Photo Atlas of Medication Administration 2009

Transcription

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PamelaEvans-Smith,
ClinicalNursingInstructor
of Missouri
University
ColumbiaMissouri
LIpplNcorr Vl u-l,ttvtsI M LKINS
A WoltersKluwerComPanY
. NewYork. London
. Baltimore
Philadelphia
Aires. HongKong. Sydney. Tokyo
Buenos
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L i p p i n c o t t ' sP h o r o A t l a so f M e d i c a t i o nA d m i n i s r r a r i o n2, e
MgdiCatiOn
adm in istratiOl'l i5 auasic
nursing
function
thatinvolves
skill-
ful technique and considerationof the patient's development and safety. The nurse administering medications needsa knowledge baseabout drugs, including drug names,preparations,
classifications,adverseeffects, and physiologic factors that affect drug action.
The nursing processcan be applied to the fundamental nursing skill of medication administration. Assessmentincludes a comprehensivemedication history as well as ongoing assessmentsof the patient's responseduring and after drug therapy.Nursing diagnosesare developed
from the assessmentdata.Patient-centeredoutcomesare evaluatedafter implementationof the
plan ofcare, tailoredto the patient'sneeds.
This chapterwill cover skills that the nurse needsto safely administer medicationsvia several routes. Pleaselook over the summary boxes in the beginning of this chapter for a quick
review of critical knowledge to assistyou in understandingthe skills related to medication
administration.
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BoX1 FiveRightsof Administration
To preventmedicationerror5alwayscheckthe FiveRights
of MedicationAdministrarion:
1 . Rightpatient
2. Rightmedication
3. Rightdosage
4. Rightroute
5. Righttime
BoX2 ClarifyingOrders
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BOX3 Know Your Medications
Beforeadministeringany unfamiliarmedications,know
the following:
Mode of action and purposeof medication(making
surethat thismedicationisappropriatefor rhepatient's
diagnosis)
Sideeffectsof and contraindications
for medication
Antagonistof medication
Safedosagerangefor medication
Interactions
with other medications
Precautions
to takeprior ro administration
Properadministrationtechnique
Another way to preventmedicationerrorsis alwaysto
clariff a medicationorderrhat is:
. lllegible
. Incomplete
. Incorrectroute or dosage
. Not expectedfor patient'scurrentdiagnosis
.
rt
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i aox + Needle/Syringe
SelectionTechnique
. When lookingar a needlepackagethe first numberis the
gaugeor diamererof the needle(eg 18,20)and rhesecond
numberisthe lengthin inches(eg1,l1/r).
. As the gaugenumberbecomeslarger,the sizeof the needle
becomessmaller:for instance,a24-gauge
needleis smaller
thanan 18-gauge
needle.
. Whengivingan injection,the viscosiry
of the medicationdirectsthe choiceof gauge(diameter).A thickermedicarion
suchasa hormoneisgiventhrougha biggerneedle,suchas
a 20gauge.A thinner-consistency
medication,
suchasmorphine,isgivenrhrougha smallerneedle,suchas a24 gauge.
. The lengthof the needleis directedby the sizeof the patient,the selectedinsertionsite,and the tissueyou arerrying to reach.An inrramuscular
injectionin an emaciated
personwould requirea shorterneedlethan the sameinjectionin an obesepatient.
. Generally,
all/r" needleis sufficientfor an intramuscurar
injectionin an adult and a 1" needleis sufficientfor a
child.A 7r" Eo 1" needleis generallyusedfor subcutaneousinjections.
. Thesizeof the syringeisdirectedby the amountof medication to be given.lf rhe amountis lessthan 1 ml usea 1-mL
syringeto administerthe medicadon.
In a 1-mLsyringethe
amountof medicationmay be roundedto the 100thdecimal place.In syringeslargerthan 1 mL, rhe amount is
roundedto the 1Othdecimalplace.lf rhe amountof medicationto be administered
is lessthan 3 mL,usea 3-mLsy,
ringe.lf the amountof medicationisequalto the sizeof the
syringe(eg 1 mL and usinga 1-mLsyringe),
you maygo up
to the next sizesyringeto preventawkwardmovements
whendeployingthe plunger.
. Whenadministering
insulin,the sizeof syringeandstrength
of insulinshouldcoincide.
U50insulinshouldbe administeredwith a syringecalibratedfor U50 insulinto prevenr
medicationerrors.
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SelectionTechnique(continued)
i aox + Needle/Syringe
Needlepackage
showingfirst
number(gauge
ordiameterofneedle)
andsecond
number(lengthoftheneedle
in inches).
needle.
needleandan18-gauge
a24-gauge
Differentneedlesizes:
Injections
BOX5 Subcutaneous
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Subcutaneousinjectionsshould contain no more than
1 mL of ffuidin one insertionsite.
injection
Thenormalanglefor insertionfor a subcutaneous
is45 to 90 degrees.
Thisangledependson the lengthofthe
needleand the amount of adiposetissuethe patient has.
An emaciatedpatientwould probablyrequirea 45-degree
angleof insertion,while an obesepatientmay requirea
angle.
90-degree
. Subcutaneous
injectionsitesinclude:
. Outer aspectof upperarm
. Abdomen
. Anterioraspectsof thigh
. Upperback
. Upperventralor dorsogluteal
area
. Insertionsiteselectiondependson patient'spreference,
nurse'spreference,
and type of medicationto be administered.
tissue
Subcutaneous
Skin
and
subcutaneous,
of insertionfor intnmuscular,
of theangles
Comparison
injections.
intradermal
conunues
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BOX5 Subcutaneouslnjections (continued)
Subcutaneous
injection
sites.
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'
n c ) x( ;l n t r a mu scu l a rS i teS e l e ction
injections
shouldcontainno morethan3 to
Intramuscular
the
thesmaller
the musclebeinginjected,
5 mL.Thesmaller
a m o u n ts h o u l db e .
injection
Thenormalangleof insertion
foran intramuscular
is72to 90 degrees.
Thisangledepends
on the lengthof the
needleand the amountof adiposetissuethe patienthas
(seeBox3).
injectionsitesinclude:
lntramuscular
. Vastuslateralis
. Ventrogluteal
. Deltoid
. Dorsogluteal
. lnsertionsiteselection
dependson:
. Amountof medication
. Viscosity
of medication
. Ageof patient/development
of muscletissue
. Preference
ofpatientand nurse
. Abilityof patientto assume
positionneededforinjection
. Theventrogluteal
recommended
siteisthemostfrequently
the
over7 monthsold because
lM injectionsitefor patients
and
of
nerves
is
free
the
site
and
muscleiswelldeveloped
by bonylandmarks.
andeasilyidentifiable
bloodvessels
Injection
site
Anterior
supeflor
iliacspine
Femoralartery
and vein
Greater
trochanter
of femur
Sciaticnerve
Deep femoral
artery
Vastuslateralis
(Outermiddlethi
Acromionprocess
Deltoidmuscle
Clavicle
Lateralfemoral
condyle
Scapula
Deepbrachial
artery
Radialnerve
I
Axilla
site
Injection
Humerus
super
Posterior
i l i a cs p i n e
Greatertrochal
Sciaticnerve
Inrramuscular
injectionsites(A) Ventrogluteal(B) Vastuslateralis(C) Deltoidmuscle(D) Dorsogluteal
VastusIateralis
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SKILL
1
The oral route is the most commonly used route. Drugs given orally are intended for
absorptionin the stomachand small intestine.
Equipment
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ASSESSE
MN T
Assessthe patient's ability to swallow medications.If the patient cannot swallow, is NPO, or
is experiencingnauseaor vomiting, the medication should be withheld, the physician notified, and proper documentationcompleted.Assessthe patient's knowledge of the medication. If the patient has a knowledge deficit about the medication, this may be the appropriate
time to begin education about the medication. If the medication may affect the patient's vital
signs, assessthem before administration. If the medication is for pain relief, assessthe patient's pain level before and after administration.
NURSING
DIAGNOSIS
Determine related factors for the nursing diagnosesbasedon the patient's current status.
Appropriate nursing diagnosesmay include:
. Impaired Swallowing
. Risk for Aspiration
. Anxiety
. Deficient Knowledge
. Noncompliance
OUTCOME
IDENTIFICATION
AND PLANNING
The expectedoutcome to achievewhen administering an oral medication is that the patient
will swallow the medication. Other outcomesthat may be appropriateinclude the following:
the patient will not aspirate;the patient has decreasedanxiety; and the patient understands
and complies with the medication regimen.
Medication in disposablecup or oral syringe
Liquid with straw if not contraindicated
Medication cart or tray
Medication Kardex or computer-generatedMAR
IMPLEMENTATION
ACTIO N
RATIONATE
l. Gather equipment. Check each medication order
againstthe original physician's order according to
agencypolicy. Clarify any inconsistencies.Check the
patient's chart for allergies.
This comparisonhelps to identify errors that may have
occurred when orders were transcribed.The physician's
order is the legal record ofmedication orders for each
agency.
2. Know the actions, special nursing considerations,safe
doseranges,purposeofadministration, and adverse
effects of the medicationsto be administered.
This knowledge aids the nurse in evaluating the therapeutic
effect of the medication in relation to the patient's disorder and can also be used to educatethe patient about
the medication.
3' Perform hand hygiene.
Hand hygiene prevents the spreadof microorganisms.
4' Move the medication cart to the outside of the patient's
room or preparefor administration in the medication
area.
Organization facilitates error-free adminisffation and saves
trme.
5. Unlock the medication cart or drawer.
Locking of the cart or drawer safeguardseachpatient's
medication supply. Hospital accrediting organizations
require medication carts to be locked when not in use.
6. Preparemedicationsfor one patientat a time.
This preventserrors in medication administration.
7. Selectthe proper medication from the drawer or stock
and compare with the Kardex or order. Check expiration datesand perform calculationsif necessary.
Comparisonof medication to physician's order reduces
errorsin medication administration.This is the first safety
check. Verify calculationswith anothernurseif necessary.
ACTION
Action7: Comparing
medication
with Kardexor order.
a. Place unit dose-packagedmedicationsin a disposable cup. Do not openwrapperuntil at the bedside.
Keep narcotics and medicationsthat require special
nursing assessments
in a separatecontainer.
b. When removing tablets or capsulesfrom a bottle,
pour the necessarynumber into the bottle cap and
then place the tablets in a medication cup. Break
only scoredtablets,if necessary,to obtain the
proper dosage.Do not touch tablets with hands.
c. Hold liquid medication bottles with the label against
the palm. Use the appropriatemeasuringdevice
when pouring liquids, and read the amount of medication at the bottom of the meniscusat eye level.
Wipe the lip of the bottle with a paper towel.
8 . Recheckeachmedicationpackageor preparationwith
R A T IO N A L E
at eyelevel.
Action7c: Measuring
a. The label is neededfor an additional safety check. Prerequisitesto giving certain medicationsmay include assessingvital signs and checking laboratory test results.
b. Pouring medication into the cap allows for easyreturn of
excessmedication to bottle. Pouring tablets or capsules
into the nurse's hand is unsanitarv.
c. Liquid that may drip onto the label makes the label difficult to read. Accuracy is possible when the appropriate
measuringdevice is used and then read accurately.
This is a second checkto guard againsta medication error.
the order asit is poured.
9. Whenall medicationsfor one patient havebeenpre-
This is athirdcheckto ensureaccuracyand to prevent errors.
pared recheckonceagainwith the medicationorder
beforetakingthem to the patient.
10.Transport medicationsto the patient's bedsidecarefully, and keep the medicationsin sight at all times.
1 1 .Seethat the patient receivesthe medicationsat the correct time,
12. ldentifythe patientcarefully.Thereare threecorrect
ways to do this:
a. Check the name on the patient's identification band.
b. Ask the patient to statehis or her name.
Careful handling and close observationprevent accidental
or deliberatedisarrangementof medications.
Check agencypolicy, which may allow for administration
within a period of 30 minutes before or 30 minutes after
designatedtime.
Identifying the patient is the nurse's responsibility to guard
againsterror.
a. This is the most reliable method. Replacethe identification band if it is missing or inaccuratein any way.
b. This requires a responsefrom the patient, but illness and
strangesurroundingsoften causepatientsto be confused.
continues
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ACTION
Action 12a: Checking
patientidentity.
c. Verify the patient's identification with a staff
member who knows the patient.
RATIONATE
Action 16: Observingpatient swallowingmedication.
c. This is anotherway to double-checkidentity.Do not use
the name on the door or over the bed, becausethesemay
be inaccurate.
13. Completenecessary
assessments
beforeadministering
medications.Checkallergybraceletor askpatientabout
allergies.Explainthe purposeand actionof eachmedica,
tion to the patient.
Assessmentis a prerequisiteto administrationof
medications.
14. Assistthe patientto an upright or lateralposition.
Swallowing is facilitated by proper positioning. An upright
or side-lying position protects the patient from aspiration.
I 5. Administermedications:
a. Offer water or other permitted fluids with pills, capsules,tablets,and someliquid medications.
b. Ask whetherthe patientprefersto takethe medications
by hand or in a cup and one at a time or all at once.
c. If the capsuleor tablet falls to the floor, it must be
discardedand a new one administered.
d. Record any fluid intake if intake and output measurementis ordered.
a. Liquids facilitateswallowingof solid drugs.Someliquid
drugs are intended to adhereto the pharyngealarea,in
which caseliquid is not offered with the medication.
b. This encouragesthe patient's participation in taking the
medications.
c. This preventscontamination.
d. This provides for accuratedocumentation.
16. Remainwith the patientuntil eachmedicationisswallowed.Neverleavemedicationat the patient'sbedside.
Unless the nurse has seenthe patient swallow the drug, the
drug cannot be recordedas administered.The patient's
chart is a legal record.Only with a physician'sorder can
medicationsbe left at the bedside.
