Kozier & Erb's
Fundamentals of Nursing
Concepts, Process, and Practice
Eleventh Edition
Chapter 35
Medication
Administration
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Introduction
• Medication
–Substance administered for diagnosis, cure,
treatment, or relief of symptom or for prevention of
disease
• Drug
–Same as medication but also refers to illicitly
obtained substance
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Introduction (2 of 4)
• Prescription
–Written direction for preparation and administration
of a drug
• Generic name
–Name used throughout the drug's lifetime
• Trade (brand) name
–Given by drug manufacturer
–Identifies it as property of that company
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Introduction (4 of 4)
• Pharmacology
–Study of effect of drugs on living organisms
• Pharmacy
–Prepares, makes, and dispenses drugs as ordered
• Pharmacist
–Person who prepares, makes, and dispenses drugs
as ordered
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Drug Standards
• Drugs can be made from
plants, minerals, or animals, or
be produced synthetically.
• Standards ensure drugs are
pure and of uniform strength,
uniform quality.
• Pharmacopeia describes drug
sources, properties, tests done,
storage methods, assay
category, normal dosages.
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Philippines
Food and Drug Administration
• is mandated to ensure the safety, efficacy or
quality of health products which include food,
drugs, cosmetics, devices, biologicals, vaccines,
in-vitro diagnostic reagents, radiation-emitting
devices or equipment, and household/urban
hazardous substances, including pesticides and
toys, or consumer products that may have an
effect on health which require regulations as
determined by the FDA.
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THE PHILIPPINE NATIONAL FORMULARY
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Legal Aspects of Administering Medications (1 of 2)
• Nursing practice acts
• Recognizing limits of own knowledge
and skill
• Take responsibility for actions
• Question any order that appears
unreasonable
• Refuse to give medication until order
is clarified
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Legal Aspects of Administering Medications (2 of 2)
• Controlled substances
–Kept under lock
–Special inventory forms
–Documentation requirements
–Procedures for discarding
–End-of-shift counts of controlled substances
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Effects of Drugs (1 of 6)
• Therapeutic effect
–Desired effect
–Reason drug is prescribed
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Effects of Drugs (2 of 6)
• Side effect
–Secondary effect
–Unintended, usually predictable
–May be harmless or harmful
• Adverse effect
–More severe side effect
–May justify discontinuation of a drug
• Drug toxicity
–Results from overdose, ingestion of external-use
drug, or buildup of drug in blood
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Effects of Drugs (3 of 6)
• Drug allergy
–Immunologic reaction to drug
–Mild to severe reactions
▪Anaphylactic reaction, anaphylaxis
• Drug tolerance
–Unusually low physiological response
–Requires increases in the dosage to maintain a
given therapeutic effect
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Effects of Drugs (4 of 6)
• Drug tolerance
–Cumulative effect
▪Increased effect resulting
from rate of dosage being
higher than rate of excretion
–Idiosyncratic effect
▪Unexpected; may be
individual to client
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Effects of Drugs (4 of 6)
• Drug interaction
–One drug alters effect of
other drug(s).
–Potentiating effect
–Inhibiting effect
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Effects of Drugs (5 of 6)
• Potentiating effect
–One or both drugs is
increased.
–Additive
▪Two of same types of
drugs increase action of
each other.
–Synergistic
▪Two different drugs
increase action of one or
another.
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Effects of Drugs (6 of 6)
• Inhibiting effect
–Effect of one or both
drugs is decreased.
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Effects of Drugs (6 of 6)
• Iatrogenic disease
–Disease unintentionally caused by medical or drug
therapy
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Drug Misuse
• Improper use of common medications
• Drug abuse
• Drug dependence
–Physiological dependence
–Psychological dependence
• Drug habituation
• Illicit drugs
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Developmental Factors
• Risks during pregnancy
• Infants require smaller dosages.
• Older adults experience decreased gastric motility
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Gender
• Distribution of body fat and fluid
• Hormonal differences
• More drug research done on men
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Genetic and Cultural Factors
• Pharmacogenomics
–Doses tailored to a client's
genetic makeup
• Pharmacogenetics
–the study of how D N A
variation in a single
gene or few genes
influences the
response to a single
drug.
