SELECTION OF SITE FOR INJECTION

Selection depends upon the following:

• Route of administration ordered by doctor
• Quantity of the drugs
• Condition of the patient
• Muscular development
• Knowledge of anatomical position of the nerves
• Rotation of the site is necessary to avoid tissue trauma

Technical Skill Needed

• Arrange the required equipment for the procedure
• Nurse must be very skillful while giving the injection according to the route ordered
• Select correct site for injection
• Prepare the medication dose accurately

Criteria for Selection of Syringes and Needles

• Intradermal: tuberculin syringe or 1 ml calibrated in 0.01 ml units. 26 or 27 gauge diameter and 3/8 to 5/8 length size of needle used
• Subcutaneous: insulin syringe or 1 ml calibrated in 40 or 80 unites syringe. 25 gauge and ½ to 5/8 inches syringe is used
• Intramuscular: 2.5 ml syringe is used it calibrated in 0.2 ml. 21, 22, 23 gauge 1 to 2 inches in length needles are used
• Intravenous: the size depends upon the amount of fluids to be injected, 18 to 20 gauge 1 to 2 inches needles use

Golden Rules of Giving Injections

Administer the right drug: to prevent mistakes, take time to check the name and spelling of each drug you administer against the patient’s medicine card. Check a drug, at least, twice before giving it. First, when you remove it from the stock cupboard and, second time, before administering it to the patient. Avoid distractions. If you are unfamiliar with the ordered drug, learn about the drug from the pharmacist and the doctor. When in doubt, clear the doubt from the doctor.

Administer the drug to the right patient: make sure that the name of the patient is correct before you give the medicines. Check the name, diagnosis, and IP number. Adopt as a practice to confirm the right patient each time you administer the drug. Never leave a drug at the patient’s bedside

Administer the right dose: you must check and double check the drug dose ordered against the dose you are about to give. Be especially careful when you are administering toxic medications, such as antineoplastic drugs. With these, the margin between a therapeutic and a potentially lethal dose is slim. Use an infusion as indicated and monitor the patient closely especially after an initial or loading dose is given or any time a close is increased

Administer the drug by the right route: the parenteral route demands more vigilance. Parenteral drugs act so rapidly that a medication error may be very harmful – even fatal. If the order doesn’t specify a route, call the doctor immediately for a clarification

Administer the drug at the right time: therapeutic blood levels of many drugs depend on consistent, regular administration times. Never give a drug more than half an hour before or after the scheduled time, without checking with the doctor

A hospital drug policy manual is one way to prevent errors associated with administration times. Make sure you coordinate drug administration with the laboratory schedule

Educate your patient about the drug he is receiving: take advantage of every opportunity to teach your patient and his family about his prescribed medication. Stress the need for consistent and timely administration. Make sure they understand the importance of taking the medications for the entire prescribed course. Many patients, who begin to feel better after the first few doses, stop taking the drug

Take patient’s complete drug history: it is necessary to know all the drugs your patient has been receiving and all the help he wants. By doing this you ensure his safety. The risk of adverse drug reactions and interactions, of course, rises with the member of drugs being taken

Find out if the patient has any drug allergies: no drug is completely safe. Any drug may cause an unpredictable reaction producing many different adverse effects – some appearing immediately, others developing over a period of time. Stay alert as you assess your patient’s reaction to any drug you give him. Warm him that he should avoid drugs that have caused even a mild allergic response

Be aware of potential drug/drug or drug/food interactions

Document each drug you administer: never document a drug before administering it but document you must after it is administered

TYPES OF DRUGS AND FLUIDS

Administered Drugs

• Preventive action: antitoxins, toxoids, vaccines and antibiotics
• Diagnostic acids: dyes and histamines
• Remedial action: antibiotics and quinine
• Palliative action: narcotics, sedatives, local anesthetics and general anesthetics
• Substitution: hormones, fluids, minerals and vitamins

Fluids

• D5W – Each 100 ml contains 5 g of glucose
• D10 W, D25 W, D50 W
• DNS – Dextrose 5% saline
• NS – Each 100 ml contains 0.9 g sodium chloride. Sodium lactate – each 100 ml contains 1.866 sodium ringer lactate
• Ringer’s solution or Hartmann’s solution

INJECTIONS

Injections are parenteral therapy. It means giving of therapeutic agents including food outside the alimentary tract.

