Three Checks and Six Rights

The nurse observes the three checks and six rights of medication administration.

Three Checks When Preparing Medications

Read the label:

1. Check the drug label with the MAR (medication administration record) when removing the container or unit-dose package.

2. Check the drug label again immediately before pouring or opening the medication, or preparing the unit-dose.

3. Check the drug label once more when replacing the container and/or before giving the unit-dose to the patient/client.

Six Rights Before Administering Medications

1. Right medication

2. Right patient/client

3. Right dosage

4. Right route

5. Right time

6. Right documentation.

Other rights that are important: the right drug preparation, right expiration date, right assessment, right evaluation, the right to receive drug education, the right to refuse a drug.

Medication Orders

A correct medication order or prescription bears the patient/client’s name, room number, date, name of drug (generic or trade), dose of the drug, route of administration, and times to administer the drug.

It ends with the signature of the physician or healthcare provider ordering the drug.

Types of Orders

1. Standing order with termination

EXAMPLE

2. Standing order without termination

EXAMPLE

3. A prn order

EXAMPLE

4. Single-dose order

EXAMPLE

5. Stat order

EXAMPLE

6. Protocols

EXAMPLE

Hospital guidelines provide for an automatic stop time on some classes of drugs; narcotic orders may be valid for only 3 days, antibiotics for 10 days. When first reading the order and transferring or transcribing the order, the nurse must take care to note the expiration time, thus alerting all staff who administer medications. It is still the prescriber’s responsibility to rewrite the order. State laws and hospital policies vary.

Order Entry

In hospitals and other institutions, the medication orders are written by a physician or licensed health care provider. These orders may be written on a paper form that is in the patient/client’s chart or, more often nowadays, on a computer (often called computerized order entry or COE).

An example of a paper form is shown in Figure 10-1.

FIGURE 10-1
Sample paper medication order.

Although other personnel, such as a ward clerk, may transcribe the medication orders, ultimately the nurse is responsible for transcribing the medication orders and administering the medications. Transcribing orders involves transferring the order, usually to an MAR; again, this usually is done on a paper form or the computer.

COE allows doctors or prescribing health care providers to input medication orders directly onto the computer. The pharmacy receives the order and adds it to the patient/client’s drug profile; subsequently, the nursing unit receives the MAR, which lists the medications and times of administration (the frequency of updates varies according to the hospital or institution). This system presents several advantages: Neither the nurse nor the pharmacist has to interpret the handwriting of the doctor or healthcare provider. The nurse does not have to transfer the written orders to an MAR, lessening the chance for error while also saving time. Moreover, a computer check identifies possible interactions among the patient/client’s medications and alerts the nurse and the pharmacist. The nurse will check the medication orders on the computer (Fig. 10-2).

FIGURE 10-2
Checking computerized orders. (From Taylor, C. [2008]. Fundamentals of nursing [6th ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 160.)

Medication Orders Guidelines

• Only licensed physicians or health care providers can write orders/prescriptions. Nurse practitioners are licensed in all states to write orders, although some restrictions apply and vary state to state.

• Medical students may write orders on charts, but orders must be countersigned by a house physician before they are legal. Medical students are not licensed.

• In states that allow nurses or paramedical personnel to prescribe drugs, these caregivers must follow hospital guidelines when carrying out orders.

• Do not carry out an order that is not clear or is illegible. Check with the physician or healthcare provider who wrote the order—do not assume anything.

• Do not carry out an order if a conflict exists with nursing knowledge. For example, Demerol (meperidine) 500 mg IM is above the average dose. Check with the physician or healthcare provider who wrote the order.

• Nursing students should not accept oral or telephone orders. The student should refer the physician to the instructor or staff nurse.

• Professional nurses may take oral or telephone orders in accord with institutional policy. The nurse must write these orders on the chart, and the physician or healthcare provider must sign them within 24 hours. Verbal orders are discouraged, and the physician should write the order if physically present in the nursing unit.

Medication Administration Record (MAR)

The MAR, a daily (24-hour) record of what medications are ordered for the patient/client, also documents the medications given by the nurse. Most MARs consist of a computerized printout (Fig. 10-3), with key identifying information—the patient/client’s name, identification (ID) number, room, date of admission, age, diagnosis, gender, and attending physician—printed at the top. Orders written during the shift have to be added to the printout by hand—a procedure that can lead to medication errors. Therefore, hospitals require that every shift or every 24 hours (policy varies according to institution), the nurse must check the MAR against the original orders in the chart to make sure that the orders are correct. As hospitals move to complete computerized charting, the MAR will be on the computer and charting done directly on the computer MAR.

Each healthcare setting will have different guidelines on charting medications. Generally, routine medications are assigned a scheduled time on the MAR. After the nurse gives the medication, a line is drawn through the time and initialed. If the medication is refused or held, the time is circled and initialed and then a reason given why the medication was not given. Medications prescribed on an as-needed basis (prn) are not assigned a scheduled time on the MAR; rather, after the medication is given, the time is then written on the MAR, a line crossed through that time, and then initialed. Different medications may be given at different scheduled times throughout the day. For example, Coumadin (warfarin) is given at 5 or 6 PM (1700 or 1800), so that the therapeutic effect is maximized. Follow institutional guidelines for medication administration times.

FIGURE 10-3
A sample 24-hour computerized medication record. Scheduled drugs are listed at the top of the sheet and prn orders at the bottom. Military time is used. The nurse draws a line through the time administered and initials to indicate that the drug was administered, then signs at the bottom of the sheet.

Systems of Administration

Institutions establish their own systems for administering medication. You might need to use tickets, the mobile cart, a locked medication cabinet near the patient/client’s bedside, and/or computer printouts.

The ticket system, rarely used, works with drugs that are dispensed in multidose containers. The nurse prepares the drugs in a medication room and then carries them on a tray to the patient/client.

Unit-dose packaging is the most widely used system. Drugs are dispensed by the pharmacy and placed in individual patient/client drawers, either on a mobile cart or in a locked cabinet at the patient/client’s bedside. The mobile cart can be wheeled into the patient/client’s room so that you can prepare medications at the bedside for administration.

A newer system uses a scanner device, scanning the patient/client’s ID band, the nurse’s ID, the MAR, and the medication in unit-dose packaging. If the scan reveals any discrepancy, the device alerts the nurse.

Ticket System

The ticket system transfers a medication order to three places: a medication ticket, the patient/client’s medication sheet, and the patient/client’s Kardex file, which contains the nursing care plan. Tickets for all patients/clients are kept in a central location. The nurse sorts them according to time of administration and compares them with the Kardex entry. If there is a discrepancy, the nurse checks the original order on the patient/client’s chart, using a three-check system:

First check: Separate the first patient/client’s tickets and place them together in a pile; read each ticket, locate the medication in the medication cart or medication room, and verify that the label matches the ticket.

Second check: Compare the dose on the ticket with the label, then calculate and pour the amount of the drug.

Third check: Before discarding the unit-dose packet or returning the container to the shelf, read the order and the label again, verifying the poured dose.