17. Performhand hygiene.
Hand hygiene preventsthe spreadof microorganisms.
18. Recordeachmedicationgiven on the medicationchart
or record using the required format.
Prompt recording avoids the possibility of accidentally
repeatingthe administration of the drug.
a. If the drug was refused or omitted, record this in the
appropriateareaon the medication record and notify
the physician.
b. Recordingof administrationof a narcotic may require
additional documentationon a narcoticrecord, stating
drug count and other specificinformation.
a. This verifies the reasonmedicationwas omitted and ensuresthat the physicianis awareof the patient's condition.
b. Controlled substancelaws necessitatecareful recording
of narcotic use. If a computerizedmedication station is
being used,the machine may document neededinformation upon withdrawal of the medication.
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R A T IO NA L E
ACTION
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Action 18: Documenting medication administrationon CMAR.
19. Check on the patient within 30 minutes to verify
responseto medication.
EVALUATION
U n e x p e c t e dS i t u a t i o n s
and Associated
In t e r v e n t i o n s
Action 19: Documentation.
This provides the opportunity for further documentation
and additional assessmentof effectivenessof pain relief
and adverseeffects of medications.
The expectedoutcomesare met when the patient swallowedthe medication,did not aspirate,
has decreasedanxiety, and understoodand complied with the medication
administration.
Patientfeels that medication is lodged in throat: Offer patient more fluids to drink. If
allowed, offer the patient bread or crackersto help move the medication to stomach.
It is unclear whetherpatient swallowed medication: Check in the patient's mouth, under
tongue, and between cheek and gum. Patientsmay "cheek" medicationsto avoid taking the
medication or to saveit for later use.This has been establishedwith many medications,especially antidepressantsand pain medication. Patientsrequiring suicide precautionsshould
be watched closely to ensurethat they are not "cheeking" the medication or hiding it in the
mouth; they may be trying to accumulatea large amount of medication to take all at once
in a suicide attempt. Substanceabusersmay cheek medication in order to accumulatea
large amount to take all at once so that they may feel a high from medication.
Patient vomits immediately or shortly after receiving oral medicafion.'Assessvomit, looking for pills or fragments.Do not readministermedication without notifying physician. If a
whole pill is seenand can be identified, physician may ask that medication be administered
again. If a pill is not seenor medicationscannot be identified, medication should not be
readministeredso that patient does not receive too large of a dose.
Child refusesto take oral medications.'Some medicationsmay be hidden in a small
amount of food, such as pudding or ice cream. Do not add to liquid, becausemedication
may alter the taste of liquids; if child then refusesto drink the rest of the liquid, you will
not know how much of the medication was ingested.Creativity may be neededwhen
devising ways to administer medicationsto a child. Seebelow for suggestions.
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Infant and Child
Considerations
' Special devices,such as oral syringes and calibrated nipples, are available in apharmacy
to ensureaccuratedose calculationsfor young children and infants.
' Some creative ways to administer medicationsto children include: have a "tea party" with
medicine cups; place syringe (without needle)or dropper in the spacebetweenthe cheek
and gum and slowly administer the medication; savea special treat for after the medication
administration (eg, movie, playroom time, or a special food if allowed).
' The FDA has received reports of infants choking on the plastic caps that fit on the end of
syringeswhen used to administer oral medications.They recommendthe following:
remove and disposeof capsbefore giving syringesto patientsor families, caution family
caregiversto disposeof capson syringesthey buy over the counter, and report any problems with syringe caps to the FDA. Companieshave begun to manufacturesyringes
labeled "oral use" without the caps on them.
Older Adult
Considerations
' Elderly patientswith arthdtis may have difficulty opening childproof caps.On request,the
pharmacistcan substitutea cap that is easierto open. A rubber band twisted around the cap
may provide a more securegrip for older patients.
HomeCare
Considerations
. Encouragethe patient to discard outdatedprescription medications.
' Discuss safe storageof medicationswhen there are children and pets in the environment.
' Discuss with parentsthe difference in over-the-countermedicationsmade for infants and
medicationsmade for children. Many times parentsdo not realize that there are different
strengthsto the actual medications,leading to under- or over-dosing.
' Encouragepatientsto carry a card listing all medications,dosage,and frequency in caseof
an emergency.
S p e c i a lC o n s i d e r a t i o n s
. If the patient questionsa medication order or statesthe medication is different from the
usual dose, always recheck and clarify with the original order or physician before giving
medication.
' If the patient's level of consciousnessis altered or his or her swallowing is impaired, check
with the physician to clarify the route of administration or alternativeforms of medication.
This may also be a solution for a pediatric or a confusedpatient who is refusing to take a
medication.
. Patientswith poor vision can requestlarge-type labels on medication containers.A magnifying lens also may be helpful.
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SKItL
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Equipment
An ampuleis a glassflaskthatcontainsa singledoseof medicationfor parenteraladminisof anyunusedportionof
tration.Becausethereis no way to preventairbornecontamination
medicationafterthe ampuleis opened,if not all themedicationis used,theremaindermust
Medicationis removedfrom anampuleafterits thin neckis broken.
be discarded.
. Sterilesyringeandfilter needle
. Ampuleof medication
. Needle(optional;for medications
thatareto be givenIM, sizedependson medication
andpatient)
beingadministered
. Antimicrobialswabor gauzepad
. MedicationKardexor computer-generated
MAR
ASSESSMENT
Assessthe ampulefor
Assessthemedicationin theampulefor anyparticlesor discoloration.
themedication.
anycracksor chips.Checkexpirationdatebeforeadministering
NURSING
DIAGNOSIS
basedon thepatient'scurent status.
Determinerelatedfactorsfor thenursingdiagnoses
may
include:
Appropriatenursingdiagnoses
. Risk for Infection
. Risk for Injury
OUTCOME
IDENTIFICATION
AND PLANNING
Theexpectedoutcometo achievewhenremovingmedicationfrom an ampuleis thatthe
medicationwill beremovedin a sterilemannerandfreefrom glassshards.
IMPLEMENTATION
A C T I ON
R A TI O N A L E
L Gather equipment. Check the medication order against
the original physician's order according to agency
policy.
occurredwhen orders were transcribed.
2. Perform hand hygiene.
Hand hygiene detersthe spreadof microorganisms.
3. Tap the stem of the ampule or twist your wrist quickly
while holding the ampule vertically.
This facilitates movement of medication in the stem to the
body of the ampule.
4. Wrap a small gauze pad or dry antimicrobial swab
This protectsthe nurse's fingers from the glass as the
ampule is broken.
around the neck of the ampule.
5. Use a snappingmotion to break off the top of the
ampule along the scoredline at its neck. Always break
away from your body.
This protectsthe nurse's face and fingers from any shattered glassfragments.
6. Removethe capfrom the filter needleby pulling it
straightoff Insertthe filter needleinto the ampule,being
carefulnot to touch the rim.
The rim of the ampuleis consideredcontaminated.Use of a
filter needlepreventsthe accidentalwithdrawing of small
glassparticleswith the medication.
7. Withdraw medication in the amount orderedplus a
small amountmore (approximately30Vo).Do not inject
air into solutions.Use either of the followins methods:
By withdrawing a small amount more of medication, any
air bubbles in the syringe can be displacedonce the
syringe is removedand therewill still be ample medication
in the syringe.
a. Insert the tip of the needleinto the ampule, which is
upright on a flat surface,and withdraw fluid into the
syringe.Touchplungerat knob only.
a. The contentsof the ampule are not under pressure;therefore, air is unnecessaryand will causethe contentsto
overflow. Handling plunger at knob only will keep shaft
of plunger sterile.
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ACTIO N
Action3: Tappingstemof ampule.
RATIONATE
Action3: Twistingmotionof wristwhileholding
ampure.
Action 7a: Withdrawingmedicationfrom uprightampule.
Action4: Snappingofftop
of ampule.
Action 7b: Withdrawingmedicationfrom
invenedamoule.
RATIONALE
ACTIO N
b. Insert the tip of the needleinto the ampule and invert the ampule. Keep the needlecenteredand not
touching the sidesof the ampule. Withdraw fluid
into syringe.Touchplungerat knobonly.
8. Wait until the needlehasbeenwithdrawnto taP the syringeand expelthe air carefully.Do not expelanyair
bubblesthat mayform in the solution.Checkthe amount
of medicationin the syringeand discardanysurplus.
9. Discard the ampule in a suitable container after comparing with the medication Kardex.
b. Surfacetension holds the fluids in the ampule when inverted. If the needletouchesthe sidesor is removed
and then reinsertedinto the ampule, surfacetension is
broken, and fluid runs out. Handling plunger at knob
only will keep shaft of plunger sterile.
Ejecting air into the solution increasespressurein the
ampule and can force the medication to spill out over the
ampule. Ampules may have overfill. Careful measurement ensuresthat conect dose is withdrawn'
Any medication that has not been removed from the ampule
must be discardedbecausethere is no way to maintain
sterility of contentsin an unopenedampule.
10. Discardthe filter needlein a suitablecontainer.lf med'
icationis to be givenlM or if agencyrequiresthe useof a
needleto administermedication,attachselectedneedle
to syringe.
Filter needleused to draw up medication should not be used
to administerthe medication, to prevent any glass shards
from entering the patient' If agencyhas a needlelessIV
system,medication is ready to be given.
Hand hygiene detersthe spreadof microorganisms'
EVALUATION
and Associated
lnterventions
The expectedoutcome is met when the medication is removed from the ampule in a sterile
manner and free from glass shards.
, Nurse cutsself while trying to open ampule: Discard ampule in casecontamination has
policy'
occurred.Bandagewound and retrieve new ampule. Report according to agency
lefi
medication
not
enough
is
there
, Alt of medication was not removedfrom the stem and
dose'
of
the
remainder
the
for
in body of ampulefordose: Retrieve anotherampule
placed on
Medication should be consideredcontaminatedonce neck of ampule has been
a nonsterile surface.
. Nurseinjects air into inverted ampule, spraying medication: Wash handsto remove any
medication. If any medication has gotten into eyes,pelform an eye irrigation' Retrieve
new ampule for medication dose.Report according to agencypolicy'
. Medication is drawn up without using a filter need.le:Replaceneedlewith a filter needle'
can be
If medication is to be given Itrrtor agencyusesa needlelessIV system,medication
injected into a new syringe and then administeredto patient'
. plunger becomescontaminatedbefore inserted into ampule.'Discard needle and syringe
it is
and siart over. If plunger is contaminatedafter medication is drawn into the syringe,
of
the
barrel
enter
not necessaryto discard and start over. The contaminatedplunger will
the
medication'
the syringe when pushing the medication out and will not contaminate
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A vial is a glass bottle with a self-sealing stopperthrough which medication is removed. For
safety in transporting and storing, the single-doserubber-cappedvial is usually covered with
a soft metal cap that can be removed easily. The rubber stopperthat is then exposedis tle
meansof entranceinto the vial.
Equipment
'
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ASSESSE
MN T
Assessthe medication in vial for any discoloration or particles. Check expiration date before
administering medication.
NURSING
DIAGNOSIS
Determine related factors for the nursing diagnosesbasedon the patient's current status.An
appropriatenursing diagnosisis Risk for Infection.
OUTCOME
IDENTIFICATION
AND PLANNING
The expectedoutcome to achieve when removing medication from a vial is withdrawal of
the medication into a syringe in a sterile manner.
Sterile syringe and needle (size dependson medication being administeredand patient)
Vial of medication
Antimicrobial swab
Secondneedle (optional)
Filter needle (optional)
IMPLEMENTATION
A C T IO N
1 . Gatherequipment.Checkmedicationorderagainstthe
originalphysician'sorderaccordingto agencypolicy.
2. Performhandhygiene'
3 . Removethemetalor plasticcapon thevial thatprotectstherubberstopper.
4' swabthe rubber top with the antimicrobial swab.
5' Remove the cap from the needleby pulling it straight
off' (Some agenciesrecommenduse of a filter needle
when withdrawing premixed medication from multidose vials') Draw back an amount of air into the
syringe that is equal to the specific dose of medication
to be withdrawn'
6' Pierce the rubber stopperin the center with the needle
tip and inject the measuredair into the spaceabove the
solution. (Do not inject air into the solution.) The vial
may be positioned upright on a flat surfaceor inverted.
7' lnvert the vial and withdrawthe needletip slightlyso
that it is belowthe fluid level.
8. Draw up the prescribed amount of medication while
holding the syringe at eye level and vertically. Be careful
to touch the plunger at knob only.
RATIONATE
This comparison
helpsto identifyerrorsthatmayhave
o."urr"i whenordersweretranscribed.
Handhygienedetersthe spreadof microorganisms.
Themetalor plasticcappreventscontamination
of the
rubbertop.
Antimicrobial swabremovessurfacebacteriaconiamination.
Before fluid is removed, injection of an equal amount of air
is required to prevent the formation of a partial vacuum,
becausea vial is a sealedcontainer. If not enough air is
injected, the negative pressuremakes it difficult to withdraw the medication. (Use of a filter needleprevents any
solid material from being withdrawn througl the needle.)
Ah bubbled through the solution could result in withdrawal
of an inaccurateamount of medication.
This preventsair from being aspiratedinto the syringe.
Holding the syringe at eye level facilitates accuratereading,
and the vertical position makesremoval of air bubbles
from the syringe easy.Handling plunger at knob only
will keep shaft of plunger sterile.
2e
s h o t oA t l a so f M e d i c a t i o nA d m i n i s t r a t i o n '
RATIONATE
ACTION
Action6: lliSSUA1f*lqfill yptlshlt
n e e d l et i P i n
Action 7: Positioning
soluUon.