An injection is the forcing of a fluid into a cavity, a blood vessel or body tissue through a hollow tube or needle

Purpose

• To get a rapid and systemic effect of the drug
• To provide the needed effect even when the patient is unconscious
• Assures that the total dosage will be administered and the same will be absorbed for the systemic action of the drug
• Provides the only means of administration for medications that cannot be given orally
• To obtain a local effect at the sight of the injection
• To restore blood volume by replacing the fluid, e.g. in shock conditions
• To give nourishment when it cannot be taken by

Types of Injections

• Intradermal: drug introduced into the dermis
• Subcutaneous: drug introduced into the subcutaneous tissue
• Intramuscular: injected into the muscles
• Intravenous: introduced into the vein
• Intraspinal: introduced into the spinal cavity
• Intra-osseous: introduced into the peritoneal cavity
• Venesection: opening a vein and introducing a tube or wide bore needle and introducing medicines an fluids or taking out blood
• Infusions: when a large quantity of medicines as fluids are to be introduced into the body
• Transfusions: it is the introduction of whole blood or plasma into a vein or artery

Factors that Favors Absorption

• Blood supply to the area: fluids injected into the blood stream will act quicker than any other methods used
• The composition of the fluid injected: solubility and diffusibility of the fluid
• Application of heat: heat dilates the blood vessels; therefore the heat applied over the site of injection increases the rate of absorption
• Massage: it stimulates the local blood supply and increases the rate of absorption
• Circulation time of the blood: absorption of medicines and fluids injected to the body will diminished in a person who has venous congestion (edema)
• Physical condition: the local disease condition of the skin and underlying tissues such as skin lesions, inflammations, etc. delays the absorption of the drug
• Addition of the substances: that tends to breakdown the natural resistance of the tissues can increase the rate of absorption

Complication of Injections

• Allergic reactions for certain drugs, e.g. penicillin
• Infections (abscess formation)
• Pyrogenic reactions (producing fever)
• Tissue trauma
• Psychic trauma
• Pain
• Accidental intravascular injections
• Foot drop and persistent paralysis of the limb
• Air embolism
• Over dose and under dose of the medication
• Errors in the administration of the medications
• Infectious hepatitis
• Circulatory overload

ORAL MEDICATION

NURSING PROCEDURES LIST CLICK HERE

Oral medication are defined as the administration of medication by mouth and ensuring that patient swallows the medicine

Purpose

• To prevent the disease
• To cure the disease
• To promote the health
• To give palliative treatment
• To give as a symptomatic treatment

Nurses Responsibility in Administration of Oral Medication

• Check the diagnosis and age of the patient
• Check the purpose of medication
• Check the identification of the patient, the name and bed number
• Check the physician’s orders for the correct name of the drug, dosage and method of administration
• Check the nurse record for the time at which the last dose was given
• Check for any contraindications present in the patient for an oral intake of the medicines such as nausea, vomiting, unconsciousness etc
• Check the character of the drug – whether it can be taken safely by the oral method
• Check the form of the drug available and the correct method of administration
• Check the level of consciousness of the patient and ability to follow instructions
• Check the abilities and limitations in swallowing the medications

Equipment

A trolley containing

•  A bowel of clean water
• Ounce glass, medicine glass, dropper teaspoon to measure the medicine
• Drinking water in a feeding cup
• Mortar and pestle to crush and powder the table if necessary
• Duster/towel to wipe the outside the bottle after pouring the medicine ordered
• Kidney tray and paper bag to discard the waste
• Medicine cards to write the medication order from patients order sheet

Preparation of the Patient

• Explain the procedure to the patient. Tell the advantages needs of medication
• If patient is allowed to sit assist him to sit
• Never give medication in flat position as there is a danger of aspiration of drug and fluid when swallowed.
• Give a mouth wash, if necessary
• If medication is ill tasting, prepare a drink to mask the taste of the medication
• Protect the bed clothes and garments with the towel placed under the chin across the chest