Having finished these checks, place each medication on a tray with the ticket in front to identify it. Then dispense the medication to the patient/client, identifying the patient/client by ID band, following two patient/client identifiers (see p. 366), and keeping the medications in sight. Complete any required nursing assessment (e.g., obtain a blood pressure or heart rate). Administer the drugs, then take the medication tray to the next patient/client and follow the same procedure. After giving all of the medications, chart them on each patient/client’s chart. If you give a stat medication (one that is given immediately), chart it and destroy the ticket.

This system has a number of disadvantages: Since every order must be transcribed to three different places, that opens three opportunities for error. Also, tickets can be lost or misplaced; an error may occur while the nurse is choosing the stock medication; and if the tickets become mixed, a medication may go to the wrong patient/client. Medications requiring assessment need some kind of ID tag, and locating the chart of each patient/client takes a lot of time.

Mobile Cart System

In the mobile cart system, the pharmacy dispenses unit-dose medications directly to the patient/client’s drawer in the mobile cart, which is labeled with the patient/client’s name. The cart contains all of the equipment the nurse might require to administer medications.

Here’s the appropriate procedure: When it’s time to administer medications, wash your hands and roll the cart to the bedside of the first patient/client. Identify the patient/client using two patient/client identifiers (see p. 366), unlock the cart, and open the medication book to that patient/client’s medication sheet.

Before giving the medication, check the sheet for special nursing actions required, such as obtaining a blood pressure or heart rate. Carry out the orders, record the results, and decide whether to withhold the medication or to administer it.

FIGURE 10-4
The nurse compares the medication with the medication order. (From Lynn, P. [2011]. Taylor’s clinical nursing skills: A nursing process approach [3rd ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 158.)

First check: Place the patient/client’s drawer on the top of the cart. Read each medication order, starting with the first medication listed. If you’re giving a dose, choose the unit-dose from the drawer and compare the label with the order (Fig. 10-4). Check the label.

Second check: After comparing the order with the unit measure, compute the dose. Check the drug label, then open or prepare the unit-dose, or pour the amount of a liquid medication.

Third check: After preparing all of the patient/client’s medications, check the drug label again, open the unit-dose packaging (if not done in the second check), identify the patient/client using two identifiers (see p. 366), and administer the drugs. Offer patient/client teaching. Remain with the patient/client until he or she has taken the medications, then provide any comfort measures, wash your hands, and return to the cart to chart the drugs administered. Replace the patient/client’s drawer, and roll the cart to the next patient/client. When all of the medications have been administered, return the mobile cart to its designated area. (Ideally, take the MAR to the patient/client’s bedside for the third check).

This system has several advantages. Two professionals—the pharmacist and the nurse—check the medication in the drawer. All of the MARs are together on the cart, which saves time. The nurse can carry out assessment and can chart the results before pouring any medication. Immediately after administering the drugs, the nurse can sign for them.

Note that with the ticket and mobile cart systems, you must check the label three times: when choosing the drug, when pouring the dose or opening the medication, and before replacing the container or giving the unit-dose to the patient/client.

In a variation of the mobile cart system, the medications are locked in a cabinet at or near the patient/client’s bedside. As with the original mobile cart system, the pharmacy fills the cabinet with the unit-dose medications. MARs are in the chart, which is in the cabinet, and the nurse prepares the medications in the same manner, using the three checks and the six rights. Having the medications and the patient/client’s chart closer to the bedside saves time for both the patient/client and the nurse.

Many hospitals are using the computerized narcotic cart or cabinet (Pyxis system) to dispense all medications (controlled substances and noncontrolled medications). The computer in the cart or cabinet stores a record of each medication, when it is due, and lists this information for each patient/client. The nurse simply goes to the Pyxis with the MAR and removes the unit-doses for each patient/client by accessing the computer. The Pyxis system uses a password and often a fingerprint identifier to identify each nurse accessing this system. This system provides yet another check to make sure that the right patient/client receives the right medication, the right dose, at the right time.

Computer Scanning System

The computer scanning system uses a portable computer scanning device, which stores information about the patient/client and the medication. The unit-dose packaging used with this system shows bar codes. The nurse’s process is simple: Prepare the medications and check each one against the MAR. Use the scanning device to scan the patient/client’s ID band, your own ID, the medication package, and the MAR (this system also ensures two patient/client identifiers). If the computer detects no discrepancy, you can continue to administer the medications as described in the previous section on the mobile cart system.

Knowledge Base in Giving Medications

• Nurses should know the following before giving medications:

• generic and trade names of drugs to be administered

• class, category of drugs to be administered

• average adult or pediatric dose depending on the patient/client population

• routes of administration

• use

• side effects and adverse effects

• contraindications

• nursing implications in administration

• signs of effectiveness

• possible drug interactions

• The nurse should be aware of the patient/client’s diagnosis and medical history, especially relative to drugs taken. Be especially alert to over the counter drugs (OTC) or herbal remedies which patients/clients often do not consider important. Check for drug allergies.

• Assess the patient/client’s need for drug information. Be prepared to implement and evaluate a nursing care plan in drug therapy.

Basic Guidelines in Giving Medications

• Always check the patient/client’s ID band before administering medications (Fig. 10-5). The Joint Commission’s 2009 National Patient Safety Goal 1 states that “two patient identifiers are used when administering medications, blood, blood components; collecting blood and other specimens for clinical testing, and providing other treatments or procedures” (see the Joint Commission Web site for updated information: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/).

• Acceptable identifiers include the following:

• The individual’s name

• An assigned ID number

• Telephone number

• Date of birth

• Social security number

• Address

• Photograph

• Other person-specific identifiers

• Checking a patient/client’s armband and the MAR usually satisfies this requirement. Check institutional policy.

• Listen to the patient/client’s comments and act on them. If a patient/client says something like “That’s not mine” or “I never took this before,” check carefully, then return to the patient/client with results of your investigation. Failure to do this will cause you to lose the patient/client’s trust and confidence and may result in a medication error.

FIGURE 10-5
Checking the patient/client’s armband. (From Evans-Smith, P. [2005]. Lippincott’s atlas of medication administration [2nd ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 8.)

• If a patient/client refuses a drug, find out why. First check the chart to see if the drug was in fact ordered, then talk to the patient/client to understand his or her reasons. After charting the reason for refusal, notify the physician or health care provider who wrote the order.

• Watch to make sure the patient/client takes the drugs. Stay until oral drugs are swallowed.

• Keep drugs within view at all times.

• Never leave any drug at the bedside unless hospital policy permits this. If a medication is left with the patient/client, inform why the drug is ordered, how to take it, and what to expect. Later, check to determine whether the drug was taken, and record the findings.

• It is a fallacy that the nurse is no longer required to calculate or prepare drugs dispensed as unit-dose. In some instances, the pharmacy may not have the exact dose on hand or the nurse may need to administer a partial dose. The label still must be read three times.

• Labels on medication must be clear. If not, return them to the pharmacy.

• If any doubt about a drug exists, do not administer it. Check further with the physician, the health care provider, the pharmacist, or a supervising nurse.

• Orders issued as “stat” take precedence and must be carried out immediately.

• Perform indicated nursing actions before administering certain medications. For example, digoxin requires an apical heart rate; antihypertensives require a blood pressure reading.

• Administer medications within 30 minutes of the time scheduled.

