ASSESS THE CLIENT’S COUGH

See Chapter 40 on proper techniques of coughing.

DETERMINE THE PRESENCE OF A GAG REFLEX

• Assess the gag reflex by stroking the posterior pharyngeal wall with a tongue blade. Never check the gag reflex in a client who does not exhibit an intact cough or swallow reflex.

• To protect the airway the client must have all three of: a positive cough, gag and swallow reflex.

Note: Prescriber and/or speech therapist should be consulted if there is any question of a client’s ability to swallow safely.

Topical medication applications

Topical medications are applied locally, most often to intact skin.

Skin applications

Many locally applied medications such as lotions, pastes and ointments (see Box 31-1) can create systemic and local effects. Nurses should wear gloves or use an applicator when applying these medications to avoid absorbing the medication through their own skin. Aseptic technique may be appropriate if the client has an open wound.

Simply applying new medications over previously applied medications does little to prevent infection or offer therapeutic benefit. Before applying medications, the nurse thoroughly cleans and assesses the skin. When applying ointments or pastes, the nurse spreads the medication evenly and thinly over the involved surface and covers the area well. Opaque ointments prevent the underlying skin from being seen. Prescribers may order a light dressing to be applied over the medication to prevent soiling of clothes and wiping away of the medication.

Each type of medication, whether an ointment, lotion or powder. should be applied in a specific way to ensure proper penetration and absorption. Lotions and creams are applied by lightly smearing onto the specified skin’s surface; the lotion or cream should not be rubbed in, as rubbing may cause irritation. A liniment is applied by rubbing it gently but firmly into the skin. A powder is dusted lightly to cover the affected area with a thin layer.

Recording of the treatment should include the type of administration, the area concerned, the name of the medication and the condition of the skin. Care must be taken to apply the treatment only to the affected area, as some medications can damage or irritate normal skin.

Nasal instillation

Clients with nasal (allergic rhinitis) or sinus (sinus infection) alterations may receive medications by spray, drops or packing (Skill 31-2). Another example is intranasal fentanyl which is used for analgesia in children older than 12 months for moderate to severe pain. The most commonly administered form of nasal instillation is decongestant spray or drops, used to relieve symptoms of sinus congestion and colds. Clients must be cautioned to avoid overuse of such medications, because a rebound effect may cause increased nasal congestion. When excess decongestant solution is swallowed, serious systemic effects may also develop, especially in children. Saline drops are safer as a decongestant for children than nasal preparations that contain sympathomimetics, for example pseudoephedrine.

SKILL 31-2 Administering nasal instillations

DELEGATION CONSIDERATIONS

Administration of nasal drops and ointments requires the problem-solving and knowledge-application abilities of professional nurses. In some states of Australia and New Zealand, client care attendants or enrolled nurses may legally be able to administer medications via this route. For this procedure, client assessment by the registered nurse is required as delegation may not be appropriate.

EQUIPMENT

• Prepared medication with clean dropper or spray container

• Facial tissue

• Disposable gloves (optional, only if client has extensive nasal drainage)

• Medication administration record (MAR)

• Penlight (to inspect nares; if ointment is to be applied to a specific lesion inside the nares)

STEPS			RATIONALE
1. For nasal drops, determine which sinus is affected by referring to healthcare record.			Affects client’s position during drug instillation.
2. Assess client’s history of hypertension, heart disease, diabetes mellitus and hyperthyroidism.			These conditions can contraindicate use of decongestants that stimulate central nervous system (CNS). Side effects of transient hypertension, tachycardia, palpitations and headache may occur.
3. Identify client; compare name on MAR with client’s ID bracelet. Ask client to state name.			Ensures that correct client receives medication.
4. Using a penlight, inspect condition of nose and sinuses. Palpate sinuses for tenderness.			Provides baseline to monitor effects of medication. Presence of discharge interferes with medication absorption.
5. Assess client’s knowledge regarding use of nasal instillations and technique for instillation and willingness to learn self-administration.			May necessitate health teaching regarding use of medications. Motivation influences teaching approach.
6. Explain procedure to client regarding positioning and sensations to expect, such as burning or stinging of mucosa or choking sensation as medication trickles into throat.			Helps client anticipate experience of procedure to reduce anxiety.
7. Perform hand hygiene. Arrange supplies and medications at bedside.			Reduces transmission of microorganisms; ensures smooth, orderly procedure.
8. Instruct client to clear or blow nose gently unless contraindicated (e.g. risk of increased intracranial pressure or nosebleeds).			Removes mucus and secretions that can block distribution of medication.
9. Administer nasal drops:
	a. Help client to supine position. b. Position head properly:		Position provides access to nasal passages.
		(1)For access to posterior pharynx, tilt client’s head backwards. (2) For access to ethmoid or sphenoid sinus, tilt head back over edge of bed or place small pillow under client’s shoulder and tilt head back (see illustration). (3) For access to frontal and maxillary sinus, tilt head back over edge of bed or pillow with head turned towards side to be treated (see illustration).	Position allows medication to drain into affected sinus.
Step 9b(2) Patient position for medication administration to ethmoid or sphenoid sinus.			Step 9b(3) Patient position for medication administration to frontal and maxillary sinus.
	c. Support client’s head with non-dominant hand.		Prevents straining of neck muscles.
	d. Instruct client to breathe through mouth.		Mouth breathing reduces chance of aspirating nasal drops into trachea and lungs.
	e. Hold dropper 1 cm above nares and instil prescribed number of drops towards midline of ethmoid bone.		Avoids contamination of dropper. Instilling towards ethmoid bone facilitates distribution of medication over nasal mucosa.
	f. Have client remain in supine position for 5 minutes.		Prevents premature loss of medication through nares.
	g. Offer facial tissue to blot runny nose, but caution client against blowing nose for several minutes.		Allows maximal amount of medication to be absorbed.
10. Help client into a comfortable position after medication is absorbed.			Restores comfort.
11. Dispose of soiled supplies in appropriate container and wash hands.			Maintains neat, orderly environment. Reduces spread of microorganisms.
12. Observe client for onset of side effects 15-30 minutes after administration.			Drugs absorbed through mucosa can cause systemic reaction.
13. Ask if client is able to breathe through nose after decongestant administration. May be necessary to have client occlude one nostril at a time and breathe deeply.			Determines effectiveness of decongestant medication.
14. Inspect condition of nasal passages between instillations.			Condition of mucosa reveals response to medication.
15. Ask client to review risks of overuse of decongestants and methods for administration.			Feedback ensures that client can self-administer medications properly.
16. Have client demonstrate self-medication.			Feedback demonstrates learning.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Record medication name, concentration, number of drops, nostril into which medication was instilled and time of administration on MAR. • Record client’s response in nurses’ notes. • Report any unusual systemic effects to nurse in charge or medical officer.	• Instruct client to expect timely resolution of problems. Instruct client on signs to observe of persistent or worsening problem. Clear nasal discharge indicates sinus problem. Yellow or greenish discharge indicates infection. • Use OTC nasal sprays or nose drops for only one client; bottles become easily contaminated with bacteria.

It is easier for clients to self-administer sprays, since they can control the spray and inhale as it enters the nasal passages. For clients who use nasal sprays repeatedly, the nurse checks the nares for irritation. The nurse learns the proper way of positioning clients to permit the medication to reach the affected sinus.

Eye instillation

Eye drops and ointments are common medications used by clients, including OTC preparations such as artificial tears. Many clients receive prescribed ophthalmic medications for glaucoma and after cataract extraction. A large percentage of clients receiving eye medications are older people. Age-related problems, including poor vision, hand tremors and difficulty grasping or manipulating containers, affect the ease with which the older person can self-administer eye medications. The nurse instructs clients and family members about the proper techniques for administering eye medications (Skill 31-3). The nurse may determine the client and family’s ability to self-administer through a return demonstration of the procedure. Showing clients each step of the procedure for instilling eye drops can improve their compliance.

SKILL 31-3 Administering ophthalmic medications

DELEGATION CONSIDERATIONS

Administration of eye drops and ointments requires the problem-solving and knowledge-application abilities of professional nurses. In some states of Australia and New Zealand, client care attendants or enrolled nurses may legally be able to administer medications via this route. For this procedure, client assessment by the registered nurse is required as delegation may not be appropriate.

EQUIPMENT

• Medication bottle with sterile eye dropper or ointment tube

• Medicated intraocular disc

• Cotton ball or tissue

• Washbasin filled with warm water, and washcloth

• Eye patch and tape (optional)

• Disposable gloves

• Medication administration record (MAR)

STEPS				RATIONALE
1. Review prescriber’s medication order for number of drops (if a liquid) and eye/s to receive medication.				Ensures correct administration of medication.
2. Identify client. Compare name on MAR with client ID band. Ask client to state name.				Ensures that correct client receives medication.
3. Assess condition of external eye structures. (May also be done just before drug instillation.)				Provides baseline data with which to compare response to medications. Indicates need to clean eye before medication.
4. Determine known allergies to any medications or to latex.				Protects client from risk of allergic medication response. May require use of non-latex gloves.
5. Determine whether client has any symptoms of visual alterations.				Certain eye medications act to either lessen or increase these symptoms.
6. Assess client’s level of consciousness and ability to follow directions.				Restlessness during procedure increases risk of accidental eye injury.
7. Assess client’s knowledge regarding medication therapy and desire to self-administer medication.				Client’s level of understanding may indicate need for health teaching.
8. Assess client’s ability to manipulate and hold dropper.				Reflects client’s ability to learn to self-administer medication.
9. Explain procedure to client.				Relieves anxiety about medication being instilled into eye.
10. Perform hand hygiene and arrange supplies at bedside; put on disposable gloves.				Reduces transmission of microorganisms; ensures a smooth, orderly procedure.
11. Ask client to lie supine or sit back in chair with head slightly hyperextended.				Position provides easy access to eye for medication instillation and minimises drainage of medication through tear duct.
Critical decision point: Do not hyperextend the neck of a client with a known neck problem or suspected cervical spine injury.
12. If crusts or drainage are present along eyelid margins or inner canthus, gently wash away. Soak any crusts that are dried and difficult to remove by applying damp washcloth or cotton ball over eye for a few minutes. Always wipe from inner to outer canthus.				Crusts or drainage harbour microorganisms. Soaking allows easy removal and prevents pressure from being applied directly over eye. Cleaning from inner to outer canthus avoids entry of microorganism into lacrimal duct.
13. Hold cotton ball or clean tissue in non-dominant hand on client’s cheekbone just below lower eyelid.				Cotton or tissue absorbs medication that escapes eye.
14. With tissue or cotton resting below lower lid, gently press downwards with thumb or forefinger against bony orbit.				Technique exposes lower conjunctival sac. Retraction against bony orbit prevents pressure and trauma to eyeball and prevents fingers from touching eye.
15. Ask client to look at ceiling and explain steps to client.				Action retracts sensitive cornea up and away from conjunctival sac and reduces stimulation of blink reflex.
	A. Instil eye drops:
		(1)With dominant hand resting on client’s forehead, hold filled medication eye dropper or ophthalmic solution approximately 1-2 cm above conjunctival sac (see illustration).		Helps prevent accidental contact of eye dropper with eye structures, thus reducing risk of injury to eye and transfer of infection to dropper. Ophthalmic medications are sterile.
		(2)Drop prescribed number of medication drops into conjunctival sac.		Conjunctival sac normally holds 1 or 2 drops. Provides even distribution of medication across eye.
		(3)If client blinks or closes eye or if drops land on outer lid margins, repeat procedure.		Therapeutic effect of drug is obtained only when drops enter conjunctival sac.
		(4)After instilling drops, ask client to close eye gently.		Helps to distribute medication. Squinting or squeezing of eyelids forces medication from conjunctival sac.
		(5)When administering medications that cause systemic effects, apply gentle pressure with finger and clean tissue on the client’s nasolacrimal duct for 30-60 seconds.		Prevents overflow of medication into nasal and pharyngeal passages. Prevents absorption into systemic circulation.
	B. Instil eye ointment:
		(1)Holding ointment applicator above lower lid margin, apply thin stream of ointment evenly along inner edge of lower eyelid on conjunctiva (see illustration) from the inner canthus to the outer canthus.		Distributes medication evenly across eye and lid margin.
		(2)Have client close eye and rub lid lightly in circular motion with cotton ball, if rubbing is not contraindicated.		Further distributes medication without traumatising eye.
Step 15A(1) Instilling eye drops.				Step 15B(1) Instilling eye ointment.
	C. Intraocular disc
		(1)Application:
			a. Open package containing the disc. Gently press your fingertip against the disc so that it adheres to your finger. Position the convex side of the disc on your fingertip (see illustration).	Allows nurse to inspect disc for damage or deformity.
			b. With your other hand, gently pull the client’s lower eyelid away from the eye. Ask client to look up.	Prepares conjunctival sac for receiving medicated disc.
			c. Place the disc in the conjunctival sac, so that it floats on the sclera between the iris and lower eyelid (see illustration).	Ensures delivery of medication.
			d. Pull the client’s lower eyelid out and over the disc (see illustration).	Ensures accurate medication delivery.
Step 15C(1)a Positioning intraocular disk on finger.		Step 15C(1)c Placing disc in conjunctival sac.		Step 15C(1)d Disc in position underneath lower eyelid.
Critical decision point: You should not be able to see the disc at this time. Repeat Step 15C(1)d if you can see the disc.
		(2)Removal:
			a. Wash hands and put on gloves. b. Explain procedure to client. c. Gently pull on the client’s lower eyelid to expose the disc. d. Using your forefinger and thumb of your opposite hand, pinch the disc gently and lift it out of the client’s eye (see illustration).	Step 15C(2)d Pinching disc to remove it from patient’s eye.
16. If excess medication is on eyelid, gently wipe it from inner to outer canthus.				Promotes comfort and prevents trauma to eye.
17. If client had eye patch, apply clean one by placing it over affected eye so entire eye is covered. Tape securely without applying pressure to eye.				Clean eye patch reduces chance of infection.
18. Remove gloves, dispose of soiled supplies in proper receptacle, and wash hands.				Maintains neat environment at bedside and reduces transmission of microorganisms.
19. Note client’s response to instillation; ask if any discomfort was felt.				Determines whether procedure was performed correctly and safely.
20. Observe response to medication by assessing visual changes and noting any side effects.				Evaluates effects of medication.
21. Ask client to discuss medication’s purpose, action, side effects and technique of administration.				Determines client’s level of understanding.
22. Have client demonstrate self-administration of next dose.				Provides feedback regarding competency with skill.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Record medication, concentration, number of drops, time of administration and eye (left, right or both) that received medication on MAR. • Record appearance of eye in nurses’ notes.	• If eye drops are stored in refrigerator, rewarm to room temperature before administering. • Many clients lack confidence in their ability to instil drops without supervision. The nurse teaches others, such as a family member, to instil drops into the client’s eye.

