Medication Administeration Part III

Minimize potential risk during medication
Objectives
By the end of this unit, the students will be able to:
◊ Recall safe medication parameters
◊ State the ten rights of medication
◊ Identify the effect of medication
◊ Discuss about medication interaction
◊ Apply medication administration precautions
◊ Apply infection prevention techniques during medication
6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 1

Safe administration of medications #1
◊ Safety is of the utmost importance for medication administration.
◊ Medication mistakes are the most common healthcare error.
◊ To help prevent errors and minimize potential risks, consider the

following safety parameters:
1. Ensure the ten right’s of medication administration.
2. Identify medication interaction and substance incompatibilities.
3. Apply medication administration precautions.
4. Apply infection prevention techniques during medication.
5. Monitor the response or effect of medication.

Safe administration of medications #2
◊ The ten rights of medication:
1. The right patient
2. The right medication
3. The right dose
4. The right route
5. The right time
6. The right documentation
7. The right education
8. The right assessment
9. The right evaluation
10. The right to refuse

Medication contraindication
◊ Contraindication is a factor that prohibits the administration of a drug
(reasons not to use a particular drug) for a specific individual.
◊ Can be individual medical condition, current medication, sensitivity, …
◊ Examples:
◊ Pregnancy is contraindication for administration of tetracycline.
◊ Immunosuppression is a contraindication for some vaccination.
◊ Types of contraindication:
1. Absolute contraindication: a proposed drug is totally impossible.
E.g., children with viral infections should not be given aspirin
because of the risk of Reye syndrome.
2. Relative contraindication: comparative and mitigated reasons or
cautions. E.g., patients with severe renal insufficiency may need
dose adjustment for cephalexin.

Effects of drugs #1
◊ There are two type of medication effect: primary & secondary effect.
1. Therapeutic effect:
◊ The primary effect of medications that are intended and desired.
◊ It is the reason that drugs are prescribed.
◊ Medications are given for the following primary effects:
A. Palliative effects: relieve the signs and symptoms of a disease,
but have no effect on the disease itself, e.g., morphine sulfate
may be given to a patient with cancer to manage pain, but it
does not destroy cancer cells.
B. Supportive effects: support body functions until other
medications can become effective, e.g., for a patient with
bacterial infection, you may give paracetamol to control fever
until blood levels of the prescribed antibiotic are effective in
combating the infection causing fever.
Effects of drugs #2
C. Substitutive effects: replace a chemical required by the body for
improved functioning, e.g., administer insulin to a diabetic patient
to replace the insulin no longer produced by the pancreas.
D. Curative and chemotherapeutic effects: destroy disease causing
microorganisms or body cells, e.g., antibiotics used to treat
infections by killing or limiting the reproduction of certain bacteria
and antineoplastic drugs used to treat cancer by limiting cell
reproduction and destroying malignant cells.
E. Restorative effects: return the body or maintain the body at
optimal levels of health, e.g., vitamin and mineral supplements are
administered to many patients recovering from surgery.
• A single medication may have many therapeutic effects, e.g.,
prednisone is indicated to decrease swelling, inhibit inflammation,
reduce allergic response & prevents rejection of transplanted organs.
Effects of drugs #3
2. Non - therapeutic effect:
◊ Secondary effect (consequence) of medications that are unintended.
◊ Includes:
◊ Side effect: predictable physiological effect that are usually well
tolerated by patients.
◊ Adverse reaction: harmful and unpredictable response.
◊ E.g., allergic reaction due to immunologic sensitization.
◊ Toxic effect: dangerous, damaging effects to an organ or tissue.
◊ No medication is totally safe and absolutely free of nontherapeutic
effects (the intensity of secondary effect is usually dose dependent).
◊ If the non-therapeutic effects are serious enough to outweigh the
benefit of therapeutic action of a medication, the nurse will likely
discontinue or prohibit the use of medications.
Effects of drugs #4
Medication interaction:
◊ One medication modifies or alters the action of another medication.
◊ Occurs in individuals who take several medications.
◊ Drug interactions may be beneficial or harmful.
◊ Interaction may be:
◊ Pharmacokinetics i.e., alter the way another medication is
absorbed, metabolized or eliminated from the body.
◊ Pharmacodynamic interactions: potentate the effect (synergistic
or additive) or decrease the effect (inhibiting or antagonistic).
◊ The more drugs a patient takes, the higher the risk of interaction.
◊ Drugs may also interact with the environment (heat, humidity), food
(high calcium concentration in dairy products inhibit tetracycline and
fluoroquinolones absorption).
Effects of drugs #5
Precautions in giving medication:
◊ Make sure the drugs and its doses are appropriate.
◊ Assess the patient before medication.
◊ Verify drug functionality (expiry date and other factors).
◊ Ensure one needle, one syringe and one patient.
◊ Do not change the needle in order to reuse the syringe.
◊ Do not combine leftover medications for later use.
◊ Follow infection prevention and control protocols.

Effects of drugs #6
Infection prevention during medication administration:
◊ Microorganisms are transmitted when the chain of infection
progresses without interruption.
◊ The transmission of microorganisms can be prevented if the chain is
broken by practices performed by healthcare providers and patients.
◊ Each link of the chain of infection necessitates specific interventions
to prevent transmission of an infectious agent.
◊ Intervention to interrupt the chain of infection:
1. Hand hygiene
2. Use the appropriate PPEs
3. Implement protective precautions if necessary
4. Safe injection practice
5. Safe used items and waste disposal
Effects of drugs #7
Magnitude of unsafe injection:
◊ Globally 50 % of all injections are unsafe (WHO).
◊ Health care workers are at an increased risk from blood borne
pathogens because they handle sharps and related wastes.
◊ HBV, HCV & HIV/AIDS are the commonest with grave implication.
◊ As MoH reported, in Ethiopia 74% of injections were unsafe.
◊ And also, 72% of health facilities practiced unsafe disposal.
◊ The prevalence rate of needle stick injury was 30 to 35%.
◊ In Ethiopian, patients prefer injections to other forms of medications
further increases the risk of disease transmission.
◊ And also, 47% injection providers are known to believe that oral
medications are less effective than injections for the treatment
of fever caused by minor illness.
Effects of drugs #8
Conditions causing risks to clients and care providers:
◊ Use of injections when there are other suitable alternatives.
◊ Apply pressure to bleeding sites with dirty material or finger.
◊ Health workers not following aseptic techniques.
◊ Client moves during administration of injection.
◊ Shortage or absence of appropriate injection or safety devices.
◊ Placing needle on a surface and unexpected places like linen.
◊ Recapping needles (either one or two hand).
◊ Overfilling of sharps containers, …etc.
Best practices in injection safety:

• Elimination of unnecessary injection and administer injections safely.
Preparing medications
Objectives
By the end of this session, the students will be able to:

◊ Describe the common medication measurement system.
◊ Describe the methods for calculating drug dosages.
◊ Identify common medication schedules and abbreviations.
◊ Explain the major steps in medication prescribing cycle.
◊ Recall the components of medication order.
◊ Recall the principle of medication order.
◊ Identify the types of medication order.

Medication measurement system #1
1. Metric system: the standard and most accurate system.
◊ The basic units of measurements:
◊ Volume = milliliter and liter.
◊ Weight = milligram, microgram and gram.
◊ Rules for metric notations:
◊ Metric abbreviations always follow the unit amount.
E.g., 2 mL, 500 mg, ...
◊ Metric abbreviations are written in lowercase letters.
◊ Except for liter, for which the “L” is capitalized.
E.g., g = gram, mL = milliliter, …etc.
◊ Fractional units are expressed as decimals.
E.g., 0.5 mL, not ½ mL.

2. Household measurement:
◊ By using the containers easily found in the home.
◊ Includes: drops, teaspoons, cups, … etc.
◊ Inaccurate and may deliver more or less dose.
◊ For accurate dose:
◊ Need to common equivalents of metric and household units.
◊ 1 mL = 15 drops (gtt)
◊ 4 mL = 1 teaspoon (tsp)
◊ 15 mL = 1 tablespoon (tbsp), …etc.
3. Solution: mass of solid substance dissolved in volume of fluid or
volume of fluid dissolved in another fluid.

Percentage concentration:
◊ Defined as the amount of drug in 100 parts of the product.
◊ Type of concentration:
1. % w/v (weight in volume) = number of grams in 100mL.
◊ A solid is dissolved in a liquid.
E.g., 5% w/v means 5 g in 100 mL.
2. % w/w (weight in weight) = number of grams in 100 g.
◊ A solid mixed with another solid.
E.g., 5% w/w means 5 g in 100 g.
3. % v/v (volume in volume) = number of mL in 100 mL.
◊ A liquid is mixed or diluted with another liquid.
E.g., 5% v/v means 5 mL in 100 mL.

