The Rules of Drug Administration. Drugs Calculation and Preservation Rules

MINISTRY OF EDUCATION AND SCIENCE OF UKRAINE MINISTRY OF HEALTHCARE OF UKRAINE SUMY STATE UNIVERSITY

NURSING CARE 4330 Methodological instructions for practical lessons

for students of the specialty 222 “Medicine” full-time training

The rules of drug administration. Drugs calculation and preservation rules. Administration of drugs through skin and mucous tunic, enteral and inhalation methods. The technique of parenteral methods of drug administration

Sumy Sumy State University 2018

Nursing care. Methodological instructions for practical lessons on the topic “The rules of drug administration. Drugs calculation and preservation rules. Administration of drugs through skin and mucous tunic, enteral and inhalation methods. The technique of parenteral methods of drugs administration” / compilers: O. I. Smiyan, O. K. Romaniuk. – Sumy : Sumy State University, 2018. – 38 p.

Department of Pediatrics

The aim of the lesson: To study the rules of calculation and preservation of drugs belonging to the general list and A and B groups; to be acquainted with the rules of drug administration to children. In addition, to study the rules and techniques of parenteral drugs administration to children. Professional motivation of students: The administration of medications to children presents a number of problems that are not encountered when giving medication to adult patients. Children vary widely in age, weight, surface area, and the ability to absorb, metabolize, and excrete medications. Nurses must be particularly alert when computing and administering drugs to infants and children. Giving medications to children is a serious responsibility. The need for accuracy in preparing and giving medications to children is even greater than with adult patients. Since the pediatric dose is often relatively small in comparison with the adult dose, a slight mistake in the amount of a drug administered represents a greater proportional error. After self-training, the student must know the following: 1. Organization of duties of the nurse of procedure room. 2. The rules of storage of medical instruments in the procedure room. 3. The rules of drugs prescription, preservation, and calculation. 4. The rules of parenteral drug administration. 5. Complications of parenteral drug administration.

Having covered the topic, the student must be able to: 1. Check the execution of the rules of prescription, preservation, and calculation of drugs of the general list or A and B groups. 2. Administer drugs through skin and mucous tunic, by oral (enteral) method. 3. Administer drugs by parenteral method.

Materials, which might be helpful: 1. The rules of drugs prescription, preservation, and calculation. 2. The methods of administering medicinal agents. 3. The rules and technique of hypodermic drug administration. 4. The rules and technique of intramuscular administration of drugs. 5. The rules and technique of intravenous instillation of drugs. 6. Possible complications of drug administration.

The Rules of Drugs Prescription, Preservation and Calculation Drugs Prescription The senior nurse of a department prescribes drugs. There is also the order of drugs admission to a department: – a doctor writes down the prescription to the prescription list; – an ambulant nurse composes demands for necessary medicinal agents and hands them to the senior nurse every day; – on this basis the senior nurse composes a special demand signed by the chief of the department and sends it to a drug

store; it should be borne in mind that narcotics, poisons, and spirits are prescribed on separate demands; – the drug store hands the necessary medicinal agents on the basis of these demands; – the senior nurse checks the correspondence of the obtained medicinal agents to the demand, the presence of labels, and their correspondence to the agents titles and dosage; the term of validity must be checked thoroughly; if the nurse has any doubts as for agents or their term of realization, the drugs are returned to the drug store; – the drugs suitable for use are given by the senior nurse to the nurse on duty’s post.

The Ten Golden Rules for Administering Drug Safely* 1. Administer the RIGHT DRUG. 2. Administer the right drug to the RIGHT PATIENT. 3. Administer the RIGHT DOSE. 4. Administer the right drug by the RIGHT ROUTE. 5. Administer the right drug at the RIGHT TIME. 6. DOCUMENT each drug you administer. 7. TEACH YOUR CLIENT about the drugs he/she is receiving. 8. Take a complete patient DRUG HISTORY. (There is a risk of adverse drug reactions when a number of drugs are taken or when a patient is taking alcohol drinks). 9. Find out if the patient has any DRUG ALLERGIES. 10. Beware of potential DRUG – DRUG or DRUG – FOOD INTERACTIONS. To protect your patient and your license, follow these guidelines for avoiding medication errors.

