Chapter 13 Medication Administration Learning Objectives List basic mathematic principles Review mathematic equivalents Differentiate temperature readings between Celsius, Fahrenheit scales Discuss formulas as basis for performing drug calculations 2 Learning Objectives (Cont d) Discuss applying basic principles of mathematics to calculation of problems associated with medication dosages Discuss legal aspects affecting medication administration Discuss 6 rights of drug administration 3 1
Learning Objectives (Cont d) Discuss medical asepsis, differences between clean, sterile techniques Describe use of standard precautions when giving medication Describe use of antiseptics, disinfectants 4 Learning Objectives (Cont d) Describe disposal of contaminated items, sharps Describe different oral dosage forms, general principles giving oral medications Describe technique, general principles of rectal medication administration 5 Learning Objectives (Cont d) Describe technique, general principles of giving medications through gastric tube Describe technique, general principles of giving medications topically Describe technique, general principles of giving medications by inhalation route 6 2
Learning Objectives (Cont d) Describe technique for withdrawing medication from ampule Describe technique for withdrawing medication from vial Describe technique, general principles of giving medications by subcutaneous route 7 Learning Objectives (Cont d) Describe technique, general principles of giving medications by intramuscular route Describe indications, equipment needed, technique used, precautions, general principles of peripheral venous access 8 Learning Objectives (Cont d) Describe indications, equipment needed, technique used, precautions, general principles of intraosseous needle placement, infusion Describe purpose, equipment needed, techniques used, complications, general principles for obtaining blood sample 9 3
Drug Dosage Calculations Systems of measurement Apothecary system Wheat grain weight, 1 unit Linear: inches, yards, miles Volume: minims, fluidrams, ounces, pints, gallons Quantities < 20, lower case Roman numerals Quantities >20, Arabic numbers, fractions Household system Dropper, teaspoon, tablespoon, cup, glass, pint, quart, gallon 10 Drug Dosage Calculations (Cont d) Systems of measurement Metric systems Drug calculations, units of 10 Weight (solids, mass): gram (g) Length: meter (m) Volume (liquid, fluid): liter (L) Pharmacology mathematic equivalents Centi Milli Micro Kilo 11 Drug Dosage Calculations (Cont d) Systems of measurement Metric conversions 12 4
Drug Dosage Calculations (Cont d) Systems of measurement Metric conversions Temperature conversions 13 Drug Dosage Calculations (Cont d) Systems of measurement Milliliters & cubic centimeters Weight conversions 14 Drug Dosage Calculations (Cont d) Working with formulas Formula 1: single dose calculations 15 5
Drug Dosage Calculations (Cont d) Working with formulas Formula 2: drip (infusion) calculations 16 Drug Dosage Calculations (Cont d) Working with formulas Formula 4: based on weight 17 Medical Direction Legal Considerations Federal, state, local laws governing purchasing, distribution, dispensing, administering drugs Medication handling diligence, accounting Medical direction, final word 18 6
Medical Direction (Cont d) Protocols: written & online Written, filed with state board of pharmacy Online, radio, cellular phone If fails, follow written protocols If event with no protocol, must get medical direction before proceeding Differ among EMS systems 19 Principles of Medication Administration Safety considerations & procedures Familiar with drug Require physician order Verify physician s order Concentrate on task Patient properly positioned Assemble, use correct supplies, equipment Handle carefully, avoid dropping, breaking Aseptic technique Carefully calculate drug doses 20 Principles of Medication Administration (Cont d) Safety considerations & procedures Check drug incompatibility Monitor for overdose signs, take corrective measures Document drug given, dose, time, route, patient s response 21 7
Principles of Medication The six rights of drug administration Right drug Right patient Right dose 22 Principles of Medication The six rights of drug administration Right time Right route Right documentation 23 Principles of Medication Medical asepsis Medically clean Source of infections & standard precautions 24 8