The following principles should be followed when administering eye medications:

• The cornea of the eye is richly supplied with pain fibres and is thus very sensitive to anything applied to it. Avoid instilling any form of eye medication directly onto the cornea.

• The risk of transmitting infection from one eye to the other is high. Avoid touching the eyelids or other eye structures with eye droppers or ointment tubes.

• Use eye medication only for the client’s affected eye unless ordered otherwise.

• Never allow a client to use another client’s eye medications.

Some medications are administered intraocularly. Medications delivered this way resemble a contact lens. The nurse places the medication disc into the conjunctival sac, where it remains in place for up to 1 week. The client receiving intraocular medications requires teaching about monitoring for adverse reactions to the disc. Clients will also need to be taught how to insert and remove the disc.

Ear instillation

Internal ear structures are very sensitive to temperature extremes. Failure to instil eardrops or irrigating fluid at room temperature may cause vertigo (severe dizziness) or nausea. Although the structures of the outer ear are not sterile, it is wise to use sterile drops and solutions in case the eardrum is ruptured. The entry of non-sterile solutions into middle-ear structures could result in infection. If any ear drainage is present, the nurse should check with the prescriber to be sure the client does not have a ruptured tympanic membrane (eardrum). A nurse should never occlude the ear canal with the dropper or irrigating syringe. Also, forcing medication into an occluded ear canal creates pressure that may injure the eardrum. Box 31-12 reviews guidelines for administering eardrops.

BOX 31-12 PROCEDURAL GUIDELINES FOR ADMINISTERING EAR MEDICATIONS

EAR DROPS

1. Have client assume side-lying position (if not contraindicated by client’s condition) with ear to be treated facing up, or client may sit in chair or at the bedside.

2. Straighten ear canal by pulling auricle down and back (children) or upwards and outwards (adult).

3. Instil prescribed drops holding dropper 1 cm above ear canal (see illustration).

4. Ask client to remain in side-lying position for 2–3 min. Apply gentle massage or pressure to tragus of ear with finger unless contraindicated due to pain.

5. At times the prescriber orders insertion of portion of cotton ball into outermost part of canal. Do not press cotton into canal. Remove cotton after 15 min.

EAR IRRIGATIONS

1. Assess the tympanic membrane or review medical record for history of eardrum perforation, which would contraindicate ear irrigation.

2. Help client assume sitting or lying position with head tilted or turned towards affected ear. Place towel under client’s head and shoulder and have client hold basin under affected ear.

3. Fill irrigating syringe with solution (approximately 50 mL).

4. Gently grasp auricle and straighten ear canal by pulling it down and back (children) or upwards and outwards (adult).

5. Slowly instil irrigating solution by holding tip of syringe 1 cm above opening of ear canal. Allow fluid to drain out during instillation. Continue until canal is cleansed or all solution is used.

The external ear structures of children differ from those of adults. When instilling drops or irrigating solutions in infants and young children, the nurse must straighten the cartilaginous canal by grasping the auricle of the ear and pulling it gently down and back. In adults the ear canal is longer and composed of underlying bone, and is straightened by pulling the auricle up and back. Failure to straighten the canal properly may prevent medicinal solutions from reaching the deeper external ear structures.

• CRITICAL THINKING

Sometimes when administering ear drops it is possible that the medicine does not go into the ear but, rather, drips out of the ear without entering. Should you administer the drop again? What should you do?

Vaginal instillation

Vaginal medications are available as pessaries (vaginal suppositories), foam, jellies or creams. Pessaries come individually packaged in foil wrappers. Storage in a refrigerator prevents the solid oval-shaped pessaries from melting. After a suppository is inserted into the vaginal cavity, body temperature causes it to melt so that it can be absorbed and distributed. Foam, jellies and creams are administered with an applicator inserter (Skill 31-4). A pessary is given with an applicator inserter in accordance with standard precautions. Clients often prefer administering their own vaginal medications and should be given privacy. After instillation of the medication, a client may wish to wear a perineal pad to collect drainage. Vaginal medications are often given to treat infection; discharge may be foul-smelling. Aseptic technique should be followed and the client should be offered frequent opportunities to maintain perineal hygiene.

SKILL 31-4 Administering vaginal medications

DELEGATION CONSIDERATIONS

Administering medications by the vaginal route requires knowledge and the necessary psychomotor skills. Although in some states of Australia and New Zealand client care attendants or enrolled nurses are legally able to administer medications via this route, delegation may be inappropriate and client assessment by registered nurses is essential.

EQUIPMENT

• Vaginal creams, foam, jelly or suppositories or irrigating solutions

• Applicators

• Disposable gloves

• Tissues

• Paper towel

• Perineal pad

• Drape

• Water-soluble lubricants

• Medication administration record (MAR)

STEPS		RATIONALE
1. Review prescriber’s order, including client’s name, medication name, form (cream or suppository), route, dosage and time of administration.		Ensures safe and correct administration of medication.
2. Perform hand hygiene.		Reduces transfer of microorganisms.
Critical decision point: Rectal and vaginal suppositories may be stored near one another in the refrigerator. Vaginal suppositories are larger and more oval.
3. Identify client; compare name on MAR with identification bracelet and ask name.		Ensures that correct client receives medication.
4. Inspect condition of external genitalia and vaginal canal (see Chapter 27).		Findings provide baseline data for monitoring effect of medication.
5. Assess client’s ability to manipulate applicator or suppository and to position self to insert medication.		Mobility restriction indicates level of assistance required from nurse.
6. Explain procedure to client. Be specific if client plans to self-administer medication. (e.g. ‘Please remove the foil covering before insertion’).		Promotes understanding. Will enable client to self-administer medication if physically able.
7. Arrange supplies at bedside.		Ensures smooth procedure.
8. Close room curtain or door.		Provides privacy.
9. Assist client to lie in dorsal recumbent position.		Provides easy access to and good exposure of vaginal canal. Also allows suppository to dissolve without escaping through orifice.
10. Keep abdomen and lower extremities draped.		Minimises embarrassment.
11. Put on disposable gloves.		Prevents transmission of microorganisms between nurse and client.
12. Be sure vaginal orifice is well illuminated by room light or gooseneck lamp.		Proper insertion requires external genitalia to be seen.
13. Insert suppository with applicator:
	a. Remove suppository from foil wrapper and place suppository into the tip of the applicator; apply liberal amount of lubricant to smooth or rounded end. Lubricate applicator.	Lubrication reduces friction against mucosal surfaces during insertion.
	b. With non-dominant gloved hand, gently retract labial folds.	Exposes vaginal orifice.
	c. Hold the applicator by the cylinder and direct applicator initially down (towards the spine) and then back and up (towards the cervix). The aim is to insert the applicator along the posterior wall of vaginal canal 5 cm into vaginal canal.	Correct placement ensures equal distribution of medication along walls of vaginal cavity.
	d. When the applicator is in the appropriate position depress the plunger, remove the applicator with the plunger depressed and wipe away remaining lubricant from around orifice and labia.	Maintains comfort.
14. Apply cream or foam:
	a. Fill cream or foam applicator following package directions.	Dose is prescribed by volume in applicator.
	b. With non-dominant gloved hand, gently retract labial folds.	Exposes vaginal orifice.
	c. With dominant gloved hand, insert applicator approximately 5–7.5 cm. Push applicator plunger to deposit medication into vagina (see illustration).	Allows equal distribution of medication along vaginal walls.
	d. Withdraw applicator and place on paper towel. Wipe off residual cream from labia or vaginal orifice.	Residual cream on applicator may contain microorganisms.
Step 14c Instillation of medication into vaginal canal.
15. Remove gloves by pulling them inside out and discard in appropriate receptacle. Perform hand hygiene.		Reduces transfer of microorganisms.
16. Instruct client to remain on back for at least 10 minutes.		Medication will be distributed and absorbed evenly throughout vaginal cavity and not be lost through orifice.
17. If reusable applicator is used, wash with soap and warm water, rinse and store for this client’s future		Vaginal cavity is not sterile. Soap and water help remove bacteria and residual cream.
18. Offer client perineal pad when she resumes mobility.		Prevents vaginal discharge from spreading to clothing.
19. Inspect appearance of discharge of vaginal canal and condition of external genitalia between applications.		Evaluates whether vaginal medication effectively reduced irritation or inflammation of tissues.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Record medication name, dose, route and time of administration on MAR. • Record character of discharge on nurses’ notes.	• Suppositories should be kept refrigerated but in a container away from children.

Rectal instillation

Rectal suppositories are thin and bullet-shaped with a rounded end which prevents anal trauma during insertion. Rectal suppositories contain medications that exert local effects such as promoting defecation, or systemic effects such as reducing nausea. Rectal suppositories often need to be refrigerated.

The client should usually be positioned in the left lateral position (Sims’ position) and the suppository placed past the internal anal sphincter and against the rectal mucosa (Skill 31-5), otherwise the suppository might be expelled before it can dissolve and be absorbed into the mucosa. With practice, a nurse learns to recognise the sensation of the sphincter relaxing around the finger. The suppository should not be forced into a mass of faecal material. It may be necessary to clear the rectum with a small cleansing enema before a suppository can be inserted.

SKILL 31-5 Administering rectal suppositories

DELEGATION CONSIDERATIONS

Administering medications by the rectal route requires the problem-solving and knowledge application abilities of professional nurses. In some states of Australia and New Zealand, client care attendants or enrolled nurses may legally be able to administer medications via this route. For this procedure, client assessment by the registered nurse is required as delegation may not be appropriate.

EQUIPMENT

• Rectal suppository

• Lubricating jelly (water soluble)

• Disposable gloves

• Tissue

• Drape

• Medication administration record (MAR)

STEPS	RATIONALE
1. Review prescriber’s order, including client’s name, medication name, form, route and time of administration.	Ensures safe and correct administration of medication.
2. Review healthcare record for relevant contraindications such as rectal surgery or bleeding.	Conditions contraindicate use of suppository.
3. Perform hand hygiene.	Reduces transfer of microorganisms.
4. Put on disposable gloves.	Prevents contact with infected faecal material.
5. Identify client; check name on MAR with client’s identification bracelet and ask client’s name.	Ensures that correct client receives medication.
6. Explain procedure. Be specific if client wishes to self-administer medication.	Promotes understanding and cooperation. Will enable client to self-administer medication if physically able.
7. Arrange supplies at bedside.	Ensures smooth procedure.
8. Close room curtain or door.	Maintains privacy and minimises embarrassment.
9. Help assume Sims’ position. Keep client draped with only anal area exposed.	Exposes anus and helps client relax external anal sphincter. Maintains privacy and facilitates relaxation.
10. Examine condition of anus externally and palpate rectal walls as needed (see Chapter 27). If gloves become soiled, dispose of them by turning them inside out and placing them in appropriate receptacle.	Determines presence of active rectal bleeding. Palpation determines whether rectum is filled with faeces, which may interfere with suppository placement. Reduces transmission of infection.
Critical decision point: Generally, rectal suppository is contraindicated in the presence of active rectal bleeding. Unless suppository is for constipation, medication placed in a rectum filled with faeces may be poorly absorbed or prematurely expelled with defecation.
11. Put on disposable gloves (if previous gloves were discarded).	Minimises contact with faecal material and reduces transmission of microorganisms.
12. Remove suppository from wrapper and lubricate rounded end (see illustration). Lubricate index finger of dominant hand.	Lubrication reduces friction as suppository enters rectal canal.
Step 12 Lubricating rounded end of suppository.
13. Ask client to take slow deep breaths through mouth and relax anal sphincter.	Forcing suppository through constricted sphincter causes pain.
14. Retract buttocks with non-dominant hand. Insert suppository gently through anus, past internal sphincter and against rectal wall, 10 cm in adults, 5 cm in children and infants. May need to apply gentle pressure to hold buttocks together momentarily.	Suppository must be placed against rectal mucosa for eventual absorption and therapeutic action.
Step 14 Inserting rectal suppository. From deWit S 2009 Fundamental concepts and skills for nursing, ed 3. Philadelphia, Saunders.
15. Withdraw finger and wipe anal area with tissue.	Provides comfort.
16. Discard gloves by turning them inside out, and dispose of them in appropriate receptacle.	Reduces transfer of microorganisms.
17. Ask client to remain flat or on side for 5 minutes.	Prevents expulsion of suppository.
18. If suppository contains laxative or faecal softener, place call light within reach.	Provides client with sense of control over elimination. Allows client to obtain assistance to bedpan or toilet.
19. Perform hand hygiene.	Reduces risk of transfer of infection.
20. Return within 5 minutes to determine whether suppository was expelled.	Reinsertion may be necessary.
21. Observe for effects of suppository (e.g. bowel movement, relief of nausea) 30 minutes after administration.	Evaluates effectiveness of medication and relief of client’s symptoms.
RECORDING AND REPORTING
• Report occurrence of rectal bleeding to medical officer.

• CRITICAL THINKING

It is very important to ask clients to explain in their own words how they take their prescribed medications. For example, there have been instances of clients being prescribed suppositories and then inserting them into their rectum still wrapped in their foil packaging! What teaching points would you include when instructing a client how to administer their own suppository?

Administering medications by inhalation

Medications administered by handheld inhalers are dispersed through an aerosol spray, mist or powder via a metered-dose inhaler or by nebulisation so that the medication is delivered directly to the membranes of the airways. The alveolar–capillary network absorbs medications rapidly.

Metered-dose inhalers

Metered-dose inhalers (MDIs) are usually designed to produce local effects such as bronchodilation. Clients who have chronic respiratory disease such as asthma, emphysema or bronchitis often receive medications by inhalation. Such medications can help control airway obstruction. Because the clients depend on medications for disease control, their knowledge must include ways to administer them safely (Skill 31-6), as some medications can have serious systemic side effects.

