Medication Administration Full Flashcards
Thanks Emily S!
When administering ophthalmic meds, make a pouch in the _____ lid by pulling skin downward over the ________. Instill the medication in the ______.
Lower, bony orbit, conjunctival pouch
What sized syringe and needle should be used for IM injections?
1-5mL syringe, needle 21-25g (21-22g most common), 1-3” needle, (1-1.5” most common)
5 rights review: How to check if the right route?
- Double check it is the right route of administration in drug book/MAR
- If a change in route is needed, request new order from physician
ex: Tylenol 650mg suppository cannot be changed to PO route without a new order!
What does the RN need to check before giving insulin or any oral hypoglycemic?
Blood glucose
Capsules cannot be ______, but they can be ______
split, opened
- Especially document for _____ medications and the first time a ____ medication is administered
PRN, new
Name some common sites of SQ injections
Back of upper arms, abdomen (1” away from umbilicus), lower back/love handles, anterior aspect of thighs, back of scapula (not common)
In the beginning of medication preparation, after you have assembled the meds, what do you do?
Check for drug expiration date, check for the five rights against the MAR
What is a stat order?
Administer med as soon as possible; emergent
ex. Morphine 4 mg IV stat
How would you tell someone to take an oral medication that was a lozenge?
Dissolve in mouth
Who can write a medication order?
Who can write an order?
- MD, DO
- Nurse Practitioner
- Nurse Midwife
- Physician Assistant
- Pharmacists & CRNAs
- Per state and facility policy
Name the 7 components of a medication order
○ Client's Full Name ○ Date and Time of Medication Order ○ Name of Medication ○ Route of Administration ○ Dosage of Drug ○ Frequency of Administration ○ Physician/Provider's Signature
What is the administration angle for intradermal injections
5-15 °, almost parallel to the skin
If patient has an NG tube hooked up to suction, turn it off, give the med, and then wait ______ to turn suction
back on to ensure __________.
30 min, medication is absorbed
Discuss the steps you would go through to administer an IM injection using the z-track method:
- Prepare medication
• Change needle after drawing up med b/c know med is irritating
- Check 5 rights- Gather supplies
- ID site
- Don gloves
- Cleanse site w/ alcohol (can use corner of alcohol pad to point to injection site)
- Displace skin laterally 1-1 ½” from injection site (using side of hand and keep it there while insert the needle)
- While holding skin, insert needle with darting motion at 90° angle
- Stabilize needle with thumb and forefinger of hand displacing skin
- Aspirate
- If no blood, inject medication slowly and steadily
- Wait 10 seconds
- Quickly withdraw needle
- Release skin
- Cover site w/ swab and DO NOT MASSAGE
- DO NOT RECAP. Activate safety feature. Place needle in sharps container uncapped.
- Remove gloves.
Talk your way through the deltoid landmarks to give an IM injection:
o Palpate lower edge of acromion process (bony process end of shoulder)
o Place 3 fingers across deltoid muscle w/ top finger at acromion process. This forms the base of a triangle
o Draw an imaginary line at axilla. This forms apex of the upside down triangle.
o Injection site = center of triangle, 2-3 finger widths (1-2”) below acromion process.
Should feel belly of muscle here
If we don’t have a filter needle for an ampoule, what should we use?
A small gauge needle (25g, 27g)
What initial assessments may be needed before giving medications?
- B/P if giving a HTN medication
- Pulse if giving cardiac drugs like Digoxin
- Pain rating if giving pain med
- Temp if giving antipyretic
On a syringe and needle, what needs to stay sterile?
- Tip of syringe, until needle attached
- Hub of needle, until attached to syringe
What is a routine order?
Give order until discontinued
ex: Cephalexin 500mg PO every 6 hours X 7 days
What is the typical volume for a SQ injection?
Up to 1 mL (can use 3mL syringe too)
Why should the patient wait a minute between puffs of a MDI?
So that bronchodilation can occur
What is the typical volume for intradermal injections?
0.1-0.5 ml (very small amount)
It’s time to go to the room and administer medication. What are your first steps?
- Bring MAR and medications to patient room
- Check 5 “Rights”
- Compare wristband to MAR
- Ask about allergies
What is the onset time for an IM injection?
Variable
What is a PRN order? What should this order always have on it?
PRN: as needed – should always have interval and indication statement
ex. Morphine 2 to 4 mg IV q 4 hours prn pain
Talk your way through the ventral gluteal landmarks:
o Palm of hand on greater trochanter of femur
WHICH HAND IS IMPORTANT: thumb towards peepee
• Right hip, use left hand and vice versa
Ask person to stick hip out like holding a baby – bony prominence is trochanter OR where hip crease is when sitting
o Index finger pointed toward anterior superior iliac spine (hip bone)
o Middle finger extended toward iliac tubercle (straight up)
o Injection site lies within triangle formed by index and middle fingers
If pt has heel on ground and moves foot in and out, can feel muscle move, to make sure right location
Name two meds where the Z-track method is commonly used:
Hydroxyzine (Vistaril) and iron
How should you manipulate the ear to give otic meds to children under 3 years old?