• Keep medications within sight at all times. Never leave medications unattended.

• Do not administer a medication if assessment shows that the drug is contraindicated or that an adverse effect may have occurred as a result of a previous dose. If you withhold a drug, notify the physician or healthcare provider who wrote the order.

Documentation

Documentation is the “sixth right” of medication administration. The always-quoted axiom is still true: “If it’s not charted, it’s not done.”

• Chart all medications after administration.

• Chart single doses, stat doses, and prn medications immediately, and note the exact time they were administered.

• Chart any nursing actions done before administering drugs (e.g., apical heart rate with digoxin or blood pressure with antihypertensives). Usually, this can be done on the MAR.

• If the drug was refused or was withheld, write the reason on the nurse’s notes and/or on the MAR, notify the healthcare provider who ordered the medication, and also the time you notified the healthcare provider and any response.

Standard Precautions Applied to Administration of Medications

When you are administering drugs, there’s a chance that the patient/client’s blood, body fluids, or tissues can come into contact with your skin or mucous membranes. Therefore, you always risk potential exposure to serious bacterial infections, fungal infections, tuberculosis, or a long list of viruses, including these: hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV), hepatitis E virus (HEV), and the human immunodeficiency virus (HIV).

The Centers for Disease Control and Prevention (CDC) in Atlanta recommends standard precautions in caring for all patients/clients and when handling equipment contaminated with blood or blood-streaked body fluids. In 1996, the term standard precautions replaced “universal precautions.” Transmission-based precautions are those used with patients/clients who have a suspected infection. For more information on these procedures, see the CDC Web site (www.cdc.gov) or the document 2007 Guideline for Isolation Precaution: Preventing Transmission of Infectious Agents in Healthcare Settings (www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf).

The following points, based on CDC guidelines, can help you determine appropriate safeguards in giving medications. Follow your institutional requirements. The safeguards you need to follow depend on the type of contact you have with patients/clients.

General Safeguards in Administering Medications

1. Oral medications: Handwashing or use of an antiseptic foam or lotion is adequate. If there’s a possibility of exposure to blood or body secretions, wear gloves.

2. Injections: Both handwashing and gloves are required. Do not recap needles. Carefully dispose of used sharps, either by holding the sharp away from you in a puncture-proof container or by using a needleguard device.

3. Heparin locks, saline locks, IV catheters, and IV needles: Wash your hands and wear gloves when inserting or removing IV needles and catheters. Dispose of used sharps in a puncture-proof container or use a needleguard device.

4. Secondary administration sets or IV piggyback (IVPB) sets: Before removing this equipment from the main IV tubing, wash your hands and put on gloves. Either use a needleless device or place used needles in a puncture-proof container.

5. Application of medication to mucous membranes: Wash your hands and wear gloves (see the following guidelines for using gowns, masks, and protective eyewear).

6. Applications to skin: Before applying such drug forms as transdermal patches or applying lotions, ointments, or creams, wash your hands and wear gloves.

Hands

1. With each patient/client, always wash your hands twice—before preparing medications and after administering medications. Use of an antiseptic foam or lotion is an acceptable alternative to hand-washing.

2. Wash your hands after removing your gloves, gown, mask, and protective eyewear, and wash them again before leaving any patient/client’s room where you have used them.

3. If your hands have come into contact with a patient/client’s blood or body fluids, wash them immediately.

4. Wash your hands after handling any equipment soiled with blood or body fluids.

Gloves

1. While administering medications, wear gloves for any direct (“hands-on”) contact with a patient/client’s blood, bodily fluids, or secretions.

2. Wear gloves when handling materials or equipment contaminated with blood or body fluids.

3. Whenever you use gloves, you must change them after completing procedures for each patient/client and between patients/clients.

Gowns

When administering medications, you need to wear a gown if there’s a risk that your clothing may become contaminated with a patient/client’s blood or body fluids.

Masks, Protective Eyewear, and Face Shields

1. A mask is required when you are caring for a patient/client on strict or respiratory isolation procedures.

2. Masks and protective eyewear or face shields are required when a medication procedure may cause blood or body fluids to splash directly onto your face, eyes, or mucous membranes.

3. You must wear masks and protective eyewear during any medication procedure known to cause aerosolization of fluids that contain chemicals or body fluids.

Management of Used Needles and Sharps

1. All used needles, syringes, sharps, stylets, butterfly needles, and IV catheters must be discarded in appropriate, labeled, puncture-proof containers.

2. Do not break, bend, or recap needles after using them. Immediately place needles in a puncture-proof container. If preparing the medication away from the bedside, carefully recap, if needed, to transport the medication safely.

3. Wear gloves and exercise caution when removing heparin locks, saline locks, IV catheters, and IV needles. Place them in a puncture-proof container. Never remove the IV needle from the IV tubing by hand. Instead, use either a clamp or the needle unlocking device on the sharps container. It’s best to use needleless systems or needleguard devices.

4. As you dispose of a sharp, keep your eyes on the sharps (puncture-proof) container.

Needleless Systems and Needleguard Devices

Needleless systems, used to reduce the risk of needlesticks and blood-borne pathogens, work in several ways. Some syringes have a needleguard device that retracts the needle into the syringe or a cap after it is used. Needleless adapters for syringes withdraw medication from vials (Fig. 10-6). Needleless systems are also available for IV tubing and for use at the patient/client’s IV site. All needleless equipment must be discarded into sharps containers.

Management of Materials Other Than Needles and Sharps

Paper cups, plastic cups, and other equipment not contaminated with blood or body fluids may be discarded according to routine hospital procedures. In situations that require strict or respiratory isolation precautions, follow the institution’s established protocol.

FIGURE 10-6
A. Needleless system adapter for vial. B. Use syringe (without needle) to withdraw medication. C. Needleless system for IV tubing.

Management of Nurse Exposed to Blood or Body Fluids

If a personal needlestick, an injury, or a skin laceration causes contact with the blood or blood-streaked body fluids of any patient/client, act immediately: Squeeze the area of contact if appropriate, wash the area with soap and copious amounts of water, and apply an acceptable antiseptic. If mucous membrane exposure occurs, flush the exposed areas with copious amounts of warm water. Follow the protocol established by the healthcare institution for management of needlestick injury or accidental exposure to blood or body fluids.

Routes of Administration

Oral Route

Regardless of which system you use to prepare the medications, the procedure for administering drugs requires specific steps. The oral route is the least expensive, the safest, and also the easiest to administer. For oral administration, patients/clients should have an intact gag reflex, be alert, and have a functioning gastrointestinal system.

Handwashing is re quired; wear gloves if there is any chance of touching mucous membranes.

1. Follow the six rights and three checks.

2. Use two patient/client identifiers to identify the patient/client.

3. Ask the patient/client if he or she has allergies to any drugs, or check the MAR or patient/client chart.

4. Before administering the medications, perform any necessary assessment (e.g., checking vital signs, apical rate, or site integrity).

5. Explain the procedure to the patient/client.

6. Assist the patient/client to a sitting position.

7. Give oral solids first, along with a full glass of water whenever possible (unless contraindicated). Then give oral liquid medications.