Procedure

• Keep the patient comfortable in bed
• Arrange the articles at the bed side
• Identify patient by name and check the name board at bed side
• Check the nurse’s record to find out when drug was last administered
• Check for special instructions  and check vital signs if needed
• Select medicine from patient’s locker and check medication label thrice
• Encourage patient to sit-up and make sure medicines are swallowed
• First give little water to moisten the mouth and then give medicine one at a time
• Stay with the patient until the medicine has been swallowed; give him a drink of water after it

After Care of the Patient and Articles

• Remove the towel and wipe the face with it
• Position the patient for good body alignment
• Take all articles to the utility room. Wash and dry all articles and replace them in their proper place
• Wash hands
• Record medications given in medication sheet and also nurses record
• Record any reaction observed after the administration of the drug
• Report any reaction to the ward sister and doctor-in-charge

Contraindications

• Continuous vomiting
• Gastric or intestinal suction
• Unconscious patient
• Patient who are unable to swallow
• Patient on nil per oral

Advantages

• This method is safe and convenient
• It is effective method
• There is no pain while administering the drug
• Allergic reactions are very less

Disadvantages

• Sometimes the patient may not swallow the medicine
• The drug may only be partially observed
• It may irritate the gastric mucosa and can cause vomiting or diarrhea and the effect is lost

SYRINGES AND NEEDLES

Drugs are administered as injections using a needle and a syringe. A syringe consists of a barrel and a plunger (piston). A type of syringe known as Luer-Lock syringe has the advantage that the needle can be locked in position. ‘Intravenous injections are given with the help of an infusion set’

Sizes: syringes are available in various sizes 1, 2, 5, 10, 20 and 50 ml. syringes may be of two materials – Glass and plastic

Glass Syringes

Advantages

• The markings are accurate and therefore exact quantity can be drawn
• The fluid level can be clearly seen as the glass is more transparent
• They can be easily sterilized by boiling and reused
• Glass syringe are resistant to punctures

Disadvantages

• Glass syringes do not break easily
• They carry a greater risk of air embolism because they are rigid
• They are more expensive. Glass syringes are no more preferred because of the risk of spreading dangerous diseases like AIDS when not properly sterilized

Plastic Syringes

Advantages

• Plastic syringes do not break easily
• Because they are collapsible, they allow proper emptying of the syringe – hence less risk of air embolism
• They are cheaper
• They are disposable

Disadvantages

• Plastic syringes are not very accurate in scale
• They cannot be easily sterilized
• They cannot be reused

Special Syringes

Insulin syringes has markings in units – (40 in 1 ml (red) or 80 in 1 ml (green) are suitable for administration of insulin

Tuberculin syringe is a syringe of 1 ml capacity with 0.01 ml markings. It is useful for administration of very small volumes

Disposable Syringes and Needles

Sterile disposable syringes are made of plastic and are packed with a needle to be fixed at the time of use

Advantages

They have the following advantages:

• Need no sterilization
• Injections are less painful as needle is sharp
• Convenient to use

Disadvantages

Works out costlier as they are not reusable

Needles

Needles are made of stainless steel, which is rust proof. The tip which is at the end of the shaft is beveled. The beveling may be short, very short or regular. Needle is available in different gauge thickness and length. The gauge numbness is from 13 (thickest) to 27 (finest). Depending on the route of administration, size of the patient and the thickness of the solution to be injected, the needle is selected