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Genetic and Cultural Factors
• Cultural factors and practices
–Values and beliefs
–Herbal remedy may speed up or slow down certain
medications' metabolism
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Diet
• Nutrients can affect action of a medication.
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Environment
• Especially affects drugs
used to alter behavior and
mood
• Temperature and
vasodilation
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Psychologic Factors
• Expectations
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Illness and Disease
• Action altered in clients with circulatory, liver, or kidney
dysfunction
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Time of Administration
• Some drugs absorbed more quickly if stomach is
empty, some when stomach is full
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Medication Orders
• Ordered by physicians
–Sometimes nurse
practitioners,
physician assistants
depending on state
laws and agency
policies
• Verbal and telephone
orders
• Abbreviations,
acronyms, and symbols
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Types of Medication Orders (1 of 2)
• Stat order
–Indicates that the medication is to be given
immediately and only once.
(e.g., Demerol 100 mg I M stat).
• Single order
–The single order or one-time order is for medication
to be given once at a specified time.
(e.g., Seconal 100 mg h s before surgery).
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Types of Medication Orders (2 of 2)
• Standing order
–Indefinitely, such as multiple vitamins daily
–Specified number, such as KCl twice daily × 2 days
• PRN order
–Such as Amphojel 15 mL prn
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Essential Parts of a Medication Order
• Full name of client
• Date and time order is
written
• Name of drug to be
administered
• Dosage of drug
• Frequency of
administration
• Route of administration
• Signature of person
writing the order
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Communicating a Medication Order (1 of 2)
• Written on chart, provided by phone or verbally
• Copied to Kardex or MAR, or on computer printout
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Communicating a Medication Order (2 of 2)
• If an order seems inappropriate
–Contact the physician
–Document in notes when the Physician called, what
was communicated, how the Physician responded
–Or, document attempts to reach Physician and
reason for withholding drug
–If medication given, document client condition
before and after dose
–If needed, document factual information on incident
report
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Systems of Measurement
Metric system Household system
• gram (g) • Drops
• milligram (m g) • Teaspoons
• and microgram (mcg) • Tablespoons
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Systems of Measurement
Metric system
1000 mg = 1,000,000 mcg =1 gram (g)
1kilogram = _____
1000 gram
1 Liter = 1000ml
2.5
___L = 2500 ml
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Metric system
Doctor’s Order
240 mg (weight) of Paracetamol
Suspension (liquid) form
D V
Formula = = amount to administer
H
240mg x 5ml = 10ml
120mg
• Basic Formula
The basic formula for calculating drug dosages is commonly used and
easy to remember:
D = Desired dose (i.e., dose ordered by primary care provider)
H = Dose on hand (i.e., dose on label of bottle, vial, ampule)
V = Vehicle (i.e., form in which the drug comes, such as tablet or liquid)
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Metric system
Doctor’s Order
125mg (weight) of Amoxicillin Suspension
D V
Formula = = amount to administer
H
125mg x 5ml = 2.5ml
250mg
• Basic Formula
The basic formula for calculating drug dosages is commonly used and
easy to remember:
D = Desired dose (i.e., dose ordered by primary care provider)
H = Dose on hand (i.e., dose on label of bottle, vial, ampule)
V = Vehicle (i.e., form in which the drug comes, such as tablet or liquid)
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Systems of Measurement
Household System
• May be used when more accurate systems not
required
• Drops, teaspoons, tablespoons, cups, and glasses
• Approximate volume equivalents between metric and
household systems include:
–15 drops = 1 ml
– 4 mL = 1 teaspoon
–15 mL = 1 tablespoon.
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Converting Units of Weight and Measure
• Converting Units of Weight
–Milligrams to grains
▪Milligram is smaller than a grain
▪1 grain = 60 mg
–Pounds to kilograms
▪2.2 lb = 1 kg
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Methods of Calculating Dosages
• Calculating for Individualized Drug Dosage
–Clients receiving chemotherapy, critically ill clients
require individualized dosages
–Body weight
▪Convert pounds to kilograms.
▪Determine drug dose per body weight by
multiplying drug dose × body weight × frequency
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Body Weight
Dosages based on weight use kilograms of body weight
and per kilogram medication recommendations to arrive at
appropriate and safe doses.
The steps involved in calculating an individualized dose
are as follows:
1. Convert pounds to kilograms.
2. Determine the drug dose per body weight by
multiplying drug dose × body weight × frequency.