8. Watch to be sure the patient/client has swallowed all of the drugs.

9. Discard paper/plastic cups according to hospital procedure.

10. Make the patient/client comfortable, wash your hands, and chart the medications given.

Special Considerations for Oral Administration

SOLIDS

• Some drugs are best taken on an empty stomach; others may be taken with food. Check a drug guide to see which is needed.

• Administer irritating oral drugs along with meals or a snack (unless contraindicated) to decrease gastric irritation.

• If the patient/client is nauseated or vomiting, withhold oral medications and notify the physician/healthcare provider.

• Even if the patient/client is NPO (nothing by mouth), the patient/client may need to receive certain drugs (e.g., an anticonvulsant for a patient/client with epilepsy). Check with the doctor or healthcare provider to determine whether you can administer oral medication with a small amount of water.

• Scored tablets can be broken and have a line across the center of the tablet.

• To break a scored tablet, use clean technique. One method is to place the tablet in a paper towel, fold the towel over, and, with your thumbs and index fingers, break the tablet along the score line. You can also use commercial pill splitters.

• Do not break unscored tablets, because you can’t be certain that the drug is evenly distributed.

• Coated tablets have a coating that makes the tablets smooth and easy to swallow. Avoid crushing coated tablets unless the drug is one that can be crushed. Check a drug guide or check with a pharmacist.

• Enteric-coated tablets are meant to dissolve in the more alkaline secretions of the intestine rather than in the highly acidic stomach juices. However, enteric-coated tablets may dissolve prematurely if a patient/client is on antacids or has a disorder that decreases stomach acidity.

• Do not crush enteric-coated tablets.

• Prolonged-release or extended-release tablets dissolve more slowly and have a longer duration of action.

• Do not crush prolonged-release tablets.

• Capsules are gelatin containers that hold a drug. Usually, the capsule holds the drug because the drug could irritate the stomach lining or the stomach acidity would decrease the drug’s potency.

• Avoid opening capsules. Occasionally, a capsule may be opened and combined with a semisolid such as applesauce or custard and administered to the patient/client. Always check with the physician or healthcare provider if another form may be available.

• Do not open spansule, timespan, time release, or sustained-release capsules. These drugs are long acting and designed to be released over time.

• If the patient/client has difficulty swallowing solids, check with the physician or healthcare provider for an order for the liquid form of the medication (if available) or crush the medications (if applicable).

• If crushing a pill won’t compromise its medication, you can crush it, preferably using a commercial pill crusher. You can also crush a pill using a mortar and pestle; just make sure to clean both implements before and after crushing so no residue remains. To help a patient/client swallow the medication, you can mix a crushed drug with water or a small amount of semisolids, such as applesauce or custard.

• If the oral route is not possible, a physician or healthcare provider can order the drug parenterally (e.g., Lasix IV instead of Lasix PO).

• Lozenges are solid tablets with medication that dissolve slowly in the mouth. These may contain sugar or syrup and may be inappropriate for patients/clients with diabetes.

• Be knowledgeable about food–drug, drug–drug, and herb–drug interactions.

• When administering solid stock medications, pour them first into the container lid and then into a paper cup, using medical asepsis. Do not touch the medication. After pouring each medication into a separate cup, you can combine several solid medications into one cup. Check all unit-dose medications three times before you discard the package container.

LIQUIDS

• Shake liquid medications thoroughly before pouring; otherwise, the drug in the liquid may settle to the bottom.

• Aqueous or water-based solutions do not need to be shaken before pouring.

• Some liquid medications require dilution. Check references for directions.

• Some liquids may have to be administered through a straw. Liquid iron preparations, for example, cause discoloring and should not come in contact with teeth.

• Pour liquids at eye level, using a medicine cup. Then place them on a flat surface to accurately measure the dose. Measure at the center of the meniscus, which is the lower curve of the liquid in the cup. To keep from spilling the medication onto the label (which could make it unreadable), pour with the label up.

• Never return any poured drug to a stock bottle once the drug has been taken from the preparation room.

• Never combine medications from two stock bottles. It is the responsibility of the pharmacist to combine drugs.

• Check drug references to determine how to disguise liquids that are distasteful or irritating. Mixing them in other liquids, such as juice, is often done unless contraindicated.

• After the patient/client has taken a liquid antacid, add 5 to 10 mL water to the cup, mix, and have the patient/client drink it as well. Because antacids are thick, some medication often remains in the cup.

• The nurse who pours medications is responsible for administering and charting. Do not give drugs that another nurse has poured.

• Syrups are solutions of sugar in water, which may disguise the medication’s unpleasant taste. Because of the sugar, syrups may be contraindicated for patients/clients with diabetes.

• Elixirs are hydroalcoholic liquids that are sweetened. These may be contraindicated for patients/clients with diabetes or a history of alcoholism.

• Fluid extracts and tinctures are alcoholic, liquid concentrations of a drug. Because these are very potent, they are ordered in small amounts. Tinctures are ordered in drops. Fluid extracts are the most concentrated of all liquids. The average dose of a fluid extract is 2 tsp or less.

• Solutions are clear liquids that contain a drug dissolved in water.

• A suspension consists of solid particles of a drug dispersed in a liquid. Be sure to shake the bottle before pouring.

• Magmas—for example, milk of magnesia—contain large, bulky particles.

• Gels—for example, magnesium hydroxide gel—contain small particles.

• Emulsions are creamy, white suspensions of fats or oils in an agent that reduces surface tension and thus makes the oil easier to swallow–for example, emulsified castor oil.

• Powders are dry, finely ground drugs, reconstituted according to directions. In liquid form, powders become oral suspensions.

• When you reconstitute a powder, write these four facts on the label: the date, the time, your initials, and the solution you made.

Nasogastric Route

When possible, obtain the medication in liquid form. Before opening capsules or crushing tablets, check with the pharmacist for alternatives. If crushing medications, crush finely so as not to clog the tube. Use either a bulb syringe or a 60-mL syringe.

First, dilute the medication with water. The fluid mixture should be at room temperature.

1. Follow the six rights and three checks.

2. Use two patient/client identifiers to identify the patient/client.

3. Ask the patient/client if he or she has allergies to any drugs, or check the MAR or patient/client chart.

4. Before administering the injection, perform any necessary assessment (e.g., checking vital signs, apical rate, or site integrity).

5. Explain the procedure to the patient/client.

6. Elevate the head of the bed to 30 degrees.

7. Put on your gloves and insert the syringe into the tube.

8. To check the position of the tube in the stomach, place a stethoscope on the stomach and insert about 15 mL of air. If you hear a swishing sound, the tube is in the proper place.

9. Aspirate the stomach’s contents. If the patient/client has been receiving tube feedings, check institutional policy regarding residual aspirate.

10. You can also test the stomach contents for acidity by using pH paper, if available. The reasoning is that the pH paper will test more acidic, confirming placement in the stomach’s acidic environment. Research supports this method, although many institutions do not have pH paper readily available on the nursing unit. One good Web site supporting this method is http://enw.org/Research-NGT.htm

11. Close off the tube by bending it back on itself (Fig. 10-7). Holding the syringe and bent tube in your nondominant hand, remove the bulb or plunger and leave the syringe in place.