* from Nursing 88 Vol. 18, August 1988 by: Cathleen McGovern, RN, BSN Quality Assurance Coordinator Edge Water Hospital Chicago, Illinois, USA.

Medication preparation and administration has many legal and ethical implications. When you administer medications, you are responsible for developing an up-to-date knowledge base. For each medication that you administer, you should be familiar with the following: – the generic and proprietary names; – the classification; – the normal dose or range of doses; – the route(s) of administration; – the desired action; – common side effects; – toxic and undesired effects. A therapeutic effect depends on the concentration of the medicine which in turn depends on the dose and the body weight of the patient. In this connection a dose is often specified with reference to a kilogram of the patient’s weight. A concrete dose should, in such cases, be calculated for each particular case. Sensitivity of people to medicinal preparations normally varies within a wide range depending on the physiological condition of the body (pregnancy, lactation), nutrition, age, and sex. Age sensitivity to medicinal preparations is especially varied. Apart from their curative effect, medicines can also cause undesirable side effects. These are biological effects that develop irregularly and cannot be predicted or foreseen. Toxic side effects can develop as a result of over dosage by error or of a suicidal attempt of the patient. Drug addiction is a well known side effect of narcotics. A special group of side effects includes various forms of idiosyncrasy and drug disease. The latter is manifested by a complex of immediate and delayed allergic responses. These

nonspecific side effects are the result of individual, congenital or acquired properties of the body. If a patient becomes adapted to a medicinal preparation, its therapeutic dose has to be increased. Some preparations, on the other hand, can be accumulated in the body, and their doses should therefore be gradually decreased, or the medication should be suspended at intervals to prevent poisoning.

Ordering and keeping medicinal preparations During his rounds, the physician prescribes various medicines which he enters in the case history of the patient and in the special prescription sheets. The nurse records these prescriptions in a special notebook according to which medicinal preparations are dispatched to the patients. The prescriptions are also put into a special notebook of medication, and also the injection list. The medicinal preparations are ordered according to the physician’s prescriptions. All medicines should be kept in a locked cabinet. It should be located in the nurse’s room, out of patient’s reach, and should always be locked. The special control is required for a storage of toxicant, strong and narcotic agents, which are kept in special compartments “A” and “B”. Each case of their application is fixed in special notebook with the patient’s name and the number of the case history. Narcotics are subjected to special care. They are kept in the safe. The key from the safe is kept by the duty doctor. The administration of narcotic drugs is carried out only in the presence of the physician. External medicines should be kept separately from those administered internally. Medicines with a strong odour (Iodoform, Lysol) and also flammable substances (alcohol, ether) should be kept separately from other medicines.

Special care should be taken in storing sterile solutions for parenteral administration. If a bottle contains several doses, it should be closed after each use. If there is any doubt about the sterility of a preparation, the medicine should be discarded. Alcoholic and ether solutions, tinctures, and extracts can be stored for a long time because microbes are quickly killed in them. But these substances are quickly evaporated which increases the concentration of the active substance and can thus cause over dosage. Some medicines (salts of silver, bromine and iodine) decompose when exposed to light and they should therefore be stored in dark bottles. The amount of medicines kept in the cabinet should not exceed a storage for 3 or 4 days. Sterile solutions (in containers other than vials) should be stored for not longer than 3 days, while antibiotic solutions, not longer than 24 hours. Ampoule solutions can be stored for months. An expiration date is usually indicated on the label.

Administration of medicines Medications can be classified according to their method or route of administration. The following methods of administration of medicinal preparations are distinguished: enteral (intestinal), external, parenteral, and by inhalation. The choice of the administration mode depends on the particular disease. Each mode has its advantages and disadvantages. Enteral administration implies taking medicines by mouth (per os) or through the rectum (per rectum); or the medicine can be placed under the tongue (sub lingua). Peroral administration is the common way of taking medicines. The advantage of the method is that medicines can be given in any form and under non-sterile conditions. The disadvantages are: first, the preparation is slowly absorbed into the blood; second, the properties of the medicine are altered by the gastric and intestinal juices. Since the absorption is slow, it is

difficult to predict the concentration of the medicine attainable in the blood and tissues.