Pull down and back
What is a nebulizer?
Aerosolized medication either given by a handheld device or by a face mask (peace pipe)
What is best given via rectal route?
Enemas/suppositories
You should/should not cover w/ gauze and massage skin after an ID injection?
Should NOT
What can the nurse use for to assist administering oral meds for patients with difficulty swallowing?
pudding or applesauce
There are a lot of ways to decrease the pain of an injection. Name a few:
o Encourage client to relax muscle
- Position patient prone with feet inverted (toe to toe, heels out) for dorsogluteal injection
o Change needle after preparing medication in syringe
o Avoid injecting into sensitive/hardened skin – want soft site
o Use needle long enough to reach muscle
o “Dart” needle quickly into muscle – quick in and quick out
o Use smallest gauge possible
o Inject medication SLOWLY (or at least steady – depends on drug)
o Do not move needle once inserted
o Withdraw needle quickly
o Use Z-track for IM injections
o EMLA cream may be applied (anesthetic for kids – need to wait 20 minutes)
o Apply pressure/ice to site before injection and pressure to site after
How should you prepare solid meds to be given in an enteral tube?
Crush pills individually and mix with 15-30 mL of warm water.
What are the best sites for intradermal injections?
Inner forearm (most common) • May use back/upper chest – mostly allergy testing
What is the best position to administer a vaginal suppository?
Dorsal recumbent or Sim’s position
Why would you use z-track?
Used to “trap” medication in muscle and prevent “tracking” of solution through tissue. Less painful.
What things do you need to review re: the physical assessment of the patient before giving medication?
- Are they alert? Oriented?
- Ability to swallow
(Should meds be crushed? Can the meds be crushed?) - NPO or not
- Ability to follow instructions
- GI motility
(Post-operative period – maybe GI function hasn’t returned? - Muscles mass (IM) – choose needle size based on muscle mass
- Water at the bedside to take meds
What is a one time order?
Give single dose and then discontinue; think: pre-op
ex: Atropine 0.3 mg subcutaneously on call to OR
What drug information do you need to know to give the medication safely?
Know the:
- Action of the drug – mechanism of action/pharmacological classification
- Normal dose ranges and routes
- Any contraindications
- Drug interactions
- How to evaluate therapeutic effects
- Give w/ or w/o food,
- Patient teaching, etc.
Which is the most difficult site to locate but also the preferred IM injection site?
Ventral gluteal. Least amt nerve endings, blood vessels, and variability in subQ tissue
Which kind of administration is used for allergy and tuberculin skin testing?
Intradermal
What is a spacer?
A chamber attached to the end of an inhaler that assists the patient in receiving a higher % of drug
with each inhalation
When possible, what do you tell the patient when you are giving them a medication?
- Name of medication
- Dosage
- Indication for use
- Pertinent patient teaching
What kind of syringe and needle is generally used for intradermal injections?
TB syringe (1 mL) small gauge 25-28G, short needle ¼” – 5/8”
Name 8 examples of oral med preparations:
- Capsule
- Pill
- Tablet
- Time-released
- Elixir, Syrup, Tincture
- Powder
- Suspension
- Troche (lozenge)
What happens after a provider orders a medication?
- Checked by pharmacy
- Checked by RN
- If paper system, may be transcribed by unlicensed person.
5 rights review: How to check if the right patient?
- “State your name and date of birth”
- Compare with armband and medical record
Where should you instruct the patient to look when administering ophthalmic medications?
Toward the ceiling
After administration, what/when do you document on the MAR?
- As soon as possible AFTER administration
- Document time administered
- Document client response
List the steps for RBVO
Step 1. Write down order first.
Step 2. Read back what you wrote.
What is the best position to administer a rectal suppository?
Sim’s position
Discuss the steps you would go through to administer and intradermal injection:
- Prepare meds
- Check 5 rights with MAR
- Gather supplies
- ID site (make sure intact skin – look for bruising, irritation, broken skin, tattoos
- Don gloves
- Cleanse site w/ alcohol and let dry
- Pull skin taut (skin towards wrist, if on forearm. Skin pulled opposite direction of needle)
- Insert needle w/ bevel up (towards ceiling) at 5-15°, 1/8” deep
- Needle should be visible under skin
- Push plunger to instill medication creating a WHEAL under skin
- Withdraw needle at same angle inserted
- DO NOT RECAP NEEDLE. Activate safety feature, place needle in sharps container uncapped.
