SmartNurse

COMPARING VENOUS ACCESS DEVICES

2012-02-05T17:08:00.000-08:00

Most I.V. infusions are delivered through one of three basic types of venous access devices: an over-the-needle cannula, a through-the-needle cannula, or a winged infusion set. To improve I.V. therapy and guard against accidental needle sticks, you can use a needle-free system and shielded or retracting peripheral I.V. catheters.

Over-the-needle cannula

Purpose:

Long-term therapy for an active or agitated patient

Advantages:

Makes accidental puncture of the vein less likely than with a needle; more comfortable for the patient when it's in place; contains radiopaque thread for easy location. Some units come with a syringe that permits easy check of blood return; some units include wings.

Disadvantage:

More difficult to insert than other devices.

Through-the-needle cannula

Purpose:

Long-term therapy for an active or agitated patient

Advantages:

Makes accidental puncture of the vein less likely than with a needle; more comfortable for the patient when it's in place; available in many lengths; most plastic cannulas contain radiopaque thread for easy location. One variant, the peripherally inserted central catheter, is commonly inserted in the antecubital vein by a specially trained nurse.

Disadvantages:

Leaking at the site, especially in an elderly patient. The cannula may be severed during insertion if pulled back through the needle.

Winged infusion set

Purpose:

Short-term therapy for cooperative adult patient; therapy of any duration for a neonate or a child or for an elderly patient with fragile or sclerotic veins

Advantages:

Less painful to insert; ideal for I.V. push drugs.

Disadvantages:

May easily cause infiltration if a rigid-needle winged infusion device is used.

Peripheral I.V. Line Insertion

2012-01-27T18:31:00.000-08:00

بِسۡمِ ٱللهِ ٱلرَّحۡمَـٰنِ ٱلرَّحِيمِ

Peripheral I.V. line insertion involves selection of a venipuncture device and an insertion site, application of a tourniquet, preparation of the site, and venipuncture. Selection of a venipuncture device and site depends on the type of solution to be used; frequency and duration of infusion; patency and location of accessible veins; the patient's age, size, and condition; and, when possible, the patient's preference.
If possible, choose a vein in the nondominant arm or hand. Preferred venipuncture sites are the cephalic and basilic veins in the lower arm and the veins in the dorsum of the hand; least favorable are the leg and foot veins because of the increased risk of thrombophlebitis. Antecubital veins can be used if no other venous access is available, to accommodate a large-bore needle, or to administer drugs that require large-volume dilution.
A peripheral line allows administration of fluids, medication, blood, and blood components and maintains I.V. access to the patient. Insertion is contraindicated in a sclerotic vein, an edematous or impaired arm or hand, or a postmastectomy arm and in patients with a mastectomy, burns, or an arteriovenous fistula. Subsequent venipunctures should be performed proximal to a previously used or injured vein.

Equipment
Alcohol pads or other approved antimicrobial solution, such as tincture of iodine 2% or 10% povidone-iodine ; gloves ; tourniquet (rubber tubing or a blood pressure cuff) ; I.V. access devices ; I.V. solution with attached and primed administration set ; I.V. pole ; sharps container ; sterile 2â€³ Ã— 2â€³ gauze pads or a transparent semipermeable dressing ; 1â€³ hypoallergenic tape â€¢ optional: arm board, roller gauze, tube gauze, warm packs, scissors.
Commercial venipuncture kits come with or without an I.V. access device. In many facilities, venipuncture equipment is kept on a tray or cart, allowing choice of correct access devices and easy replacement of contaminated items.

Preparation of equipment
Check the information on the label of the I.V. solution container, including the patient's name and room number, type of solution, time and date of its preparation, preparer's name, and ordered infusion rate. Compare the physician's orders with the solution label to verify that the solution is the correct one. Then select the smallest-gauge device that's appropriate for the infusion (unless subsequent therapy will require a larger one). Smaller gauges cause less trauma to veins, allow greater blood flow around their tips, and reduce the clotting risk.
If you're using a winged infusion set, connect the adapter to the administration set, and unclamp the line until fluid flows from the open end of the needle cover. Then close the clamp and place the needle on a sterile surface, such as the inside of its packaging. If you're using a catheter device, open its package to allow easy access.

Implementation
Place the I.V. pole in the proper slot in the patient's bed frame. If you're using a portable I.V. pole, position it close to the patient.
Hang the I.V. solution with attached primed administration set on the I.V. pole.
Verify the patient's identity by comparing the information on the solution container with the patient's wristband.
Wash your hands thoroughly. Then explain the procedure to the patient to ensure his cooperation and reduce anxiety. Anxiety can cause a vasomotor response resulting in venous constriction.
Selecting the site
Select the puncture site. If long-term therapy is anticipated, start with a vein at the most distal site so that you can move proximally as needed for subsequent I.V. insertion sites. For infusion of an irritating medication, choose a large vein distal to any nearby joint. Make sure the intended vein can accommodate the cannula.
Place the patient in a comfortable, reclining position, leaving the arm in a dependent position to increase capillary fill of the lower arms and hands. If the patient's skin is cold, warm it by rubbing and stroking the arm, or cover the entire arm with warm packs for 5 to 10 minutes.
Applying the tourniquet
Apply a tourniquet about 6" (15 cm) above the intended puncture site to dilate the vein (as shown at top of next page). Check for a radial pulse. If it isn't present, release the tourniquet and reapply it with less tension to prevent arterial occlusion.

Lightly palpate the vein with the index and middle fingers of your nondominant hand. Stretch the skin to anchor the vein. If the vein feels hard or ropelike, select another.
If the vein is easily palpable but not sufficiently dilated, one or more of the following techniques may help raise the vein. Place the extremity in a dependent position for several seconds, and gently tap your finger over the vein or rub or stroke the skin upward toward the tourniquet. If you have selected a vein in the arm or hand, tell the patient to open and close his fist several times.
Leave the tourniquet in place for no longer than 3 minutes. If you can't find a suitable vein and prepare the site in that time, release the tourniquet for a few minutes. Then reapply it and continue the procedure.
Preparing the site
Put on gloves. Clip the hair around the insertion site if needed. Clean the site with alcohol pads or another approved antimicrobial solution, according to your facility's policy.
NURSING ALERT Don't apply alcohol after applying 10% povidone-iodine because the alcohol negates the beneficial effect of the povidone-iodine.
Work in a circular motion outward from the site to a diameter of 2â€³ to 4â€³ (5 to 10 cm) (as shown below) to remove flora that would otherwise be introduced into the vascular system with the venipuncture. Allow the antimicrobial solution to dry.

If ordered, administer a local anesthetic. Make sure the patient isn't sensitive to lidocaine.
Lightly press the vein with the thumb of your nondominant hand about 1Â½â€³ (4 cm) from the intended insertion site. The vein should feel round, firm, fully engorged, and resilient.
Grasp the access cannula. If you're using a winged infusion set, hold the short edges of the wings (with the needle's bevel facing upward) between the thumb and forefinger of your dominant hand. Then squeeze the wings together. If you're using an over-the-needle cannula, grasp the plastic hub with your dominant hand, remove the cover, and examine the cannula tip. If the edge isn't smooth, discard and replace the device. If you're using a through-the-needle cannula, grasp the needle hub with one hand, and unsnap the needle cover. Then rotate the access device until the bevel faces upward.
Using the thumb of your nondominant hand, stretch the skin taut below the puncture site to stabilize the vein.

Tell the patient that you are about to insert the device.
Hold the needle bevel up and enter the skin directly over the vein at a 15- to 25-degree angle.

Aggressively push the needle directly through the skin and into the vein in one motion. Check the flashback chamber behind the hub for blood return, signifying that the vein has been properly accessed. (You may not see a blood return in a small vein.)
Then level the insertion device slightly by lifting the tip of the device up to prevent puncturing the back wall of the vein with the access device.
If you're using a winged infusion set, advance the needle fully, if possible, and hold it in place. Release the tourniquet, open the administration set clamp slightly, and check for free flow or infiltration.
If you're using an over-the-needle cannula, advance the device to at least half its length to ensure that the cannula itselfâ€”not just the introducer needleâ€”has entered the vein. Then remove the tourniquet.
Grasp the cannula hub to hold it in the vein, and withdraw the needle. As you withdraw it, press lightly on the catheter tip to prevent bleeding.

Advance the cannula up to the hub or until you meet resistance.
To advance the cannula while infusing I.V. solution, release the tourniquet and remove the inner needle. Using sterile technique, attach the I.V. tubing and begin the infusion. While stabilizing the vein with one hand, use the other to advance the catheter into the vein. When the catheter is advanced, decrease the I.V. flow rate. This method reduces the risk of puncturing the vein's opposite wall because the catheter is advanced without the steel needle and because the rapid flow dilates the vein.
To advance the cannula before starting the infusion, first release the tourniquet. While stabilizing the vein and needle with one hand, use the other to advance the catheter off the needle and further into the vein up to the hub. Next, remove the inner needle and, using sterile technique, quickly attach the I.V. tubing. This method often results in less blood being spilled.

If you're using a through-the-needle cannula, remove the tourniquet, hold the needle in place with one hand and, with your opposite hand, grasp the cannula through the protective sleeve. Then slowly thread the cannula through the needle until the hub is within the needle collar. Never pull back on the cannula without pulling back on the needle to avoid severing and releasing the cannula into the circulation, causing an embolus. If you feel resistance from the valve, withdraw the cannula and needle slightly and reinsert them, rotating the cannula as you pass the valve. Then withdraw the metal needle, split the needle along the perforated edge (according to the manufacturer's instructions), and carefully remove it from around the cannula. Dispose of the needle pieces appropriately. Remove the stylet and protective sleeve, and attach the administration set to the cannula hub. Open the administration set clamp slightly, and check for free flow or infiltration.
Dressing the site
After the venous access device has been inserted, clean the skin completely. If necessary, dispose of the stylet in a sharps container. Then regulate the flow rate.
You may use a transparent semipermeable dressing to secure the device.

If you don't use a transparent dressing, cover the site with a sterile gauze pad or small adhesive bandage.
Loop the I.V. tubing on the patient's limb, and secure the tubing with tape. The loop allows some slack to prevent dislodgment of the cannula from tension on the line.
Label the last piece of tape with the type, gauge of needle, and length of cannula; date and time of insertion; and your initials. Adjust the flow rate as ordered.
If the puncture site is near a movable joint, place an arm board under the joint and secure it with roller gauze or tape to provide stability because excessive movement can dislodge the venous access device and increase the risk of thrombophlebitis and infection.
When an arm board is used, check frequently for impaired circulation distal to the infusion site.

Removing a peripheral I.V. line
A peripheral I.V. line is removed on completion of therapy, for cannula site changes, and for suspected infection or infiltration; the procedure usually requires gloves, a sterile gauze pad, and an adhesive bandage.
To remove the I.V. line, first clamp the I.V. tubing to stop the flow of solution. Then gently remove the transparent dressing and all tape from the skin.
Using sterile technique, open the gauze pad and adhesive bandage and place them within reach. Put on gloves. Hold the sterile gauze pad over the puncture site with one hand, and use your other hand to withdraw the cannula slowly and smoothly, keeping it parallel to the skin. (Inspect the cannula tip; if it isn't smooth, assess the patient immediately, and notify the physician.)
Using the gauze pad, apply firm pressure over the puncture site for 1 to 2 minutes after removal or until bleeding has stopped.
Clean the site and apply the adhesive bandage or, if blood oozes, apply a pressure bandage.
If drainage appears at the puncture site, send the tip of the device and a sample of the drainage to the laboratory to be cultured according to your facility's policy. (A draining site may or may not be infected.) Then clean the area, apply a sterile dressing, and notify the physician.
Instruct the patient to restrict activity for about 10 minutes and to leave the dressing in place for at least 1 hour. If the patient experiences lingering tenderness at the site, apply warm packs and notify the physician.
Special considerations
ELDER ALERT Apply the tourniquet carefully to avoid pinching the skin. If necessary, apply it over the patient's gown. Make sure skin preparation materials are at room temperature to avoid vasoconstriction resulting from lower temperatures.
If the patient is allergic to iodine-containing compounds, clean the skin with alcohol.
If you fail to see blood flashback after the needle enters the vein, pull back slightly and rotate the device. If you still fail to see flashback, remove the cannula and try again or proceed according to your facility's policy.
Change a gauze or transparent dressing whenever you change the administration set (every 48 to72 hours or according to your facility's policy).
Be sure to rotate the I.V. site, usually every 48 to 72 hours or according to your facility's policy.
Home care
Most patients who receive I.V. therapy at home have a central venous line. But if you're caring for a patient going home with a peripheral line, you should teach him how to care for the I.V. site and identify certain complications. If the patient must observe movement restrictions, make sure he understands them.
Teach the patient how to examine the site, and instruct him to notify the physician or home care nurse if redness, swelling, or discomfort develops; if the dressing becomes moist; or if blood appears in the tubing.
Also tell the patient to report any problems with the I.V. line, for instance, if the solution stops infusing or if an alarm goes off on an infusion pump. Explain that the I.V. site will be changed at established intervals by a home care nurse.
If the patient is using an intermittent infusion device, teach him how and when to flush it. Finally, teach the patient to document daily whether the I.V. site is free from pain, swelling, and redness.
Complications
Peripheral line complications can result from the needle or catheter (infection, phlebitis, and embolism) or from the solution (circulatory overload, infiltration, sepsis, and allergic reaction).

Documentation
In your notes or on the appropriate I.V. sheets, record the date and time of the venipuncture; type and gauge of the needle and length of the cannula; anatomic location of the insertion site; and reason the site was changed.
Also document the number of attempts at venipuncture (if you made more than one), type and flow rate of the I.V. solution, name and amount of medication in the solution (if any), any adverse reactions and actions taken to correct them, patient teaching and evidence of patient understanding, and your initials.

Volume-Control Sets

2011-12-21T17:57:00.000-08:00

A volume-control set is an I.V. line with a graduated chamber that delivers precise amounts of fluid and shuts off when the fluid is exhausted, preventing air from entering the I.V. line. It may be used as a secondary line in adults for intermittent infusion of medication.

PEDIATRIC ALERT A volume-control set is used as a primary line in children for continuous infusion of fluids or medication.

Equipment

Volume-control set , I.V. pole (for setting up a primary I.V. line) , I.V. solution , 20G to 22G 1â€³ needle or needle-free adapter , alcohol pads , medication in labeled syringe , tape , label.

Although various models of volume-control sets are available, each one consists of a graduated fluid chamber (120 to 250 ml) with a spike and a filtered air line on top and administration tubing underneath. Floating-valve sets have a valve at the bottom that closes when the chamber empties; membrane-filter sets have a rigid filter at the bottom that, when wet, prevents the passage of air.

Preparation of equipment

Ensure the sterility of all equipment, and inspect it carefully to ensure the absence of flaws. Take the equipment to the patient's bedside.

Implementation

Wash your hands, and explain the procedure to the patient. If an I.V. line is already in place, observe its insertion site for signs of infiltration and infection.
Remove the volume-control set from its box and close all the clamps.
Remove the protective cap from the volume-control set spike, insert the spike into the I.V. solution container, and hang the container on the I.V. pole.
Open the air vent clamp and close the upper slide clamp. Then open the lower clamp on the I.V. tubing, slide it upward until it's slightly below the drip chamber, and close the clamp (as shown at top of next page).

If you're using a valve set, open the upper clamp until the fluid chamber fills with about 30 ml of solution. Then close the clamp, and carefully squeeze the drip chamber until it is half full.
If you're using a volume-control set with a membrane filter, open the upper clamp until the fluid chamber fills with about 30 ml of solution, and then close the clamp.
Open the lower clamp, and squeeze the drip chamber flat with two fingers of your opposite hand (as shown below). If you squeeze the drip chamber with the lower clamp closed, you'll damage the membrane filter.

Keeping the drip chamber flat, close the lower clamp. Now release the drip chamber so that it fills halfway.
Open the lower clamp, prime the tubing, and close the clamp. To use the set as a primary line, insert the distal end of the tubing into the catheter or needle hub. To use the set as a secondary line, attach a needle to the adapter on the volume-control set. Wipe the Y-port of the primary tubing with an alcohol pad, and insert the needle. Then tape the connection.
If you're using a needle-free system, attach the distal end of the tubing to the Y-port of the primary tubing, following the manufacturer's instructions.
To add medication, wipe the injection port on the volume-control set with an alcohol pad and inject the medication. Place a label on the chamber, indicating the drug, dose, and date. Don't write directly on the chamber because the plastic absorbs ink.
Open the upper clamp, fill the fluid chamber with the prescribed amount of solution, and close the clamp. Gently rotate the chamber (as shown below) to mix the medication.

Turn off the primary solution (if present) or lower the drip rate to maintain an open line.
Open the lower clamp on the volume-control set, and adjust the drip rate as ordered. After completion of the infusion, open the upper clamp and let 10 ml of I.V. solution flow into the chamber and through the tubing to flush them.
If you're using the volume-control set as a secondary I.V. line, close the lower clamp and reset the flow rate of the primary line. If you're using the set as a primary I.V. line, close the lower clamp, refill the chamber to the prescribed amount, and begin the infusion again.

Special considerations

Always check compatibility of the medication and the I.V. solution. If you're using a membrane-filter set, avoid administering suspensions, lipid emulsions, blood, or blood components through it.
If you're using a floating-valve set, the diaphragm may stick after repeated use. If it does, close the air vent and upper clamp, invert the drip chamber, and squeeze it. If the diaphragm opens, reopen the clamp and continue to use the set.
If the drip chamber of a floating-valve diaphragm set overfills, immediately close the upper clamp and air vent, invert the chamber, and squeeze the excess fluid from the drip chamber back into the graduated fluid chamber.

Documentation

If you add a drug to the volume-control set, record the amount and type of medication, amount of fluid used to dilute it, and date and time of infusion.

Common Symptom of Hemorrhoid

2011-11-24T20:16:00.000-08:00

Human has been blessed with an anus, it is fair to assume that he has also been doubly blessed with haemorrhoids. The word ‘‘haemorrhoid’’is derived from the Greek haema (blood) and rhoos (flowing), and it was probably Hippocrates(460 BC) who was the first to apply thename to the flow of blood from the veins of the anus.

for more information, click this link http://benmari.blogspot.com/2011/11/common-presenting-symptom-of.html

Teaching Your Patient About I.V. Therapy

2011-11-14T21:31:00.000-08:00

Many patients are apprehensive about peripheral I.V. therapy. So before you begin therapy, tell your patient what to expect before, during, and after the procedure. Thorough patient teaching can reduce anxiety, making therapy easier. Follow these guidelines.

Before insertion

Describe the procedure. Tell him that â€œintravenousâ€ means inside the vein and that a plastic catheter or needle will be placed in his vein. Explain that fluids containing nutrients or medications will flow from a bag or bottle through a length of tubing and then through the plastic catheter or needle into his vein.
Tell him about how long the catheter or needle will stay in place. Explain that the physician will decide how much and what type of fluid the patient needs.
If the patient will receive a local anesthetic at the insertion site, ask him if he's allergic to lidocaine. If in doubt, use another anesthetic. Tell him that this injection will numb the site to reduce the pain of I.V. device insertion.
If no anesthetic will be used, tell the patient that he may feel transient pain at the insertion site but that the discomfort will stop when the catheter or needle is in place.
Tell him that I.V. fluid may feel cold at first but that this sensation should last only a few minutes.

During therapy

Instruct the patient to report any discomfort after the catheter or needle has been inserted and the fluid has begun to flow.
Explain any restrictions as ordered. As appropriate, tell the patient that he may be able to walk and, depending on the insertion site and the device, to shower or take a tub bath during therapy.
Teach him how to care for the I.V. line. Tell him not to pull at the insertion site or tubing, not to remove the container from the I.V. pole, and not to kink the tubing or lie on it. Instruct him to call a nurse if the flow rate suddenly slows or speeds up.

At removal

Explain that removing a peripheral I.V. line is a simple procedure. Tell the patient that pressure will be applied to the site until the bleeding stops. Reassure him that when the device is out and the bleeding stops, he'll be able to use the affected arm or leg as before therapy.

WHEN TO USE AN IN-LINE FILTER

2011-11-08T19:47:00.000-08:00

An in-line filter removes pathogens and particles from I.V. solutions, helping to reduce the risk of infusion phlebitis. But because in-line filters are expensive and their installation is cumbersome and time-consuming, they aren't used routinely. Many facilities allow use of an in-line filter only when administering an admixture. If you're unsure of whether to use a filter, check your facility's policy or follow this list of do's and don'ts.

Do's

Use an in-line filter:

when administering solutions to an immunodeficient patient.
when administering total parenteral nutrition.
when using additives comprising many separate particles, such as antibiotics requiring reconstitution, or when administering several additives.
when using rubber injection ports or plastic diaphragms repeatedly.
when phlebitis is likely to occur.

Be sure to change the in-line filter according to the manufacturer's recommendations (typically every 24 to 36 hours). If you don't, bacteria trapped in the filter releases endotoxin, a pyrogen small enough to pass through the filter into the bloodstream.

Use an add-on filter of larger pore size (1.2 microns) when infusing lipid emulsions and albumin mixed with nutritional solutions.

Don'ts

Don't use an in-line filter:

when administering solutions with large particles that will clog a filter and stop I.V. flow, such as suspensions, lipid emulsions, and high-molecular-volume plasma expanders. These require specialized filters.
when administering a drug dose of 5 mg or less because the filter may absorb it.

Tips and Strategies for Studying Pharmacology

2011-11-01T22:19:00.000-07:00

There is a question like this: "There are so many drugs, trade names, side effects, etc. I can't possibly remember it all, so any suggestions on how to study?"
I found that we had to do multiple things to learn Pharm.

Concentrate on therapeutic classifications and their prototypes.
Compare a newly encountered drug with a prototype when possible.
Try to understand how the drug acts in the body.
Concentrate your study efforts on major characteristics.
Keep an authoritative, up-to-date drug reference readily available, preferably at work and home.
Use your own words when taking notes or writing drug information cards.
Mentally rehearse applying drug knowledge in nursing care.

Peripheral I.V. Therapy Preparation

2011-10-17T05:02:00.000-07:00

Selection and preparation of appropriate equipment are essential for accurate delivery of an I.V. solution. Selection of an I.V. administration set depends on the rate and type of infusion desired and the type of I.V. solution container used. Two types of drip sets are available: the macrodrip and the microdrip. The macrodrip set can deliver a solution in large quantities at rapid rates because it delivers a larger amount with each drop than the microdrip set. The microdrip set, used for pediatric patients and certain adult patients who require small or closely regulated amounts of I.V. solution, delivers a smaller quantity with each drop.

Administration tubing with a secondary injection port permits separate or simultaneous infusion of two solutions; tubing with a piggyback port and a backcheck valve permits intermittent infusion of a secondary solution and, on its completion, a return to infusion of the primary solution. Vented I.V. tubing is selected for solutions in nonvented bottles; nonvented tubing is selected for solutions in bags or vented bottles. Assembly of I.V. equipment requires sterile technique to prevent contamination, which can cause local or systemic infection.

Equipment

I.V. solution â€¢ alcohol pad â€¢ I.V. administration set â€¢ in-line filter, if needed â€¢ I.V. pole â€¢ medication and label, if necessary.

Preparation of equipment

Verify the type, volume, and expiration date of the I.V. solution. Discard outdated solution. If the solution is contained in a glass bottle, inspect the bottle for chips and cracks; if it's in a plastic bag, squeeze the bag to detect leaks. Examine the I.V. solution for particles, abnormal discoloration, and cloudiness. If present, discard the solution and notify the pharmacy or dispensing department. If ordered, add medication to the solution, and place a completed medication-added label on the container. Remove the administration set from its box, and check for cracks, holes, and missing clamps.

Implementation

Wash your hands thoroughly to prevent introducing contaminants during preparation.
Slide the flow clamp of the administration set tubing down to the drip chamber or injection port, and close the clamp.

Preparing a bag

Place the bag on a flat, stable surface or hang it on an I.V. pole.
Remove the protective cap or tear the tab from the tubing insertion port.
Remove the protective cap from the administration set spike.
Holding the port firmly with one hand, insert the spike with your other hand.
Hang the bag on the I.V. pole, if you haven't already, and squeeze the drip chamber until it is half full.

Preparing a nonvented bottle

Remove the bottle's metal cap and inner disk, if present.
Place the bottle on a stable surface and wipe the rubber stopper with an alcohol pad.
Remove the protective cap from the administration set spike, and push the spike through the center of the bottle's rubber stopper. Avoid twisting or angling the spike to prevent pieces of the stopper from breaking off and falling into the solution.
Invert the bottle. If its vacuum is intact, you'll hear a hissing sound and see air bubbles rise (this may not occur if you've already added medication). If the vacuum isn't intact, discard the bottle and begin again.
Hang the bottle on the I.V. pole, and squeeze the drip chamber until it's half full.

Preparing a vented bottle

Remove the bottle's metal cap and latex diaphragm to release the vacuum. If the vacuum isn't intact (except after medication has been added), discard the bottle and begin again.
Place the bottle on a stable surface and wipe the rubber stopper with an alcohol pad.
Remove the protective cap from the administration set spike, and push the spike through the insertion port next to the air vent tube opening.
Hang the bottle on the I.V. pole, and squeeze the drip chamber until it's half full.

Priming the I.V. tubing

If necessary, attach a filter to the opposite end of the I.V. tubing, and follow the manufacturer's instructions for filling and priming it. Purge the tubing before attaching the filter to avoid forcing air into the filter and, possibly, clogging some filter channels. Most filters are positioned with the distal end of the tubing facing upward so that the solution will completely wet the filter membrane and all air bubbles will be eliminated from the line. (See When to use an in-line filter.)
If you aren't using a filter, aim the distal end of the tubing over a wastebasket or sink and slowly open the flow clamp. (Most distal tube coverings allow the solution to flow without having to remove the protective cover.)
Leave the clamp open until the I.V. solution flows through the entire length of tubing to release trapped air bubbles and force out all the air.
Invert all Y-ports and backcheck valves and tap them, if necessary, to fill them with solution.
After priming the tubing, close the clamp. Then loop the tubing over the I.V. pole.
Label the container with the patient's name and room number, date and time, container number, ordered rate and duration of infusion, and your initials.

