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administration of parenteral medications
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Chapter 022
- 1. Chapter 22 ADMINISTRATION OF PARENTERAL MEDICATIONS Copyright©2018,ElsevierInc.Allrightsreserved.
- 2. Parenteral Medication Administration • Medications administered by the parenteral route enter body tissues and the circulatory system by injection • What are the four routes of parenteral medication administration? • Failure to inject a medication correctly results in complications Copyright©2018,ElsevierInc.Allrightsreserved. 2
- 3. Principles for Practice Communicate with interprofessional team and assess patient’s priorities of care and preferences Use technology available when preparing and giving medications Educate about each medication Minimize a patient’s discomfort when giving injections Copyright©2018,ElsevierInc.Allrightsreserved. 3
- 4. Patient-Centered Care • Research shows that ethnicity, genetics, and culture influence drug response, pharmacokinetics, pharmacodynamics, and patient adherence and education • Knowledge about variations in therapeutic dose and adverse effects as well as cultural considerations is essential in administering medications to different ethnic groups Copyright©2018,ElsevierInc.Allrightsreserved. 4
- 5. Evidence-Based Practice • Select needle size based on patient gender, weight and body mass index, condition, site, drug, and volume • Make the ventrogluteal site the first choice wherever possible for deep intramuscular injections as there are reduced risks of nerve or muscle injury • Assess the skin and the patient’s condition • Inject at 90°, dart-like, to the hub of the needle and inject at 1 mL per second • Wait at least 10 seconds before withdrawing the needle Copyright©2018,ElsevierInc.Allrightsreserved. 5
- 6. Safety Guidelines 1. Be vigilant; avoid distractions while preparing an injection. 2. Verify that the medications have not expired. 3. Use at least two identifiers before administering medications and check against the medication administration record (MAR). Copyright©2018,ElsevierInc.Allrightsreserved. 6
- 7. Safety Guidelines (Cont.) 4. Clarify unclear medication orders and ask for help whenever you are uncertain about an order or calculation. 5. Follow all policies related to use of the technology and do not use “workarounds.” 6. Use strict aseptic technique during medication preparation and administration. Copyright©2018,ElsevierInc.Allrightsreserved. 7
- 8. Safety Guidelines (Cont.) 7. Most of the time, you cannot delegate medication administration. 8. No-interruption zones (NIZs) have been recommended by the Institute for Safe Medicine Practices. 9. Insert the needle at the proper angle, smoothly, and quickly 10. Inject the medication slowly but smoothly. Copyright©2018,ElsevierInc.Allrightsreserved. 8
- 9. Safety Guidelines (Cont.) 11. Hold the syringe steady once the needle is in the tissue to prevent tissue damage. 12. Withdraw the needle smoothly at the same angle used for insertion. 13. Gently apply an antiseptic pad (e.g., alcohol) or dry, sterile gauze pad to the site 14. Apply gentle pressure at the injection site. 15. Rotate injection sites to prevent the formation of indurations and abscesses Copyright©2018,ElsevierInc.Allrightsreserved. 9
- 10. Needlestick Prevention The implementation of safe needle devices can prevent needlestick injuries Sharps with engineered sharps injury protection (SESIP) 10 Copyright©2018,ElsevierInc.Allrightsreserved.
- 11. Needlestick Prevention (Cont.) Sharps disposal containers May be used one-handed Colored red or labeled with biohazard symbol 11 Copyright©2018,ElsevierInc.Allrightsreserved.
- 12. Equipment Syringes Single-use Disposable Luer-Lok Non–Luer-Lok Many sizes 12 Copyright©2018,ElsevierInc.Allrightsreserved.
- 13. Equipment (Cont.) Needles Attached or packaged separately Disposable Three parts Vary in length and gauge 13 Copyright©2018,ElsevierInc.Allrightsreserved.
- 14. Equipment (Cont.) Disposable injection units Single-dose Prefilled Disposable 14 Copyright©2018,ElsevierInc.Allrightsreserved.
- 15. Preparing Injections: Ampules and Vials Skill 22-1 Ampules Glass top must be snapped off Require a filter Vials Rubber seal Single-dose or multi- dose 15 Copyright©2018,ElsevierInc.Allrightsreserved.
- 16. Delegation and Collaboration The task of preparing injections from ampules and vials cannot be delegated to nursing assistive personnel (NAP) Copyright©2018,ElsevierInc.Allrightsreserved. 16
- 17. Mixing Parenteral Medications in One Syringe Procedural Guideline 22-1 Some medications need to be mixed from two vials or from a vial and an ampule Mixing compatible medications avoids the need to give a patient more than one injection Consult a compatibility chart or a pharmacist for compatible medications Copyright©2018,ElsevierInc.Allrightsreserved. 17
- 18. Quick Quiz! How will the nurse mix medication that has been diluted in a vial? A.Shake the vial vigorously. B.Turn the vial upside down. C.Roll the vial in the palms. D.Stir the contents with the needle. Copyright©2018,ElsevierInc.Allrightsreserved. 18
- 19. Delegation and Collaboration The task of mixing medications in one syringe cannot be delegated to NAP The nurse directs the NAP about: Potential side effects of medications and the need to report their occurrence to the nurse Copyright©2018,ElsevierInc.Allrightsreserved. 19
- 20. Administering Intradermal Injections Skill 22-2 Typically given for skin testing Use a tuberculin (TB) or small syringe with a short, ⅜- to ⅝-inch, fine-gauge (25 to 27) needle Insertion angle is 5 to 15 degrees Inject only small amounts of medication (0.01 to 0.1 mL) intradermally Copyright©2018,ElsevierInc.Allrightsreserved. 20
- 21. Quick Quiz! The nurse performing an intradermal (ID) injection feels resistance when inserting the medication. What should the nurse do next? A.Remove the needle. B.Dilute the medication. C.Advance the needle. D.Inject the medication. Copyright©2018,ElsevierInc.Allrightsreserved. 21
- 22. Delegation and Collaboration The task of administering ID injections cannot be delegated to NAP The nurse directs NAP about: Potential medication side effects and the need to report their occurrence to the nurse Reporting to the nurse any change in the patient’s condition Copyright©2018,ElsevierInc.Allrightsreserved. 22
- 23. Recording and Reporting • Record drug, dose, route, site, time, and date on MAR immediately after administration, not before • Record in your notes area of ID injection and appearance of skin Copyright©2018,ElsevierInc.Allrightsreserved. 23
- 24. Recording and Reporting (Cont.) • Report to patient’s health care provider any undesirable effects from medication and document adverse effects according to institutional policy • Record patient teaching, validation of understanding, and patient’s response to medication Copyright©2018,ElsevierInc.Allrightsreserved. 24
- 25. Special Considerations Teaching Do not squeeze medication from site Negative skin tests may not rule out allergies Wear identification band listing all allergies Do not wash off markings around site Observe for skin reactions Copyright©2018,ElsevierInc.Allrightsreserved. 25
- 26. Special Considerations (Cont.) Pediatric Test immediately if exposed to people with confirmed or suspected TB If ongoing exposure suspected, test for TB every 2 to 3 years Gerontological Hold skin taut to ensure that ID injection is administered correctly Copyright©2018,ElsevierInc.Allrightsreserved. 26
- 27. Administering Subcutaneous Injections Skill 22-3 Inject in small doses Base needle length and angle on patient weight and estimate of subcutaneous tissue What sites are used for subcutaneous injections? 27 Copyright©2018,ElsevierInc.Allrightsreserved.