12. Flush the tube with at least 30 mL of water to ensure patency (Fig. 10-8). Release the closing off of the tube; gravity will cause the water to flow in.

FIGURE 10-7
Bend the tube back on itself to close the tube. (From Taylor, C. [2008]. Fundamentals of nursing [6th ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 1473.)

FIGURE 10-8
Flush the tube with at least 30 mL of water. (From Taylor, C. [2008]. Fundamentals of nursing [6th ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 1473.)

FIGURE 10-9
Pour the medication into the syringe. (From Taylor, C. [2008]. Fundamentals of nursing [6th ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 1470.)

13. Pour the medication into the syringe (Fig. 10-9). As in step 12, gravity will cause the medication to flow in. Occasionally, you may apply slight pressure with the plunger of the syringe.

14. If the patient/client shows discomfort, stop the procedure and wait until he or she appears relaxed.

15. Before all of the medication flows in, flush the tube by adding at least 30 mL of water to the syringe (see Fig. 10-8).

16. Shut the tube by bending it back on itself before the syringe completely empties.

17. Remove the syringe and either clamp the tube or restart tube feedings.

18. If possible, leave the head of the bed elevated at least 30 minutes to 1 hour.

19. Make the patient/client comfortable, wash your hands, and chart the medications given.

Parenteral Route

General Guidelines

You can give medications by IM (intramuscular), subcutaneous, IV, IVPB, IVP (IV push), or intradermal routes. Use the parenteral route when a patient/client cannot take the drug orally, when you want to obtain a rapid systemic effect, or when the oral route would destroy a drug or render it ineffective. With parenteral routes, use aseptic technique.

Syringes for Injection

The most common syringe used for injections is a standard 3-mL size, marked in minims and in milli-liters to the nearest tenth. The precision (tuberculin) syringe is marked in half-minims and milliliters to the nearest hundredth. There are two insulin syringes (insulin is only given in an insulin syringe): a regular 1-mL size marked to 100 units and a 0.5-mL size (low dose) marked to 50 units.

Needles for Injections

Each of the four syringes described above has a different injection needle.

FIGURE 10-10
When choosing a needle, the nurse must consider the needle gauge, bevel, and length. Gauge refers to the inside diameter of the needle; the smaller the gauge, the larger the diameter. Bevel refers to the angle at which the needle tip is opened, and length is the distance from the tip to the hub of the needle.

The term gauge (G) indicates the needle’s diameter or width. The higher the gauge number, the finer or smaller the needle’s diameter. In the gauges directly above, the low-dose insulin syringe needle has the smallest diameter (28 gauge), which makes it the finest needle in this group.

The length of the needle you use depends on the route of injection. For deep IM injections, you use a long needle. For subcutaneous injections, you use a short needle. Gauge numbers 23, 25, 26, and 28 in inch length are used in subcutaneous injections for adults and in IM injections for children and emaciated patients/clients. Numbers 20, 22 and 23 in 1 and 1½ inch lengths are used for IM injections; 20 and 21 in 1 to 2 inch lengths are for IV therapy and very viscous liquids in IM injections; and 14, 16 and 18 in 1 to 2 inch lengths are for blood transfusions.

Choosing which type of needle to use for an adult or a child depends on three factors: the route of administration, the size and condition of the patient/client, and the amount of adipose tissue present at the site (Fig. 10-10). Most hospitals use needleless systems to draw up parenteral medications and for IV therapy. This helps to prevent accidental needle sticks. IM, subcutaneous, and intradermal injections are given with the technique illustrated in Figure 10-11.

FIGURE 10-11
An injection is administered with a quick, dartlike motion into taut skin that has been spread or bunched together.

FIGURE 10-12
Comparison of angles of intersection for IM, subcutaneous, and intradermal injections.

Angle of Insertion

INTRAMUSCULAR. For an IM injection, hold the syringe at a right angle to the skin. Give the injection at a 90-degree angle (Fig. 10-12). IM sites have a good blood supply, and absorption is rapid.

SUBCUTANEOUS. For subcutaneous injections, hold the syringe at a 45-degree angle, with the opening or beveled edge up, when you insert the needle. You can administer some subcutaneous injections at a 90-degree angle if the subcutaneous layer of fat is thick and the needle is short. Be careful to reach the correct site. When in doubt, use the 45-degree angle. Subcutaneous sites have a poor blood supply, and absorption is prolonged (see Fig. 10-12).

INTRADERMAL. If you’re doing skin testing for allergies and tuberculosis, use a 25 G or other fine needle. Hold the syringe at a 15-degree angle with the opening or beveled edge up (see Fig. 10-12).

Preparing Parenteral Medications

Handwashing is required.

DRUGS THAT ARE LIQUIDS IN VIALS

1. Clean the top of the vial with an alcohol pad.

2. Draw up into the syringe an amount of air equivalent to the desired amount of solution.

3. Inject the needle (or needleless device) through the rubber diaphragm into the vial. Some institutions require use of a filter needle, which prevents large particles from entering the syringe.

FIGURE 10-13
A. Inject air into the vial. B. Invert the vial, hold it at eye level, and draw up the desired amount of medication into the syringe. (From Lynn, P. [2011]. Taylor’s clinical nursing skills: A nursing process approach [3rd ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 173.)

4. Expel air from the syringe into the vial (Fig. 10-13A). This increases the pressure in the vial and makes it easier to withdraw medication.

5. Invert the vial, hold it at eye level, and draw up the desired amount of medication into the syringe (Fig. 10-13B).

6. Withdraw the needle or needleless device quickly from the vial. Remove the device or needle, and attach the appropriate needle to the syringe for administration.

DRUGS THAT ARE POWDERS IN VIALS

1. Clean the top of the vial with an alcohol pad.

2. Draw up the amount of calculated diluent from a vial of distilled water or normal saline for injection. If a different diluent is indicated, follow pharmaceutical directions.

3. Add the diluent to the powder, and roll the vial between your hands to make the powder dissolve. Then, label the vial with the solution made, your initials, and the date and time.

4. Clean the top of the vial again.

5. Draw up into the syringe an amount of air equivalent to the amount of solution desired.

6. Inject the needle or needleless device through the rubber diaphragm into the vial. Some institutions require use of a filter needle, which prevents large particles from entering the syringe.

7. Expel the air into the vial. This increases pressure in the vial and makes it easier to remove medication.

8. Invert the vial, hold it at eye level, and draw up the desired amount of medication into the syringe.

9. Withdraw the needle or needleless device quickly from the vial. Remove the device or needle, and attach the appropriate needle to the syringe for administration.

10. Check the directions for storing any remaining drug.

Note: When the whole amount of powder contained in a vial is needed for an IVPB medication, you can use a reconstitution device as a way of diluting the powder without a syringe.

FIGURE 10-14
A. Withdrawing medication from an upright ampule. B. Withdrawing medication from an inverted ampule. (From Lynn, P. [2011]. Taylor’s clinical nursing skills: A nursing process approach [3rd ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 170.)