Special considerations

Before initiation of I.V. therapy, the patient should be told what to expect. (See Teaching your patient about I.V. therapy)
Always use sterile technique when preparing I.V. solutions. If you contaminate the administration set or container, replace it with a new one to prevent introducing contaminants into the system.
If necessary, you can use vented tubing with a vented bottle. To do this, don't remove the latex diaphragm. Instead, insert the spike into the larger indentation in the diaphragm.
Change I.V. tubing every 48 or 72 hours according to your facility's policy or more frequently if you suspect contamination. Change the filter according to the manufacturer's recommendations or sooner if it becomes clogged.

Documentation

Document the type of solution used and any additives added to the solution.

Intravascular Therapy

2011-10-10T21:09:00.000-07:00

More than 80% of hospitalized patients receive some form of I.V. therapy. Although you may not be called on to insert all types of I.V. lines, you'll be responsible for maintaining the lines and preventing complications throughout therapy. You'll also be responsible for helping the physician perform minor surgical procedures, such as insertion of central venous (CV) and arterial lines.

This chapter explains the administration methods and primary uses of I.V. therapy. You'll review how to prepare for I.V. therapy; how to insert, maintain, and remove specific I.V. lines and devices; how to control infection and maintain flow rates; and how to monitor the patient's response to therapy. You'll also learn about patient-teaching responsibilities and home care issues.

I.V. DELIVERY METHODS

The factors involved in choosing an I.V. delivery method include the therapy's purpose and duration; the patient's diagnosis, age, and health history; and the condition of his veins. For example, in peripheral I.V. therapy, you'll administer I.V. solutions through a vein in the arm, hand, leg, or footâ€”typically, for short-term or intermittent therapy.

In CV therapy, you'll give I.V. solutions through a central vein such as the superior vena cava. These lines are often inserted through the subclavian and the internal or external jugular veins. This method is typically used for patients who need a large volume of fluid or a hypertonic solution, caustic drug, or high-calorie parenteral nutrition solution. Midline and peripherally inserted central catheters are used both in home care and in health care facilities. Implanted vascular access devices provide a variation on CV infusion. The infused solution enters a central vein through an access device surgically implanted in a subcutaneous pocket. This method is used for patients who require long-term (months to years) I.V. therapy.

Uses of I.V. therapy

The most common uses of I.V. therapy are maintaining and restoring fluid and electrolyte balance, administering drugs, transfusing blood, and delivering parenteral nutrition.

The I.V. route allows rapid, effective drug administration. Commonly infused drugs include antibiotics, thrombolytics, histamine₂-receptor antagonists, antineoplastic agents, cardiovascular drugs, anticonvulsants, and patient-controlled analgesics. Usually, you'll give an I.V. drug over a short periodâ€”in some cases by direct injection, called I.V. push. (See chapter 5, Drug administration.)

With blood transfusion, your nursing responsibilities include administering blood and blood components as well as monitoring patients receiving therapy. Transfusion aims to maintain adequate blood volume, prevent cardiogenic shock, increase the blood's oxygen-carrying capacity, and maintain hemostasis.

Parenteral nutrition is the administration of nutrients by the I.V. route. Low-concentration parenteral nutrition solutions are administered through a peripheral vein; more highly concentrated ones are administered through a central vein. If you're caring for a patient who is receiving parenteral nutrition, you'll need to know how to recognize changes in fluid and electrolyte status and in glucose, amino acid, mineral, and vitamin levels. You'll also need to judge your patient's response to the nutrient solution and to detect early signs of complications.

Patient teaching

Many patients are apprehensive about I.V. therapy. To allay their fears, you can provide information that explains and clarifies this therapy. Use pamphlets and videotapes if available. If possible, show the patient the actual equipment, and explain how it will be used during therapy.

Allow the patient to express fears and concerns, and convey reassurance by answering his questions fully. You may want to involve a family member or caregiver in these discussions to further reassure the patient.

Home I.V. therapy

More and more patients are receiving I.V. therapy at home. Home therapy benefits patients by making them feel more comfortable and allowing them to perform many of their normal activities. Its lower cost benefits both patients and health care facilities.

Home care patients may receive fluids or such medications as antibiotics, antifungals, chemotherapeutic agents, insulin, chelating agents, and analgesics. Some blood products have been given at home after an initial transfusion in a health care facility.

Candidates for home I.V. therapy should be selected carefully. Such patients must be willing and able to administer therapy safely, learn the potential complications and interventions, understand the basics of asepsis, and obtain the necessary supplies. Patients who need help must enlist a home caregiver, such as a family member or friend, to assist them in administering I.V. therapy.

When teaching the home care patient, demonstrate procedures and answer any questions. Have the patient or family members give return demonstrations whenever possible. Teaching should begin in the facility and be completed before the patient is discharged. You may want to include a family member or caregiver in your patient teaching.

Documentation

You need to document I.V. therapy for many reasons. First, an accurate description of your care provides legal protection for you and the facility. Furthermore, thorough documentation furnishes health care insurers with the records they need of the equipment and supplies used. You may document I.V. therapy on progress notes, a special I.V. therapy sheet or flowchart, or a nursing plan of care on the patient's chart. You also must document it on the intake and output sheet.

Drug Implants

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A newer method of advanced drug delivery involves implanting drugs beneath the skinâ€”subdermally or subcutaneouslyâ€”as well as targeting specific tissues with radiation implants.

With subdermal implants, flexible capsules are placed under the skin. The drug most commonly administered by this method is levonorgestrel, a synthetic hormone used for long-term contraception. Small Silastic capsules filled with the hormone are placed under the skin of the patient's upper arm, and the drug then diffuses through the capsule walls continuously.

With subcutaneous implants, drug pellets are injected into the skin's subcutaneous layer. The drug is then stored in one area of the body, called a depot. A newer treatment for prostate cancer cells calls for implants of goserelin acetate, a synthetic form of luteinizing hormone. By inhibiting pituitary gland secretion, goserelin implants reduce testosterone levels to those previously achieved only through castration. This reduction causes tumor regression and suppression of symptoms.

Radiation drug implants with a short half-life may be placed inside a body cavity, within a tumor or on its surface, or in the area from which a tumor has been removed. Implants that contain iodine 125 are used for lung and prostate tumors; gold 198, for oral and ocular tumors; and radium 226 and cesium 137, for tongue, lip, and skin therapy. These implants are usually inserted by a physician with a nurse assisting. Some specially trained nurses may insert or inject intradermal implants. Radiation implants are usually put in place in an operating room or a radiation oncology suite.

Equipment

For subdermal implants

Sterile surgical drapes â€¢ sterile gloves â€¢ antiseptic solution â€¢ local anesthetic â€¢ set of implants â€¢ needles â€¢ 5-ml syringe â€¢ #11 scalpel â€¢ #10 trocar â€¢ forceps â€¢ sutures â€¢ sterile gauze â€¢ tape.

For subcutaneous implants

Alcohol pad â€¢ drug implant in a preloaded syringe â€¢ local anesthetic (for some patients).

For radiation implants

RADIATION PRECAUTION sign for the patient's door â€¢ warning labels for the patient's wristband and personal belongings â€¢ film badge or pocket dosimeter â€¢ lead-lined container â€¢ long-handled forceps â€¢ masking tape â€¢ portable lead shield.

Implementation

Explain the procedure and its benefits and risks to the patient, and show her a set of implants.

Inserting subdermal implants

Assist the patient into a supine position on the examination table. During the procedure, stay and provide support as necessary.
After anesthetizing the upper portion of the nondominant arm, the physician will use a trocar to insert each capsule through a 2-mm incision. After insertion, he'll remove the trocar and palpate the area. He'll then close the incision and cover it with a dry compress and sterile gauze.

The steps below describe how levonorgestrel subdermal contraceptive implants are inserted:

Have the patient lie supine on the examination table and flex the elbow of her nondominant arm so that her hand is opposite her head.
Swab the insertion site with antiseptic solution. (The ideal insertion site is inside the upper arm about 3â€³ to 4â€³ [7.5 to 10 cm] above the elbow.)
Cover the arm above and below the insertion site with sterile surgical drapes.
The physician fills a 5-ml syringe with a local anesthetic, inserts the needle under the skin, and injects a small amount of anesthetic into several areas, each about 1Â½â€³ to 2â€³ (4 to 5 cm) deep, in a fanlike pattern.
The physician uses the scalpel to make a small, shallow incision (about 2 mm) through the skin.
Next, he inserts the tip of the trocar through the incision at a shallow angle beneath the skin. He makes sure the trocar bevel is up so that he can place the capsules in a superficial plane. He advances the trocar slowly to the first mark near the hub of the trocar. The tip of the trocar should now be about 1Â½â€³ to 2â€³ from the incision site. The physician then removes the obturator and loads the first capsule into the trocar.
He gently advances the capsule with the obturator toward the tip of the trocar until he feels resistance. Next, he inserts each succeeding capsule beside the last one in a fanlike pattern. With the forefinger and middle finger of his free hand, he fixes the position of the previous capsule, advancing the trocar along the tips of his fingers. This ensures a suitable distance of about 15 degrees between capsules and keeps the trocar from puncturing the previously inserted capsules.

Inserting subcutaneous implants

Help the patient into the supine position, and drape him so that his abdomen is accessible. Remove the syringe from the package, and make sure you can see the drug in the chamber. Clean a small area on the patient's upper abdominal wall with the alcohol pad.
As you stretch the skin at the injection site with one hand, grip the needle with the fingers of your other hand around the barrel of the syringe. Insert the needle into subcutaneous fat at a 45-degree angle. Don't attempt to aspirate. If blood appears in the syringe, withdraw the needle and inject a new preloaded syringe and needle at another site. Don't attempt to aspirate. If blood appears in the syringe, withdraw the needle and inject a new preloaded syringe and needle at another site.
Next, change the direction of the needle so that it's parallel to the abdominal wall. With the barrel hub touching the patient's skin, push the needle in. Then withdraw it about Â½â€³ (1.3 cm) to create a space for the drug. Depress the plunger. Withdraw the needle and bandage the site.
Inspect the tip of the needle. If you can see the metal tip of the plunger, the drug has been discharged.

Inserting radiation implants

To prepare for a radiation implant, first place the lead-lined container and long-handled forceps in a corner of the patient's room. With masking tape, mark a safe line on the floor 6â€² (2 m) from the bed to warn visitors of the danger of radiation exposure. Place the lead shield in the back of the room to wear when providing care.
Place an emergency tracheotomy tray in the room if an implant will be inserted in the patient's mouth or neck.
To insert the implant, the physician makes a small incision in the skin and creates a pocket in the tissue. He inserts the implant and closes the incision. If the patient is being treated for tonsillar cancer, he'll undergo a bronchoscopy, during which radioactive pellets are implanted in tonsillar tissue.
Your role in the implant procedure is to explain the treatment and its goals to the patient. Review radiation safety procedures and visitation policies. Talk with the patient about long-term physical and emotional aspects of the therapy, and discuss home care.

Special considerations

Special care may be necessary, depending on the type of implant used.

Subdermal implants

Tell the patient to resume normal activities but to protect the site during the first few days after implantation. Advise her not to bump the insertion site and to keep the area dry and covered with a gauze bandage for 3 days.
Tell the patient to report signs of bleeding or infection at the insertion site.
Tell the patient to notify the physician immediately if one of the implanted capsules falls out before the skin heals over the implants. If it's a contraceptive implant, it may no longer be effective. Advise the patient to use alternative means of contraception until she sees the physician. If pregnancy is suspected, the implants must be removed immediately.

Subcutaneous implants

Be aware that if an implant must be removed, a physician will order an X-ray to locate it.
Tell the patient to check the administration site for signs of infection or bleeding.
Goserelin implants must be changed every 28 days. Female patients should be advised to use a nonhormonal form of contraception.

Radiation implants

Know that if laboratory work is required during treatment, a technician wearing a film badge will obtain the specimen, affix a RADIATION PRECAUTION label to the specimen container, and alert laboratory personnel. If urine tests are needed, ask the radiation oncology department or laboratory technician how to transport the specimens safely.
Minimize your own exposure to radiation. Wear a personal, nontransferable film badge or dosimeter at waist level during your entire shift. Turn in the film badge regularly. Pocket dosimeters measure immediate exposure.
Use the three principles of time, distance, and shielding. Time: Plan to give care in the shortest time possible. Less time equals less exposure. Distance: Work as far away from the radiation source as possible. Give care from the side opposite the implant or from a position that allows the greatest working distance possible. Prepare the patient's meal trays outside his room. Shielding: Wear a portable shield, if necessary.
Make sure that the patient's room is monitored daily by the radiation oncology department and that disposable items are monitored and removed according to your facility's policy.
Keep away staff members and visitors who are pregnant or trying to conceive or father a child. The gonads and a developing embryo or fetus are highly susceptible to the damaging effects of ionizing radiation.
If you must take the patient out of his room, notify the appropriate department of the patient's status to allow time for the necessary preparations.
Collect a dislodged implant with long-handled forceps, and place it in a lead-lined container.
A patient with a permanent implant may not be released until his radioactivity level is less than 5 millirems per hour at a distance of about 3â€² (1 m).
If a patient with an implant dies while on the unit, notify the radiation oncology staff so that a temporary implant can be properly removed and stored. If the implant was permanent, the staff will also determine which precautions should be followed after postmortem care measures.

Complications

Complications vary, depending on the type of implant used.

Subdermal implants

Possible reactions to levonorgestrel include hyperpigmentation at the insertion site, menstrual irregularities, headache, nervousness, nausea, dizziness, adnexal enlargement, dermatitis, acne, appetite and weight changes, mastalgia, hirsutism, and alopecia. More serious reactions include breast abnormalities, mammographic changes, diabetes, elevated cholesterol or triglyceride levels, hypertension, seizures, depression, and gallbladder, heart, or kidney disease.

Subcutaneous implants

Goserelin implants may cause anemia, lethargy, pain, dizziness, insomnia, anxiety, depression, headache, chills, fever, edema, heart failure, arrhythmias, stroke, hypertension, peripheral vascular disease, nausea, vomiting, diarrhea, impotence, renal insufficiency, urinary obstruction, rash, sweating, hot flashes, gout, hyperglycemia, weight increase, and breast swelling and tenderness.

Radiation implants

Depending on the implant site and dosage, complications include implant dislodgment, tissue fibrosis, xerostomia, radiation pneumonitis, airway obstruction, muscle atrophy, sterility, vaginal dryness or stenosis, fistulas, altered bowel habits, diarrhea, hypothyroidism, infection, cystitis, myelosuppression, neurotoxicity, and secondary cancers.

Documentation

For subdermal and subcutaneous implants, document the name of the drug, insertion or administration site, date and time of insertion, and patient's response to the procedure. Note the date that implants should be removed and a new set inserted or the date of the next administration, as appropriate.

For radiation implants, document radiation precautions taken during treatment, adverse reactions, patient and family teaching and their responses, patient's tolerance of isolation procedures and the family's compliance with procedures, and referrals to local cancer services.

ADMINISTERING INTRAPLEURAL DRUGS

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In intrapleural administration, the physician injects a drug into the pleural space using a catheter.

Help the patient lie on one side with the affected side up. The physician inserts a needle into the fourth to eighth intercostal space, 3â€³ to 4â€³ (7.6 to 10 cm) from the posterior midline. He then advances the needle medially over the superior edge of the patient's rib through the intercostal muscles until it tangentially penetrates the parietal pleura, as shown. The catheter is advanced into the pleural space through the needle, which is then removed.

INTRAPLEURAL DRUGS

2011-09-18T18:18:00.000-07:00

An intrapleural drug is injected through the chest wall into the pleural space or instilled through a chest tube placed intrapleurally for drainage. Physicians use intrapleural administration to promote analgesia, treat spontaneous pneumothorax, resolve pleural effusions, and administer chemotherapy.

Intrapleurally administered drugs diffuse across the parietal pleura and innermost intercostal muscles to affect the intercostal nerves. During intrapleural injection of a drug, the needle passes through the intercostal muscles and parietal pleura on its way to the pleural space.

The internal intercostal muscle is a key landmark for needle placement. It resists the advancing needle, becoming the posterior intercostal membrane in the posterior chest region.

Drugs commonly given by intrapleural injection include tetracycline, streptokinase, anesthetics, and chemotherapeutic agents (to treat malignant pleural effusion or lung adenocarcinoma).

Contraindications for this route include pleural fibrosis or adhesions, which interfere with diffusion of the drug to the intended site; pleural inflammation; sepsis; and infection at the puncture site. Patients with bullous emphysema and those receiving respiratory therapy using positive end-expiratory pressure also shouldn't have intrapleural injections because the injections may exacerbate an already compromised pulmonary condition.

Equipment

An intrapleural drug is given through a #16 to #20 or #28 to #40 chest tube if the patient has empyema, pleural effusion, or pneumothorax. Otherwise, it's given through a 16G to 18G blunt-tipped intrapleural (epidural) needle and catheter. Accessory equipment depends on the type of access device the physician uses. All equipment must be sterile.

For intrapleural catheter insertion

Gloves â€¢ gauze â€¢ antiseptic solution, such as povidone-iodine â€¢ drape â€¢ local anesthetic, such as 1% lidocaine â€¢ 3- or 5-ml syringe with 22G 1â€³ and 25G 5/8â€³ needles â€¢ 18G needle or scalpel â€¢ 16G to 18G blunt-tipped intrapleural needle and catheter â€¢ saline-lubricated glass syringe â€¢ dressings â€¢ sutures â€¢ tape.

For chest tube insertion

Towels â€¢ gloves â€¢ gauze â€¢ antiseptic solution, such as povidone-iodine â€¢ 3- or 5-ml syringe â€¢ local anesthetic, such as 1% lidocaine â€¢ 18G needle or scalpel â€¢ chest tube with or without trocar (#16 to #20 catheter for air or serous fluid, #28 to #40 catheter for blood, pus, or thick fluid) â€¢ two rubber-tipped clamps â€¢ sutures â€¢ drain dressings â€¢ tape â€¢ thoracic drainage system and tubing.

For drug administration

Sterile gloves â€¢ sterile gauze pads â€¢ povidone-iodine solution â€¢ prescribed medication â€¢ appropriate-sized needles and syringes â€¢ 1% lidocaine, if necessary â€¢ dressings â€¢ tape.

Implementation

Explain the procedure to the patient to allay his fears. Encourage him to follow instructions.

Inserting an intrapleural catheter

The physician inserts the intrapleural catheter at the patient's bedside with the nurse assisting.
Position the patient on his side with the affected side up. The physician will insert the catheter into the fourth to eighth intercostal space, 3â€³ to 4â€³ (7.6 to 10 cm) from the posterior midline. (See Administering intrapleural drugs.)
The physician puts on sterile gloves, cleans around the puncture site with antiseptic-soaked gauze, and then covers the area with a sterile drape. Next, he fills the 3- or 5-ml syringe with local anesthetic and injects it into the skin and deep tissues.
The physician punctures the skin with the 18G needle or scalpel, which helps the blunt-tipped intrapleural needle penetrate the skin over the superior edge of the lower rib in the chosen interspace. Keeping the bevel tilted upward, he directs the needle medially at a 30- to 40-degree angle to the skin. When the needle tip punctures the posterior intercostal membrane, he removes the stylet and attaches a saline-lubricated glass syringe containing 2 to 4 cc of air to the needle hub.
During puncture, tell the patient to hold his breath (or momentarily disconnect him from mechanical ventilation) until the needle is removed to help prevent the needle from injuring lung tissue.
The physician advances the needle slowly. When the needle punctures the parietal pleura, negative intrapleural pressure moves the plunger outward. He then removes the syringe from the needle and threads the intrapleural catheter through the needle until he has advanced it about 2â€³ (5 cm) into the pleural space. Without removing the catheter, he carefully withdraws the needle.
Tell the patient that he can breathe again (or reconnect mechanical ventilation).
After inserting the catheter, the physician coils it to prevent kinking and then sutures it securely to the patient's skin. He confirms placement by aspirating the catheter. Resistance indicates correct placement in the pleural space; aspirated blood means that the catheter probably is misplaced in a blood vessel, and aspirated air means that it's probably in a lung. He will then order a chest X-ray to detect pneumothorax.
Apply a sterile dressing over the insertion site to prevent catheter dislodgment. Take the patient's vital signs every 15 minutes for the 1st hour after the procedure and then as needed.

Inserting a chest tube

The physician inserts the chest tube with the nurse assisting. (For more information on chest tube insertion, Respiratory care.)
First, position the patient with the affected side up, and drape him with sterile towels.
The physician puts on gloves and cleans the appropriate site with antiseptic-soaked gauze. If the patient has a pneumothorax, the physician uses the second intercostal space as the access site because air rises to the top of the pleural space. If the patient has a hemothorax or pleural effusion, the physician uses the sixth to eighth intercostal space because fluid settles to the bottom of the pleural space.
The physician fills the syringe with a local anesthetic and injects it into the site. He makes a small incision with the 18G needle or scalpel, inserts the appropriate-sized chest tube, and immediately connects it to the thoracic drainage system or clamps it close to the patient's chest. He then sutures the tube to the patient's skin.
Tape the chest tube to the patient's chest distal to the insertion site to help prevent accidental dislodgment. Also tape the junction of the chest tube and drainage tube to prevent their separation. Apply sterile drain dressings, and tape them to the site.
After insertion, the physician checks tube placement with an X-ray. Check the patient's vital signs every 15 minutes for 1 hour and then as needed. Auscultate his lungs at least every 4 hours to assess air exchange in the affected lung. Diminished or absent breath sounds mean that the lung hasn't reexpanded.

Administering the medication

The physician injects medication through the intrapleural catheter or chest tube with the nurse assisting.
If the patient will receive chemotherapy, expect to give an antiemetic at least 30 minutes beforehand.
Position the patient with the affected side up. Help the physician move the dressing away from the intrapleural catheter or chest tube and clamp the drainage tube, if present.
The physician disinfects the access port of the catheter or chest tube with antiseptic-soaked gauze. Draw up the appropriate medication dose, and hand it to the physician with the vial for verification.
The physician injects the medication. If it's an anesthetic, he gives a bolus or loading dose initially and then a continuous infusion. For tetracycline, he mixes it with an anesthetic such as lidocaine to alleviate pain during injection.
Reapply the dressings around the catheter. Monitor the patient closely during and after drug administration to gauge the effectiveness of drug therapy and to check for complications and adverse effects.

Special considerations

Make sure the patient has signed a consent form.
Before catheter insertion, ask the patient to urinate to promote comfort. If the patient is receiving a continuous infusion, label the solution bag clearly. Cover all injection ports so that other drugs aren't injected into the pleural space accidentally.
If the chest tube dislodges, cover the site at once with a sterile gauze pad and tape it in place. Stay with the patient, monitor his vital signs, and observe carefully for signs and symptoms of tension pneumothorax: hypotension, distended jugular veins, absent breath sounds, tracheal shift, hypoxemia, dyspnea, tachypnea, diaphoresis, chest pain, and weak, rapid pulse. Have another nurse call the physician and gather the equipment for reinsertion.
Keep rubber-tipped clamps at the bedside. If a commercial chest tube system cracks or a tube disconnects, use the clamps to clamp the chest tube close to the insertion site temporarily. Be sure to observe the patient closely for signs of tension pneumothorax because no air can escape from the pleural space while the tube is clamped.
You can wrap a piece of petroleum gauze around the chest tube at the insertion site to make an airtight seal; then apply the sterile dressing. After the chest tube is removed, use petroleum gauze to dress the wound; then cover it with a new piece of sterile gauze.
After the catheter is removed, inspect the skin at the entry site for signs of infection and then cover the wound with a sterile dressing.

Complications

Pneumothorax or tension pneumothorax may occur if the physician accidentally injects air into the pleural cavity. These complications are more likely to occur in a patient who is on mechanical ventilation.

Accidental catheter placement in the lung can lead to respiratory distress; catheter placement within a vessel can increase the medication's effects. With catheter fracture, lung puncture may occur. Laceration of intercostal vessels can cause bleeding.

Local anesthetic toxicity can lead to tinnitus, metallic taste, light-headedness, somnolence, visual and auditory disturbances, restlessness, delirium, slurred speech, nystagmus, muscle tremor, seizures, arrhythmias, and cardiovascular collapse. A local anesthetic containing epinephrine can cause tachycardia and hypertension.

Intrapleural chemotherapeutic drugs can irritate the pleura chemically and cause such systemic effects as neutropenia and thrombocytopenia. Administering intrapleural tetracycline without an anesthetic can cause pain.

The insertion site can become infected. However, meticulous skin preparation, strict sterile technique, and sterile dressings usually prevent infection.

Documentation

Document the drug administered, drug dosage, patient's response to the treatment, and condition of the catheter insertion site.

Administering Endotracheal Drugs

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In an emergency, some drugs may be given through an endotracheal (ET) tube if I.V. access isn't available. They may be given using the syringe method or the adapter method.

Before injecting any drug, check for proper placement of the ET tube, using your stethoscope. Make sure that the patient is supine and that her head is level with or slightly higher than her trunk.

Syringe method

Remove the needle before injecting medication into the ET tube. Insert the tip of the syringe into the ET tube, and inject the drug deep into the tube (as shown above).

Adapter method

A device recently developed for ET drug administration provides a more closed system of drug delivery than the syringe method. A special adapter placed on the end of the ET tube (as shown below) allows needle insertion and drug delivery through the closed stopcock.

Endotracheal Drugs

2011-09-04T19:57:00.000-07:00

When an I.V. line isn't readily available, drugs can be administered into the respiratory system through an endotracheal (ET) tube. This route allows uninterrupted resuscitation efforts and avoids such complications as coronary artery laceration, cardiac tamponade, and pneumothorax, which can occur when emergency drugs are administered intracardially.

Drugs given endotracheally usually have a longer duration of action than drugs given I.V. because they're absorbed in the alveoli. For this reason, repeat doses and continuous infusions must be adjusted to prevent adverse effects. Drugs most commonly given by this route include atropine, epinephrine, and lidocaine.