SKILL 31-6 Using metered-dose inhalers (MDIs)

DELEGATION CONSIDERATIONS

Administering MDI and supervising clients who self-administer MDIs require the problem-solving and knowledge-application abilities of professional nurses. In some states of Australia and New Zealand, client care attendants or enrolled nurses may legally be able to administer medications via this route. For this procedure, client assessment by the registered nurse is required as delegation may not be appropriate.

EQUIPMENT

• MDI with medication canister

• Spacer (e.g. Volumatic) (optional)

• Facial tissues (optional)

• Washbasin or sink with warm water

• Paper towel

• Medication administration report (MAR)

STEPS			RATIONALE
1. Review prescriber’s order, including client’s name, medication name, number of inhalations.			Ensures safe and correct administration of medication.
2. Identify client, compare name on MAR with client’s ID bracelet and ask client’s name.			Ensures that correct client receives medication.
3. Assess client’s ability to hold, manipulate and depress canister and inhaler. Assess respiration and level of dyspnoea, and auscultate chest.			Any impairment of grasp or presence of hand tremors interferes with client’s ability to depress canister within inhaler.
4. Assess client’s readiness and ability to learn: client asks questions about medication, disease or complications; requests education in use of inhaler; is mentally alert; participates in own care. Client should not be fatigued, in pain or in respiratory distress. Assess level of understanding of technical vocabulary terms, and purpose and action of prescribed medications.			Affects client’s ability to understand explanations and actively participate in teaching process. Mental or physical limitations affect client’s ability to learn and the methods nurse uses for instruction. Knowledge of disease is essential for client to realistically understand use of inhaler.
5. Assess medication schedule and number of inhalations prescribed for each dose.			Influences explanations nurse provides for use of inhaler.
6. If previously instructed in self-administration of inhaled medicine, assess client’s technique in using an inhaler.			Nurse’s instruction may require only simple reinforcement, depending on client’s level of dexterity.
7. Instruct client in comfortable environment by sitting in chair in hospital room or sitting at kitchen table in home.			Client will be more likely to remain receptive of nurse’s explanations.
8. Provide adequate time for teaching session.			Prevents interruptions. Instruction should occur when client is receptive.
9. Perform hand hygiene and arrange equipment needed.			Reduces transfer of microorganisms; saves time.
10. Allow client opportunity to manipulate inhaler, canister and spacer device. Explain and demonstrate how canister fits into inhaler.			Client must be familiar with how to use equipment.
11. Explain what metered dose is, and warn client about overuse of inhaler, including medication side effects.			Client must not arbitrarily administer excessive inhalations because of risk of serious side effects. If medication is given in recommended doses, side effects are uncommon.
12. Explain steps for administering inhaled dose of medication (demonstrate steps when possible):			Use of simple, step-by-step explanations allows client to ask questions at any point during procedure.
	a. Remove mouthpiece cover from inhaler.
	b. Shake inhaler well.		Ensures fine particles are aerosolised.
	c. Have client take a deep breath and exhale.		Prepares the client’s airway to receive the medication.
	d. Instruct the client to position the inhaler in one of two ways.		Directs aerosol spray towards airway. Positioning the mouthpiece 2.5–5 cm from the mouth is considered the best way to deliver the medication.
		(1)Open lips and place inhaler in mouth with opening towards back of throat (see illustration). (2) Position the device 2.5–5 cm from the mouth (see illustration).
	e. With the inhaler properly positioned, have client hold inhaler with thumb at the mouthpiece and the index and middle fingers at the top. This is called a three-point or lateral hand position.		MDIs work best when clients use a three-point or lateral hand position to activate canisters.
	f. Instruct client to tilt head back slightly, inhale slowly and deeply through mouth and depress medication canister fully.		Medication is distributed to airways during inhalation. Inhalation through mouth rather than nose draws medication more effectively into airways.
	g. Hold breath for approximately 10 seconds.		Allows tiny drops of aerosol spray to reach deeper branches of airways.
	h. Exhale through pursed lips.		Keeps small airways open during exhalation.
Step 12d(1) Inhaler placed in mouth with opening towards back of throat.			Step 12d(2) Inhaler positioned 2.5–5 cm from the mouth.
13. Explain steps to administer inhaled dose of medication using a spacer such as a Volumatic (demonstrate when possible):
	a. Remove mouthpiece cover from MDI and mouthpiece of spacer.		Inhaler fits into end of spacer.
	b. Insert MDI into end of spacer.		Spacer traps medication released from the MDI; the client then inhales the drug from the device. These devices deposit up to 80% more medication in the lungs rather than in the oropharynx.
	c. Shake inhaler well.		Ensures fine particles are aerosolised.
	d. Place spacer mouthpiece in mouth and close lips. Do not insert beyond raised lip on mouthpiece. Avoid covering small exhalation slots with the lips (see illustration).		Medication should not escape through mouth.
			Step 13d Spacer mouthpiece placed between lips. Care must be taken not to cover the exhalation slots with the lips.
	e. Breathe normally through spacer mouthpiece.		Allows client to relax before delivering medication.
	f. Depress medication canister, spraying one puff into spacer.		Emits spray that allows finer particles to be inhaled. Large droplets are retained in spacer.
	g. Breathe in slowly and fully (for 5 seconds).		Ensures particles of medication are distributed to deeper airways.
	h. Hold full breath for 5–10 seconds.		Ensures full medication distribution.
14. Instruct client to wait 2-5 minutes between inhalations or as ordered by prescriber.			Medications must be inhaled sequentially. First inhalation opens airways and reduces inflammation. Second or third inhalation penetrates deeper airways.
15. Instruct client against repeating inhalations before next scheduled dose.			Medications are prescribed at intervals during day to provide constant drug levels and minimise side effects. Beta-adrenergic MDIs are used either on an ‘as needed’ basis or regularly every 4–6 h.
16. Explain that client may feel gagging sensation in throat caused by droplets of medication on pharynx or tongue.			Results when inhalant is sprayed and inhaled incorrectly.
17. Instruct client to rinse mouth with water.			Reduces buccal absorption of medication.
18. Instruct client in removing medication canister and cleaning inhaler in warm water.			Accumulation of spray around mouthpiece can interfere with proper distribution during use. Some medicines can also increase risk of oral candida (thrush) if not washed from mouth.
19. Ask if client has any questions.			Clarifies misconceptions or misunderstanding.
20. Have client explain and demonstrate steps in use of inhaler. Teach client how to check the volume of the inhaler.			Return demonstration provides feedback for measuring client’s learning.
21. Ask client to explain medication schedule.			Improves likelihood of compliance with therapy.
22. Ask client to describe side effects of medication and criteria for calling prescriber.			Will allow client to recognise signs of overuse and need to seek medical support when medications are ineffective.
23. After medication instillation, assess client’s respirations and auscultate lungs.			Determines status of breathing pattern and adequacy of ventilation.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Document in nurses’ notes what skills were taught and client’s ability to perform skills. • Record time when client used MDI (number of puffs). • Report any undesirable effects from medication.	• Teach clients how to determine fullness of canisters, using displacement in water (see illustration below).
Determining fullness of canisters.

An MDI delivers a measured dose of medication with each push of a canister—approximately 2–8 kg of hand pressure must be used to activate the aerosol. It is important to assess hand strength and psychomotor skill, as both can diminish with age and from the effects of chronic respiratory disease.

In many cases, a more even absorption of the medication is achieved by the use of a spacer, a device that mixes the medication with room air inside the spacer before it is inhaled (see Research highlight overleaf). Clients should be encouraged to use these devices to improve the action of their medication and reduce absorption of the drug via the oral mucosa.

Medications administered via the inhalation route exert local and systemic effects; for example salbutamol relieves bronchospasm via a local effect on the respiratory system but also acts systemically, potentially increasing heart rate and causing headaches. Clients should rinse the mouth after using this type of medication.

Administering medications by irrigation

Medications may be used to irrigate or wash out a body cavity and are delivered in a stream of solution. Irrigation solutions are most commonly sterile water, saline or antiseptic solutions and are used for the eye, ear, throat, vagina and urinary tract. If there is a break in the skin or mucosa, the nurse uses aseptic technique. When the cavity to be irrigated is not sterile, as is the case with the ear canal (see Box 31-12) or vagina, clean technique is acceptable. In healthcare settings, however, use sterile solutions. Irrigations can be used to clean an area, instil a medication or be applied hot or cold to injured tissue.

Parenteral administration of medications

Parenteral administration of medications is the administration of medications by a route that bypasses the GI tract (e.g. topical or injectable routes). The term ‘parenteral administration’ is often used to refer to injections. This is an invasive procedure that must be performed using aseptic techniques (Box 31-13). After a needle pierces the skin, there is risk of infection. Each type of injection requires certain skills to ensure the medication reaches its target location. The effects of a parenterally administered medication can develop rapidly, depending on the rate of medication absorption. The nurse closely observes the client’s response.

BOX 31-13 PREVENTING INFECTION DURING AN INJECTION

• To prevent contamination of solution, draw medication from ampoule quickly. Do not allow it to stand open.

• To prevent needle contamination, avoid letting needle touch contaminated surface (e.g. outer edges of ampoule or vial, outer surface of needle cap, nurse’s hands, countertop, table surface).

• To prevent syringe contamination, avoid touching length of plunger or inner part of barrel. Keep tip of syringe covered with cap or needle.

• To prepare skin, wash skin soiled with dirt, drainage or faeces with soap and water and dry. Use friction and a circular motion while cleaning with an antiseptic swab. Swab from centre of site, and move outwards in a 5 cm radius.

RESEARCH HIGHLIGHT

Research focus

In acute asthma, inhaled beta-2-agonists have in the past been administered for relief of bronchospasm using wet nebulisation. More recently, clinicians and researchers have argued that metered-dose inhalers with a holding chamber (spacer) are just as effective, easier to use as they do not require a power source or regular maintenance and less expensive.

Research abstract

A systematic review of the research comparing the effects of holding chambers compared with nebulisers for the delivery of beta-2-agonists for acute asthma was undertaken.

2295 children and 614 adults were included from 27 trials from emergency room and community settings. In addition, six trials on inpatients with acute asthma (213 children and 28 adults) were also reviewed.

Method of delivery of beta-2-agonist did not appear to affect hospital admission rates. In adults, the relative risk of admission for spacer versus nebuliser was 0.97 (95% CI: 0.63–1.49). The relative risk for children was 0.72 (95% CI: 0.47–1.09). In children, length of stay in the emergency department was significantly shorter when the spacer was used, with a mean difference of −0.53 hours (95% CI: −0.62 to −0.44 hours). Length of stay in the emergency department for adults was similar for the two delivery methods.

Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, mean difference −6.27% baseline (95% CI: −8.29 to −4.25% baseline).

Evidence-based practice

• Metered-dose inhalers with holding chamber produced outcomes that were at least equivalent to nebuliser delivery.

• Holding chambers may have some advantages compared with nebulisers for children with acute asthma.

Reference

Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma, Cochrane Database Syst Rev. 2006;(2). doi: 10.1002/14651858.CD000052.pub2. CD000052.

Equipment

Various syringes and needles are available, each designed to deliver a certain volume of a medication to a specific type of tissue.

SYRINGES

Syringes consist of a cylindrical barrel and a close-fitting plunger with a tip designed to fit the hub of a hypodermic needle. In general, syringes are classified as being Luer-lock or non-Luer-lock, based on the design of the syringe tip. Luer-lock syringes require needles that are twisted onto the tip and automatically lock in place (Figure 31-13A,B). This design prevents the inadvertent removal of the needle. Non-Luer-lock syringes require needles that slip firmly onto the tip (Figure 31-13C,D).

FIGURE 31-13 Types of syringes. A, 5 mL syringe (Luer-lock). B, 3 mL syringe (Luer-lock). C, Tuberculin syringe marked in 0.01 mm (hundredths) for doses < 1 mL. D, Insulin syringe marked in units (50).

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Most healthcare institutions use disposable single-use plastic syringes, which are inexpensive and easy to manipulate. A syringe is filled by aspiration, pulling the plunger outwards while the needle tip remains immersed in the prepared solution. The nurse may handle the outside of the syringe barrel and the handle of the plunger. To maintain sterility, avoid letting any unsterile object touch the tip or inside of the barrel, the hub, the shaft of the plunger or the needle (Figure 31-14). Syringe sizes range from 0.5 to 60 mL with a scale along the barrel divided into tenths of a millilitre.

FIGURE 31-14 Parts of a syringe.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

INSULIN SYRINGES

These are available in sizes that hold 0.3–1 mL (Figure 31-13) and are calibrated in units. Insulin syringes that hold 0.3 mL are known as low-dose syringes. Most insulin syringes are U-100s, designed for use with U-100 strength insulin. Each millilitre of solution contains 100 units of insulin; 1 mL = 100 units.

NEEDLES

Needles come individually packaged to allow flexibility in choosing the right needle for a client. Some needles are preattached to standard-sized syringes. Most needles are disposable and have 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. When inserted into tissue the bevel creates a narrow incision that quickly closes when the needle is removed, preventing leakage of medication, blood or serum. A short-bevelled tip is best for intravenous injections because it is not easily occluded against the inside of a blood vessel wall. Long-bevelled tips are sharper and narrower; this minimises discomfort when entering subcutaneous or intramuscular tissue. Large-diameter, flat-tip needles are only used for drawing up medications (i.e. not used directly on clients).

The nurse chooses the needle length (Figure 31-15) according to the client’s size and weight and the type of tissue into which the medication is to be injected. A child or slender adult generally requires a shorter needle. The nurse uses longer needles (25–38 mm) for intramuscular injections and shorter needles (9–16 mm) for subcutaneous injections.

FIGURE 31-15 Needles. Top to bottom: 19 gauge, 38 mm length; 20 gauge, 25 mm length; 21 gauge, 25 mm length; 23 gauge, 25 mm length; and 25 gauge, 16 mm length.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

The smaller the needle gauge, the larger the needle diameter (Figure 31-15). The selection of a gauge depends on the viscosity of fluid to be injected or infused. An intramuscular injection requires a 23 or 24 gauge needle. Subcutaneous injections require smaller diameter needles such as a 25 or 26 gauge needle. A 26 gauge needle is used for an intradermal injection.