- 28. Administering Subcutaneous Injections Skill 22-3 (Cont.) Injection pen Needleless injection system Subcutaneous injection device 28 Copyright©2018,ElsevierInc.Allrightsreserved.
- 29. Special Considerations for Administration of Insulin Patients choose one anatomic area and rotate sites within that region Absorption rates of insulin vary on the basis of the injection site Timing of injections is critical for correct insulin administration Copyright©2018,ElsevierInc.Allrightsreserved. 29
- 30. Special Considerations for Administration of Heparin Patients are at risk for bleeding Assess for contraindications and medication interactions Administer subcutaneously or intravenously Low-molecular-weight heparins Copyright©2018,ElsevierInc.Allrightsreserved. 30
- 31. Delegation and Collaboration The task of administering subcutaneous injections cannot be delegated to NAP The nurse directs NAP about: Potential medication side effects and the need to report their occurrence to the nurse Copyright©2018,ElsevierInc.Allrightsreserved. 31
- 32. Recording and Reporting • Immediately after administration, record on MAR the medication, dose, route, site, time, and date given. Correctly sign MAR according to institutional policy • Record in nurses’ notes patient teaching, validation of understanding, and patient’s response to medication • Report to patient’s health care provider any undesirable effects from medication and document adverse effects in record Copyright©2018,ElsevierInc.Allrightsreserved. 32
- 33. Special Considerations Teaching Wear identification band Techniques for self-administration Pediatric Administer to small children only amounts up to 0.5 mL subcutaneously Copyright©2018,ElsevierInc.Allrightsreserved. 33
- 34. Special Considerations (Cont.) Gerontological Use upper abdominal site when the patient has little subcutaneous tissue Home care Safe disposal of sharps Reuse of syringes Injection techniques that minimize patient discomfort Copyright©2018,ElsevierInc.Allrightsreserved. 34
- 35. Administering Intramuscular Injections Skill 22-4 Requires a longer and larger-gauge needle Injection sites Ventrogluteal Vastus lateralis Deltoid 35 Copyright©2018,ElsevierInc.Allrightsreserved.
- 36. Injection Sites: Ventrogluteal Safe for adults and children Use landmarks to identify injection site 36 Copyright©2018,ElsevierInc.Allrightsreserved.
- 37. Injection Sites: Vastus Lateralis Used in adults Preferred site for administration of biologics to infants, toddlers, and children 37 Copyright©2018,ElsevierInc.Allrightsreserved.
- 38. Injection Sites: Deltoid Easily accessible Use for small medication volumes (2 mL or less) 38 Copyright©2018,ElsevierInc.Allrightsreserved.
- 39. Delegation and Collaboration The task of administering intramuscular injections cannot be delegated to NAP The nurse directs NAP about: Potential medication side effects and the need to report their occurrence to the nurse Reporting to the nurse any change in the patient’s condition Copyright©2018,ElsevierInc.Allrightsreserved. 39
- 40. Recording and Reporting • Immediately after administration, record on MAR the medication, dose, route, site, time, and date given. Correctly sign MAR according to institutional policy • Record in nurses’ notes patient teaching, validation of understanding, and patient’s response to medication • Report to patient’s health care provider any undesirable effects from medication and document adverse effects in record Copyright©2018,ElsevierInc.Allrightsreserved. 40
- 41. Special Considerations Teaching Self-injection techniques Observation of injection sites Pediatric Assistance holding and distracting children Pain-management techniques Copyright©2018,ElsevierInc.Allrightsreserved. 41
- 42. Special Considerations (Cont.) Gerontological Age-related considerations Home care Administration techniques Pain-management techniques Safe sharps disposal Copyright©2018,ElsevierInc.Allrightsreserved. 42
- 43. Administering Medications by Intravenous (IV) Bolus Skill 22-5 An IV bolus introduces a concentrated dose of a medication directly into a vein by way of an existing IV access Usually requires a small fluid volume Common in emergencies to deliver a fast-acting medication quickly Patients must be monitored closely for adverse reactions Copyright©2018,ElsevierInc.Allrightsreserved. 43
- 44. Administering Medications by IV Bolus Skill 22-5 (Cont.) Four strategies to reduce harm 1.Use commercially available or pharmacy prepared IV push medication whenever possible. 2.Do not dilute IV push medications unless recommended by the manufacturer, agency policy, or reference literature. 3.IV push medications should be administered at the rate recommended by the manufacturer, agency policy, or reference literature. 4.Appropriately label of clinical prepared syringes. Copyright©2018,ElsevierInc.Allrightsreserved. 44
- 45. Delegation and Collaboration The task of administering medications by IV bolus cannot be delegated to NAP The nurse directs NAP about: Potential actions and side effects of the medications and to report occurrence Reporting patient complaints of moisture or discomfort around insertion site Obtaining required vital signs and reporting them to nurse Copyright©2018,ElsevierInc.Allrightsreserved. 45
- 46. Recording and Reporting • Immediately record on the MAR the medication administration, including drug, dose, route, time instilled, and date and time administered. Include initials or signature • Report to patient’s health care provider any adverse reactions. Patient’s response sometimes indicates need for additional medical therapy • Record in nurses’ notes patient’s medication response Copyright©2018,ElsevierInc.Allrightsreserved. 46
- 47. Special Considerations Teaching Explain IV medication purpose and signs of adverse effects Pediatric Infuse IV push medications slowly and in small volumes Follow institutional policies when administering medications via IV bolus Copyright©2018,ElsevierInc.Allrightsreserved. 47
- 48. Special Considerations (Cont.) Gerontological Reduced function of renal and metabolical systems Home care Medication administration technique Safe medication storage Emergency contact information Copyright©2018,ElsevierInc.Allrightsreserved. 48
- 49. Administering Intravenous Medications by Piggyback, Intermittent Infusion Sets, and Mini-Infusion Pumps Skill 22-6 Use small volumes of compatible IV fluids infused over a desired time 49 Copyright©2018,ElsevierInc.Allrightsreserved.