Endotracheal drugs are usually administered in an emergency situation by a physician, an emergency medical technician, or a critical care nurse. Although guidelines may vary, depending on state, county, or city regulations, the basic administration method is the same. (See Administering endotracheal drugs.)

Endotracheal drugs may be given using the syringe method or the adapter method. Usually used for bronchoscopy suctioning, the swivel adapter can be placed on the end of the tube and, while ventilation continues through a bag-valve device, the drug can be delivered with a needle through the closed stopcock.

Equipment

ET tube â€¢ gloves â€¢ stethoscope â€¢ handheld resuscitation bag â€¢ prescribed drug â€¢ syringe or adapter â€¢ sterile water or normal saline solution.

Preparation of equipment

Verify the order on the patient's medication record by checking it against the physician's order. In an emergency situation, verify the physician's verbal order. Wash your hands. Check ET tube placement by using a handheld resuscitation bag and stethoscope.

Calculate the drug dose. Adult advanced cardiac life support guidelines recommend that drugs be administered at 2 to 2Â½ times the recommended I.V. dose. Next, draw the drug up into a syringe. Dilute it in 10 ml of sterile water or normal saline solution. Dilution increases drug volume and contact with lung tissue.

Implementation

Put on gloves.
Move the patient into the supine position, and make sure his head is level with or slightly higher than his trunk.
Ventilate the patient three to five times with the resuscitation bag. Then remove the bag.
Remove the needle from the syringe, and insert the tip of the syringe into the ET tube. Inject the drug deep into the tube.
After injecting the drug, reattach the resuscitation bag and ventilate the patient briskly. This propels the drug into the lungs, oxygenates the patient, and clears the tube.
Discard the syringe in an appropriate sharps container.
Remove and discard your gloves.

Special considerations

Be aware that the drug's onset of action may be quicker than it would be by I.V. administration. If the patient doesn't respond quickly, the physician may order a repeat dose.

Complications

Potential complications of endotracheal drug administration result from the prescribed drug, not the administration route.

Documentation

Record the date and time of drug administration, drug administered, and patient's response.

How The Ommaya Reservoir Works

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To insert an Ommaya reservoir, the physician drills a burr hole and inserts the device's catheter through the patient's nondominant frontal lobe into the lateral ventricle. The reservoir, which has a self-sealing silicone injection dome, rests over the burr hole under a scalp flap. This creates a slight, soft bulge on the scalp about the size of a quarter. Usually, drugs are injected into the dome with a syringe.

Ommaya Reservoir

2011-08-21T19:00:00.000-07:00

Also known as a subcutaneous cerebrospinal fluid (CSF) resevoirrvoir, an Ommaya reservoir allows delivery of long-term drug therapy to the CSF by way of the brain's ventricles. The reservoir spares the patient repeated lumbar punctures to administer chemotherapeutic drugs, analgesics, antibiotics, and antifungals. It's most commonly used for chemotherapy and pain management, specifically for treating central nervous system (CNS) leukemia, malignant CNS disease, and meningeal carcinomatosis.

The reservoir is a mushroom-shaped silicone apparatus with an attached catheter. It's surgically implanted beneath the patient's scalp in the nondominant lobe, and the catheter is threaded into the ventricle through a burr hole in the skull. (See How the Ommaya reservoir works, page 262.) Besides providing convenient, comparatively painless access to CSF, the Ommaya reservoir permits consistent and predictable drug distribution throughout the subarachnoid space and CNS. It also allows for measurement of intracranial pressure (ICP).

Before reservoir insertion, the patient may receive a local or general anesthetic, depending on his condition and the physician's preference. After an X-ray confirms placement of the reservoir, a pressure dressing is applied for 24 hours, followed by a gauze dressing for another day or two. The sutures may be removed in about 10 days. However, the reservoir can be used within 48 hours to deliver drugs, obtain CSF pressure measurements, drain CSF, and withdraw CSF specimens.

The physician usually injects drugs into the Ommaya reservoir, but a specially trained nurse may perform this procedure if allowed by your facility's policy and the state's nurse practice act. This sterile procedure usually takes 15 to 30 minutes.

Gale Encyclopedia of Cancer: Ommaya reservoir

Equipment

Equipment varies but may include the following: preservative-free prescribed drug (at room temperature) â€¢ sterile or chemotherapy gloves â€¢ povidone-iodine solution â€¢ sterile towel â€¢ two 5- or 10-ml syringes â€¢ 25G needle or 22G Huber needle â€¢ sterile gauze pad â€¢ collection tubes for CSF (if ordered) â€¢ vial of bacteriostatic normal saline solution.

Preparation of equipment

Using the sterile towel, establish a sterile field near the patient. Prepare a syringe with the preservative-free drug to be instilled and place it, the CSF collection tubes, and the normal saline solution on the sterile field.

Implementation

If your patient is scheduled to receive an Ommaya reservoir, explain the procedure before reservoir insertion. Make sure the patient and his family understand the potential complications, and answer any questions they may have. Reassure the patient that any hair shaved for the implant will grow back and that only a coin-sized patch must remain shaved for injections. (Hair regrowth will be slower if the patient is receiving chemotherapy.)

Ommaya reservoir: An entry from Thomson Gale's Gale Encyclopedia of Cancer, 2nd ed.

Instilling medication

Obtain baseline vital signs.
Position the patient so that he's either sitting or reclining. The head of the bed may be elevated or flat.
Put on gloves and prepare the patient's scalp with the povidone-iodine solution, working in a circular motion from the center outward. Use a gauze pad to move the patient's hair and expose the reservoir.
Placing the 25G needle at a 45-degree angle, insert it into the reservoir and aspirate 3 ml of clear CSF into a syringe. (If the aspirate isn't clear, check with the physician before continuing.)
Continue to aspirate as many milliliters of CSF as you will instill of the drug. Then detach the syringe from the needle hub, attach the drug syringe, and instill the medication slowly, monitoring for headache, nausea, and dizziness. (Some facilities use the CSF instead of a preservative-free diluent to deliver the drug.)
Instruct the patient to lie quietly for 15 to 30 minutes after the procedure. This may prevent meningeal irritation leading to nausea and vomiting.
Cover the site with a sterile dressing, and apply gentle pressure for a moment or two until superficial bleeding stops.
Monitor the patient for adverse drug reactions and signs of increased ICP, such as nausea, vomiting, pain, and dizziness. Assess for adverse reactions every 30 minutes for 2 hours, then every hour for 2 hours and, finally, every 4 hours.

Special considerations

The physician may prescribe an antiemetic to be administered 30 minutes before the procedure to control nausea and vomiting.
After the reservoir is implanted, the patient may resume normal activities. Instruct him to protect the site from bumps and traumatic injury while the incision heals. Tell him that unless complications develop, the reservoir may function for years.
Instruct the patient and his family to notify the physician if signs of infection develop at the insertion site (for example, redness, swelling, tenderness, and drainage) or if the patient develops headache, neck stiffness, or fever, which may indicate a systemic infection.

Complications

Infection may develop but can usually be treated successfully by injection of antibiotics directly into the reservoir. Persistent infection may require removal of the reservoir.

Catheter migration or blockage may cause symptoms of increased ICP, such as headache and nausea. If the physician suspects this problem, he may gently push and release the reservoir several times (a technique called pumping). With his finger on the patient's scalp, the physician can feel the reservoir refill. Slow filling suggests catheter migration or blockage, which must be confirmed by a computed tomography scan. Surgical correction is required.

Documentation

Record the appearance of the reservoir insertion site before and after access, the patient's tolerance of the procedure, the amount of CSF withdrawn and its appearance, and the name and dose of the drug instilled.

ANA Standards of Clinical Nursing Practice

2011-08-14T21:29:00.000-07:00

Standard I. Assessment: The nurse collects patient health data.
Standard II. Diagnosis: The nurse analyzes the assessment data in determining diagnoses.
Standard III. Outcome Identification: The nurse identifies expected outcomes individualized to the patient.
Standard IV. Planning: The nurse develops a plan of care that prescribes interventions to attain expected outcomes.
Standard V. Implementation: The nurse implements the interventions identified in the plan of care.
Standard VI. Evaluation: The nurse evaluates the patient’s progress toward attainment of outcomes.

Placement Of A Permanent Epidural Catheter

2011-08-08T18:29:00.000-07:00

An epidural catheter is implanted beneath the patient's skin and inserted near the spinal cord at the first lumbar (L1) interspace. For temporary analgesic therapy (less than 1 week), the catheter may exit directly over the spine and be taped up the patient's back to the shoulder. For prolonged therapy, the catheter may be tunneled subcutaneously to an exit site on the patient's side or abdomen or over his shoulder.

Placement Of A Permanent Epidural Catheter

Reducing bleeding and pain during epidural catheter insertion.(EVIDENCE FOR PRACTICE)(Clinical report): An article from: AORN Journal

Understanding Intrathecal Injections

2011-08-02T19:51:00.000-07:00

An intrathecal injection allows the physician to inject medication into the subarachnoid space of the spinal canal. Certain drugsâ€”such as anti-infectives, or antineoplastics used to treat meningeal leukemiaâ€”are administered by this route because they can't readily penetrate the blood-brain barrier through the bloodstream. Intrathecal injection may also be used to deliver anesthetics, such as lidocaine, to achieve regional anesthesia (as in spinal anesthesia) and for pain management with medications such as preservative-free morphine.

An invasive procedure performed under sterile conditions by a physician with the nurse assisting, intrathecal injection requires informed patient consent. The injection site is usually between the third and fourth (or fourth and fifth) lumbar vertebrae, well below the spinal cord to avoid the risk of paralysis. This procedure may be preceded by aspiration of spinal fluid for laboratory analysis.

Contraindications to intrathecal injection include inflammation or infection at the puncture site, septicemia, and spinal deformities (especially when considered as an anesthesia route).

Intrathecal Drug Therapy for Spasticity and Pain: Practical Patient Management

Drug Infusion Maintenance (Adult) Protocol

2011-07-29T20:57:00.000-07:00

Patients are routinely transported between facilities with an infusion device delivering a drug. In many cases these patients are stable but require a registered nurse (RN) escort because of the infusion device. Appropriately trained EMT escorts can provide this function.

Indications
1. Stable patients requiring drug infusion based on hospital treatment protocols.
Contraindications
1. Patient age less than 16 years.
2. Infusion of agents not approved by this protocol.
3. Infusion of agents requiring titration or variable dosing schedules / regimens.
4. Infusion of agents by central venous access devices.

Drug Doses and Frequencies
Drugs dosages and infusion rates are to be determined by the referring
physician. A written order signed by the physician for the infusion must be obtained.

Procedure
1. Perform patient assessment and record vital signs.
2. Assess that patient meets criteria for this protocol.
3. Ensure there are no contraindications to use of this protocol.
4. Follow the protocol for the maintenance of an infusion pump (adult).
5. Consider requesting that a second intravenous line be started, as a backup, at the referring facility.
6. Monitor and reassess patient en route.

7. Notify receiving facility of patient’s condition and medication used.
Note:
EMS personnel must be prepared to reestablish the intravenous line, if necessary.
EMS personnel must monitor the patient for any signs of adverse effect of the infusion and be prepared to discontinue the infusion, if necessary.

Documentation Requirements
The following information must be documented on the patient care report form:
1. Patient’s presenting signs and symptoms, including vital signs.
2. Indications for protocol use.
3. Order for infusion signed by referring physician.
4. Dosage and concentration of drug being delivered by infusion pump.

5. Patient assessment, including vital signs at regular intervals during transport. A acceptable interval is q20-30 minutes, unless required more frequently by referring physician.
6. Volume (and dosage if required) delivered during transport, and volume remaining in infusion pump.
7. Record of any alarms or error messages displayed by the infusion device during transport, with a description of corrective action to manage alarm or message.
8. Changes from baseline, if any, that occur during transport.
9. Signature and license number of EMT performing any transfer of function skills.

EPIDURAL ANALGESICS

2011-07-25T06:00:00.000-07:00

In this procedure, the physician injects or infuses medication into the epidural space, which lies just outside the subarachnoid space where cerebrospinal fluid (CSF) flows. The drug diffuses slowly into the subarachnoid space of the spinal canal and then into the CSF, which carries it directly into the spinal area, bypassing the blood-brain barrier. In some cases, the physician injects medication directly into the subarachnoid space. (See Understanding intrathecal injections.)

Epidural analgesia helps manage acute and chronic pain, including moderate to severe postoperative pain. It's especially useful in patients with cancer or degenerative joint disease. This procedure works well because opioid receptors are located along the entire spinal cord. Opioid drugs act directly on the receptors of the dorsal horn to produce localized analgesia without motor blockade. Opioids, such as preservative-free morphine, fentanyl, and hydromorphone, are administered as a bolus dose or by continuous infusion, either alone or in combination with bupivacaine (a localanesthetic). Infusion through an epidural catheter is preferable because it allows a smaller drug dose to be given continuously.

The epidural catheter, inserted into the epidural space, eliminates the risks of multiple I.M. injections, minimizes adverse cerebral and systemic effects, and eliminates the analgesic peaks and valleys that usually occur with intermittent I.M. injections. (See Placement of a permanent epidural catheter.)

Typically, epidural catheter insertion is performed by an anesthesiologist using sterile technique. When the catheter has been inserted, the nurse is responsible for monitoring the infusion and assessing the patient.

Epidural analgesia is contraindicated in patients who have local or systemic infection, neurologic disease, coagulopathy, spinal arthritis or a spinal deformity, hypotension, marked hypertension, or an allergy to the prescribed medication and in those who are undergoing anticoagulant therapy.

Equipment

Volume infusion device and epidural infusion tubing (depending on your facility's policy) â€¢ patient's medication record and chart â€¢ prescribed epidural solutions â€¢ transparent dressing or sterile gauze pads â€¢ epidural tray â€¢ labels for epidural infusion line â€¢ silk tape â€¢ optional: monitoring equipment for blood pressure and pulse, apnea monitor, pulse oximeter.

Have on hand the following drugs and equipment for emergency use: naloxone, 0.4 mg I.V.; ephedrine, 50 mg I.V. â€¢ oxygen â€¢ intubation set â€¢ handheld resuscitation bag.

Preparation of equipment

Prepare the infusion device according to the manufacturer's instructions and your facility's policy. Obtain an epidural tray. Make sure that the pharmacy has been notified ahead of time regarding the medication order because epidural solutions require special preparation. Check the medication concentration and infusion rate against the physician's order.

Implementation

Explain the procedure and its potential complications to the patient. Tell him that he'll feel some pain as the catheter is inserted. Answer any questions he has. Make sure that a consent form has been properly signed and witnessed.
Position the patient on his side in the knee-chest position, or have him sit on the edge of the bed and lean over a bedside table.
After the catheter is in place, prime the infusion device, confirm the appropriate medication and infusion rate, and then adjust the device for the correct rate.
Help the anesthesiologist connect the infusion tubing to the epidural catheter. Then connect the tubing to the infusion pump.
Bridge-tape all connection sites, and apply an EPIDURAL INFUSION label to the catheter, infusion tubing, and infusion pump to prevent accidental infusion of other drugs. Then start the infusion.
Tell the patient to report immediately any pain. Instruct him to use a pain scale from 0 to 10, with 0 denoting no pain and 10 denoting the worst pain imaginable. A response of 3 or less typically indicates tolerable pain. If the patient reports a higher pain score, the infusion rate may need to be increased. Call the physician or change the rate within prescribed limits.
If ordered, place the patient on an apnea monitor for the first 24 hours after beginning the infusion.
Change the dressing over the catheter's exit site every 24 to 48 hours, as needed, or as specified by your facility's policy. The dressing is usually transparent to allow inspection of drainage and commonly appears moist or slightly blood-tinged.
The epidural generally isn't sutured in place and it's important that you don't manipulate the catheter during a dressing change.
Change the infusion tubing every 48 hours or as specified by your facility's policy.
Change the epidural solution every 24 hours.

Removing an epidural catheter

Typically, the anesthesiologist orders analgesics and removes the catheter. However, your facility's policy may allow a specially trained nurse to remove the catheter.
If you feel resistance when removing the catheter, stop and call the physician for further orders.
Be sure to save the catheter. The physician will want to examine the catheter tip to rule out any damage during removal.

Special considerations

Assess the patient's respiratory rate, blood pressure, and oxygen saturation every 2 hours for 8 hours and then every 4 hours for 8 hours during the first 24 hours after starting the infusion. Then assess the patient once per shift, depending on his condition or unless ordered otherwise. Your facility may require more frequent assessments. Notify the physician if the patient's respiratory rate is less than 10 breaths/minute or if his systolic blood pressure is less than 90 mm Hg.
Assess the patient's sedation level, mental status, and pain-relief status every hour initially and then every 2 to 4 hours until adequate pain control is achieved. Notify the physician if the patient appears drowsy; experiences nausea and vomiting, refractory itching, or inability to void, which are adverse effects of certain opioid analgesics; or complains of unrelieved pain. A change in sedation level (the patient becoming somnolent) is an early indicator of the respiratory depressant effects of the opioid. Respiratory depression usually occurs during the first 24 hours and is treated with I.V. naloxone. Nausea, vomiting, and pruritus may also be treated with low-dose I.V. naloxone.
Assess the patient's lower-extremity motor strength every 2 to 4 hours. If sensorimotor loss (numbness and leg weakness) occurs, large motor nerve fibers have been affected and the dose may need to be decreased. Notify the physician because he may need to titrate the dosage in order to identify the dose that provides adequate pain control without causing excessive numbness and weakness.
Keep in mind that drugs given epidurally diffuse slowly and may cause adverse effects, including excessive sedation, up to 12 hours after the infusion has been discontinued.
The patient should always have a peripheral I.V. line (either continuous infusion or heparin lock) open to allow immediate administration of emergency drugs.
If CSF leaks into the dura mater at the initial puncture site, the patient usually experiences a headache. This postanalgesia headache worsens with postural changes, such as standing and sitting. The headache can be treated with a â€œblood patch,â€ in which the patient's own blood (about 10 ml) is withdrawn from a peripheral vein and then injected into the epidural space. When the epidural needle is withdrawn, the patient is instructed to sit up. Because the blood clots seal off the leaking area, the blood patch should relieve the patient's headache immediately. The patient need not restrict his activity after this procedure.

Home care

Home use of epidural analgesia is possible only if the patient or a family member is willing and able to learn the care needed. The patient also must be willing and able to abstain from alcohol and street drugs because these substances potentiate opioid action.

Complications

Potential complications of epidural analgesic administration include adverse effects from opioids or local anesthetics, and catheter-related problems, such as infection, epidural hematoma, or catheter migration. Infection is treated with antibiotics. Epidural hematomas should be observed and any increase in size should be reported to the physician.

Catheter migration occurs when the epidural catheter migrates out of the epidural space toward the skin. If this occurs, the patient will have decreased pain relief and leaking at the catheter site. Notify the physician because the infusion needs to be stopped and the catheter removed. Contact the physician for further pain management orders. The catheter can also migrate through the dura into the subarachnoid space if the epidural dose is too high for the smaller subarachnoid space, and the dose may eventually be toxic in high concentrations (the patient may show signs of increasing somnolence and eventually a decrease in respirations). Assess the patient and notify the physician immediately. The infusion needs to be stopped, the catheter removed, and the patient may need to be treated with I.V. naloxone and oxygen therapy.

Documentation

Record the patient's response to treatment, catheter patency, condition of the dressing and insertion site, vital signs, and assessment results. Also document the labeling of the epidural catheter, changing of the infusion bags, ordered analgesics, if any, and patient's response.

MANAGING EXTRAVASATION

2011-07-20T04:57:00.000-07:00

Extravasationâ€”the infiltration of a vesicant drug into the surrounding tissueâ€”can result from a punctured vein or leakage around a venipuncture site. If vesicant drugs or fluids extravasate, severe local tissue damage may result. This may cause prolonged healing, infection, cosmetic disfigurement, and loss of function and may necessitate multiple debridements and, possibly, amputation.

Extravasation of vesicant drugs requires emergency treatment. Follow your facility's protocol. Essential steps include:

Stop the I.V. flow, aspirate the remaining drug in the catheter, and remove the I.V. line, unless you need the needle to infiltrate the antidote.
Estimate the amount of extravasated solution and notify the physician.
Instill the appropriate antidote according to your facility's protocol.
Elevate the extremity.
Record the extravasation site, patient's symptoms, estimated amount of infiltrated solution, and treatment. Include the time you notified the physician and the physician's name. Continue documenting the appearance of the site and associated symptoms.
Depending on your facility's protocol, apply either ice packs or warm compresses to the affected area. Ice is applied to all extravasated areas for 15 to 20 minutes every 4 to 6 hours for about 3 days. For etoposide and vinca alkaloids, heat is applied.
If skin breakdown occurs, apply dressings as ordered.
If severe tissue damage occurs, plastic surgery and physical therapy may be needed.

CLASSIFYING CHEMOTHERAPEUTIC DRUGS

2011-07-17T21:23:00.000-07:00

Chemotherapeutic drugs may be classified as irritants, vesicants, or nonvesicants.

Irritants

Carmustine
Dacarbazine
Etoposide
Ifosfamide
Streptozocin
Topotecan

Vesicants

Dactinomycin
Daunorubicin
Doxorubicin
Mechlorethamine
Mitomycin-C
Mitoxantrone
Paclitaxel
Vinblastine
Vincristine

Nonvesicants

Asparaginase
Bleomycin
Carboplatin
Cisplatin (if > 20 ml of 0.5 mg/ml, it is considered a vesicant)
Cyclophosphamide
Cytarabine
Floxuridine
Fluorouracil

Intraperitoneal Chemotherapy - An Alternative Approach

2011-07-12T18:05:00.000-07:00

Administering chemotherapeutic drugs into the peritoneal cavity has several benefits for patients with malignant ascites or ovarian cancer that has spread to the peritoneum. This technique passes drugs directly to the tumor area in the peritoneal cavity, exposing malignant cells to high concentrations of chemotherapyâ€”up to 1,000 times the amount that can be safely given systemically. What's more, the semipermeable peritoneal membrane permits prolonged exposure of malignant cells to the drug.

Typically, intraperitoneal chemotherapy is performed using a peritoneal dialysis kit, but drugs can also be administered directly to the peritoneal cavity by using a Tenckhoff catheter (as shown at right). This method can be performed on an outpatient basis, if necessary; it uses equipment that's readily available on most units with oncology patients.

In this technique, the chemotherapy bag is connected directly to the Tenckhoff catheter with a length of I.V. tubing, the solution is infused, and the catheter and I.V. tubing are clamped. Then the patient is asked to change positions every 10 to 15 minutes for 1 hour to move the solution around in the peritoneal cavity.

After the prescribed dwell time, the chemotherapeutic drugs are drained into an I.V. bag. The patient is encouraged to change positions to facilitate drainage. Then the I.V. tubing and catheter are clamped, the I.V. tubing is removed, and a new intermittent infusion cap is fitted to the catheter. Finally, the catheter is flushed with a syringe of heparin flush solution.

Chemotherapeutic Drug Administration

2011-07-07T06:25:00.000-07:00

Administration of chemotherapeutic drugs requires skills in addition to those used when giving other drugs. For example, some drugs require special equipment or must be given through an unusual route. Others become unstable after a while, and still others must be protected from light. Finally, the drug dosage must be exact to avoid possibly fatal complications. For these reasons, only specially trained nurses and physicians should give chemotherapeutic drugs.

Chemotherapeutic drugs may be administered through a number of routes. Although the I.V. route (using peripheral or central veins) is used most commonly, these drugs may also be given orally, subcutaneously, I.M., intra-arterially, into a body cavity, through a central venous catheter, through an Ommaya reservoir into the spinal canal. They may also be administered into an artery, the peritoneal cavity, or the pleural space. (See Intraperitoneal chemotherapy: An alternative approach.)

The administration route depends on the drug's pharmacodynamics and the tumor's characteristics. For example, if a malignant tumor is confined to one area, the drug may be administered through a localized, or regional, method. Regional administration allows delivery of a high drug dose directly to the tumor. This is particularly advantageous because many solid tumors don't respond to drug levels that are safe for systemic administration.

Chemotherapy may be administered to a patient whose cancer is believed to have been eradicated through surgery or radiation therapy. This treatment, known as adjuvant chemotherapy, helps to ensure that no undetectable metastasis exists. A patient may also receive chemotherapy before surgery or radiation therapy. This is called induction chemotherapy (or neoadjuvant or synchronous chemotherapy). Induction chemotherapy helps improve survival rates by shrinking a tumor before surgical excision or radiation therapy.

In general, chemotherapeutic drugs prove more effective when given in higher doses, but their adverse effects often limit the dosage. An exception to this rule is methotrexate. This drug is particularly effective against rapidly growing tumors, but it's also toxic to normal tissues that are growing and dividing rapidly. However, physicians have discovered that they can give a large dose of methotrexate to destroy cancer cells and then, before the drug has had a chance to permanently damage vital organs, give a dose of folinic acid as an antidote. The antidote stops the effects of methotrexate, thus preserving normal tissue.

Equipment

Prescribed drug â€¢ gloves â€¢ aluminum foil or a brown paper bag (if the drug is photosensitive) â€¢ normal saline solution â€¢ syringes and needleless adapters â€¢ infusion pump or controller â€¢ impervious containers labeled CAUTION: BIOHAZARD.

Preparation of equipment

Verify the drug, dosage, and administration route by checking the medication record against the physician's order. Make sure you know the immediate and delayed adverse effects of the ordered drug. Follow administration guidelines for appropriate procedures in this chapter.

Implementation

Assess the patient's physical condition, and review his medical history.
Make sure you understand what chemotherapeutic agent needs to be given and by what route, and provide the necessary teaching and support to the patient and his family.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Determine the best site to administer the drug. When selecting the site, consider drug compatibilities, frequency of administration, and vesicant potential of the drug. (See Classifying chemotherapeutic drugs.) For example, if the physician has ordered the intermittent administration of a vesicant drug, you can give it either by instilling the drug into the side port of an infusing I.V. line or by direct I.V. push. If the vesicant drug is to be infused continuously, you should administer it only through a central venous line or a vascular access device. On the other hand, nonvesicant agents (including irritants) may be given by direct I.V. push, through the side port of an infusing I.V. line, or as a continuous infusion.

