N205 OCT. 16 PARENTERAL MEDICATION ADMINISTRATION
Objectives: Upon completion of this class, the student will be able to:
1. Discuss the pathophysiology of coronary heart disease;
2. Describe interdisciplinary care of clients with CHD;
3. Describe and demonstrate correct injection techniques with IM, intradermal, and subQ injections;
4. Describe and demonstrate correct administration of insulin, including two types in one syringe;
5. Discuss how to prevent puncture injuries;
6. Describe and demonstrate safe use of ampules and vials for medication administration;
7. Discuss and demonstrate correct technique for reconstituting powdered medications;
8. Discuss how to apply general principles of safe drug administration with the above techniques.
I. CORONARY HEART DISEASE (CHD, CAD)
“Coronary heart disease (CHD), also called coronary artery disease (CAD), ischaemic heart disease, atherosclerotic heart disease, is the end result of the accumulation of atheromatous plaques within the walls of the arteries that supply the myocardium (the muscle of the heart) with oxygen and nutrients.” (wikipedia)
A. Pathophysiology
1. Atherosclerosis: progressive, plaque; lipids. “athero” means ‘lump of porridge.’ This actually does lead to hardening, or ‘arteriosclerosis.’ Arteriosclerosis also happens as a normal process of aging due to loss of elastin protein throughout the body, which creates high systolic BP.
2. Myocardial ischemia: imbalance of oxygen supply & demand to myocardium; platelet aggregation; angina. This means reversible, and the tissue signals its suffocation with pain.
Heart pain: may or may not be pain, can be referred to areas other than the chest, can be weight, tingling, tightness, etc. Old women tend to deny chest pain and pass it off as gi upset.
In the hosp, we want to prevent ischemia from becoming an MI.
3. Myocardial infarction: “The term myocardial infarction is derived from myocardium (the heart muscle) and infarction (tissue death due to oxygen starvation)…. If impaired blood flow to the heart lasts long enough, it triggers a process called the ischemic cascade; the heart cells die (chiefly through necrosis) and do not grow back. A collagen scar forms in its place.”
4. Risk factors: modifiable and nonmodifiable. Same as HTN; TOB, ETOH, obesity, little exercise, high fat diet, DM, stress, race, genetics are a high factor
B. Interdisciplinary Management
1. Diagnosis: lab values; ECG; symptoms. Post-MI pts show Q waves, or funky Q waves or something about Q waves
2. Risk Factor management:
When people come into the hospital with chest pain we’ll often put O2 on them.
3. Medications: statins [atorvastatin/Lipitor: anti lipidemic]; ASA; antiHTN; asprin works as a blood thinner to prevent further clotting. Beta-blockers are Rx’ed to unload the work on the heart muscle. Sometimes a “Beta-Blockade” is Rx’ed—when you do this you usually hold meds if the S-BP is <90>
4. Complimentary: yoga, yoga for sissies, meditation, breathing. Things we can do for our pts: give education, give them control, distract them with a walk, leave them alone so they can sleep. Community support: rehab and support groups.
5. Health promotion
6. Nursing diagnoses: name six:
- Impaired tissue perfusion r/t occlusion of coronary artery AEB angina
- knowledge deficit r/t drug admin AEB non-compliance
- anxiety r/t surg a.e.b. pt not sleeping
- Fear r/t angina AEB insomnia
- Pain r/t CAD AEB “oh crap there’s an elephant on my chest”
- Altered health maintenance
C. Client with Angina Pectoris
1. Pathophysiology: deficient blood flow to tissues and then ouch ouch.
2. Types: stable, variant [vasospasm] Prinzmetal’s, unstable
3. Management: nitrates; beta blockers; calcium channel blockers; community based care
D. Client with Acute Coronary Syndrome (ACS): seems to mean something bad, painful and cardiac is going on, but we don’t exactly what; ischemic, MI, angina…we have to rule out all these things.