Principles of Medication Medical asepsis Antiseptics vs. disinfectants Disinfection Antiseptic Sterilization Sepsis 25 Principles of Medication Medical asepsis Proper drug handling Care of site 26 Prevention of Injuries & Exposures Sharps handling Do not recap needle by hand, dispose in approved container Do not overfill sharps containers No regular trash Retrieve any placed on stretcher Ensure all sharps accounted for before removing patient from ambulance 27 9
Administration Enteral medication administration Giving oral medications 28 Enteral medication administration Giving sublingual medications Place under tongue with gloved fingers Not swallowed, spit out, or rinsed Advantages, accessibility, rapid onset Nitroglycerin most common 29 Skill 13-1 Sublingual Med Administration When giving nitroglycerin spray, do not shake before use; remove plastic canister cover Hold container upright with index finger on top of grooved button; position close to mouth, without touching Firmly press button to release spray under patient s tongue Release button and ask patient to close mouth and avoid swallowing; replace canister cover 30 10
Administration Enteral medication administration Giving buccal medications Placed in pocket between teeth & cheek Glucose for diabetic 31 Skill 13-2 Rectal Diazepam (Valium) Place child on side, facing you; measure for weight Open package, remove syringe, remove cover, lubricate tip Bend child s upper leg forward so knee is close to chest Expose rectum by separating child s buttocks Insert lubricated syringe tip all the way into rectum Slowly count to 3 while pushing plunger in until it stops Slowly count to 3 before removing plunger Slowly count to 3 while holding child s buttocks together, preventing leakage; monitor child s respiratory rate and depth; be prepared to assist breathing as necessary 32 Administration Enteral medication administration Giving medications by gastric route Orgastric tube (OG) Nasogastric tube (NG) 33 11
Skill 13-3 Nasogastric Tube Insertion Prep; place patient in sitting position with stretcher head at 45- degree angle or greater; give patient cup of water with straw; measure tube: tip of nose to earlobe, then xiphoid process; mark tube Prep 1 st 2-3 inches of tube with water-soluble lubricant Have patient tilt head forward and sip water through straw when asked to swallow 34 Skill 13-3 Nasogastric Tube Insertion (Cont d) Slowly insert tube into nostril; advance tube as patient swallows until premeasured mark is reached; in case of resistance, do not advance tube, withdraw and retry; if resistance continues, attempt other nostril Verify tube placement by injecting ~20 ml of air into tube while listening over epigastrium with stethoscope; if correct, rush of air will be heard; tape tube in place 35 Administration Parenteral medication administration Topical medications 36 12
Giving inhaled medications Metereddose inhalers 37 Skill 13-4 MDI Medication Administration Prep; patient sitting; assemble inhaler, attach spacer if needed; shake inhaler gently before use Position mouthpiece ~2 finger widths from mouth; if using spacer, patient s lips close around mouthpiece Ask patient to inhale deeply and exhale, then inhale slowly while inhaler is activated, hold breath for 10 seconds, and exhale through pursed lips Observe patient; document procedure 38 Administration Giving inhaled medications Nebulizers 39 13
Skill 13-5 Small Volume Nebulizer Prep; patient sitting; assemble small volume nebulizer; attach mouthpiece to large end of T-shaped piece Attach extension tubing to small end of T-shaped piece Unscrew cap Fill base of cup with correct medication; if a bronchodilator, additional liquid (i.e., normal saline) may be added, if ordered 40 Skill 13-5 Small Volume Nebulizer Attach cap; shake to mix medication and diluent (if used); attach oxygen supply to nebulizer cup, then to oxygen source Attach cup to bottom of T-shaped piece; adjust oxygen rate 6-10 L/min to create fine mist Patient sitting; if able, patient may hold mouthpiece alone, if not, hold it for patient; ask patient to inhale slowly, pause 2-3 seconds, exhale through pursed lips; continue until medication is gone; observe patient; document procedure 41 Administration Giving inhaled medications Tracheal medications Use endotracheal tube Rapid onset of action Bag-mask device disperses drug across alveoli Remove needle from syringe before instilling medication in ET tube 42 14
Skill 13-6 ET Drug Administration Prep; ventilate patient s lungs with several compressions of bag-mask device Briefly disconnect oxygen source from ET tube (unless ET tube has drug port); briefly discontinue CPR (if applicable); administer medication into ET tube After administration, give positive-pressure ventilations, resume oxygen/cpr as needed 43 Administration Giving intranasal medications 44 Injectable medications Equipment Needles, syringes 45 15