Check your facility's policy before administering a vesicant. Because vein integrity decreases with time, some facilities require that vesicants be administered before other drugs. Conversely, because vesicants increase vein fragility, some facilities require that vesicants be given after other drugs.

Evaluate your patient's condition, paying particular attention to the results of recent laboratory studies, specifically the complete blood count, blood urea nitrogen level, platelet count, urine creatinine level, and liver function studies.
Determine whether the patient has received chemotherapy before, and note the severity of any adverse effects.
Check his drug history for medications that might interact with chemotherapy. As a rule, you shouldn't mix chemotherapeutic drugs with other medications. If you have questions or concerns about giving the chemotherapeutic drug, talk with the physician or pharmacist before you give it.
Next, double-check the patient's chart for the complete chemotherapy protocol order, including the patient's name, drug's name and dosage, and route, rate, and frequency of administration. See if the drug's dosage depends on certain laboratory values. Be aware that some facilities require two nurses to verify the dosage order of high-alert medications and to check the drug and amount being administered.
Check to see whether the physician has ordered an antiemetic, fluids, a diuretic, or electrolyte supplements to be given before, during, or after chemotherapy administration.
Evaluate the patient's and his family's understanding of chemotherapy, and make sure the patient or a responsible family member has signed the consent form.
Next, put on gloves. Keep them on through all stages of handling the drug, including preparation, priming the I.V. tubing, and administration.
Before administering the drug, perform a new venipuncture proximal to the old site. Avoid giving chemotherapeutic drugs through an existing I.V. line. To identify an administration site, examine the patient's veins, starting with his hand and proceeding to his forearm.
When an appropriate line is in place, infuse 10 to 20 ml of normal saline solution to test vein patency. Never test vein patency with a chemotherapeutic drug. Next, administer the drug as appropriate: nonvesicants by I.V. push or admixed in a bag of I.V. fluid; vesicants by I.V. push through a piggyback set connected to a rapidly infusing I.V. line.
During I.V. administration, closely monitor the patient for signs of a hypersensitivity reaction or extravasation. Check for adequate blood return after 5 ml of the drug has been infused or according to your facility's guidelines.
After infusion of the medication, infuse 20 ml of normal saline solution. Do this between administrations of different chemotherapeutic drugs and before discontinuing the I.V. line.
Dispose of used needles and syringes carefully. To prevent aerosol dispersion of chemotherapeutic drugs, don't clip needles. Place them intact in an impervious container for incineration. Dispose of I.V. bags, bottles, gloves, and tubing in a properly labeled and covered trash container.
Wash your hands thoroughly with soap and warm water after giving any chemotherapeutic drug, even though you have worn gloves.

Special considerations

Observe the I.V. site frequently for signs of extravasation and an allergic reaction (swelling, redness, urticaria). If you suspect extravasation, stop the infusion immediately. Leave the I.V. catheter in place and notify the physician. A conservative method for treating extravasation involves aspirating any residual drug from the tubing and I.V. catheter, instilling an I.V. antidote, and then removing the I.V. catheter. Afterward, you may apply heat or cold to the site and elevate the affected limb. (See Managing extravasation.)
During infusion, some drugs need protection from direct sunlight to avoid possible drug breakdown. If this is the case, cover the vial with a brown paper bag or aluminum foil.
When giving vesicants, avoid sites where damage to underlying tendons or nerves may occur (veins in the antecubital fossa, near the wrist, or in the dorsal surface of the hand).
If you're unable to stay with the patient during the entire infusion, use an infusion pump or controller to ensure drug delivery within the prescribed time and rate.
Observe the patient at regular intervals and after treatment for adverse reactions. Monitor his vital signs throughout the infusion to assess any changes during chemotherapy administration.
Maintain a list of the types and amounts of drugs the patient has received. This is especially important if he has received drugs that have a cumulative effect and that can be toxic to such organs as the heart and kidneys.

Complications

Common adverse effects of chemotherapy are nausea and vomiting, ranging from mild to debilitating. Another major complication is bone marrow suppression, leading to neutropenia and thrombocytopenia. Other adverse effects include intestinal irritation, stomatitis, pulmonary fibrosis, cardiotoxicity, nephrotoxicity, neurotoxicity, hearing loss, anemia, alopecia, urticaria, radiation recall (if drugs are given with or soon after radiation therapy), anorexia, esophagitis, diarrhea, and constipation.

I.V. administration of chemotherapeutic drugs may also lead to extravasation, causing inflammation, ulceration, necrosis, and loss of vein patency.

Documentation

Record the location and description of the I.V. site before treatment or the presence of blood return during bolus administration. Also record the drugs and dosages administered, sequence of drug administration, needle type and size used, amount and type of flushing solution, and site's condition after treatment. Document any adverse reactions, the patient's tolerance of the treatment, and topics discussed with the patient and his family.

Nursing Care Plan for Nephrotic Syndrome

2011-07-03T05:02:00.000-07:00

Nephrotic syndrome is kidney disease with proteinuria, hypoalbuminemia, and edema. Nephrotic range proteinuria is 3 grams per day or more. On a single, “spot” urine collection, it is 2 grams of protein per gram of urine creatinine.

Recent studies

In a retrospective study, Vivarelli et al investigated whether, in children with idiopathic nephrotic syndrome, the period of time between the onset of steroid therapy and syndrome remission can serve as a prognostic indicator. The study included 103 patients with idiopathic nephrotic syndrome and had a median follow-up time of 43 months. The authors found that in patients who did not suffer relapse or who relapsed infrequently, the median period between treatment onset and remission was less than 7 days. In patients who frequently relapsed or who developed steroid-dependent nephrotic syndrome, the median time to remission was more than 7 days after treatment began. The authors concluded that the length of time between steroid treatment onset and remission is an early prognostic indicator for patients with idiopathic nephrotic syndrome.

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Chemotherapeutic Drug Preparation And Handling

2011-07-02T15:52:00.000-07:00

When preparing chemotherapeutic drugs, take extra care, both for the patient's safety and for your own. Patients who receive chemotherapeutic drugs risk teratogenic, mutagenic, and carcinogenic effects, but the people who prepare and handle the drugs are at risk as well. Although the danger from handling these drugs hasn't been fully determined, chemotherapeutic drugs can increase the handler's risk of reproductive abnormalities. These drugs also pose environmental threats, and the best method for handling them hasn't been determined.
Transition Metal Complexes as Drugs and Chemotherapeutic Agents (Catalysis by Metal Complexes)

The Occupational Safety and Health Administration (OSHA) has set down guidelines for handling chemotherapeutic drugs. Although these guidelines are simply recommendations, adhering to them will help ensure both your safety and that of your environment.

The OSHA guidelines outline two basic requirements. The first is that all health care workers who handle chemotherapeutic drugs must be educated and trained. A key element of such training involves learning how to reduce your exposure when handling the drugs. The second requirement states that the drugs should be prepared in a class II biological safety cabinet.

Equipment

Prescribed drug or drugs â€¢ patient's medication record and chart â€¢ long-sleeved gown â€¢ latex powder-free surgical gloves â€¢ face shield or goggles â€¢ eyewash â€¢ plastic absorbent pad â€¢ alcohol pads â€¢ sterile gauze pads â€¢ shoe covers â€¢ impervious container with the label CAUTION: BIOHAZARD for the disposal of any unused drug or equipment â€¢ I.V. solution â€¢ diluent (if necessary) â€¢ compatibility reference source â€¢ medication labels â€¢ class II biological safety cabinet â€¢ disposable towel â€¢ hydrophobic filter or dispensing pin â€¢ 18G needle â€¢ syringes and needles of various sizes â€¢ I.V. tubing with luer-lock fittings â€¢ I.V. controller pump (if available).

Have a chemotherapeutic spill kit available that includes water-resistant, nonpermeable, long-sleeved gown with cuffs and back closure â€¢ shoe covers â€¢ two pairs of gloves (for double gloving) â€¢ goggles â€¢ mask â€¢ disposable dustpan â€¢ plastic scraper (for collecting broken glass) â€¢ plastic-backed or absorbable towels â€¢ container of desiccant powder or granules (to absorb wet contents) â€¢ two disposable pads â€¢ punctureproof, leakproof container labeled BIOHAZARD WASTE â€¢ container of 70% alcohol for cleaning the spill area.

Implementation

Remember to wash your hands before and after drug preparation and administration.
Prepare the drugs in a class II biological safety cabinet.
Wear protective garments (such as a long-sleeved gown, powder-free gloves, and a face shield or goggles), as indicated by your facility's policy. Don't wear the garments outside the preparation area.
Don't eat, drink, smoke, or apply cosmetics in the drug preparation area.
Before you prepare the drug (and after you finish), clean the internal surfaces of the cabinet with 70% alcohol and a disposable towel. Discard the towel in a leakproof chemical waste container.
Cover the work surface with a clean plastic absorbent pad to minimize contamination by droplets or spills. Change the pad at the end of the shift or whenever a spill occurs.
Consider all the equipment used in drug preparation as well as any unused drug as hazardous waste. Dispose of them according to your facility's policy.
Place all chemotherapeutic waste products in labeled, leakproof, sealable plastic bags or other appropriate impervious containers.

Special considerations

Prepare the drugs in accordance with current product instructions, paying attention to compatibility, stability, and reconstitution technique.
Take precautions to reduce your exposure to chemotherapeutic drugs. Systemic absorption can occur through ingestion of contaminated materials, skin contact, and inhalation. You can inhale a drug without realizing it, such as while opening a vial, clipping a needle, expelling air from a syringe, or discarding excess drug. You can also absorb a drug from handling contaminated stools or body fluids.
For maximum protection, mix all chemotherapeutic drugs in an approved class II biological safety cabinet. Also, prime all I.V. bags that contain chemotherapeutic drugs under the hood. Leave the hood blower on 24 hours a day, 7 days a week.
If a hood isn't available, prepare drugs in a well-ventilated work space, away from heating or cooling vents and other personnel. Vent vials with a hydrophobic filter, or use negative-pressure techniques. Also, use a needle with a hydrophobic filter to remove solution from a vial. To break an ampule, wrap a sterile gauze pad or alcohol pad around the neck of the ampule to cut the contamination risk.
Make sure the biological safety cabinet is examined every 6 months or any time the cabinet is moved by a company specifically qualified to perform this work. If the cabinet passes certification, the certifying company will affix a sticker to the cabinet attesting to its approval.
Use only syringes and I.V. sets that have luer-lock fittings. Label all chemotherapeutic drugs with a CHEMOTHERAPY HAZARD label.
Don't clip needles, break syringes, or remove the needles from syringes. Use a gauze pad when removing syringes and needles from I.V. bags of chemotherapeutic drugs.
Place used syringes and needles in a punctureproof container, along with other sharp or breakable items.
When mixing chemotherapeutic drugs, wear latex surgical gloves and a gown of low-permeability fabric with a closed front and cuffed long sleeves. When working steadily with chemotherapeutic drugs, change gloves every 30 minutes. If you spill a drug solution or puncture or tear a glove, remove the gloves at once. Wash your hands before putting on new gloves and any time you remove your gloves.
If some of the drug comes in contact with your skin, wash the involved area thoroughly with soap (not a germicidal agent) and water. If eye contact occurs, flood the eye with water or an isotonic eyewash for at least 5 minutes while holding the eyelid open. Obtain a medical evaluation as soon as possible after accidental exposure.
If a major spill occurs, use a chemotherapeutic spill kit to clean the area.
Discard disposable gowns and gloves in an appropriately marked, waterproof receptacle when contaminated or when you leave the work area.
Don't place any food or drinks in the same refrigerator as chemotherapeutic drugs.
Become familiar with drug excretion patterns, and take appropriate precautions when handling a chemotherapy patient's body fluids.
Give male patients a urinal with a tight-fitting lid. Wear disposable latex surgical gloves when handling body fluids. Before flushing the toilet, place a waterproof pad over the toilet bowl to avoid splashing. Wear gloves and a gown when handling linens soiled with body fluids. Place soiled linens in isolation linen bags designated for separate laundering.
When providing home care, empty waste products into the toilet close to the water to minimize splashing. Close the lid and flush two or three times. Place soiled linens in a washable pillowcase; then launder them twice, separately from other household linens. Wear gloves when handling contaminated linens, bedclothes, or other materials.
Women who are pregnant, trying to conceive, or breast-feeding should exercise caution when handling chemotherapeutic drugs.

Home care

When teaching your patient about handling chemotherapeutic drugs, discuss appropriate safety measures. If the patient will be receiving chemotherapy at home, teach him how to dispose of contaminated equipment. Tell the patient and his family to wear gloves whenever handling chemotherapy equipment and contaminated linens or bedclothes. Instruct them to place soiled linens in a separate washable pillowcase and to launder the pillowcase twice, with the soiled linens inside, separately from other linens.

All materials used for the treatment should be placed in a leakproof container and taken to a designated disposal area. The patient or his family should make arrangements with either a hospital or a private company for pickup and proper disposal of contaminated waste.

Complications

Chemotherapeutic drugs may be mutagenic. Chronic exposure to chemotherapeutic drugs may damage the liver or chromosomes. Direct exposure to these drugs may burn and damage the skin.

Documentation

Document each incident of exposure according to your facility's policy.

I.V. Bolus Injection

2011-06-30T20:54:00.000-07:00

The I.V. bolus injection method allows rapid drug administration. It can be used in an emergency to provide an immediate drug effect. It can also be used to administer drugs that can't be given I.M., to achieve peak drug levels in the bloodstream, and to deliver drugs that can't be diluted, such as diazepam, digoxin, and phenytoin. The term bolus usually refers to the concentration or amount of a drug. I.V. push is a technique for rapid I.V. injection.
Deep injection technique may prolong results: tri-site bolus technique treats an area often uncorrected after facelift or blepharoplasty.(Dermatologic Surgery): An article from: Skin & Allergy News

Bolus doses of medication may be injected directly into a vein, through an existing I.V. line, or through an implanted vascular access port (VAP). The medication administered by these methods usually takes effect rapidly, so the patient must be monitored for an adverse reaction, such as cardiac arrhythmia and anaphylaxis. I.V. bolus injections are contraindicated when rapid drug administration could cause life-threatening complications. For certain drugs, the safe rate of injection is specified by the manufacturer.

Some facilities permit only specially trained nurses (such as emergency department, critical care, and chemotherapy nurses) to give bolus injections.

Equipment

Patient's medication record and chart â€¢ gloves â€¢ prescribed medication â€¢ 20G needle and syringe â€¢ diluent, if needed â€¢ tourniquet â€¢ povidone-iodine or alcohol pad â€¢ sterile 2â€³ Ã— 2â€³ gauze pad â€¢ adhesive bandage â€¢ tape â€¢ optional: winged-tip needle with catheter and second syringe (and needle) filled with normal saline solution; noncoring needle if used with a VAP; heparin flush solution.

Winged-tip needles are commonly used for this purpose because they can be quickly and easily inserted. They're ideal for repeated drug administration, as in weekly or monthly chemotherapy. Another useful dosage form is the ready injectable.

Preparation of equipment

Verify the order on the patient's medication record by checking it against the physician's order. Know the actions, adverse effects, and administration rate of the medication to be injected. Draw up the prescribed medication in the syringe and dilute it if necessary.

Implementation

Confirm the patient's identity, wash your hands, put on gloves, and explain the procedure.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.

Giving direct injections

Select the largest vein suitable for an injection. The larger the vein, the more diluted the drug will become, minimizing vascular irritation.
Apply a tourniquet above the injection site to distend the vein.
Clean the injection site with an alcohol or a povidone-iodine pad, working outward from the puncture site in a circular motion to prevent recontamination with skin bacteria.
If you're using the drug syringe's needle, insert it into the vein at a 30-degree angle with the bevel up. The bevel should reach Â¼â€³ (0.6 cm) into the vein. If you're using a winged-tip needle, insert the needle (bevel up), tape the butterfly wings in place when you see blood return in the tubing, and attach the syringe containing the medication.
Pull back on the syringe plunger, and check for blood backflow, which indicates that the needle is in the vein.
Remove the tourniquet and inject the medication at the appropriate rate.
Pull back slightly on the syringe plunger and check for blood backflow again. If blood appears, this indicates that the needle remained in place and all the injected medication entered the vein.
Flush the line with the normal saline solution from the second syringe to ensure delivery of all the medication.
Withdraw the needle and apply pressure to the injection site with a sterile gauze pad for at least 3 minutes to prevent hematoma formation.
Apply the adhesive bandage to the site after bleeding has stopped.

Giving injections through an existing I.V. line

Check the compatibility of the medication with the I.V. solution.
Close the flow clamp, wipe the injection port with an alcohol pad, and inject the medication as you would a direct injection. (Some I.V. lines have a secondary injection port or a T-connector; others have a needleless adapter or latex cap at the end of the I.V. tubing where the blunt-tipped administration device is attached.)
Open the flow clamp, and readjust the flow rate.
If the drug isn't compatible with the I.V. solution, flush the line with normal saline solution before and after the injection. (For additional information, see â€œIntermittent infusion devices,â€ page 250.)

Giving a bolus injection through a VAP

Wash your hands, put on gloves, and clean the injection site with an alcohol or a povidone-iodine pad, starting at the center of the port and working outward in a circular motion over a 4â€³ to 5â€³ (10- to 12.7-cm) diameter. Do this three times.
Palpate the area over the port to locate the port septum.
Anchor the port between the thumb and first two fingers of your nondominant hand. Then, using your dominant hand, insert the needle into the appropriate area of the device and deliver the injection. (See â€œVascular access device maintenance)

Special considerations

Because drugs administered by I.V. bolus or push injections are delivered directly into the circulatory system and can produce an immediate effect, an acute allergic reaction or anaphylaxis can develop rapidly. If signs of anaphylaxis (dyspnea, cyanosis, seizures, and increasing respiratory distress) occur, notify the physician immediately and begin emergency procedures, as necessary. Also watch for signs of extravasation (redness, swelling). If extravasation occurs, stop the injection, estimate the amount of infiltration, and notify the physician.
If you're giving diazepam or chlordiazepoxide hydrochloride through a winged-tip needle or an I.V. line, flush with normal saline solution to prevent drug precipitation resulting from incompatibility.

Complications

Excessively rapid administration may cause adverse effects, depending on the medication administered.

Documentation

Record the amount and type of drug administered, time of injection, appearance of the site, duration of administration, and patient's tolerance of the procedure. Also note the drug's effect and any adverse reactions.

Using A Needleless System For Intermittent Infusions

2011-06-27T19:35:00.000-07:00

You can use a needleless I.V. system, such as the CLAVE Needleless Connector (shown below), to administer intermittent infusion medication when you need to convert an I.V. line to a heparin lock. To make the conversion:

clamp the I.V. tubing and remove the administration set from the catheter or needle hub
connect the adapter
inject the remaining dilute heparin or saline solution to fill the line and prevent clot formation.

Intermittent Infusion Devices

2011-06-24T15:33:00.000-07:00

An intermittent infusion injection device, or heparin lock, eliminates the need for multiple venipunctures or for maintaining venous access with a continuous I.V. infusion. This device allows intermittent administration by infusion or by the I.V. bolus or I.V. push injection method.

Dilute heparin or saline solutions are typically injected as the final step in this procedure to prevent clotting in the device. When heparin is used, the device must be flushed with normal saline solution before and after the prescribed medication is administered in case the heparin and the medication are incompatible. The device may then be reflushed with the heparin flush solution.

Equipment

Patient's medication record and chart â€¢ gloves â€¢ alcohol pads â€¢ three 3-ml syringes with needleless adapter â€¢ normal saline solution â€¢ extra intermittent infusion device â€¢ prescribed medication in an I.V. container with administration set and needle (for infusion) or in a syringe with needle (for I.V. bolus or push) â€¢ tourniquet â€¢ tape â€¢ optional: T-connector, dilute heparin solution, sterile bacteriostatic water.

The concentration of dilute heparin solution ranges from 10 to 100 units/ml. The solution is available in a cartridge-injection system in doses of 10 to 100 units/ml. If this system is used, substitute its syringe for the 3-ml syringe and the heparin cartridge for the heparin solution. Normal saline solution is available in a similar cartridge system.

Preparation of equipment

Verify the order on the patient's medication record by checking it against the physician's order. Wash your hands, and then wipe the tops of the normal saline solution, heparin flush solution, and medication containers with alcohol pads.

Fill two of the 3-ml syringes (bearing 22G needles) with normal saline solution; if required by facility policy, draw 1 ml of heparin flush solution into the third syringe. If you'll be infusing medication, insert the administration set spike into the I.V. container, attach the needleless adapter, and prime the line. If you'll be giving an I.V. injection, fill a syringe with the prescribed medication.

Implementation

Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband. Explain the procedure.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Put on gloves. Wipe the injection port of the intermittent infusion device with an alcohol pad, and insert the needleless adapter of a saline-filled syringe.
Aspirate the syringe and observe for blood to verify the patency of the device. If none appears, apply a tourniquet slightly above the site, keep it in place for about 1 minute, and then aspirate again. If blood still doesn't appear, remove the tourniquet and inject the normal saline solution slowly.
NURSING ALERT Stop the injection immediately if you feel any resistance because resistance indicates that the device is occluded. If this occurs, insert a new heparin lock.
If you feel no resistance, watch for signs of infiltration (puffiness or pain at the site) as you slowly inject the saline solution. If these signs occur, insert a new intermittent infusion device.
If blood is aspirated, slowly inject the saline solution and observe for signs of infiltration. The saline solution flushes out any residual heparin solution that might be incompatible with the medication.
Withdraw the saline syringe and needleless adapter.

Administering I.V. bolus or push injections

Insert the needleless adapter and syringe with the medication for the I.V. bolus or push injection into the injection port of the device.
Inject the medication at the required rate. Then remove the needleless adapter and syringe from the injection port.
Insert the needleless adapter of the remaining saline-filled syringe into the injection port and slowly inject the saline solution to flush all medication through the device.
Remove the needleless adapter and syringe, and insert and inject the heparin (or saline) flush solution to prevent clotting in the device.

Administering an infusion

Insert and secure the needleless adapter attached to the administration set.
Open the infusion line, and adjust the flow rate as necessary.
Infuse medication for the prescribed length of time; then flush the device with normal saline solution and heparin flush solution, as you would after a bolus or push injection, according to your facility's policy.
To administer fluids and drugs simultaneously or to administer a medication incompatible with the primary I.V. solution, you may want to use a T-connector or needleless adapter. (See Using a needleless system for intermittent infusions.)

Special considerations

If you're giving a bolus injection of a drug that's incompatible with saline solution, such as diazepam (Valium), flush the device with bacteriostatic water.
Some facilities use diluted heparin solution (10 to 100 units/ml) to prevent clotting in the cannula. Others use 2 to 3 ml of normal saline solution or some other solution or dilution. Check your facility's policy.
Intermittent infusion devices should be changed regularly (usually every 48 to 72 hours), according to standard precautions guidelines and your facility's policy.
If you can't rotate injection sites because the patient has fragile veins, document this fact.

Complications

Infiltration and a specific reaction to the infused medication are the most common complications.

Documentation

Record the type and amount of drug administered and times of administration. Include all I.V. solutions used to dilute the medication and flush the line on the intake record. Also document the use of dilute heparin solution.

Secondary I.V. Lines

2011-06-21T20:35:00.000-07:00

A secondary I.V. line is a complete I.V. setâ€”container, tubing, and microdrip or macrodrip systemâ€”connected to the lower Y-port (secondary port) of a primary line instead of to the I.V. catheter or needle. It can be used for continuous or intermittent drug infusion. When used continuously, a secondary I.V. line permits drug infusion and titration while the primary line maintains a constant total infusion rate.

When used intermittently, a secondary I.V. line is commonly called a piggyback set. In this case, the primary line maintains venous access between drug doses. Typically, a piggyback set includes a small I.V. container, short tubing, and a macrodrip system. This set connects to the primary line's upper Y-port, also called a piggyback port. Antibiotics are most commonly administered by intermittent (piggyback) infusion. To make this set work, the primary I.V. container must be positioned below the piggyback container. (The manufacturer provides an extension hook for this purpose.)

Most drugs can be piggybacked with a needle-free system, which consists of a blunt-tipped plastic insertion device and a rubber injection port. The port may be part of a special administration set or an adapter for existing administration sets. The rubber injection port has a preestablished slit that can open and reseal immediately. The needle-free system aims to reduce the risk of accidental needle-stick injuries.

I.V. pumps may be used to maintain constant infusion rates, especially with a drug such as lidocaine. A pump allows more accurate titration of drug dosage and helps maintain venous access because the drug is delivered under sufficient pressure to prevent clot formation in the I.V. cannula.

Equipment

Patient's medication record and chart â€¢ prescribed I.V. medication â€¢ prescribed I.V. solution â€¢ administration set with secondary injection port â€¢ needleless adapter â€¢ alcohol pads â€¢ 1â€³ adhesive tape â€¢ time tape â€¢ labels â€¢ infusion pump â€¢ extension hook and appropriate solution for intermittent piggyback infusion â€¢ optional: normal saline solution for infusion with incompatible solutions.

For intermittent infusion, the primary line typically has a piggyback port with a backcheck valve that stops the flow from the primary line during drug infusion and returns to the primary flow after infusion. A volume-control set can also be used with an intermittent infusion line.

Preparation of equipment

Verify the order on the patient's medication record by checking it against the physician's order. Wash your hands. Inspect the I.V. container for cracks, leaks, and contamination, and check drug compatibility with the primary solution. Verify the expiration date. Check to see whether the primary line has a secondary injection port. If it doesn't and the medication is to be given regularly, replace the I.V. set with one that has a secondary injection port.

If necessary, add the drug to the secondary I.V. solution. To do so, remove any seals from the secondary container, and wipe the main port with an alcohol pad. Inject the prescribed medication, and gently agitate the solution to mix the medication thoroughly. Properly label the I.V. mixture. Insert the administration set spike and attach the needle. Open the flow clamp and prime the line. Then close the flow clamp.