DISPOSABLE INJECTION UNITS

Disposable single-dose, pre-filled syringes are available for some medications (Figure 31-16). The nurse must be careful to check the medication and concentration because all pre-filled syringes appear very similar. With these syringes, the nurse does not have to prepare medication dosages except to expel portions of unneeded medication. Another type of injection system involves screwing a plunger-like device into the end of a pre-filled vial containing a needle. The nurse advances the plunger to expel excess medication as in a regular syringe. After the medication is given, the entire unit is disposed of in an appropriate receptacle (sharps container). This system is designed to reduce the risk of needle-stick injuries.

FIGURE 31-16 A, Carpuject syringe and prefilled sterile cartridge with needle. B, Assembling the Carpuject. C, The cartridge slides into the syringe barrel; turn and lock syringe into the cartridge. D, Screw plunger into end of cartridge. Expel excess medication (not shown) to obtain accurate dose.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Preparing an injection from an ampoule

Ampoules contain single doses of medication in a liquid. Ampoules are available in several sizes, from 1 mL to 10 mL or more. An ampoule may be made of glass or plastic with a constricted neck that must be snapped off to allow access to the medication (Figure 31-17A). A colour ring or a large dot is sometimes placed on the neck to indicate where the ampoule is pre-scored to be broken easily. Aspiration of the medication into a syringe is completed using a drawing-up needle (usually an 18 or 19 gauge needle), which is discarded and replaced by the injection needle (Skill 31-7). A filter needle may be used instead of a drawing-up needle (if required by institutional policy).

FIGURE 31-17 A, Medication in ampoules. B, Medication in vials.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

SKILL 31-7 Preparing injections

DELEGATION CONSIDERATIONS

Preparing injections from ampoules and vials requires the problem-solving and knowledge-application abilities of professional nurses. In some states of Australia and New Zealand, client care attendants or enrolled nurses may legally be able to administer medications via this route. For this procedure, client assessment by the registered nurse is required as delegation may not be appropriate.

EQUIPMENT

• Medication in an ampoule:

— Syringe and two needles (filter needle optional)

— Small gauze pad or alcohol swab

• Medication in a vial:

— Syringe and two needles (filter needle optional)

— Small gauze pad or alcohol swab

— Diluent (e.g. normal saline or sterile water)

• Both:

— Medication administration record (MAR)

STEPS			RATIONALE
1. Review order, including name and medication name, dose, route of administration and time of administration.			Ensures correct administration of medication.
2. Review pertinent information related to medication, including action, purpose, side effects and nursing implications.			Allows nurse to administer medication properly and to monitor client’s response.
3. Check date of expiration of medication vial or ampoule.			Medication potency may increase or decrease when outdated.
4. Assess client’s body build, muscle size and weight.			Determines type and size of syringe and needles for injection.
5. Perform hand hygiene.			Reduces transmission of microorganisms.
6. Prepare medication.
	A. Ampoule preparation
		(1)Tap top of ampoule lightly and quickly with finger until fluid moves from neck of ampoule (see illustration).	Dislodges any fluid that collects above neck of ampoule. All solution moves into lower chamber.
		(2)Place small gauze pad around neck of ampoule.	Placing pad around neck of ampoule protects nurse’s fingers from trauma as glass tip is broken off.
		(3)Snap neck of ampoule quickly and firmly away from hands (see illustration).	Protects nurse’s fingers and face from shattering glass.
		(4)Draw up medication quickly.	System is open to airborne contaminants.
		(5)Hold ampoule upside down, or set it on a flat surface. Insert syringe or filter needle (see agency policy) into centre of ampoule opening. Do not allow needle tip or shaft to touch rim of ampoule.	Broken rim of ampoule is considered contaminated. When ampoule is inverted, solution does dribble out if needle tip or shaft touches rim of ampoule.
Step 6A(1) Tapping ampoule to move fluid down neck	Step 6A(3) Snapping neck away from hands		Step 6A(6) Medication aspirated with (A) ampoule inverted and (B) ampoule on flat surface
		(6)Aspirate medication into syringe by gently pulling back on plunger (see illustration).	Withdrawal of plunger creates negative pressure within syringe barrel, which pulls fluid into syringe.
		(7)Keep needle tip under surface of liquid. Tip ampoule to bring all fluid within reach of the needle.	Prevents aspiration of air bubbles.
		(8)If air bubbles are aspirated, do not expel air into ampoule.	Air pressure may force fluid out of ampoule and medication will be lost.
		(9)To expel excess air bubbles, remove needle from ampoule. Hold syringe with needle pointing up. Tap side of syringe to cause bubbles to rise towards needle. Draw back slightly on plunger, and then push plunger upwards to eject air. Do not eject medication.	Withdrawing plunger too far will remove it from barrel. Holding syringe vertically allows fluid to settle in bottom of barrel. Pulling back on plunger allows fluid within needle to enter barrel so fluid is not expelled. Air at top of barrel and within needle is then expelled.
		(10)If syringe contains excess medication, use sink for disposal. Hold syringe vertically with needle tip up and slanted slightly towards sink. Slowly eject excess medication into sink. Recheck medication level in syringe by holding it vertically.	Medication is safely dispersed into sink. Position of needle allows medication to be expelled without flowing down needle shaft. Rechecking fluid level ensures proper dose.
		(11)Change needle on syringe.	New needle prevents tracking medication through skin and subcutaneous tissues. New needle is sharp and correct gauge and length.
	B. Vial containing a solution
		(1)Remove cap covering top of unused vial to expose sterile rubber seal, keeping rubber seal sterile. If reusing multidose vial, firmly and briskly wipe surface of rubber seal with alcohol swab and allow it to dry.	Vial comes packaged with cap to prevent contamination of rubber seal. Cap cannot be replaced after seal removal. Allowing alcohol to dry prevents needle from being coated with alcohol and mixing with medication.
		(2)Pick up syringe and remove needle cap. Pull back on plunger to draw amount of air into syringe equivalent to volume of medication to be aspirated from vial.	Air must first be injected into vial to prevent build-up of negative pressure in vial when aspirating medication.
		(3)With vial on flat surface, insert tip of needle with bevelled tip entering first through centre of rubber seal (see illustration). Apply pressure to tip of needle during insertion.	Centre of seal is thinner and easier to penetrate. Injecting bevelled tip first and using firm pressure prevent coring of rubber seal, which could enter vial or needle.
Step 6B(3) Inserting needle through centre of rubber seal with vial on flat surface.	Step 6B(5) Vial inverted to allow fluid to be withdrawn.		Step 6B(10) Tapping barrel of syringe to dislodge air bubbles.
		(4)Inject air into the vial’s airspace, holding on to plunger. Hold plunger with firm pressure; plunger may be forced backwards by air pressure within the vial.	Air must be injected before aspirating fluid. Injecting into vial’s airspace prevents formation of bubbles and inaccuracy in dose.
		(5)Invert vial while keeping firm hold on syringe and plunger (see illustration). Hold vial between thumb and middle fingers of non-dominant hand. Grasp end of syringe barrel and plunger with thumb and forefinger of dominant hand to counteract pressure in vial.	Inverting vial allows fluid to settle in lower half of container. Position of hands prevents forceful movement of plunger and permits easy manipulation of syringe.
		(6)Keep tip of needle below fluid level.	Prevents aspiration of air.
		(7)Allow air pressure from the vial to fill syringe gradually with medication. If necessary, pull back slightly on plunger to obtain correct amount of solution.	Positive pressure within vial forces fluid into syringe (unless vial has been used several times).
		(8)When desired volume has been obtained, position needle into vial’s airspace; tap side of syringe barrel carefully to dislodge any air bubbles. Eject any air remaining at top of syringe into vial.	Forcefully striking barrel while needle is inserted in vial may bend needle. Accumulation of air displaces medication and causes dose errors.
		(9)Remove needle from vial by pulling back on barrel of syringe.	Pulling plunger rather than barrel causes plunger to separate from barrel, resulting in loss of medication.
		(10)Hold syringe at eye level, at 90-degree angle, to ensure correct volume and absence of air bubbles. Remove any remaining air by tapping barrel to dislodge any air bubbles (see illustration). Draw back slightly on plunger; then push plunger upwards to eject air. Do not eject fluid.	Holding syringe vertically allows fluid to settle in bottom of barrel. Pulling back on plunger allows fluid within needle to enter barrel so fluid is not expelled. Air at top of barrel and within needle is then expelled.
		(11)Change needle to appropriate gauge and length according to route of medication.	Inserting needle through a rubber stopper may dull bevelled tip. New needle is sharper. Because no fluid is along shaft, needle will not track medication through tissues.
		(12)For multidose vial, make label that includes date of mixing, concentration of medication per millilitre and nurse’s initials.	Ensures that future doses will be prepared correctly. Some medications must be discarded after certain number of days after mixing of vial.
	C. Vial containing a powder (reconstituting medications)
		(1)Remove cap covering vial of powdered medication.	Cap prevents contamination of rubber seal.
		(2)Draw up diluent into syringe following Steps 5B(2) to 5B(10).	Prepares diluent for injection into vial containing powdered medication.
		(3)Insert tip of needle through centre of rubber seal of vial of powdered medication. Inject diluent into vial. Remove needle.	Diluent begins to dissolve and reconstitute medication.
		(4)Mix medication thoroughly. Roll in palms. Do not shake.	Ensures proper dispersal of medication throughout solution. Shaking produces bubbles.
		(5)Draw up the prescribed volume of reconstituted medication into syringe.	Once diluent has been added, concentration of medication (mg/mL) determines dose to be given.
7. Dispose of soiled supplies. Place broken ampoule and/or used vials and used needle in puncture-proof and leakproof sharps container. Clean work area and perform hand hygiene.			Correct disposal of glass and needle prevents accidental injury to staff. Controls transmission of infection.

Preparing an injection from a vial

A vial is a single-dose or multidose container with a rubber seal at the top (Figure 31-17B). A metal or plastic cap protects the seal until it is ready for use. Vials can contain liquid or dry forms of medications; those that are unstable in solution are packaged dry. The vial label or package insert specifies the solvent or diluent used to dissolve the medication and the amount of diluent needed to prepare a desired medication concentration. Normal saline and sterile distilled water are commonly used to dissolve medications. Unlike the ampoule, the vial is a closed system, and air must be injected into it to permit easy withdrawal of the solution. Failure to inject air before drawing up creates a vacuum within the vial that makes withdrawal difficult (Skill 31-7).

Mixing medications

If two medications are compatible, it is possible to mix them in one injection as long as the final volume is within accepted limits for the site to be used. A client will then receive just one injection at a time. Most nursing units have charts that list common compatible medications, as do the manufacturers’ instructions. If there is any uncertainty about medication compatibility, consult a pharmacist.

Mixing medications from two vials

It is no longer best practice (or common) that multiuse vials are used, except sometimes in vaccination programs or in some areas of anaesthetics. However, if multidose vials are used and a client requires one injection drawn from two different multiuse vials, then the nurse applies the following principles when mixing the medications:

• Do not contaminate the contents of one vial with those of another.

• Ensure the final dosage is accurate.

• Maintain aseptic technique.

Only one syringe is needed to mix medications from two vials, assuming both drugs are compatible (Figure 31-18). The nurse takes an appropriately sized syringe with a needle attached and aspirates the volume of air equivalent to the dose of the first medication (vial A). The nurse injects the air into vial A, making sure the needle does not touch the solution. The nurse withdraws the needle, aspirates air equivalent to the dose of the second medication (vial B), and then injects the volume of air into vial B. The nurse immediately withdraws the medication from vial B into the syringe. At this point the medication from vial A has not contaminated vial B. The nurse applies a new sterile needle to the syringe and inserts it into vial A, being careful not to push the plunger and expel the medication within the syringe into the vial. The nurse then withdraws the desired amount of medication from vial A into the syringe. If a vial has excess positive pressure, the plunger may move before the nurse is ready, causing an accidental withdrawal of too much of the medication. If excess medication is withdrawn, the whole solution in the syringe must be discarded; under no circumstances is the excess fluid returned to the vial. After withdrawing the necessary amount, the nurse withdraws the needle and applies a new needle for administration to the client. The process of mixing two medications in one syringe is complex, and should be done only by experienced nurses.

FIGURE 31-18 Steps in mixing medications from two vials.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Mixing medications from one vial and one ampoule

Mixing medications from a vial and an ampoule is simple because it is not necessary to add air to withdraw medication from an ampoule. The nurse prepares medication from the vial first and, using the same syringe and needle, withdraws medication from the ampoule. This technique prevents contamination of the solution in the vial and the needle.

Mixing and preparing insulin

Insulin is the hormone used to treat diabetes mellitus as well as some other medical disorders. It must be administered by injection because it is a protein and therefore would be broken down and destroyed in the GI tract. Most diabetic clients requiring insulin learn to self-administer injections. The medication is available in 100 units per mL of solution. When preparing insulin, the correct syringe must be used. A 100-unit scaled syringe is used to prepare 100-unit insulin (see Figure 31-13C).

Insulin is classified by rate of action, including rapid, intermediate and long-acting. Each type has a different onset, peak and duration of action. A client with diabetes may require more than one type of insulin. For example, by receiving a rapid-acting (regular) and an intermediate-acting (NPH) insulin, a client receives more-sustained control of blood glucose over 24 hours.

Regular insulin is a clear solution that acts rapidly and can be given either subcutaneously or intravenously. Other types of insulin are cloudy because of the addition of a protein, which slows absorption. The slower-acting insulin can be given only subcutaneously.

Insulin is ordered by specific dosage at select times, or by a sliding scale. A sliding scale dictates a certain dosage based on the client’s blood-glucose level (BGL) (Box 31-14). Only regular insulin is used for sliding scales. If more than one type of insulin is required to manage the client’s diabetes, the nurse can mix two different types of insulin into one syringe, provided the volume of the injection is not too large (see Box 31-15). This minimises the discomfort associated with multiple injections. The mixing of insulin, however, is less common today because stable pre-mixed insulin (70% NPH and 30% regular, or 50% of each) is available.

BOX 31-14 EXAMPLE OF SLIDING SCALE INSULIN ORDER (IN UNITS (U) OF INSULIN)

Give regular insulin subcut:

2 U for glucose 5.1–7.0 mmol/L

4 U for glucose 7.1–10 mmol/L

6 U for glucose 10.1–13 mmol/L

For glucose > 13.1 mmol/L, call prescriber.