Example:
1. Given a 40 % glucose solution, what volume is required to make 40 mL
of a 10 % glucose solution?
◊ Answer:
◊ 10 % glucose solution contains 10 gram per 100 mL.
◊ 100 ml = 10 gram
◊ 40 ml = ?
◊ (40 ml × 10 gram) ÷ 100 ml => 400 ÷ 100 => 4 gram.
◊ 40 % glucose solution contains 40 gram per 100 mL.
◊ 40 gram = 100 ml
◊ 4 gram = ?
◊ (4 g × 100 ml) ÷ 40 g => 400 ÷ 40 => 10 mL.
◊ There fore, 4 grams are found in 10 mL, which is the volume
required to make the diluted solution.
Control questions:
1. How many grams of sodium chloride are there in a liter infusion of
sodium chloride 0.9%?
A. 0.9 gram C. 1.8 gram
B. 9 gram D. 18 gram
2. How many grams of sodium chloride are there in a 500 mL infusion
of sodium chloride 0.45%?
B. 0.9 gram D. 4.5 gram
3. How much sodium bicarbonate is there in a 200 mL infusion sodium
bicarbonate 8.4% w/v?
B. 8.4 gram D. 33.6 gram
◊ mg/mL concentrations:
◊ Defined as the number of milligrams of drug per milliliter of liquid.
E.g. amoxicillin, 250 mg/5 mL = 250 mg in 5 mL.
◊ Ratio strengths or 1 in … concentrations:
◊ Defined as one gram in many milliliters.
◊ For example:
◊ 1 in 1,000 means 1 g in 1,000 mL.
◊ 1 in 10,000 means 1 g in 10,000mL.
◊ Parts per Million (ppm):
◊ Defined as one gram in 1,000,000 mL or one milligram in 1 liter.
◊ Used to describe very dilute concentrations.

Mole and millimole:
◊ Mole is a unit used to count atoms and molecules.
◊ Mole is the SI unit for the amount of a substance.
◊ For elements or atoms, one mole = the atomic mass in grams.
◊ Example:
◊ The atomic mass of potassium is 39.
◊ So, 1 mole of potassium has a mass of 39 g.
◊ For molecules, one mole = the molecular mass in grams.
◊ Example:
◊ The molecular weight of sodium chloride is 58.5.
◊ Therefore, 1 mole of sodium chloride has a mass of 58.5 g.
◊ Millimoles: one millimole is equal to one-thousandth of a mole.
◊ One millimole = the atomic mass or molecular mass in milligrams.
• Example: how many millimoles of sodium chloride are there in a liter
of sodium chloride 0.9 % w/v?
• Steps:
1. Calculate the weight of sodium chloride in a liter.
2. Calculate millimoles of sodium chloride in a liter
Molecular weight NaCl mmol in a liter:

NaCl weight in a liter: of NaCl in 1 mole:
• 1 mole = 58.5 g
◊ 100 mL = 0.9 g • 58.5 g = 1000 mmol
• Na = 23 g
◊ 1000 mL = x • Cl = 35.5 g • 9g=Y
◊ X = 1000 mL * 0.9 g • Y = 9 g × 1000 mmol
100 mL
• NaCl = 58.5 g. 58.5 g
◊ X = 9 g in 1000 mL • Y = 154 mmol

Units:
◊ Indicate the strength of drug concentration in 1 mL of a solution.
◊ Examples of drugs: insulin, heparin, penicillin,… etc.
◊ Always read a container label to know units per milliliter.
Milliequivalents (mEq):
◊ Indicate strength of ion concentration in a drug.
◊ mEq is the number of grams of a solid contained in 1 mL of a solution.
◊ Electrolytes are measured in mEq, example, potassium chloride (KCl).
◊ mEq = mg × valency ÷ molecular weight.
E.g., determine the amount of mEq in 600 mg KCl tablet?
(600 mg × 1) ÷ 74.5 = 8.05 mEq.

Control questions:
1. Drug A is available as a 5% solution. Kalkidan, who weighs 7 kg, is to be
given drug A at a dose of 6 mg/kg/dose twice daily for 5 days. What
volume of this solution of drug A should Kalkidan be given daily?
A. 0.75 mL C. 1.55 mL
B. 1.68 mL D. 2.75 mL
2. A 1 in 10, 000 solution of potassium permanganate contains which of
the following concentrations?
A. 50 mg KMnO4 in 500 mL. C. 1 mg KMnO4 in 100 mL.
B. 5 mg KMnO4 in 500 mL. D. 1mg KMnO4 in 1000 mL.
3. Which of the following volumes of an adrenaline 1 in 1000 solution
would be given by intramuscular injection to a 2 years old child for
treatment of anaphylaxis if the dose were 120 micrograms stat?
A. 12 mL B. 120 mL C. 0.12 mL D. 0.24 mL
Clinical dose calculation #1
◊ Accurate dosage calculation is critical component in safe
administration of medications because medication is usually
packaged in average unit dose.
◊ Amount to administer = Ordered dose × amount on hand
Dose on hand
◊ Example 1: you ordered morphine sulfate 2 mg IV, but medication
is available in vial containing 10 mg/mL.
◊ Amount of morphine to administer = 2 mg × 1 mL = 0.2 mL.
10 mg
◊ Example 2: you ordered clarithromycin, 500 mg. Medication is
available clarithromycin 250 mg in 1 tablet.
◊ Amount of clarithromycin tablet = 500 mg × 1 tablet = 2 tablet.
250 mg

◊ Infants and children cannot receive the same dose of medication as
adults because child’s physiologic immaturity influences how a drug
is absorbed, distributed, metabolized and excreted.
◊ Therefore, pediatric dosages are based on:
1. Based on age (Young’s rule): adult dose x child age in years
Child age in years + 12
2. Based on weight (Clark’s rule): adult dose x child weight in kg
Average adult weight (70 kg)
3. Based on surface area: = child surface area x adult dose
Adult body surface area (1.72 m2)

Example:
◊ For a drug - A with the adult dose of 500 mg, what would be the dose
for 7 years old child weighing 22 kg? a child has a body surface area
(BSA) of 0.75 m2. Calculate based on age, weight and BSA.
A. Based on age: 500 mg x 7 years = 185 mg
7 years + 12
B. Based on weight: 500 mg x 22 kg = 150 mg
70 kg
C. Based on BSA: 0.75 m2 x 500 mg = 220 mg
1.72 m2

Miscellaneous drug formula & calculation #1
Calculating percentage and volume: 5% = X gram
◊ Method – 1: 100 % 500 ml
Weaker solution = Solute • 100 X = 2,500
Stronger solution = Solvent • X = 2500/100 = 25 gram.
◊ Example: you need to dilute a stock solution of 100% strength to
a 5% solution. How much solute will you need to add to obtain
500 ml of the 5% solution?
◊ Method – 2:
Desired strength × Total amount of desired solution
Available strength
◊ Example: Example: You need to make 100 ml of a 20% solution,
using an 80% solution. How much of the 80% solution must you
add to the sterile water to yield a final volume of 100 ml of a
20% solution? 0.2 × 100 mL = 0.25 × 100 mL = 25 mL.
0.8
Preparing dilution
◊ Method - 1:
1. Calculate dilution factor:
= strength of concentrate ÷ strength of dilute solution.
2. Determine concentrate solution:
= final volume ÷ dilution factor.
◊ Example: calculate the amount of benzalkonium chloride solution
needed to prepare a 150 mL of a solution of benzalkonium chloride 10
% w/v. Benzalkonium chloride solution is a 50 % w/v concentration.
1. Dilution factor = 50 % ÷ 10 % = 5 times
2. Dilute solution = 150 ÷ 5 = 30 mL of concentrate solution
◊ Diluted solution = 30 mL + 120 mL of water = 150 mL.