Some medications are available in vials that are suitable for hanging directly on an I.V. pole. Instead of preparing medication and injecting it into a container, you can inject diluent directly into the medication vial. Then you can spike the vial, prime the tubing, and hang the set, as directed.

Implementation

Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
If the drug is incompatible with the primary I.V. solution, replace the primary solution with a fluid that's compatible with both solutions, such as normal saline solution, and flush the line before starting the drug infusion. Many facility protocols require that the primary I.V. solution be removed and that a sterile I.V. plug be inserted into the container until it's ready to be rehung. This maintains the sterility of the solution and prevents someone else from inadvertently restarting the incompatible solution before the line is flushed with normal saline solution.
Hang the secondary set's container, and wipe the injection port of the primary line with an alcohol pad.
Insert the needleless adapter from the secondary line into the injection port, and secure it to the primary line.
To run the secondary set's container by itself, lower the primary set's container with an extension hook. To run both containers simultaneously, place them at the same height. (See Assembling a piggyback set, page 250.)
Open the clamp and adjust the drip rate. For continuous infusion, set the secondary solution to the desired drip rate; then adjust the primary solution to achieve the desired total infusion rate.
For intermittent infusion, adjust the primary drip rate, as required, on completion of the secondary solution. If the secondary solution tubing is being reused, close the clamp on the tubing and follow your facility's policy: Either remove the needleless adapter and replace it with a new one, or leave it securely taped in the injection port and label it with the time it was first used. In this case, also leave the empty container in place until you replace it with a new dose of medication at the prescribed time. If the tubing won't be reused, discard it appropriately with the I.V. container.

Special considerations

If policy allows, use a pump for drug infusion. Put a time tape on the secondary container to help prevent an inaccurate administration rate.
When reusing secondary tubing, change it according to your facility's policy, usually every 48 to 72 hours. Similarly, inspect the injection port for leakage with each use, and change it more often if needed.
Unless you're piggybacking lipids, don't piggyback a secondary I.V. line to a total parenteral nutrition line because of the risk of contamination. Check your facility's policy for possible exceptions.

Complications

The patient may experience an adverse reaction to the infused drug. In addition, repeated punctures of the secondary injection port can damage the seal, possibly allowing leakage or contamination.

Documentation

Record the amount and type of drug and the amount of I.V. solution on the intake and output and medication records. Note the date, duration and rate of infusion, and patient's response, where applicable.

Understanding INTRAOSSEOUS INFUSION

2011-06-17T15:32:00.000-07:00

During intraosseous infusion, the bone marrow serves as a noncollapsible vein; thus, fluid infused into the marrow cavity rapidly enters the circulation by way of an extensive network of venous sinusoids. Here, the needle is shown positioned in the patient's tibia.

INTRAOSSEOUS INFUSION

2011-06-16T05:25:00.000-07:00

When rapid venous infusion is difficult or impossible, intraosseous infusion allows delivery of fluids, medications, or whole blood into the bone marrow. Performed on infants and children, this technique is used in such emergencies as cardiopulmonary arrest, circulatory collapse, hypokalemia from traumatic injury or dehydration, status epilepticus, status asthmaticus, burns, near-drowning, and overwhelming sepsis.

Any drug that can be given I.V. can be given by intraosseous infusion with comparable absorption and effectiveness. Intraosseous infusion has been used as an acceptable alternative for infants and children.

Intraosseous infusion is commonly undertaken at the anterior surface of the tibia. Alternative sites include the iliac crest, spinous process and, rarely, the upper anterior portion of the sternum. Only personnel trained in this procedure should perform it. Usually, a nurse assists. (See Understanding intraosseous infusion.)

This procedure is contraindicated in patients with osteogenesis imperfecta, osteopetrosis, and ipsilateral fracture because of the potential for subcutaneous extravasation. Infusion through an area with cellulitis or an infected burn increases the risk of infection.

Equipment

Bone marrow biopsy needle or specially designed intraosseous infusion needle (cannula and obturator) â€¢ povidone-iodine pads â€¢ sterile gauze pads â€¢ sterile gloves â€¢ sterile drape â€¢ bone marrow set â€¢ heparin flush solution â€¢ I.V. fluids and tubing â€¢ 1% lidocaine â€¢ 3- or 5-ml syringe â€¢ tape.

Preparation of equipment

Prepare I.V. fluids and tubing as ordered.

Implementation

If the patient is conscious, explain the procedure to allay his fears and promote his cooperation. Ensure that the patient or a responsible family member understands the procedure and signs a consent form.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Check the patient's history for hypersensitivity to the local anesthetic. If the patient isn't an infant, tell him which bone site will be infused. Inform him that he will receive a local anesthetic and will feel pressure from needle insertion.
Wash your hands.
Provide a sedative, if ordered, before the procedure.
Position the patient based on the selected puncture site.
Using sterile technique, the physician cleans the puncture site with a povidone-iodine pad and allows it to dry. He then covers the area with a sterile drape.
Using sterile technique, hand the physician the 3- or 5-ml syringe with 1% lidocaine so that he can anesthetize the infusion site.
The physician inserts the infusion needle through the skin and into the bone at an angle of 10 to 15 degrees from vertical. He advances it with a forward and backward rotary motion through the periosteum until it penetrates the marrow cavity. The needle should â€œgiveâ€ suddenly as it enters the marrow and stand erect when released.
Then the physician removes the obturator from the needle and attaches a 5-ml syringe. He aspirates some bone marrow to confirm needle placement.
The physician replaces this syringe with a syringe containing 5 ml of heparin flush solution and flushes the cannula to confirm needle placement and clear the cannula of clots and bone particles.
Next, the physician removes the syringe of flush solution and attaches I.V. tubing to the cannula to allow infusion of medications and I.V. fluids.
Put on sterile gloves.
Clean the infusion site with povidone-iodine pads, and then secure the site with tape and a sterile gauze dressing.
Monitor vital signs and check the infusion site for bleeding and extravasation.

Special considerations

Facility policy may vary as to securing the site and dressing materials used. Some facilities may use transport dressings. Check your facility's policy and procedure manual.
Intraosseous infusion should be discontinued as soon as conventional vascular access is established (within 2 to 4 hours, if possible). Prolonged infusion significantly increases the risk of infection.
After the needle has been removed, place a sterile dressing over the injection site, and apply firm pressure to the site for 5 minutes.
Intraosseous flow rates are determined by needle size and flow through the bone marrow. Fluids should flow freely if needle placement is correct. Normal saline solution has been given intraosseously at a rate of 600 ml/minute and up to 2,500 ml/hour when delivered under pressure of 300 mm Hg through a 13G needle.

Complications

Common complications include extravasation of fluid into subcutaneous tissue, resulting from incorrect needle placement; subperiosteal effusion, resulting from failure of fluid to enter the marrow space; and clotting in the needle, resulting from delayed infusion or failure to flush the needle after placement. Other complications include subcutaneous abscess, osteomyelitis, and epiphyseal injury.

Documentation

Record the time, date, location, and patient's tolerance of the procedure. Document the amount of fluid infused on the input and output record.

Displacing The Skin For Z-TRACK Injection

2011-06-12T01:12:00.000-07:00

By blocking the needle pathway after an injection, the Z-track technique allows I.M. injection while minimizing the risk of subcutaneous irritation and staining from such drugs as iron dextran. The illustrations here show how to perform a Z-track injection.

Before the procedure begins, the skin, subcutaneous fat, and muscle lie in their normal positions.

To begin, place your finger on the skin surface, and pull the skin and subcutaneous layers out of alignment with the underlying muscle. You should move the skin about Â½â€³ (1 cm).

Insert the needle at a 90-degree angle at the site where you initially placed your finger. Inject the drug and withdraw the needle.

Finally, remove your finger from the skin surface, allowing the layers to return to their normal positions. The needle track (shown by the dotted line) is now broken at the junction of each tissue layer, trapping the drug in the muscle.

Z-Track Injection

2011-06-06T18:20:00.000-07:00

The Z-track method of I.M. injection prevents leakage, or tracking, into the subcutaneous tissue. It's typically used to administer drugs that irritate and discolor subcutaneous tissue, primarily iron preparations such as iron dextran. It may also be used in elderly patients who have decreased muscle mass. Lateral displacement of the skin during the injection helps to seal the drug in the muscle.

This procedure requires careful attention to technique because leakage into subcutaneous tissue can cause patient discomfort and may permanently stain some tissues.

Equipment

Patient's medication record and chart â€¢ two 20G 1Â¼â€³ to 2â€³ needles â€¢ prescribed medication â€¢ gloves â€¢ 3- or 5-ml syringe â€¢ two alcohol pads.

Preparation of equipment

Verify the order on the patient's medication record by checking it against the physician's order. Wash your hands.

Make sure the needle you're using is long enough to reach the muscle. As a rule of thumb, a 200-lb (90.7-kg) patient requires a 2â€³ needle; a 100-lb (45-kg) patient, a 1Â¼â€³ to 1Â½â€³ needle.

Attach one needle to the syringe, and draw up the prescribed medication. Then draw 0.2 to 0.5 cc of air (depending on your facility's policy) into the syringe. Remove the first needle and attach the second to prevent tracking the medication through the subcutaneous tissue as the needle is inserted.

Implementation

Confirm the patient's identity, explain the procedure, and provide privacy.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Place the patient in the lateral position, exposing the gluteal muscle to be used as the injection site. The patient may also be placed in the prone position.
Clean an area on the upper outer quadrant of the patient's buttock with an alcohol pad.
Put on gloves. Then displace the skin laterally by pulling it away from the injection site. (See Displacing the skin for Z-track injection.)
Insert the needle into the muscle at a 90-degree angle.

Aspirate for blood return; if none appears, inject the drug slowly, followed by the air. Injecting air after the drug helps clear the needle and prevents tracking the medication through subcutaneous tissues as the needle is withdrawn.
Wait 10 seconds before withdrawing the needle to ensure dispersion of the medication.
Withdraw the needle slowly. Then release the displaced skin and subcutaneous tissue to seal the needle track. Don't massage the injection site or allow the patient to wear a tight-fitting garment over the site because it could force the medication into subcutaneous tissue.
Encourage the patient to walk or move about in bed to facilitate absorption of the drug from the injection site.
Discard the needles and syringe in an appropriate sharps container. Don't recap needles to avoid needle-stick injuries.
Remove and discard your gloves.

Special considerations

Never inject more than 5 ml of solution into a single site using the Z-track method. Alternate gluteal sites for repeat injections.
Always encourage the patient to relax the muscle you'll be injecting because injections into tense muscle are more painful than usual and may bleed more readily.
If the patient is on bed rest, encourage active range-of-motion (ROM) exercises or perform passive ROM exercises to facilitate absorption from the injection site.
I.M. injections can damage local muscle cells, causing elevated serum enzyme levels (for example, of creatine kinase) that can be confused with the elevated enzyme levels resulting from damage to cardiac muscle, as in myocardial infarction. If measuring enzyme levels is important, suggest that the physician switch to I.V. administration and adjust dosages accordingly.

Complications

Discomfort and tissue irritation may result from drug leakage into subcutaneous tissue. Failure to rotate sites in patients who require repeated injections can interfere with the absorption of medication. Unabsorbed medications may build up in deposits. Such deposits can reduce the desired pharmacologic effect and may lead to abscess formation or tissue fibrosis.

Documentation

Record the medication, dosage, date, time, and site of injection on the patient's medication record. Include the patient's response to the injected drug.

Nursing Approach to Neurological Assessment

2011-06-04T18:13:00.000-07:00

Neurological assessment should be an integral part of the entire physical assessment. The approach to neurological assessment should be systematic and include pertinent health history, for example coexisting conditions, the developmental status of the child, the nature and extent of the injury or surgery performed, and potential complications. Sources of this information include the verbal report or patient record and the neurosurgeon, neurologist, or other medical providers. Nurses must be aware that other physical and developmental disorders not directly associated with the neurological condition, such as renal, cardiac, or pulmonary, may also affect the patient’s long-term prognosis and ultimate quality of life. Care planning should be a team approach that involves the parents and the multidisciplinary team to assure optimal outcomes. Factors that impact the assessment will be the age of the child, the family dynamics, the nature of the child’s illness, the setting in which the assessment takes place, and input from other member of the multidisciplinary team.

Importance of Neurological Assessment of the Neonate, Infant, Child, and Adolescent

2011-06-04T18:10:00.000-07:00

Serial, consistent, and well-documented neurological assessments are the most important aspect of nursing care for the pediatric neurosurgical patient. Subtle changes in the neurological assessment may first be noted by a bedside nurse. Keen observation skills and the ability to extract information about a patient’s baseline level of neurological function from the parents or primary caregivers are essential. The nurse’s response to assessment changes is essential to the prevention of secondary neurological sequelae and other complications associated with neurological disorders. These potential complications include, among others, inability to protect the airway, immobility, endocrine disorders related to central hormonal dysregulation, impaired communication, and behavioral issues.

It is understood that children are not always under the care and custody of their parents.

LOCATING I.M. INJECTION SITES

2011-06-02T04:51:00.000-07:00

Read more : http://careville.blogspot.com/2011/12/intramuscular-injections-site-selection.html
Deltoid

Find the lower edge of the acromial process and the point on the lateral arm in line with the axilla. Insert the needle 1â€³ to 2â€³ (2.5 to 5 cm) below the acromial process, usually two or three fingerbreadths, at a 90-degree angle or angled slightly toward the process. Typical injection: 0.5 ml (range: 0.5 to 2.0 ml).

Ventrogluteal

Locate the greater trochanter of the femur with the heel of your hand. Then, spread your index and middle fingers from the anterior superior iliac spine to as far along the iliac crest as you can reach. Insert the needle between the two fingers at a 90-degree angle to the muscle. (Remove your fingers before inserting the needle.) Typical injection: 1 to 4 ml (range: 1 to 5 ml).

Dorsogluteal

Inject above and outside a line drawn from the posterior superior iliac spine to the greater trochanter of the femur. Or, divide the buttock into quadrants and inject in the upper outer quadrant, about 2â€³ to 3â€³ (5 to 7.6 cm) below the iliac crest. Insert the needle at a 90-degree angle. Typical injection: 1 to 4 ml (range: 1 to 5 ml).

Vastus lateralis

Use the lateral muscle of the quadriceps group, from a handbreadth below the greater trochanter to a handbreadth above the knee. Insert the needle into the middle third of the muscle parallel to the surface on which the patient is lying. You may have to bunch the muscle before insertion. Typical injection: 1 to 4 ml (range: 1 to 5 ml; 1 to 3 ml for infants).

I.M. Injection

2011-06-01T04:19:00.000-07:00

I.M. injections deposit medication deep into muscle tissue. This route of administration provides rapid systemic action and absorption of relatively large doses (up to 5 ml in appropriate sites). I.M. injections are recommended for patients who are uncooperative or can't take medication orally and for drugs that are altered by digestive juices. Because muscle tissue has few sensory nerves, I.M. injection allows less painful administration of irritating drugs.
WY: `Medical Assistant' Botches I.M. Injection: RN & MD Standards of Care Are Applicable.(Brief Article): An article from: Hospital Law's Regan Report

The site for an I.M. injection must be chosen carefully, taking into account the patient's general physical status and the purpose of the injection. I.M. injections shouldn't be administered at inflamed, edematous, or irritated sites or at sites that contain moles, birthmarks, scar tissue, or other lesions. I.M. injections may also be contraindicated in patients with impaired coagulation mechanisms, occlusive peripheral vascular disease, edema, and shock; after thrombolytic therapy; and during an acute myocardial infarction because these conditions impair peripheral absorption. I.M. injections require sterile technique to maintain the integrity of muscle tissue.

Oral or I.V. routes are preferred for administration of drugs that are poorly absorbed by muscle tissue, such as phenytoin, digoxin, chlordiazepoxide, and diazepam.

Equipment

Patient's medication record and chart â€¢ prescribed medication â€¢ diluent or filter needle, if needed â€¢ 3- or 5-ml syringe â€¢ 20G to 25G 1â€³ to 3â€³ needle â€¢ gloves â€¢ alcohol pads â€¢ 2â€³ Ã— 2â€³ gauze pad.

The prescribed medication must be sterile. The needle may be packaged separately or already attached to the syringe. Needles used for I.M. injections are longer than subcutaneous needles because they must reach deep into the muscle. Needle length also depends on the injection site, patient's size, and amount of subcutaneous fat covering the muscle. The needle gauge for I.M. injections should be larger to accommodate viscous solutions and suspensions.

Preparation of equipment

Verify the order on the patient's medication record by checking it against the physician's order. Also note whether the patient has any allergies, especially before the first dose.

Check the prescribed medication for color and clarity. Also note the expiration date. Never use medication that's cloudy or discolored or contains a precipitate unless the manufacturer's instructions allow it. Remember that for some drugs (such as suspensions), the presence of drug particles is normal. Observe for abnormal changes. If in doubt, check with the pharmacist.

Choose equipment appropriate to the prescribed medication and injection site, and make sure it works properly. The needle should be straight, smooth, and free of burrs.

For single-dose ampules

Wrap an alcohol pad around the ampule's neck and snap off the top, directing the force away from your body. Attach a filter needle to the needle and withdraw the medication, keeping the needle's bevel tip below the level of the solution. Tap the syringe to clear air from it. Cover the needle with the needle sheath.

Before discarding the ampule, check the medication label against the patient's medication record. Discard the filter needle and the ampule. Attach the appropriate needle to the syringe.

For single-dose or multidose vials

Reconstitute powdered drugs according to instructions. Make sure all crystals have dissolved in the solution. Warm the vial by rolling it between your palms to help the drug dissolve faster.

Wipe the stopper of the medication vial with an alcohol pad, and then draw up the prescribed amount of medication. Read the medication label as you select the medication, as you draw it up, and after you've drawn it up to verify the correct dosage.

Don't use an air bubble in the syringe. A holdover from the days of reusable syringes, air bubbles can affect the medication dosage by 5% to 100%. Modern disposable syringes are calibrated to administer the correct dose without an air bubble.

Gather all necessary equipment and proceed to the patient's room.

Implementation

Confirm the patient's identity by asking his name and checking his wristband for name, room number, and bed number.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Provide privacy, explain the procedure to the patient, and wash your hands.
Select an appropriate injection site. The gluteal muscles (gluteus medius and minimus and the upper outer corner of the gluteus maximus) are used most commonly for healthy adults, although the deltoid muscle may be used for a small-volume injection (2 ml or less). Remember to rotate injection sites for patients who require repeated injections.
PEDIATRIC ALERT For infants and children, the vastus lateralis muscle of the thigh is used most often because it's usually the best developed and contains no large nerves or blood vessels, minimizing the risk of serious injury. The rectus femoris muscle may also be used in infants but is usually contraindicated in adults.
Position and drape the patient appropriately, making sure the site is well exposed and that lighting is adequate.
Loosen the protective needle sheath, but don't remove it.
After selecting the injection site, gently tap it to stimulate the nerve endings and minimize pain when the needle is inserted. (See Locating I.M. injection sites, page 244.) Clean the skin at the site with an alcohol pad. Move the pad outward in a circular motion to a circumference of about 2â€³ (5 cm) from the injection site, and allow the skin to dry. Keep the alcohol pad for later use.
Put on gloves. With the thumb and index finger of your nondominant hand, gently stretch the skin of the injection site taut.
While you hold the syringe in your dominant hand, remove the needle sheath by slipping it between the free fingers of your nondominant hand and then drawing back the syringe.
Position the syringe at a 90-degree angle to the skin surface, with the needle a couple of inches from the skin. Tell the patient that he'll feel a prick as you insert the needle. Then quickly and firmly thrust the needle through the skin and subcutaneous tissue, deep into the muscle.
Support the syringe with your nondominant hand, if desired. Pull back slightly on the plunger with your dominant hand to aspirate for blood. If no blood appears, slowly inject the medication into the muscle. A slow, steady injection rate allows the muscle to distend gradually and accept the medication under minimal pressure. You should feel little or no resistance against the force of the injection.
NURSING ALERT If blood appears in the syringe on aspiration, the needle is in a blood vessel. If this occurs, stop the injection, withdraw the needle, prepare another injection with new equipment, and inject another site. Don't inject the bloody solution.
After the injection, gently but quickly remove the needle at a 90-degree angle.
Using a gloved hand, cover the injection site immediately with the used alcohol pad or 2â€³ Ã— 2â€³ gauze pad, apply gentle pressure, and unless contraindicated, massage the relaxed muscle to help distribute the drug.
Remove the alcohol pad, and inspect the injection site for signs of active bleeding or bruising. If bleeding continues, apply pressure to the site; if bruising occurs, you may apply ice.

Watch for adverse reactions at the site for 10 to 30 minutes after the injection.
ELDER ALERT An older patient will probably bleed or ooze from the site after the injection because of decreased tissue elasticity. Applying a small pressure bandage may be helpful.
Discard all equipment according to standard precautions and your facility's policy. Don't recap needles; dispose of them in an appropriate sharps container to avoid needle-stick injuries.

Special considerations

To slow their absorption, some drugs for I.M. administration are dissolved in oil or other special solutions. Mix these preparations well before drawing them into the syringe.
PEDIATRIC ALERT The gluteal muscles can be used as the injection site only after a toddler has been walking for about 1 year.
Never inject into sensitive muscles, especially those that twitch or tremble when you assess site landmarks and tissue depth. Injections into these trigger areas may cause sharp or referred pain, such as the pain caused by nerve trauma.
Keep a rotation record that lists all available injection sites, divided into various body areas, for patients who require repeated injections. Rotate from a site in the first area to a site in each of the other areas. Then return to a site in the first area that is at least 1â€³ (2.5 cm) away from the previous injection site in that area.
If the patient has experienced pain or emotional trauma from repeated injections, consider numbing the area before cleaning it by holding ice on it for several seconds or consider the use of an eulectic mixture of local anesthetics (EMLA) cream applied 60 to 90 minutes prior to the procedure. If you must inject more than 5 ml of solution, divide the solution and inject it at two separate sites.
Always encourage the patient to relax the muscle you'll be injecting because injections into tense muscles are more painful than usual and may bleed more readily.
I.M. injections can damage local muscle cells, causing elevations in serum enzyme levels (creatine kinase [CK]) that can be confused with elevations resulting from cardiac muscle damage, as in myocardial infarction. To distinguish between skeletal and cardiac muscle damage, diagnostic tests for suspected myocardial infarction must identify the isoenzyme of CK specific to cardiac muscle (CK-MB) and include tests to determine lactate dehydrogenase and aspartate aminotransferase levels. If it's important to measure these enzyme levels, suggest that the physician switch to I.V. administration and adjust dosages accordingly.
Dosage adjustments are usually necessary when changing from the I.M. route to the oral route.

Complications

Accidental injection of concentrated or irritating medications into subcutaneous tissue or other areas where they can't be fully absorbed can cause sterile abscesses to develop. Such abscesses result from the body's natural immune response in which phagocytes attempt to remove the foreign matter.

Failure to rotate sites in patients who require repeated injections can lead to deposits of unabsorbed medications. Such deposits can reduce the desired pharmacologic effect and may lead to abscess formation or tissue fibrosis.

ELDER ALERT Because older patients have decreased muscle mass, I.M. medications can be absorbed more quickly than expected.

Documentation

Chart the drug administered, dose, date, time, route of administration, and injection site. Also, note the patient's tolerance of the injection and the injection's effects, including any adverse effects.

GIVING AN INTRADERMAL INJECTION

2011-05-31T12:52:00.000-07:00

Secure the patient's forearm. Insert the needle at a 10- to 15-degree angle so that it just punctures the skin's surface. The antigen should raise a small wheal as it's injected.

List of Nursing Diagnosis NANDA 2011

2011-05-28T21:31:00.000-07:00

Label: List of Nursing Diagnosis NANDA 2011, NANDA, Nursing Diagnosis

Nanda Nursing Diagnosis List 2011

List of NANDA Nursing diagnosis Accepted for Use and Research Divided into 13 domains and 47 classes, below the full list of 13 Domains and 47 classes NANDA Nursing diagnosis. And complete list of NANDA Nursing diagnosis based on alphabetical order.

Domains Health Promotions
1. Health awareness
2. Health management
Domains nutrition’s
1. ingestion
2. digestion
3. Absorption
4. Metabolism
5. Hydration
Domains Elimination/exchange
1. Urinary System
2. Gastrointestinal System
3. Integumentary system
4. Pulmonary System
Domains Activity/Rest
1. Sleep/Rest
2. Activity/Exercise
3. Energy Balance
4. Cardiovascular-pulmonary Responses
5. Self-Care
Domains Perception/Cognition
1. Attention
2. Orientation
3. Sensation/Perception Cognition
4. Communication
Domains Self Perception
1. Self-Concept
2. Self-Esteem
3. Body Image
Domains Role Relationship
1. Caregiving Roles
2. Family Relationship
3. Role Performance
Domains Sexuality
1. Sexual Identity
2. Sexual Function
3. Reproduction
Domains Coping/Stress Tolerance
1. Post-Trauma Responses
2. Coping Responses
3. Neuro-behavioral Stress
Domains Life Principles
1. Values
2. Beliefs
3. Values/Belief/action Congruence
Domains Safety/protection
1. infection
2. Physical Injury
3. Violence
4. Environmental Hazards
5. Defensive Processes
6. Thermo regulation
Domains Comfort
1. Physical Comfort
2. Environmental Comfort
3. social Comfort
Domains Growth/Development
1. Growth
2. Development
Label: List of Nursing Diagnosis NANDA 2011, NANDA, Nursing Diagnosis

INTRADERMAL INJECTION SITES

2011-05-28T21:01:00.000-07:00

The most common intradermal injection site is the ventral forearm. Other sites (indicated by dotted areas) include the upper chest, upper arm, and shoulder blades. Skin in these areas is usually lightly pigmented, thinly keratinized, and relatively hairless, facilitating detection of adverse reactions.

INTRADERMAL INJECTION

2011-05-28T20:58:00.000-07:00

Because little systemic absorption of intradermally injected agents takes place, this type of injection is used primarily to produce a local effect, as in allergy or tuberculin testing. Intradermal injections are administered in small volumes (usually 0.5 ml or less) into the outer layers of the skin.