DRUGS IN GLASS AMPULES

1. Tap the top of the ampule with your finger to clear out any drug.

2. Place an unopened alcohol pad or small gauze pad around the neck of the ampule.

3. Hold the ampule sideways.

4. Place your thumbs above the ampule neck and your index fingers below it.

5. Press down with your thumbs to break the ampule, snapping the tip away from one’s self.

6. Place the ampule on a flat surface, insert the tip of the needle into the ampule, and withdraw fluid (Fig. 10-14A) or invert the ampule, hold it at eye level, insert the syringe needle or needleless device, and withdraw the dose (Fig. 10-14B). Some institutions require use of a filter needle, which prevents large particles from entering the syringe. Important: Do not add air before removing the dose, because if you do, medication will spray from the ampule.

7. Withdraw the needle or needleless device from the ampule. Remove the device or needle, and attach the appropriate needle to the syringe for administration.

UNIT-DOSE CARTRIDGE AND HOLDER

1. Insert the cartridge into the metal or plastic holder, and screw it into place (see Figure 3-10, Chapter 3).

2. Move the plunger forward until it engages the shaft of the cartridge.

3. Twist the plunger until it is locked into the cartridge.

4. The holder is reusable, but the cartridge is not. Place the cartridge in a sharps container after use. (See www.hospira.com/products/CarpujectSyringeSystem.aspx for animation of preparing an unit-dose cartridge.)

UNIT-DOSE PREFILLED SYRINGES

1. The medication is already in the syringe (see Fig. 3-9, Chapter 3).

2. Some prefilled syringes are simple and require no action other than removing the needle cover; others are packaged for compactness and include directions for preparing the syringe for use.

3. These prefilled syringes are disposable.

MIXING TWO MEDICATIONS IN ONE SYRINGE

General Principles

1. Consult a standard reference to determine that the drugs are compatible.

2. When in doubt about compatibility, prepare medications separately and administer them into different injection sites.

3. When medications are in both a vial and an ampule, draw up the medication from the vial first.

4. When you’re preparing two types of insulin in one syringe, first draw into the syringe the vial containing regular insulin. (Regular insulin has not been adulterated with protein as have other insulins such as protamine zinc insulin.)

Method

1. Clean both vials with an alcohol pad.

2. Choose one vial as the primary. Example: With vials of a narcotic and a nonnarcotic, the narcotic is the primary. With two insulins, regular insulin is the primary.

3. Inject air into the second vial in an amount equaling the medication to be withdrawn. Do not let the needle touch the medication.

4. Inject air into the primary vial in an amount equaling the medication to be withdrawn, then withdraw the medication in the usual way. Some institutions require use of a filter needle, which prevents large particles from entering the syringe. Make sure there are no air bubbles.

5. Insert the needle or needleless device into the second vial. Don’t touch the plunger, because if you do, you might push the primary medication into the second vial.

6. Slowly withdraw the needed amount of drug from the second vial. The two medications are now combined.

7. Remove the needle or needleless device from the second vial. Remove the device or needle, and attach the appropriate needle to the syringe for administration. Note: Some authorities suggest changing the needle after withdrawing medication from the primary vial. Such a change may result in air bubbles, so to obtain an accurate dose, be careful when you withdraw the second medication.

Choosing the Site for Intradermal, Intramuscular, or Subcutaneous Injections

Avoid the following areas for injections: bony prominences, large blood vessels, nerves, sensitive areas, bruises, hardened areas, abrasions, and inflamed areas; areas contraindicated from previous medical procedures, such as mastectomies, renal shunts, and grafts; and areas with recent medical procedures (i.e., scars and incision lines). The site for IM injections should be able to accept 2 mL; if you’re giving repeated injections, rotate sites.

Identifying the Injection Site—Adults

INTRAMUSCULAR. Common sites are the dorsogluteal, the ventrogluteal, the vastus lateralis, and the deltoid muscles.

Dorsogluteal Site. The thick gluteal muscles of the buttocks (the dorsogluteal site has been associated with possible injury due to the proximity of the sciatic nerve. Also extensive subcutaneous tissue at this site may cause the IM injection to actually be in the subcutaneous tissue. Follow your institutional policy regarding this injection site for IM injections).

Patient/Client’s Position. Either prone or lying on the side, with both buttocks fully exposed.

FIGURE 10-15
A. Identification of the dorsogluteal site using a diagonal between the bony prominences. B. Locating the exact site.

Method:

• Choose the area very carefully to avoid striking the sciatic nerve, major blood vessels, or bone.

• The landmarks of the buttocks are the crest of the posterior ilium as the superior boundary and the inferior gluteal fold as the lower boundary.

• You can identify the exact site in either of these two ways:

1. Diagonal landmark (Fig. 10-15):

• Find the posterior superior iliac spine and the greater trochanter of the femur.

• Draw an imaginary diagonal line between these two points, and give the injection lateral and superior to that line, 1 to 2 inches below the iliac crest (to avoid hitting the iliac bone).

• If you hit the bone, withdraw the needle slightly and continue the procedure.

• This is the preferred method because all of the landmarks are bony prominences.

2. Quadrant landmark (Fig. 10-16):

• Divide the buttocks into imaginary quadrants.

• Your vertical line extends from the crest of the ilium to the gluteal fold.

• Your horizontal line extends from the medial fold of the buttock to the lateral aspect of the buttock.

• Next, locate the upper aspect of the upper outer quadrant.

• Give the injection in this area, 1 to 2 inches below the crest of the ilium (to avoid hitting bone). To select the precise site, palpate the crest of the ilium.

• If you hit the bone when injecting, withdraw the needle slightly and continue the procedure.

Ventrogluteal Site. The ventral part of the gluteal muscle, which has no large nerves or blood vessels and less fat. This site is the safest because of those reasons.

Patient/Client’s Position. Either supine, lying on the side, sitting, or standing

FIGURE 10-16
A. Identification of the dorsogluteal injection site using quadrants. Draw an imaginary line from the iliac crest to the gluteal fold and from the medial to the lateral buttock. B. The “x” indicates the injection area.

Method:

• Find the greater trochanter, the anterior superior iliac spine, and the iliac crest.

• Stand by the patient/client’s knee.

• Use the hand opposite to the patient/client’s leg (i.e., left leg, right hand).

• Then place the palm of your hand on the greater trochanter.

• Point your index finger toward the anterior superior iliac spine, and point your middle finger toward the iliac crest.

• The injection site lies in the center of the triangle, between your middle finger and index finger (Fig. 10-17).

FIGURE 10-17
A. The ventrogluteal site for IM injections; the “x” indicates the injection site. B. Locating the exact site. Note the hand used is opposite to the patient/client’s leg: right hand on left leg. (From Evans-Smith, P. [2005]. Lippincott’s atlas of medication administration [2nd ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 31.)

FIGURE 10-18
A. Vastus lateralis injection site. B. Locating the site. The “x” indicates the injection site.

Vastus Lateralis Site. The lateral thigh

Patient/client’s position. Either supine, lying on the side, or standing

Method:

• Measure one hand’s width below the greater trochanter and one hand’s width above the knee (Fig. 10-18).

• Ask the patient/client to point the big toe to the center of his or her body, an action that relaxes the vastus muscle.

• Give the injection in the lateral thigh.