Syringes Tuberculin Measurement scale on a 3-mL syringe Needle with protective sheath 46 Injectable medications Parenteral medication containers 47 Skill 13-7 Withdrawing From An Ampule Prep: medical director s orders, PPE, six rights Check medication clarity; verify drug not expired; check concentration Clear contents from top by holding upright and gently tapping container s top with finger or gently swirl ampule to displace medication from container s top 48 16
Skill 13-7 Withdrawing From An Ampule (Cont d) Wrap ampule neck/top Snap off top away from body Replace syringe s sterile needle with filter needle to keep out glass particles Place needle into ampule solution, withdraw dose of medication; if needle is not long enough to reach bottom of ampule, invert to withdraw desired dose; do not touch ampule outer surface/rim; do not inject air in ampule Tap syringe to remove air bubble, push plunger to expel air; replace sterile needle; properly dispose sharps 49 Skill 13-8 Withdrawing From A Vial Prep: medical director s orders, PPE, six rights; check medication clarity; verify drug not expired; check concentration Remove protective cover on vial s stopper, if present; cleanse rubber stopper with alcohol; let dry Hold vial with thumb/forefinger, insert needle into vial; with needle tip above solution, push syringe plunger to inject air equal to desired dose to prevent vacuum Invert vial/syringe; hold at eye level with needle below level of solution in vial; if syringe does not fill automatically, pull down plunger to desired dose 50 Skill 13-8 Withdrawing From A Vial (Cont d) Tap syringe to remove air bubble, push plunger to expel air; adjust plunger for desired dose Remove needle from vial; reverify dose; properly dispose sharps 51 17
Administration Injectable medications Intralingual injections Injected into underside of tongue 25-gauge, 5/8-inch needle 52 Injection routes A, intramuscular (IM) B, subcutaneous (Sub-Q) C, intradermal (ID) D, intravenous (IV) 53 Injectable medications Subcutaneous injections 54 18
Skill 13-9 Subcutaneous Injection Prep; prepare correct medication dose; select injection site; cleanse site with alcohol wipe using circular motion from center out; allow to dry Gently pinch skin and lift subcutaneous tissue away from muscle Insert needle at 45-degree angle with quick, darting motion Release skin; pull back plunger, check for blood; if blood present, remove needle; if no blood, press plunger, inject medication; withdraw needle; massage area; apply bandage if bleeding; observe patient; properly dispose sharps; document 55 Administration Injectable medications Intramuscular injections Into muscle layer Rapid onset Complications Deltoid site Dorsogluteal site Ventrogluteal site Vastus lateralis, rectus femoris sites 56 Deltoid Site 57 19
Dorsogluteal Site 58 Ventrogluteal Site 59 Vasrus Lateralis & Rectus Femoris Sites 60 20
Skill 13-10 Intramuscular Injection Prep; prepare correct medication dose; select injection site; cleanse site with alcohol wipe using circular motion from center out; allow to dry Spread skin at site; hold skin taut, insert needle at 90-degree angle with quick, darting motion Pull back plunger slightly, check for blood; if blood present, remove needle; if no blood, inject medication with slow, continuous motion, withdraw needle; massage area; apply pressure with gauze if bleeding, apply bandage if needed; observe patient; properly dispose sharps; document 61 Administration Vascular access Venous access Intravenous cannulation Venipuncture Intravenous therapy 62 Vascular access Peripheral venous access Intravenous catheters Saline lock Over-the needle Through-theneedle Hollow needle 63 21
Vascular access Peripheral venous access Factors in selection Purpose of infusion Amount, type of fluid, medication to be infused Accessibility, size, condition of vein Patient s age, size, general health, hand dominance, mobility Presence of disease, injury, prior surgery Presence of shunt, graft Experience, skill at venipuncture 64 Peripheral intravenous sites 65 Peripheral intravenous sites 66 22
Peripheral intravenous sites 67 Vascular access Peripheral venous access Peripheral intravenous insertion 68 Skill 13-11 Peripheral Venous Access PPE; assemble supplies; use appropriate fluid; check expiration date; check solution clarity; check bag for leaks; select appropriate select catheter length/gauge/microdrip/ macrodrip as appropriate; clamp tubing Insert spiked end of tubing into bag Squeeze drip chamber until chamber fills halfway; loosen protective cap over needle adapter to allow air to escape; open clamp slowly; flush air from tubing; flick tubing with finger to remove air bubbles; close clamp; retighten cap 69 23