◊ Method - 2:
◊ Vc * Cc = Vd * Cd
◊ Where
• Vc = volume of concentrated solution
• Cc = concentration of concentrate
• Vd = volume of diluted solution
• Cd= concentration of diluted solution
◊ Example: calculate the amount of benzalkonium chloride solution
needed to prepare a 150 mL of a solution of benzalkonium chloride 10
% w/v. Benzalkonium chloride solution is a 50 % w/v concentration.
◊ Vc * 50 = 150 * 10
◊ Vc = 150 * 10 = 30 mL
50

Dosage administration schedule
Schedule Abbreviation
Before meals AC
After meals PC
Immediately Stat
When needed PRN
Every morning q am
Every evening q pm
Every day QD (but better to write “daily”)
Twice times per day BID
Three times per day TID
Four times per day QID
Every four hour q4h
Every one hour qh
Common medication related abbreviation
Explanation Abbreviation
By mouth PO
Suppository Supp
Right ear, left ear, each ear AD, AS, AU
Right eye, left eye, each eye OD, OS, OU
Drop gtt
Intramuscular IM
Intravenous IV
Subcutaneous SC or Sq
Discontinue D/C
Tablet Tab
Tablespoon tbsp
Teaspoon tsp
Medication prescription #1
◊ Prescription is a drug order that is issued and signed by a registered
and licensed medical professional in accordance with requirements
of the executive body or through an approved prescription.
◊ Prescriber is any medical practitioner who is registered and licensed
or authorized by the appropriate body to write a prescription.
◊ Good prescribing practice (GPP): prescribing the right medicine for
the right patient, in the right dosage of the right formulation and for
the right length of time.
◊ Requirements for good prescribing practice:
1. Knowledge of disease pathophysiology and clinical pharmacology.
2. Assess the benefit-to-risk ratio by considering seriousness of the
problem to be treated and the effect of drugs (safety, interaction,
contraindication, …etc.)

◊ Major steps to be performed in the prescribing cycle during the
rational treatment and prescribing process:
1. Defining patient’s problem (making a correct diagnosis).
2. Specify therapeutic objective (what wants to achieve).
3. Choose treatment (efficacy, safety and affordable).
4. Writing prescription.
5. Give information and instruction.
6. Monitor treatment.

◊ Principles of medication order:
1. Medication should only be prescribed in generic name.
2. Do not use dangerous abbreviations.
◊ Example: IU may mistaken as IV. So, need to be use “unit.”
◊ QD may mistaken as OD. So, need to be use “daily.”
3. Do not abbreviate drug names: may be confused or misinterpreted
due to similar abbreviation.
◊ E.g.,MSO4 (morphine sulphate), MgSO4 (magnesium sulphate).
4. Do not use dangerous dose designation: trailing zero & lack of leading
zero (decimal point is overlooked resulting in a 10 fold dose error).
◊ Never use a zero after a decimal point.
E.g. 3.0 mg may interpreted as 30 mg. so, write 3 mg.
◊ Always use a zero before a decimal point.
E.g., .3 mg may interpreted as 3 mg. so, write 0.3 mg.
Do not use list of common abbreviations
Abbreviation Preferred term
U Write unit
IU Write international unit
QD Write daily
QOD Write every other day
MS Write morphine sulphate
MSO4 and MgSO4 Write magnesium sulphate
CC Write mL
µg Write mcg or microgram
The following drug dose measurements have been found on a patient chart.
Which dose measurement unit violate the acceptable prescribing practice?
A. 1.4 g B. 20 mL C. 26 units D. 100 µg
Components of medication prescription or order:
◊ Patient full name, address and MRN.
◊ Patient age and sex.
◊ Clinical diagnosis.
◊ Name and dosage of the medication.
◊ Route, frequency and duration of administration.
◊ Situation, e.g., when medication should be held, tapered, …
◊ Prescribers (health care provider’s) name, occupation and signature.
◊ Date and time the order is written.

Types of medication order:
1. STAT: a single dose of medication is to be given immediately and
only once, e.g., morphine sulphate 4 mg IV stat.
2. Single (also called one - time order): to be given only once at a
specified time, e.g., lorazepam 1 mg before surgery.
3. PRN (as needed order): to be given whenever the patient requires.
E.g. paracetamol 1000 mg po every 4 - 6 hours PRN.
4. Standing order: order that carried out until the order is canceled or
the required number of days has lapsed.
E.g., furosemide 40 mg orally twice daily for 2 days.

Administration of medications
Objectives
By the end of this unit, the students will be able to:
◊ Define route of medication administration
◊ Recall the route selection criteria
◊ Name the types of medication administration routes
◊ Describe the advantages and disadvantages of common routes
◊ Name the necessary equipment's for parenteral routes
◊ Define fluid therapy.
◊ State the clinical indications and nursing implication of IV fluids.
◊ Identify the complication of IV therapy and its prevention.

Medication administration #1
Route of medication administration
◊ Route is the way in which the drug dosage form is given.
◊ The route of administration selected depends on:
1. The characteristics of the drug.
E.g. insulin is destroyed in gastrointestinal tract.
So, insulin is administered subcutaneously.
2. The purpose of medication i.e., desired effect.
◊ Local or systemic effect.
3. Patient characteristics.
◊ Unconscious patient.
◊ The patient is vomiting.
◊ The patient has impaired GI system.

◊ There are several routes of medication administration:
1. Enteral: by way of the gastrointestinal tract.
◊ Includes; oral, sublingual, buccal and rectal.
2. Respiratory tract: inhalation and nebulization.
3. Parenteral: intradermal, subcutaneous, intramuscular & intravenous.
4. Topical: dermatological or skin
◊ Each route has indications or advantages and disadvantages.
◊ And also has specific technique to deliver the medication safely.
◊ Nurses must be knowledgeable and possess the necessary skills to
administer medications safely.

A. Oral administration
◊ Medications given by mouth and swallowed with fluid.
◊ And also, given by a tube into the stomach.
◊ Drug is absorbed in the stomach or intestines.
◊ Types of oral medication preparations: capsule, tablet and liquid.
◊ Have slower onset of action and more prolonged effect.
◊ Advantages: convenient, least expensive, easy to administer, does
not break the skin barrier and administration usually does not
cause stress.
◊ Disadvantages: inappropriate for clients with vomiting, drugs may
have unpleasant taste or odor, inappropriate when GIT motility
reduced, inappropriate if client cannot swallow like coma, drugs
may irritate gastric mucosa, drugs can be aspirated by clients, …

B. Sublingual administration:
◊ Place medication under tongue where it dissolves.
◊ The medication should not be swallowed.
◊ Advantages: same as oral plus drug is rapidly absorbed into the
bloodstream (rapid absorption could also be a disadvantage).
◊ More potent than oral route because drug directly enters the
blood and bypasses liver.
◊ Disadvantages: drug must remain under a tongue until dissolved
and absorbed, contraindicated for individuals who are unable to
maintain a tablet in place until dissolved.
◊ If swallowed, drug may be inactivated by gastric secretions.
◊ Nitroglycerin is one example of a drug commonly given in this
manner.

C. Buccal administration:
◊ Pertaining to the cheek i.e.,

medication is held in the mouth
against the mucous membranes of
the cheek until the drug dissolves.
◊ Advantage: same as for sublingual.
◊ Disadvantage: drug must remain

against cheek until dissolved and
absorbed.

D. Rectal administration
◊ Inserting the medication into the rectum.
◊ Advantages:
◊ Can be used for drug having objectionable taste or odor.
◊ Drug released at slow, steady rate.
◊ Disadvantages:
◊ Dose absorbed is unpredictable.
◊ May be perceived as unpleasant by client.

Parenteral route:
◊ The word “parenteral” is coined from the Greek words “para
enteron” meaning “to avoid the intestines.”
◊ Drugs administered via other routes other than oral, rectal or
respiratory routes are considered parenteral, by injection.
◊ Sterile equipment and drug solutions are essential.
◊ The common routes for parenteral administration:
1. Subcutaneous (Sc): into subcutaneous tissue, just below skin.
2. Intramuscular (IM): into a muscle.
3. Intradermal (ID): into the dermis.
4. Intravenous (IV): into a vein.
◊ The main advantage is fast absorption.

◊ Less common routes for parenteral administration:
◊ Intra-arterial: into an artery.
◊ Intracardiac: into the heart muscle.
◊ Intraosseous: into a bone.
◊ Intrathecal or intraspinal: into the spinal canal.
◊ Intrapleural: into the pleural space.
◊ Epidural: into the epidural space.
◊ Intra-articular: into a joint.
◊ The characteristics of the tissues affect the rate of medication
absorption and the onset of medication action.
◊ Before injecting the medication, know the volume of medication to
administer, the characteristics and viscosity of the medication and
the location of anatomical structures underlying injection site.