Deltoid Site. The upper arm, at the deltoid, a small muscle close to the radial and brachial arteries. Use this site for IM injections only if specifically ordered, and inject no more than 2 mL of medication.

Patient/Client’s Position. Either sitting or lying down

Method:

• The boundaries are the lower edge of the acromion process (shoulder bone) and the axilla (armpit) (Fig. 10-19).

• Give the injection into the lateral arm between these two points, about 2 inches below the acromion process.

FIGURE 10-19
The deltoid muscle site for IM injections. The “x” indicates the injection site.

SUBCUTANEOUS SITES. Commonly, the upper arms, anterior thighs, lower abdomen, and upper back (Fig. 10-20). Insulin subcutaneous is administered in the arm, lower abdomen, and thigh. Heparin subcutaneous is given in the lower abdomen.

Method:

• To avoid reaching muscle, give the injection at a 45-degree angle.

• You can give subcutaneous injections at a 90-degree angle if the subcutaneous layer of fat is thick. Diabetic patients/clients usually give their insulin only at the 90-degree angle.

• Inject no more than 1 mL of medication.

FIGURE 10-20
Sites for subcutaneous injection. The deltoid muscle may be used for subcutaneous injections, or, when ordered, for small IM injections. (From Lynn, P. [2011]. Taylor’s clinical nursing skills: A nursing process approach [3rd ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 184.)

INTRADERMAL (INTRACUTANEOUS) SITE. Typically, the inner aspect of the forearm. The intradermal site is used for skin testing for allergies and diseases such as tuberculosis. Intradermal skin testing requires follow-up evaluations to determine if the skin test is positive. Injecting an antigen causes an antigen–antibody sensitivity reaction if the individual is susceptible. If the test is positive, the area will become raised, warm, and reddened.

Identifying the Injection Site—Children

The site for the IM injection in a child depends on the child’s age, the child’s size, and the volume and density of medication being administered. Infants cannot tolerate volumes greater than 0.5 mL in a single site. Older infants or small children can tolerate 1 mL in a single site. Needle gauges range from 21G to 25G; 27G is often used with newborns and premature infants.

The preferred site for infants is the vastus lateralis muscle (Fig. 10-21). Give the medication on the lateral aspect of the anterior thigh. After the child has been walking for more than a year, you can use the dorsogluteal site; usually, however, that site is not recommended for children less than 5 years old. For the older child and adolescent, you can use the same injection sites as for adults.

Administering Injections

Basic Guidelines for All Injections

Handwashing and gloves are required.

1. Follow the six rights and three checks.

2. Use two patient/client identifiers to identify the patient/client.

3. Ask the patient/client if he or she has allergies to any drugs, or check the MAR or patient/client chart.

4. Before administering the injection, perform any necessary assessment (e.g., checking vital signs, apical rate, or site integrity).

FIGURE 10-21
A. For infants under walking age, use the vastus lateralis muscle for IM injections. B. Technique for administering an IM injection to an infant. Note the way the nurse uses their body to restrain and stabilize the infant. (From Pillitteri, A. [2002]. Maternal and child health nursing [4th ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 1102.)

5. Explain the procedure to the patient/client.

6. Ask the patient/client where the last injection was given. Choose a different site, because the sites should be rotated.

7. Clean the area with an alcohol pad, using a circular motion from the center out. Allow to dry.

8. Place the alcohol pad between your fingers or lay it on the patient/client’s skin above the site.

INTRAMUSCULAR INJECTIONS

Follow steps 1–8 above, then:

9. After drawing up the dose, remove the needle cover.

10. Make the skin taut by mounding the tissue between your thumb and index finger or by spreading the tissue firmly.

11. Dart the needle in quickly (Fig. 10-22A).

12. Hold the barrel with your nondominant hand, and with your dominant hand pull the plunger back. This action, called aspiration, makes sure the needle is not in a blood vessel (Fig. 10-22B).

13. If blood enters the syringe, withdraw the needle, discard both the needle and the syringe into a sharps container, and prepare another injection.

14. If no blood is aspirated, inject the medication slowly (Fig. 10-22C).

15. Remove the needle quickly.

FIGURE 10-22
A. Dart the needle into the skin. B. Aspirate slowly. C. Inject medication slowly.

16. To inhibit bleeding, press down on the area with the alcohol pad or a dry gauze pad.

17. Do not recap the needle. Dispose of the needle and syringe in a sharps container. Make the patient/client comfortable, wash your hands, and chart the medication, documenting the site of injection.

Subcutaneous Heparin (or Low Molecular Weight Heparin Such as Lovenox)

A heparin injection indicates several changes in routine injection technique. Because heparin and Lovenox (enoxaparin) are anticoagulants, you must take care to minimize tissue trauma; slow bleeding at the site of the injection can cause bruising. Give the injection with a fine (25G) ½-inch needle into the lower abdominal fold, at least 2 inches from the umbilicus.

Follow steps 1–8 above, then:

9. After drawing up the dose, change the needle to prevent leakage along the tract. (For Lovenox injections, the dose comes premixed with an air bubble in the prefilled syringe. Do not expel the air bubble before administration.)

10. With your nondominant hand, bunch (pinch) the tissue to a depth of at least 1/2 inch. If the area is obese, you can spread the skin rather than pinching it together.

11. Inject the needle at a 90-degree angle.

12. To minimize tissue damage, do not aspirate.

13. Inject the medication slowly.

14. Remove the needle quickly.

15. Do not massage the area. If the site bleeds, apply pressure with a dry gauze pad or alcohol pad for 1 to 2 minutes.

16. Do not recap the needle. Dispose of the needle and syringe in a sharps container. Make the patient/client comfortable, wash your hands, and chart the medication, documenting the site of injection.

Subcutaneous Insulin

Insulin is administered with a special insulin syringe, measured in 100 units or 50 units (low-dose insulin syringe). Figure 10-20 shows the sites for insulin injection.

Follow steps 1–8 above, then:

9. Draw up the ordered dose in the correct insulin syringe. If you’re mixing two insulins, follow the correct procedure (see p. 146–147).

10. With another nurse, double-check the dose in the insulin syringe.

11. With your nondominant hand, bunch (pinch) the tissue to a depth of at least ½ inch. If the area is obese, you can spread the skin rather than pinching it together.

12. Inject the needle at a 45- or 90-degree angle.

13. To minimize tissue damage, do not aspirate.

14. Inject the medication slowly.

15. Remove the needle quickly.

16. Do not massage the area. If the site bleeds, apply pressure with a dry gauze pad or alcohol pad for 1 to 2 minutes.

17. Do not recap the needle. Dispose of the needle and syringe in a sharps container. Make the patient/client comfortable, wash your hands, and chart the medication, documenting the site of injection.

You can also administer insulin with a prefilled insulin pen or insulin device. The pen or insulin device has a needle attached for each injection, and a dial on the pen or insulin device measures the correct insulin dose. The technique matches the one described above, but you must hold the device for 6 to 10 seconds before removing it from the skin. Dispose of the needle in a sharps container.

To administer insulin continuously by the subcutaneous route, use an insulin pump, typically near the abdominal area of the patient/client. The pump’s preset rate delivers the insulin via tubing through a needle inserted in the subcutaneous tissue. You can adjust the settings according to the patient/client’s insulin needs. Change the sites every 2 to 3 days or as needed.