BOX 31-15 PROCEDURAL GUIDELINES FOR MIXING TWO KINDS OF INSULIN IN ONE SYRINGE

1. Lente insulins (Semilente, Lente, Ultralente) may be mixed with each other, in any ratio.

2. Regular insulin may be mixed with any ratio.

3. Mixing of regular and lente insulin is not recommended except for clients already adequately controlled on such a mixture. This is because of the binding of lente insulin with regular insulin, delaying onset of action.

To prepare insulin from two vials, the nurse or client follows these steps:

1. With an insulin syringe and needle, inject air equal to the dose of insulin to be withdrawn into the vial of modified insulin (cloudy vial). Do not touch the tip of the needle to the solution.

2. Remove the syringe from the vial of modified insulin.

3. With the same syringe, inject air, equal to the dose of insulin to be withdrawn, into the vial of unmodified (regular) insulin (clear vial). Then withdraw the correct dose.

4. Remove the syringe from the unmodified (regular) insulin. Carefully remove air bubbles in the syringe to ensure correct dose.

5. Return to the vial of modified insulin and withdraw the correct dose.

6. Administer mixture of insulins within 5 minutes of preparing it. Regular insulin binds with modified (NPH) insulin, thus reducing the action of the regular insulin.

Always prepare the unmodified (regular) insulin first. This prevents adding modified insulin to the unmodified (regular) vial. If two modified forms are mixed, it makes no difference which vial is prepared first.

Modified from White JR, Campbell RK 1996 In Haire-Joshu D, editor, Management of diabetes mellitus: perspectives of care across the life span, ed 2. St Louis, Mosby.

Before withdrawing insulin from a vial, the vial should be rotated for at least 1 minute between both hands. This re-suspends the modified insulin preparations and helps to warm the medication. Insulin vials should not be shaken. Shaking causes bubbles to form, which take up space and alter the dosage.

Administering injections

Each injection route is unique with regard to the type of tissue into which the medication is to be injected. The characteristics of the tissue involved influence the rate of medication absorption and thus the onset of medication action. Before injecting a medication, the nurse should know the volume of the medication to administer, the medication’s characteristics, including viscosity, and the location of anatomical structures underlying injection sites (Skill 31-8).

SKILL 31-8 Administering injections

DELEGATION CONSIDERATIONS

Administering injections requires the problem-solving and knowledge-application abilities of professional nurses. For this procedure, delegation to nurse assistants is inappropriate. In some states of Australia and New Zealand, client care attendants or enrolled nurses may legally be able to administer medications via this route. For this procedure, client assessment by the registered nurse is required as delegation may not be appropriate.

EQUIPMENT

• Proper size syringe and needle:

— Subcutaneous (subcut): Syringe (1–3 mL) and needle (25 to 26 gauge)

— Intramuscular (IM): Syringe 2–3 mL for adult, 0.5–1 mL for infants and small children. Two needles: 21 to 24 gauge

— Intradermal (ID): 1 mL tuberculin syringe with preattached 26 or 27 gauge needle

• Small gauze pad and/or alcohol swab

• Vial or ampoule of medication or skin test solution

• Disposable gloves

• Medication administration record (MAR)

STEPS			RATIONALE
For all injections
1. Review prescriber’s medication order for client’s name, medication name, dose, time and route of administration.			Ensures safe and correct administration of medication.
2. Assess client’s history of and known response to allergies.			Certain substances have similar compositions; nurse should not administer any substance with known allergic response.
3. Observe verbal and non-verbal responses towards receiving injection.			Injections can be painful. Anxiety can increase pain.
4. Assess for contraindications.
	A. For subcutaneous injections		Reduced tissue perfusion interferes with medication absorption and distribution. Physiological changes of ageing or client illness may influence the amount of SC tissue a client possesses. This influences methods of administering injections.
	Assess for factors such as circulatory shock or reduced local tissue perfusion. Assess adequacy of client’s adipose tissue.
	B. For intramuscular injections		Atrophied muscle absorbs medication poorly. Factors interfering with blood flow to muscles impair medication absorption.
	Assess for factors such as muscle atrophy, reduced blood flow or circulatory shock.
5. Prepare correct medication dose from ampoule or vial (see Skill 31-7). Check carefully. Be sure all air is expelled.			Ensures that medication is sterile. Preparation techniques differ for ampoule and vial.
6. Identify client; check identification bracelet with MAR and ask client’s name.			Ensures correct client receives ordered medication.
7. Explain steps of procedure and tell client injection will cause a slight burning or sting.			Helps minimise client’s anxiety.
8. Close room curtain or door.			Provides privacy.
9. Wash hands thoroughly; apply disposable gloves.			Reduces transfer of microorganisms.
10. Keep sheet or gown draped over body parts not requiring exposure.			Selection of correct injection site may require exposure of body parts.
11. Select appropriate injection site. Inspect skin surface over sites for bruises, inflammation or oedema.
	a. subcut: Palpate sites for masses or tenderness. Avoid these areas. For daily insulin, rotate site daily. Be sure needle is correct size by grasping skinfold at site with thumb and forefinger. Measure fold from top to bottom; needle should be half length.
	b. IM: Note integrity and size of muscle and palpate for tenderness or hardness. Avoid these areas. If injections are given frequently, rotate sites.
	c. ID: Note lesions or discolourations of forearm. Select site three to four fingerwidths below antecubital space and a handwidth above wrist.
Critical decision point: Injection sites should be free of abnormalities that may interfere with medication absorption. Sites used repeatedly can become hardened from lipohypertrophy (increased growth in fatty tissue). An ID site should be clear so that results of skin test can be seen and interpreted correctly.
12. Help client to comfortable position:
	a. subcut: Have client relax arm, leg or abdomen, depending on site chosen for injection.		Relaxation of site minimises discomfort.
	b. IM: Have client lie flat, on side or prone, depending on site chosen.		Reduces strain on muscle and minimises discomfort of injections.
	c. ID: Have client extend elbow and support it and forearm on flat surface.		Stabilises injection site for easiest accessibility.
	d. Talk with client about subject of interest.		Distraction reduces anxiety.
Critical decision point: Ensure that client’s position is not contraindicated by medical condition.
13. Relocate site using anatomical landmarks.			Injection into correct anatomical site prevents injury to nerves, bones and blood vessels.
14. Clean site with an antiseptic swab. Apply swab at centre of the site and rotate outwards in a circular direction for about 5 cm (see illustration).			Mechanical action of swab removes secretions containing microorganisms.
Note: Some agencies may not require the use of alcohol swabs before giving an injection, but the evidence for this is not clear so many agencies will still require this step.
15. Hold swab or gauze between third and fourth fingers of non-dominant hand.			Gauze or swab remains readily accessible when needle is withdrawn.
16. Remove needle cap from needle by pulling it straight off.			Prevents needle from touching and contaminating sides of cap.
17. Hold syringe between thumb and forefinger of dominant hand:
	a. subcut: Hold as dart, palm down (see illustration) or hold syringe across tops of fingertips.		Quick, smooth needle insertion minimises discomfort.
	b. IM: Hold as dart, palm down.
	c. ID: Hold bevel of needle pointing up.		With bevel up, medication is less likely to be deposited into tissues below dermis.
18. Administer injection:
	A. Subcutaneous
		(1)For average-size client, spread skin tightly across injection site or pinch skin with non-dominant hand.	Needle penetrates tight skin more easily than loose skin. Pinching skin elevates subcutaneous tissue and may desensitise area.
		(2)Inject needle quickly and firmly at 45- to 90-degree angle. Then release skin, if pinched.	Injecting medication into compressed tissue irritates nerve fibres.
		(3)For obese client, pinch skin at site and inject needle at 90-degree angle below tissue fold.	Obese clients have fatty layer of tissue above subcutaneous layer.
		(4)Inject medication slowly.	Aspiration of heparin injection may cause the needle to move, creating tissue damage and bleeding (haematoma).
Step 14 Cleaning site using circular motion.	Step 17a Holding syringe as a dart.		Step 18B(3) Pulling back on plunger to aspirate drug.
	B. Intramuscular:
		(1)Position non-dominant hand at proper anatomical landmarks and pull skin down to administer in a Z-track.	Speeds insertion and reduces discomfort. Creates zigzag path through tissues that seals needle track to avoid leaking of medication into subcutaneous tissue.
		(2)If client’s muscle mass is small, grasp body of muscle between thumb and fingers.	Ensures that medication reaches muscle mass.
		(3)Insert needle quickly at 90-degree angle into muscle. After needle enters site, grasp lower end of syringe barrel with non-dominant hand. Move dominant hand to end of plunger. Avoid moving syringe while slowly pulling back on plunger to aspirate drug (see illustration). If blood appears in syringe, remove needle, discard medication and syringe and repeat procedure.	Properly performed injection requires smooth manipulation of syringe parts. Movement of syringe may displace needle and cause discomfort. Aspiration of blood into syringe indicates IV placement of needle; subcut and IM injections are not for IV use (dermis is relatively vascular).
Critical decision point: If blood appears in syringe (indicating needle is in the bloodstream rather than into the muscle), remove needle and dispose of medication and syringe correctly. Repeat preparation procedure.
		(4)Inject medication slowly.	Slow injection reduces pain and tissue trauma.
		(5)Smoothly and steadily withdraw needle and release skin.	Support of tissues around infection site minimises discomfort during needle withdrawal. Some advocate use of dry gauze to minimise client discomfort associated with alcohol on non-intact skin.
	C. Intradermal
		(1)With non-dominant hand, stretch skin over site with forefinger or thumb.	Needle pierces tight skin more easily.
		(2)With needle almost against client’s skin, insert it slowly at a 5- to 15-degree angle until resistance is felt. Then advance needle through epidermis to approximately 3 mm below skin surface. Needle tip can be seen through skin.	Ensures needle tip is in dermis.
		(3)Inject medication slowly. Normally, resistance is felt. If not, needle is too deep; remove and begin again.	Slow injection minimises discomfort at site. Dermal layer is tight and does not expand easily when solution is injected.
		(4)While injecting medication, notice that small bleb approximately 6 mm resembling mosquito bite appears on skin’s surface (see illustration).	Bleb indicates medication is deposited in dermis.
Step 18C(4) Injection creates a small bleb.
19. Withdraw needle while applying alcohol swab or gauze gently over site. Support of tissue around injection site minimises discomfort during needle withdrawal.			Some advocate the use of dry gauze to minimise client discomfort associated with alcohol on non-intact skin.
20. Do not massage site after subcut injection of heparin or insulin or after IM or ID injection.			Massage of site after heparin injection may cause bleeding; massage after insulin injection may increase absorption of insulin. Massage of IM site may cause underlying tissue damage. Massage of ID site may disperse medication into underlying tissue and alter test results.
21. Help client to comfortable position.			Gives client sense of wellbeing.
22. Discard uncapped needle or needle enclosed in safety shield and attached syringe into puncture and leakproof receptacle.			Needles should not be recapped before disposal. Safety shields prevent needle-stick injuries.
23. Remove disposable gloves and perform hand hygiene.			Reduces transmission of microorganisms.
24. Stay with client for 3–5 minutes and observe for any adverse reactions.			Severe anaphylactic reaction is characterised by dyspnoea, wheezing and circulatory collapse.
25. Ask whether client feels any acute pain, burning, numbness or tingling at injection site.			Continued discomfort may indicate injury to underlying bones or nerves.
26. Inspect site, noting any bruising or induration.			Bruising or induration indicates complication associated with injection. Notify nurse in charge or medical officer. Provide warm compress to site.
27. Return to evaluate client’s response to medication in 10-30 minutes. IM medications absorb quickly; undesired effects may also develop rapidly.			Nurse’s observations determine efficacy of medication action.
28. Ask client to explain purpose and effects of medication.			Evaluates client’s understanding of information taught.
29. For ID injections, use skin pencil and draw circle around perimeter of injection site. Read site within 48–72 hours of injection.			Site must be read at various intervals to determine test results. Pencil mark makes site easy to find.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Chart medication dose, route, site, time and date given in medication record. • Report any undesirable effects from medication to nurse in charge or medical officer. • Record client’s response to medications in nurses’ notes.	• Clients with hypertrophy of the skin from repeated insulin injections (common with beef or pork formulations) should be taught not to use the site for 6 months.

Inability to administer injections correctly can have negative consequences. Failure to select an injection site in relation to anatomical landmarks can result in nerve or bone damage during needle insertion. It can also result in failure to administer the drug into the correct tissue, for example intramuscularly instead of subcutaneously. Inability to maintain stability of the needle and syringe unit could result in pain for the client and possibly tissue damage. If the nurse fails to aspirate the syringe before injecting an intramuscular medication, the medication may accidentally be injected directly into an artery or vein. Injecting too large a volume of medication for the site selected causes extreme pain and may result in local tissue damage.

Many clients, particularly children, fear injections. Clients with serious or chronic illness are often given several injections daily. The nurse may be able to minimise a client’s discomfort in the following ways:

• Use topical anaesthetic creams or patches to reduce the sensation of the injection.

• Use a sharp-bevelled needle in the smallest suitable length and gauge.

• Position the client as comfortably as possible to reduce muscular tension.

• Select the proper injection site, using anatomical landmarks.

• Divert the client’s attention from the injection through conversation.

• Insert the needle quickly and smoothly to minimise tissue pulling.

• Hold the syringe steady while the needle remains in tissues.

• Inject the medication slowly and steadily.

• Massage the injected area gently for several seconds (unless contraindicated, e.g. anticoagulants).

There are several different types of injections: subcutaneous, intramuscular and intradermal.

Subcutaneous injections

These involve placing medications into the loose connective tissue under the dermis (Skill 31-8). Because subcutaneous tissue is not as richly supplied with blood, absorption of the medication is somewhat slower than with intramuscular injections. Because subcutaneous tissue contains pain receptors, the client may experience some discomfort. The best subcutaneous injection sites are the outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs (Figure 31-19). The site most often recommended for heparin and insulin injection is the abdomen (Figure 31-20). Other sites include the scapular areas of the upper back and the upper ventral or dorsal gluteal areas.

FIGURE 31-19 Sites recommended for subcutaneous injections.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

FIGURE 31-20 Giving subcutaneous heparin in the abdomen.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

The injection site chosen should be free of skin lesions, bony prominences and large underlying muscles or nerves. Clients with diabetes should practise intra-site rotation of insulin injections. Use of the same part of the body (e.g. abdomen) for a sequence of injections provides more consistency in the absorption of the insulin; the injections should be given at least 2.5 cm away from the previous site. Rotation of sites within an anatomical region ensures more consistent absorption times. Repeated injection into the same site causes a natural immune response, resulting in lipodystrophy.