- 50. Administering Intravenous Medications by Piggyback, Intermittent Infusion Sets, and Mini-Infusion Pumps Skill 22-6 (Cont.) Needle safety Safe needle systems Needleless systems Copyright©2018,ElsevierInc.Allrightsreserved. 50
- 51. Delegation and Collaboration The task of administering IV medications by piggyback, intermittent infusion sets, and mini- infusion pumps cannot be delegated to NAP The nurse directs NAP about: Potential medication actions and side effects and the need to report their occurrence to the nurse Reporting any patient complaints of moisture or discomfort around IV insertion site Reporting to the nurse any change in patient’s condition or vital signs Copyright©2018,ElsevierInc.Allrightsreserved. 51
- 52. Recording and Reporting • Immediately record on the MAR or computer printout the medication, dose, route, infusion rate, and date and time administered. Include initials of signature • Record on intake and output (I&O) form volume of fluid in medication bag or Volutrol • Report to patient’s health care provider any adverse reactions Copyright©2018,ElsevierInc.Allrightsreserved. 52
- 53. Special Considerations Teaching Explain medication purpose, administration rate, and adverse effects Pediatric To assess fluid balance, monitor I&O carefully when infusing IV medications Copyright©2018,ElsevierInc.Allrightsreserved. 53
- 54. Special Considerations (Cont.) Gerontological Risk of medication toxicity Risk for fluid volume overload Home care Explain steps of medication administration, signs of complications, and management of complications Copyright©2018,ElsevierInc.Allrightsreserved. 54
- 55. Administering Continuous Subcutaneous Medications Skill 22-7 Fewer risks and less expense than IV administration Easy to operate in the home care setting 55 Copyright©2018,ElsevierInc.Allrightsreserved.
- 56. Administering Continuous Subcutaneous Medications Skill 22-7 (Cont.) Use a small-gauge (25 to 27) winged butterfly IV needle or a special commercially prepared Teflon cannula Use the same anatomic sites for subcutaneous injections and the upper chest Requires a computerized pump with safety features Copyright©2018,ElsevierInc.Allrightsreserved. 56
- 57. Delegation and Collaboration The task of administering continuous subcutaneous infusion (CSQI) medications cannot be delegated to NAP The nurse directs NAP about: Potential medication side effects or reactions; reporting occurrence to nurse Reporting to the nurse complications at the CSQI needle insertion site Obtaining any required vital signs and reporting them to the nurse Copyright©2018,ElsevierInc.Allrightsreserved. 57
- 58. Recording and Reporting • After initiating CSQI, immediately document medication administration details in patient’s medical record. Use initials or signature • For opioids, follow policy to document waste • Record patient response to medication and appearance of site every 4 hours or per policy • Report to patient’s provider any adverse effects from medication or infection at insertion site and document according to agency policy Copyright©2018,ElsevierInc.Allrightsreserved. 58
- 59. Special Considerations Teaching Wear medical alert identification, carry backup batteries and medication, and explain diabetes management and pump care Pediatric Improves glycemic control and offers greater flexibility for adolescents Clean/change sites every 48 to 72 hours Copyright©2018,ElsevierInc.Allrightsreserved. 59
- 60. Special Considerations (Cont.) Gerontological Hypodermoclysis therapy Home care Explain desired effect of medication, side effects, adverse effects, pump operation, medication administration, supply disposal, and site-cleansing procedures Copyright©2018,ElsevierInc.Allrightsreserved. 60
Editor's Notes
- This chapter reviews one procedure and seven skills: preparing injections: ampules and vials; mixing parenteral medications in one syringe; administering intradermal injections; administering subcutaneous injections; administering intramuscular injections; administering medications by intravenous bolus; administering intravenous medications by piggyback, intermittent infusion sets, and mini-infusion pumps; and administering continuous subcutaneous medications.
- The route of medication administration is the path by which a drug comes in contact with the body. Parenteral means administered in a manner other than through the digestive tract (in this case, by injection). Bullet 2 Answer: The four routes are subcutaneous injection, intramuscular (IM) injection, intradermal (ID) injection, and intravenous (IV) injection or infusion. Subcutaneous injection: Injection into tissues just under the dermis of the skin Intramuscular (IM) injection: Injection into the body of a muscle Intradermal (ID) injection: Injection into the dermis just under the epidermis Intravenous (IV) injection or infusion: Injection into a vein Injected medications are more quickly absorbed than oral medications; parenteral routes are used when patients are vomiting, cannot swallow, and/or are restricted from taking oral fluids. Injections are invasive procedures, and you must use aseptic technique. [Ask students: where is a subcutaneous injection made? Discuss: into tissues just under the dermis of the skin.]
- When managing a patient’s medications, communicate clearly with the interprofessional team, assess and incorporate the patient’s priorities of care and preferences, use the best evidence when making decisions about patient care. Educate patients and family caregivers about each medication they take while you are administering medications. Patients often are able to identify inappropriate medications. Make sure that you answer all of their questions before administering medications. Educate family caregivers if appropriate. Minimize a patient’s discomfort when giving an injection: Use sharp, beveled needles in the shortest length and smallest gauge possible. Change the needle if liquid medication coats the shaft of the needle. Position and flex a patient’s limbs to reduce muscular tension. Divert the patient’s attention away from the injection procedure. Apply a vapocoolant spray (e.g., Fluori-Methane spray or ethyl chloride) or topical anesthetic (e.g., EMLA cream) to an injection site before giving a medication when possible, or placing wrapped ice on the site for a minute before injection.
- You need skill in communicating with and educating diverse patient populations. For example, if a patient’s culture values patience and modesty; make your questions specific and take time when assessing their knowledge about adverse drug effects. Cultural assessment also yields information about dietary preferences, tobacco and alcohol use, and use of herbal remedies that affect drug action and response. Cultural context is essential in planning education for patients and families (Burcham and Rosenthal, 2016).
- There is an increasing evidence that addresses practice guidelines for administration of intramuscular injections. Intramuscular injection technique has been modified over the past several years in response to evidence and research about best practices for patient assessment and site selection. In the past site selection was not evidence based, and needle selection was based on nursing preference and ritualistic practice. There is now enough consensual evidence to develop guidelines for administration of intramuscular injections.