What is an MDI?
Metered dose inhaler
For any IM injection below the waist what length needle should be used?
1 ¼”- 1 ½” long needle
What is the administration angle for a SQ injection?
45 or 90° (mostly 90° b/c you can “pinch an inch” on most ppl, but 45° appropriate for thinner people)
What should you take special note of with ophthalmic meds?
There often needs to be a certain time period to wait between meds if doing multiple eye meds
You sometimes need to check electrolytes, name a medication in which you need to do this?
Lasix – check K+ levels
What is an injection method used w/ irritating medications?
Z-track method
Beginning of medication preparation, what is the the first step, after proper hand hygiene?
Assemble the medications in the medication room/mobile med cart.
5 rights review: How to check if the right drug?
- Compare drug to MAR
- Note expiration date
- Know indication: “Why is the patient taking this medication?”
How do you use an insulin pen?
o “Dial” the dose to appropriate units (eg 10)
o Insert needle into patients using SUBQ method
o WAIT
o Dial returns to zero
o Then, remove needle
(Not always used, only at some facilities. Sometimes one pen used on multiple patients. Talk to someone beforehand to make sure you know how a particular insulin pen works.)
How is inventory done with controlled substances?
Done by 2 nurses at set intervals.
Name three rules of topical meds:
- Make sure previous dose is removed, before applying new dose.
- Apply patches to non-hairy, INTACT areas of the body
- Do NOT touch topical medications with ungloved hands (!!)
What administration angle should be used for an IM injection?
90°
What is the 3rd leading cause of death in the US?
Medication errors
What is the most common general medication administration time rule?
Give up to 30 minutes before to 30 minutes after (dosage window)
Discuss the steps you would go through to administer an IM injection:
• Prepare medication
• Check 5 rights
• Gather supplies
• ID site using landmarks
• Don gloves
• Cleanse site w/ alcohol
• Pull skin taut (esp. if below waist, may pinch deltoid only)
• Hold needle like a dart
• Insert needle quickly at a 90° angle
• Stabilize needle
• Aspirate for blood (draw back plunger slightly) NOTE: WE HAVE BEEN TOLD NOT TO ASPIRATE FOR VX IM INJ BY OTHER PROFS
o If see blood, immediately remove needle and put in sharps container.
o Draw up new med and draw into new site to make sure not in blood vessel
• If no blood, instill medication slow and steady
• Quickly remove needle
• DO NOT RECAP. Activate safety feature. Place needle in sharps container uncapped.
• Massage site with alcohol swab.
• Remove gloves
What do you do if/when you make a medication error?
1) Make sure the patient is okay!!
2) Notify the provider/charge nurse
3) Complete an incident report
5 rights review: When is the appropriate window to give meds?
- Medication given 30 minutes before or 30 minutes after time ordered is acceptable.
- Refer to policy and procedure manual.
- *Standard administration times are set by each facility.
ex: Once daily dose: 1000; BID dose 0900, 2100
Discuss the steps you would go through to administer a SQ injection:
• Prepare meds • Go through 5 rights • Gather supplies • ID site ( BIG PINCH - where you can pinch an inch or more) • Don gloves • Cleanse site w/ alcohol • Bunch the skin o Hold needle like dart • Pierce skin with QUICK motion at 45-90° angle • DO NOT ASPIRATE • Inject medication steady rate • Quickly remove needle • DO NOT RECAP. Activate safety feature. Place needle in sharps container uncapped.
What position is best for the patient to be in to administer most meds?
High fowler’s
How would you tell someone to take an oral medication that was buccal?
Between cheek and teeth and let dissolve
If a medication is not given/refused, what do you document?
Document reason (e.g., blood sugar low – no insulin, pt. refusal)
What is the most dangerous IM injection site?
Dorsal guteal bc of sciatic nerve location; ONLY USE IF DIRECTED TO DO SO by drug guide/manufacturer
Talk your way through the dorsal gluteal landmarks:
o Absolutely most dangerous site
o Locate posterior iliac spine (indentation above buttocks, right where bone starts to come up)
o Locate greater trochanter at hip
o Draw an imaginary line between these 2 landmarks
o Injection site is above and lateral to the line (a lot higher than you think it is)
- DO NOT USE OLD TECHNIQUE of dividing buttocks into quadrants. Can hit sciatic nerve and cause foot drop
What is a RBVO?
Read Back Verbal Order. The practice of repeating back an order that is given verbally in person or over the phone. It is done to ensure accuracy.
What is the onset time with SQ injections?
Within 30 minutes
What is the best way to give nasal medications?