9. If any air bubbles accumulatein the syringe, tap the
barrel of the syringe sharply and move the needlepast
the fluid into the air spaceto reinject the air bubble into
the vial. Return the needletip to the solution and continue withdrawal of the medication.
10. After the correct dose is withdrawn, remove the needle
from the vial and carefully replacethe cap over the
needle.If a filter needlehasbeenusedto draw up the
medication and the medication needsto be administered through a needle,remove the filter needle and replaceit with a new needle'(Someagenciesrecommend
changing needles,if neededto administer the medication, before administering the medication')
11. lf a multidosevialis beingused,labelthe vialwith the
dateandtime opene4andstorethe vialcontainingthe
to agencypolicy'
remainingmedicationaccording
12. Performhandhygiene.
15
at eye
medication
Action8: Withdrawing
level.
Removal of air bubbles is necessaryto ensureaccuratedose
of medication.
This preventscontamination of the needle and protectsthe
nuise againstaccidentalneedlesticks'A one-handed
recap method may be used as long as care is taken not to
contaminatethe needleduring the process'Filter needle
used to draw up medication should not be used to administer the medication to prevent any solid material from
entering the Patient'
Becausethe vial is sealed,the medication inside remains
sterile and can be used for future injections' Labeling the
openedvials with a date and time limits its use after a
specifictime Period.
Hand hygienedetersthe spreadof microorganisms'
conttnues
ffi
tU
L i p p i n c o t t ,psh o r oA t l a so f M e d i c a t i oA
n d m i n i s r r a t i o2ne,
ACTION
RATIONALE
moveairbubbles.
Action 11: Vialwirh labelattached
EVALUATION
Theexpectedoutcomeis met whenthemedicationis withdrawninto the
syringein a sterile
mannerandis readyfor administration.
UnexpectedSituations
and Associated
Interventions
' A piece of rubber stopper is noticedfloating
in medication in syringe: Apply a filter needle
tothe syringe and inject medication into a new syringe. Filter needie
should remove any
solid material from the medication.
' As needleattachedto syringe
fitled with air is insened into vial, theplunger is immediately
pulled down: If possibleto withdraw medication,continue
stepsas explainedabove.If such
a vacuum has formed that this is impossible,remove syringe and injeci
more air into the
vial. This is causedby withdrawal of medication without the addition
of air into the vial.
' Plunger is contaminatedbefore
injecting air into vial: Discardneedle and syringe and start
over' If plunger is contaminatedafter medication is drawn into syringe,
it is not-necessary
to discard and start over. The contaminatedplunger will enter
tfre Uanef of the syringe
when pushing the medication out and will not contaminatethe medication.
L i p p i n c o t t ' sP h o t o A t l a so f M e d i c a t i o nA d m i n i s t r a t i o n2' e
17
SKILT
4
in the pancreas,
Insulin, a naturally occurring hormone producedby the islets of Langerhans
no insulin
produce
I
type
mellitus
diabetes
with
enablescells to use carbohylrates. Patiints
use by
for
available
are
insulin
of
types
Several
or produce insulin in insufiicient amounts.
are
and
action
of
duration
and
onset
their
in
patients with diabetesmellitus. Insulins vary
mellidiabetes
of
cases
Many
acting.
long
and
classifiedas short acting, intermediateacting,
Review
insulins)'
NPH
(eg,
and
regular
tus are regulatedwith a combination of two insulins
the duration and peak times of each type of insulin'
Equipment
ASSESSE
MN T
.
.
.
.
Two vials of insulin
Sterileinsulin syringewith 25- to 31-gaugeneedle
Antimicrobial swabs
short acting
Assessthe clarity of eachvial of insulin. In the past, clear insulins have been
there is a new longand cloudy insulins have been long acting, but this is no longer the case:
familiar with each
acting insulin on the market that is clear. Therefore, it is important to be
particular insulin's peak and half-life before removing it from the vial.
NURSING
DIAGNOSIS
current status'An
Determine related factors for the nursing diagnosesbasedon the patient's
appropriatenursing diagnosisis Risk for Infection'
OUTCOME
IDENTIFICATION
AND PLANNING
in one syringe
The expectedoutcome to achievewhen mixing two different types of insulin
is ready for
and
is that the insulin is appropriately mixed in the syringe in a sterile manner
administration.
IMPLEMENTATION
ACTION
1. Gather equipment.Check medication order againstthe
original physician's order according to agencypolicy'
3. If necessary,remove the cap that protects the rubber
stopperon eachvial.
(NPH,Lente),roll and agitate
4. lf insulinis a suspension
the vialto mix it well.
5. Cleansethe rubber tops with antimicrobial swabs.
6. Remove cap from needle.Inject air into the modified
insulin preparation(eg, NPH insulin)' Touch plunger at
knob only. Use an amount of air equal to the amount of
medication to be withdrawn. Do not allow needleto
touch medicationin vial.Removeneedle.
R A T IO N A L E
occurred when orders were transcribed'
The cap Protectsthe rubber toP.
need to be mixed before withdrawal.
Antimicrobial swab removes surfacecontamination' It is
questionablewhether cleaning with alcohol actually disinfects or insteadtransfersresident bacteriafrom the
handsto another surface.Becauseit is difficult in a
healthcarefacility to keep an insulin vial in its original
box as recommended,the practice of cleansingwith alcohol will most likelY continue.
Regular insulin should never be contaminatedwith NPH or
any insulin modified with addedprotein' Placing air in
the NPH insulin first without allowing the needleto contact the insulin ensuresthat regular insulin is not contaminated with the additional protein in the NPH' Handling
plunger by knob only ensuressterility of shaft ofplunger'
conilnues
18
L i p p i n c o r r 'Ps h o t oA r l a so f M e d i c a t i o nA d m i n i s t r a r r o n
2 ,e
sKtr-t
4
ACTIO N
RATIONALE
Action 4: MixingNpH insulin.
7 . Inject air into the regularinsulin without additional
protein.Use an amountof air equalto the amountof
medicationto be withdrawn.
8 . Invert vial of regularinsulin and aspirateamountpre_
scribed.Invert and thenremoveneedlefrom vial.
Action 6: Injecting
airintomodified
insulin
An equal amount of air must be injected into the vacuum to
allow easy withdrawal of medication.
Regular insulin that containsno additional protein is not
contaminatedby insulin that contains slobulin or
protamine.
3
d;r,
d
4:golZi_.!t":Ug air into regularinsulin.
Action 8: Wirhdrawing regularinsulin
conttnues
ACTION
RATIONALE
9. Cleansethe rubber top of the modified insulin vial' Insert the needleinto this vial, invert it, and withdraw the
medication. Carefully replacethe cap over the needle.
10. Store the vials according to agencyrecommendations.
Previous addition of air eliminates need to createpositive
pressure.Capping the needlepreventscontamination and
protectsthe nurse againstaccidentalneedlesticks'A onehandedrecap method may be used as long as care is
taken to ensurethat the needleremains sterile'
Insulin need not be refrigeratedbut must be protectedfrom
temperatureexffemes.
:, .
i :ril!:rr
19
i.
EVALUATION
(in a sterile manner) in
The expectedoutcome is met when the insulin is mixed appropriately
the syrilngefollowing the stepsabove and is ready for administration'
and Associated
lnterventions
, Nursecontaminatesplunger before injecting air into insulin vial: Discard needle and
into the
syringe and start over. If ilunger is contaminatedafter medication is drawn
will enter
plunger
contaminated
The
syringe, it is not n.."rrury to discard and start over.
the
contaminate
not
will
and
out
the banel of the syringe when pushing the medication
medication.
. Nurseallows NpH insulin to come in contact with syringe before entering the regular
insulin vial: Discard needleand syringe and start over'
. Nursenotices that the combinedamount is not the ordered anxount(eg, nurse has less or
over' There is no
more units in combinedsyringe than ordered): Discard syringe and start
way to know for sure which dosageis wrong'
. Nurseinjects regular insulin into NPH vial; Discard vial and syringe and start over'
continues
20
s h o t oA r l a so f M e d i c a t i o nA d m i n i s t r a t i o n2.e
' An insulin-cartridge pen (the Novolin Pen) is
available that allows the patient to dial the
colrect dose ofinsulin and pressa button to releasethe dose quickly through a short, fine,
27-gatge needle.
' A type I diabetic patient who is visually impaired
may find it helpful to use a magnifying
apparatusthat fits around the syringe.
' Before attempting to explain or demonstrate
devices that help low-vision diabetic patients
to preparetheir medication, attempt to use the device yourself under similar circumstances.To detect any difficulties the patient may experience,practice using the aid with
your eyesclosedor in a poorly lit room.
Considerations
SKILT
5
The intradermalroute has the longestabsorptiontime of all parenteralroutes.For this
reason,
intradermal injections are usedfor diagnosticpu{poses,such as the tuberculin test
and teststo
determinesensitivity to various substances.The advantageof the intradermalroute
for these
testsis that the body's reaction to substancesis easily visible, and degreesof reaction
are discernible by comparativestudy. Intradermal injections are placedjust below the
epidermis.
Equipment
.
.
.
.
.
.
ASSESSE
MN T
Assessthe patient for any allergies.Assessthe site on the patient where the injection
is to be
given; it should not be given in broken or open skin. Avoid areasthat are highly
pigmented
and hairy. Assessthe patient's knowledge of reasonfor injection. This may provide
an
opportune time for patient education.
NURSING
DIAGNOSIS
Determine related factors for the nursing diagnosesbasedon the patient's
current status.
. Risk for Allergy Response
. Anxiety
OUTCOME
IDENTIFICATION
AND PTANNING
The expected outcome to achieve when administering an intradermal injection
is appearanceof
a wheal or blister at the site of injection. Other outcomesthat may be appropriate
inilude the
following: the patient understandsthe rationalefor the injection;ih" puii"nt
experiencesno allergy response;the patient refrainsfrom rubbing the site; and the patLnt's
anxiety is decreased.
Medication
Sterile syringe and needle (25 to 27 gauge, y4,,to %,, long)
Antimicrobial swab
Disposablegloves
Acetone and2x 2 sterile gauze square(optional)
IMPTEMENTATION
ACTION
l. Assembleequipmentand checkthe physician,sorder.
RATIONATE
This ensuresthat the patient receivesthe right medication
at the right time by the proper route. Many intradermal
drugs are potent allergensand may causea significant
reaction if given in an incorrect dose.
ACTION
RATIONATE
2. Explain the procedureto the patient.
Explanation encouragescooperationand reduces
apprehension.
Hand hygiene detersthe spreadof microorganisms' Gloves
act as a barrier and protect the nurse's handsfrom accidental exposureto blood during the injection procedure'
3. Perform hand hygiene. Don disposablegloves.
21
4. If necessary,withdraw medication from an ampule or
vial as describedin Skills 2 and3.
5. Select an areaon the inner aspectof the forearm that is
not heavily pigmented or covered with hair. The upper
chest and upper back beneaththe scapulaealso are sites
for intradermal injections.
The forearm is a convenient and easylocation for introducing an agent intradermally. Hair or lesions at the injection
of skin changesat
site may interfere with assessments
6. Cleansethe areawith an antimicrobialswabwhile wiping
with a firm, circular motion and moving outward from
the injection site.Allow the skin to dry. If the skin is oily'
cleanthe areawith a pledgetmoistenedwith acetone.
Pathogenson the skin can be forced into the tissuesby the
needle.Introducing alcohol into tissuesirritates the tissuesand is uncomfortable for the patient. Acetone is
effective for removing oily substancesfrom the skin'
7. Remove the needlecap with the nondominant hand by
pulling it straightoff.
Taut skin provides an easyentranceinto intradermal tissue'
8. Use the nondominant hand to spreadthe skin taut over
the injection site.
The cap protectsthe needlefrom contact with microorganisms.This techniquelessensthe risk of an accidental needlestick.
Intradermal tissue is enteredwhen the needle is held as
nearly parallel to the skin as possible and is inserted
9. Placethe needlealmostflat againstthe Patient'sskin,
bevelsideup, and insertthe needleinto the skin so that
the point ofthe needlecanbe seenthrough the skin.Insert
the needleonly about '/"" with entire bevelunderthe skin.
the site.
about/g".
10. Slowly inject the agentwhile watchingfor a small
wheal or blister to appear.If none appears,withdraw
the needleto ensurebevel is in interdermal tissue.
If a small wheal or blister appears,the agent is in the intradermaltissue.
I L Once the agenthas been injected, withdraw the needle
quickly at the sameangle that it was inserted-
Withdrawing the needlequickly and at the angle at which it
enteredthe skin minimizes tissue damageand discomfort
for the patient.
skintaut.
ActionE: Holdingforearm
conunues
22
L i p p i n c o t r ' sP h o t o A t l a s o f M e d i c a t i o nA d m i n i s t r a t r o n2, e
ACTION
R A T IO N A t E
t levelwiththeskin.
12. Do not massageareaafter removingneedle.Tell patient
not to rub or scratchsite.
13. Do not recap the used needle.Discard the needleand
syringe in the appropriate receptacle.
14. Assist the patient to a position of comfort.
15. Remove gloves and disposeof them properly. perform
hand hygiene.
16. Chart the administration of the medication as well as
the site of administration. Some agenciesrecommend
circling the injection site with ink. Charting may be
documentedon CMAR, including location.
17. Observethe areafor signs of a reaction at orderedinter_
vals, usually at24 to 72 hours. Inform the patient of
this inspection.
g medication.
Massagingtle areawhereanintradermalinjectionis given
may interferewith testresultsby spreadingmedicationto
underlyingsubcutaneous
tissue.