Classification of the medications depend on their route. Enteral medication:  oral medication: any medication given by mouth;  sublingual medications: medications placed under the tongue and absorbed into the blood vessels underneath the tongue (e. g., nitroglycerin);  buccal medications: medication against the mucous membranes of the cheek (e. g., lozenges). Topical medications: agents applied to the skin and mucous membranes for absorption or for local therapy. In addition to administration onto the skin, topical agents include optic medications (medications administered into the eye), otic medications (medications administered into the ear), nasal medications (medications administered into the nose), vaginal medications (medications administered into the vagina), rectal medications (medications inserted or instilled into the rectum), and pulmonary medications (medications inhaled into the respiratory tract). Medications given by the sublingual and buccal routes are also sometimes classified as topical medications. Parenteral medications are those given by injection with a needle. Parenteral medications are the most rapidly absorbed because they are administered directly into or close to the circulation or into their sites of action. Routes of traction for parenteral medications are: Subcutaneous route – administration into the subcutaneous tissue, under the skin; intradermal route – administration under the epidermis, into the dermis;

intramuscular route – administration into a muscle; intravenous route – administration into a vein; intra-arterial route – administration into an artery; intracardiac route – administration into the heart muscle; intraosseous route – administration into a bone; intrathecal route – administration into the spinal canal; epidural route – administration into the space external to the dura mater of the spinal canal. Oral medications are absorbed in the gastrointestinal (GI) tract (i. e., the mouth, stomach, and small intestine). The two forms of oral medications are solid and liquid. Solid forms. Solid forms of medication include tablets, capsules, and powders. Tablets are solid forms of medicinal compounds measured and shaped to a specific dosage and form by the manufacturer. Prolonged acting (sustained-release) tablets are oral medications specially formulated for gradual absorption. Fast acting tablets may contain substances such as lactose that speed up absorption in the stomach. Coated tablets are oral medications with a hard surface that impedes absorption until the medication reaches the small intestine. Some tablets must be chewed, whereas others are swallowed whole. On the other hand, lozenges are tablets that should be completely dissolved in the mouth without chewing. Generally, lozenges exert their therapeutic effects directly on the oral mucosa. Capsules are oral preparations in which one or more medicinal substances are placed inside a small shell, which is usually made of gelatin, dissolves in the GI tract and releases the medication for absorption. Capsules are swallowed whole. Dry medications that are mixed with liquids (water or juices) before oral administration are called powders. Many powders are sold in bulk and must be measured and diluted immediately before administration.

Liquid forms. Liquid medications include syrups, medications that are blended into a sugared or thick flavoured liquid. Be wary of using syrups for people with diabetes, because these preparations often contain sugar. Solutions are homogenous mixtures of liquids and solids. Medications in solution are more likely to be unpalatable and may therefore need to be diluted or followed by liquids. Suspensions are mixtures of solid particles in a liquid medium in which the particles precipitate out when the suspension is left standing. Therefore, suspensions, such as gels and magmas (thick milky suspensions of an inorganic substance), must be shaken before each administration. Emulsions are suspensions made from fats, oils, or petrolatum suspended in a second liquid. These preparations must also be shaken before measurement and administration. Take care to avoid the client’s aspiration (inhalation) of these substances, because oils and fats cause severe pneumonia if drawn into the lungs. Elixirs are drug preparations in a solvent medium of alcohol and water (a hydro alcoholic medium). Sugar is often added to improve the taste. Like syrups, elixirs mask unpalatable medications and simplify administration. Tinctures are dissolved in a hydro alcoholic medium but are more potent than elixirs. Some tinctures are for topical use only, so it is important to distinguish between oral and topical. Tincture preparations. It is also important to use tinctures and elixirs cautiously in people who are or may be alcoholic. Oral administration of medicines is not recommended for patients who have impaired swallowing, particularly those with suspected or actual stroke, are unconscious or refuse to take medications orally. In such cases, discuss the situation with the person, physician, and pharmacist as appropriate.

