red Flags: Long-bone deformity distal to access site on same bone; unable to locate landmarks.

8.Stabilize IO catheter and remove needle.

9.Dispose of sharps in appropriate sharps container.

10.Attach syringe to IO needle.

11.Aspirate bone marrow and administer saline

flush (Figure SBS 45-3).

12. Inspect site for infiltration. If swollen, removeneedle and apply pressure.

13.Attach administration set, and run fluid wide open.

14.Ensure free flow and no swelling, and adjust todesired rate.

15.Secure device (Figure SBS 45-4).

Step-by-Step 45

Steps:


2.Select appropriate device and prepareequipment.

3.Locate intraosseous (IO) site (Figure SBS 45-1).(Possible sites include tibia, distal femur,humerus, sternum, or iliac crest.)

4.Cleanse site with alcohol and/or iodine.

5.Place IO device against bone.

6. Insert needle straight into bone at a 90-degreeangle (Figure SBS 45-2).

7.Stop at proper depth or when resistance is nolonger felt (popping sensation).

SBS 45-1

SBS 45-2

SBS 45-4

SBS 45-3

195

Continued


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Step-by-Step 48

Drug Administration

16.Ensure that five patient rights of drugadministration are met.

17.Draw medication using aseptic technique.

18.Dispose of needle in a sharps container.

19.Cleanse port with alcohol prep.

20.Attach syringe to port.

21.Occlude line between fluid and port bypinching line or adjusting three-way stopcock(Figure SBS 45-5).

22.Push medication at proper rate, and flush tubingafter administration.

23.Monitor patient for desired and adverse effects.

Critical Criteria:

Use appropriate standard precautions.

Use intraosseous needle in a safe manner.

Immediately dispose of sharps in appropriatecontainer.

Observe for infiltration at site.

Ensure that five rights of medicationadministration are followed.

Intravenous Drug Bolus

Conditions:The candidate should perform this skill on a simulated patient under existing indoor,ambulance, or outdoor lighting, temperature, and weather conditions.

Indications: A patient who requires a medication bolus delivered intravenously.

Red Flags: Medications given through the IV route are rapid acting. Deliver medications at appropriaterate and at appropriate time intervals. Always observe for infiltration.

Steps:


2.Explain procedure to a conscious patient.

3.Ensure patient is not allergic to the medication.

4.Ensure IV flows without infiltration.


SBS 45-5


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12.Withdraw needle from IV tubing and dispose insharps container.

13.Flush IV tubing, and set flow to desired rate(Figure SBS 48-4).

14.Thoroughly document medication administration.


Critical Criteria:

Use standard precautions.

Check for patient allergies and medication

reactions. Ensure that five rights of medication

administration have been met.

Cleanse the IV port prior to injection.

Immediately dispose of sharps in an appropriatecontainer.

Monitor patient for changes in condition.

6.Assemble pre-filled syringe, or draw medicationinto syringe (Figure SBS 48-1).

7.Expel air from syringe.

8.Cleanse IV port with alcohol prep.

9.Attach syringe to IV port (Figure SBS 48-2).

10.Occlude IV line between port and IV bag, orclose roller clamp.

11.Push medication at the proper rate (FigureSBS 48-3) while observing for infiltration.

SBS 48-1

SBS 48-3

SBS 48-2

SBS 48-4


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9.Mark bag with drug name and concentration,date and time of administration, and initials ofperson preparing and administering infusion.

10.Dispose of any sharps in appropriate container.

11.Cleanse IV port with alcohol prep.

12.Connect infusion IV set to main IV and stop flowof main IV (Figure SBS 49-3).

13.Secure line with tape (Figure SBS 49-4).

Steps:

1.Use appropriate standard precautions.2.Explain procedure to a conscious patient.


4.Ensure IV flows without infiltration.


6.Calculate drug dosage in drips per minute

(gtt/min).7.Prepare IV solution or spike premixed bag

(Figure SBS 49-1).