Skill 13-11 Peripheral Venous Access (Cont d) Apply tourniquet ~4 inches above injection site, tight enough to restrict venous blood flow without restricting arterial circulation; if vein not distended, ask patient to open and close fist several times; cross ends of tourniquet and apply tension Fold middle of one end of tourniquet under opposite end to form loop; leave distal portion of folded end free to allow onehanded release of tourniquet Cleanse site; allow to dry 70 Skill 13-11 Peripheral Venous Access (Cont d) With nondominant hand, anchor vein by pressing thumb ~2 inches directly below insertion site; hold skin taut Puncture vein (direct or indirect method); use dominant hand to hold IV catheter; once punctured, quickly lower IV catheter until hub is nearly parallel to skin When blood is seen, advance catheter 2-3 mm more to be sure of vein, then advance catheter over the needle to catheter hub Apply light pressure to vein proximal to catheter tip to slow blood escape 71 Skill 13-11 Peripheral Venous Access (Cont d) Remove needle portion of cannula with dominant hand; properly dispose needle Attach syringe to IV catheter; withdraw blood if samples needed Release tourniquet; connect administration set to catheter; check connection is secure Slowly open clamp on tubing; look for swelling or fluid leakage at site; if patent, adjust flow of infusion to prescribed rate Secure catheter in place 72 24
Administration External jugular vein cannulation 73 Vascular access Central venous access Into vena cava from subclavian, EJ, femoral vein Need for long-term IV therapy Large volumes of fluid Blood products, hypertonic solutions, caustic medications, parenteral feeding solutions Placement of transvenous pacemaker electrodes Central venous pressure monitoring, central venous sampling 74 Parenteral medication administration Complications Local Systemic 75 25
Vascular access Intravenous medications Bolus Piggyback Infusion pumps 76 Skill 13-12 IV Bolus Medication Six rights; ask patient about allergies; check medication concentration, clarity, expiration date; calculate, prep dose, fill syringe with correct dose Check site for infiltration; once certain that catheter is in vein, cleanse injection port closest to patient with alcohol swab; recheck medication, dose Connect syringe to injection port; pinch tubing above port; give correct dose at proper push rate Remove syringe; release tubing; allow IV solution to flow at prescribed rate; properly dispose sharps; observe patient; document 77 Skill 13-13 IVPB Medication Six rights; check allergies; select correct medication; check clarity, expiration dates of medication and IV solution Calculate, draw up, medication into syringe; calculate flow rate of piggyback medication in drops per minute; cleanse port on bag with alcohol swab; inject correct dose into solution; gently shake bag Connect secondary admin set to medication solution; fill drip chamber and flush air from tubing; connect secondary admin set to primary solution tubing 78 26
Skill 13-13 IVPB Medication (Cont d) Check site for infiltration; raise piggyback solution until higher than primary solution; tape connection Recheck medication dose; open clamp on piggyback tubing; adjust flow rate to calculated desired dose; properly dispose sharps; observe patient; label piggyback solution (date, time, name, amount of medication added to bag, preparer s initials); document 79 Administration Vascular access Intraosseus infusion Indications 80 Vascular access Intraosseus infusion Sites Anterior tibial approach Distal femur approach 81 27
Vascular access Intraosseus infusion Sites Distal tibia approach Anterior superior illiac spinal approach 82 Skill 13-14 Pediatric IO Infusion Select IV fluid; prep; PPE; place infant/child supine; support popliteal fossa; optimize positioning Identify needle insertion landmarks Cleanse site; stabilize leg; angle needle away from joint; insert needle with firm pressure Advance needle with twisting motion; angle 60-90 degrees, toward toes Advance needle until pop, or decrease in resistance is felt Unscrew cap; remove stylet; attach 10-mL saline-filled syringe; attempt to aspirate bone marrow into syringe; if successful, slowly inject 10-20 ml saline to clear needle 83 Skill 13-14 Pediatric IO Infusion (Cont d) Observe for swelling; if aspiration unsuccessful, consider other indicators of correct needle position If infiltration present, remove IO needle, attempt another site; if no infiltration signs, attach standard IV tubing; syringe, pressure infuser, or IV infusion pump may be needed to infuse fluids Secure needle/tubing with bulky sterile dressing and tape; observe site every 5-10 minutes; monitor for infiltration; assess distal pulse; tape admin set to foot 84 28