Properdisposalof the needleprotectsthe nursefrom accidentalinjection.Most accidentalpuncturewoundsoccur
whenrecappingneedles.
This providesfor the well-beingof the patient.
Handhygienedeiersthe spreadof microorganisms.
Accuratedocumentationis necessaryto preventmedication
error. Circling the injection site easilyidentifiesthe site
of the intradermalinjectionand allowsfor carefulobservation of the exactarea.
With manyinfradermalinjections,thenursewill needto
look for a localizedreactionin the areaofthe injection.
EVATUATION
The expectedoutcomesilre met when the nurse notes a wheal or blister at site of injection;
patient understoodthe rationale for the injection; the patient experiencedno allergy
,"rponr"; the patient does not rub or scratchthe site; and the patient's anxiety is decreased.
and Associated
lnterventions
. Nursedoes not note wheal or blister at site of injection: Medication has been injected subcutaneously.Nurse may need to obtain order to repeatprocedure.
. Medication leaks out of injection site before needle is withdrawn: Needle was insertedless
than t/s".Nurse may needto obtain order to repeatprocedure'
. Nurse sticksself with needlebefore injection.' Discard needle and syringe appropriately'
Follow agencypolicy regarding needlestickinjury. Preparenew syringe with medication
and administerto patient. Complete appropriatepaperwork and follow agency's policy regarding needlesticks.
. Nurse sticksself with needleafter injectior.' Follow agency's policy regarding needlestick
injuries. Discard needle and syringe appropriately.Complete the appropriatepaperwork'
Do not documentneedlestickin patient'snotes.
. Afier or during injection, the patient pulls awayfrom the needle before medication is
deliveredfutly; Remove and appropriately discard needle.Attach a new needleto the
syringe and administer the remaining medicatton.
. Since the needleis entering only the dermal portion of tissue,where there are no large blood vessels,aspiration (pulling back on the plunger) is not recommendedfor an inffadermal injection.
. Some agenciesrecommendadministering intradermal injections with the bevel down insteadof the bevel up.
SKlLL
6
Subcutaneoustissuelies betweenthe epidermis and the muscle. Becausethere is subcutaneoustissue all over the body, various sites are used for subcutaneousinjections. These sites
are the outer aspectof the upper arm, the abdomen(from below the costal margin to the iliac
crests),the anteiior aspectsbithe thigh, the upper back, and the upper ventral or dorsogluteal
area(seeBox 5). This route is used to administer insulin, heparin, and certain immunizations. If needed,review the specif,csof the particular medication before administrating.
Equipment
ASSESSMENT
NURSING
DIAGNOSIS
.
.
.
.
.
.
Medication
Sterile syringe and needle(size dependson medication being administeredand patient)
Antimicrobial swabs
Disposablegloves
Cotton balls or dry sponge(optional)
Assessthe patient for any allergies.Assessthe patient's knowledge of the medication. If the
patient has a knowledge deficit about the medication, this may be an appropriatetime to
tegin education abouithe medication. Assessthe areawhere injection is to be given' Subinjections should not be given into areasof skin that are broken or open.
"utun"ou,
Determine related factors for the nursing diagnosesbasedon the patient's current status'
.
.
.
.
Deficient Knowledge
Acute Pain
Anxiety
Risk for Allergy Response
connnues
I
24
OUTCOME
IDENT!FICATION
AND PTANNING
The expectedoutcome to achieve when administering a subcutaneousinjection is that the
patient receivesmedication via the subcutaneousroute. Other outcomesthat may be appropriate include the following: the patient understandsthe reasonfor the procedureand has
minimal pain, decreasedanxiety, and no allergic response.
IMPTEMENTATION
ACTION
RATIONALE
l. Assembleequipmentand checkthe physician'sorder.
This ensuresthat the patient receivesthe right medication at
the right time by the proper route.
2. Explain the procedureto the patient.
Explanation encouragespatient cooperationand reduces
apprehension.
vial as describedin Procedures2 and 3.
5' Identify the patient carefully by checking the identification band on the patient's wrist and asking the patient
his or her name. Close the curtain to provide privacy.
Don disposablegloves.
It is the nurse's responsibility to guard againsterror. Gloves
act as a barrier and proteci the nurse's handsfrom accidental exposureto blood during the injection procedure.
6. Have the patient assumea position appropriatefor the
most commonly usedsites.SeeBox 5.
a. Outer aspectof upper arm: the patient's arm should
be relaxed and at the side of the body.
b. Anterior thighs: the patient may sit or lie with the
leg relaxed.
c. Abdomen: the patient may lie in a semirecumbent
position.
Injection into a tenseextremity causesdiscomfort.
7. Locate the site of choice according to directions given
in Box 5. Ensure that the areais not tender and is free
of lumps or nodules.
Good visualization is necessaryto establishthe correct
location of the site and avoid damageto tissues.Nodules
or lumps may indicate a previous injection site where
absorptionwas inadequate.
8. Clean the areaaround the injection site with an antimicrobial swab.Use a firm, circular motion while moving outward from the injection site. Allow areato dry.
9. Remove the needlecap with the nondominant hand,
pulling it straight off.
Friction helps to clean the skin. A clean areais contaminated when a soiled object is rubbed over its surface.
l0' Grasp and bunch the areasurrounding the injection site
or spreadthe skin at the site.
The cap protects the needlefrom contact with microorganisms.This technique lessensthe risk of an accidental needlestick.
This provides for easy, less painful entry into the subcutaneoustissue.The decisionto pinch or spreadtissueat
the injection site dependson the size ofthe patient.If
the patient is thin, skin needsto be bunchedto createa
skin fold.
conttnues
L i p p i n c o t t ' sP h o t o A t l a so f M e d i c a t i o nA d m i n i s t r a t i o n2, e
75
RATIONALE
ACTION
t
t,fi
'*$
t
in.jection
site.
Action8: Cleaning
aroundinjectionsite'
Action 10: Bunchingtissue
1 1 .Holdthe syringein the dominanthand betweenthe
Inserting the needlequickly causesless pain to the patient.
Subcutaneoustissue is abundantin well-nourished, wellhydrated people and sparein emaciated,dehydrated,or
very thin persons.For a thin person,it is best to insert the
needle at a 45-degreeangle.
thumb and forefinger.Injectthe needlequicklyat an
dependingon the amount
angleat 45 to 90 degrees,
and turgor of the tissueand the lengthof the needle,
asshown.
12. After the needleis in place, releasethe tissue.If you
have a large skin fold pinched up, ensurethat the needle staysin place as the skin is released.Immediately
move your nondominant hand to steadythe lower end
of the syringe. Slide your dominant hand to the tip of
the barrel.
1 3 .Aspirate,if recommended,by pulling backgentlyon the
plungerof the syringeto determinewhetherthe needleis
in a blood vessel.lf blood appears,the needleshouldbe
withdrawn,the medicationsyringeand needlediscarde4
and a newsyringewith new medicationprepared.Do not
aspiratewhengivinginsulinor anyJormoJheparin.
Injecting the solution into compressedtissuesresults in
pressureagainstnerve fibers and createsdiscomfort. If
there is alarge skin fold, the skin may retract away from
the needle.The nondominant hand securesthe syringe
and allows for smooth asPiration.
Discomfort and possibly a seriousreaction may occur if a
drug intended for subcutaneoususe is injected into a
vein. Heparin is an anticoagulantand may causebruising
if aspirated.Becausethe insulin needleis so small, aspiration after insulin has proved unreliable in predicting
needleplacement.
::
S
-,
*
tl
:
*
Action 11: Insertingneedle
6
r^
fii
I
ri:,
#
;i]
conilnues
26
L r p p r n c o t t ' sP h o t o A t l a s o f M e d i c a t i o n A d m i n i s r r a t i o n .2 e
ACTIO N
RATIONALE
14. If no blood appears,inject the solutionslowly.
Rapid injection ofthe solution createspressurein the tissues,resultingin discomfort.
1 5 .Withdraw the needlequickly at the sameangle at
Slow withdrawal of the needlepulls the tissuesand causes
discomfort. Applying countertractionaround the injection
site helps to prevent pulling on the tissue as the needleis
withdrawn. Removing the needle at the sameangle at
which it was inserted minimizes tissuedamageand discomfort for the patient.
which it was inserted.
a r.:
.f{r*
I' *
#
!'
slh
16. Massagethe areagently with cottonball or dry swab.
Do not massage
a subcutaneous
heparinor insulininjection site.Apply a small bandageif needed.
Massaginghelps to distribute the solution and hastensits
absorption.Massagingthe site of a heparin injection
causesadditional bruising. Massagingafter an insulin injection may contribute to unpredictableabsorptionof the
medication.
a
conilnues
L i p p i n c o t c 'Psh o t oA t l a so f M e d i c a t i o nA d m i n i s t r a t i o n2,e
RATIONALE
ACTION
17. Do not recap the used needle.Discard the needleand
syringe in the appropriatereceptacle.
Proper disposal of the needleprotects the nurse from accidental injection. Most accidentalpuncture wounds occur
when recapping needles.
18. Assist the patient to a position of comfort.
This provides for the well-being of the patient.
19. Remove gloves and disposeof them properly. Perform
hand hygiene.
20. Chart the administration of the medication, including
the site of adminisffation. This charting can be done on
CMAR.
Accurate documentationis necessaryto prevent medication
erTor.
21. Evaluate the responseof the patient to the medication
within an appropriatetime frame.
Reaction to medication given by the parenteralroute may
occur within 15 to 30 minutes after injection.
EVATUATION
The expectedoutcomesare met when the patient has received the medication via the subcutaneousroute; understandsthe reasonfor the procedure;experiencedminimal pain; has decreasedanxiety; and has had no allergic response'
and Associated
lnterventions
. Whenskinfold is released,needlepulls out of skin: Remove and appropriately discard
needle.Attach new needleto syringe and administer injection.
. Patient refusesto let nurse administer medication in another location: Explain the rationale behind rotating injection sites.Discussother available injection sites with patient' If
patient will still not allow injection in anotherarea,administer medication to patient, document patient's refusal and discussion,and notify physician.
. Nurse sticksself with needlebefore injectiorz.'Discard needle and syringe appropriately.
Follow the agency's policy regarding needlesticks.Preparea new syringe with medication
and administerto patient. Complete appropriatepaperwork.
. Nurse sticksself with needleafter injectionr Discard needleand syringe appropriately.
Follow agency's policy regarding needlesticks.Complete appropriatepaperwork' Do not
document needlestickin patient's notes.
. After or during injection, patient pulls awayfrom needlebefore medication is delivered
needleto syringe and
fully: Remove and appropriately discard needle.Attach a new
administer remaining medication.
lnfant and Child
Considerations
. Do not tell a child that an injection will not hurt. Describe the feel of the injection as a
pinch or a sting. A child who believes you have been dishonestwith him or her is less
likely to cooperatewith future procedures.
Older Adult
Considerations
. Many elderly patientshave less adiposetissue.Adjust the angle of the needle accordingly.
You do not want to inadvertently give a subcutaneousmedication intramuscularly.
HomeCare
Considerations
. According to the American DiabetesAssociation, reuseof insulin syringesin the home
setting appearssafe.Once the needleis dull, it should be discarded(usually after2to
10 uses).
28
s h o r oA t l a so f M e d r c a t i o n
A d m i n i s t r a r i o n2,e
sKttt_
7
The intramuscularroute is often used for drugs that are irritating becausethere are few nerve
endings in deep muscle tissue.If a sore or inflamed muscle is entered,however, the muscle
may act as a trigger area,and severereferred pain often results. It is best to palpate a muscle
before injection. Select a site that does not feel tender to the patient and where the tissue does
not contract and become firm and tense.Avoid nodules, lumps, and scars.
Absorption occurs as in subcutaneousadministration but more rapidly becauseof the greater
vascularity of muscle tissue.The amount of 5 mL is consideredthe maximum to be given in
one site for an adult with well-developed muscles,although the patient's size and the site
used(eg, deltoid muscle)may necessitatesmallerinjection (Nicoll & Hesby,2002).
An important point in the administration of an intramuscularinjection is the selectionof a
safe site away from large nerves,bones,and blood vessels(seeBox 6). When care is not
taken, common complications include abscesses,necrosisand skin slough, nerve injuries,
lingering pain, and periostitis (inflammation of the membranecovering a bone).
The sites for injecting intramuscularmedications should be rotated when therapy requires
repeatedinjections. The sites describedin this skill may all be used on a rotating basis.
Whatever pattern of rotating sitesis used, a description of it should appearin the patient's
plan of nursingcare.
Equipment
.
.
'
.
.
.
ASSESSE
MN T
Assessthe patient for any allergies.Assessthe patient's knowledge of the medication. If the
patient has a knowledge deficit about the medication, this may be an appropriatetime to
begin education about the medication. Assesstle areawhere the injection is to be given.
Intramuscularinjections should not be given into areasof skin that are broken or open. If the
medication is for pain, assessthe patient's level of pain. If the medication may affect the
patient's vital signsor laboratorytest results,checkthem before administeringthe medication.
NURSING
DIAGNOSIS
Appropriate diagnosesmay include:
. Acute Pain
. Anxiety
. Risk for Injury
. Risk for Impaired Skin Integrity
OUTCOME
IDENTIFICATION
AND PTANNING
The expectedoutcome to achievewhen administering an intramuscularinjection is that the
patient receivesthe medication via the intramuscularroute. Other outcomesthat may be
appropriateinclude the following: the patient understandsthe reasonsfor the injection; has
minimal pain; has no allergy response;has decreasedanxiety; and experiencesno injury; and
patient'sskin remainsintact.