- Be sure that your patients receive the appropriate medications. Know why your patient is receiving each medication; know what you need to do before, during, and after medication administration; and evaluate after administration the effectiveness of medications and any adverse effects. [Discuss locations of expiration dates for various medication packaging.] Follow agency policy for patient identification.
- Consult with your peers, pharmacists, and other health care providers, and be sure that you have resolved all concerns related to medication administration before preparing and giving medications. A workaround bypasses a procedure, policy, or problem in a system. Nurses who use “workarounds; fail to follow agency protocols, policies, or procedures during medication administration in an attempt to get medications administered to patients in a more timely manner. [If needed, review strict aseptic technique for medication preparation and administration.]
- Ensure that you follow standards set by the Nurse Practice Act in your state and guidelines established by your health care agency. Licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) usually can administer medications via the oral (PO), subcutaneous, IM, and ID routes. Some states allow certified medication assistants (CMAs) to administer some types of medications (e.g., oral medication) in long-term care facilities. No-interruption zones (NIZs) are created by placing red tape or tile borders on the floor around medication carts. Nurses standing in these zones are not to be interrupted.
- The most frequent route of exposure to bloodborne disease for health care workers is needlestick injury. Research has shown that most needlestick injuries occur in patient rooms and in the operating room. Employers are required to maintain a current exposure control plan and seek employee input when considering changing medical devices. These injuries occur when health care workers recap needles, mishandle IV lines and needles, or leave needles at a patient’s bedside. A sharp with engineered sharps injury protection (SESIP) is a device that is effective in preventing needlesticks. One type of SESIP is a blunt-end cannula; another is a safety syringe equipped with a plastic guard or sheath that slips over the needle as it is withdrawn from the skin. The guard immediately covers the needle, eliminating the chance for a needlestick injury. A variety of other SESIP devices are found in needleless IV line connection systems. [Shown is Figure 22-2: A, Needleless system. B, Safety needle system. C, Detail of safety needle system. (A and B Courtesy and © Becton, Dickinson and Company.)] [Review with students Box 22-1, Recommendations for the Prevention of Needlestick Injuries.]
- Special puncture- and leak-proof containers are available in health care agencies for the disposal of sharps. Containers are made so that only one hand needs to be used when disposing of an uncapped needle. In addition, containers must stand upright, must not be allowed to overfill, and must be colored red or labeled with a biohazard symbol. [Shown is Figure 22-3: Sharps disposal using only one hand.]
- Syringes come with or without a sterile needle or with a needleless SESIP device. Non–Luer-Lok syringes use needles or needleless devices that slip onto the tip. Luer-Lok syringes use standard needles or needleless devices that are twisted onto the tip and lock themselves in place. The Luer-Lok design prevents accidental removal of a needle from the syringe. Syringe sizes range in capacity from 0.5 to 60 mL; syringes are most commonly marked in a scale of tenths of a milliliter. [Shown at top is Figure 22-4: Parts of a syringe.] [Shown at bottom is Figure 22-5: A, 5-mL syringe. B, 3-mL syringe. C, Tuberculin syringe marked in 0.01 (hundredths) for doses of less than 1 mL. D, Insulin syringe marked in units (50).] When you select a syringe, choose the smallest syringe size possible to improve accuracy of medication preparation. Avoid injecting a large volume of fluid into tissues; larger volumes create pain and discomfort for the patient. Use tuberculin (TB) syringes to prepare small amounts of medications for ID and subcutaneous injections. Insulin syringes come with preattached needles and are calibrated in units. Use a larger syringe to administer some IV medications, add medications to IV solutions, and irrigate drainage tubes. Some syringes are packaged with their needle attached; some syringes require you to change the needle based on the viscosity of the medication, route of administration, and size of the patient. Before use, carefully examine the syringe to determine the measurement scale and ensure that you use the correct syringe for preparing the ordered medication.
- Some needles come attached to syringes; others come packaged individually to allow flexibility in selecting the right needle for a patient. Most needles are made of stainless steel. A needle has three parts: the hub, which fits onto the tip of a syringe; the shaft, which connects to the hub; and the bevel, or slanted tip. The bevel creates a narrow slit when injected into tissue that quickly closes after the needle is removed to prevent leakage of medication, blood, or serum. [Shown at top is Figure 22-6: Parts of a needle.] [Shown at bottom is Figure 22-7: A, Capped needle placed on syringe tip. B, Needle secured.] Some needles come with filters for preparation of medications. Never use filters when administering a medication. Most needles vary in length from ⅜ to 3 inches, and they are color coded for ease of selection. Use longer needles (1 to 1½ inches) for IM injections and shorter needles (⅜ to ⅝ inch) for subcutaneous injections. The tip of a needle, or the bevel, is always slanted. The bevel creates a narrow slit when injected into tissue that quickly closes after the needle is removed to prevent leakage of medication, blood, or serum. Longer beveled tips are sharper and narrower, which minimizes tissue discomfort during a subcutaneous or IM injection. Choose needle length according to the patient’s size and weight, type of tissue to be injected, and route of administration. The selection of a gauge depends on the viscosity of fluid to be injected. [Review with students Figure 22-8: Needles come in a variety of gauges and lengths. Choose correct needle, gauge, and length for the injection ordered.]
- Single-dose, prefilled, disposable syringes are available for some medications. You do not need to prepare medication doses, except perhaps to expel unneeded portions of medication or air. [Shown is Figure 22-9: A, Carpuject syringe holder and prefilled sterile cartridge with needles. B, Assembling the Carpuject. C, The cartridge slides into the syringe barrel, turns, and locks at the needle end. D, The plunger screws into the cartridge end.] Check the medication and concentration carefully because prefilled syringes appear very similar. Prefilled unit-dose systems such as Tubex and Carpuject injection systems include reusable plastic syringe holders and disposable, prefilled, sterile glass cartridge units. To assemble a prefilled system, place the cartridge, barrel first, into the plastic syringe holder. While following manufacturer instructions, turn the plunger rod to the left (counterclockwise) and the lock to the right until it “clicks.” Then remove the needle guard and advance the plunger to expel air and excess medication as with a regular syringe (see figure). The cartridge may be used with SESIP needles. After giving the medication, dispose of the glass cartridge safely in a puncture- and leak-proof container.