TERMINOLOGY

• Pharmacotherapeutics: it deals with the relative effects of drugs in human systems for various disorders
• Pharmacokinetics: it is the study of genetically induced drug responses that are often responsible for some idiosyncratic (unexplainable) responses
• Pharmacodynamics: it deals with experimental science pertaining to theories of drug action
• Pharmacokinetics: it is the study of how drugs enter the body, reach their site of action, are metabolized and eliminated from the body
• Absorption: it is the passage of drug molecules into the blood. To exert therapeutic effect the drugs must depend on the physical properties of the drug, route of administration, presence or absence of food in the stomach and interaction with the drugs
• Distribution: after a drug is absorbed, it is distributed within the body, to tissues and organs and ultimately to its specific site of action
• Metabolism: after a drug reaches its site of action, it is metabolized into an inactive form, detoxified and degraded chiefly by liver. Also the lungs, kidneys, blood and intestines metabolize drugs
• Excretion/Elimination: when drugs are metabolized they exit the body through the kidneys, liver, bowels and exocrine glands
• Drug: it is a substance used in the diagnosis, treatment, cure, relief or prevention of a disease. The terms “medication”, medicine, medicinal are used synonymously with the term “drug”. A drug cannot repair diseased tissues or organs. It can only facilitate normal cellular function. Drugs are given to produce a “therapeutic effect” but these may also cause secondary effects and lethal effects. A single medication may have many therapeutic effects. For example, aspirin is an analgesic, antipyretic and anti-inflammatory drug. It reduces platelet count
• Side-effects: unintended but anticipated secondary effects, which may be harmless or injurious
• Adverse reaction: it is the secondary effect which reflects the drug’s action on other areas of the body
• Toxic effects: usually develop after a prolonged intake of high doses of medication due to accumulation of drug in the blood because of impaired metabolism or excretion
• Lethal effects: excess amount of drugs within the body may have a lethal effect
• Iatrogenic disease: disease caused unintentionally by drug therapy. Hepatic toxicity resulting in biliary obstruction
• Idiosyncratic reaction: when the client over-reacts or under-reacts to a drug or has a reaction different from normal
• Allergic reaction: it is an unpredictable immunological response after exposure to an initial dose of medication. A drug allergy may be mild or severe (anaphylactic reaction). Common allergy symptoms are utricaria, eczema, pruritus and rhinitis
• Drug abuse: it is inappropriate intake of a substance either continually or periodically. It has two main facets: drug dependence and drug habituation
• Drug dependence: it is an individual’s physiological or psychological reliance on or need to take a drug or substance
• Drug habituation: it denotes a mild form of psychological dependence. The habituated individual develops the habit of taking the substance and feels better after taking it
• Drug tolerance: an increase in dosage may be needed to cause a therapeutic effect in persons with low metabolism in response to a drug
• Drug interaction: when one drug modifies the action of another drug interaction occurs
• Synergistic effect: when the physiological action of two drugs in combination is greater than the effect of the drugs when given separately. For example, diuretics and vasodilators act together to keep the blood pressure at a desirable level
• Antagonist: drugs that have no special pharmacological action of their own but inhibit or prevent the action of a drug to produce a response
• Bioavailability: the proportion of the administered dose of a drug, which reaches the circulation
• Pharmacological/Chemical name: it provides an exact description of the drug’s composition. An example of its chemical name is acetylsalicylic acid (ASA), which is commonly known as aspirin
• Trade name/Brand name: the name under which a manufacturer markets a drug. A drug may have many different trade names
• Generic name: the name that is proposed by the company that first develops the drug
• Material Media: it is a record/book which deal with source, physical and chemical properties, preparations and uses of drugs
• Pharmacopeias: it is an official document containing a list of drugs which have established their use. It contains a description of physical properties and tests for identification, purification and potency of drugs
• Monthly Index of Medical Specialties (MIMS): it is published every month. It contains information on drugs, their trade names, along with the name of the manufacturing company with indications and contraindications of the drug, cost of the product
• Formulary: it is a collection of formulas and prescriptions

DEFINITIONS

• Drug (Drogue means a dry herb in French) is a substance used in the diagnosis, prevention or treatment of a disease. WHO definition “A drug is any substance or product that is used or intended to be used to modify or explore physiological systems or pathological states for the benefit of the recipient”
• Pharmacokinetics is the study of the absorption, distribution, metabolism and excretion of drugs, i.e. what the body does to the drug (in Greek Kinesis = movement)
• Pharmacodynamics is the study of the effects of the drugs on the body and their mechanism of action, i.e. what the drug does to the body. Therapeutics deals with the use of drugs in the prevention and treatment of disease
• Toxicology deals with the adverse effects of drugs and also the study of poisons, i.e. detection, prevention and treatment of poisonings. (toxicon = poison in Greek)
• Chemotherapy is the use of chemicals for the treatments of infections. The term now also includes the use of chemical compounds to treat malignancies