Administration Fast1 IO system 85 EZ-IO device 86 Vascular access Intraosseus infusion Precautions for FAST1 use, not recommended Precautions of EZ-IO device, not recommended 87 29
Parenteral medication administration Vascular access Intraosseus infusion Contraindications Possible complications 88 Vascular access Unbilical vein access 89 Fibrinolytic Initiation & Monitoring Dissolve clots Acute myocardial infarction, stroke Must be given before clot disrupts blood flow, cause tissue necrosis Thorough history, rate monitoring 90 30
Blood Infusions Implications & reactions Reaction possible Headache Change in consciousness level Skin flushing Nausea, vomiting Breathing difficulty Chills Weak, thready pulse with tachycardia Hypotension Fever 91 Blood Infusions (Cont d) Reaction Immediately discontinue blood infusion Open primary IV line Rapidly infuse normal saline High-flow oxygen Continually monitor patient for changes Contact medical direction for orders Save blood bag, tubing, must be returned to lab for analysis 92 Obtaining Blood Sample Purpose Baseline evaluation Safety precautions Label tube with patient name, date, time, your initials Tape sample to bag, give to ER receiving party 93 31
Chapter Summary Medication administration Drugs originally measured to apothecary system, based on grain of wheat Household system, dropper, teaspoon, tablespoon, cup, glass, pint, quart, gallon, expressed in Arabic numbers, fractions, decimals not used 94 Chapter Summary (Cont d) Metric system used for drug calculations, based on unit of 10 Basic units in metric system Weight, gram Length, meter Volume, liter 95 Chapter Summary (Cont d) Four commonly used units in drug calculations: centi, milli, micro, kilo Calculating drug dosages, must be able to convert milligrams to grams, grams to milligrams, milligrams to micrograms, micrograms to milligrams Body temperature, Celsius, Fahrenheit 96 32
Chapter Summary (Cont d) Formulas necessary to calculate dosages Formula 1: single dose calculations DD x V divided by DH Formula 2: drip(infusion) calculations Total volume to be infused divided by total time of infusion in minutes, multiplied by drops divided by ml Formula 3: drip not based on weight DD x V divided by DH, multiplied by gtt divided by ml Formula 4: drip based on weight Calculate patient s weight in lbs by 2.2 Multiply patient s weight in kg by desired dose/kg 97 Chapter Summary (Cont d) Formulas necessary to calculate dosages Formula 4: drip based on weight Prepare infusion, calculate dose on hand Cross out like terms that appear in numerator & denominator, 1 for 1 Paramedic authorized to give medications under direction of physician Federal, state, local laws govern purchasing, distribution, dispensing, administration of drugs Must know local policies, procedures 98 Chapter Summary (Cont d) Protocols, written form of medical direction Must be signed by medical director Medical direction given by cell phone, radio If no communication, written protocols followed Safety protocols, procedures with medication Be familiar with drug given Convey important information about patient to online physician 99 33
Chapter Summary (Cont d) Safety protocols, procedures with medication Verify physician s order Concentrate on task at hand Patient properly positioned Assemble, use correct supplies, equipment Handle drugs carefully, avoid dropping, breaking Always use aseptic technique Carefully calculate dosages Monitor for overdose signs Carefully document 100 Chapter Summary (Cont d) Six rights of drug administration Right drug Right patient Right dose Right time Right route Right documentation Standard precautions, must do every time in contact with patient 101 Chapter Summary (Cont d) Disinfection involves cleaning emergency vehicle, stretcher, equipment with disinfectants, toxic to body tissues Antisepsis, cleanse local skin areas before needle puncture, alcohol-based/iodinebased products used 102 34
Chapter Summary (Cont d) Sterilization makes object free of all life forms, uses extreme heat, certain chemicals Proper precautions when handling sharps Medications given orally, rectally, gastric tube, topically, inhalation, injection, through vascular access, intraosseous infusion 103 Chapter Summary (Cont d) Blood sample needed before starting any IV lines, giving medications 104 Questions? 105 35