Explore alternatives such as stopping the medication or administering medication in a more acceptable form or by an alternative route (e. g., injection or nasogastric tube). Topical or external medications are applied to the skin or mucous membranes. Some categories, of topical medications include antiseptics for cleaning the skin and mucous membranes, local anesthetics, antipruritic, moisturizers and other soothing agents, antibiotics, and anti- inflammatory agents. Most topical medications are given for their local effects (i. e., the medication exerts its action in the area around the administration site). Some topical medications, however, exert systemic effects – they are carried via the blood to tissues or organs located away from the area of administration. Nitroglycerin, for example, is absorbed through the skin but affects the coronary blood vessels. Topical Medication Preparations. Topical medication comes in different forms, such as: Lotions are suspensions of insoluble powder in water or ingredients dissolved in a thickened liquid (e. g., calamine lotion). Creams are oils dispersed in 60 to 80 per cent water to form a thick liquid or soft solid (e. g., antifungal cream). Both lotions and creams evaporate when applied, leaving a layer of medication on the skin. They protect and lubricate the skin without blocking evaporation of natural skin moisture. Little of the medication is absorbed. Ointments are semi solid preparations in a fat, oil, wax, or water soluble base. Ointments contain 25 to 50 per cent water. Petrolatum is a widely used ointment. Ointments are moderately or fully occlusive on the skin and therefore have an emollient or softening effect. Moisture retention also enhances medication absorption. Hence, ointments provide the most

effective vehicle for absorption of therapeutic agents into the skin. Powders for topical use are mixtures of chemicals in a dry form that are usually dusted onto the skin. They promote dryness by absorbing skin moisture. Powders wear off easily and must be applied more frequently than other topical preparations. Gels are semisolid mixtures that liquefy when applied to the skin. After application, gels evaporate quickly and dry to a nonocclusive film. Some corticosteroids are supplied in gel form to prevent absorption and systemic effects. Aerosols are liquid or powder medications suspended in a mist, often in an alcohol-based spray. These medications are sprayed onto a site at a controlled pressure, leaving a film of active ingredients behind. They are used to treat damaged skin and mucous membranes that are too painful to touch directly. Topical medications are most frequently administered to the mucous membranes of the mouth, vagina, rectum, bladder, and respiratory tract.

Determination of the Drug Dosage It is the physician’s responsibility to prescribe drugs in the correct dosage to achieve the desired effect without endangering the health of the child. However, nurses must have an understanding of the safe dosage of medications they administer to children as well as the expected action, possible side effects and signs of toxicity. Unlike adult medications, there are no standardized dosage ranges for children in the pediatric age groups and with a few exceptions, drugs are prepared and packaged in average adult-dosage strengths. Factors related to growth and maturation significantly alter the capacity of an individual to metabolize and excrement functioning in this capacity and are less apt to fuss than they

would if the medication was administered by a stranger. Individual decisions need to be made regarding parental presence and participation, such as in helping with restraint, during injections.

Preservation and Calculation of Drugs Liquid medicines (mixtures), decoctions, vaccines, and eye drops cannot be preserved for a long period; that is why they are to be kept in a fridge. Other drugs are preserved in special cupboards, which are marked and closed. There are separate shelves for agents, which are introduced intravenously, for external application, sterilized solutions, smelly substances, inflammable substances (spirit, ether), and bandaging materials. Drugs are to be kept in corresponding vessels: infusions and mixtures in jars of one liter and half a liter capacity, drops in small bottles, ointments in small jars; drugs, which are destroyed in the sunlight (iodine, bromine), are to be kept in dark vessels. The nurse cannot change drug package herself, pour drugs from one vessel to another. It is strictly prohibited to tear the label off, cross any writings, stick non-standard labels, put different pills and powders into one pack. It is necessary to keep an eye on drugs term of validity. Drugs made in a drug store (mixtures, infusion, decoctions, mucilage, and eye drops) are to be preserved for not more than 2 days. The term of validity of sterilized solutions and emulsions is 3 days, of other drugs – 10 days. The term of validity of factory drugs is 2–5 years. All liquid forms of medicinal agents, protein agents included (serums, insulin), some antibiotics, ointments are to be kept in the fridge at +2–10 °C temperature. Small safes are used for storage of poisonous and strong medicines. Poisonous and narcotic medicinal agents are kept in a safe labelled with “A” letter (narcotics, atropine), and strong