Subcutaneous administration:
◊ Inject medication into loose connective tissue underlying dermis.
◊ Subcutaneous tissue does not contain as many blood vessels as
muscles, thus medications are absorbed more slowly than with IM.
◊ Subcutaneous tissue contains pain receptors, patients often
experience slight discomfort.
◊ Injection into blood vessel is rare, not need to aspirate.
◊ Subcutaneous tissue is sensitive to irritating solutions and large
volumes of medications, thus administer only small volumes:
◊ For adults: 0.5 to 1.5 mL of medications.
◊ For children up to 0.5 mL of medications.
◊ Choose injection site that is free of skin lesions, bony prominences
and underlying nerves.
◊ Example of medication on SC: vaccines, insulin and heparin.
◊ The best subcutaneous injection sites include:
a) The outer posterior aspect of the upper arms.
b) The anterior aspects of the thighs.
◊ Other areas: the abdomen, the scapular areas of the upper back, and
the upper ventrogluteal and dorsogluteal areas.
◊ Use 25 - gauge needle size with 5/8 - inch for 45 - degree angle.
◊ 3/8 - inch needle for 90 - degree angle.
◊ For children, ½-inch need inserted at 45 - degree angle.
◊ For insulin injection, use insulin syringe.
◊ Advantages: onset of drug action faster than oral medication.
◊ Disadvantages: must involve sterile technique, more expensive than
oral medications, only small volume can be administered, slower
absorption than IM, some drugs can irritate tissues and cause pain.
Subcutaneous injection site and angles

Intramuscular administration:
◊ Injection of medication into deep muscle tissue, which has a rich
blood supply and allows medication to absorb faster than by the
subcutaneous route.
◊ Risk for injecting drugs directly into blood vessels, therefore,
whenever administering medication by the IM route, first verify
that the injection is justified via aspiration.
◊ Viscosity of medication, injection site, patient’s weight influence
needle gauge and length selection.
◊ The angle of insertion for IM injection is 90 degree.
◊ Needle is 1 ½ - inches and #21 or #22 gauge.
◊ Advantages of IM injection: can administer larger volume than via
SC route and drug is rapidly absorbed.

◊ Disadvantages: breaks the skin barrier, can be anxiety producing, can
cause discomfort, obese clients may be given subcutaneous injection
if needle is not long enough.
◊ Maximum volume of medication for IM injection:
◊ Well developed adults is 2 to 3 mL.
◊ Older children, older adults and thin adults is 2 mL.
◊ Older infants and small children is 1 mL.
◊ Younger infants is 0.5 mL.
◊ IM injection site or muscle: ventrogluteal, vastus lateralis & deltoid.
• Dorsogluteal site of the buttock is not routinely used due to its

location near major blood vessels and nerves, as well as having
inconsistent depth of adipose tissue.
1. Ventrogluteal muscle: the gluteus medius where the thickness of
subcutaneous tissue is less than other injection sites, relatively fewer
nerves and blood vessels, muscles are large & well developed.
◊ Preferred site for adults, children and infants for large volumes and
viscous and irritating solutions (maximum volume of fluid is 3 mL).
◊ To locate ventrogluteal muscle, use “V” and “G” method.
2. Vastus lateralis muscle: muscle is thick and well developed, located on
anterior lateral aspect of the thigh.
◊ Used for adults and children, for infants receiving vaccines.
3. Deltoid muscle: easily accessible, but not well developed (maximum
volume of fluid is 1 mL.
◊ Potential for injury because axillary, radial, brachial & ulnar nerves
& brachial artery lie on upper arm under triceps & along humerus.
Rectus femoris muscle (anterior thigh) is used occasionally for IM injection.
Lateral view of the right buttock showing the gluteal muscles for IM injection

Vastus lateralis site Rectus femoris muscle

Landmarks for the deltoid muscle of the upper arm, used for IM injections
Z - track method in IM injections:
◊ A technique for pulling the skin during an injection, it prevents
leakage of medication into subcutaneous tissues, seals medication
in muscle and minimizes irritation.
◊ Pull the overlying skin and subcutaneous tissues approximately 2.5
to 3.5 cm laterally to the side with ulnar side of the nondominant
hand.
◊ Hold the skin in this position until administered the injection.
◊ Clean site and inject the needle deeply into muscle.
◊ Aspirate the injection and if no blood is returned on aspiration,
inject medication slowly into the muscle.
◊ Keep the needle inserted for 10 seconds to allow the medication to
disperse evenly and release the skin after withdrawing the needle.

◊ This leaves a zigzag path that seals the needle track wherever tissue
planes slide across one another.
◊ The medication is sealed in the muscle tissue.
Z - track method of injection and after release following Z - track method.

Intradermal administration: drug into the dermal layer of the skin.
◊ Used for skin testing, e.g., tuberculosis screening, allergy testing.
◊ Because such medication is potent, injected into the dermis where
blood supply is reduced, drug absorption occurs slowly.
◊ May have anaphylactic reaction if medication enters the
circulation too rapidly.
◊ Short syringe (3/8 to 5/8 inch), fine - gauge (25 to 27) needle.
◊ Angle of insertion is 15 degree.
◊ Inject only small amount, 0.01 to 0.1 mL.
◊ If bleb does not appear or site bleeds after needle withdrawal,
medication may have entered subcutaneous tissues (skin test
results will not be valid).
◊ Advantages: absorption is slow (in testing for allergies).
◊ Disadvantages: administer small amount, breaks the skin barrier.
Common sites for ID injection:

• Inner lower arm
• Upper chest
• Back beneath scapulae

Schematic presentation of injection methods

Intravenous administration:
◊ Injections or infusion of drugs and fluids directly into a vein.
◊ Drug products are considered to be 100% absorbed.
◊ Used for drugs, fluids and/or electrolytes.
◊ Convenient route for rapidly infusing large volumes of fluid.
◊ Types of IV administration:
1. Bolus: when the dose is administered over a few minutes.
◊ Primarily administered by a syringe directly into the vein.
2. IV drip or infusion: the drug product is administered over several
minutes to hours from an infusion bag.
◊ Unfavorable reactions are prone to occur, since high concentrations
of drug may be attained rapidly in both plasma and tissues.

Indication for the use of IV route:
◊ To guarantee delivery and distribution.
◊ To rapidly restore electrolyte and fluid balance.
◊ To achieve an immediate pharmacologic effect.
◊ To treat serious, life-threatening conditions.
◊ To provide continuous nutrition (total parenteral nutrition) when
patients are unable to be fed by mouth or enteral feeing.
◊ To avoid complications which might result if other administration
routes are employed e.g., hematomas at the site of IM injections in a
patient with a bleeding diathesis.
◊ For blood transfusion and hemodynamic monitoring.

Sites of intravenous cannulation


Topical administration:
◊ Applied locally to the skin or to mucous membranes.
◊ Eye, ear canal, nose, vagina and rectum.
◊ Topical applications include the following:

1. Dermatological preparations:
◊ Applied to skin including transdermal patch.
2. Instillations and/or irrigations:
◊ Applied into body cavities or orifices.

Skin application:
◊ Preparation: ointment, paste, cream, lotion, powders and patches.
◊ Before applying the dermatological preparation thoroughly clean the
area with soap and water and dry the area by using a patting motion.
◊ Skin encrustations harbor microorganisms and the previously applied
applications can prevent the medication from coming in contact with
the area to be treated.
◊ Advantages: primarily provides local effect, painless, easy to
administer and limited side effects.
◊ Disadvantages: patients with skin abrasions are risk for rapid
medication absorption and systemic effects, medications are
absorbed through skin slowly, may irritate the skin and may be messy
and may soil clothes.

Nasal instillation:
◊ The common form is decongestant spray or drops.
◊ Used to relieve sinus congestion and cold symptoms.
◊ Take caution to avoid abuse of nasal medications because overuse leads
to a rebound effect in which the nasal congestion worsens.
◊ If swallows decongestant solution, serious systemic effects can develop.
Position for instilling nose drops

Eye or ophthalmic medications
◊ Medicinal substances administered into the eye.
◊ In the form of eyedrops and ointments and produce a local effect.
◊ Advantages: provides medication directly to the desired site.
◊ Disadvantages: difficult to self – administer and damage may occur
to eye if the tip of the dropper or tube touches the eye.
◊ Principles when administering eye medications;
a. Avoid instilling any form of eye medication directly onto the
cornea because cornea has many pain fibers and is very sensitive
to anything applied to it.
b. Avoid touching eyelids or other structures with eyedropper/tube.
c. Never allow a patient to use another patient’s eye medications.