Disposablegloves
Medication
Sterile syringe and needle (size dependson medication being administeredand patient)
Antimicrobial swab
Dry sponge
conunues
IMPLEMENTATION
ACTIO N
29
RATIONATE
1. Assembleequipmentand checkthe physician'sorder.
the right time by the Properroute.
2. Explain procedureto patient.
Explanation encouragescooperationand alleviates
apprehension.
vial as describedin Procedures2 and 3.
5. Do not add air to the syringe.
6. Identify the patient carefully. There are three correct
ways to do this:
a. Check the name on the patient's identification
badge.
b. Ask the patient his or her name.
c. Verify the patient's identification with a staff member who knows the patient.
7. Provide for privacy. Have the patient assumea position
appropriatefor the site selected,and encouragethe
patient to relax.
a. Ventrogluteal: the patient may lie on the back or
side with the hip and knee flexed.
b. Vastus lateralis: the patient may lie on the back or
may assumea sitting position.
c. Deltoid: the patient may sit or lie with arm relaxed.
d. Dorsogluteal: the patient may lie prone with toes
pointing inward or on the side with the upper leg
flexed and placed in front of the lower leg.
The addition of air to the syringe is potentially dangerous
and may result in an overdoseof medication.
Identifying the patient is the nurse's responsibility to guard
againsterror.
a. This is the most reliable method' Replacethe identification band if it is missing or inaccuratein any way.
b. This requires a responsefrom the patient, but illness and
strangesurroundingsoften causepatients to be confused.
c. This is anotherway to double-checkidentity' Do not use
the name on the door or over the bed, becausethesemay
be inaccurate.
Injection into a tensemuscle causesdiscomfort.
siteinjection.
for ventrogluteal
Action7a: Positioning
contmues
30
ACTION
Action 7c: Positioning
for deltoidmusclesiteinjection.
RATIONATE
Action7d: Positioning
for dorsogluteal
siteinjection.
8. Locate the site ofchoice according to directions given
in Box 6. Ensure that the areais nontenderand free of
lumps or nodules.Don disposablegloves.
Good visualization is necessaryto establishthe correct
location of the site and avoid damageto tissues.Nodules
or lumps may indicate a previous injection site where
absorptionwas inadequate.Gloves act as a barrier and
protect the nurse's handsfrom accidentalexposureto
blood during the injection procedure.
9. Cleantheareathoroughlywith an antimicrobialswab,
usingfriction.Allow to dry.
10. Removetheneedlecapby pulling it straightoff.
Pathogenspresenton the skin and antimicrobial agent can
be forced into the tissuesby the needle,
n . Displace the skin in aZ-trackmanner by pulling to
one side or spreadthe skin at the site using your nondominanthand.
12. Hold the syringe in your dominant hand betweenthe
thumb and forefinger. Quickly dart the needleinto the
tissueat a 90-degreeangle.
1 3 .As soonas the needleis in place,useyour nondominant hand to hold the lower end of the syringe. Slide
your dominant hand to the tip of the barrel.
14.Aspirateby slowly(for at least5 seconds)pulling backon
the plungerto determinewhetherthe needleis in a
blood vessel.lf blood is aspirateddiscardthe needle,
syringe,and medication,preparea new sterilesetup,and
injectanothersite.
The cap protects the needlefrom contact with microorganisms, This techniquelessensthe risk of an accidental
needlestickand also preventsinadvertently unscrewing
the needlefrom the barrel of the syringe.
This makes the tissuetaut and minimizes discomfort. Using
the Z-track method prevents seepageof the medication
into the needletrack and is less painful.
A quick injection is less painful. Insening the needle at a
90-degreeangle facilitates entry into muscle tissue.
This acts to steadythe syringe and allows for smooth
aspiration.
Discomfort and possibly a seriousreaction may occur if a
drug intended for intramuscularuse is injected into a
vein. Allowing slow aspirationfacilitates backflow of
blood evenif needleis in a small,low-flow blood vessel.
conunues
ffi#ffi
ACTIO N
RATIONALE
Action 11: Spreadingthe skin at ventroglutealsite.
Action 12: Inserting
needlein the ventrogluteal
site.
Action 14: Aspirating.
1 5 .If no blood is aspirated,inject the solution slowly
Injecting slowly helps to reduce discomfort by allowing
time for solution to dispersein the tissues.
(10 secondsper mL of medication).
1 6 .Remove needle slowly and steadily. Releasedisplaced
tissue if Z-track techniquewas used.
t 7 . Apply gentle pressureat the site with a small, dry
sponge.
1 8 .Do not recap used needle.Discard needle and syringe
in appropriatereceptacle.
19. Assist patient to position of comfort. Encouragepatient
Slow withdrawal allows the medication to begin to diffuse
through the muscle. Releasingdisplacedskin sealsmedication in the tissues.
Light pressurecausesless trauma and irritation to the tissues.
Massaging can force medication into subcutaneoustissues.
Proper disposal of needleprotects nurse from accidental
injection. Most accidentalpuncture wounds occur when
recapping needles.
Exercise promotes absorptionof medication.
to exerciseexffemity used for injection if possible.
20. Remove gloves and disposeof them properly. Perform
hand hygiene.
31
ffi
ACTION
RATIONATE
-*-:
Action 15: Injectingmedication.
Action 17: Applyingpressure
at the injectionsite.
21. Chart the administration of the medication, including
etTor.
the site of administration. This may be documentedon
the CMAR.
22. Evaluatepatient's responseto medication within an
appropriatetime frame. Assesssite, if possible,within
2 to 4 hours after adminisffation.
Reaction to medication given by the parenteralroute is
a possibility. Visualization of the site also allows for
assessmentof anv untoward effects.
EVALUATION
Theexpectedoutcomesaremetwhenthepatienthasreceivedthemedicationvia theintramuscularroute;understood
thereasonsfor injection;hadminimalpain;experienced
no
allergyresponse;
hasdecreased
anxiety;andexperienced
no injury; andpatient'sskin
remainedintact.
and Associated
Interventions
. Nurse sticlcsself with needlebefore injectiorz.'Discard needleand syringe appropriately.
Follow the agency's policy regarding needlesticks.Preparea new syringe with medication
and administer to the patient. Complete appropriatepaperwork.
' Nurse sticksselfwith needleafter injectiou Discard needle and syringe appropriately.
Follow the agency's policy regarding needlesticks.Complete appropriatepaperwork.
Do not document needlestickin the patient's notes.
' After or during injection, patient pulls away
from needlebefore medication is delivered
fully: Remove and discard needleappropriately.Attach a new needleto syringe and
administer remaining medication in a new site.
' While injecting needle into patient, nurse hits patient's bone: Withdraw and discard the
needle.Apply new needleto syringe and administer in alternatesite. Document incident
in patient's notes.Notify physician. May need to complete incident report.
Infant and Child
Considerations
' Safe adminishation of an intramuscularinjection into an infant's vastuslateralis muscle
may require use of a 1" needlerather than the commonly used5/s"needle.A 1" needleconsistently allows penetrationinto the muscle and safe administration of the medication.
ffi
Medications may be addedto the patient's infusion solution. The recommendedprocedureis
for the pharmacistto add the prescribeddrug to a large volume of IV solution, but sometimes
the drug is addedin the nursing unit, in which casesterile technique must be maintained.
When medication is administeredby continuous infusion, the patient receivesit slowly and
over a long period. Although sometimesthis can be an advantagewhen it is desirableto give
the medication slowly, it is a disadvantagewhen the patient needsto receive the drug more
quickly. Also, if for some reasonall of the solution cannot be infused, the patient will not
receive the prescribedamount of the medication. The patient receiving medication by a continuous IV infusion should be checkedfor possible adverseeffects at least every hour.
Equipment
. Medication preparedin a syringe with a 19- to 21-gaugeneedle,blunt needle or needleless
device (follow agencypolicy)
. IV fluid container (bag or bottle)
. Antimicrobial swab
. Label to be attachedto the IV container
. Medication Kardex or computer-generatedMAR
ASSESSE
MN T
Assessthe patient for allergies.Assessthe patient's knowledge of the medication. If patient
has a knowledge deficit, this may be an appropriatetime to begin education about the
medication.
NURSING
DIAGNOSIS
. Risk for Injury
. Anxiety
OUTCOME
IDENTIFICATION
AND PLANNING
The expectedoutcome to achievewhen adding medicationsto an IV solution container is
that the medication is addedto an adequateamount of IV solution and mixed appropriately.
Other outcomesthat may be appropriateinclude the following: medication is delivered to the
patient in a safe and effective way; patient experiencesno allergy response;patient remains
infection free; and patient understandsand experiencesdecreasedanxiety regarding medication infusion.
IMPLEMENTATION
ACTION
RATIONATE
1. Gather all equipment. Check the medication order with
the physician's order and that medication is compatible
with IV fluid. Take equipmentto patient's bedside.
Checking the order ensuresthat the patient receivesthe correct medication at the correct time and in the right manner. Compatibility of medication and solution prevents
complications. Having equipment available savestime
and facilitates performanceof the task.
3 . Identify patient by checking identification band on pa-
This ensuresthat the medication is given to the right person'
tient's wrist and asking patient his or her name. Check
for any allergies patient may have.
A
-.
Explain procedureto patient.
Explanation allays patient anxiety.
continues
34
L i p p i n c o t t ' sP h o t o A r l a so f M e d i c a t i o nA d m i n i s t r a t i o n2, e
ACTION
RATIONATE
5. Add the medicationsto the fV solution that is infusing:
a. Checkthat the volume in the bagor bottle is adequate.
b. Close the [V clamp.
a. The volumeshouldbe sufficientto dilute the drug
b. This preventsbackflowdirectly to the patientof improp-
erly diluted medication.
c. Clean the medication port with an antimicrobial
swab.
d. Steadythe container and uncap the needleor
needlelessdevice and insert it into the port. Inject
the medication.
e. Remove the container from the IV pole and gently
rotate the solutions.
f. Rehang the container, open the clamp, and readjust
the flow rate.
g. Attach the label to the container so that the doseof
medicationthat hasbeenadded is apparent.
f. This ensuresthe infirsion of the fV with the medicationat
the prescribedrate.
g. This confirmsthat the prescribeddoseof medicationhas
beenaddedto the IV solution.
Action 5b: Closingthe lV clamp.
Action 5c Cleaningthe medicationporc
Action 5d: Steadying
bagand uncappingneedle.
c . This detersentry of microorganismswhenthe port is
punctured.
d. This ensuresthat the needleor needleless
deviceenters
the containerandmedicationcanbe dispersedinto the
solution.
e. This mixesthemedicationwith the solution.
Action 5d: Inseningneedleinto port
connnues
ACTIO N
Action 5e: Rotatingsolution to distribute medication.
RATIONALE
ffow rate.
Action 5ft Readiusting
6. Add ttre medication to the IV solution before the infusion:
a. Carefully remove any protective cover and locate
the injection port. Clean with an antimicrobial swab.
b. Uncap the needle or needlelessdevice and insert
into the port. Inject the medication.
c. Withdraw and insert the spike into the proper entry
site on the bag or bottle.
d. With tubing clamped, gently rotate the IV solution
in the bag or bottle. Hang the IV.
e. Attach the labelto the containersothat the doseof
medicationthat hasbeenaddedis apparent.
l. Dispose of equipment according to agencypolicy.
8 . Perform hand hygiene.
9. Chart the addition of medication to the IV solution.
This may be done on the CMAR.
1 0 .Evaluate the patient's responseto medication within
the appropriatetime frame.
a. This detersentry of microorganismswhen the needle
puncturesthe port.
b. This ensuresthat the needle entersthe container and that
medication can be dispersedinto the solution.
c. This puncturesthe seal in the IV bag or bottle.
d. This mixes the medication with the solution.
e. This confirms that the prescribeddose of medication has
been addedto the IV solution.
This preventsinadvertent injury from the equipment.
e1Tors.
Patientsrequire careful observationbecausemedications
given by the IV route may have a rapid effect.
35
T
L i p p i n c o t t ' sP h o t o A t l a so f M e d i c a r i o nA d m i n i s r r a t i o n2, e
EVALUATION
The expected outcomes are met when the medication is added to an adequateamount of fV
solution and mixed appropriately; patient received the medication in a safe and effective way;
patient experiencedno allergy response;patient experiencedno infection; patient understood
reasonsfor procedure; and patient experienceddecreasedanxiety regarding medication infusion.
UnexpectedSituations
and Associated
lnterventions
There is not enoughN solution in container: Obtain new IV fluid from medication station
and add medication. Remove current IV bag and replace with newly admixed IV fluid.
(Some institutions would prefer that the pharmacy mix any new bags so that the process
may be done in a sterile environment.)
Nurse realizes that wrong medication or wrong amount of medication was added to the IV
bag: Immediately stop infusion. Assesspatient for any distressand notify physician. Follow agencypolicy for medication error. Remove bag of IV fluids and replacewith IV containing ordered medication.
Nurse sticksself with needlewhile trying to inject medication into port: Discard syringe
and needle.Preparenew syringe with medicatron.
Needle goes through side ofmedication injection port: Discard syringe,needle,and current
bag of IV solution. Replacewith newly admixed IV fluid. (Some institutions would prefer
pharmacymix any new bags so that the processmay be done in a sterile environment.)
sKltt
I
A medication can be administeredas an IV bolus or push. This involves a single injection of
a concentratedsolution administereddirectlv into an IV line.
Equipment
.
.
.
.
ASSESSMENT
Assesspatient's IV site, noting any swelling, coolness,leakageof fluid from IV site, or pain.
If fluids are infusing through the IV, assessfluid's compatibility with medication to be administered and determine rate at which medication is to be given. Assesspatient for allergies. Assess
patient's knowledge of medication. If patient has a knowledge deficit, this may be an appropriate time to begin educationabout the medication.