Intradermal Skin Testing

Follow steps 1–8 above, then:

9. Draw up the ordered dose in a 1-mL syringe.

10. Place your nondominant hand around the arm from below, and pull the skin tightly to make the forearm tissue taut. Hold the syringe in your four fingers and thumb, with the bevel (opening) of the needle up.

11. Then insert the needle about 1/8 inch, almost parallel to the skin (Fig. 10-23A). You will be able to see the needle under the skin. Inject the solution so that it raises a small wheal (a raised bump or a blister) (Fig. 10-23B).

12. Afterward, remove the needle and allow the injection site to dry.

13. Do not massage the skin.

14. Do not recap the needle. Dispose of the needle and syringe in a sharps container. Make the patient/client comfortable, wash your hands, and chart the medication, documenting the site of injection.

Z-Track Technique for Intramuscular Injections

Some medications, such as Imferon (iron dextran) and Vistaril (hydroxyzine), are irritating to the tissues and can stain the skin. The Z-track method, used at the dorsogluteal or ventrogluteal site, can prevent medication from leaking from the tissue onto the skin.

Follow steps 1–8 above, then:

9. After preparing the medication, change the needle to prevent leakage along the tract.

10. Add 0.2 mL of air to the syringe. As the medication is injected, the air will rise to the top of the syringe and will be administered last—thus sealing off the medication and preventing it from leaking onto the skin.

FIGURE 10-23
A. Inserting the needle almost level with the skin. B. Observing for wheal while injecting medication. (From Lynn, P. [2011]. Taylor’s clinical nursing skills: A nursing process approach [3rd ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 182.)

FIGURE 10-24
Z-track technique—dorsogluteal site. The tissue is retracted to one side and held there until the injection is given. When the hand is removed, the tissue closes over the injection tract, preventing medication from rising to the surface.

11. Clean the area with an alcohol pad, using a circular motion from the center out. Allow to dry.

12. Place the alcohol pad between your fingers or lay it on the patient/client’s skin above the site.

13. Use the fingers on your nondominant hand to retract the tissue to the side. Hold this position during the injection (Fig. 10-24).

14. Inject at a 90-degree angle, as usual. Before giving this injection, be sure to aspirate (Fig. 10-25).

15. After giving the injection, count 10 seconds.

16. Then remove the needle quickly.

17. Remove the hand that has been retracting the tissue.

18. Do not massage the site.

19. Using an alcohol pad or dry gauze pad, press down on the site to inhibit bleeding.

20. Do not recap the needle. Dispose of the needle and syringe in a sharps container. Make the patient/client comfortable, wash your hands, and chart the medication, documenting the site of injection.

FIGURE 10-25
Displacing tissue in a Z-track manner and darting needle into tissue.

IV Administration

Handwashing and gloves are required.

IV drugs may be given in a number of ways: continuous IV infusion, secondary or piggyback IV infusion (IVPB), IVP (IV push) (slow or fast), and flushing of an IV saline lock (sometimes called heplock or heparin lock, although heparin is not used to flush peripheral IVs) or INT (intermittent needle therapy). Because IV medications introduce the drug directly into the bloodstream—thus having an immediate effect—you must follow strict asepsis technique.

Several types of IV needles are appropriate for inserting into a vein. The most common is the cathlon or “over the needle,” in which a plastic catheter covers the needle. After inserting the needle in the vein, you withdraw the needle and the plastic catheter stays in place for a specified amount of time.

Usually, IV needles are inserted in the hand or forearm (Fig. 10-26). For long-term IV therapy, however, you can insert a central venous catheter (Fig. 10-27) or use a peripherally inserted central catheter (PICC) (Fig. 10-28). Information on IV calculations is found in Chapters 6 and 7.

FIGURE 10-26
Infusion sites available in the hand or forearm. (From Taylor, C. [2008]. Fundamentals of nursing [6th ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 1709.)

FIGURE 10-27
Triple lumen central venous catheter (TLC or CVC). (From Taylor, C. [2008]. Fundamentals of nursing [6th ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 1708.)

FIGURE 10-28
Peripherally inserted central catheter (PICC). (From Taylor, C. [2008]. Fundamentals of nursing [6th ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 1706.)

Basic guidelines regarding peripheral IV therapy:

1. Use aseptic technique for insertion of the IV needle.

2. Use an occlusive dressing to secure the IV needle. Most healthcare settings use a clear plastic dressing over the IV needle site so that constant monitoring of the site can occur.

3. Verify IV fluid and IV medication orders before administration. Calculate the correct dose. Check an approved compatibility guide to determine the compatibility of IV fluids and IV medications. Flush the IV tubing between administrations of incompatible solutions. IVP drugs may or may not need to be diluted prior to administration. IVP drugs also vary as to how “fast” to push the drug. Consult institutional policy and drug handbooks.

4. Infuse IV fluids and IV medications according to policy and procedures of the institution. Use an infusion pump if available.

5. Monitor and assess the IV site frequently and according to institutional guidelines. Monitor the IV site for swelling, color, temperature, and pain.

6. Follow institutional guidelines for changing the IV site, changing the IV fluids, and changing the IV tubing. Generally, a peripheral IV site is changed every 72 hours, IV fluids every 24 hours, and IV tubing every 72 to 96 hours.

For further information about IV insertion and IV medication administration, consult a nursing pharmacology textbook, IV therapy textbook, or nursing fundamentals textbook.

Application to Skin and Mucous Membranes

Topical drug preparations have two purposes: to cause a local effect or to act systematically. To create a systemic effect, the drug must be absorbed into the circulation.

Follow these steps for all medications:

Handwashing and gloves are required.

1. Follow the six rights and three checks.

2. Use two patient/client identifiers to identify the patient/client.

3. Ask the patient/client if he or she has allergies to any drugs, or check the MAR or patient/client chart.

4. Before administering the injection, perform any necessary assessment (e.g., checking vital signs, apical rate, or site integrity).

5. Explain the procedure to the patient/client.

Ear Drops

Follow steps 1–5 above, then:

6. The ear drops, labeled either “otic” or “auric,” should be warmed to body temperature.

7. Help the patient/client into a comfortable position: either sitting upright, head tilted toward the unaffected side, or lying on the side with the affected ear up.

8. With a dropper, draw the medication into the dropper.

9. Straighten the ear canal by pulling the pinna up and back (for an adult) or down and back (for a child 3 years or younger (Fig. 10-29).

10. Placing the tip of the dropper at the opening of the canal, instill the medication into the canal (Fig. 10-30).

11. The patient/client should then rest on the unaffected side for 10 to 15 minutes. If the patient/client wishes, place a cotton ball in the canal.

12. To prevent cross-contamination, the patient/client should have his or her own medication container.

13. Make sure the patient/client is comfortable, dispose of your gloves, and then wash your hands and chart the medication.

FIGURE 10-29
Technique for administering eardrops in children under 3 years old. (From Lynn, P. [2011]. Taylor’s clinical nursing skills: A nursing process approach [3rd ed.]. Philadelphia, PA: Lippincott Williams & Wilkins, p. 244.)

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