Only small doses (0.5–1 mL) of water-soluble medications should be given subcutaneously, because the tissue is sensitive to irritating solutions and large volumes of medications. Collection of medications within the tissues can cause a sterile abscess, which appears as a hard, painful lump under the skin.

A client’s bodyweight indicates the depth of the subcutaneous layer, so the nurse must choose the needle length and angle of insertion based on weight. Generally, a 25 gauge 26 mm needle inserted at a 45-degree angle (Figure 31-21) or a 13 mm needle inserted at a 90-degree angle deposits medications into the subcutaneous tissue of a normal-sized client. A child may require only a 13 mm needle. If the client is obese, pinch the tissue and use a needle that is long enough to insert through fatty tissue at the base of the skin fold. The preferred needle length is half the width of the skin fold. Thin clients may have insufficient tissue for subcutaneous injections; the upper abdomen is the best site for injection with thin clients.

FIGURE 31-21 Comparison of angles of insertion for intramuscular (90 degrees), subcutaneous (45 degrees) and intradermal (15 degrees) injections.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

To ensure the medication reaches the subcutaneous tissue, the nurse follows this rule: if 5 cm of tissue can be grasped, the needle should be inserted at a 90-degree angle; if 2.5 cm of tissue can be grasped, the needle should be inserted at a 45-degree angle.

Intramuscular injections

The intramuscular (IM) route provides faster medication absorption than the subcutaneous, because of the greater vascularity of muscle. Muscle is less sensitive to irritating and viscous medications. There is less danger of causing tissue damage when medications enter deep muscle. There is, however, a risk of inadvertently injecting medications directly into blood vessels. The nurse uses a longer and heavier-gauge needle to pass through subcutaneous tissue and penetrate deep muscle tissue. Bodyweight and the amount of adipose tissue can influence needle size selection. For example, an obese client may require a needle 77 mm long, and a thin client may require a needle only 12–25 mm long.

The angle of insertion for an intramuscular injection is 90 degrees (Figure 31-21). A normal, well-developed client can tolerate 3–4 mL of medication into a larger muscle without severe muscle discomfort. A larger volume of medication is unlikely to be absorbed properly. Children, older adults and thin clients can tolerate only 2 mL of an intramuscular injection, and no more than 1 mL is recommended for small children and older infants (Wong and others, 2004).

Repeated injections into the same muscle can cause severe discomfort. With the client relaxed, palpate the muscle to rule out any hardened lesions. Discomfort is minimised by helping the client assume a position which reduces muscle strain.

Intramuscular sites

When selecting an intramuscular site (Box 31-16), consider whether the area is free from infection or necrosis; the presence of localised areas of bruising or abrasions or tenderness; the location of underlying bones, nerves and major blood vessels; and the volume of medication to be administered.

BOX 31-16 CHARACTERISTICS OF INTRAMUSCULAR SITES

VASTUS LATERALIS

• Lacks major nerves and blood vessels.

• Rapid drug absorption.

VENTROGLUTEAL

• A deep site, situated away from major nerves and blood vessels.

• Less chance of contamination in incontinent adults or infants.

• Easily identified by any prominent bony landmark.

DELTOID

• Easily accessible but muscle not well developed in most people.

• Used for small amounts of medications.

• Not used in infants or children with underdeveloped muscles.

• Potential for injury to radial and ulnar nerves or brachial artery.

VENTROGLUTEAL

The ventrogluteal muscle is a safe site for all clients, with a maximum dose of 4 mL. The gluteus medius and minimus are situated deep and away from major nerves and blood vessels. Injuries such as fibrosis, nerve damage, abscess, tissue necrosis, muscle contraction, gangrene and pain are rare.

Locate the muscle by placing the heel of the hand over the greater trochanter of the client’s hip, with the wrist perpendicular to the femur. The right hand is used for the left hip, and the left hand is used for the right hip. Point the thumb towards the client’s groin and the fingers towards the client’s head, point the index finger to the anterosuperior iliac spine and extend the middle finger back along the iliac crest towards the buttock. The index finger, the middle finger and the iliac crest form a triangle, and the injection site is the centre of the triangle (Figure 31-22). The client may lie on the side or the back. Flexing of the knee and hip helps the client relax this muscle.

FIGURE 31-22 A, Landmarks for ventrogluteal site. B, Locating IM injection for ventrogluteal site.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

VASTUS LATERALIS

The vastus lateralis muscle is normally used in adult clients, for volumes up to 5 mL. The muscle is thick and well developed, is located on the anterior lateral aspect of the thigh and extends in an adult from a handwidth above the knee to a handwidth below the greater trochanter of the femur (Figure 31-23). The middle third of the muscle is the suggested site for injection. The width of the muscle usually extends from the midline of the thigh to the midline of the thigh’s outer side. With young children or cachetic (wasted) clients, it helps to grasp the body of the muscle during injection to be sure that the medication is deposited in muscle tissue. To help relax the muscle, ask the client to lie flat with the knee slightly flexed. The injection can also be given while the client is in the sitting position.

FIGURE 31-23 A, Landmarks for vastus lateralis site. B, Giving IM injection in vastus lateralis site.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

DORSOGLUTEAL

The dorsogluteal muscle has been a traditional site for intramuscular injections for volumes of 1–4 mL. Because of the risk of striking major blood vessels or the underlying sciatic nerve and the risk of causing permanent or partial paralysis of the involved leg, this site is not recommended by this text.

DELTOID

Although the deltoid muscle is easily accessible, this muscle is often not well developed and is not recommended for injection volumes over 2 mL. The radial and ulnar nerves and brachial artery lie within the upper arm along the humerus (Figure 31-24). This site should only be used for small volumes of medication, or when other sites are inaccessible. To locate the deltoid muscle, fully expose the client’s upper arm and shoulder (a tight-fitting sleeve should not be rolled up). Ask the client to relax the arm by flexing the elbow. The client may 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 centre of the triangle, about 2.5–5 cm below the acromion process. The site may also be located by placing four fingers across the deltoid muscle, with the top finger along the acromion process. The injection site is then three finger-widths below the acromion process.

FIGURE 31-24 A, Landmark for deltoid site. B, Giving IM injection in deltoid muscle.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

• CRITICAL THINKING

The volume of an ordered IM injection is 4 mL. Identify the muscles you could use to administer this volume, and select the length of needle required for an obese client in this situation.

Special techniques for IM injections

AIR-LOCK TECHNIQUE

Intramuscular injections using the air-lock technique are less irritating to subcutaneous tissues during needle withdrawal. A small volume of air injected behind a bolus of medication clears the needle of medication, preventing it leaking through subcutaneous tissues. This technique should be used only when recommended in the medication information insert. Examples include Wyeth’s vaccines prepared with aluminium adjuvant, diphtheria and tetanus toxoid and the pertussis vaccine. After preparing the proper dose, draw up 0.2 mL of air. The needle is then injected downwards at a 90-degree angle so that the air rises to the top of the medication towards the plunger. As the medication is injected into the muscle, the air follows the medication, creating an air lock (Figure 31-25). Administering the medication with the needle at an angle of less than 90 degrees allows the air to collect along the barrel of the syringe and enter the muscle too soon, causing medication to leak into subcutaneous tissues.

FIGURE 31-25 Administering IM injection by the air-lock technique prevents tracking of caustic medications through subcutaneous tissue.

Z-TRACK METHOD

When irritating preparations such as iron are given intramuscularly, the Z-track method of injection minimises irritation and staining by sealing the medication in muscle tissue. Select an IM site, preferably in larger, deeper muscles such as the ventrogluteal muscle. A new needle must be applied to the syringe after preparing the medication so that no solution remains on the outside needle shaft. After preparing the site with an antiseptic swab, pull the overlying skin and subcutaneous tissues approximately 2.5–3.5 cm to the side. Holding the skin taut with the non-dominant hand, inject the needle deep into the muscle. If there is no blood return on aspiration, the nurse injects the medication slowly. The needle remains inserted for 10 seconds to allow the medication to disperse evenly. Withdraw the needle and then release the skin. This leaves a zigzag path that seals the needle track where tissue planes slide across one another (Figure 31-26). The medication cannot escape from the muscle tissue. Massage of the site is contraindicated as it could force medication into subcutaneous tissues.

FIGURE 31-26 A, Pulling on overlying skin during IM injection moves tissue to prevent later tracking. B, The Z-track left after injection prevents the deposit of medication through sensitive tissue.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Intradermal injections

The nurse typically gives intradermal injections for skin testing, for example tuberculin screening and allergy tests. These medications are potent, so they are injected into the dermis, where blood supply is reduced and medication absorption occurs slowly. A client may have a severe anaphylactic reaction if the medication enters the circulation too rapidly.

Skin testing requires the nurse to be able to clearly see the injection sites for changes in colour and tissue integrity. Intradermal sites should be lightly pigmented, free of lesions and relatively hairless. The inner forearm and upper back are ideal locations.

The nurse uses a small hypodermic syringe for skin testing. The angle of insertion for an intradermal injection is 5–15 degrees (see Figure 31-21). As the nurse injects the medication, a small bleb (bubble) resembling a mosquito bite should appear on the skin’s surface. If a bleb does not appear or if the site bleeds after needle withdrawal, there is a good chance that the medication entered subcutaneous tissues. In this case, test results will be invalid.

Safety in administering medications by injection

Needleless devices

A large number of needle-stick injuries occur in healthcare settings each year. These injuries commonly occur when nurses forget to recap needles, mishandle intravenous lines and needles or contact stray needles left at a client’s bedside. The risk of exposure of health workers to blood-borne pathogens has led to the development of ‘needleless devices’ or special needle safety devices. Special syringes designed with a sheath or guard that covers the needle after it is withdrawn from the skin are available (Figure 31-27). The needle is immediately covered, eliminating the chance of a needle-stick injury. The syringe and sheath are disposed of together in a sharps receptacle. ‘Needleless’ syringes (e.g. Interlink system) for use with needleless injection ports on intravenous lines are widely used.

FIGURE 31-27 Needle with plastic guard to prevent needle-sticks. A, Position of guard before injection. B, After injection the guard locks in place, covering the needle.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Needles and other instruments considered ‘sharps’ are always disposed of into clearly marked sharps containers (Figure 31-28). Containers should be puncture- and leak-proof. A needle should never be forced into a full receptacle.

FIGURE 31-28 Sharps disposal using only one hand.

Needle recapping

The practice of recapping contaminated needles is not recommended and is against institutional policy.

Intravenous administration

The nurse administers medications intravenously by the following methods:

• as mixtures, within large volumes of IV fluids

• by injection of a bolus, or small volume, of medication through an existing intravenous infusion line or intermittent venous access (referred to as a heparin or medication lock)

• by ‘piggyback’ infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line.

• direct intravenous injection into the vein via a 21–25 gauge needle and syringe.

In the first three methods, the client has either an existing IV infusion line or an access site, such as an intermittent infusion. The IV route is often used in emergencies when a fast-acting medication must be delivered quickly (Skill 31-9).

SKILL 31-9 Adding medications to intravenous fluid containers

DELEGATION CONSIDERATIONS

Adding medications to IV fluid containers requires the problem-solving and knowledge-application abilities of professional nurses. For this procedure, delegation to nurse assistants is inappropriate. (In some institutions the pharmacist may add medications to primary containers of IV solutions.)

EQUIPMENT

• Vial or ampoule of prescribed medication

• Syringe of appropriate size (5–20 mL)

• Sterile interlink cannula or needle (19 to 21 gauge) with special filters (optional)

• Correct diluent (e.g. sterile water, normal saline)

• Sterile IV fluid container of ordered fluid volume

• Alcohol or antiseptic swab

• Label to attach to IV bag or bottle

• Medication administration record (MAR)