NURSING
DIAGNOSIS
. Acute Pain
. Anxiety
Antimicrobial swab
Watch with secondhand, or stopwatch
Disposablegloves
Medication preparedin a syringe with needlessdevice or 23- to 25-gauge,1" needle
(if needlelesssystemin use, needleis not needed).
llii#$
OUTCOME
IDENTIFICATION
AND PLANNING
The expectedoutcome to achievewhen adding a bolus IV medication to an existing IV is
that the IV bolus is given safely. Other outcomesthat may be appropriateinclude the following: patient experiencesno or minimal discomfort; patient experiencesno allergy response;
patient is knowledgeableabout medication being addedby bolus IV; patient remains infection free; and patient has no, or decreased,anxlety.
IMPLEMENTATION
ACTION
RATIONATE
1. Bring equipment to patient's bedside.Check the medication order with the physician's order. Check a drug
resourceto clarify whether medication needsto be
diluted before administration.
Having equipment available savestime and facilitates performance of the task. Checking the order ensuresthat the
patient receivesthe correct medication at the correct time
and in the right manner.
3. Perform hand hygiene. Don clean gloves.
Hand hygiene detersthe spreadof microorganisms.Gloves
protect the nurse from exposureto bloodborne pathogens.
4. Identify patient by checking the identification band on
patient's wrist and asking patient his or her name.
This ensuresthat medication is given to right person.
lV sitefor presenceof inflammationor infiltration.
5. Assess
IV medication must be given directly into a vein for safe
administration.
6. Selectinjectionport on tubing that is closestto
venipuncture site. Clean port with antimicrobial swab.
Using port closestto needleinsertion site minimizes dilution of medication. Cleaning detersentry of microorganisms when port is punctured.
7. Uncap syringe. Steadyport with your nondominant
hand while inserting needlelessdevice or needleinto
center of port.
This suppons injection port and lessensrisk for accidentally
dislodging IV or entering port incorrectly.
injectionport.
Action6: Cleaning
8 . Move your nondominant hand to sectionof IV tubing
systeminto port.
needleless
Action7: lnserting
This minimizes dilution of IV medication with IV solution.
directly behind orjust distal to injection port. Fold
tubing betweenyour fingers to temporarily stop flow
of IV solution.
9 . Pull back slightly on plungerjust until blood appearsin
tubing. If no blood appears,medication may still be administered while assessingIV insertion site for signs of
infiltration.
This ensuresinjection of medication into a vein,
conlnues
t7
ffi€
s h o t oA r l a so f M e d i c a t i o nA d m i n i s r r a t i o n2,e
ACTIO N
RATIONATE
10. Inject medication at recommendedrate (seeSpecial
Considerationsbelow).
This delivers correct amount of medication at proper interval accordins to manufacturer's directions.
Action8: Interrupting
lV ffow.
11. Removeneedle.Do not cap it. Releasetubing and
allow IV to flow at proper rate.
This preventsaccidentalneedlestick.
12. Dispose of syringe in proper receptacle.
Proper disposalpreventsaccidentalinjury and spreadof
microorganisms.
13. Removeglovesand perform handhygiene.
Hand hygiene detersspreadof microorganisms.
14. Chart administration of the medication. This mav be
doneon the CMAR.
eITOrS.
15. Evaluate patient's responseto medication within appropriate time frame.
Patient requires careful observationbecausemedications
given by IV bolus injection may have a rapid effect.
EVATUATION
and Associated
Interventions
The expectedoutcomesare met when the patient receivesthe medication via an IV bolus;
had no, or minimal, discomfort; experiencedno allergy response;understoodrationale for
medication addedby bolus IV; experiencedno infection; and experienceddecreasedanxiety.
Upon assessingpatient's N site before administering medication, nurse notes that N has
infiltrated: Stop IV fluid and remove IV from extremity. RestartIV in a different location,
Continue to monitor new IV site as medication is administered.
While administeringmedication,nurse notesa cloudy, white substanceformingin N tubing:
Stop IV from flowing and stop administering medication. Clamp IV at site nearestto
patient. Tubing will need to be flushed thoroughly to get rid of any remaining precipitate.
Check literature regarding incompatibilities of medications.
while nurse is administering medication,patient begins to complain of pain at IV site:
Stop medication. AssessIV site for any signs of infiltration or phlebitis. You may want to
flush the IV with normal saline to check for patency. If the IV site appearswithin normal
limits, resumemedication administration at a slower rate.
conanues
itififrff
Agency policy may recommendthe following variations when injecting a bolus IV
medication:
. Releasefolded tubing after each increment of the drug has been administeredat prescribed rate to facilitate delivery of medication.
. Use a syringe with I mL normal saline to flush tubing after an IV bolus is delivered to
ensurethat residual medication in tubing is not delivered too rapidly'
Consider how fast IV fluid is flowing to determine whether a flush of normal saline is in
order after administering medication. If IV fluid is flowing less than 50 mL per hour, it
may take medication up to 30 minutes to reach patient. This dependson what type of
tubing is being used in the agency.
If the IV is a small gauge(22 to 24 gaxge)placed in a small vein, a blood return may not
occur even if IV is intact. Also, patient may complain of stinging and pain at site while
medication is being administereddue to irritation of vein. Placing a warm pack over vein
or slowing the rate may relieve discomfort.
SKILL
10
Medications can be administeredby intermittent IV infusion. The drug is mixed with a small
amount of the IV solution (50 to 100 mL) and administeredover a short period at the prescribed interval (eg, every 4 hours). Needlelessdevices (recommendedby the Centersfor
DiseaseControl and Prevention and the Occupational Safety and Health Administration)
prevent needlesticksand provide accessto the primary venousline. Either blunt-ended
cannulasor recessedconnection ports may be used.
A patient with an IV line in place can receive the solution containing the medication by way of
a piggyback setup,a mini-infusion pump, or a volume-control administrationset (eg, Pediatrol
oiVotottot). TheIV piggyback delivery systemrequiresthe intermittent or additive solution to
be placedhigher than the primary solution container.An extensionhook provided by the manufacturer provides for easy lowering of the main fV container. The port on the primary IV line
has a back-checkvalve that automaticallystopsthe flow of the primary solution, allowing the
secondaryor piggyback solution to flow when connected.Becausemanufacturers'designs
vary, cnett ttre directionscarefully for the systemsusedin your agency.The nurseis responsible for calculatingand manually adjustingthe flow rate of the IV intermittent infusion or regulating the infusion with an infusion pump or controller.
The mini-syringe pump for intermittent infusion is battery operatedand allows medication
mixed in a syringe to be connectedto the primary line and delivered by mechanicalpressure
applied to the syringe plunger.
Medications can also be placed in a controlled-volume administration set for intermittent IV
infusion. The medication is diluted with a small amount of solution and administered
through the patient's IV line. This type of equipment is also used for infusing solutions into
childien and older patients when the volume of fluid infused must be monitored carefully.
ffi
s h o t oA c l a so f M e d i c a t i o nA d m i n i s t r a t i o n2.e
Equipment
For Piggyback or Mini-infusion Pump:
. Gloves (optional)
. Medication preparedin labeled piggyback set or syringe (5 to 100 mL)
. Secondaryinfusion tubing (microdrip or macrodrip)
. Needlelessdevice, stopcock, or sterile needle (2I- to 23-gatge)
. Tape
. Metal or plastic hook
. Miniinfusion pump
. Date label for tubing
For Volume-Control Set:
. Gloves (optional)
. Volume-control set (eg, Volutrol, Buretrol, Burette)
. Medication (in vial or ampule)
. Syringe with needlelessdevice attachedor a20- or 2l-gauge needle
. Medication label
ASSESSMENT
Assesspatient for allergies.Assesspatient's knowledge of the medication. If patient has a
knowledge deficit, this may be an appropriatetime to begin education about the medication.
Assesspatient's IV site, noting any swelling, coolness,leaking of fluid from IV site, or pain.
If fluids are infusing through the IV, assessthe fluid's compatibility with the medication to
be administered.
NURSING
DIAGNOSIS
Appropriate nursing diagnosesinclude:
. Acute Pain
OUTCOME
IDENTIFICATION
AND PTANNING
The expectedoutcome to achievewhen administeringIV medicationsby piggyback, volumecontrol administration set, or mini-infusion pump is that the medication is delivered via the
parenteralroute. Other outcomesthat may be appropriateinclude the following: patient
experiencesno or minimal discomfort; patient experiencesno allergy response;patient
remains infection free; and patient understandsthe rationale for medication administration.
IMPLEMENTATION
ACTION
1. Gather equipment and bring to patient's bedside.Check
the medication order againstthe original physician's
order according to agencypolicy.
RATIONATE
Having equipment available savestime and facilitates performance of the task. Checking the order ensuresttrai ttre
and in the risht manner.
ffi
L i p p i n c o t t ' sP h o r oA t l a so f M e d i c a t i o nA d m i n i s t r a t i o n2, e
ACTION
R A T IO N A L E
2. Identify patient by checking identification band on
This ensuresthat the medication is given to the right person.
4. Perform hand hygiene and don gloves.
protect the nurse when connecting setupto an existing IV'
lV sitefor presenceof inflammationor infiltration.
5. Assess
Medication must be administereddirectly into a vein that is
not inflamed to avoid injuring surrounding tissue.
Using Piggyback Infusion
6. Attach infusion tubing to piggyback set containing
diluted medication. Place label on tubing with appropriate date and attach needleor needlelessdevice to
end of tubing according to manufacturer's directions.
Open clamp and prime tubing. Close clamp.
This removes air from tubing and preservessterility of
setup.Tubing for piggyback setup may be used for 48 to
72 hours, dependingon agencypolicy.
7. Hangpiggybackcontaineron lV pole,positioningit
higherthanprimarylV accordingtomanufacturer's
recommendations.Use metal or plastic hook to lower
primary IV.
Position of container influencesflow of IV fluid into
primary setuP.
8. Use antimicrobial swab to clean appropriateport.
This detersentry of microorganismswhen piggyback setup
is connectedto Port.
9. Connectpiggybacksetupto:
a. Needlelessport
b. Stopcock: turn stopcockto "open" position
c. Primary IV line: uncap needleand insert into secondary IV port closestto top of primary tubing. Use
strip of tape to securesecondaryset tubing to primary infusion tubing. Primary line is left unclamped
if port has a backflow valve.
a&b. Needlelesssystemsand stopcock setup eliminate the
need for a needleand are recommendedby the
Centersfor DiseaseControl and Prevention.
stabilizesneedlein infusion port and preventsit
Tape
c.
from slipping out. Backflow valve in primary line secondary port stopsflow of primary infusion while piggyback solution is infusing. Once completed,backflow
valves opensand flow of primary solution resumes.
10. Open clamp on piggyback set and regulate flow at prescribed delivery rate or set for secondaryinfusion on
infusion pump. Monitor medication infusion at periodic
intervals.
Delivery over a 30- to 60-minute interval is usually a safe
method of administering IV medication. It is important to
verify the safe administration rate for each drug to pre-
11. Clamp tubing on piggyback set when solution is
infused. Follow agencypolicy regarding disposal of
equipment.
This reducesrisk for contaminating primary IV setup'
12. Readjustflow rate of primary IV.
Piggyback medication administration may intemrpt normal
flow rate of primary IV' Rate readjustmentmay be
necessary.
vent adverseeffects.
41
42
L r p ; rp . e i s s 1 ) h o r oA r l a so f , \ l e d i c a r i oA
n d m i n i s r r a t i o n2,e
sKttt
10
ACTION
RATIONATE
i
|-!
A c t i o n 7 : P o s i t i o n i n gp r g g y b a c ck o n t a i n e ro n
lV oole
Action 8: Cleaningin.lecrionport.
Action 9: Connectingpiggybackserup to
needlelessoorr
11l
l'l
ll
Action10:Adjusting
primary
lVffuidto administer
piggyback
A c t i o n 1 0 : A d j u s t i n gp u m p r a t e .
Using a Mini-infusion Pump
13. Connectpreparedsyringeto mini-infusiontubing.
Specialtubing connectspreparedmedicationto primary
IV line.
14. Fill tubing with medicationby applying gentlepressure
to syringeplunger.
This removesair from tubing.
15. Insert syringeinto mini-infusionpump accordingto
manufacturer's directions.
Syringemust fit securelyin pump apparatusfor proper
operatlon.
conttnues
43
RATIONALE
ACTION
connec16. Useantimicrobialswabto cleanseappropriate
contor. Connectmini-infusiontubingto appropriate
nector,asin Action9.
17. Programpumpto begininfusion.Setalarmif recommendedby manufacturer.
18. Recheckflow rateof primaryIV oncepumphascompleteddeliveryof medication.
Usinga Volume-ControlAdministrationSet
19. Withdrawmedicationfrom vial or ampuleinto preparedsyringe.SeeSkill 2 or 3.
20. OpenclampbetweenIV solutionandvolume-control
setup.Follow manufacsetor secondary
administration
desiredamountof
fill
with
and
turer'sinstructions
IV solution.Closeclamp.
Action20: Bagwith volumecontrolset
21. Use antimicrobial swab to clean injection port on secondary setup.
22. Remove clamp and insert needleor blunt needleless
device into port while holding syringe steady.Inject
medication. Mix gently with IV solution.
This detersentry of microorganismswhenpiggybacksetup
to port.ProperconnectionallowsIV medis connected
into PrimarYline'
flow
to
ication
Pumpdeliversmedicationat controlledrate' Alarm is recfor usewith IV lock apparanrs.
ommended
Normal flow rateof primary IV may havebeenalteredby
mini-infusionpumP.