3. Choose a method of drug calculation to determine the
amount of medication to administer.
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Body Weight
Example On hand: Keflex oral suspension 125 mg per 5 Ml
Order: Keflex, 20 mg/kg/day in three divided doses. The client
weighs 20 pounds.
On hand: Keflex oral suspension 125 mg per 5 Ml
1. Convert pounds to kilograms: 20 ÷ 2.2 = 9 kg
2. Multiply drug dose × body weight × frequency:
20 mg×9 kgx1 day = 180 mg/day
180÷3 divided doses=60 mg per dose
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Body Weight
Example On hand: Keflex oral suspension 125 mg per 5 Ml
Order: Keflex, 20 mg/kg/day in three divided doses. The client
weighs 20 pounds.
On hand: Keflex oral suspension 125 mg per 5 Ml
60 mg per dose
D V
Formula = = amount to administer
H
= 60mg x 5ml
= 2.4ml
125mg
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Routes of Administration (1 of 3)
• Oral
–Most common, least expensive, most convenient
• Sublingual
–Not to be swallowed, but dissolved
• Buccal
–Cheek
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Routes of Administration (2 of 3)
Parenteral route - by needle
• Intramuscular- into the • intrathecal or intraspinal-
muscle; into the spinal canal;
• Intradermal- under the • Epidural- into the epidural
epidermis (into the dermis) space
• Intravenous- into a vein • intra-articular- into a joint.
• intra-arterial- into an artery
• Intracardiac - into the heart
muscle
• Intraosseous- into the bone
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Routes of Administration (3 of 3)
Topical applications are those applied to a
circumscribed surface area of the body.
– Dermatologic -applied to the skin
– Instillations and irrigations- applied into body
cavities or orifices such as the urinary
bladder, eyes, ears, nose, rectum, or vagina
– Inhalations - administered into the
respiratory system by a nebulizer or positive
pressure breathing apparatus.
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Routes of Administration
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Routes of Administration
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Routes of Administration
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Routes of Administration
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Routes of Administration
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Routes of Administration
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Ten “Rights” of Medication
Administration
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Administering Medications Safely (1 of 2)
• Always assess health status
• Take medication history
–Include OTC drugs and supplements, allergies,
normal eating habits
• Include client's illness or current condition, intended
drug and route
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Administering Medications Safely (2 of 2)
• Assess ability to self-administer
• Assess socioeconomic factors
–Transportation
–Money for medication
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Medication Administration Errors (1 of 2)
• Can occur at all stages of the administration process
• Common reasons nurses do not follow five rights
–Poor pharmacologic knowledge
–Miscalculations
–Interruptions
▪Such as monitor alarms, telephones, and
inquiries from family or healthcare team
members
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Medication Administration Errors (2 of 2)
• Common reasons nurses do not follow five rights
–Increased workloads
–Fatigue
• Technology
–Barcode medication administration
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Process of Administering Medications
1. Identify the client
2. Inform the client
3. Administer the drug
4. Provide adjunctive interventions as indicated
5. Record the drug administered
6. Evaluate the client's response to the drug
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Developmental Considerations (1 of 3)
• Growth and development especially important in administering medication to very
young and very old
• Infants and Children
– Most often provided in sweetened liquid form
– Do not mix into milk or orange juice
– Be honest about injections hurting
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Developmental Considerations (2 of 3)
• Older Adults
– Altered memory
– Decreased visual acuity
– Decrease in renal function
– Less complete and slower absorption from gastrointestinal tract
– Increased proportion of fat to lean body mass
– Decreased liver function
– Decreased organ sensitivity
– Altered quality of organ responsiveness
– Decrease in manual dexterity
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Oral Medications
• NPO "nothing by mouth" or
Latin "nil per os"
• Oral most common route
• Preferred unless digestive
problem (e.g., nausea and
vomiting)
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Nasogastric and Gastrostomy
Medications
• Nasogastric tube, gastrostomy tube
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Parenteral Medications
• Parenteral administration is a common nursing
procedure.