8.Fill drip chamber, and flush tubing (Figure

SBS 49-2).

Step-by-Step 49Intravenous Drug Infusion


Indications: A patient who requires medications continuously delivered intravenously.

Red Flags: Medications given through the IV route are rapid acting. Pay close attention to the rate ofadministration. Always observe for infiltration of primary IV.

SBS 49-1

SBS 49-2

SBS 49-3

SBS 49-4

198


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14.Adjust to proper drip rate.



Critical Criteria:


Check for patient allergies and medicationreactions.

Ensure that five rights of medicationadministration have been met.

Cleanse medication port prior to insertion.

Dispose of sharps immediately after use.

Ensure that infusion is set at proper rate.

Monitor patient for desired and adverse effects.

Intramuscular Drug Administration


Indications: A patient whose condition requires the administration of a medication through theintramuscular route. A patient who does not have vascular access, and the required medication can beadministered intramuscularly.

Red Flags: May not be effective in poorly perfused tissue.


7.Locate administration site (deltoid, thigh, orbuttocks).

8.Cleanse site with alcohol prep.

9.Stabilize skin with fingers, or pinch to raise skinslightly (Figure SBS 50-2).

Step-by-Step 50

Steps:





5.Using a 20-gauge or smaller needle, drawmedication into syringe (Figure SBS 50-1).

SBS 50-1 SBS 50-2

Continued


19/27

10. Insert needle at 90-degree angle, and quicklyadvance into muscle.

11.Attempt to aspirate for blood (Figure SBS 50-3).If blood returns, withdraw needle and try adifferent site.

12.Slowly inject medication.

13.Withdraw needle from patient, and dispose ofneedle and syringe in appropriate sharpscontainer.

14.Apply sterile gauze and direct pressure to site(Figure SBS 50-4).


16.Monitor for redness and swelling.


Critical Criteria:


Check for patient allergies.

Ensure that five rights of medication

administration have been met. Insert needle at 90-degree angle.

Aspirate for blood prior to medicationadministration.



Step-by-Step 52Nebulized Drug Administration

Conditions:The candidate should perform this skill on a simulated patient in a sitting or supine position(stretcher, chair, or bed) under existing indoor, ambulance, or outdoor lighting, temperature, and weatherconditions.

Indications: A patient whose condition requires the administration of a medication through the nebulizedroute.

Red Flags: Equipment used to nebulize medications can vary significantly. Practice with your localsystems equipment until you are comfortable with assembly and use.

SBS 50-3

SBS 50-4


20/27


Steps:


2. Explain procedure to a conscious patient.3.Ensure the patient is not allergic to the medication.

4.Ensure that five patient rights of drug

administration are met.

5.Place medication in nebulizing chamber (FigureSBS 52-1).

6.Screw on chamber cover.

7.Attach oxygen tubing to nebulizer chamber, andattach tubing to oxygen source (Figure SBS 52-2).

8.Assemble administration set according tomanufacturers instructions, ensuring nebulizerchamber remains upright.

9.Attach T-piece to nebulizing chamber (FigureSBS 52-3).

10.Adjust flow of oxygen to nebulizer to create asteady mist of medication (68 L/min).

11. Instruct patient to seal lips around mouth-

piece, and direct him or her to breathe slowlyand deeply (Figure SBS 52-4).

12.Alternately, attach set to an in-line adapter, andventilate with a bag-mask at 1220 breaths/mintimed with patients inspiratory effort (FigureSBS 52-5).

13.Alternately, attach nebulizer to simple mask(Figure SBS 52-6) and adjust the flow ofoxygen to create a steady mist of medication(68 L/min).

14.Refill chamber per local protocol.

SBS 52-1

SBS 52-2

SBS 52-3

SBS 52-4

SBS 52-5

SBS 52-6

Continued

202 P t 2 F d ti f C i ti A t d C iti l C


21/27


Step-by-Step 53

15. Thoroughly document medicationadministration.

16.Monitor patient for desired and adverseeffects.