Pharmacy is the science of identification, compounding and dispensing of drugs. It also includes collection, isolation, purification, synthesis and standardization of medicinal substances

SOURCES OF DRUGS

The source of drugs could be natural or synthetic

• Natural sources: drugs can be obtained from

         Plants, e.g. atropine, morphine, quinine, digoxin, pilocarpine, physostigmine

Animals, e.g. insulin, heparin, gonadotropin and antitoxic sera

Minerals, e.g. magnesium sulfate, aluminium hydroxide, iron, sulfur, and radioactive isotopes

Microorganisms: antibacterial agents are obtained from some bacteria and fungi. We thus have penicillin’s, cephalosporins, tetracyclines and other antibiotics

Human: some drugs are obtained from man, e.g. immunoglobulin from blood, growth hormone from anterior pituitary and chorionic gonadotropins from the urine of pregnant women

• Synthetic, most drugs are now synthesized, e.g. quinolones, omeprazole, sulfonamides, pancuronium, neostigmine
• Many drugs are obtained by cell cultures, e.g. urokinase from cultured human kidney cells. Some are now produced by recombinant DNA technology, e.g. human insulin, tissue plasminogen activator and some drugs by hybridoma technique, e.g. monoclonal antibodies

DRUG INFORMATION SOURCES

Official Compendia

Official compendia include information sources (or books) on drugs which are recognized by the government of that country as ‘legal standard’. Thus Indian Pharmacopoeia, National Formulary, British Pharmacopoeia, Codex, Pharmaceutical Codex, United States Pharmacopoeia and such other Pharmacopeias are official compendia

• Pharmacopeia: it is the official publication containing a list of drugs and medical preparations. In Greek ‘Pharmacon’ means drug and ‘poeia’ is to make. It contains list of drugs and related substances that are proved for use, their source, formulae and other information needed to prepare the drugs, their physical properties, tests for their identity, purity and potency
• Each country may follow its own pharmacopoeia. We thus have Indian pharmacopoeia, British Pharmacopoeia, United States Pharmacopoeia, USSR and Japan Pharmacopeia. The European Pharmacopoeia was published by the Public Health Committee and the European Pharmacopoeia Commission. The international Pharmacopoeia is published by WHO in many languages like English, French, Spanish, and Russian
• The first pharmacopoeia of India was published in 1868. But later under the British rule, the British Pharmacopoeia was followed. After independence, a committee was set up and Indian Pharmacopoeia was released in 1955. Experts from pharmaceutical industry, drug control laboratories and research and teaching institutions helped the committee. All pharmacopoeia are revised at regular periods to delete old useful drugs and to include newly introduced ones
• Drug formulary also provides information on drugs. The National formulary is a smaller book that contains information on formulations which are used therapeutically. It is prepared by the National Formulary Committee set up by the Ministry of Health Government of India. Expert opinion is also taken from medical associations, hospitals, teaching institutions and pharmaceutical industry in preparing this book

Non-official Compendia

The books other than the official compendia which provide information on drugs are known as non-official drug compendia

Textbook: these include the textbooks of pharmacology, journals and periodicals. Textbooks like-The Pharmacological basis of therapeutics by Goodman and Gilman, Merck Index, the United States Dispensary, Remington’s Pharmaceutical Sciences and others are quite informative. Many Indian textbooks are also available.

Journals: several journals are published by local, national, international medical organizations. They provide updated information on drugs with research and review articles

Local: several regional (e.g. southern, northern) and state level medical societies release journals at regular intervals

National: Indian Pharmacological Society, Indian Society of Clinical Pharmacology and other similar national level organizations bring out journals at regular intervals