Ear or otic medications:
◊ Medicinal substances administered into ear & produce a local effect.
◊ Advantages: provides medication directly to the desired site.
◊ Disadvantage: may require removal of earwax (cerumen) for
medication to reach the involved tissue and may cause damage if
drops fall directly onto the tympanic membrane.
◊ Internal ear structures are very sensitive to temperature extremes,
instill eardrops or irrigating solutions at room temperature to
prevent vertigo, nausea.
◊ Although the structures of the outer ear are not sterile, sterile
solutions are used in case eardrum is ruptured, to prevent infection.
◊ If drainage, check the eardrum is not ruptured before instilling drops.
◊ Forcing medication into occluded ear canal creates pressure that
injures eardrum (perform ear irrigations if the external ear canal is
occluded with cerumen.
Reading assignment:
◊ Vaginal administration.
◊ Rectal administration.

Equipment's for parenteral medication #1
Syringe and needle:
◊ Available in a variety of sizes.
◊ Each size is designed to deliver a certain volume of a medication and
to a specific type of tissue.
◊ Determine the appropriate size of syringe, length and gauge of
needle, volume of solution, medication route and body size of the
patient.
Five milliliter syringe
Example
Insulin syringe

Anatomy of syringe and needle

Needle size
Needle size and color

Intravenous canula size

Inhalation administration #1
◊ Medications administered through aerosol spray, mist or powder
that penetrates the respiratory system.
◊ Means of drug delivery:
1. Pressurized metered-dose inhalers (PMDIs).
◊ Apply pressure to the top of the canister
2. Breath-actuated metered-dose inhalers (BAIs).
◊ Release medication when a patient raises a lever and inhale.
3. Dry powder inhalers (DPIs).
◊ Create aerosol when patient inhales via a reservoir.
◊ Advantages: introduces drug throughout respiratory tract, rapid
localized relief and drug can be administered to unconscious client.
◊ Disadvantages: drug for localized effect can have systemic effect and
of use only for the respiratory system.
Inhalation administration #2
Metered dose
inhaler without
spacer
MDI using
spacer device
Dry powder inhaler

Intravenous fluid therapy #1
◊ Supplemental fluids used in IV therapy to restore or maintain normal
fluid volume and electrolyte balance, to avoid dehydration and
prevent inadequate tissue perfusion during a period when the patient
is unable to achieve or when oral (enteral) route is not possible.
◊ IV fluid therapy is an efficient and effective way of supplying fluids
directly into intravascular fluid compartment, in replacing electrolyte
losses and in administering medications and blood products.
◊ Types of IV fluids: based on their diffusion ability from capillary walls:
1. Crystalloid: diffuse freely from intravascular to interstitial fluid
compartment.
2. Colloid: do not pass freely from plasma to interstitial fluid.
• IV fluids have a range of physiologic effects and should be considered

to be drugs with indications, dose ranges, cautions and side effects.

1. Crystalloid fluid: solutions with small molecules that can diffuse
freely from intravascular to interstitial fluid compartments.
◊ Distribution across compartment is 3 to 1 ratio (interstitial:
intravascular) under normal physiologic condition.
◊ Choice for clinical application is based on tonicity, which is a
measure of osmotic or water gradient between intracellular and
extracellular compartment.
◊ Based on tonicity in relation to plasma, crystalloid solutions can be:
Isotonic solution Hypertonic solution Hypotonic solution

1. Isotonic solution: have the same osmolality as blood plasma.
◊ Do not exert an osmotic effect and function to expand
intravascular volume without disturbing ion concentration or
causing fluid shift, e.g., Normal saline (0.9% NaCl), RL & dextrose.
A. Normal saline: the commonest administered fluid
◊ Also called 0.9% saline, physiological saline, isotonic saline.
◊ Composed of water, Na+ and Cl- with a PH of 5.7.
◊ Provide major extracellular electrolytes.
◊ Corrects both water and electrolyte deficit.
◊ Increase the intravascular volume.
• Normal saline is commonly used as a vehicle for compatible drugs in

parenteral administration.

◊ Indication of normal saline:
◊ To maintain effective blood volume and blood pressure
◊ Water and salt depletion: diarrhea , vomiting, diuresis.
◊ Hypovolemic shock (distributed in extracellular space & expanding
the intravascular volume), DKA management, hyperkalemia, …etc.
◊ Brain injury, hypochloraemic metabolic alkalosis, hyponatraemia, ..
◊ Effect of normal saline: affects the acid base balance (metabolic acidosis
i.e., hyperchloremic acidosis because of high chloride concentration in
0.9% saline relative to plasma (154 vs 103 mEq/L).
◊ Interstitial edema via increased interstitial fluid tonicity due to high
sodium load, sodium retention by suppressing the RAS axis and
decreases in renal perfusion as a result of chloride-mediated renal
vasoconstriction
◊ Contraindication for normal saline:
◊ Hypernatremia, hyperchloremia, hypertension, pre – eclampsia, in
patient with edema due to CHF, renal failure and cirrhosis,
hyperchloremic metabolic acidosis, dehydration with severe
hypokalemia (infusion of NS without additional K+ supplementation
can aggravate electrolyte imbalance).
B. Ringer lactate:
◊ Ion concentration: Na+, Cl-, K+, Ca2+, HCO3-
◊ Has the same tonicity as blood.
◊ Indication: fluid of choice for (burn , surgery, dehydration),
electrolyte replacement (sodium depletion), to treat metabolic
acidosis and DKA.
◊ Usual rate of administration is 20 - 30 mL/kg.

Contraindication to RL:
◊ Severe liver disease, severe hypoxia and shock.
◊ Impaired lactate metabolism end up with lactic acidosis.
◊ Simultaneous infusion of RL and blood →
◊ Inactivation of anticoagulant by binding with calcium in RL, clots
◊ Certain drugs: amphotericin, ampicillin, doxycycline should not be
mixed with RL.
◊ Calcium binds with these drugs and reduces bioavailability and
efficiency.
◊ Acute cerebral edema (requiring osmotic therapy) , should avoid all
hypotonic or isotonic fluid.

C. Dextrose:
◊ Has subtypes (D5W, 50%, 10 % and DNS).
◊ Effect of dextrose in fluid: protein sparing effect (suppress

gluconeogenesis), volume effect, enhance lactate production and
effect of hyperglycemia
◊ Avoid in clients at risk for increased intracranial pressure.
◊ Because it causes cerebral edema.
◊ Should not administer with blood because it causes hemolysis.

Read about Hartmann's solution: what is this? What are the indications?
What are the contraindications? What are the complications?

Nursing considerations for isotonic solutions:
◊ Take baseline data:

◊ Assess patient’s vital signs, edema status, lung and heart sounds.
◊ Continue monitoring during and after the infusion.
◊ Observe for signs of fluid overload or hypervolemia:

◊ Hypertension, bounding pulse, dyspnea, peripheral edema,
jugular venous distention, … etc.
◊ Monitor for continued hypovolemia:

◊ Decreased urine output, poor skin turgor, hypotension, …

2. Hypertonic solutions:
◊ Have higher osmolality than plasma and resulting in a movement
of water out of the cell, e.g., 3% and 5% sodium chloride.
◊ Indicated for emergent replacement of serum solutes
(hyponatremia with neurologic symptoms, rapid correction may
cause central pontine myelinolysis)
◊ Infuse at very low rate to avoid overload or pulmonary edema
◊ May need diuretic therapy to assist in fluid excretion
◊ Nursing considerations for hypertonic solutions:
◊ Take baseline data, continue monitoring during and after infusion
◊ Watch for signs of hypervolemia
◊ Assess health history (dehydration, kidney and heart diseases)
◊ Do not administer peripherally, …etc.

3. Hypotonic solutions:
◊ Have lower osmolality than plasma and resulting in movement of
water into the cell.
◊ Usually used to provide free water for excretion of body wastes,
treat cellular dehydration and replace the cellular fluid, e.g., 0.45%
sodium chloride, used for replacing water in patients who have
hypovolemia with hypernatremia.
Nursing considerations for hypotonic solutions:
◊ Take baseline data, continue monitoring during and after infusion.
◊ Do not administer in contraindicated condition (liver disease, burn)
◊ Monitor for manifestations of fluid volume deficit.
◊ Warning on excessive infusion.
◊ Do not administer along with blood products.

Colloid fluids:
◊ Solution with large solute molecules that do not pass freely from
plasma to interstitial fluid, e.g., albumin, blood, …
◊ The retained molecules in a colloid fluid create an osmotic force

called the colloid osmotic pressure or oncotic pressure that holds
water in the intravascular compartment
◊ Useful for expanding intravascular volume and raise blood pressure.
◊ Indicated for patients in malnourished states and patients who

cannot tolerate large infusions of fluid.