The ventral forearm is the most commonly used site for intradermal injection because of its easy accessibility and lack of hair. In extensive allergy testing, the outer aspect of the upper arms may be used as well as the area of the back located between the scapulae. (See Intradermal injection sites.)

Equipment

Patient's medication record and chart â€¢ tuberculin syringe with a 26G or 27G Â½â€³ to 3/8â€³ needle â€¢ prescribed medication â€¢ gloves â€¢ alcohol pads.

Preparation of equipment

Verify the order on the patient's medication record by checking it against the physician's orders. Inspect the medication to make sure it isn't abnormally discolored or cloudy and doesn't contain precipitates. Wash your hands.

Choose equipment appropriate to the prescribed medication and injection site, and make sure it works properly. Check the medication label against the patient's medication record. Read the label again as you draw up the medication for injection.

Implementation

Verify the patient's identity by asking his name and checking the name, room number, and bed number on his wristband against his medical record.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Tell him where you'll be giving the injection.
Instruct the patient to sit up and to extend his arm and support it on a flat surface, with the ventral forearm exposed.
Put on gloves.
With an alcohol pad, clean the surface of the ventral forearm about two or three fingerbreadths distal to the antecubital space. Make sure the test site you have chosen is free from hair or blemishes. Allow the skin to dry completely before administering the injection.
While holding the patient's forearm in your hand, stretch the skin taut with your thumb.
With your free hand, hold the needle at a 10- to 15-degree angle to the patient's arm, with its bevel up.
Insert the needle about 1/8â€³ (0.3 cm) below the epidermis at sites 2â€³ (5 cm) apart. Stop when the needle's bevel tip is under the skin, and inject the antigen slowly. You should feel some resistance as you do this, and a wheal should form as you inject the antigen. (See Giving an intradermal injection.) If no wheal forms, you have injected the antigen too deeply; withdraw the needle, and administer another test dose at least 2â€³ from the first site.
Withdraw the needle at the same angle at which it was inserted. Don't rub the site. This could irritate the underlying tissue, which may affect test results.
Circle each test site with a marking pen, and label each site according to the recall antigen given. Instruct the patient to refrain from washing off the circles until the test is completed.
Dispose of needles and syringes according to your facility's policy.
Remove and discard your gloves.
Assess the patient's response to the skin testing in 24 to 48 hours.

Special considerations

In patients who are hypersensitive to the test antigens, a severe anaphylactic response can result. This requires immediate epinephrine injection and other emergency resuscitation procedures. Be especially alert after giving a test dose of penicillin or tetanus antitoxin.

Documentation

On the patient's medication record, document the type and amount of medication given, the time it was given, and the injection site. Note skin reactions and other adverse reactions.

TECHNIQUE FOR SUBCUTANEOUS INJECTION

2011-05-22T01:30:00.000-07:00

Before giving the injection, elevate the subcutaneous tissue at the site by grasping it firmly.

Insert the needle at a 45- or 90-degree angle to the skin surface, depending on needle length and the amount of subcutaneous tissue at the site. Some medications, such as heparin, should always be injected at a 90-degree angle.

TYPES OF INSULIN INFUSION PUMPS

2011-05-18T20:55:00.000-07:00

A subcutaneous insulin infusion pump provides continuous, long-term insulin therapy for patients with type 1 diabetes mellitus. Complications include infection at the injection site, catheter clogging, and insulin loss from loose reservoir-catheter connections. Insulin pumps work on either an open-loop or a closed-loop system.

Open-loop system

The open-loop pump is used most commonly. It infuses insulin but can't respond to changes in the patient's serum glucose levels. These portable, self-contained, programmable insulin pumps are smaller and less obtrusive than everâ€”about the size of a credit cardâ€”and have fewer buttons.

The pump delivers insulin in small (basal) doses every few minutes and large (bolus) doses that the patient sets manually. The system consists of a reservoir containing the insulin syringe, a small pump, an infusion-rate selector that allows insulin release adjustments, a battery, and a plastic catheter with an attached needle leading from the syringe to the subcutaneous injection site. The needle is typically held in place with waterproof tape. The patient can wear the pump on his belt or in his pocketâ€”practically anywhere as long as the infusion line has a clear path to the injection site.

Close-up of open-loop infusion pump

The infusion-rate selector automatically releases about one-half the total daily insulin requirement. The patient releases the remainder in bolus doses before meals and snacks. He must change the syringe daily, and the needle, catheter, and injection site every other day.

Closed-loop system

The self-contained closed-loop system detects and responds to changing serum glucose levels. The typical closed-loop system includes a glucose sensor, a programmable computer, a power supply, a pump, and an insulin reservoir. The computer triggers continuous insulin delivery in appropriate amounts from the reservoir.

Nonneedle catheter system

In the nonneedle delivery system, a tiny plastic catheter is inserted into the skin over a needle using a special insertion device (shown below). The needle is then withdrawn, leaving the catheter in place (shown in inset). This catheter can be placed in the abdomen, thigh, or flank and should be changed every 2 to 3 days.

Nonneedle catheter insertion system

LOCATING SUBCUTANEOUS INJECTION SITES

2011-05-16T17:55:00.000-07:00

Subcutaneous (S.C.) injection sites (as indicated by the dotted areas in the illustration below) include the fat pads on the abdomen, upper hips, upper back, and lateral upper arms and thighs. For S.C. injections administered repeatedly, such as insulin, rotate sites. Choose one injection site in one area, move to a corresponding injection site in the next area, and so on.

When returning to an area, choose a new site in that area. Preferred injection sites for insulin are the arms, abdomen, thighs, and buttocks. The preferred injection site for heparin is the lower abdominal fat pad, just below the umbilicus.

SUBCUTANEOUS INJECTION

2011-05-09T18:02:00.000-07:00

When injected into the adipose (fatty) tissues beneath the skin, a drug moves into the bloodstream more rapidly than if given by mouth. Subcutaneous (S.C.) injection allows slower, more sustained drug administration than I.M. injection; it also causes minimal tissue trauma and carries little risk of striking large blood vessels and nerves.

Absorbed mainly through the capillaries, drugs recommended for S.C. injection include nonirritating aqueous solutions and suspensions contained in 0.5 to 2 ml of fluid. Heparin and insulin, for example, are usually administered S.C. (Some diabetic patients, however, may benefit from an insulin infusion pump.)

Drugs and solutions for S.C. injection are injected through a relatively short needle, using meticulous sterile technique. The most common S.C. injection sites are the outer aspect of the upper arm, anterior thigh, loose tissue of the lower abdomen, upper hips, buttocks, and upper back. (See Locating subcutaneous injection sites, page 238.) Injection is contraindicated in sites that are inflamed, edematous, scarred, or covered by a mole, birthmark, or other lesion. It may also be contraindicated in patients with impaired coagulation mechanisms.

Equipment

Prescribed medication â€¢ patient's medication record and chart â€¢ 25G to 27G 5/8â€³ or Â½â€³ needle â€¢ gloves â€¢ 1- or 3-ml syringe â€¢ alcohol pads â€¢ 2â€³ Ã— 2â€³ gauze pad â€¢ optional: antiseptic cleaning agent, filter needle, insulin syringe, insulin pump. (See Types of insulin infusion pumps.)

Preparation of equipment

Verify the order on the patient's medication record by checking it against the physician's order. Also note whether the patient has any allergies, especially before the first dose.

Inspect the medication to make sure it isn't abnormally discolored or cloudy and doesn't contain precipitates (unless the manufacturer's instructions allow it).

Wash your hands. Choose equipment appropriate to the prescribed medication and injection site, and make sure it works properly.

Check the medication label against the patient's medication record. Read the label again as you draw up the medication for injection.

For single-dose ampules

Before discarding the ampule, check the medication label against the patient's medication record. Discard the filter needle and the ampule. Attach the appropriate needle to the syringe.

For single-dose or multidose vials

Reconstitute powdered drugs according to instructions. Make sure all crystals have dissolved in the solution. Warm the vial by rolling it between your palms to help the drug dissolve faster.

Clean the vial's rubber stopper with an alcohol pad. Pull the syringe plunger back until the volume of air in the syringe equals the volume of drug to be withdrawn from the vial.

Without inverting the vial, insert the needle into the vial. Inject the air, invert the vial, and keep the needle's bevel tip below the level of the solution as you withdraw the prescribed amount of medication. Cover the needle with the needle sheath. Tap the syringe to clear any air from it.

Check the medication label against the patient's medication record before discarding the single-dose vial or returning the multidose vial to the shelf.

Implementation

Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Explain the procedure to the patient and provide privacy.
Select an appropriate injection site. Rotate sites according to a schedule for repeated injections, using different areas of the body unless contraindicated. (Heparin, for example, should be injected only in the abdomen if possible.)
Put on gloves.
Position and drape the patient if necessary.
Clean the injection site with an alcohol pad, beginning at the center of the site and moving outward in a circular motion. Allow the skin to dry before injecting the drug to avoid a stinging sensation from introducing alcohol into subcutaneous tissues.
Loosen the protective needle sheath.
With your nondominant hand, grasp the skin around the injection site firmly to elevate the subcutaneous tissue, forming a 1â€³ (2.5-cm) fat fold.
Holding the syringe in your dominant hand, insert the loosened needle sheath between the fourth and fifth fingers of your other hand while still pinching the skin around the injection site. Pull back the syringe with your dominant hand to uncover the needle by grasping the syringe like a pencil. Don't touch the needle.
Position the needle with its bevel up.
Tell the patient he'll feel a needle prick.
Insert the needle quickly in one motion at a 45- or 90-degree angle. (See Technique for subcutaneous injection.) Release the patient's skin to avoid injecting the drug into compressed tissue and irritating nerve fibers.
Pull back the plunger slightly to check for blood return. If none appears, begin injecting the drug slowly. If blood appears on aspiration, withdraw the needle, prepare another syringe, and repeat the procedure.
Don't aspirate for blood return when giving insulin or heparin. It isn't necessary with insulin and may cause a hematoma with heparin.
After injection, remove the needle gently but quickly at the same angle used for insertion.
Cover the site with an alcohol pad or a 2â€³ Ã— 2â€³ gauze pad and massage the site gently (unless contraindicated, as with heparin and insulin) to distribute the drug and facilitate absorption.
Remove the alcohol pad, and check the injection site for bleeding and bruising.
Dispose of injection equipment according to your facility's policy. To avoid needle-stick injuries, don't resheath the needle.

Special considerations

When using prefilled syringes, adjust the angle and depth of insertion according to needle length.

For insulin injections

To establish more consistent blood insulin levels, rotate insulin injection sites within anatomic regions. Preferred insulin injection sites are the arms, abdomen, thighs, and buttocks.
Make sure the type of insulin, unit dosage, and syringe are correct.
When combining insulins in a syringe, make sure they're compatible. Regular insulin can be mixed with all other types. Prompt insulin zinc suspension (Semilente insulin) can't be mixed with NPH insulin. Follow your facility's policy regarding which insulin to draw up first.
Before drawing up insulin suspension, gently roll and invert the bottle. Don't shake the bottle because this can cause foam or bubbles to develop in the syringe.

For heparin injections

The preferred site for a heparin injection is the lower abdominal fat pad, 2â€³ (5 cm) beneath the umbilicus, between the right and left iliac crests. Injecting heparin into this area, which isn't involved in muscle activity, reduces the risk of local capillary bleeding. Always rotate the sites from one side to the other.
Inject the drug slowly into the fat pad. Leave the needle in place for 10 seconds after injection; then withdraw it.
Don't administer an injection within 2â€³ of a scar, a bruise, or the umbilicus.
Don't aspirate to check for blood return because this can cause bleeding into the tissues at the site.
Don't rub or massage the site after the injection. Rubbing can cause localized minute hemorrhages or bruises.
If the patient bruises easily, apply ice to the site for the first 5 minutes after the injection to minimize local hemorrhage and then apply pressure.

Complications

Concentrated or irritating solutions may cause sterile abscesses to form. Repeated injections in the same site can cause lipodystrophy. A natural immune response, lipodystrophy can be minimized by rotating injection sites.

Documentation

Record the time and date of the injection, medication and dose administered, injection site and route, and patient's reaction.

CARTRIDGE-INJECTION SYSTEM

2011-05-09T17:57:00.000-07:00

A cartridge-injection system, such as Tubex or Carpuject, is a convenient, easy-to-use method of injection that facilitates accuracy and sterility. The device consists of a plastic cartridge-holder syringe and a prefilled medication cartridge with needle attached.

The medication in the cartridge is premixed and premeasured, which saves time and helps ensure an exact dose. The medication remains sealed in the cartridge and sterile until the injection is administered to the patient.

The disadvantage of this system is that not all drugs are available in cartridge form. However, compatible drugs can be added to partially filled cartridges.

ADMIXTURE OF DRUGS IN A SYRINGE

2011-05-08T23:31:00.000-07:00

Combining two drugs in one syringe avoids the discomfort of two injections. Usually, drugs can be mixed in a syringe in one of four ways. They may be combined from two multidose vials (for example, regular and long-acting insulin), from one multidose vial and one ampule, from two ampules, or from a cartridge-injection system combined with either a multidose vial or an ampule.

Such combinations are contraindicated when the drugs aren't compatible and when the combined doses exceed the amount of solution that can be absorbed from a single injection site.

Equipment

Prescribed medications â€¢ patient's medication record and chart â€¢ alcohol pads â€¢ syringe and needle â€¢ optional: cartridge-injection system and filter needle.

The type and size of the syringe and needle depend on the prescribed medications, patient's body build, and route of administration. Medications that come in prefilled cartridges require a cartridge-injection system. (See Cartridge-injection system.)

Implementation

Verify that the drugs to be administered agree with the patient's medication record and the physician's orders.
Calculate the dose to be given.
Wash your hands.

Mixing drugs from two multidose vials

Using an alcohol pad, wipe the rubber stopper on the first vial. This decreases the risk of contaminating the medication as you insert the needle into the vial.
Pull back the syringe plunger until the volume of air drawn into the syringe equals the volume to be withdrawn from the drug vial.
Without inverting the vial, insert the needle into the top of the vial, making sure that the needle's bevel tip doesn't touch the solution. Inject the air into the vial and withdraw the needle. This replaces air in the vial, thus preventing creation of a partial vacuum on withdrawal of the drug.
Repeat the steps above for the second vial. Then, after injecting the air into the second vial, invert the vial, withdraw the prescribed dose, and then withdraw the needle.
Wipe the rubber stopper of the first vial again and insert the needle, taking care not to depress the plunger. Invert the vial, withdraw the prescribed dose, and then withdraw the needle.

Mixing drugs from a multidose vial and an ampule

Using an alcohol pad, clean the vial's rubber stopper.
Pull back on the syringe plunger until the volume of air drawn into the syringe equals the volume to be withdrawn from the drug vial.
Insert the needle into the top of the vial and inject the air. Then invert the vial and keep the needle's bevel tip below the level of the solution as you withdraw the prescribed dose. Put the sterile needle cover over the needle.
Wrap a sterile gauze pad or an alcohol pad around the ampule's neck to protect yourself from injury in case the glass splinters. Break open the ampule, directing the force away from you.
If desired, switch to the filter needle at this point to filter out any glass splinters.
Insert the needle into the ampule. Be careful not to touch the outside of the ampule with the needle. Draw the correct dose into the syringe.
If you switched to the filter needle, change back to a regular needle to administer the injection.

Mixing drugs from two ampules

An opened ampule doesn't contain a vacuum. To mix drugs from two ampules in a syringe, calculate the prescribed doses and open both ampules, using sterile technique. If desired, use a filter needle to draw up the drugs. Then change to a regular needle to administer them.

Special considerations

Insert a needle through the vial's rubber stopper at a slight angle, bevel up, and exert slight lateral pressure. This way you won't cut a piece of rubber out of the stopper, which can then be pushed into the vial.
When mixing drugs from multidose vials, be careful not to contaminate one drug with the other. Ideally, the needle should be changed after drawing the first medication into the syringe. This isn't always possible because many disposable syringes don't have removable needles.
NURSING ALERT Never combine drugs if you're unsure of their compatibility, and never combine more than two drugs. Although drug incompatibility usually causes a visible reaction, such as clouding, bubbling, or precipitation, some incompatible combinations produce no visible reaction even though they alter the chemical nature and action of the drugs. Check appropriate references and consult a pharmacist when you're unsure about specific compatibility. When in doubt, administer two separate injections.
Some medications are compatible for only a brief time after being combined and should be administered within 10 minutes after mixing. After this time, environmental factors, such as temperature, exposure to light, and humidity, may alter compatibility.
To reduce the risk of contamination, most facilities dispense parenteral medications in single-dose vials. Insulin is one of the few drugs still packaged in multidose vials. Be careful when mixing regular and long-acting insulin. Draw up the regular insulin first to avoid contamination by the long-acting suspension. (If a minute amount of the regular insulin is accidentally mixed with the long-acting insulin, it won't appreciably change the effect of the long-acting insulin.) Check your facility's policy before mixing insulins.
When you combine a cartridge-injection system and a multidose vial, use a separate needle and syringe to inject air into the multidose vial. This prevents contamination of the multidose vial by the cartridge-injection system.

Documentation

Record the drugs administered, injection site, and time of administration. Document adverse drug effects or other pertinent information.

RECTAL SUPPOSITORIES AND OINTMENTS

2011-05-04T17:42:00.000-07:00

A rectal suppository is a small, solid, medicated mass, usually cone-shaped, with a cocoa butter or glycerin base. It may be inserted to stimulate peristalsis and defecation or to relieve pain, vomiting, and local irritation. Rectal suppositories commonly contain drugs that reduce fever, induce relaxation, interact poorly with digestive enzymes, or have a taste too offensive for oral use. Rectal suppositories melt at body temperature and are absorbed slowly.

Because insertion of a rectal suppository may stimulate the vagus nerve, this procedure is contraindicated in patients with potential cardiac arrhythmias. It may have to be avoided in patients with recent rectal or prostate surgery because of the risk of local trauma or discomfort during insertion.

An ointment is a semisolid medication used to produce local effects. It may be applied externally to the anus or internally to the rectum. Rectal ointments commonly contain drugs that reduce inflammation or relieve pain and itching.

Equipment

Rectal suppository or tube of ointment and applicator â€¢ patient's medication record and chart â€¢ gloves â€¢ water-soluble lubricant â€¢ 4â€³ Ã— 4â€³ gauze pads â€¢ optional: bedpan.

Preparation of equipment

Store rectal suppositories in the refrigerator until needed to prevent softening and, possibly, decreased effectiveness of the medication. A softened suppository is also difficult to handle and insert. To harden it again, hold the suppository (in its wrapper) under cold running water.

Implementation

Verify the order on the patient's medication record by checking it against the physician's order.
Make sure the label on the medication package agrees with the medication order. Read the label again before you open the wrapper and again as you remove the medication. Check the expiration date.
Wash your hands with warm water and soap.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Explain the procedure and the purpose of the medication to the patient.
Provide privacy.

Inserting a rectal suppository

Place the patient on his left side in Sims' position. Drape him with the bedcovers to expose only the buttocks.
Put on gloves. Remove the suppository from its wrapper, and lubricate it with water-soluble lubricant.
Lift the patient's upper buttock with your nondominant hand to expose the anus.
Instruct the patient to take several deep breaths through his mouth to help relax the anal sphincters and reduce anxiety or discomfort during insertion.
Using the index finger of your dominant hand, insert the suppositoryâ€”tapered end firstâ€”about 3â€³ (7.6 cm), until you feel it pass the internal anal sphincter. Try to direct the tapered end toward the side of the rectum so that it contacts the membranes. (See How to administer a rectal suppository or ointment.)
Ensure the patient's comfort. Encourage him to lie quietly and, if applicable, to retain the suppository for the appropriate length of time. A suppository administered to relieve constipation should be retained as long as possible (at least 20 minutes) to be effective. Press on the anus with a gauze pad if necessary until the urge to defecate passes.
Remove and discard your gloves.

Applying rectal ointment

Put on gloves.
To apply externally, use gloves or a gauze pad to spread medication over the anal area.
To apply internally, attach the applicator to the tube of ointment and coat the applicator with water-soluble lubricant.
Expect to use about 1â€³ (2.5 cm) of ointment. To gauge how much pressure to use during application, squeeze a small amount from the tube before you attach the applicator.
Lift the patient's upper buttock with your nondominant hand to expose the anus.
Instruct the patient to take several deep breaths through his mouth to relax the anal sphincters and reduce anxiety or discomfort during insertion.
Gently insert the applicator, directing it toward the umbilicus.
Slowly squeeze the tube to eject the medication.
Remove the applicator and place a folded 4â€³ Ã— 4â€³ gauze pad between the patient's buttocks to absorb excess ointment.
Detach the applicator from the tube and recap the tube. Then clean the applicator thoroughly with soap and warm water.
Special considerations
- Because the intake of food and fluid stimulates peristalsis, a suppository for relieving constipation should be inserted about 30 minutes before mealtime to help soften the feces in the rectum and facilitate defecation. A medicated retention suppository should be inserted between meals.
- Instruct the patient to avoid expelling the suppository. If he has difficulty retaining it, place him on a bedpan.
- Make sure the patient's call button is handy, and watch for his signal because he may be unable to suppress the urge to defecate. For example, a patient with proctitis has a highly sensitive rectum and may not be able to retain a suppository for long.
- Be sure to inform the patient that the suppository may discolor his next bowel movement. Anusol suppositories, for example, can give feces a silver-gray pasty appearance.
Documentation
Record the administration time, dose, and patient's response.

PLACING DRUGS IN THE ORAL MUCOSA

2011-04-19T23:38:00.000-07:00

Buccal and sublingual administration routes allow some drugs, such as nitroglycerin and methyltestosterone, to enter the bloodstream rapidly without being degraded in the GI tract. To give a drug buccally, insert it between the patient's cheek and teeth (as shown below). Ask him to close his mouth and hold the tablet against his cheek until the tablet is absorbed.

To give a drug sublingually, place it under the patient's tongue (as shown below), and ask him to leave it there until it's dissolved.

BUCCAL, SUBLINGUAL, AND TRANSLINGUAL DRUGS

2011-04-19T23:08:00.000-07:00

Certain drugs are given buccally, sublingually, or translingually to prevent their destruction or transformation in the stomach or small intestine. These drugs act quickly because the oral mucosa's thin epithelium and abundant vasculature allow direct absorption into the bloodstream.

Drugs given buccally include nitroglycerin and methyltestosterone; drugs given sublingually include ergotamine tartrate, isosorbide dinitrate, and nitroglycerin. Translingual drugs, which are sprayed onto the tongue, include nitrate preparations for patients with chronic angina.

Equipment

Patient's medication record and chart â€¢ prescribed medication â€¢ medication cup.

Implementation

Verify the order on the patient's medication record by checking it against the physician's order on his chart.
Wash your hands with warm water and soap. Explain the procedure to the patient if he's never taken a drug buccally, sublingually, or translingually before.
Check the label on the medication before administering it to make sure you'll be giving the prescribed medication. Verify the expiration date of all medications, especially nitroglycerin.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.

Buccal and sublingual administration

For buccal administration, place the tablet in the buccal pouch, between the cheek and gum. For sublingual administration, place the tablet under the patient's tongue. (See Placing drugs in the oral mucosa, page 234.)
Instruct the patient to keep the medication in place until it dissolves completely to ensure absorption.
Caution him against chewing the tablet or touching it with his tongue to prevent accidental swallowing.
Tell him not to smoke before the drug has dissolved because nicotine's vasoconstrictive effects slow absorption.

Translingual administration

To administer a translingual drug, tell the patient to hold the medication canister vertically, with the valve head at the top and the spray orifice as close to his mouth as possible.
Instruct him to spray the dose onto his tongue by pressing the button firmly.
Remind the patient using a translingual aerosol form that he shouldn't inhale the spray but should release it under his tongue. Also tell him to wait 10 seconds or so before swallowing.

Special considerations

Don't give liquids to a patient who is receiving buccal medication because some buccal tablets can take up to 1 hour to be absorbed. Tell the patient not to rinse his mouth until the tablet has been absorbed.
Tell the angina patient to wet the nitroglycerin tablet with saliva and to keep it under his tongue until it has been fully absorbed.

Complications
Some buccal medications may irritate the mucosa. Alternate sides of the mouth for repeat doses to prevent continuous irritation of the same site. Sublingual medicationsâ€”such as nitroglycerinâ€”may cause a tingling sensation under the tongue. If the patient finds this annoying, try placing the drug in the buccal pouch instead.

Documentation
Record the medication administered, dose, date and time, and patient's reaction, if any.

What Cancer Patients Should Be Aware

2011-04-03T23:04:00.000-07:00

One of the greatest mysteries on earth may be the occurrence of cancer. It’s been known globally and almost all human beings are extremely much afraid when it comes to this problem. It is also probably the most leading kinds of illness that has killed several people in a short period of time. It has been discovered through the scientist long time but its birth still continues to be a mystery even up to this moment.

Researchers and physicians are trying their very best to trace the origin of cancer. The information and researches about this kind of disease can be found in books and even in the internet. We already have millions of content articles about most cancers and its causes that have been released in order to notify the public. There are also several campaigns that are becoming introduced to the public to fight most cancers. Their primary objective would be to make people aware that cancer does not choose it’s victims. It can occur to anyone regardless of your age or race.
Almost all people possess something to comment or even say about cancer. You will find rooms of information that has been discussed to the public. Some of these bunches of information tend to be true and some are not. However some people are not really well-informed about the origins and causes of cancer they are still conscious with the idea that this type of illness can genuinely bring these phones death. Actually they are convinced that there is no cure with regard to cancer. They also believe that you aren’t cancer is not to expect. They are misdirected with the indisputable fact that once you curently have cancer providing live a normal and longer life.