• Absorbed more quickly than oral route
–Careful and accurate administration
• Aseptic technique
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Equipment (1 of 7)
• Syringes
–Parts
▪Tip, which connects with needle
▪Barrel
▪Plunger
–Hypodermic
▪Syringes vary
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Equipment (2 of 7)
• Syringes
–Insulin
▪Common problems with insulin pen
–Needlestick injuries
–Errors in technique
–Using the pen for more than one client
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Equipment (2 of 7)
• Syringes
–Tuberculin
▪Narrow
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Equipment (3 of 7)
• Syringes
–Luer-Lok syringe
▪Requires needle to be twisted onto it
–Non-Luer-Lok syringe
▪Has smooth graduated tip
▪Needles are slipped onto it
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Equipment (4 of 7)
• Syringes
–Prefilled unit-dose systems
▪Prefilled syringes ready for use
▪Prefilled sterile cartridges and needles that
require attachment of reusable holder before use
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Equipment (5 of 7)
• Needles
–Stainless steel
–Most disposable
–Parts
▪Hub
▪Cannula or shaft
▪Bevel
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Equipment (6 of 7)
• Needles
–Characteristics
▪Slant or length of bevel
▪Length of shaft
▪Gauge (diameter) of shaft
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Equipment (7 of 7)
• Preventing Needlestick Injuries
–Needles and sharps present one of greatest
dangers to healthcare workers.
–Passive devices
▪Retracts immediately
–Active devices
▪Requires nurse to activate safety feature
▪Do not recap!
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Preparing Injectable Medications (1 of 4)
• Ampules and Vials
–Ampule
▪Glass container designed to
hold a single dose of a drug
▪Must be broken at constricted
neck to access medication
–Vial
▪Small glass bottle with sealed
rubber cap
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Preparing Injectable Medications (2 of 4)
• Ampules and Vials
–Vial
▪Must be pierced with needle
and air must be injected
before medication is
withdrawn
–Reconstitution
▪Adding diluents to powdered
drug to reconstitute
–Single- or multi-dose
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Preparing Injectable Medications (3 of 4)
• Mixing Medications in One Syringe
–Can be done with compatible drugs (e.g., two types
of insulin)
–Push amount of air equal to dose into first vial
–Push amount of air equal to dose of second drug
into second vial
–Withdraw correct amount of drug from second
vial
–With newly attached, sterile needle, carefully
withdraw correct amount of drug from first vial
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Intradermal Injections
• Very small amounts administered just below epidermis
• Allergy testing
• Tuberculosis
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Subcutaneous Injections
• Injected just beneath skin
• Vaccines, insulin, heparin
• Syringe depends on medication
given, thickness of skin fold
• Sites need to be rotated in an
orderly fashion to minimize
tissue damage, aid absorption.
• Aspiration no longer
recommended
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Subcutaneous Injection Site
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Intramuscular Injections (1 of 6)
• Absorbed more quickly than
subcutaneous because muscle
more vascular
–Large volumes can be
tolerated.
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Intramuscular Injections (2 of 6)
• Size of syringe varies.
–Adult standard is 1.5 inches, 21 or 22 gauge.
• Factors determining size and length
–Muscle
–Type of solution
–Adipose tissue
–Age of client
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Intramuscular Injections (3 of 6)
• Ventrogluteal Site
–Preferred
▪No large nerves, vessels
▪Sealed off by bone
–Side-lying position most accessible
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Intramuscular Injections (3 of 6)
• Vastus Lateralis Site
–Best for infants, young
children
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Intramuscular Injections (4 of 6)
• Dorsogluteal Site
–Not preferred, should be avoided
–Close to sciatic nerve and
superior gluteal nerve
▪Complications have occurred.
–Numbness
–Pain
–Paralysis
–Subcutaneous tissue
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Intramuscular Injections (5 of 6)
• Rectus Femoris Site
–Easily accessible to
clients who
administer their own
injection
–May cause
discomfort for some
people
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Intramuscular Injections (5 of 6)
• Deltoid Site
–Close to radial nerve,
artery
–No more than 1 mL of
solution can be
administered
–Hepatitis B vaccine
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Intramuscular Injections (6 of 6)
• Intramuscular Injection Technique
–Also called Z-track
–Less painful
–Decreases leakage of irritant medication into
subcutaneous tissue
–Traps medication in muscle layer
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Intramuscular Injections (6 of 6)
• Intramuscular Injection Technique
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Intravenous Medications (1 of 3)
• Route appropriate for rapid effect (direct to bloodstream) or for medication that irritates
tissue
• Large-volume infusions
– Safest, easiest
– Main danger is hypervolemia
• Intermittent Intravenous Infusions
– Volume-controlled infusion (often used for children)
– Intravenous push (IVP) or bolus
– Intermittent injection ports (devices).