STEPS		RATIONALE
1. Check prescriber’s order to determine type of IV solution to use and type of medication and dosage.		Client’s overall physical condition dictates type of IV solution used. Ensures safe and accurate medication administration.
2. Collect information necessary to administer drug safely, including action, purpose, side effects, normal dose, time of peak onset and nursing implications.		Allows nurse to give medication safely and to monitor client’s response to therapy.
3. When more than one medication is to be added to IV solution, assess for compatibility of medications.		Medications are often incompatible when mixed together. Chemical reactions that occur result in clouding or crystallisation of IV fluids. Check clinical agency policy for approved medication compatibility list.
4. Assess client’s systemic fluid balance, as reflected by skin hydration and turgor, bodyweight, pulse, blood pressure and urine output.		Danger of continuous IV infusions is that fluids may infuse too rapidly, causing circulatory overload.
5. Assess client’s history of medication allergies.		IV administration of medications causes rapid effects. Allergic response can be immediate.
6. Assess IV insertion site for signs of infiltration or phlebitis.		An intact, properly functioning site ensures medication is given safely.
7. Perform hand hygiene and use gloves if this is agency policy (i.e. for cytotoxic or antibiotic medicines).		Reduces transfer of microorganisms.
8. Assemble supplies in medication room (or other area as designated by clinical agency).		Ensures orderly procedure, with less likelihood of contaminating supplies.
9. Prepare prescribed medication from vial or ampoule (see Skill 31-7).		Ensures accurate delivery of medication.
10. Identify client by reading identification band and asking name. Compare with MAR.		Ensures correct client receives medication.
11. Assess client’s understanding of purpose of medication therapy.		May reveal need for education.
12. Add medication to new container (usually done in medication room):
	a. Solution in a bag: locate medication injection port on plastic IV solution bag. Port has small stopper at end. Do not select port for the IV tubing insertion or air vent.	Medication injection port is self-sealing to prevent introduction of microorganisms after repeated use.
	b. Solution in a bottle: locate injection site on IV solution bottle, which is often covered by a cap.	Accidental injection of medication through main tubing port or air vent can alter pressure within bottle and cause fluid leaks through air vent. Cap seals bottle to maintain its sterility.
	c. Wipe off port or injection site with alcohol/antiseptic swab (see illustration).	Reduces risk of introducing microorganisms.
	d. Remove needle cap or sheath from syringe and insert needle of syringe or needleless device through centre of injection port or site; inject medication (see illustration).	Injection of needle into sides of port may produce leak and lead to fluid contamination.
	e. Withdraw syringe from bag or bottle.
	f. Mix medication and IV solution by holding bag or bottle and turning it gently end to end.	Allows even distribution of medication.
	g. Complete medication label with name and dose of medication, date, time and nurse’s initials and attach to bottle or bag (see illustration). Optional (check agency policy): Apply a flow strip that identifies the time the solution was hung and intervals indicating fluid levels. Spike bag or bottle with IV tubing and prime the tubing with the fluid.	Label can be easily read during infusion of solution. Informs nurses and other healthcare workers of contents of bag or bottle. Priming the line removes the air within the tubing which reduces risk of air embolism.
Step 12c Wiping port with alcohol/antiseptic swab.	Step 12d Injecting medicine through centre of port.	Step 12g Completing medication label.
Critical decision point: Do not use felt-tip markers on plastic surfaces. The ink can penetrate the plastic and leak into the IV solution.
13. Bring assembled items to client’s bedside and check client’s name against the prescriber’s orders.		Ensures correct client receives ordered medication.
14. Prepare client by explaining that medication is to be given through existing IV line or one to be started. Explain that no discomfort should be felt during medication infusion. Encourage client to report symptoms of discomfort.		Most IV medications do not cause discomfort when diluted. Pain at insertion site may be early indication of infiltration.
15. Regulate infusion at prescribed rate.		Prevents rapid infusion of fluid.
16. Add medication to existing container:
	a. Prepare vented IV bottle or plastic bag:
	(1)Check volume of solution remaining in bottle or bag.	Ensures the appropriate minimal volume is available to dilute medication adequately.
	(2)Close off IV infusion clamp.	Prevents medication from directly entering circulation as it is injected into bag or bottle.
	(3)Wipe off medication port with an alcohol or antiseptic swab.	Mechanically removes microorganisms that could enter container during needle insertion.
	(4)Insert syringe needle or needleless device through injection port and inject medication.	Injection port is self-sealing and prevents fluid leaks.
	(5)Lower bag or bottle from IV pole and gently mix. Rehang bag.	Ensures medication is evenly distributed.
	b. Complete medication label and attach it to bag or bottle.	Informs nurses and doctors of contents of bag or bottle.
	c. Regulate infusion to desired rate.	Prevents rapid infusion of fluid.
17. Properly dispose of equipment and supplies. Do not cap needle on syringe. Specially sheathed needles are discarded as a unit with needle covered.		Proper disposal of needle prevents injury to nurse and client. Capping of needles increases risk of needle-stick injuries.
18. Perform hand hygiene.		Reduces transmission of microorganisms.
19. Observe client for signs or symptoms of adverse reaction.		IV medications can cause rapid effects.
20. Observe for signs and symptoms of fluid volume excess.		Rapid uncontrolled infusion can cause circulatory overload.
21. Periodically return to client’s room to assess IV insertion site and rate of infusion.		Over time IV site may become infiltrated or cannula may become malpositioned. Flow rate may change according to client’s position or volume left in container.
22. Observe for signs or symptoms of IV infiltration.		Infiltrated medications can injure tissue.
RECORDING AND REPORTING
• Record solution and medication added to parenteral fluid on appropriate form. • Report any adverse reactions to nurse in charge or prescriber.

When using any method of IV medication administration, clients must be closely observed for symptoms of adverse reactions; this includes assessing vital signs before, during and after infusion. After a medication enters the bloodstream, it begins to act immediately and there is no way to stop its action. Special care must be taken to avoid errors in dose calculation and preparation. The seven rights of safe medication administration should be double-checked and the desired action and side effects known. The known antidote should be available during administration. The nurse uses the principles of aseptic non-touch technique when preparing and administering IV medications (see Chapter 29).

The IV route is best when it is necessary to establish constant therapeutic blood levels. Medications which are highly alkaline and irritating to muscle and subcutaneous tissue cause less discomfort when given intravenously.

Large-volume infusions

Of the methods of administering IV medications, mixing medications in large volumes of fluids is the safest and easiest. Medications are diluted in large volumes (500 mL or 1000 mL) of compatible IV fluids, such as normal saline or dextrose solution. In some agencies the pharmacist adds medications to the primary container of IV solution to ensure asepsis. Because the medication is not in a concentrated form, the risk of side effects or fatal reactions is reduced when infused over the prescribed timeframe. Vitamins and potassium chloride are two types of medications commonly added to IV fluids.

Intravenous infusions which contain drugs should be administered via a volume-controlled system to ensure the medication is given at the ordered rate. If the volume is given too quickly, the risk of adverse reactions or side effects (e.g. fluid overload, drug overdose or cardiac arrest) is increased; slow administration, however, may not allow the medication to reach therapeutic levels.

Intravenous bolus

An IV bolus involves introducing a concentrated dose of a medication directly into the systemic circulation via the side-arm of the IV giving set or directly into an IV cannula (Skill 31-10). The use of a bolus which requires only a small amount of fluid to deliver the medication is an advantage when the client’s daily fluid intake is restricted.

SKILL 31-10 Administering medications by intravenous bolus

DELEGATION CONSIDERATIONS

Administering medications by intravenous bolus requires the problem-solving and knowledge-application abilities of professional nurses. For this procedure, delegation to nurse assistants is inappropriate.

DEFINITIONS

Bolus: method of rapid IV medication administration; refers to the concentration or amount of medication.

Flush: solution (usually 5–10 mL normal saline) is slowly administered to check patency of cannula; to flush medication from cannula or to create a lock (saline or heparin).

EQUIPMENT

IV medication (existing infusion):

• Disposable gloves

• Medication in vial or ampoule

• Syringe

• Needleless device or sterile needles (21 and 25 gauge)

• Antiseptic swab

• Watch with second-hand or digital readout

• Medication administration record (MAR)

IV flush (IV lock):

• Disposable gloves

• Medication in vial or ampoule

• Syringe

• Vial of appropriate flush solution (5–10 mL saline most common, but heparin may also be used; if heparin is used, most common concentration is 10–100 units; check agency policy)

• Needleless device or sterile needles (21 and 25 gauge)

• Alcohol or antiseptic swab

• Watch with second-hand or digital readout

• Medication administration record (MAR)

STEPS				RATIONALE
1. Check the prescriber’s order for type, dosage, route and time of medication.				Ensures safe and accurate medication administration.
2. Assess IV insertion site for signs of infiltration or phlebitis.				Confirming the placement of the IV catheter and the integrity of the surrounding tissue ensures that the medication is administered safely.
3. If medication is to be pushed into an IV line, assess the patency of the line.				The IV line must be patent for medication to reach venous circulation effectively.
4. Prepare ordered medication from vial or ampoule (see Skill 31-7). Read directions carefully for proper IV dilution of medications.				Directions can be found in Australian Injectable Handbook, from package instructions or in MIMS Annual.
5. After drawing up medications, remove the needle (for needleless system) otherwise apply a small-gauge needle to the syringe (this system is rarely used).				Used to insert through IV line with needle system only.
6. Perform hand hygiene. Put on gloves.				During IV bolus administration, risk of blood exposure is low. However, nurse may manipulate IV dressing or expose site while completing other activities. Gloves reduce exposure.
7. Check client’s identification by looking at identification bracelet and asking name and any known allergies.				Ensures that medication is administered to correct client.
8. Administer medications by IV medication (existing infusion):
	a. Select injection port of IV tubing closest to client. (Circle on port may indicate site for needle insertion.) If add-on 0.22 micrometre filter is used, give medication below filter next to client.			Allows for easier fluid aspiration to obtain blood return. Injection ports are self-sealing and will not leak.
	b. Clean injection port with antiseptic swab. Allow to dry.			Prevents introduction of microorganisms during needle insertion.
	c. Connect syringe to IV line (needleless) or insert needle of syringe containing prepared drug through centre of injection port (see illustration).			Prevents damage to port’s diaphragm and subsequent leakage.
	d. Check patency (Box 31-17) to ensure safe and adequate medication administration.			Final check that medication is being delivered into the bloodstream.
	e. Leave concurrent compatible infusion running and inject medication slowly over several minutes as per directions on medication package. Use watch to time administration (see illustration).			Ensures safe medication infusion. Rapid injection of IV medication can prove fatal.
	f. After injecting medication, withdraw syringe, and recheck fluid infusion rate.			Injection of bolus may alter rate of fluid infusion. Rapid fluid infusion can cause circulatory overload.
Step 8c Connecting syringe to needleless IV line.				Step 8e Using a watch to time administration of medication.
9. Administer medications into IV cannula (non-concurrent infusion) (IV lock or a needleless system):
	A. Prepare flushing solutions			Flush solution keeps heparin lock patent after medication is administered.
		(1)Flushing with heparin:
			a. Prepare syringe with heparin flush solution as per prescriber’s orders.
			b. Prepare 2 syringes with 5-10 mL of normal saline.
		(2)Flushing with saline only:
			a. Prepare 2 syringes with 5-10 mL of normal saline each.
	B. IV lock
		(1)Clean lock’s rubber diaphragm with antiseptic swab.		Prevents introduction of microorganisms during needle insertion.
		(2)Insert needle of syringe containing normal saline through centre of diaphragm (only for needle-based systems)
		(3)Pull back gently on syringe plunger and look for blood return.		Determines whether IV needle or catheter is positioned in vein.
Critical decision point: At times a heparin lock will not yield a blood return even though the lock is patent.
		(4)Flush reservoir with saline by pushing slowly on plunger.		Clears needle and reservoir of blood.
Critical decision point: Observe closely the area of skin above the IV catheter. Note any puffiness or swelling as the reservoir is flushed, which could indicate infiltration into the tissues, requiring removal of the catheter.
		(5)Remove needle and syringe.
		(6)Clean lock’s diaphragm with antiseptic swab.		Prevents transmission of infection.
		(7)Insert needle of syringe containing prepared medication through centre of diaphragm (see illustration).		Using centre of diaphragm prevents leakage.
Step 9B(7) Inserting needle of syringe through centre of lock diaphragm.
		(8)Inject medication bolus slowly over several minutes. (Each medication has recommended rate for bolus administration. Check package directions.) Use watch to time administration.		Rapid injection of IV medication can result in death.
		(9)After administering bolus, withdraw syringe.
		(10)Clean lock’s diaphragm with antiseptic swab.		Prevents transmission of microorganisms.
		(11)Repeat injection of normal saline.		Flushes reservoir and needle of medication.
		(12)Heparin flush: insert needle of syringe containing heparin through diaphragm. Inject heparin slowly, and remove syringe.		Maintains patency of needle by inhibiting clot formation.
	C. IV needleless valve cap
		(1)Insert syringe (without a needle) containing normal saline into the valve.
		(2)Flush reservoir with saline by pushing slowly on plunger.		Clears reservoir of any blood.
		(3)Remove the syringe.
		(4)Insert syringe containing prepared medication into the valve.
		(5)Inject medication slowly over several minutes. Follow precautions in Step 9B(8).		Rapid injection of IV drug can result in death.
		(6)After administering bolus, withdraw syringe.
		(7)Repeat injection of 1 mL of normal saline.
		(8)See Step 9B(12).
		(9)Replace sterile cap over valve.
RECORDING AND REPORTING
• Record medication, dose, time and route on appropriate form. • Report any side effects immediately to prescriber, because they could be life-threatening.

The IV bolus is the most dangerous method of administering medications, because there is no time to correct errors. In addition, a bolus may cause direct irritation to the lining of blood vessels.

Before administering a bolus, the nurse confirms placement and patency of the IV line (Box 31-17). Accidental injection of a medication into the tissues around a vein can cause pain, sloughing of tissues, abscesses and even tissue necrosis, depending on the medication’s composition. The rate of administration of an IV bolus medication is usually determined by the amount of medication that can be given each minute. The rate of infusion is critical and the nurse must resist the temptation to hurry the procedure. The nurse should determine the recommended concentration and rate of administration, the purpose for which a medication is prescribed and any potential adverse effects related to the rate or route of administration. It is important that the rate of infusion is slowed if the client complains of pain. The bolus should be stopped immediately if the client shows any signs of adverse effects of the medication.

BOX 31-17 PROCEDURAL GUIDELINES FOR CHECKING THE PATENCY OF AN INTRAVENOUS CANNULA

Flushing—not always a reliable indicator, as little resistance may be experienced even when cannula has tissued.

Lack of pain around the IV site—problematic, as infiltration of isotonic solutions generally does not produce discomfort.

Oedema and coolness of IV site—a medication should never be given intravenously if the insertion site appears puffy or oedematous or the IV fluid cannot flow at the proper rate. This is not always descriptive of extravasation, for it depends on the site and previous status of tissues.

Checking for blood return—the inability to obtain a blood return may suggest that the needle or catheter is in the client’s tissues or is resting against the vein wall. Unreliable, as blood may flow freely with seepage of solution into tissues around the cannula.

Obstructing the venous flow above the cannula by the application of a tourniquet or occlusion by finger pressure—may be advised in determining patency. If the IV cannula is in the vein, the flow rate will decrease or stop with obstruction of venous flow; whereas with infiltration, the flow rate will continue unchanged.

Patient-controlled analgesia (PCA) is one form of bolus administration (see Chapter 41). A small-volume infusion pump or syringe pump/syringe-driver (Figure 31-29) is equipped with a handheld button which, when pressed by the client, delivers a pre-set dose of the medication as a bolus. PCA allows clients to assess and treat their pain on a continuous basis. For a PCA to be effective, the client must be well informed on how the device works and have the coordination to use the handset.

FIGURE 31-29 Small-volume infusion pump.

Image: Dreamstime/Linqong.

Volume-controlled infusions

Control of the volume of fluid or medication administered via an intravenous infusion is very important, especially if the client is young or elderly, or if the medication in the infusion has serious side effects or is given in small doses. Using volume-controlled infusions has several advantages:

• It reduces the risk of rapid-dose infusion by IV push. Medications are diluted and infused over a longer time, for example, 30–60 minutes.

• It allows administration of medications while they are still in a stable condition (e.g. antibiotics are stable for a limited time in solution).

• It allows control of IV fluid intake.

• It may be used to allow clients to control their own medication use (i.e. PCA).

One way of administering a medication IV is to mix it with a small amount (50–100 mL) of compatible IV fluid. The fluid is within a secondary fluid container separate from the primary infusion. The secondary infusion connects directly to the primary IV line or to separate tubing that inserts into the primary line.