It is indeed correct that it is very hard to have cancer. This kind of disease has something to do with genetics. This type of illness runs in the family. It can be inherited through any member of the family. It is because most cancers cells can also penetrate the actual DNA of a patient. Children whose parents were diagnosed with cancer have a higher possible ways to develop or even acquire most cancers.
One of the earliest method or ways to deal with cancer is actually chemotherapy. It is the process of getting rid of cancer tissue using specific types of medicines. Drugs that are being used during chemotherapy are intended to slow down or even destroy and stop the growth of cancer tissue in the body. It’s been used as one of the most effective ways associated with treating cancer.
Nowadays scientist managed to find a new way of treating cancer with the help of technologies. One of the latest ways of preventing cancer cells is actually radiation. The radiation has been known to eliminate and destroy cancer cells in a short period of time. A therapy utilizing radiation has been introduced to sufferers with this kind of illness particularly those who are suffering from prostate cancer. The advantage of radiation is that it can specifically target and obtain rid of most cancers cells.
You ought to be more cautious about your health. Should you experience the early symptoms of cancer of the prostate you must be aware with its unwanted effects. You can see much more at http://newcancertreatment.org/blog/

GIVING MEDICATIONS THROUGH A GASTROSTOMY TUBE

2011-04-03T22:47:00.000-07:00

Surgically inserted into the stomach, a gastrostomy tube reduces the risk of fluid aspiration, a constant danger with a nasogastric (NG) tube. To administer medication by this route, prepare the patient and medication as for an NG tube. Then gently lift the dressing around the tube to assess the skin for irritation. Report any irritation to the physician. If none appears, follow these steps:

Remove the dressing that covers the tube. Then remove the dressing or plug at the tip of the tube, and attach the syringe or funnel to the tip.
Release the clamp and instill about 10 ml of water into the tube through the syringe to check for patency. If the water flows in easily, the tube is patent. If it flows in slowly, raise the funnel to increase pressure. If the water still doesn't flow properly, stop the procedure and notify the physician.
Pour up to 30 ml of medication into the syringe or funnel. Tilt the tube to allow air to escape as the fluid flows downward. Just before the syringe empties, add medication as needed.
After giving the medication, pour in about 30 ml of water to irrigate the tube.
Tighten the clamp, place a 4â€³ Ã— 4â€³ gauze pad on the end of the tube, and secure it with a rubber band.
Cover the tube with two more 4â€³ Ã— 4â€³ gauze pads, and secure them firmly with tape.
Keep the head of the bed elevated for at least 30 minutes after the procedure to aid digestion.

Step 1 Lung Cancer Malignancy Survival Fee

2011-04-03T02:53:00.000-07:00

When some may be diagnosed together with stage 1 lung most cancers, the individual usually asks the health practitioner is there a lung melanoma survival charge for their current concern. This seriously isn’t a surprise for some doctors mainly because cancer on the lung, even on the earliest portions, has a very low tactical rate. Many people are thankful however since the life expectations of someone who has been diagnosed with first stage cancer in the lung have a much better ratio than individuals who are in the advanced cases in the disease.
Several of variables that will affect one’s lung cancer survival rate although the patient was just identified of period 1 lung cancer tumor Commission Takers. Among the factors to become considered is definitely age. In relation of survivors regarding cancer belonging to the lung, you will discover a bigger percentage of people beneath 50 years old that was cured and also survived than those of an more mature age.
The site and most cancers type is likewise a substantial factor in terms of lung cancer malignancy survival quote. In some individuals malignant tissues or growths tend hence slowly affect other cellular material or tissues from the lungs. This kind of tumor is much easier to handle via radiation or maybe chemotherapy as well as surgery in addition than other forms of malignancy.

Sex is additionally a thing in overall survival quote. Women experienced a increased ratio with survival in comparison with men every one the circumstances of cancer belonging to the lungs through the entire earth.
One’s capacity to reply to medication or perhaps treatment can be a huge plus when it comes to rate associated with survival Facebook Cash Code. Tolerance for you to treatment are different among patients with cancerous tumors into their body. One should have a good physical and mental capacity to be able to go from the pains with medication.
When 1 quits smoking for the initial point of cancer with the lung these have shown a big improvement from the survival chances on the patient.
Complete lung malignancy survival rate of an patient in a very five calendar year period for your stage 1 cancer with the lung is actually 60 for you to 80% prospects for survival. Recent scientific studies today show that whenever cancer belonging to the lungs appeared to be detected inside the earliest time possible, survival possibilities may increase as long as 90 percent or maybe higher Xtreme Profit Robot. With all the advancements inside medical technological know-how today, clinical detection or trials to spot the simplest form of tumors are in hand so that you can help physicians and patients alike.

GIVING MEDICATIONS THROUGH AN NG TUBE

2011-04-01T21:22:00.000-07:00

Holding the nasogastric (NG) tube at a level somewhat above the patient's nose, pour up to 30 ml of diluted medication into the syringe barrel. To prevent air from entering the patient's stomach, hold the tube at a slight angle and add more medication before the syringe empties. If necessary, raise the tube slightly higher to increase the flow rate.

After you've delivered the whole dose, position the patient on her right side, head slightly elevated, to minimize esophageal reflux.

NASOGASTRIC TUBES

2011-03-28T18:35:00.000-07:00

Besides providing an alternate means of nourishment, a nasogastric (NG) tube or gastrostomy tube allows direct instillation of medication into the GI system of patients who can't ingest the drug orally. Before instillation, the patency and positioning of the tube must be carefully checked because the procedure is contraindicated if the tube is obstructed or improperly positioned; if the patient is vomiting around the tube; or if his bowel sounds are absent.

Oily medications and enteric-coated or sustained-release tablets or capsules are contraindicated for instillation through an NG tube. Oily medications cling to the sides of the tube and resist mixing with the irrigating solution, and crushing enteric-coated or sustained-release tablets to facilitate transport through the tube destroys their intended properties.

Equipment

Patient's medication record and chart â€¢ prescribed medication â€¢ towel or linen-saver pad â€¢ 50- or 60-ml piston-type catheter-tip syringe â€¢ feeding tubing â€¢ two 4â€³ Ã— 4â€³ gauze pads â€¢ stethoscope â€¢ gloves â€¢ diluent â€¢ cup for mixing medication and fluid â€¢ spoon â€¢ 50 ml of water â€¢ rubber band â€¢ gastrostomy tube and funnel, if needed â€¢ optional: mortar and pestle, clamp.

For maximum control of suction, use a piston syringe instead of a bulb syringe. The liquid for diluting the medication can be juice, water, or a nutritional supplement.

Preparation of equipment

Gather equipment for use at the bedside. Liquids should be at room temperature. Administering cold liquids through an NG tube can cause abdominal cramping. Although this isn't a sterile procedure, make sure the cup, syringe, spoon, and gauze are clean.

Implementation

Verify the order on the patient's medication record by checking it against the physician's order.
Wash your hands and put on gloves.
Check the label on the medication three times before preparing it for administration to make sure you'll be giving the medication correctly.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
If the prescribed medication is in tablet form, crush the tablets to ready them for mixing in a cup with the diluting liquid. Request liquid forms of medications, if available. Bring the medication and equipment to the patient's bedside.
Explain the procedure to the patient; provide privacy.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
Unpin the tube from the patient's gown. To avoid soiling the sheets, fold back the bed linens to the patient's waist and drape his chest with a towel or linen-saver pad.
Elevate the head of the bed so that the patient is in Fowler's position, as tolerated.
After unclamping the tube, take the 50- or 60-ml syringe and create a 10-cc air space in its chamber. Then attach the syringe to the end of the tube.
Auscultate the patient's abdomen about 3â€³ (7.6 cm) below the sternum with the stethoscope. Then gently insert the 10 cc of air into the tube. When you hear the air bubble entering the stomach, gently draw back on the piston of the syringe. The appearance of gastric contents implies that the tube is patent and in the stomach. (However, only an X-ray can positively confirm the tube's position.) If no gastric contents appear when you draw back on the syringe, the tube may have risen into the esophagus, and you'll have to advance it before proceeding.
If you meet resistance when aspirating for gastric contents, stop the procedure. Resistance may indicate a nonpatent tube or improper tube placement. (Keep in mind that some smaller NG tubes may collapse when aspiration is attempted.) If the tube seems to be in the stomach, resistance probably means that the tube is lying against the stomach wall. To relieve resistance, withdraw the tube slightly or turn the patient.
After you have established that the tube is patent and in the correct position, clamp the tube, detach the syringe, and lay the end of the tube on the 4â€³ Ã— 4â€³ gauze pad.
Mix the crushed tablets or liquid medication with the diluent. If the medication is in capsule form, open the capsules and empty their contents into the liquid. Pour liquid medications directly into the diluent. Stir well. (If the medication was in tablet form, make sure the particles are small enough to pass through the eyes at the distal end of the tube.)
Reattach the syringe, without the piston, to the end of the tube and open the clamp.
Deliver the medication slowly and steadily. (See Giving medications through an NG tube.)
If the medication flows smoothly, slowly add more until the entire dose has been given.
If the medication doesn't flow properly, don't force it. If it's too thick, dilute it with water. If you suspect that tube placement is inhibiting the flow, stop the procedure and reevaluate tube placement.
Watch the patient's reaction throughout the instillation. If he shows any sign of discomfort, stop the procedure immediately.
As the last of the medication flows out of the syringe, start to irrigate the tube by adding 30 to 50 ml of water. Irrigation clears medication from the sides of the tube and from the distal end, reducing the risk of clogging.
PEDIATRIC ALERT For a child, irrigate the tube using only 15 to 30 ml of water.
When the water stops flowing, quickly clamp the tube. Detach the syringe and dispose of it.
Fasten the NG tube to the patient's gown.
Remove the towel or linen-saver pad and replace bed linens.
Leave the patient in Fowler's position, or have him lie on his right side with the head of the bed partially elevated. Tell him to maintain this position for at least 30 minutes after the procedure. This position facilitates the downward flow of medication into his stomach and prevents esophageal reflux.
You may be asked to deliver medications through a gastrostomy tube. (See Giving medications through a gastrostomy tube.)
If medication is prescribed for a patient with a gastrostomy feeding button, ask the physician to order the liquid form of the drug if possible. If not, you may give a tablet or capsule dissolved in 30 to 50 ml of warm water (15 to 30 ml for children). To administer medication this way, use the same procedure as for feeding the patient through the button. (See â€œGastrostomy feeding button care,â€ page 577.) Then draw up the dissolved medication into a syringe and inject it into the feeding tube.
Withdraw the medication syringe, and flush the tube with 50 ml of warm water.
PEDIATRIC ALERT Flush the tube with 30 ml of water for a child.
Then replace the safety plug, and keep the patient upright at a 30-degree angle for 30 minutes after giving the medication.

Special considerations

To prevent instillation of too much fluid (for an adult, more than 400 ml of liquid at one time), don't schedule the drug instillation with the patient's regular tube feeding, if possible.
If you must schedule a tube feeding and medication instillation simultaneously, give the medication first to ensure that the patient receives the prescribed drug therapy even if he can't tolerate an entire feeding. Remember to avoid giving foods that interact adversely with the drug. Tube feedings of Osmolite or Isocal must be held 2 hours before and 2 hours after phenytoin administration.
If the patient receives continuous tube feedings, stop the feeding and check the quantity of residual stomach contents. If it's more than 50% of the previous hour's intake, withhold the medication and feeding and notify the physician. An excessive amount of residual contents may indicate intestinal obstruction or paralytic ileus.
If the NG tube is attached to suction, be sure to turn off the suction for 20 to 30 minutes after administering medication.
If possible, teach the patient who requires long-term treatment to instill his medication himself through the NG tube. Have him observe the procedure several times before trying it himself.
Remain with the patient when he performs the procedure for the first few times so that you can provide assistance and answer any questions. Encourage him and correct any errors in technique, as necessary.

Documentation

Record the instillation of medication, date and time of instillation, dose, and patient's tolerance of the procedure. On his intake and output sheet, note the amount of fluid instilled.

MEASURING LIQUID MEDICATIONS

2011-03-28T18:34:00.000-07:00

To pour liquids, hold the medication cup at eye level. Use your thumb to mark off the correct level on the cup. Then set the cup down and read the bottom of the meniscus at eye level to ensure accuracy. If you've poured too much medication into the cup, discard the excess. Don't return it to the bottle.

Here are a few additional tips:

Hold the container so that the medication flows from the side opposite the label so it won't run down the container and stain or obscure the label. Remove drips from the lip of the bottle first and then from the sides, using a clean, damp paper towel.
For a liquid measured in drops, use only the dropper supplied with the medication.

ORAL DRUGS

2011-03-28T18:33:00.000-07:00

Because oral administration is usually the safest, most convenient, and least expensive method, most drugs are administered by this route. Drugs for oral administration are available in many forms: tablets, enteric-coated tablets, capsules, syrups, elixirs, oils, liquids, suspensions, powders, and granules. Some require special preparation before administration, such as mixing with juice to make them more palatable; oils, powders, and granules most often require such preparation.

Sometimes oral drugs are prescribed in higher dosages than their parenteral equivalents because after absorption through the GI system, they are immediately broken down by the liver before they reach the systemic circulation.

ELDER ALERT Oral dosages normally prescribed for adults may be dangerous for elderly patients.

Oral administration is contraindicated for unconscious patients; it may also be contraindicated in patients with nausea and vomiting and in those unable to swallow.

Equipment

Patient's medication record and chart â€¢ prescribed medication â€¢ medication cup â€¢ optional: appropriate vehicle, such as jelly or applesauce, for crushed pills commonly used with children or elderly patients, and juice, water, or milk for liquid medications; drinking straw; mortar and pestle for crushing pills.

Implementation

Verify the order on the patient's medication record by checking it against the physician's order.
Wash your hands.
Check the label on the medication three times before administering it to make sure you'll be giving the prescribed medication. Check when you take the container from the shelf or drawer, again before you pour the medication into the medication cup, and again before returning the container to the shelf or drawer. If you're administering a unit-dose medication, check the label for the final time at the patient's bedside immediately after pouring the medication and before discarding the wrapper.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Assess the patient's condition, including level of consciousness and vital signs, as needed. Changes in the patient's condition may warrant withholding medication. For example, you may need to withhold a medication that will slow the patient's heart rate if his apical pulse rate is less than 60 beats/minute.
Give the patient his medication and an appropriate vehicle or liquid, as needed, to aid swallowing, minimize adverse effects, or promote absorption. For example, cyclophosphamide is given with fluids to minimize adverse effects; antitussive cough syrup is given without a fluid to avoid diluting its soothing effect on the throat. If appropriate, crush the medication to facilitate swallowing.
Stay with the patient until he has swallowed the drug. If he seems confused or disoriented, check his mouth to make sure he has swallowed it. Return and reassess the patient's response within 1 hour after giving the medication.

Special considerations

Make sure you have a written order for every medication given. Verbal orders should be signed by the physician within the specified time period. (Hospitals usually require a signature within 24 hours; long-term-care facilities, within 48 hours.)
Notify the physician about any medication withheld, unless instructions to withhold are already written.
Use care in measuring out the prescribed dose of liquid oral medication. (See Measuring liquid medications, page 230.)
Don't give medication from a poorly labeled or unlabeled container. Don't attempt to label or reinforce drug labels yourself. This must be done by a pharmacist.
Never give a medication poured by someone else. Never allow your medication cart or tray out of your sight. This prevents anyone from rearranging the medications or taking one without your knowledge. Never return unwrapped or prepared medications to stock containers. Instead, dispose of them and notify the pharmacy. Keep in mind that the disposal of any opioid drug must be cosigned by another nurse, as mandated by law.
If the patient questions you about his medication or the dosage, check his medication record again. If the medication is correct, reassure him. Make sure you tell him about any changes in his medication or dosage. Instruct him, as appropriate, about possible adverse effects. Ask him to report anything he thinks may be an adverse effect.
To avoid damaging or staining the patient's teeth, administer acid or iron preparations through a straw. An unpleasant-tasting liquid can usually be made more palatable if taken through a straw because the liquid contacts fewer taste buds.
If the patient can't swallow a whole tablet or capsule, ask the pharmacist if the drug is available in liquid form or if it can be administered by another route. If not, ask him if you can crush the tablet or open the capsule and mix it with food. Keep in mind that many enteric-coated or time-release medications and gelatin capsules shouldn't be crushed. Remember to contact the physician for an order to change the administration route when necessary.
PEDIATRIC ALERT Oral medications are relatively easy to give to infants because of their natural sucking instinct and, in infants under 4 months old, their undeveloped sense of taste.

Documentation

Note the drug administered, dose, date and time, and patient's reaction, if any. If the patient refuses a drug, document the refusal and notify the charge nurse and the patient's physician, as needed. Also note if a drug was omitted or withheld for other reasons, such as radiology or laboratory tests, or if, in your judgment, the drug was contraindicated at the ordered time. Sign out all opioids given on the appropriate opioids central record.

VAGINAL MEDICATIONS

2011-03-20T23:19:00.000-07:00

Vaginal medications include suppositories, creams, gels, and ointments. These medications can be inserted as a topical treatment for infection (particularly Trichomonas vaginalis and monilial vaginitis) or inflammation or as a contraceptive. Suppositories melt when they contact the vaginal mucosa, and their medication diffuses topically (as effectively as creams, gels, and ointments).

Vaginal medications usually come with a disposable applicator that enables placement of medication in the anterior and posterior fornices. Vaginal administration is most effective when the patient can remain lying down afterward to retain the medication.

Equipment

Patient's medication record and chart â€¢ prescribed medication and applicator, if necessary â€¢ water-soluble lubricant â€¢ gloves â€¢ small sanitary pad.

Implementation

If possible, plan to insert vaginal medications at bedtime, when the patient is recumbent.
Verify the order on the patient's medication record by checking it against the physician's order.
Confirm the patient's identity by asking her name and checking the name, room number, and bed number on her wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Wash your hands, explain the procedure to the patient, and provide privacy.
Ask the patient to void.
Ask the patient if she would rather insert the medication herself. If so, provide appropriate instructions. If not, proceed with the following steps.
Help her into the lithotomy position.
Expose only the perineum.

Inserting a suppository

Remove the suppository from the wrapper, and lubricate it with water-soluble lubricant.
Put on gloves and expose the vagina.
With an applicator or the forefinger of your free hand, insert the suppository about 2â€³ (5 cm) into the vagina. (See How to insert a vaginal suppository.)

Inserting ointments, creams, or gels

Insert the plunger into the applicator. Then attach the applicator to the tube of medication.
Gently squeeze the tube to fill the applicator with the prescribed amount of medication. Detach the applicator from the tube, and lubricate the applicator.
Put on gloves and expose the vagina.
Insert the applicator as you would a small suppository, and administer the medication by depressing the plunger on the applicator.

After vaginal insertion

Remove and discard your gloves.
Wash the applicator with soap and warm water and store it, unless it's disposable. If the applicator can be used again, label it so that it will be used only for the same patient.
To prevent the medication from soiling the patient's clothing and bedding, provide a sanitary pad.
Help the patient return to a comfortable position, and advise her to remain in bed as much as possible for the next several hours.
Wash your hands thoroughly.

Special considerations

Refrigerate vaginal suppositories that melt at room temperature.
If possible, teach the patient how to insert the vaginal medication because she may have to administer it herself after discharge. Give her a patient-teaching sheet if one is available.
Instruct the patient not to wear a tampon after inserting vaginal medication because it would absorb the medication and decrease its effectiveness.
Instruct the patient to avoid sexual intercourse during treatment.

Complications

Vaginal medications may cause local irritation.

Documentation

Record the medication administered as well as time and date. Note adverse effects and any other pertinent information.

POSITIONING THE PATIENT FOR NOSE DROP INSTILLATION

2011-03-03T19:46:00.000-08:00

To administer drops for relief of ordinary nasal congestion, help the patient to a reclining or supine position with her head tilted slightly toward the affected side. Aim the dropper upward, toward the patient's eye, rather than downward, toward her ear.

NASAL MEDICATIONS

2011-02-24T21:41:00.000-08:00

Nasal medications may be instilled by means of drops, a spray (using an atomizer), or an aerosol (using a nebulizer). Most drugs instilled by these methods produce local rather than systemic effects. Drops can be directed at a specific area; sprays and aerosols diffuse medication throughout the nasal passages.

Most nasal medications, such as phenylephrine, are vasoconstrictors, which relieve nasal congestion by coating and shrinking swollen mucous membranes. Because vasoconstrictors may be absorbed systemically, they are usually contraindicated in hypersensitive patients. Other types of nasal medications include antiseptics, anesthetics, and corticosteroids. Local anesthetics may be administered to promote patient comfort during rhinolaryngologic examination, laryngoscopy, bronchoscopy, and endotracheal intubation. Corticosteroids reduce inflammation in allergic or inflammatory conditions and nasal polyps.

Equipment

Prescribed medication â€¢ patient's medication record and chart â€¢ emesis basin (with nose drops only) â€¢ facial tissues â€¢ optional: pillow, small piece of soft rubber or plastic tubing, gloves.

Implementation

Verify the order on the patient's medication record by checking it against the physician's order. Note the concentration of the medication. Phenylephrine, for example, is available in various concentrations from 0.125% to 1%. Verify the expiration date.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Explain the procedure and provide privacy.
Wash your hands. Put on gloves if you notice drainage from the nostrils.

Instilling nose drops

When possible, position the patient so that the drops flow back into the nostrils, toward the affected area. (See Positioning the patient for nose drop instillation.)
Draw up some medication into the dropper.
Push up the tip of the patient's nose slightly. Position the dropper just above the nostril, and direct its tip toward the midline of the nose so that the drops flow toward the back of the nasal cavity rather than down the throat.
Insert the dropper about 3/8â€³ (1 cm) into the nostril. Don't let the dropper touch the sides of the nostril because this would contaminate the dropper or could cause the patient to sneeze.
Instill the prescribed number of drops, observing the patient carefully for signs of discomfort.
To prevent the drops from leaking out of the nostrils, ask the patient to keep his head tilted back for at least 5 minutes and to breathe through his mouth. This also allows sufficient time for the medication to constrict mucous membranes.
Keep an emesis basin handy so that the patient can expectorate any medication that flows into the oropharynx and mouth. Use a facial tissue to wipe any excess medication from the patient's nostrils and face.

P.227
Clean the dropper by separating the plunger and pipette and flushing them with warm water. Allow them to air-dry.

Using a nasal spray

Have the patient sit upright with his head tilted back slightly. Alternatively, have the patient lie on his back with his shoulders elevated, neck hyperextended, and head tilted back over the edge of the bed. Support his head with one hand to prevent neck strain.
Remove the protective cap from the atomizer.
To prevent air from entering the nasal cavity and to allow the medication to flow properly, occlude one of the patient's nostrils with your finger. Insert the atomizer tip into the open nostril.
Instruct the patient to inhale, and as he does so, squeeze the atomizer once, quickly and firmly. Use just enough force to coat the inside of the patient's nose with medication. Then tell the patient to exhale through his mouth.
If ordered, spray the nostril again. Then repeat the procedure in the other nostril.
Instruct the patient to keep his head tilted back for several minutes and to breathe slowly through his nose so that the medication has time to work. Tell him not to blow his nose for several minutes.

Using a nasal aerosol

Instruct the patient to blow his nose gently to clear his nostrils.
Insert the medication cartridge according to the manufacturer's directions. With some models, you'll fit the medication cartridge over a small hole in the adapter. When inserting a refill cartridge, first remove the protective cap from the stem. Spacer inhalers may be recommended. (See â€œHandheld oropharyngeal inhalers,â€ page 223.)
Shake the aerosol well before each use, and remove the protective cap from the adapter tip.
Hold the aerosol between your thumb and index finger, with your index finger positioned on top of the medication cartridge.
Tilt the patient's head back, and carefully insert the adapter tip in one nostril while sealing the other nostril with your finger.
Press the adapter and cartridge together firmly to release one measured dose of medication.
Shake the aerosol and repeat the procedure to instill medication into the other nostril.
Remove the medication cartridge, and wash the nasal adapter in lukewarm water daily. Allow the adapter to dry before reinserting the cartridge.

Special considerations

PEDIATRIC ALERT Before instilling nose drops in a young child, attach a small piece of tubing to the end of the dropper. Do the same for an uncooperative patient.
If using a metered-dose pump spray system, prime the delivery system with four sprays or until a fine mist appears. Reprime the system with two sprays or until a fine mist appears if 3 or more days have lapsed since the last use.
When using an aerosol, be careful not to puncture or incinerate the pressurized cartridge. Store it at temperatures below 120Â° F (48.9Â° C).
To prevent the spread of infection, label the medication bottle so that it will be used only for that patient.
Teach the patient how to instill nasal medications correctly so that he can continue treatment after discharge if necessary. Caution him against using nasal medications longer than prescribed because they may cause a rebound effect that worsens the condition. A rebound effect occurs when the medication loses its effectiveness and relaxes the vessels in the nasal turbinates, producing a stuffiness that can be relieved only by discontinuing the medication.
Inform the patient of possible adverse reactions. In addition, explain that when corticosteroids are given by nasal aerosol, therapeutic effects may not appear for 2 days to 2 weeks.
Teach the patient good oral and nasal hygiene.

Complications

Some nasal medications may cause restlessness, palpitations, nervousness, and other systemic effects. For example, excessive use of corticosteroid aerosols may cause hyperadrenocorticism and adrenal suppression.

Documentation

Record the medication instilled and its concentration, number of drops or instillations administered, and whether the medication was instilled in one or both nostrils. Also note the time and date of instillation and any resulting adverse effects.

TYPES OF HANDHELD INHALERS

2011-01-17T17:24:00.000-08:00

Handheld inhalers use air under pressure to produce a mist containing tiny droplets of medication. Drugs delivered in this form (such as mucolytics and bronchodilators) can travel deep into the lungs.

Turbo-inhaler

Metered dose inhaler with capsules

Nasal inhaler

Inhaler with built-in spacer

HANDHELD OROPHARYNGEAL INHALERS

2011-01-17T17:19:00.000-08:00

Handheld inhalers include the metered dose inhaler (or nebulizer), the turbo-inhaler, and the nasal inhaler. These devices deliver topical medications to the respiratory tract, producing local and systemic effects. The mucosal lining of the respiratory tract absorbs the inhalant almost immediately. Examples of common inhalants are bronchodilators, used to improve airway patency and facilitate mucous drainage; mucolytics, which attain a high local concentration to liquefy tenacious bronchial secretions; and corticosteroids, used to decrease inflammation.