- Ampules contain single doses of injectable medication in a liquid form and are available in sizes from 1 to 10 mL or more. An ampule is made of glass with a constricted, prescored neck that is snapped off to allow access to the medication. Filter needles must be used when preparing medication from a glass ampule. [Ask students: why do you need to use a filter needle to withdraw medication from an ampule? Discuss: to prevent glass particles from being drawn into the syringe.] Do not use the filter needle to administer the medication. Place a needle of appropriate size on the syringe after withdrawing the medication. [Shown is Figure 22-10: A, Medication in ampules. B, Medication in vials.] A vial is a single-dose or multi-dose plastic or glass container with a rubber seal at the top. After you open a single-dose vial discard it, regardless of the amount of medication used. When using a multi-dose vial, write on the vial label the date that the vial is opened. Verify how long an open multi-dose vial may be used, and discard when expired. A metal or plastic cap protects a rubber seal of the vial. Remove the cap when you first prepare the vial for use. Vials may contain a liquid or dry form of medication; medications that are unstable in solution are packaged in dry form and must be dissolved with a solvent or diluent. Normal saline and sterile distilled water are the most common solutions. Some vials have two chambers separated by a rubber stopper. One chamber contains the diluent solution; the other contains the dry medication. Before preparing the medication, push on the upper chamber to dislodge the rubber stopper and allow the powder and the diluent to mix. Unlike an ampule, a vial is a closed system. You must inject air into the vial to permit easy withdrawal of the solution. Occasionally the health care provider orders an injectable medication that must be reconstituted because it comes in a powdered form. This frequently occurs with a time-sensitive injectable medication, which must be administered within a specific time period to guarantee full drug effectiveness.
- Mixing compatible medications avoids the need to give a patient more than one injection. Most nursing units have medication compatibility charts. Compatibility charts are provided in drug reference guides, are posted within patient care areas, and are available electronically. If you are uncertain about medication compatibilities, consult a pharmacist. When mixing medications from a vial and an ampule, prepare medications from the vial first and then withdraw medication from the ampule using the same syringe and a filter needle. When mixing medications from two vials, do not contaminate one medication with another, ensure that the final dose is accurate, and maintain aseptic technique. Often patients with diabetes mellitus receive a combination of different types of insulin to control their blood glucose levels. Before preparing insulin, gently roll all cloudy insulin preparations (Humulin-N) between the palms of your hands to resuspend the insulin. If more than one type of insulin is required to manage the patient’s diabetes, you can mix them into one syringe if they are compatible. Always prepare the short- or rapid-acting insulin first to prevent it from being contaminated by the longer-acting insulin. Before preparing insulin, gently roll all cloudy insulin preparations (Humulin-N) between the palms of your hands to resuspend the insulin [Review with students Box 22-2, Recommendations for Mixing Insulins.]
- Correct answer: C Rationale: Ensures proper dispersal of medication throughout solution and prevents formation of air bubbles.
- Medications for skin testing are potent. They are injected into the dermis, where blood supply is reduced and drug absorption occurs slowly. A patient may have an anaphylactic reaction if the medications enter the circulation too rapidly. For patients with a history of multiple allergies, the physician may perform skin testing; this often requires you to visually inspect the test site. Make sure that the ID sites are free of lesions and injuries and relatively hairless. [Ask students: why is it important that drug absorption is slow during allergy testing? Discuss: a patient may have an anaphylactic reaction if medications enter the circulation too rapidly.] Administer to children only amounts up to 0.1 mL. If a bleb does not appear, or if the site bleeds after needle withdrawal, the medication may have entered subcutaneous tissue. In this situation, skin test results will not be valid.
- Correct answer: D Rationale: Inject medication slowly. Normally, the nurse will feel resistance. If not, the needle is too deep; remove and begin again. Dermal layer is tight and does not expand easily when solution is injected.
- [Ask students if they notice the pattern for injectable medications. They cannot be delegated to nursing assistive personnel (NAP).]
- Correctly sign the MAR according to institutional policy.
- [Ask students: when could a child receive ongoing exposure to individuals at high risk for TB? Discuss: HIV-infected, homeless, incarcerated.]
- Subcutaneous injections involve depositing medication into the loose connective tissue underlying the dermis. Subcutaneous tissue does not contain as many blood vessels as muscles, and medications are absorbed more slowly than with IM injections. Physical exercise or application of hot or cold compresses influences the rate of drug absorption by altering local blood flow to tissues. Any condition that impairs blood flow is a contraindication for subcutaneous injections. Subcutaneous tissue is sensitive to irritating solutions and large volumes of medications. Thus, you only administer small volumes (0.5 to 1.5 mL) of water-soluble medications subcutaneously to adults. In children, you give smaller volumes up to 0.5 mL. Because subcutaneous tissue contains pain receptors, the patient often experiences some discomfort. The best subcutaneous injection sites include the outer aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs. Choose an injection site that is free of skin lesions, bony prominences, and large underlying muscles or nerves. Nurses typically use a 25-gauge, 5/8-inch (16 mm) needle inserted at a 45-degree angle or a ½-inch (12 mm) needle inserted at a 90-degree angle to administer subcutaneous medications to a normal-size adult patient. Some children require only a ½-inch needle. If the patient is obese, pinch the tissue and use a needle long enough to insert through fatty tissue at the base of the skinfold. Thin patients often do not have sufficient tissue for subcutaneous injections; the upper abdomen is usually the best site in this case. If you can grasp 2 inches (5 cm) of tissue, insert the needle at a 90-degree angle; if you can grasp 2.5 cm (1 inch) of tissue, insert the needle at a 45-degree angle. when administering insulin, needles of 3/16 inch (4 to 5 mm) administered at a 90-degree angle should be used to reduce pain and achieve adequate control of blood sugars with minimal adverse effects for people of all BMIs, including children. [Shown is Figure 22-12: Common sites for subcutaneous injections.]
- Several new technologies are available for administration of subcutaneous injections. Injection pens are a technology that patients can use to self-administer medications (e.g., epinephrine, insulin, interferon) subcutaneously. The patient pinches the skin, inserts the needle, and injects a predetermined medication dose. Teaching is essential to ensure that patients use the correct injection technique and deliver the correct dose of medication. The disadvantages to this technology include increased risk for needlestick injury and user’s lack of knowledge and skill in administration technique. Needleless injection systems use high pressure to penetrate the skin with the medication into the subcutaneous tissue. The subcutaneous injection device (e.g., Insuflon) is inserted into the subcutaneous tissue; the needle is then removed, leaving the cannula in the tissue to provide an avenue for administering medications for up to 3 days without the need to puncture the skin with each injection. [Shown is Figure 22-13: Insulin injection pen. (From Lewis SL, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 8, St Louis, 2011, Mosby.)] [Shown is Figure 22-14: Jet injection system is held perpendicular to skin. (Image courtesy Pharmajet. All rights reserved.)]