A. Human albumin: a solution derived from plasma
◊ Used to increase the circulating volume and restore protein levels
in conditions such as burns, pancreatitis, … etc.
◊ Considered blood transfusion products and uses the same
protocols and nursing precautions when administering
◊ Contraindicated: severe anemia and heart failure.
◊ Angiotensin-converting enzyme inhibitors should be withheld for
at least 24 hours before administering albumin.
◊ Nursing considerations for colloid solutions:
◊ Assess allergy history, use a large-bore needle (18-gauge),
document baseline data and continue monitoring during and after
the infusion, monitor coagulation indexes, …etc.

Fluid requirement calculation: maintenance fluid (for sensible losses)
For hourly (one hour) For daily (24 hours)
4/2/1 principle or rule: 100/50/20 rule:
• 4 mL for the first 10 kg + 2 mL • 100 mL for the first 10 kg +
for the second 10 kg + 1 mL for • 50 mL for the second 10 kg +
the remaining kg. • 20 mL for the remain kg
E.g. for a 50 kg patient: E.g. for a 50 kg patient:
• The 1st 10kg x 4 = 40 mL/hr • 100 ml x 10 kg = 1000 mL
• The 2nd 10kg x 2 = 20 mL/hr • 50 mL x 10 kg = 500 mL
• The remain 30 kg x 1 = 30 mL/hr • 20 mL x 30 kg = 600 mL
=> total 90 mL per hour. => 2,100 mL for 24 hours.
Consideration while the patient is on maintenance fluid:
◊ Insensible loss:
◊ 300 to 500 mL per 24 hours.
◊ Fever:
◊ For each degree of fever above 37, 2 to 2.5 mL/kg/day.
• Ongoing loss (bleeding, drainages, any GI loss):

• For 1 mL blood loss 3 mL crystalloid.
• For other losses 1 : 1
• 3rd space loss (fluid extravasation on the wound side):
• Depends on the size of the wound or surgical site and
• The usual ranges is 4 to 8 mL/kg/24 hours.
◊ Flow rate (drop per minute): the speed at which IV solution is
delivered.
Flow rate = total volume * drop factors
Time in minutes
 Drop factor for crystalloid fluids is 17 – 20 (usually 20).
 Drop factor for colloid is 15.
◊ Time: how long will the required volume last.
Infusion time = total volume to infuse
Rate (millimeters per hour being infused)
◊ Volume: how many mL of IV solution would be required to run an IV
for a given time at a specific flow rate?
Volume = Rate * Time

Examples:
1. Your clients maintenance fluid prescription reads 1000 mL of normal
saline to infuse over 12 hours. The drop factor is 20. You prepares to
set the flow rate at how many drops per minute?
= Total volume * drop factor = 1000 mL * 20 = 28 gtt
Time in minutes 720 minutes
2. You prescribe 1000 mL D5W to infuse at a rate of 110 mL/hour. You
determine that it will take how many hours for 1 L to infuse?
Infusion time = Total volume to infuse
Millimeters per hour being infused
= 1000 mL = 9 hours
110 mL/hour

3. A physician prescribes 3000 mL of D5W to be administered over a 24
- hour period. You determines that how many milliliters per hour will
be administered to the client?
Milliliters per hour = Total volume in milliliters
Number of hours
= 3000 mL
24 hour
= 125 mL/hour

Complications of intravenous therapy:
1. Embolism or thrombus: obstruction caused by a bolus of air.
2. Infiltration: seepage of IV fluid out of the vein and into the

surrounding interstitial spaces.
3. Phlebitis: inflammation of vein that can occur from mechanical or

chemical (medication) trauma or from a local infection.
4. Sepsis, …etc.
 Read more about IV therapy complications.

Standards to decrease IV therapy related infection:
◊ Hand hygiene before and after the procedure.
◊ Clean skin site vigorously before venipuncture.
◊ Inspect and palpate catheter insertion site.
◊ Change gauze dressings that cover a catheter site every 48 hours.
◊ Change IV tubes every 96 hours.

Blood transfusion
Objectives
◊ Define blood transfusion.
◊ Describe the components of blood transfusion.
◊ Recall the advantages of blood component transfusion.
◊ Explain transfusion reaction.
◊ Recall nursing intervention for transfusion reaction.

Blood transfusion #1
◊ In this world still no alternative of human blood.
◊ Volume of blood in human body is 7% to 8% of body weight.
◊ Components in a unit of whole blood:
◊ 55% plasma.
◊ 45% formed elements (RBC, WBC and platelet).
◊ In human body there is 60 - 80 mL of blood/kg/minute.
◊ From this 16 mL is reserved.
◊ Healthy person donates 8 mL/kg of blood.
◊ Person weigh 45 kg to 55 kg can donate only 350 mL of blood.
◊ Person weigh above 55 kg can donate 450 mL.

◊ The intravenous administration of whole blood or its components for
therapeutic purposes is called blood transfusion.
◊ Transfusions restore intravascular volume with whole blood or
albumin, restore oxygen carrying capacity of blood with red blood
cells (RBCs) and provide clotting factors and/or platelets.
◊ Despite precautions, transfusion carries risks.
◊ Compatibility (pretransfusion test) of recipient & donor is essential.
◊ Compatibility test:
◊ ABO system (name by the presence of antigen on RBC).
◊ Rh system (name based on presence or absence of Rh factor).
◊ There is natural antibodies on plasma.
◊ There is no naturally occurring antibodies to Rh antigen.

ABO blood group system
Blood group Antigen Antibody
A A Anti B
B B Anti A
AB AB None
O None Anti A and anti B
Rh blood group system Blood group Antigen

Rh negative Lack of D antigen
Rh positive Presence of D antigen
Rh null Absence of any Rh antigens

Donate to Blood group Receive from
A+, AB+ A+ A+, A-, O+, O-
A+, AB+, A-, AB- A- A-, O-
AB+ AB+ Everyone
AB+, AB- AB- A-, B-, AB-, O-
B+, AB+ B+ B+, B-, O+, O-
B+, AB+, B-, AB- B- B-, O-
O+, A+, B, AB+ O+ O+, O-
Everyone O- O-
• Universal donor is O- because they can give to the whole world.

1. Whole blood transfusion: indicated for active blood loss (postpartum
hemorrhage), accidental trauma for massive transfusion, newborn
baby exchange transfusion done for hyperbilirubinemia, …etc.
◊ Each unit increase the hematocrit level 3% or hemoglobin 1 g/dL.
◊ The increase may not be apparent until 48 to 72 hours.
◊ Contraindicated for patients with severe chronic anemia.
2. Packed red blood cells: blood product used to replace erythrocytes.
◊ Indicated for anemic cases: thalassemia, hemolytic anemia, iron -
deficiency anemia, … etc.
◊ Usual dose is 10 - 15 mL/kg.
◊ Each unit increases the hemoglobin level by 1 g/dL (Hct by 3%).
◊ The change in laboratory values takes 4 to 6 hours after completion
of the blood transfusion and evaluation of an effective response is
based on resolution of anemia features & an increase in RBC count.
3. Platelets: platelets are essential for the hemostasis.
◊ Indication: thrombocytopenia and platelet dysfunctions.
◊ Evaluation of an effective response is based on improvement in
platelet count and normally are elevated 1 hour after transfusion.
◊ The usual adult dose is 4 - 6 units of platelets or 1 unit/10 kg.
◊ For pediatric age group, 5 - 10 mL/kg.
◊ 1 unit of platelets is 50 – 60 mL.
4. Fresh frozen plasma (FFP): used to provide clotting factors.
◊ Indicated for patients with bleeding due to multiple coagulation
factor deficiencies: liver disease, disseminated intravascular
coagulation (DIC), burn, deficiency of coagulation factors, …etc.
◊ After 1 unit transfusion coagulation factors raised, 2 – 3%.
◊ Volume of 1 unit FFP is 200 - 300 mL.
◊ The appropriate dose is 10 - 15 mL/kg of body weight.
Advantages of blood component transfusion:
◊ Maximizes the use of 1 unit of blood.

◊ Components can reduce the shortage of blood.
◊ Maximum benefit to a patient with minimum risk.
◊ Better proper patient management with appropriate deficient parts.
◊ Cost effective product: from a unit of whole blood can prepare

different types of components.

Nursing consideration:
◊ Use large catheter (18 or 20 gauge).
◊ Because blood is more viscous than crystalloid IV fluids.
◊ Prime the tubing with 0.9% sodium chloride.
◊ To reduce hemolysis (breakdown of RBCs).
◊ Start a transfusion slowly.
◊ To allow for early detection of a transfusion reaction.
◊ Stay with the patient during the first 15 minutes.
◊ The time when a reaction is most likely to occur.