Critical Criteria:


Ensure that five rights of medicationadministration are met.

Assist ventilations as necessary.

Keep in-line nebulizer chamber upright.

Subcutaneous Drug Administration

Conditions: The candidate should perform this skill on a simulated patient under existing indoor,ambulance, or outdoor lighting, temperature, and weather conditions.

Indications: A patient whose condition requires the administration of a medication through thesubcutaneous route.

Red Flags: May not be effective in poorly perfused tissue.

Steps:




4.Ensure five patient rights of drug administrationare met.

5.Using a 22-gauge or smaller needle, drawmedication into syringe (Figure SBS 53-1). Maygive maximum of 1 mL of fluid.

SBS 53-1



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7.Locate administration site (upper arm, abdomen,or thigh).

8.Cleanse site with alcohol prep.9.Pinch skin to lift it slightly (Figure SBS 53-2).

10. Insert needle at a 45-degree angle.

11.Smoothly advance needle into subcutaneoustissue (Figure SBS 53-3).

12.Attempt to aspirate for blood with syringe(should be difficult). If blood returns, withdraw

and try a different site.

13. Inject the medication (Figure SBS 53-4).

14.Withdraw needle, and dispose of needle andsyringe in appropriate sharps container.

15.Place gauze over injection site, and apply directpressure.

16.Thoroughly document medicationadministration.

17.Monitor administration site for redness andswelling.

18.Monitor the patient for desired and adverse

effects.

Critical Criteria:


Check for patient allergies.

Check expiration date of medication.


Insert needle at 45-degree angle.


Aspirate for blood prior to medicationadministration.

Monitor for desired and adverse effects.

SBS 53-2

SBS 53-3

SBS 53-4

204 Part 2 Foundations of Communication Assessment and Critical Care

58


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Step-by-Step 58Rectal Drug Administration

Conditions: The candidate should perform this skill on a simulated pediatric patient under existing indoor,ambulance, or outdoor lighting, temperature, and weather conditions.

Indications: A pediatric patient whose condition requires the administration of a medication via the rectalroute.

Red Flags: Feeding tube or syringe must be inserted deep enough into rectal space in order to delivermedication. Forceful insertion can perforate the bowel wall. Remove needle prior to insertion of syringe into rectum.

Steps:


2.Explain procedure to a conscious patient orparents.



5.Draw up medication using aseptic technique

(Figure SBS 58-1).

6.Remove and dispose of needle in appropriatesharps container.

7.Choose administration option:a. Attach an extension: large-bore IV catheterwithout needle or cut 3.0 ET tube.

b. Use a tuberculin (TB) syringe without needle.c. Insert a suppository with gloved finger.

8.Lubricate administration device or suppositoryand finger with water-soluble jelly only.

9.Gently insert into anus (Figure SBS 58-2). Ifusing a suppository, insert with gloved finger.

10.Advance past both sphincter muscles.

11.Slowly deliver medication.

12.Remove syringe and hold buttocks together(Figure SBS 58-3).

13.Dispose of syringe in appropriate container.


SBS 58-1

SBS 58-2

SBS 58-3

204



24/27


15.Monitor patient for desired and adverse effects(Figure SBS 58-4).

Critical Criteria:


Check for patient allergies and medicationreactions.


Lubricate administration device or suppositoryand finger before administration.

Pinch buttocks closed after administration.


Monitor patient for desired and adverse effects.

Connections

Chapter 15, Pharmacology, in the textbook con-tains additional information on medicationindications, contraindications, precautions, andspecial considerations. See Box 15-6 in the text-book for a description of the patient rightsthat are identified in the DOT curricula.

Chapter 10, Therapeutic Communications andHistory Taking, in the textbook describes tech-niques that can be helpful in obtaining informa-

tion from patients. Chapter 9, Safety and Scene Size-Up, in the

textbook includes additional information onBSI precautions.