Head down and leaning forward different from book
If you only need to use a half vial of a medication that is a controlled substance, what do you do with the rest?
Waste it. Must be witnessed and documented by another nurse
How should you manipulate the ear to give otic meds to an adult?
Pull up and back
4 Types of Medication Orders
- Written Orders – preferred
- Verbal Orders (VO) – should only be done in critical situations (e.g., “push epi”)
- Telephone Orders (TO)
- Protocols
What should you know for any PRN drug?
Know the last time of administration
More than ____ (ex. vials) to equal a dose is a RED FLAG
3
*ex: IV med that takes 10 vials doesn’t seem right…double check the order!
How should patients be positioned while giving otic meds?
Side lying
At what temp should otic meds ideally be given?
Room temp
What are blunt needs used for?
Used for filling meds
Never crush what kinds of oral meds?
Sustained release, controlled release, or enteric coated pills
Can patients bring medications from home?
Yes but must have order and checked by pharmacist
What should you see under the skin after you inject the medication intradermally?
A wheal
When administering medications in a enteral tube (e.g., PEG tube, nasogastric tube, etc.), in what form should they be?
Liquid
Stay with patient until all medications are taken!
Just a reminder!
Name 3 common SQ injections
heparin, lovenox, and insulin
How many medications should you prepare at a time?
One
What do we use filter needles for?
- For ampoules. Mechanism inside to filter glass out
How long should the patient who received a vaginal suppository stay in position after so that the medication stays in place and gets absorbed?
15-20 minutes
What is the process when using an MDI (4 steps)?
1) Breathe out
2) inhale slow and steady – push and inhale simultaneously
3) hold breath
4) breathe out slowly
Places to find meds! What is often kept in an automated medication-dispensing systems (Pyxis)?
Opiods
Name the parts of the syringe
Tip, barrel, plunger
How would you tell someone to take an oral medication that was sublingual?
Dissolve under the tongue (NO first-pass effect!)
What is the angle used for a SQ injection?
45-90° angle
What is a now order?
Patient not in emergency situation, but want to get meds to patient ~ 15 min; since of urgency
What is medication reconciliation?
The process of checking home meds vs meds ordered in the hospital when admitted and when discharged
Places to find meds! What is a mobile cart?
- Locked cassettes or drawers for each patient
- May have “floor stock” drawer
What if you don’t see a wheal after the ID injection?
May need to redo
Time to give the medication via enteral tube. How do you do this?
Check placement – is it in the right spot?, flush with water (~15cc), administer medication, flush with water, administer medication, flush with water.
Name 3 common medications that require checking drug levels?
Digoxin, Dilantin, Theophylline
What are the 3 checks of medications (triple check!!)
1) Against MAR before preparing medication (e.g., getting it from Pyxis)
2) Against MAR after preparing the medication
3) At the bedside
What do we recommend the patient do after receiving a rectal suppository?
Stay in position and “hold it” (if for bowel function)
What should you do with syringes if not in the original container BEFORE removing from medication room
Label syringes
Where are you injecting medication when you administer a SQ injection?
In adipose tissue, between skin and muscle
What do you monitor for after giving?
Effect – did it do what it was supposed to?
What volume can you go up to for an IM injection?
Up to 4 ml depending on muscle
Name some complications that can come from an IM injection:
o Pain
o Damage tissue: sterile abscess, hematomas, muscle contraction, bruising, skin discoloration, nerve damage
- Use landmarks to find locations
o Bone injury (hit bone w/ needle)
o Speed shock (if med goes into vein or artery)
o Infection
What size needle and syringe should you use for a SQ injection?
TB or insulin syringe (can also use 3 ml syringe), 25-27g needle, length ½”- 5/8”
5 rights review: How to check if the right dose?
- Know the usual dose and question any dose outside of safe range
- Validate calculations of divided doses with another nurse
- Check high alert medications (ie heparin, insulin, digoxin) with another nurse
How should you instruct the patient to intake the nasal medication?
Steady inhalation
If medication should be given on empty stomach: stop tube feeding for _____ minutes before and after med
administration.
15-30 minutes
What does the RN check after a provider orders a medication?
- Allergies
- Appropriate med
- Appropriate dose
- Checking total order to make sure it is something the patient should be getting (refer back to chart – things can get changed quickly)
Talk your way through the vastus lateralis landmarks (outer middle aspect of thigh):
o One hand above knee
o One hand below greater trochanter
- Have someone bend at hip, put hand at top of leg, that’s where greater trochanter is
o Locate midline of anterior thigh and midline of lateral thigh
o Injection site is middle third lateral aspect of the thigh
- Front of thigh is a different muscle
Why should you avoid tattoos if possible with intradermal injections?
It makes it easier to assess skin later for rxns