◊ Adverse reaction occurs as a result of receiving blood transfusion:
1. Hemolytic reaction: occurs when incompatible RBCs agglutinate
and causing potentially life - threatening immune response. E.g., if
a patient who is type A accidentally receives type B blood,
antibodies in the patient’s blood attack the type B antigens.
2. Circulatory overload: occurs when the patient receives massive
transfusions for hemorrhagic shock or when a patient with normal
intravascular volume receives blood.
3. Acquire transmitted disease: diseases transmitted by blood from
asymptomatic infected donors. E.g., malaria, HBV and HCV, HIV
infection and AIDS, cytomegalovirus infection, … etc.
4. Allergic i.e., anaphylaxis.

A. Acute transfusion reaction:
◊ Allergic reaction. Clinical features of transfusion reaction:
◊ Febrile nonhemolytic reaction. • Chills, dark or red urine and fever.
◊ Hemolytic transfusion reaction. • Fainting or dizziness.
◊ Septic transfusion reaction. • Skin flushing or diaphoresis.
◊ Acute lung injury.
• Shortness of breath or dyspnea.
◊ Circulatory overload.
• Back or flank pain.
B. Delayed transfusion reaction:
◊ Thrombocytopenia. • Hives and itching/pruritis/urticaria.
◊ Delayed hemolytic transfusion reaction.
◊ Post transfusion purpura.
◊ Bone marrow failure.

Nursing interventions for transfusion reaction:
◊ Stop the transfusion immediately.
◊ Maintain IV line using 0.9% normal saline.
◊ Remain with patient:
◊ Observe signs and symptoms
◊ Monitor vital signs every 5 minutes.
◊ Immediately notify the concerned body.
◊ If necessary administer emergency drugs:
◊ Antihistamines, vasopressors, … etc.
◊ Document the reaction, treatment and outcome.

Blood donor selection criteria:
◊ Donations interval should not be < 3 months.
◊ For platelet apheresis donation, interval is 7 days.
◊ The donor shall be in good health.
◊ Vital sign in acceptable limit and free from diseases.
◊ Should be in the age group of 18 - 65 years.
◊ Should not be < 45 kg to donate 350 mL of blood.
◊ Hemoglobin should not be less than 12.5 gm/dL.

Care after blood donation:
◊ Take a rest for minimum of 20 minutes.
◊ Take some snacks and juice.
◊ Contains high sugar and helps in backup blood sugar.
◊ Have a meal that contains high protein.
◊ Such as chicken, fish, egg, … etc.
◊ Don’t take any kind of alcohol

◊ For 8 - 10 hours after donating the blood.

Health benefits of donating blood:
◊ Reduce the accumulated and unwanted iron load from the body.
◊ Reduce the one - third of chance of heart diseases.
◊ Reduces the viscosity of blood.
◊ Stimulate the production of new blood cells and refreshe the
system.
◊ Formation of new RBC within 48 hours.
◊ After donating blood, the count of blood cells decrease, which
stimulates bone marrow to produce new red blood cells in
order to replenish the loss.
◊ One unit of blood (450 mL) when donated burns 650 calories in
donor’s body so it helps in utilizing the calories.
◊ Tested for syphilis, HIV, hepatitis and other diseases, …etc.

Defer the donor temporarily
Conditions Period of deferment
Abortion 6 months
History of blood transfusion 6 months
Major surgery 12 months
Minor surgery 6 months
Typhoid 12 month after recovery
Malaria 3 month
Immunization (e.g., tetanus) 15 days
Rabies vaccination 1 year after vaccination
Tuberculosis 5 years after complete treatment

Defer the donor permanently:
◊ Abnormal bleeding tendencies
◊ Hepatitis B and C infections
◊ Chronic nephritis
◊ Heart disease
◊ Epilepsy, schizophrenia
◊ Cerebrovascular diseases
◊ Diabetes, asthma
◊ Leprosy,
◊ Kala-azar
◊ Cancer, … etc.

Types of donation and transfusion
1. Autologous and autotransfusion:
◊ Collection and reinfusion of a patient’s own blood.
◊ Donation is before a scheduled procedure.
◊ Duration depends on the type of the procedure and patient status,
e.g. up to 6 weeks before surgery.
◊ Reduces the risk of disease transmission and reactions.
◊ Not applicable for leukemia and bacteremia patient.
2. Allogeneic donation and transfusion:
◊ Collection and infusion of donor’s blood to a patient.
◊ Pre - collection and transfusion test is required.

Monitoring and managing client response
Objectives
◊ Define adverse drug reaction.
◊ Recall the possible risk factors for ADRs.
◊ Identify the type of ADRs.
◊ Evaluate and manage patients with ADRs.
◊ Describe about medication errors.
◊ Discuss about drug storage.

Adverse drug reaction #1
◊ Adverse drug reactions are cause of significant morbidity and
mortality in patients in all areas of health care today.
◊ There is wide variation in the current health care literature, but it has
been estimated that more than ½ of ADRs are preventable.
◊ WHO define ADRs “drug-related event that is noxious and
unintended and occurs at doses normally used in humans for
prophylaxis, diagnosis or therapy of disease or for the modification
of physiological function”.
◊ The united states FDA’s definition of adverse drug event is any
adverse event associated with the use of drug in human, including
the following: adverse event occurring from drug overdose, from
drug abuse, from drug withdrawal and any significant failure of
expected pharmacological action.

Factors predisposing to ADRs:
◊ Age
◊ Renal impairment
◊ Hepatic impairment
◊ Frailty
◊ Polypharmacy
◊ Previous history of ADRs
◊ Genetics
◊ Sex, … etc.

Adverse drug reaction can be divided into:
A. Dose - related (type A): predictable.
◊ Caused by excess of desired pharmacological effect.
◊ Due to incorrect dosage or altered pharmacokinetics.
◊ More common with drugs that have a low therapeutic index.
Example:
◊ Respiratory depression with opioid analgesia.
◊ Cough with ACE inhibitors, …etc.
◊ Ways to minimize type - A reactions:
1. Understanding the pharmacology of the prescribed drug.
2. Monitoring drugs with a narrow therapeutic window.
3. Avoiding polypharmacy when possible.

B. Non – dose related (type B):
◊ Idiosyncratic and allergic reactions, unpredictable and rare.
◊ Have a considerable mortality.
◊ Hypersensitivity reactions, which are of four types:
1. Type I: immediate hypersensitivity reactions
2. Type II: cytotoxic hypersensitivity reactions
3. Type III: immune - complex reactions
4. Type IV: delayed hypersensitivity reactions
◊ Hypersensitivity reactions = immunological reaction (exaggerated
immune and inflammatory responses that result in adverse outcome)
◊ Inherited diseases predispose to drug toxicity (e.g., G6PD).

Type I: immediate hypersensitivity reaction (e.g., anaphylaxis, allergic).
◊ Drug and metabolites sensitize by antigen presenting cells.
◊ Sensitized drugs present to T – cells.
◊ T-cells signal and stimulate B-cells to produce IgE antibodies.
◊ Which bind on mast cells and basophils as well as eosinophils.
◊ Results in degranulation of the cells and the release of chemical
mediators (histamine, prostaglandins, kinins, …).
◊ Causes smooth muscle contraction of airway and GI tract,
vasodilatation and increase capillary permeability, enhance mucus
production, pruritis and gastric acid secretion.
◊ Examples of medication that induce reactions: antibiotics.

◊ Evaluation:
◊ Full history and physical examination
◊ Presentation, onset, previous history, medical record review, …
◊ Onset of type – I hypersensitivity reaction:
◊ For parenteral drugs, 5 – 30 minutes.
◊ For oral drugs 2 hours.
◊ Clinical features of type - I hypersensitivity reaction:
◊ Rash, erythema, pruritis, edema, flushing, bronchospasm,
wheezing, rhinitis and GI symptoms (e.g., abdominal cramp).
◊ Also anaphylaxis shock features: hypotension, tachycardia,
tachypnea, loss of consciousness, … etc.
◊ Workup: serum immunologic and chemical mediator analysis,
eosinophil and basophil count, … etc.
Management of type – I hypersensitivity reaction:
◊ Rapid recognition and treatment is essential.
◊ Monitor vital signs and secure the airway
◊ Lay flat (supine) or semi – recumbent position to reduce
hypotension.
◊ Withdraw the offending agent (e.g., stop drug infusion)
◊ Basic life support should be started if necessary.
◊ Essential drugs:
1. Adrenaline (epinephrine)
2. Antihistamine (chlorphenamine, diphenhydramine)
3. Steroid (hydrocortisone, methylprednisolone)

Type – II reaction:
◊ Drug interacts with IgG and IgM.
◊ Activation of complement and lysis occurs.
E.g: thrombocytopenia, neutropenia and hemolytic anemia
◊ Common drugs: penicillin, thiazides and cephalosporins.
◊ Evaluation: clinical presentation and investigation to r/o DDx.
◊ Management:
1. Disease specific defined protocol
2. Systemic glucocorticoids:
◊ To suppress antibody response and prevent tissue damage.