Chapter 17, Documentation and Communication,in the textbook details information on perform-ing a radio consultation and what elements ofmedication administration documentation areimportant to capture on the patient care report.

Link to the companion DVD for a chapter-basedquiz, audio glossary, animations, games andexercises, and, when appropriate, skill sheetsand skill Step-by-Steps.

Street SecretsShortcuts Drug dosage calculations can be a

nightmare for many paramedics. The need to per-form them in any situationlet alone a situationin which one is caring for a critical patient whohas a very low blood pressurecan send the mostconfident paramedic into a meltdown. The follow-ing simple formulas are shortcuts that will give

you a close estimate of the number of drops perminute that you need to administer to a patientreceiving a dopamine infusion. These shortcuts

are based on the use of a 60-gtt/mL IV administra-tion set. This method should not be used in a test-ing environment because it is not 100% accurate.Shortcut 1 is for use with a dopamine IV bag thathas a concentration of 1,600 mcg/mL and is usedto obtain a 5-mcg/min dose.

(Weight in kg 10) (2) 1 drip rate in gtt/minforpatient receiving 5-mcg/min dose.

Example:The patient weighs 80 kg.80 10 8

8 2 16

16 1 15 gtt/min

Shortcut 2 is for use with a dopamine IV bag thathas a concentration of 800 mcg/mL and is used toobtain a 5-mcg/min dose.

(Weight in kg 5) (2) 2 drip rate in gtt/min for

patient receiving 5-mcg/min dose.

Example: The patient weighs 60 kg.

60 5 12

12 2 24

24 2 22 gtt/min

Note: The paramedic should always ensure thepatency of the IV by aspirating prior to injectingany medication. This is crucial because drugs

injected into the tissues instead of the blood-stream could have a detrimental effect on thepatient.

SBS 58-4



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The Drug Box

There are no specific drugs related to this chapter con-tent.

Answers

Are You Ready?

1. The patient is critically ill. The infant is seizing and blue(cyanotic). This alone is evidence of a life-threateningemergency.

2.Airway, airway, airway! Followed by breathing and cir-culation.

3. Any four of the following: fever, hypoglycemia, headinjury, ingestion (poisoning), hypoxia, arrhythmia,epilepsy, hypovolemia, and electrolyte imbalance.

4. You should perform a blood sugar test. If the patient ishypoglycemic and you stop the seizure with an anticon-vulsant, you may not remember to check the patientsblood sugar, and a blood sugar level low enough to causeseizures can cause significant damage if left untreated.

5. Administration of medications needs to be in compli-

ance with local EMS policies and protocols, but for thesake of this exercise general guidelines are as follows:

a. The first choice would be IV administration of med-ications because of the relative ease of establishingan IV, the relatively minimal invasiveness of theprocedure, and the rapid onset of action of medica-tions administered intravenously. You also have aroute to administer IV fluids in the setting of hypo-volemia.

b. The second choice would be based on the type of

medication being administered. If you are deliveringan anticonvulsant such as a benzodiazepine, the rectalroute should be considered next. This route does notallow for correction of hypovolemia or hypoglycemia.

c. If the patient is hypoglycemic and/or hypovolemic,another more invasive, yet very effective, means ofdelivering medications to a critical patient is via theintraosseous route (Figure 16-2).

d. Another possibility for the administration of somemedications is the intranasal route, but the absorp-tion rate is not as rapid, and there is no possibilityfor addressing fluid deficits or hypoglycemia.