- Anatomic injection site rotation is no longer necessary because newer human insulins carry a lower risk for hypertrophy. Patients choose one anatomic area (e.g., the abdomen) and systematically rotate sites within that region; this maintains consistent insulin absorption from day to day. Absorption rates of insulin vary on the basis of injection site. Insulin is most quickly absorbed in the abdomen and most slowly in the thighs. When health care providers plan insulin injection times, blood glucose levels are used to determine when the patient will eat. Knowing the peak action and duration of the insulin is essential when developing an effective diabetes management plan. [Review with students Table 22-2, Comparison of Insulin Preparations.] [Review with students Box 22-3, General Guidelines for Insulin Administration.]
- Heparin therapy provides therapeutic anticoagulation to reduce the risk for thrombus formation by suppressing clot formation. Results from coagulation blood tests (e.g., activated partial thromboplastin time [aPTT] and partial thromboplastin time [PTT]) allow you to monitor the desired therapeutic range for IV heparin therapy. Before administering heparin, assess for preexisting conditions that contraindicate its use, including cerebral or aortic aneurysm, cerebrovascular hemorrhage, severe hypertension, and blood dyscrasias. Assess for conditions in which increased risk for hemorrhage is present. [Ask students: what are some conditions that carry an increased risk for hemorrhage? Discuss: recent childbirth; severe diabetes and renal disease; liver disease; severe trauma; and active ulcers or lesions of the gastrointestinal (GI), genitourinary (GU), or respiratory tract.] Assess the patient’s current medication regimen, including use of over-the-counter (OTC) and herbal medications for possible interaction with heparin Low-molecular-weight heparins (LMWHs) (e.g., enoxaparin) are more effective than heparin in some patients. The anticoagulant effects are more predictable. LMWHs have a longer half-life and require less laboratory monitoring but are expensive. To minimize the pain and bruising associated with LMWH, it is given subcutaneously on the right or left side of the abdomen, at least 5 cm (2 inches) away from the umbilicus (the patient’s “love handles”). Administer LMWH in its prefilled syringe with the attached needle and do not expel the air bubble in the syringe before giving the medication. There is some new evidence to support a slower injection rate of 30 second to reduce bruising and pain.
- [Discuss your institution’s policy about signature on MAR.]
- Teaching Instruct patient to wear medical identification bracelet indicating important medical information, including bleeding tendencies, illnesses (e.g., diabetes), and allergies. Patients who require daily injections need to learn techniques of self-administration. Teach injection techniques to a family member or a significant other.
- Home care [Ask students: what are some ways for patients to safely dispose of sharps? Discuss:] Allowing patients to transport their own sharps containers from home to collection sites (e.g., doctor’s office, a hospital, a pharmacy). Mailing used syringes to a collection site (mail-back programs). Syringe exchange programs. Special devices that destroy the needle on the syringe, rendering it safe for disposal. If the patient cannot implement any of these options, have him or her dispose of needles and other sharps in a hard plastic or metal container with a tightly sealed lid (e.g., empty detergent bottle or coffee can). Most insulin preparations have bacteriostatic properties that inhibit bacterial growth on the skin. Therefore, patients with diabetes may reuse their syringes at home if they can safely recap the needles. Syringes should be discarded when the needles become dull or bent or contact any surface other than the skin. Wiping the needle off with alcohol is not recommended because the silicon coating on the needle is removed, making injection more painful. Immunocompromised patients and patients with poor personal hygiene, acute illness, or open hand wounds should not reuse syringes. Teach patient and family caregiver injection techniques that minimize patient discomfort.
- The IM injection route deposits medication into deep muscle tissue, which has a rich blood supply, allowing medication to be absorbed faster than by the subcutaneous route. Injecting drugs directly into blood vessels involves increased risk. Any factor that interferes with local tissue blood flow affects the rate and extent of drug absorption. Needle size selection is influenced by viscosity of the medication, injection site, patient’s weight, and amount of adipose tissue. Determine needle gauge by the medication to be administered. Some medications, such as hepatitis B and tetanus, diptheria, and pertussis (Tdap) immunizations, are only given intramuscularly. Use a longer and heavier-gauge needle to pass through subcutaneous tissue and penetrate deep muscle tissue. A patient’s BMI and the amount of adipose tissue influence needle size selection. Many needles available in health care settings are not long enough to reach the muscle, especially in patients who are obese and females. Muscle is less sensitive to irritating and viscous medication. A normal, well-developed adult can safely tolerate 2 to 5 mL of medication in larger muscles such as the ventrogluteal. Older adults, thin patients, and children tolerate less. Administer IM injections so the needle is perpendicular to the patient’s body and as close to a 90-degree angle as possible. Rotate IM injection sites to decrease the risk for hypertrophy. The Z-track method, a technique for pulling the skin during an injection, is recommended for IM injections. [Shown is Figure 22-16: A, Pulling on overlying skin with dorsum of hand during IM injection moves tissue to prevent later tracking. B, Z-track left after injection prevents deposit of medication through sensitive tissue.] To reduce injection site discomfort, there is no longer any need to aspirate after the needle is injected when administering vaccines. It is the nurse’s responsibility to follow agency policy for aspirating after injecting the needle. Keep the needle inserted for 10 seconds to allow the medication to disperse evenly. Release the skin after withdrawing the needle.
- The ventrogluteal muscle involves the gluteus medius and gluteus minimus and is a safe injection site for adults and children. The ventrogluteal site is recommended for volumes greater than 2 mL. To locate the ventrogluteal muscle, have a patient lie in either the supine or lateral position; place the heel of your hand over the greater trochanter of the patient’s hip with the wrist almost perpendicular to the femur. Use your right hand for the left hip and the left hand for the right hip. Point the thumb toward the patient’s groin; point the index finger to the anterior superior iliac spine; and extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle. The injection site is the center of the triangle. To relax this muscle, patients lie on their side or back, flexing the knee and hip. [Shown is Figure 22-17: A, Anatomic view of ventrogluteal injection site. B, Injection at ventrogluteal site avoids major nerves and blood vessels.]
- The muscle is thick and well developed; it is located on the anterior lateral aspect of the thigh. It extends in an adult from a handbreadth above the knee to a handbreadth below the greater trochanter of the femur. Use the middle third of the muscle for injection. The width of the muscle usually extends from the midline of the thigh to the midline of the outer side of the thigh. With young children or cachectic patients, it helps to grasp the body of the muscle during injection to ensure that the medication is deposited in muscle tissue. To help relax the muscle, ask the patient to lie flat with the knee slightly flexed and the foot externally rotated, or to assume a sitting position. [Shown is Figure 22-18: A, Landmarks for vastus lateralis site. B, Giving IM injection in vastus lateralis site.]