Three volume-control infusion methods are commonly used in Australasia: a secondary small-volume drip chamber or burette placed between the client and the primary infusion, a piggyback and/or tandem set and mechanical ‘pumps’.

VOLUME-CONTROL ADMINISTRATION SETS

Volume-control administration sets (burettes) are small (50–150 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. The priming filling of the set varies, however, depending on the type of filter (floating valve or membrane) within the set. Follow package directions for priming sets.

LARGE VOLUME-CONTROLLED SYSTEM

This system is a mains-power or battery-operated pump which controls the rate at which the infusion is delivered, and supplies a history of how much fluid has been delivered, the rate of delivery and any problems (alarms) which may have been encountered. There are many pumps available and the nurse must be careful to set up and run the device according to the manufacturer’s instructions. An example of a volume-controlled system is shown in Skill 31-11.

SKILL 31-11 Administering intravenous medications by piggyback/tandem set-up, intermittent intravenous infusion sets and mini-infusion pumps

DELEGATION CONSIDERATIONS

Administering medications by IV fluid by piggyback/tandem set-up, intermittent intravenous infusion sets and mini-infusion pumps requires the problem-solving and knowledge-application abilities of professional nurses. For this procedure, delegation is inappropriate.

EQUIPMENT

Piggyback, tandem or mini-infusion pump

• Gloves (for connecting IV tubing)

• Medication prepared in 5–150 mL labelled infusion bag or syringe

• Short microdrip or macrodrip tubing set for piggyback/tandem

• Needleless device

• Needles (21 or 23 gauge, only if stopcocks or other needleless methods are not available)

• Stopcocks

• Mini-infusion pump

• Adhesive tape (optional)

• Alcohol or antiseptic swab

• IV pole or rack

• Medication administration record (MAR)

Volume-control administration set

• Gloves (for connecting IV tubing)

• Burette

• Infusion tubing (may have needleless system attachment)

• Syringe (5–20 mL)

• Vial or ampoule of ordered medication

• Medication label

• Medication administration record (MAR)

STEPS				RATIONALE
1. Check prescriber’s order to determine type of IV solution to be used, type of medication, dose, route and time of administration.				Client’s overall physical condition dictates type of IV solution used. Ensures safe and accurate medication administration.
2. Collect information necessary to administer medication safely, including action, purpose, side effects, normal dose, time of peak onset and nursing implications.				Allows nurse to give medication safely and to monitor client’s response to therapy.
3. Assess patency of client’s existing IV infusion line (Box 31-17).				IV line must be patent for medication to reach venous circulation effectively.
4. Assess IV insertion site for signs of infiltration or phlebitis: redness, pallor, swelling, tenderness on palpation.				Confirmation of placement of IV needle or catheter and integrity of surrounding tissues ensures medication is administered safely.
5. Assess client’s history of medication allergies.				Effects of medications can develop rapidly after IV infusion. Nurse should be aware of clients at risk.
6. Assemble supplies at bedside. Inform client that medication will be given through IV equipment.				Medication preparation is not usually required. Nurse may assemble infusion tubing and bag of medication in medication room or client’s room. Allows client to understand procedure and minimises anxiety.
7. Perform hand hygiene and put on gloves.				Reduces transmission of infection. During handling of IV tubing there is some risk of blood exposure.
8. Check name on MAR with client’s identification bracelet and ask client’s name and any known allergies.				Ensures medication is administered to correct client.
9. Assess client’s understanding of purpose of medication therapy.				May reveal need for education.
10. Explain purpose of medication and side effects to client and explain that medication is to be given through existing IV line. Encourage client to report symptoms of discomfort at site.				Keeps client informed of planned therapies.
11. Administer infusion:
	A. Piggyback or tandem infusion
		(1)Connect infusion tubing to medication bag. Allow solution to fill tubing by opening regulator flow clamp (priming).		Infusion tubing should be filled/primed with solution and free of air bubbles to prevent air embolus.
		(2)Hang piggyback medication bag above level of primary fluid bag. (Hook may be used to lower main bag.) Hang tandem infusion at same level as primary fluid bag (see illustration).		Height of fluid bag affects rate of flow.
		(3)Connect tubing of piggyback or tandem infusion to appropriate connector on primary infusion line:
			a. Stopcock: Wipe off stopcock port with alcohol swab and connect tubing. Turn stopcock to open position.	Stopcock eliminates need for needle.
			b. Needleless system: Wipe off needleless port, and insert tip of piggyback or tandem infusion tubing (see illustration).	Establishes route for IV medication to enter main IV line.
		(4)Regulate flow rate of medication solution by adjusting regulator clamp. (Usually medication should infuse within 20-90 min.) Make your client comfortable and stay with them for 3-5 mins to watch for signs of allergic reaction.		Provides slow, intermittent infusion of medication in 20-90 min; maintains therapeutic blood levels. Read medication package insert for specific information on how long to infuse the medication.
		(5)After medication has infused, check flow regulator on primary infusion. Back-check valve on piggyback stops flow of the primary infusion until second medication infuses. The tandem and primary infusions flow together until the tandem set empties.		Valve prevents backup of medication into main infusion line. Checking flow rate ensures proper administration of IV fluids.
		(6)Regulate main infusion line to desired rate, if necessary.		Infusion of piggyback may interfere with the main line infusion rate.
		(7)Leave secondary bag and tubing in place for future medication administration or discard in appropriate containers.		Establishment of secondary line produces route for microorganisms to enter main line. Repeated changes in tubing increase risk of infection transmission (check clinical agency policy).
Step 11A(2) Position of tandem infusion bag.				Step 11A(3)b Needleless system: inserting tip of piggyback infusion tubing into port.
	B. Volume-control administration set (e.g. burette)
		(1)Assemble supplies in medication room.		Controls risk of contaminating IV solution.
		(2)Prepare medication from vial or ampoule (see Skill 31-7).		Ensures medication is sterile.
		(3)Explain procedure to client. Encourage client to report symptoms of discomfort at site. Check client’s name against prescriber’s orders and assess client’s condition to ascertain if it is appropriate to administer medication.		Keeps client informed of planned therapies.
		(4)Fill burette chamber with desired amount of fluid (50-100 mL) by opening clamp between chamber and main IV bag (see illustration).		Small volume of fluid dilutes IV medication and reduces risk of too-rapid infusion.
		(5)Close clamp and check to be sure clamp on air vent of chamber is open.		Prevents additional leakage of fluid into chamber. Air vent allows fluid in chamber to exit at regulated rate.
		(6)Clean injection port on top of chamber with antiseptic swab.		Prevents introduction of microorganisms during medication insertion.
		(7)Remove needle cap or sheath and insert syringe needle through port, then inject medication (see illustration). Gently rotate chamber between hands. If burette has a needleless valve then inject medication directly into the burette with the syringe only.		Rotating mixes medication with solution in chamber to ensure equal distribution.
Step 11B(4) Filling burette chamber with fluid from main IV bag.				Step 11 B(7) Injecting medication into burette chamber.
		(8)Regulate IV infusion rate to allow medication to infuse at the required rate.		For optimal therapeutic effect, medication should infuse in prescribed time interval.
		(9)Label chamber with name of medication, dosage, total volume including diluent and time of administration.		Alerts nurses to medication being infused. Prevents other medications from being added to chamber.
		(10)Dispose of uncapped needle or needle enclosed in safety shield and syringe in proper container. Remove gloves and wash your hands.		Prevents accidental needle-stick injuries and transfer of microorganisms.
		(11)Make your client comfortable and stay with them for 3-5 minutes to ensure that they have not had any adverse reactions. During the infusion ensure you check the infusion rate and condition of the IV site.		Ensures timely intervention can occur in the case of allergy or infiltrated IV site.
		(12)After the medicine has infused, check and regulate the flow of the primary infusion. Leave secondary bag and tubing in place for future medicine administration or discard according to agency policy.
	C. Mini-infusor/syringe driver administration
		(1)Connect prefilled syringe to mini-infusion tubing.		Special tubing designed to fit syringe delivers medication to main IV line.
		(2)Carefully apply pressure to syringe plunger, allowing tubing to fill with medication.		Ensures tubing is free of air bubbles to prevent air embolus.
		(3)Place syringe into mini-infusor/syringe driver pump (follow product directions). Be sure syringe is secure.
		(4)Connect mini-infusion tubing to main IV line.
			(a)Stopcock: Wipe off stopcock port with alcohol swab and connect tubing. Turn stopcock to open position.	Stopcock reduces risk of needle-stick injuries.
			(b)Needleless system: Wipe off needleless port and insert tip of mini-infusor tubing.	Needleless system reduces risk of needle-stick injuries.
		(5)Explain purpose of medication and side effects to client and explain that medication is to be given through existing IV line. Ask client to report symptoms of discomfort at site. Check client’s name against prescriber’s orders and assess client’s condition to ascertain if it is appropriate to administer medication.		Informs client of planned therapies and assesses if medicine is given to the correct client.
		(6)Hang infusion pump with syringe on IV pole alongside main IV bag. Press button on pump to begin infusion. Optional: set alarm.		Pump automatically delivers medication at safe, constant rate based on volume in syringe. (Alarm is used if medication is delivered into heparin/saline lock.)
		(7)Remove disposable gloves. Wash hands.		Reduces transmission of infection.
12. Observe client for signs of adverse reactions.				IV medications act rapidly.
13. During infusion, periodically check infusion rate and condition of IV site.				IV must remain patent for proper medication administration. Development of infiltration necessitates discontinuing infusion.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Record medication, dose, route and time administered on MAR. • Record volume of fluid in medication bag or chamber on intake and output form. • Report any adverse reactions to nurse in charge or prescriber.	• Ensure that all needles contaminated by blood are disposed of in puncture-resistant containers (e.g. small sharps container, or if not available a coffee tin while a sharps container is being organised). • Piggyback tubing and intravenous container should be disposed of in non-puncture container or according to agency policy.

MINI-INFUSOR OR SYRINGE-PUMP

A mini-infusor pump is mains-powered or battery-operated and allows medications to be given in very small amounts (5–60 mL) within controlled infusion times, often using standard syringes (Figure 31-29). It is important that the infusion site is checked regularly for signs of puffiness, redness or pain (signs that IV has ‘tissued’). Mechanical devices may continue the infusion without problems even if the site is damaged.

PIGGYBACK INFUSION

A piggyback is a small IV bag or bottle (25–100 mL) connected to short tubing lines that in turn connect to the upper port of a primary infusion line, or to an intermittent venous access. 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 set-up, the main line does not infuse when the piggybacked medication is infusing. The port of the primary IV line contains a back-check valve that automatically stops 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 again flows. The term ‘piggyback line’ is often used for the tandem infusion method described below.

A tandem infusion set-up is a small IV bag or bottle (25–100 mL) connected to a short tubing line in the lower port of a primary infusion line, or to an intermittent venous access line. The tandem set is placed at the same height as the primary infusion bag or bottle. In the tandem set-up, the tandem and the main line infuse simultaneously. The nurse must monitor the tandem set-up closely. If the tandem set-up is not immediately clamped when the medication is infused, the IV solution from the primary line will back up into the tandem line.

INTERMITTENT VENOUS ACCESS

An intermittent venous access is an IV catheter not connected to an infusion, and is used for medication administration at designated intervals (Figure 31-30). If it is inserted peripherally it is often called an ‘IV bung’; other devices may be inserted centrally (Portacath or peripherally inserted central catheter (PICC line) which may give intermittent venous access also).

FIGURE 31-30 Intermittent lock covered with a rubber diaphragm. Requires a needle to flush.

From Potter PA, Perry AG 2002 Fundamentals of nursing, ed 5. St Louis, Mosby.

The advantages of intermittent venous access include:

• cost savings resulting from the omission of continuous IV therapy

• convenience to the nurse by eliminating constant monitoring of flow rates

• increased mobility, safety and comfort for the client.

Prior to medication administration the cannula must be checked for patency (see Box 31-17). After an IV bolus or piggyback medication has been administered through an intermittent venous access, the access must be flushed with a solution to maintain patency and to ensure that all of the medication is administered into the vein. It is now widely accepted that normal saline is as effective as the traditionally used heparin flush solution for peripheral catheters.

KEY CONCEPTS

• Learning medication classifications improves understanding of nursing implications for administering medications with similar characteristics.

• Medication legislation regulates the production, distribution, prescription and administration of medications.

• All controlled substances are handled according to strict procedures that account for each medication.

• The nurse applies understanding of the physiology of medication action when timing administration, selecting routes, initiating actions to promote medication efficacy and observing responses to medications.

• The older person’s body undergoes structural and functional changes that alter actions of medication and influence the manner in which nurses provide medication therapy.

• Children’s medication doses are calculated on the basis of body surface area and/or weight.

• Each medication order should include the client’s name, the order date, the medication name, dosage, route and time of administration and the prescriber’s signature.

• A medication history should reveal allergies, medications a client is taking and client’s compliance with therapy.

• The nursing process should be used when administering medications.

• Nurses should involve clients in the planning of medication administration.

• The seven rights of medication administration ensure accurate preparation and administration of medication doses: right medication, right dose, right client, right route, right time, right reason and right documentation.

• Nurses should administer only medications they prepare, and prepared medications are never left unattended.

• Medications should be charted immediately after administration.

• A nurse uses clinical judgment in determining the best time to administer prn medications.

• The nurse reports a medication error immediately.

• When preparing medications, the nurse checks the medication container label against the medication administration record three times.

• Air locks prevent leaking of medication through subcutaneous tissues and localise the medication in muscle tissue.

• The Z-track method for intramuscular injections protects subcutaneous tissues from irritating parenteral fluids.

• Failure to select injection sites by anatomical landmarks may lead to tissue, bone or nerve damage.

• Application of the principles of quality use of medications (QUM) improves client outcomes.

ONLINE RESOURCES

Australian Commission on Safety and Quality in Health Care; medication safety program, www.safetyandquality.gov.au/our-work/medication-safety

Health Quality and Safety Commission New Zealand; national medication safety program, www.hqsc.govt.nz/our-programmes/medication-safety

National Medicines Policy (Australia), www.health.gov.au/internet/main/publishing.nsf/content/nmp-objectives-policy.htm

Quality Use of Medicines, www.health.gov.au/internet/main/publishing.nsf/Content/nmp-quality.htm