“This is an umbrella term used to cover any group of clinical symptoms compatible with acute myocardial ischemia. Acute myocardial ischemia is chest pain due to insufficient blood supply to the heart muscle that results from coronary artery disease (also called coronary heart disease). Acute coronary syndrome thus covers the spectrum of clinical conditions ranging from unstable angina to non-Q-wave myocardial infarction and Q-wave myocardial infarction. These life-threatening disorders are a major cause of emergency medical care and hospitalization in the
1. Pathophysiology
2. Manifestations
3. Care: Lab values; antiplatelet drugs; revascularization; PTCA; CABG
E. Client with Acute MI
1. Pathophysiology
2. Manifestations
3. Complications
4. Care: fibrinolytics; antidysrhythmics
II. MEDICATION PREPARATION
A. Check MAR for 5 rights
B. Perform hand hygiene
C. Preparing medications from vials and ampules
1. sterile technique
2. protection from injury
3. ensure all medication is obtained from vial or ampule
D. Mixing medications in one syringe
1. Use syringe to draw up the volume of air equal to volume of drug to be withdrawn from both vials; inject air into each vial. Air to air: don’t put bubbles into the liquid.
2. Withdraw drug from second vial
3. Attach new sterile needle and withdraw drug from first vial we didn’t do that…
4. Example: Regular insulin 10 Units and NPH insulin 30 Units. Go “RN” or regular, then NPH.
first put 40 units of air into the syringe
a. Inject 30 units of air into NPH vial and withdraw needle and syringe; don’t touch insulin in vial
b. Inject 10 Units of air into Regular insulin vial and withdraw 10 units of regular insulin (withdraw Regular first)
c. Reinsert needle into NPH vial and carefully withdraw 30 Units NPH insulin only
d. Carefully recap syringe
e. Use only insulin syringes to give insulin and don’t use insulin syringes for anything except insulin
if you dirty your needle, don’t use it, you’re introducing bugs into your patient and that’s bad. You can replace the needle with a fresh one and not waste the med.
III. INTRADERMAL INJECTIONS like Tuberculin test. Hit the forearm b/c not people don’t have much adipose tissue there.
A. Safe procedure: hand hygiene; check MAR; check patient
B. Procedure
1. Select site; forearm
2. gloves
3. cleanse the skin at sire with circular motion starting at the center
4. prepare syringe
5. expel air
6. grasp syringe with dominant hand at hub
7. hold needle parallel to skin with bevel up
8. insert needle tip, inject fluid while pulling skin taunt
9. withdraw needle quickly; do not massage area
10. dispose syringe and needle into sharps container; remove gloves
11. document material injected, site, time, dosage, route, and signature
III. SUBCUTANEOUS DRUG ADMINISTRATION: don’t aspirate
A. Safe procedure
B. Sites: abdomen, outer aspect of upper arm
C. Equipment: Needles: #25 gauge, 5/8 inch
D. Technique:
1. patient privacy , gloves, clean site with alcohol leaving swab near site
2. 90 degree angle with short needles
3. pinch the tissue
4. dart in with dominant hand; no aspiration, inject drug, withdraw quickly
5. apply pressure with nondominant hand; do not rub site if heparin given
6. activate the needle safety device and dispose immediately into sharps container
7. document
lovenox is injected w/ a small bolus of air to ‘seal in’ the heparin.
IV. INTRAMUSCULAR INJECTIONS: don’t dart a long needle all the way. Unless you’re poking Ali’s arm. That thing’s the size of
A. Safe procedure
B. Sites: ventrogluteal, deltoid, dorsogluteal
C. Equipment: #22 gauge, 1in needles (shorter with elderly clients); 1 or 3 ml syringes
D. Technique:
1. hand hygiene, patient privacy
2. prepare medication
3. prepare patient
4. select and clean site, place swab on patient’s skin near site
5. gloves
6. inject quickly with darting motion at 90 degree angle
7. hold barrel of syringe with nondominant hand and aspirate by pulling back on plunger with dominant hand for 5 seconds. Wow, 5 seconds is a long time. If you get blood, pull out, dump the whole syringe and start over.
8. if no blood in syringe, inject drug slowly
9. wait 10 seconds then withdraw quickly. Are they kidding? Sit there for 10 seconds?
10. apply pressure at site
11. activate needle safety device and discard in sharps container
12. document
13. assess effectiveness of drug at appropriate time
V. CASE SCENARIOS: Describe and demonstrate correct technique.
1. Diabetic patient to receive 10 Units Lantus insulin subQ q hs.
Same patient on sliding scale. Blood sugar is 256. MD order indicates Regular insulin 8 Units subQ BS >250.
Same patient to receive Regular insulin 10 Units and NPH insulin 20 units subQ q am.
2. Enoxaparin 80 mg subQ BID.
3. Flu vaccination, .5 ml IM to elderly clients at Senior Expo Fair.
4. Annual TB 0.2 ml intradermal test by Employee Health Nurse at PVH.
5. Aspirate contents of ampule containing 1 mL medication.
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