- Although the deltoid site is easily accessible, the muscle is not well developed in many adults. There is potential for injury because the axillary, radial, brachial, and ulnar nerves and the brachial artery lie within the upper arm under the triceps and along the humerus. Carefully assess the condition of the deltoid muscle; consult medication references for suitability of medication; and carefully locate the injection site using anatomic landmarks. Use this site for small medication volumes; for administration of routine immunizations in toddlers, older children, and adults; or when other sites are inaccessible because of dressings or casts. Locate the deltoid muscle by fully exposing the patient’s upper arm and shoulder and asking him or her to relax the arm at the side, or by supporting the patient’s arm and flexing the elbow. Do not roll up any tight-fitting sleeve. Allow the patient to sit, stand, or lie down. Palpate the lower edge of the acromion process, which forms the base of a triangle in line with the midpoint of the lateral aspect of the upper arm. The injection site is in the center of the triangle, about 3 to 5 cm (1 to 2 inches) below the acromion process. Locate the apex of the triangle by placing four fingers across the deltoid muscle with the top finger along the acromion process. The injection site is three fingerwidths below the acromion process. You locate the apex of the triangle by placing four fingers across the deltoid muscle with the top finger along the acromion process. [Shown is Figure 22-19: A, Landmarks for deltoid site. B, Giving IM injection in deltoid site.]
- Teaching Patients who require regular injections (e.g., vitamin B12) need to learn techniques of self-administration. Teach a family member or significant other injection techniques and the importance of rotating sites to decrease the risk for hypertrophy. Have patient perform several return demonstrations of medication preparation to validate that learning has taken place. Instruct patient and family member or significant other to observe injection sites for complications and to immediately report complications to the health care provider. Instruct patient and family member or significant other to observe for effectiveness of medication and adverse reactions and to report to the health care provider ineffectiveness of medication and adverse reactions. Pediatric Children can be very anxious or fearful of needles. Help with proper positioning and with holding the child is sometimes necessary. Distraction caused by blowing bubbles and providing pressure at the injection site before giving the injection can help alleviate anxiety. If possible, apply EMLA cream to the injection site at least 1 hour before IM injection, or use a vapocoolant spray (e.g., ethyl chloride) just before injection to decrease pain.
- Gerontological Older patients may have decreased muscle mass, which reduces drug absorption from IM injections. In addition, older adults may have loss of muscle tone and strength that impairs mobility, placing them at high risk for falls from guarding an injection site. Home care Self-administration of an IM injection is difficult, especially in the vastus lateralis. Teach a significant other to identify and administer injections at this site. Instruct adult patients who require frequent injections to apply EMLA cream to the injection site before administration. Patients need instruction in safe disposal of syringes and needles (see Skill 22-3, Home Care Considerations) See Skill 43-1 for information about modifying safety risks in the home.
- Advantages and disadvantages are involved in administering IV push medications. [Review with students Box 22-5, Advantages and Disadvantages of the Intravenous Push Method.] [Review with students Box 22-6, Pain-Management Benefits with Use of Continuous Subcutaneous Infusion.] Because these medications act quickly, it is essential that you monitor patients closely for adverse reactions. The IV bolus is a dangerous method because it allows no time to correct errors. Administering an IV push medication too quickly can cause death. A bolus may cause direct irritation to the lining of blood vessels; always confirm placement of the IV catheter or needle. Never give an IV bolus if the insertion site appears edematous or reddened, or if IV fluids do not flow at the ordered rate. Accidental injection of some medications into tissues surrounding a vein can cause pain, sloughing of tissues, and abscesses.
- The Institute for Safe Medication Practices has identified four strategies to reduce harm from rapid IV push medications. Verify the rate of administration of IV push medication using institutional guidelines or a medication reference manual. Review the amount of medication that a patient will receive each minute, the recommended concentration, and the rate of administration. Understand the purpose of the medication and any potential adverse reactions related to the rate and route of administration. Confirm agency guidelines regarding requirements for special monitoring. IV push medications may be given through an existing continuous IV infusion or an intermittent venous access (commonly called a saline lock). A saline lock is an IV catheter with a small “well” or chamber covered by a rubber cap. An IV catheter can be converted into a lock by inserting a special rubber-seal injection cap into the end of the catheter (see Chapter 28). Use of a lock saves time by eliminating constant monitoring of an IV line. It also offers better mobility, safety, and comfort for patients by eliminating the need for a continuous IV line. After you administer an IV bolus through an intermittent venous access, flush with a normal saline solution to keep it patent.
- Teaching Teach patient and/or significant other that effects of IV push medications occur rapidly. Explain reasons for giving medication slowly, and teach signs of adverse effects. Pediatric The therapeutic dosage of IV push medications for infants and children is often small and difficult to prepare accurately, even with a tuberculin syringe. You need to infuse these medications slowly and in small volumes because of the risk for fluid volume overload. To maintain pediatric patient safety, carefully follow institutional policies when administering medications via IV bolus.
- Gerontological The renal and metabolic systems do not function as efficiently because of the aging process. To reduce the risk for adverse effects of IV push medications, have good drug knowledge about adverse effects and drug interactions. Older patients may tolerate IV push medications if they are given over longer periods. Home care IV push medications are frequently given in the home. Nurses, pharmacists, and health care providers need to collaborate closely in the care of these patients. Patients and families who are independently responsible for managing IV medications need to understand all aspects of administration safety. Adequate eyesight and manual dexterity are necessary to manipulate the syringe. Patients need to understand their venous access device, the rate at which to give medications, and how to flush their access device. Patients need to safely store their medications and dispose of their IV supplies, and they should know whom to contact in case of an emergency.