medicines (adrenalin, caffeine) – in a safe labelled with “B” letter. The list of preserved agents, single and daily doses for different age and antidote (antipoison) scale are set on the inner side of the safe’s door. The quantity of poisonous and narcotic agents must not exceed a 5-day need; the quantity of strong medicines must not exceed a 10-day need. The senior nurse keeps the safe’s key and the book of A and B agent groups calculation. The senior nurse conducts drugs calculation; she has the notebook of medicinal agents calculation signed by the head doctor. The book of narcotic, poisonous, and strong medicines calculation is conducted separately. This book is to be strung together, numbered, signed by the head doctor, and contain an official stamp. The senior nurse conducts calculation of narcotics used, puts in the number of the case history, the patient’s name, and the quantity of drugs used.

Methods of Medicinal Agents Administration 1. Enteral method – gastrointestinal tract administration of such types: per oral; rectal. 2. Parenteral method – drugs administration by dint of injections accompanied by coverlet damage. Injections are of the following types: intradermal (intracutaneous); hypodermic; intramuscular; intravenous; through skin and mucous tunics without their damage; external acoustic meatuses, mouth or nose mucous tunics, eye mucous tunics; electrophoresis; inhalation. Other ways of drug administration: into pleural cavity, spinal canal, retrobulbarly, intraosseous way of injection, etc. Powders, mixtures, and tinctures are introduced to children by the enteral method (through mouth). The nurse gives to children medicinal agents and water to wash them down. Children are not to be given medicinal agents into

hands. One must be sure the child has swallowed the pill and washed it down with little frequent draughts. As for little children, it is better to introduce peroral medicinal agents as liquids (syrups, drops). However, in case of necessity, pills may be triturated, and in order to ease swallowing and aspiration prophylaxis of respiratory tract, the obtained powder is to be dissolved in a small quantity of liquid. As for infants, it is better to divide the prescribed dose of medicinal agent into some consequent small draughts.

Oral Administration The oral route is preferred for administering medications to children whenever possible. Because of the ease of administration of oral medications, most are dissolved or suspended in liquid preparations. Although some children are able to swallow or chew solid medications at an early age, solid preparations are not recommended for young children. There is danger of aspiration in any oral preparation, but solid forms (pills, tablets, capsules) are especially hazardous if their administration causes marked resistance or crying. Many liquid preparations are prescribed in measurements of teaspoons. However, the teaspoon (and other household measures) is an inaccurate measuring device and is subject to error from a number of variables. For example, household teaspoons vary greatly in capacity, and different persons using the same spoon pour different amounts. This variability is also influenced by the adequacy of available light, the colour of the liquid, and the size of the bottle from which it is poured. Therefore a drug ordered in teaspoons should be measured in milliliters – the established standard is 5 ml per teaspoon. A convenient hollow-handled medicine spoon is available to accurately measure and administer the drug.

Aqueous solution 20 drops = l g. Alcoholic solution 40 drops = l g. Another unreliable device for measuring liquids is the drop, which varies to a greater extent than the teaspoon or measuring cup. Droppers are available in numerous sizes but, even with the standard USP dropper, the volume of a drop will vary according to the viscosity of the liquid measured. Viscid fluids produce much larger drops than thin liquids. Many medications are supplied with caps or droppers designed for measuring each specific preparation. These are accurate when used to measure that specific medication but are not reliable for measuring other liquids. Emptying dropper contents into a medicine cup invites additional error. Since some of the liquid clings to the sides of the cup, a significant amount of the drug can be lost. The primary contraindications to giving oral medications include the presence of gastrointestinal alterations, the inability of a patient to swallow food or fluids, and the use of gastric suction. Certain forms of oral medications cause an unpleasant aftertaste and can cause gastric irritation. The nurse uses techniques of administration to minimize any undesired effects and maintain the client’s safety. Oral medications come in two forms: solid and liquid. However there are various types of solid and liquid preparations. The following tips ensure proper oral medication preparation: 1. Give an adequate amount of fluid with tablets and capsules. 2. If appropriate, instruct the patient to chew the drug before swallowing. 3. Mix powdered medications with liquids just before administration. 4. Give effervescent powders and tablets to the patient immediately after they are dissolved.