The use of these inhalers may be contraindicated in patients who can't form an airtight seal around the device and in patients who lack the coordination or clear vision necessary to assemble a turbo-inhaler. Specific inhalant drugs may also be contraindicated. For example, bronchodilators are contraindicated if the patient has tachycardia or a history of cardiac arrhythmias associated with tachycardia.

Equipment

Patient's medication record and chart â€¢ metered dose inhaler, turbo-inhaler, or nasal inhaler â€¢ prescribed medication â€¢ normal saline solution (or another appropriate solution) for gargling â€¢ optional: emesis basin. (See Types of handheld inhalers)

Implementation

Verify the order on the patient's medication record by checking it against the physician's order.
Wash your hands.
Check the label on the inhaler against the order on the medication record. Verify the expiration date.
Confirm the patient's identity by asking his name and by checking his name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Explain the procedure to the patient.

Using a metered dose inhaler

Shake the inhaler bottle to mix the medication and aerosol propellant.
Remove the mouthpiece and cap. Note: Some metered dose inhalers have a spacer built into the inhaler. Pull the spacer away from the section holding the medication canister until it clicks into place.
Insert the metal stem on the bottle into the small hole on the flattened portion of the mouthpiece. Then turn the bottle upside down.
Have the patient exhale; then place the mouthpiece in his mouth and close his lips around it.
As you firmly push the bottle down against the mouthpiece, ask the patient to inhale slowly and to continue inhaling until his lungs feel full. This action draws the medication into his lungs. Compress the bottle against the mouthpiece only once.
Remove the mouthpiece from the patient's mouth, and tell him to hold his breath for several seconds to allow the medication to reach the alveoli. Then instruct him to exhale slowly through pursed lips to keep the distal bronchioles open, allowing increased absorption and diffusion of the drug and better gas exchange.
Have the patient gargle with normal saline solution, if desired, to remove medication from the mouth and back of the throat. (The lungs retain only about 10% of the inhalant; most of the remainder is exhaled, but substantial amounts may remain in the oropharynx.)
Rinse the mouthpiece thoroughly with warm water to prevent accumulation of residue.

Using a turbo-inhaler

Hold the mouthpiece in one hand, and with the other hand, slide the sleeve away from the mouthpiece as far as possible.
Unscrew the tip of the mouthpiece by turning it counterclockwise.
Firmly press the colored portion of the medication capsule into the propeller stem of the mouthpiece.
Screw the inhaler together again securely.
Holding the inhaler with the mouthpiece at the bottom, slide the sleeve all the way down and then up again to puncture the capsule and release the medication. Do this only once.
Have the patient exhale and tilt his head back. Tell him to place the mouthpiece in his mouth, close his lips around it, and inhale onceâ€”quickly and deeplyâ€”through the mouthpiece.
Tell the patient to hold his breath for several seconds to allow the medication to reach the alveoli. (Instruct him not to exhale through the mouthpiece.)
Remove the inhaler from the patient's mouth, and tell him to exhale as much air as possible.
Repeat the procedure until all the medication in the device is inhaled.
Have the patient gargle with normal saline solution, if desired, to remove medication from the mouth and back of the throat. Be sure to provide an emesis basin if the patient needs one.
Discard the empty medication capsule, put the inhaler in its can, and secure the lid. Rinse the inhaler with warm water at least once a week.

Using a nasal inhaler

Have the patient blow his nose to clear his nostrils.
Shake the medication cartridge and then insert it in the adapter. (Before inserting a refill cartridge, remove the protective cap from the stem.)
Remove the protective cap from the adapter tip.
Hold the inhaler with your index finger on top of the cartridge and your thumb under the nasal adapter. The adapter tip should be pointing toward the patient.
Have the patient tilt his head back. Then tell him to place the adapter tip into one nostril while occluding the other nostril with his finger.
Instruct the patient to inhale gently as he presses the adapter and the cartridge together firmly to release a measured dose of medication. Be sure to follow the manufacturer's instructions. With some medications, such as dexamethasone sodium phosphate (Turbinaire), inhaling during administration isn't desirable.
Tell the patient to remove the inhaler from his nostril and to exhale through his mouth.
Shake the inhaler, and have the patient repeat the procedure in the other nostril.
Have the patient gargle with normal saline solution to remove medication from his mouth and throat.
Remove the medication cartridge from the nasal inhaler, and wash the nasal adapter in lukewarm water. Let the adapter dry thoroughly before reinserting the cartridge.

Special considerations

When using a turbo-inhaler or nasal inhaler, make sure the pressurized cartridge isn't punctured or incinerated. Store the medication cartridge below 120Â° F (48.9Â° C).
If you're using a turbo-inhaler, keep the medication capsules wrapped until needed to keep them from deteriorating.
Spacer inhalers may be recommended to provide greater therapeutic benefit for children and for patients who have difficulty with coordination. A spacer attachment is an extension to the inhaler's mouthpiece that provides more dead-air space for mixing the medication. Some inhalers have built-in spacers.
Teach the patient how to use the inhaler so that he can continue treatments himself after discharge, if necessary. Explain that overdosageâ€”which is commonâ€”can cause the medication to lose its effectiveness. Tell him to record the date and time of each inhalation as well as his response to prevent overdosage and to help the physician determine the drug's effectiveness. Also, note whether the patient uses an unusual amount of medicationâ€”for example, more than one cartridge for a metered-dose nebulizer every 3 weeks. Inform the patient of possible adverse reactions.
If more than one inhalation is ordered, advise the patient to wait at least 2 minutes before repeating the procedure.
If the patient is also using a steroid inhaler, instruct him to use the bronchodilator first and then wait 5 minutes before using the steroid. This allows the bronchodilator to open the air passages for maximum effectiveness.

Documentation

Record the inhalant administered as well as the dose and time. Note any significant change in the patient's heart rate and any other adverse reactions.

POSITIONING THE PATIENT FOR EARDROP INSTILLATION

2011-01-16T22:29:00.001-08:00

Before instilling eardrops, have the patient lie on his side. Then straighten the patient's ear canal to help the medication reach the eardrum. For an adult, gently pull the auricle up and back; for an infant or a young child, gently pull down and back.

Adult

Child

EARDROPS

2011-01-16T22:19:00.000-08:00

Eardrops may be instilled to treat infection and inflammation, soften cerumen for later removal, produce local anesthesia, or facilitate removal of an insect trapped in the ear by immobilizing and smothering it.

Instillation of eardrops is usually contraindicated if the patient has a perforated eardrum, but it may be permitted with certain medications and adherence to sterile technique. Other conditions may also prohibit instillation of certain medications into the ear. For instance, instillation of drops containing hydrocortisone is contraindicated if the patient has herpes, another viral infection, or a fungal infection.

Equipment

Prescribed eardrops â€¢ patient's medication record and chart â€¢ light source â€¢ facial tissue or cotton-tipped applicator â€¢ optional: cotton ball, bowl of warm water.

Preparation of equipment

Verify the order on the patient's medication record by checking it against the physician's order.

To avoid adverse effects (such as vertigo, nausea, and pain) resulting from instillation of eardrops that are too cold, warm the medication to body temperature in the bowl of warm water or carry it in your pocket for 30 minutes before administration. If necessary, test the temperature of the medication by placing a drop on your wrist. (If the medication is too hot, it may burn the patient's eardrum.) Before using a glass dropper, make sure it isn't chipped to avoid injuring the ear canal.

Implementation

Wash your hands.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Provide privacy if possible. Explain the procedure to the patient.
Have the patient lie on the side opposite the affected ear.
Straighten the patient's ear canal. For an adult, pull the auricle of the ear up and back. (See Positioning the patient for eardrop instillation.)
PEDIATRIC ALERT For an infant or a child under age 3, gently pull the auricle down and back because the ear canal is straighter at this age.
Using a light source, examine the ear canal for drainage. If you find any, clean the canal with a tissue or cotton-tipped applicator because drainage can reduce the medication's effectiveness.
Compare the label on the eardrops with the order on the patient's medication record. Check the label again while drawing the medication into the dropper. Check the label for the final time before returning the eardrops to the shelf or drawer.
To avoid damaging the ear canal with the dropper, gently support the hand holding the dropper against the patient's head. Straighten the patient's ear canal once again, and instill the ordered number of drops. To avoid patient discomfort, aim the dropper so that the drops fall against the sides of the ear canal, not on the eardrum. Hold the ear canal in position until you see the medication disappear down the canal. Then release the ear.
Instruct the patient to remain on his side for 5 to 10 minutes to let the medication run down into the ear canal.
If ordered, tuck the cotton ball loosely into the opening of the ear canal to prevent the medication from leaking out. Be careful not to insert it too deeply into the canal because this would prevent drainage of secretions and increase pressure on the eardrum.
Clean and dry the outer ear.
If ordered, repeat the procedure in the other ear after 5 to 10 minutes.
Assist the patient into a comfortable position.
Wash your hands.

Special considerations

Remember that some conditions make the normally tender ear canal even more sensitive, so be especially gentle when performing this procedure. Wash your hands before and after caring for the patient's ear and between caring for each ear.
To prevent injury to the eardrum, never insert a cotton-tipped applicator into the ear canal past the point where you can see the tip. After applying eardrops to soften the cerumen, irrigate the ear as ordered to facilitate its removal.
If the patient has vertigo, keep the side rails of his bed up and help him during the procedure as needed. Also, move slowly and unhurriedly to avoid exacerbating his vertigo.
Teach the patient to instill the eardrops correctly so that he can continue treatment at home, if necessary. Review the procedure and let the patient try it himself while you observe.
If both an ointment and drop have been ordered, the drops should be administered first.

Documentation

Record the medication used, the ear treated, and the date, time, and number of eardrops instilled. Also document any signs or symptoms that the patient experienced during the procedure, such as drainage, redness, vertigo, nausea, and pain.

HOW TO INSERT AND REMOVE AN EYE MEDICATION DISK

2011-01-09T04:37:00.000-08:00

Small and flexible, an oval eye medication disk consists of three layers: two soft outer layers and a middle layer that contains the medication. Floating between the eyelids and the sclera, the disk stays in the eye while the patient sleeps and even during swimming and athletic activities. The disk frees the patient from having to remember to instill his eyedrops. When the disk is in place, ocular fluid moistens it, releasing the medication. Eye moisture or contact lenses don't adversely affect the disk. The disk can release medication for up to 1 week before needing replacement. Pilocarpine, for example, can be administered this way to treat glaucoma.

Contraindications include conjunctivitis, keratitis, retinal detachment, and any condition in which constriction of the pupil should be avoided.

To insert an eye medication disk

Arrange to insert the disk before the patient goes to bed. This minimizes the blurring that usually occurs immediately after disk insertion.

Wash your hands and put on gloves.
Press your fingertip against the oval disk so that it lies lengthwise across your fingertip. It should stick to your finger. Lift the disk out of its packet.
Gently pull the patient's lower eyelid away from the eye and place the disk in the conjunctival sac. It should lie horizontally, not vertically. The disk will adhere to the eye naturally.

Pull the lower eyelid out, up, and over the disk. Tell the patient to blink several times. If the disk is still visible, pull the lower lid out and over the disk again. Tell the patient that when the disk is in place, he can adjust its position by gently pressing his finger against his closed lid. Caution him against rubbing his eye or moving the disk across the cornea.
If the disk falls out, wash your hands, rinse the disk in cool water, and reinsert it. If the disk appears bent, replace it.
If both of the patient's eyes are being treated with medication disks, replace both disks at the same time so that both eyes receive medication at the same rate.
If the disk repeatedly slips out of position, reinsert it under the upper eyelid. To do this, gently lift and evert the upper eyelid and insert the disk in the conjunctival sac. Then gently pull the lid back into position, and tell the patient to blink several times. Again, the patient may press gently on the closed eyelid to reposition the disk. The more the patient uses the disk, the easier it should be for him to retain it. If he can't retain it, notify the physician.
If the patient will continue therapy with an eye medication disk after discharge, teach him how to insert and remove it himself. To check his mastery of these skills, have him demonstrate insertion and removal for you.
Also, teach the patient about possible adverse reactions. Foreign-body sensation in the eye, mild tearing or redness, increased mucous discharge, eyelid redness, and itchiness can occur with the use of disks. Blurred vision, stinging, swelling, and headaches can occur with pilocarpine, specifically. Mild symptoms are common but should subside within the first 6 weeks of use. Tell the patient to report persistent or severe symptoms to his physician.

To remove an eye medication disk

You can remove an eye medication disk with one or two fingers. To use one finger, put on gloves and evert the lower eyelid to expose the disk. Then use the forefinger of your other hand to slide the disk onto the lid and out of the patient's eye. To use two fingers, evert the lower lid with one hand to expose the disk. Then pinch the disk with the thumb and forefinger of your other hand and remove it from the eye.
If the disk is located in the upper eyelid, apply long circular strokes to the patient's closed eyelid with your finger until you can see the disk in the corner of the patient's eye. When the disk is visible, you can place your finger directly on the disk and move it to the lower sclera. Then remove it as you would a disk located in the lower lid.

INSTILLING EYE MEDICATIONS

2011-01-09T04:20:00.001-08:00

To instill eyedrops, pull the lower lid down to expose the conjunctival sac. Have the patient look up and away, then squeeze the prescribed number of drops into the sac. Release the patient's eyelid, and have him blink to distribute the medication.

To apply an ointment, gently lay a thin strip of the medication along the conjunctival sac from the inner canthus to the outer canthus. Avoid touching the tip of the tube to the patient's eye. Then release the eyelid, and have the patient roll his eye behind closed lids to distribute the medication.

EYE MEDICATIONS

2011-01-08T05:14:00.000-08:00

Eye medicationsâ€”drops, ointments, and disksâ€”serve diagnostic and therapeutic purposes. During an eye examination, eyedrops can be used to anesthetize the eye, dilate the pupil to facilitate examination, and stain the cornea to identify corneal abrasions, scars, and other anomalies. Eye medications can also be used to lubricate the eye, treat certain eye conditions (such as glaucoma and infections), protect the vision of neonates, and lubricate the eye socket for insertion of a prosthetic eye.

Understanding the ocular effects of medications is important because certain drugs may cause eye disorders or have serious ocular effects. For example, anticholinergics, which are commonly used during eye examinations, can precipitate acute glaucoma in patients with a predisposition to the disorder.

Equipment

Prescribed eye medication â€¢ patient's medication record and chart â€¢ gloves â€¢ warm water or normal saline solution â€¢ sterile gauze pads â€¢ facial tissues â€¢ optional: ocular dressing.

Preparation of equipment

Make sure the medication is labeled for ophthalmic use. Then check the expiration date. Remember to date the container the first time you use the medication. After it's opened, an eye medication may be used for a maximum of 2 weeks to avoid contamination.

Inspect ocular solutions for cloudiness, discoloration, and precipitation, but remember that some eye medications are suspensions and normally appear cloudy. Don't use any solution that appears abnormal. If the tip of an eye ointment tube has crusted, turn the tip on a sterile gauze pad to remove the crust.

Implementation

Verify the order on the patient's medication record by checking it against the physician's order on his chart.
Wash your hands.
Check the medication label against the patient's medication record.
NURSING ALERT Make sure you know which eye to treat because different medications or doses may be ordered for each eye.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Explain the procedure to the patient and provide privacy. Put on gloves.
If the patient is wearing an eye dressing, remove it by gently pulling it down and away from his forehead. Take care not to contaminate your hands.
Remove any discharge by cleaning around the eye with sterile gauze pads moistened with warm water or normal saline solution. With the patient's eye closed, clean from the inner to the outer canthus, using a fresh sterile gauze pad for each stroke.
To remove crusted secretions around the eye, moisten a gauze pad with warm water or normal saline solution. Ask the patient to close the eye, and then place the gauze pad over it for 1 or 2 minutes. Remove the pad, and then reapply moist sterile gauze pads, as necessary, until the secretions are soft enough to be removed without traumatizing the mucosa.
Have the patient sit or lie in the supine position. Instruct him to tilt his head back and toward the side of the affected eye so that excess medication can flow away from the tear duct, minimizing systemic absorption through the nasal mucosa.

Instilling eyedrops

Remove the dropper cap from the medication container, if necessary, and draw the medication into it. Be careful to avoid contaminating the dropper tip or bottle top.
Before instilling the eyedrops, instruct the patient to look up and away. This moves the cornea away from the lower lid and minimizes the risk of touching the cornea with the dropper if the patient blinks.
You can steady the hand holding the dropper by resting it against the patient's forehead. Then, with your other hand, gently pull down the lower lid of the affected eye and instill the drops in the conjunctival sac. Try to avoid placing the drops directly on the eyeball to prevent the patient from experiencing discomfort. (See Instilling eye medications.) If you're instilling more than one drop agent, you should wait 5 or more minutes between agents.

Applying eye ointment

Squeeze a small ribbon of medication on the edge of the conjunctival sac from the inner to the outer canthus. Cut off the ribbon by turning the tube. You can steady the hand holding the medication tube by bracing it against the patient's forehead or cheek. If you're applying more than one ribbon of medication, wait 10 minutes before applying the second medication.

Using a medication disk

A medication disk can release medication in the eye for up to 1 week before needing to be replaced. Pilocarpine, for example, can be administered this way to treat glaucoma. (See How to insert and remove an eye medication disk.)

After instilling eyedrops or eye ointment

Instruct the patient to close his eyes gently, without squeezing the lids shut. If you instilled drops, tell the patient to blink. If you applied ointment, tell him to roll his eyes behind closed lids to help distribute the medication over the surface of the eyeball.
Use a clean tissue to remove any excess solution or ointment leaking from the eye. Remember to use a fresh tissue for each eye to prevent cross-contamination.
Apply a new eye dressing if necessary. (See â€œHot and cold eye compresses,â€ page 693.)
Return the medication to the storage area. Make sure you store it according to the label's instructions.
Wash your hands.

Special considerations

When administering an eye medication that may be absorbed systemically (such as atropine), gently press your thumb on the inner canthus for 1 to 2 minutes after instilling drops while the patient closes his eyes. This helps prevent medication from flowing into the tear duct.
To maintain the drug container's sterility, never touch the tip of the bottle or dropper to the patient's eyeball, lids, or lashes. Discard any solution remaining in the dropper before returning the dropper to the bottle. If the dropper or bottle tip has become contaminated, discard it and obtain another sterile dropper. To prevent cross-contamination, never use a container of eye medication for more than one patient.
Teach the patient to instill eye medications so that he can continue treatment at home, if necessary. Review the procedure and ask for a return demonstration.
If an ointment and drops have been ordered, the drops should be instilled first.

Complications

Instillation of some eye medications may cause transient burning, itching, and redness. Rarely, systemic effects may also occur.

Documentation

Record the medication instilled or applied, eye or eyes treated, and date, time, and dose. Note any adverse effects and the patient's response.

APPLYING A TRANSDERMAL MEDICATION PATCH

2011-01-06T20:13:00.001-08:00

If the patient will be receiving medication by transdermal patch, instruct him in its proper use, as described below:

Explain to the patient that the patch consists of several layers. The layer closest to his skin contains a small amount of the drug and allows prompt introduction of the drug into the bloodstream. The next layer controls release of the drug from the main portion of the patch. The third layer contains the main dose of the drug. The outermost layer consists of an aluminized polyester barrier.
Teach the patient to apply the patch to appropriate skin areas, such as the upper arm or chest and behind the ear. Warn him to avoid touching the gel or surrounding tape. Tell him to use a different site for each application to avoid skin irritation. If necessary, he can shave the site. Caution him to avoid any area that may cause uneven absorption, such as skin folds, scars, and calluses, or any irritated or damaged skin areas. Also, tell him not to apply the patch below the elbow or knee.
Instruct the patient to wash his hands after application to remove any medication that may have rubbed off.
Warn the patient not to get the patch wet. Tell him to discard it if it leaks or falls off and then to clean the site and apply a new patch at a different site.
Instruct the patient to apply the patch at the same time at the prescribed interval to ensure continuous drug delivery. Bedtime application is ideal because body movement is reduced during the night. Finally, tell him to apply a new patch about 30 minutes before removing the old one.

TRANSDERMAL DRUGS

2011-01-06T20:11:00.000-08:00

Through an adhesive patch or a measured dose of ointment applied to the skin, transdermal drugs deliver constant, controlled medication directly into the bloodstream for a prolonged systemic effect.

Medications available in transdermal form include nitroglycerin, used to control angina; scopolamine, used to treat motion sickness; estradiol, used for postmenopausal hormone replacement; clonidine, used to treat hypertension; nicotine, used for smoking cessation; and fentanyl, an opioid analgesic used to control chronic pain. Nitroglycerin ointment dilates coronary vessels for up to 4 hours; a nitroglycerin disk or pad can produce the same effect for as long as 24 hours. A scopolamine patch can relieve motion sickness for as long as 72 hours, transdermal estradiol lasts for up to 1 week, clonidine and nicotine patches last for 24 hours, and a fentanyl patch can last for up to 72 hours.

Contraindications for transdermal drug application include skin allergies or skin reactions to the drug. Transdermal drugs shouldn't be applied to broken or irritated skin because they would increase irritation, or to scarred or callused skin, which might impair absorption.

Equipment

Patient's medication record and chart â€¢ gloves â€¢ prescribed medication (patch or ointment) â€¢ application strip or measuring paper (for nitroglycerin ointment) â€¢ adhesive tape â€¢ plastic wrap (optional for nitroglycerin ointment) or semipermeable dressing.

Implementation

Verify the order on the patient's medication record by checking it against the physician's order.
Wash your hands and, if necessary, put on gloves.
Check the label on the medication to make sure you'll be giving the correct drug in the correct dose. Note the expiration date.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Explain the procedure to the patient and provide privacy.
Remove any previously applied medication.

Applying transdermal ointment

Place the prescribed amount of ointment on the application strip or measuring paper, taking care not to get any on your skin. (See Applying nitroglycerin ointment, page 217.)
Apply the strip to any dry, hairless area of the body. Don't rub the ointment into the skin.
Tape the strip and ointment to the skin.
If desired, cover the application strip with the plastic wrap, and tape the wrap in place.

Applying a transdermal patch

Open the package and remove the patch.
Without touching the adhesive surface, remove the clear plastic backing.
Apply the patch to a dry, hairless areaâ€”behind the ear, for example, as with scopolamine. (See Applying a transdermal medication patch.)
Write the date, time, and your initials on the dressing.

After applying transdermal medications

Store the medication as ordered.
Instruct the patient to keep the area around the patch or ointment as dry as possible.
If you didn't wear gloves, wash your hands immediately after applying the patch or ointment to avoid absorbing the drug yourself.

Special considerations

Reapply daily transdermal medications at the same time every day to ensure a continuous effect, but alternate the application sites to avoid skin irritation. Before reapplying nitroglycerin ointment, remove the plastic wrap, application strip, and any remaining ointment from the patient's skin at the previous site.
When applying a scopolamine or fentanyl patch, instruct the patient not to drive or operate machinery until his response to the drug has been determined.
Warn a patient using a clonidine patch to check with his physician before taking an over-the-counter cough preparation because such drugs may counteract clonidine's effects.

Complications

Topical medications may cause skin irritation, such as pruritus and a rash. The patient may also suffer adverse effects of the specific drug administered. For example, transdermal nitroglycerin medications may cause headaches and, in elderly patients, orthostatic hypotension. Scopolamine has various adverse effects; dry mouth and drowsiness are the most common. Transdermal estradiol carries an increased risk of endometrial cancer, thromboembolic disease, and birth defects. Clonidine may cause severe rebound hypertension, especially if withdrawn suddenly.

Documentation

Record the type of medication; date, time, and site of application; and dose. Also note any adverse effects and the patient's response.

APPLYING NITROGLYCERIN OINTMENT

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Unlike most topical medications, nitroglycerin ointment is used for its transdermal systemic effect. It's used to dilate the veins and arteries, thus improving cardiac perfusion in a patient with cardiac ischemia or angina pectoris.

To apply nitroglycerin ointment, start by taking the patient's baseline blood pressure so that you can compare it with later readings. Remove any previously applied nitroglycerin ointment. Gather your equipment. Nitroglycerin ointment, which is prescribed by the inch, comes with a rectangular piece of ruled paper to be used in applying the medication. Squeeze the prescribed amount of ointment onto the ruled paper (as shown below). Put on gloves, if desired, to avoid contact with the medication.

After measuring the correct amount of ointment, tape the paperâ€”drug side downâ€”directly to the skin (as shown at right). (Some facilities require you to use the paper to apply the medication to the patient's skin, usually on the chest or arm. Spread a thin layer of the ointment over a 3â€³ [7.6-cm] area.) For increased absorption, the physician may request that you cover the site with plastic wrap or a transparent semipermeable dressing.

After 5 minutes, record the patient's blood pressure. If it has dropped significantly and he has a headache (from vasodilation of blood vessels in his head), notify the physician immediately. He may reduce the dose. If the patient's blood pressure has dropped but he has no symptoms, instruct him to lie still until it returns to normal.

USING MEDICATED SHAMPOOS

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Medicated shampoos include keratolytic and cytostatic agents, coal tar preparations, and lindane (gamma benzene hexachloride) solutions. They can be used to treat such conditions as dandruff, psoriasis, and head lice. However, they're contraindicated in patients with broken or abraded skin.

Because application instructions may vary among brands, check the label on the shampoo before starting the procedure to ensure use of the correct amount. Keep the shampoo away from the patient's eyes. If any shampoo should accidentally get in his eyes, irrigate them promptly with water. Likewise, keep the shampoo from running into the patient's mouth. Selenium sulfide, used in cytostatic agents, is extremely toxic if ingested.

To apply a medicated shampoo, follow these steps:

Prepare the patient for shampoo treatment.
Shake the bottle of shampoo well to mix the solution evenly.
Wet the patient's hair thoroughly and wring out excess water.
Apply the proper amount of shampoo, as directed on the label.
Work the shampoo into a lather, adding water as necessary. Part the hair and work the shampoo into the scalp, taking care not to use your fingernails.
Leave the shampoo on the scalp and hair for as long as instructed (usually 5 to 10 minutes). Then rinse the hair thoroughly.
Towel-dry the patient's hair.
After the hair is dry, comb or brush it. Use a fine-tooth comb to remove nits if necessary.