Thecorrectdoseis preparedfor dilutionin theIV solution'
This dilutesthe medicationin the minimal amountof solution. Reclampingpreventsthecontinuedadditionof ffuid
to the volumeto be mixed with medication.
Action 20: Adjustingclampbetweenbag
andvolumecontrolset.
This detersentry of microorganismswhenneedlepunctures
port.
This ensuresthatmedicationis evenlymixedwith solution'
connnues
44
L i p p i n c o c t 'Ps h o t oA r l a so f M e d i c a t i o nA d m i n i s t r a t i o n2,e
A C T IO N
RATIONATE
23. Openclampbelowsecondary
setupandregulateat prescribeddeliveryrate.Monitor medicationinfusionat
periodicintervals.
24. Attachthe medicationlabelto the volume-controldevice.
25.Place syringe with uncappedneedlein designated
container.
ction poft.
Delivery over a 30- to 60-minute interval is a safe method
of administering IV medication.
This preventsmedication error.
Proper disposal ofneedle protects the nurse againstaccidental injection. Most accidentalpuncture wounds occur
when recapping needles.
Action 22: Holding syringesteadywhile insertingblunt needlelessdevice inro port and injecting
medication.
27. Chaft administration of medication after it has been
infused. This can be done on the CMAR.
28. Evaluate patient's responseto medication within appropriate time frame.
Patientrequires careful observationbecausemedications
given by the parenteralroute may have a rapid effect.
EITOTS.
conttnues
ACTION
EVALUATION
and Associated
In t e r v e n t i o n s
lnfant and Child
Considerations
R A T IO NA L E
parenteral
The expectedoutcomes are met when the patient has received the medication via the
experiroute; experienced no, or minimal, discomfort; experiencedno allergy response;and
administration'
medication
for
rationale
the
understood
patient
enced no infection; and the
. (Jpon assessingthe N sitebefore administering medication, the nurse notes that the N
IV in a
his infiltrated.-Stop IV fluid and remove the IV from the extremity. Restart the
administered'
is
medication
as
IV
site
different location. Continue to monitor the new
. While administering medication, the nurse notes a cloudy, white substanceforming in the
to prevent
IV tubing: Stop the IV from flowing and stop administering the medication
to the
site
nearest
the
IV
at
the
precipitate from entering the patient's circulation. Clamp
precipitate'
remaining
of
any
rid
to
puti"nt. The tubing will-need io be flushedthoroughly
Alruy, check the literature regarding incompatibilities of medications before administering'
. While nurse is administering-medication,the patient begins to complain of pain at the
phlebitis'
IV site:Stop the medication. Assessthe IV site for any signs of infiltration or
IV
site
If
the
patency.
for
You may *unt to flush the IV with normal saline to check
rate'
a
slower
at
appearswithin normal limits, resumemedication administration
. Small infants and children with fluid restrictions may not tolerate the added IV fluid
children'
neededfor administration with piggyback or volume-control systems'For these
consider using the mini-infusion pump.
s h o t oA t l a so f M e d i c a c i o A
n d m i n i s t r a t i o n2.e
sKtLr.
11
A heparin or saline lock, or intermittent venous accessdevice, is used for patients who require intermittent IV medication but not a continuous IV infusion. This device consistsof a
needleor catheterconnectedto a short length oftubing cappedwith a sealedinjection port.
After the catheteris in place in the patient's vein, the catheterand tubing are anchoredio the
patient's arm so that the catheterremains in place until the patient no longer requires the
repeatedIV medication.
An IV lock allows the patient more freedom than a continuousIV infusion. The patient is
connectedto the IV line when it is time to receive the medication and disconnectedwhen the
medication is completed.A saline flush rather than a heparin flush is used in many agencies
to maintain the patency of the lock. Using saline eliminates any possible systemic effects on
coagulation,developmentof a heparin allergy, and drug incompatibility that may occur
when a heparin solution is used.The intermittent infusion is not starteduntil the nurse confirms IV placement.The saline lock is flushed after the infusion is completed to clear the
vein of any medication. Positive pressureis used when flushing a saline lock to prevent clot
formation in the catheter.
Equipment
.
.
.
.
.
.
.
Medication
Saline vial
Sterile syringe (two) with needlelessdevice or 2l-gaugeneedle
Antimicrobial swabs
Watch with secondhand or stopwatchfeature
Gloves (optional)
For Bolus Injection:
. Sterile syringe (two) with needlelessdevice
For Intermittent IV Delivery:
. Needlelessdevice or25-gauge needle
' IV setup with needlelessdevice attachedto tubing
or a 25-gaugeneedle
. Adhesive tape (optional)
ASSESSE
MN T
Assessthe patient for allergies.Assessthe patient's knowledge of the medication. If patient
has a knowledge deficit, this may be an appropriatetime to begin education about the
medication. Assessthe patient's IV site, noting any swelling, coolness,leaking of fluid from
IV
site,or pain.
NURSING
DIAGNOSIS
Determine related factors for the nursing diagnosesbasedon the patient's current
status.Appropriate nursing diagnosesmay include:
. Acute Pain
OUTCOME
IDENTIFICATION
AND PLANNING
The expectedoutcome to achieve when introducing drugs through a heparin or IV
lock using
the saline flush is that the medication is delivered via the parent;ral route. Other
outcomes
that may be appropriateinclude the following: patient experiencesno or minimal
discomfort;
patient experiencesno allergy response;patient experiencesno infection; and patient
understandsthe rationale for medication administration.
conUnues
IMPLEMENTATION
ACTION
1. Assemble equipment and check physician's order.
Explain procedureto patient.
4. Withdraw 1 to 2 mL of sterile saline from the vial into
the syringe as describedin Skill 3.
5. Don clean gloves and prepareto administer medication'
RATIO NA LE
the right time by the ProPerroute'
This ensuresthat the right patient is receiving the medication. Explanation alleviatesthe patient's apprehension
about IV drug administration.
Using saline eliminates concernsabout drug incompatibilities and the effect on systemic circulation that exists with
heparin.
Gloves protect the nurse's handsfrom contact with the
patient'sblood.
6. For Bolus fV Injection:
a. Checkdrug packagefor correct injection rate for lV
pushroute.
b. Clean port of lock with antimicrobial swab.
c. Stabilize port with your nondominant hand and insert
needlelessdevice or needleof syringe of normal
saline into port.
pon with antimicrobial
swab.
Action6b: Cleaning
d. Aspirate gently and check for blood return (blood retum
doesnot alwaysoccur eventhough lock is patent).
e. Gently flush with 1 mL of normal saline.Remove
syringe.
f. Insert needlelessdevice or needleof syringe with
medication into port and gently inject medication,
using a watch to verify correct injection rate. Do not
is felt. If the lock is
forcethe injectionif resistance
medication
Remove
clogged, it must be changed.
is complete.
when
administration
syringe and needle
a. Using the correct injection rate prevents speedshock
from occurring.
b. Cleaning removes surfacebacteria at the lock entry site.
c. This allows for careful insertion into the center circle of
the lock.
with bluntneedleinto port.
syringe
Action6c: Inserting
d. Blood return usually indicatesthat the catheteris in the
vein.
e . Saline flush ensuresthat the IV line is patent. A patient's
complaint of pain or resistanceto the flush detectedby
the nurse may indicate that the IV line is not patent.
t. Easy installation of medication usually indicates that the
lock is still patent and in the vein. If force is used against
resistance,a clot may break away and causea blockage
elsewherein the body.
47
48
s h o t oA r l a so f M e d i c a t i o nA d m i n i s t r a t i o n2,e
ACTION
RATIONATE
Action 6e: Flushingsalinelock.
g. Remove syringe with medication from port. Stabi_
lize port with your nondominant hand and insert
needlelessdevice or needle of syringe of normal
salineinto port. Slowlyflush reservoirwith 1 to 2 mL
of sterilesalineusingpositivepressure.To gain posi_
tive pressure,you can either clamp the IV tubing as
you are still flushing the last of the saline into the IV
or remove the syringe as you are still flushing the re_
mainder of the saline into the IV. Remove syringe
and discard uncappedneedlesand syringes in the
appropriate receptacle.Remove gloves and discard
appropriately.
g. Positive pressurepreventsblood from backing into IV
catheterand causingthe IV to clot off.
Action69: ClampinglV.
7. For Drug Administration via
an Intermittent Delivery System:
a. Use a drug resourcebook to check for the correct flow
rate of the medication(the usualis 30 to 60 minutes).
b. Connect infusion tubing to medication setup according to manufacturer's directions using sterile technique. Hang IV setup on pole. Open clamp and allow
solution to clear IV tubing of air. Reclamp tubing.
c. Attach needlelessconnector or sterile 25-gauge
needleto end of infusion tubing.
d. Clean port of lock with antimicrobial swab.
e. Stabilize port with your nondominant hand and insert
needlelessdevice or needleof syringe of normal
saline into port.
a. Using the correct injection rate prevents speedshock
from occurring.
b. This removes air from the tubing and preservesthe
sterility of the setup.
c. A small-gaugeneedleprevents damageto the lock.
d. Cleaning removes surfacebacteria at the lock entry site.
e. This allows for careful insertion into the por1.
continues
2e
L i p p i n c o t t ' sP h o t o A t l a so f M e d i c a t i o nA d m i n i s t r a t i o n '
ACTIO N
f. Aspirate gently and check for blood return (blood return
doesnot always occur even though lock is patent)'
g. Gently flush with 1 mL of normal saline.Remove
synnge.
h. Insert blunt needlelessdevice or needle attachedto
tubing into port. Ifnecessary, securewith tape'
i. Open clamp and regulate flow rate or attach to IV
pump or controller according to manufacturer's directions. Close clamp when infusion is complete'
j. Remove needlelessconnectoror needle from lock'
Carefully replaceuncapped,used needleor needleless
device with a new sterile one' Allow medication setup
to hang on pole for future use according to agency
policy. Stabilize port with your nondominant hand
and insert needlelessdevice or needle of syringe of
normal saline into the port' Slowlyflush the reservoir
with 1 to 2 mL of sterilesalineusingpositivepressure'
49
R A T IO N A L E
f. Blood return usually indicatesthat the catheteris in
the vein.
g. Saline flush ensuresthat the IV line is patent'
h. Tape securesthe needlein the lock port'
i. This ensuresthat the patient receivesthe medication
at the correct rate.
j. This preventspossibleneedlestickwith contaminated
needle. Agency policy specifies length of time for safe
use of IV infusion tubing. Saline clears the line of medication with less of the systemic effects of the heparin
flush. Positive pressureprevents blood from backing
into IV catheter and causing the IV to clot off'
L r p p r n c o t r 'Psh o r oA t l a so f M e d i c a t i o nA d m i n i s r r a r i o n2 ,e
ACTIO N
RATIONALE
Action7h: Attachingtubingto salinelock.
To gain positive pressure,you can either clamp the IV
tubing as you are still flushing the last ofthe salineinto
9. Check injection site and IV lock at least every g hours
and administer a small amount of saline (2 to 3 mL) if
medicationis not given at leastevery g to 12 hours.
10. Changeheparinlockat least every72to 96 hoursor
11. Chart administrationof medicationor salineflush.
This ensurespatency of systemfor continuing injections.
Changing a heparin lock regularly and having it free of clot_
ted blood reducesdangersof infection and emboli in the
circulating blood.
erTor.
conilnues
L i p p i n c o r t 'P
s h o t oA t l a so f M e d i c a t i o nA d m i n i s t r a c i o 2n e'
ACTION
RATIONATE
tubingfrom lock.
Action7i: Removing
EVALUATION
and Associated
lnterventions
lnfant and Child
Considerations
via the parThe expectedoutcomesare met when the patient has received the medication
enteral route; experiencedno or minimal discomfort; experiencedno allergy response;
remains infection free; and understoodthe rationale for medication administration'
, (Jpon assessingthe IV site before administering medication, nurse notes that the N has
location'
iifiltrated: Stop IV fluid andiemove IV from extremity. RestartIV in a different
Continue to monitor new IV site as medication is administered'
. While nurse is administering medication,patient begins to complain of pain at the N site:
phlebitis' You may
Stop the medication. Assessthe IV site for any signs of infiltration or
site appearswithin
IV
If
the
want to flush the IV with normal saline to check for patency.
normal limits, resumemedication administration at a slower rate.
. Nursenotes white, cloudy particles forming in lock during medication administration:
from lock' Insert
Stop administering the medication. Remove needleor needlelessdevice
attempting
plunger,
on
needle or needlelessdevice attachedto empty syringe and pull back
on
IV
lock
to remove any fluid remaining in lock. If unable to pull back fluid, change
changed'
to
be
need
before resuming medication aJministration. Entire IV setup and lock may
. As nurse is attempting to accesslock, needleor tip of syringe touchespatient's arm:
Discard needle and syringe. Preparenew dose for administration'
. Some agenciesrecommendthe use of single-dosesaline vials without preservativein the
phlebitis with heparin
solution. Preservativesmay be linked to an increasedincidence of
locks. RoshanKetab 02I-669 50 639
. If the volume of medication being administeredis small (<1.0 mL), always include the
take this into
amount of flush solution as part of the total amount to be injected and
if the medication
account when determining how fast to push a medication' For example,
to be
solution
of
amount
total
the
and
per
minute
-l
t.o
is to be injected at a ftteor
solution volume
injected iiZ.ZSmL (0.25 mL medication volume plus 2.0 mL saline flush
2 minutes
equals2.25 m1),then the medication would be injected over a period of
15 seconds.
51
L i p p i n c o t r ' sP h o r o A t l a so f M e d i c a t i o nA d m i n i s t r a t i o n 2. e
SKILL
12
Eyedropsare instilled for their local effects, such as for pupil dilation or constriction when
examining the eye, for treating an infection, or to help control intraocular pressure(for patients
with glaucoma).The type and amount of solution dependon the purposeof the instillation.