Active Learning

1.a. 2.2 lb; b. 1,000 g; c. 1,000 mg; d. 1,000 mcg; e. 1,000mL; f. 1 mL; g. 5 mL; h. 15 mL; i. 30 mL; j. 65 mg;k. 1/10 or 0.1 L; l. 1/100 or 0.01 m; m. 1/1,000 or 0.001 g;n. 1/1,000,000 or 0.000001 g

5.

a. In order for you to administer 0.1 mg/kg of adeno-sine to this 33-lb (15 kg) patient, you will need to

administer 0.5 mL.b. In order to administer 1.5 mg/kg of lidocaine to this

132-lb cardiac arrest patient, you will need todeliver 4.5 mL.

c. To administer a 0.02-mg/kg dose of atropine to this22-lb (10 kg) child, you must administer 2 mL ofatropine.

d. In order to deliver 1,120 mL/hour, you will need todeliver 187 gtt/min.

e. The 500-mL bag of normal saline dripping at arate of 120 gtt/min through a 10-gtt/mL adminis-tration set will be completed in 41.66 or about42 minutes.

f. In order to administer 300 mL of fluid over 45 min-utes via a 10-gtt/min administration set, you willneed to set your drip rate at 67 gtt/min.

g. Drops per minute = 16.8 gtt/min. Run the infusionat 17 drops per minute to infuse 3 mcg/kg/min ofdopamine to your patient.

h. For your 165-lb patient to receive 15 mcg/kg/minof dobutamine from an IV bag that contains 250 mgof dobutamine in 500 mL of normal saline, using a60-gtt/min administration set, the patient needs toget a 135-gtt/min infusion.

i. In order for your 88-lb patient to receive 20 mcg/kg/min of dopamine (200 mg/250 mL D5W) via amicro-drip administration set, you will need toadminister 60 gtt/min.

j. In order to deliver 2 mg/min, you will need to set

the IV drip rate of the 60-gtt/mL administration setat 30 gtt/min.

You Are There: Reality-Based Cases

Case 1

1.The patient is sick: he has chest pain and shortness ofbreath, and he is hypertensive, tachycardic, and tachyp-neic. He has an oxygen saturation of 92% on room air,and he speaks in five- to six-word sentences. He has JVD,pedal edema, supraclavicular retractions, and cracklesin the bilateral bases of his lung fields.

2.The first priority in this patient, or any patient for thatmatter, is airway, breathing, and circulation.

FIGURE 16-2The intraosseous route is an effective alternativeto the intravenous route of medication and fluid administration.



26/27

3.Perform complete primary and secondary examinationsincluding vital signs, ECG, and pulse oximetry; take amedical history, including medications and allergies tomedications.

4.

Does the patient have any allergies to medications?

Will the patients current hemodynamic status allowfor the administration of the chosen medication?

Will the administration of the chosen medicationnegatively impact the patients medical condition(s)?(For example, if the patient has a history of ulcers,will the administration of aspirin have a negativeimpact on the patient?)

Will the administration of the chosen medicationinteract negatively with any of the medications thatthe patient takes on a regular basis?

5. Prior to administering any medication, a paramedicshould be aware of its indications, contraindications, pre-cautions, side effects, interactions, and therapeutic effects.The paramedic should also be familiar with the appropri-ate route of administration for that particular medication,as well as the appropriate rate of administration.

6.

The right patient The right medication

The right dosage

The right route

The right time

7. Immediately dispose of sharps in an approved container.Never re-cap sharps!

8. There could be several reasons why a paramedic mayadminister some medications and not others. It is likely

that the nitroglycerin and aspirin were administeredaccording to standing orders. (Standing orders are pre-established medication orders that paramedics mayadminister based on specific parameters. A completeassessment, history, and physical examination must beperformed prior to medication administration by stand-ing orders.) For some medications and procedures, aparamedic must consult with a physician prior toadministering the medications or performing the proce-dures.

9. Determine whether the patient has been compliant withhis or her prescribed medications. (Is there any chancethe patient is taking either too much or too little of theprescribed medication? An overdose or an underdose ofmedication can have a dramatic impact on the patientscondition.)

Test Yourself

1. d

The unopened pill bottles in the patients kitchen are agood indication that he has not been taking his pre-scribed medication. Medications such as antipsychotics(which help control delusions) must be taken continu-ally to maintain their effectiveness.