Type – III reaction: drug interact with IgG and forms immune complex.
◊ The process takes place in three steps:
1. Immune complex formation: exogenous antigen (foreign proteins
such as pharmaceutical products) triggers an antibody formation.
◊ Antigens bind to antibodies, forming circulating immune complexes,
which can later migrate out of plasma and deposit in host tissues.
2. Complex deposition: pathogenicity depend on antigen-antibody
ratio:
◊ When antibody is excess, complexes are insoluble, do not circulate
and are phagocytosed by macrophages in lymph nodes and spleen.
◊ When antigen is excess, the aggregates are smaller and they freely
filter out of circulation in organs where the blood is transformed
into other fluids such as urine & synovial fluid (deposit in glomeruli,
synovial joint, …).

3. Inflammatory reaction:
◊ After deposition of the immune complexes, the final step is
activation of the complement (C3 and C5), which then recruit
macrophages and neutrophils and causes inflammatory damage
to tissues.
◊ Depending on the site, symptoms of vasculitis (blood vessels),
arthritis (joints) or glomerulonephritis (glomeruli) develop.
◊ Cause:
◊ Drugs contain heterologous protein:
E.g., antivenin, vaccine, antitoxin,
◊ Other medication: cephalosporins, penicillins, ciprofloxacin,
griseofulvin, metronidazole, streptomycin, sulfonamides,
tetracycline, barbiturates, captopril, carbamazepine, … etc.

◊ Clinical features:
◊ Depend on the type of antigen and route of exposure.
◊ IV entry can lead to vasculitis, arthritis glomerulonephritis.
◊ Local injection of antigen can cause necrotizing skin lesion.
◊ Evaluation:
◊ Immunologic assay (IgG), CBC, blood complement levels,
◊ Inflammatory markers (ESR and CRP), urinalysis
◊ Imaging (x – ray)
◊ Management: based on clinical presentation
◊ Removal of the offending agent is the mainstay of treatment.
◊ Antihistamines and nonsteroidal anti-inflammatory drugs.
◊ Corticosteroids (to suppress the inflammation if severe).

Type – IV reaction (cell mediated):
◊ Mediated by T cells that provoke inflammatory reaction against drugs.
◊ After exposure, initial local immune and inflammatory response occurs
that attracts leukocytes (WBCs).
◊ The antigen engulfed by macrophages and monocytes is presented to T
cells, becomes sensitized and activated & these cells release cytokines
and chemokines, which cause tissue damage and result in illnesses.
◊ Drugs: antibiotics (sulfa drugs, TTC), NSAIDs, anticonvulsants
◊ Evaluation:
◊ Non-specific features (weakness, weight loss, fever) and rash.
◊ Multiorgan involvement (heart, lungs, liver, and kidneys).
◊ Management: depends on the clinical condition that resulted from.

Grades of adverse drug reactions
◊ Adverse drug reactions are graded according to intensity:

◊ Grade 1 = mild.
◊ Grade 2 = moderate. • Intensity is a measure of the extent

to which an adverse reaction
◊ Grade 3 = severe.
develops in an individual.
◊ Grade 4 = disabling.
◊ Grade 5 = death.

Pharmacovigilance:
◊ The science or activities relating to the assessment, detection,

understanding and prevention of adverse effects or reactions or
other drug-related problems is called pharmacovigilance.
◊ The scope of pharmacovigilance:

◊ Drugs including vaccines
◊ Biologics including blood and other cellular products
◊ Traditional including herbal medicines
◊ Medical devices

The aims of pharmacovigilance:
◊ Identify the previously unrecognized ADRs
◊ Identify subgroups of patients at particular risk of ADRs
◊ Ensure the balance of its benefits and harms via continuous

surveillance of a product throughout the duration of its use
◊ Detection of inappropriate prescription and administration
◊ Further elucidation of products pharmacological property
◊ Detection of clinically important drug interactions

Reporting adverse drug reactions:
◊ Most ADRs are not reported and this can lead to delays in identifying
important reactions.
◊ The reasons for failure to report ADRs:
◊ Complacency, guilt, ignorance, diffidence, lethargy, … etc.
◊ Adverse drug reactions should be reported to pharmacovigilance
center at EFDA using any of the four mechanisms:
1. Online reporting system: http://www.fmhaca.gov.et/
2. The yellow, prepaid report form available at the facility
3. The medsafety mobile application
◊ Can be downloaded from google play store
4. 8482 (toll free line)

Medication error
◊ Any preventable event that may cause or lead to inappropriate
medication use or harm to patient (death or serious injury).
◊ As a nurse, it’s essential to be vigilant in prevention of medication error.
◊ Common errors: inaccurate prescribing, administration of the wrong
medicine, giving the medication using the wrong route or time
interval, administering extra doses and failing to administer a
medication.
◊ Causes: lack of knowledge (drug dosage, drug interaction, route, …),
lack of information about patient (allergy, laboratory result, medical
condition), faulty communication (the written prescription is unclear,
abbreviations are misunderstood, poor or no documentation, ... etc.)
◊ Prevent and/or avoid error: three checks (before and after preparation
and before actual administration) and apply medication rights.

Storage of medication #1
◊ Methods of medicine storage and arrangement:
1. Pharmacotherapeutic category
2. Alphabetical order by generic name
3. Dosage forms
◊ Points should be considered:
◊ Demarcate with sufficient empty space.
◊ Put in well ventilated ,dry and protect from sun light and heat.
◊ Arrange in first expiry first out (FEFO) or first in first out (FIFO).
◊ Always store cold-chain items in the refrigerator.
◊ Keep high security products such as narcotic drugs and
psychotropic substances in appropriate secured places.
◊ Store with clear labeling instructions.

Storage of medication #2
◊ Storage conditions can be arranged in two classes:
1. Normal storage conditions:
◊ Dry, clean, well – ventilated and at room temperature.
• Room temperature: 15 to 25 °C.
2. Special storage conditions:
◊ Cold storage conditions (e.g., vaccine and insulin).
• From +2 °C to +8°C.
◊ Combustible or flammable (e.g., alcohol).
◊ Secured (e.g., narcotic, psychoactive drugs).

Thank you !!!
 Any experience is good experience !
Berhanu Wale (BSc and MSc)
Contact me via
6/11/2024

Medication Administeration Part III

Uploaded by

Copyright:

Available Formats

You might also like

Medication Administeration Part III

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Medication Administeration Part III

Uploaded by

Copyright:

Available Formats

Minimize potential risk during medication

By the end of this unit, the students will be able to:

◊ Recall safe medication parameters

◊ State the ten rights of medication

◊ Identify the effect of medication

◊ Discuss about medication interaction

◊ Apply medication administration precautions

◊ Apply infection prevention techniques during medication

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 1

◊ Medication mistakes are the most common healthcare error.

◊ To help prevent errors and minimize potential risks, consider the

2. Identify medication interaction and substance incompatibilities.

3. Apply medication administration precautions.

4. Apply infection prevention techniques during medication.

5. Monitor the response or effect of medication.

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 2

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 3

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 4

◊ Make sure the drugs and its doses are appropriate.

◊ Assess the patient before medication.

◊ Verify drug functionality (expiry date and other factors).

◊ Ensure one needle, one syringe and one patient.

◊ Do not change the needle in order to reuse the syringe.

◊ Do not combine leftover medications for later use.

◊ Follow infection prevention and control protocols.

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 9

Best practices in injection safety:

By the end of this session, the students will be able to:

◊ Describe the methods for calculating drug dosages.

◊ Identify common medication schedules and abbreviations.

◊ Explain the major steps in medication prescribing cycle.

◊ Recall the components of medication order.

◊ Recall the principle of medication order.

◊ Identify the types of medication order.

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 13

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 14

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 15

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 16

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 19

Molecular weight NaCl mmol in a liter:

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 21

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 22

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 24

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 25

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 26

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 28

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 29

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 32

1. Defining patient’s problem (making a correct diagnosis).

2. Specify therapeutic objective (what wants to achieve).

3. Choose treatment (efficacy, safety and affordable).

5. Give information and instruction.

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 33

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 36

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 37

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 38

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 39

6/11/2024 Berhanu Wale (BSc and MSc) Contact me via 40