Equipment
.
.
.
.
ASSESSE
MN T
Assessthe patient for allergies.Assessthe affected eye for any drainage,erythema,or
swelling. Assessthe patient's knowledge of medication. If patient has a knowledge deficit,
this may be an appropriatetime to begin education about the medication.
NURSING
DIAGNOSIS
. Risk for Injury
OUTCOME
IDENTIFICATION
AND PLANNING
The expectedoutcome to achieve when administering eyedropsis that the medication is
delivered successfullyinto the eye. Other outcomesthat may te appropriateinclude the
following: patient experiencesno allergy response;patient's
free from injury;
"y".onuin,
and patient understandsthe rationale for medication administratron.
Gloves
Medication
Tissue, washcloth
IMPTEMENTATION
ACTION
RATIONATE
1' Bring equipment to patient's bedside.Check medication
order againstoriginal physician's order according to
agencypolicy'
Having equipment available savestime and facilitates performance oftask. Checking the order ensuresthat the
2. Identify patienr by checking identification band on
Ask patient about any allergies.
Explanation allays patient anxrety.
4. Perform hand hygiene and don gloves.
protect the nurse when coming in contact with drainage
from eyes (solution or tears).
5. Offer tissue to patient.
Solution and tearsmay spill from the eye during the
procedure.
6. Cleansethe eyetidsand eyelashes
ofany drainagewith a
washclothmoistenedwith normalsalinesolution, proceedingfrom the inner canthusto the outer canthus.Use
eachareaofthe washclothonly once.
7' Tilt patient's head back stightly. The head may be turned
slightly to the affected side'
Debris can be carried into the eye when the conjunctival sac
is exposed.By using eachareaofwashcloth once and
going from the inner canthusto the outer canthus,debris
is kept away from the lacrimal duct.
Tilting patient's head back slightly makes it easierto reach
the conjunctival sac.This should be avoided ifthe patient
has a cervical spine injury. Turning the head to the af_
fected side helps to prevent solution or tearsfrom flowins
toward the opposite eye.
ACTIO N
fr
lidsandlashes
Action6: Cleaning
8. Remove cap from medication bottle, being careful to
not touch the inner side of the caP.
9. Invert the monodrip plastic containerthat is commonly
used to instill eyedrops.Have patient look up and focus
on somethingon the ceiling.
53
R A T IO N A L E
Action7: Positionin
Touching the inner side of the cap may contaminatethe
bottle of medication.
By having the patient look up and focus on somethingelse,
the procedureis less traumatic.
10. Place thumb or two fingers near margin of lower eyelid
immediately below eyelashes,and exert pressure
downward over bony prominenceof cheek.Lower conjunctival sac is exposedas lower lid is pulled down.
The eyedrop should be placed in the conjunctival sac,not
directly on the eYeball.
11. Hold droppercloseto eye,but avoidtouchingeyelidsor
containerand allow prescribednumber
lashes.Squeeze
ofdrops to fall in lowerconiunctivalsac.
Touching the eye, eyelids, or lashescan contaminatethe
medication in the bottle; startle the patient, causingblinking; or injure the eye. Do not allow medication to fall
onto cornea.This may injure the corneaor causethe
patient to have an unpleasantsensation.
Action 10: Holdingeyein Position.
conilnues
L i p p i n c o t r 'P
s h o t oA t l a so f M e d i c a t i o nA d m i n i s t r a t r o n2 .e
ACTION
RATIONALE
12. Releaselower lid after eyedropsare instilled. Ask
patient to close eyes gently.
This allows the medication to be distributed over the
entire eye.
13. Apply gentle pressureover inner canthusto prevenr
eyedropsfrom flowing into tear duct.
This minimizes the risk of systemic effects from the
medication.
Action 12: Eyesclosed.
e.
14. Instruct patient not to rub affected eye.
15. Remove gloves and perform hand hygiene.
16. Chart administration of medication. This may be done
on the CMAR.
17. Evaluate patient's responseto medication within appro_
priate time frame.
This preventsinjury andirritationto eye.
Handhygienedetersthe spreadof microorganisms.
Accuratedocumentation
is necessary
to preventmedication
EITOTS.
The patient needsto be evaluatedfor any adverseaffects
from the medication.
EVATUATION
The expectedoutcomesare met when the patient has received the eyedrops;experienced
no
adverseaffects, including allergy responseor injury; and understoodthe rationale for
the
medication administration.
and Associated
Interventions
' Drop is placed on eyelid or outer margin
of eyelid due to patient blinking or moving: Do
not count this drop in total number of drops administered.Allow the patient to regain
composure and proceed with application of medication.
' Nurse cannot open eyelids due to dried
crust and matting of eyelids..Place a warm wet
washcloth over the eye and allow it to remain there for approximately 3 minutes. you
may
need to repeatthis procedureif there is a large amount of matting.
-Bottle
' Bottle comesin contact with eyeball when
applying medicatiow
is contaminated;
discard appropriately.Notify pharmacy or retrieve new bottle for oncoming shift.
Infant and Child
Considerations
' To apply eyedropsin a small child, two
or more people may be neededto restrain the
child. Make surethe child does not reach up to the eye for fear ofjabbing the medication
bottle into the eye.
SKILL
13
Drugs are instilled into the auditory canal for their local effect. They are used to soften wax,
relieve pain, apply local anesthesia,destroy organisms,or destroy an insect lodged in the
canal, which can causealmost intolerable discomfort. If the ear canal has swollen to the
point that medication cannot pass,a long piece of cotton material called a wick is inserted so
that one end is near the middle ear and the other end is external. This cotton acts as a wick to
help medication get to the inner ear.
The tympanic membraneseparatesthe external ear from the middle ear. Normally, it is intact
and closesthe entranceto the middle ear completely. If it is ruptured or has been openedby
surgical intervention, the middle ear and the inner ear have a direct passageto the external
ear. When this occurs, instillations should be performed with the greatestof care to prevent
forcing materialsfrom the outer ear into the middle ear and the inner ear. Sterile techniqueis
used to prevent infection.
Equipment
.
.
.
.
.
.
ASSESSMENT
Assessthe affected ear for any drainageor tenderness.Assessthe patient for allergies'
Assessthe patient's knowledge of medication. If the patient has a knowledge deficit about
the medication, this may be an appropriatetime to begin education'
NURSING
DIAGNOSIS
. Anxiety
. Acute Pain
OUTCOME
IDENTIFICATION
AND PLANNING
The expectedoutcome to achievewhen administering eardropsis that drops are administered
successfully.Other outcomesthat may be appropriateinclude the following: patient understandsthe rationale for the ear drop instillation and has decreasedanxiety; patient remains
free from pain; and patient experiencesno allergy response.
Medication (warmedto3'7oC[98.6'F])
Tissue
Cotton ball (optional)
Gloves (optional)
Washcloth (optional)
IMPLEMENTATION
ACTION
l. Bring equipment to patient's bedside.Check physician's
order.
patient's wrist and asking patient his or her name' Ask
patient regarding any medication allergies.
4. Perform hand hygiene and don gloves (gloves are to be
worn if drainageis present).
RATIONATE
Having equipment available savestime and facilitates performance of task. Checking the order ensuresthat the
This ensuresthat the medication is given to the right person'
from ear.
r
L i p p i n c o t t ' sP h o r o A t l a so f M e d i c a t i o nA d m i n i s t r a t i o n2. e
ACTION
RATIONATE
5. Offer tissue to patient.
Solution may spill from the ear during the procedureand
run toward the eye.
6. Cleanseexternal ear of any drainagewith cotton ball or
washclothmoistenedwith normal saline.
Debris and drainagemay prevent some of the medication
from entering the ear canal.
7 . Place patient on unaffected side in bed, or if ambulatory, have patient sit with head well tilted to the side so
that affected ear is uppermost.
This positioning preventsthe drops from escapingfrom
the ear.
8. Draw up amount of solution neededin dropper. Do not
return excessmedication to stock bottle. A prepackaged monodrip plastic container may also be used.
Risk for contamination is increasedwhen medication is
returned to the stock bottle.
9. Straightenauditorycanalby pullingcartilaginouspor,
tion of pinna up and backin an adult and down and back
in an infant or a child youngerthan 3 years,
Pulling on the pinna as describedhelps to straightenthe
canal properly for ear drop instillation.
Action 7: Adult positioned
for eardrop instillarion
Action9: Technique
for administering
eardropsin adult.
continues
L i p p i n c o t t ' sP h o t o A t l a so f M e d i c a t i o nA d m i n i s t r a t i o n 2, e
ACTION
10. Hold dropper in ear with its tip above auditory canal.
For an infant or an irrational or confusedpatient, protect dropper with a piece of soft tubing to help prevent
injury to ear.
11. Allow dropsto fall on sideof canal.
57
R A T IO N A T E
By holding the dropper in the ear, the majority of medication will enter the ear canal. The hard tip of the dropper
can damagethe tympanic membraneif it is jabbed into
the ear.
is
It uncomfortable for the patient if drops fall directly onto
the tympanic membrane.
12. Releasepinna after instilling drops, and have patient
maintain the position to prevent escapeof medication.
Medication should remain in ear canal for at least 5 minutes'
13. Gently presson tragus a few times.
Pressingon tragus causesmedication from canal to move
toward tympanic membrane.
Cotton ball can help prevent medication from leaking out of
14. If ordered, loosely insert a cotton ball into ear canal.
ear canal.
15. Remove gloves and perform hand hygiene.
16. Document medicationadministrationand any drainage
from ear noted.Documentationmav be done on CMAR.
to tragus.
Action 13: Applyingpressure
This provides accuratedocumentationand helps to prevent
medication errors.
Action 14: Cotton ball insertedin ear.
continues
EVATUATION
The expectedoutcomesare met when the patient has received the eardropssuccessfully;
understoodthe rationale for ear drop instillation and exhibited no or decreasedanxiety;
experiencedno or minimal pain; and experiencedno allergy response.
and Associated
Interventions
Medication runsfrom ear into eye: Notify physician and check with the pharmacy. Eye
irrigation may need to be performed.
Patient complains of extremepain when nursepresseson tregus: Allow patient to presson
tragus.If pain is too much, this part may be deferred.
Infant and Child
Considerations
Distraction techniques,such as TV or a quiet toy, may be helpful when attempting to keep
a child quiet for 5 minutes. Reading to the child may not be appropriatebecausethe child's
hearing may be compromisedduring medication administration.
sKltt
14
Nasal instillations are used to treat allergies, sinus infections, and nasal congestion.Medications with a systemic effect, such as vasopressin,may also be preparedas a nasal instillation.
The noseis normally not a sterile cavity, but becauseof its connection with the sinuses.
medical asepsisshould be observedcarefully when using nasal instillations.
Equipment
.
.
.
.
ASSESSMENT
Assessthe patient for allergies.Assessthe patient's knowledge of medication. If the patient
has a knowledge deficit about the medication, this may be an appropriatetime to begin
education.Assessthe naresfor any drainageor broken skin.
NURSING
DIAGNOSIS
. Risk for Impaired Skin
. Acute Pain
OUTCOME
IDENTIFICATION
AND PTANNING
The expectedoutcome to achieve when instilling nose drops is that the medication is administered successfully.Other outcomesthat may be appropriateinclude the following: patient
understandsthe rationale for the nose drop instillation; patient experiencesno allergy
response;patient's skin remains intact; patient experiencesno, or minimal, pain.
Medication
Gloves
Tissue
IMPTEMENTATION
ACTION
58
RATIONATE
l' Bring equipment to patient's bedside.Check physician's
order'
Having equipment available savestime and facilitates performance oftatk. Checking the order ensuresthat the
patient's wrist and asking patient his or her name.Also
ask patient regarding any medication allergies.
ffi
ACTIO N
RATIONATE
4. Perform hand hygiene and don gloves (gloves are to be
worn if drainageis present).
from nose.
5 , Providepatientwith papertissuesand askpatientto
Blowing the nose clearsthe nasal mucosaprior to medication administration.
blowhisor her nose.
is lying down, tilt headback over a pillow.
Thesepositionsallow the solution to flow well back into the
nares.Do not tilt headif patient has a cervical spineinjury.
Draw sufficient solution into dropper for both nares.
Do not return excesssolution to a stock bottle.
Returning solution to a stock bottle increasesthe risk for
contamination of the stock bottle.
6. Have patient sit up with head tilted well back. If patient
n
Action 6: Patientpositionedfor nosedrops.
8. Hold tip of noseup and place dropperjust inside naris,
about one third of an inch. Instill prescribednumber of
drops in one naris and then into the other. Protect dropper with a piece of soft tubing if patient is an infant or
young child. Avoid touching naris with dropper.
Action 7: Drawingup nosedrops.
The soft tubing will protect the patient's naresfrom injury
during administration of medication. Touching the naris
may causethe patient to sneezeand will contaminatethe
dropper.
Action 8: Administeringnosedrops.
continues
tffim
60
9. Have patient remain in position with head tilted back
for a few minutes.
10. Document medication administration and any drainage
from nose noted. Documentation may be done on the
CMAR.
Tilting the head back preventsthe escapeof the medication.
This provides accuratedocumentationand helps to prevent
medication errors.
EVATUATION
The expectedoutcomesare met when the patient has received the nose drops successfully;
understoodthe rationale for nosedrop instillation; and experiencedno allergy response;
patient's skin remainedintact; and patient experiencedno, or minimal, pain or discomfort.
and Associated
Interventions
. Patient sneezesimmediatelyafter receiving nosedrops: Do not repeatthe dosage,because
you cannot determinehow much medication was actually absorbed.
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Photo Atlas of Medication Administration 2009

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