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Intravenous Medications (2 of 3)
• Volume-Controlled Infusions
–Set such as Buretrol,
Soluset, Volutrol, and
Pediatrol
–Often used with children,
older clients when
volume administered is
critical and must be
carefully monitored
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Intravenous Medications (3 of 3)
• Intravenous Push
–Or bolus
–Undiluted and used in emergency
–Errors may not be corrected and drug may irritate
the lining of blood vessels.
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Intravenous Medications (3 of 3)
• Intermittent Infusion Devices
–For clients receiving long-term
therapy
–SASH flushing procedure
(saline–administer drug–
saline–heparin)
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Topical Medications (1 of 9)
• Percutaneous
• Transdermal patch
• Skin Applications
–Clean skin before applying
–Wear gloves
–Use surgical asepsis in presence of open wound
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Topical Medications (2 of 9)
• Ophthalmic Medications
–Liquid or ointment medication into eye
▪Irrigation - An eye irrigation is
administered to wash out the
conjunctival sac to remove secretions
or foreign bodies or to remove
chemicals that may injure the eye.
▪Instillation Medications for the eyes,
called ophthalmic medications, are
instilled in the form of liquids or
ointments
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Topical Medications (2 of 9)
• Ophthalmic Medications
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Topical Medications (2 of 9)
• Ophthalmic Medications
Instillation
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Topical Medications (3 of 9)
• Otic Medications
– Administer medication to external auditory canal
▪ Irrigation
▪ Instillation
– Position of canal varies with age.
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Topical Medications (4 of 9)
• Nasal Medications
–Shrink swollen mucus
membranes
–Loosen secretions and
facilitate drainage
–Treat infections of
nasal cavity and
sinuses
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Topical Medications (6 of 9)
• Vaginal Medications
– Creams, jellies, foams, or suppositories
– Infections or discomfort
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Topical Medications (7 of 9)
• Rectal Medications
–Can be used when the drug has
objectionable taste or odor
–Use primarily for their local
actions such as laxative and
fecal softeners.
–After the drug is inserted, the
patient should remain in that
position for 5 minutes.
–If laxatives, it must remain in
position for 35 to 45 minutes.
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Inhaled Medications (1 of 3)
• Nebulizer is a small machine that
vaporizes a liquid medication into
a fine mist that is inhaled, using a
face mask or handheld device
• Dry powder inhaler (DPI)- A
capsule is inserted into the center
of the chamber of the inhalation
device. A piercing device
punctures the capsule, which
allows the medication to be
released upon inhalation by the
client
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Inhaled Medications (1 of 3)
• Metered-dose inhaler (MDI)
is the most common type of
device used to deliver
respiratory drugs. It is a
pressurized container of
medication that can be used
by the client to release the
medication through a
mouthpiece.
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Inhaled Medications (2 of 3)
• Metered-dose inhaler (MDI)
–Client teaching
▪Remove mouthpiece cap
▪Exhale comfortably
▪Hold canister upside down
▪Press down once and inhale
slowly and deeply through the
mouth
▪Hold breath for 10 seconds or
as long as one can
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Inhaled Medications (3 of 3)
• Metered-dose inhaler (MDI)
–Client teaching
▪Remove inhaler away from mouth
▪Exhale slowly through pursed lips
▪Repeat inhalation if ordered
▪Rinse mouth with tap water
▪Clean MDI mouthpiece after each use
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Irrigations
• Irrigation (lavage) - the washing out of a body
cavity by a stream of water or other fluid that
may or may not be medicated.
• Stream of water or other fluid
–Clean body cavity
–Remove foreign object, secretions
–Apply heat/cold
–Apply antiseptic
–Reduce inflammation
–Relieve discomfort
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• End of the topic
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The doctor ordered Magnesium Sulfate 3gm/ hour IV.
Magnesium Sulfate come in 60gm/1000mL IV bottle. You
would set your pump at _____mL/hour.
D V
Formula = = amount to administer
H
= 3gm x 1000ml
= 50gram
60gm
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