2. A contraindication is a reason that a medication shouldnot be considered. Common contraindications includesensitivity, pregnancy, and certain diseases.

3. b

Prior to administering any medication you should col-lect enough information through history taking and fromthe physical examination to ensure a correct diagnosisis made so the proper therapy is selected. Postadminis-tration follow-up procedures include reassessing andmonitoring the patient for effects.

4. c

When looking for medications in a patients home youshould be alert for prescription medication, OTC medi-cations, herbal preparations, drug paraphernalia, andany signs of medication abuse or misuse.

5. True

Check all expiration dates on a regular basis. To makeit easier to check for expiration, mark the box clearlywith the expiration date or circle the date on the con-tainer.

6. a

The fallen needle must be replaced with a new, sterileneedle. Before performing an administration, it is a goodidea to collect extra supplies in case something becomescontaminated or is not appropriate for use.

7. d

Used needles and syringes should be disposed of in anappropriate biohazard receptacle. These storage devicesmay be red or yellow and often carry warning labels.

8. Narcotic

9. Answers may include: ensure that all necessary medica-

tions have not expired. Confirm that all medicationshave been stored and handled in accordance with theirmanufacturers recommendations. Make sure the appro-priate supplies are available to prepare and administerevery medication in the formulary (an adequate numberand selection of syringes, needles, IV solutions, IVadministration sets, etc.).

Every agency will have its own guidelines regardingthe management of medications. Some services requirea thorough count and expiration date check with the

change of every shift, while other services may requireweekly, monthly, or random spot checks. Make sureyou are informed of, and abide by, your agencysguidelines.

10. False

Attempting to use a needle in a needle-less system willcontaminate or damage it.

11. d

Given the location of your partners rash, and knowing

that her symptoms cleared when she was away fromher job and then returned, you should suspect anallergic reaction to her latex gloves. Between 5% and17% of all health-care workers are estimated to beallergic to latex.



27/27

12. a

When familiarizing yourself with your services formu-lary, you should read the accompanying literature fromthe medication package box (called the package insert)to determine if there are any special storage or handlingrequirements.

13. Extreme heat from steam under pressure (autoclaving),dry heat, and ethylene oxide gas.

Sterilization kills all biotic material, including bacterialspores. Human tissue and some equipment cannot besterilized.

14. To confirm that the correct medication has been selectedfor administration, you can first repeat the drug nameand dosage when received during consultation; then

carefully read the medication name before taking it outof the box; and finally ask another member of the patientcare team to verify the name on the medication con-tainer.

This three-step approach is a good, systematic way tomake sure you are administering the correct medication.Although it may not always be practical to follow allthree steps in the field, you should alwayscheck to con-firm that the right medication has been selected foradministration.

15. b

Minimize the possibility of an accidental needle stickby performing all injections or IVs while the ambulanceis stationary. If patient transport has begun, gather andprepare the equipment while the ambulance is moving.When ready, ask the driver to pull over and stop for a

minute while you perform the venipuncture. Once theflash of blood is seen in the needle chamber, if the roadsurface is relatively smooth, the driver can go while youfinish securing the line.

16. cFor expiration dates that only list the month and year,the last day of the month is considered the expirationdate.

17. d

A 1998 survey of 3,162 emergency medicine residentsfound that over 50% reported having at least one occu-pational exposure to blood during their training, andover 70% of the exposures were from a needle stick orsharp object.

18. False

A study observed that over three-fourths of all peopletaking a prescription medication were not taking itaccording to the directions.

19. c

Administration of medication requires authorizationfrom medical direction. This permission may take theform of off-line written protocol and standing orders, orit may require real-time, online physician direction via

telephone, radio, or satellite consultation.20. a

Although it is important to know whether a patient is tak-ing medication or has any known allergies, this informa-tion should not delay treatment during life-threateningevents.

workbook chapter16

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