- One method of administering IV medications uses small volumes (25 to 250 mL) of compatible IV fluids infused over a desired period. This method reduces the risk for rapid dose infusion and provides independence for patients. Patients must have an established IV line that is kept patent by a continuous infusion or by intermittent flushes of normal saline. You can administer intermittent infusion of medication with any of the following methods: A piggyback is a small (25- to 250-mL) IV bag or bottle connected to a short tubing line that connects to the upper Y-port of a primary infusion line or to an intermittent venous access such as a saline lock. The piggyback tubing is a microdrip or macrodrip system. The set is called a piggyback because the small bag or bottle is set higher than the primary infusion bag or bottle. In the piggyback setup, the main line does not infuse when a compatible piggybacked medication is infusing. The port of the primary IV line contains a back-check valve that automatically stops the flow of the primary infusion once the piggyback infusion flows. After the piggyback solution infuses and the solution within the tubing falls below the level of the primary infusion drip chamber, the back-check valve opens, and the primary infusion starts to flow again. Volume-control administration sets (e.g., Volutrol, Buretrol, Pediatrol) are small (50- to 150-mL) containers that attach just below the primary infusion bag or bottle. The set is attached and filled in a manner similar to that used with a regular IV infusion. However, the priming filling of the set is different, depending on the type of filter (floating valve or membrane) within the set. Follow package directions for priming sets. The mini-infusion pump is battery operated and delivers medication in very small amounts of fluid (5 to 60 mL) within controlled infusion times using standard syringes. [Shown is Figure 22-20: Mini-infusion pump.]
- The Needle Safety and Prevention Act of 2001 mandates that health care institutions use safe needle devices and manufactured needleless systems to reduce needlestick injury. Systems with catheter ports or Y-connector sites are designed to contain a needle housed in a protective covering. Needleless infusion lines allow a direct connection with the IV line via a recessed connection port, a blunt-ended cannula, or a shielded-needle device, eliminating the risk for exposure to an IV needle.
- Teaching Review all IV medications with patient and significant others, including why patient is receiving the medication and potential adverse effects, including allergic responses. Teach patient and/or significant others not to alter the ordered rate of infusion without consulting the prescriber. IV medications need to be infused at a specified rate to achieve their desired effect and avoid adverse effects. Teach patient and/or significant others to report any adverse effects immediately. Pediatric Infants and young children are more vulnerable to alterations in fluid balance and do not adjust quickly to changes in fluid balance. Therefore, to assess fluid balance, monitor intake and output (I&O) carefully when infusing IV medications.
- Gerontological Altered pharmacokinetics of medications and the effects of polypharmacy place older adults at risk for medication toxicity. Carefully monitor the response of older adults to IV medications. Older adults are at risk for developing fluid volume overload and require careful assessment for signs of overload and heart failure. Home care Patients and significant others who administer IV medications at home require education about the steps of medication administration. The patient or significant other needs to perform several return demonstrations of IV medication administration before performing this task independently. In addition, patients and significant others need to know signs of IV medication administration complications such as phlebitis and infiltration and what to do for any problems that arise.
- The continuous subcutaneous infusion (CSQI or CSCI) route of medication administration is used for selected medications (e.g., opioids, insulin). The route is also effective with medications to stop preterm labor (e.g., terbutaline) and to treat pulmonary hypertension (e.g., treprostinil sodium). One factor that determines the infusion rate of CSQI is the rate of medication absorption. Most patients can absorb 1 to 2 mL/hr of medication, but the rate of absorption is more dependent on osmotic pressure than rate of administration. With CSQI, patients are able to manage their illness and/or pain without the risks and expenses involved with IV medication administration. The route is relatively easy for patients and families to learn and understand in the home setting. CSQI improves oncological and postoperative pain control in infants, children, and adults and can be used for patients with diabetes mellitus. The newest CSQI system integrates an insulin pump with real-time continuous glucose monitoring. Patients with diabetes mellitus using insulin pumps need less intensive training in the use of the pump and generally require less insulin because it is absorbed and used more efficiently. [Review with students Box 22-6, Pain-Management Benefits with Use of Continuous Subcutaneous Infusion.] [Review with students Box 22-7, Patient Selection Criteria for Use of Insulin Pumps.] [Shown is Figure 22-21: Mini-Med Paradigm REAL-Time Insulin CSQI Pump and Continuous Glucose Monitoring System. (Courtesy Medtronic, Inc., North-ridge, Calif.)]
- The procedures followed to initiate and discontinue CSQI therapy are similar, regardless of the type of medication being delivered. Use the needle with the shortest length and the smallest gauge necessary to establish and maintain the infusion. Use the same anatomic sites for subcutaneous injections and the upper chest. Site selection depends on a patient’s activity level and the type of medication delivered. Insulin is absorbed most consistently in the abdomen; thus choose a site in the abdomen away from the waistline. Always avoid sites where the tubing of the pump could be disturbed. Rotate sites used for medication administration at least every 2 to 7 days, or whenever complications such as leaking occur. The CSQI route requires a computerized pump with safety features, including lockout intervals and warning alarms. Ideally, medication pumps are individualized on the basis of the medication being delivered and the patient’s needs. You also need to consider the availability and cost of the pump and its supplies. When possible, have patients select the pump that fits their individual and home needs and is easiest to use.
- Record in nurses’ notes patient’s response to medication and appearance of site every 4 hours or according to agency policy. Patient’s condition often indicates need for additional medical therapy.
- Teaching Instruct patient to wear medical alert bracelet along with medical information, including disease (e.g., diabetes), allergies, and a contact phone number for the pump manufacturer for technical support. Instruct patients to carry backup batteries and extra medication if they are going to be away from home. Patients receiving insulin require intensive diabetes management education. Never immerse pumps in water or expose them to x-ray films or magnetic resonance imaging. [Review with students Box 22-8, Education Topics for Patients Receiving Insulin with Continuous Subcutaneous Infusion.] Pediatric CSQI improves glycemic control in children and adolescents. Rates of severe hypoglycemia, catheter-site infection, and weight gain are decreased. Insulin pumps offer greater flexibility for adolescents, placing the responsibility of diabetes management on the child. Extensive child and family education is needed in using CSQI. Clean and change CSQI sites in children every 48 to 72 hours, or at the first signs of inflammation.
- Gerontological CSQI delivers isotonic IV solutions to dehydrated older adults, known as hypodermoclysis therapy. This method of providing hydration avoids the need to transfer a patient from home or a long-term care agency to an acute care hospital. Infuse fluids slowly (e.g., 30 mL/hr) during the first hour of therapy. If the patient remains comfortable, you can increase the rate of infusion. Usually, infusion rates do not exceed 60 mL/hr. Hypodermoclysis is an easy-to-use, safe, and cost-effective alternative to IV hydration for older adults. Home care Patients in the home using CSQI need a responsible family caregiver if available. Educate the patient, family, and/or significant others about the desired effect of the medication, side effects and adverse effects of the medication, operation of the pump, how to evaluate the effectiveness of the medication, when and how to assess and rotate injection sites, and when to call a health care provider about problems. Patients need to know where and how to obtain and dispose of all required supplies. Patients managing CSQI at home may use an antibacterial soap (e.g., Hibiclens, pHisoHex) instead of alcohol and chlorhexidine to clean the insertion site.