5. Never crush enteric-coated tablets or capsules. 6. Do not give fluids after a child takes a syrup. Fluids will wash the medication away.

Administering Oral Medications Remember: 1. Principles of medical asepsis. 2. Pharmacokinetics of drug actions. 3. Drug dosage calculation. Implementation: 1. Wash hands. 2. Preparing tablets or capsules from bottle: Put required number into a bottle cap and transfer medications to medication cup. Do not touch medicines with fingers. Extra tablets or capsules may be returned to bottle. 3. Prepare liquids: a) remove a bottle cap from the container and place the cap upside down; b) hold the bottle with a label against palm of the hand while pouring; c) hold the medication cup at eye level and fill to desired level on scale ( the scale should be even with fluid level at bottom of meniscus); d) discard excess liquid in the cup into sink. Wipe lip of the bottle with paper towel. 4. Compare medication form or card with the prepared drug and container. 5. Return stock containers or unused unit/dose medications to shelf or drawer and read label again.

6. Place medications and cards or form together on a tray or cart. 7. Do not leave drugs unattended. 8. Give medications to a patient at correct time. 9. Identify the patient: ask a child to state his name. 10. Perform any necessary preadministration assessment for specific medications (e. g., blood pressure or pulse assessment). 11. Patient may wish to hold solid medications in a hand or cup before placing in the mouth. Offer full glass of water or juice with drugs being swallowed. For sublingual administered drugs have the client place medication under tongue and allow it to dissolve completely. Caution the patient against swallowing. 12. If a patient is unable to hold medications, place a medication cup to his lips and gently introduce each drug into his mouth. 13. If a tablet or capsule falls on the floor, discard it and repeat preparation. 14. Stay with the patient until he has completely swallowed each medication. If uncertain whether patient has swallowed the medication, ask him to open his mouth. 15. Dispose of soiled supplies and wash hands. 16. Return medication cards or forms to the appropriate file for next administration time. 17. Replenish the stock such as cups and straws, return the cart to the medicine room and clean the work area.

Optic, Otis, and Nasal Administration There are few differences in administering eye, ear, and nose medication to children and to adults. The major difficulty is in gaining their cooperation or employing restraining techniques. The infant or young child’s head is immobilized. Older children need only explanation and direction. For greater comfort medications stored in the refrigerator should be warmed to room temperature before instillation. For example, cold solutions striking the tympanic membrane may produce pain or vertigo.

Optic Administration To instill eye medication the child is placed supine or sitting with the head extended and the child is asked to look up. One hand is used to pull the lower lid downward; the hand that holds the dropper rests on the head so that it may move synchronously with the child’s head, thus reducing the possibility of trauma to a struggling child or dropping medication on the face. As the lower lid is pulled down, a small conjunctiva sac is formed; the solution or ointment is applied to this area, never directly on the eyeball. Another effective technique is to pull the lower lid down and out to form a cup effect, into which the medication is dropped. The lids are gently closed to prevent expression of the medication, and the child is asked to look in all directions to enhance even distribution of the preparation. Excess medication is wiped from the inner canthus outward to prevent contamination to the contralateral eye. Instilling eye drops in infants can be most difficult since infants often clench the lids tightly closed. One approach is to place the drops in the nasal corner where the lids meet. The medication pools in this area and when the child opens the lids the medication flows onto the conjunctiva. For young children

playing a game can be helpful. Ointment can be applied when the child is sleeping by gently pulling down the lower lid and placing the ointment in the lower conjunctival sac.

Administering Eye drops and Ointment Remember: 1. Principles of medical asepsis. 2. Anatomy and physiology of the eye. 3. Principles of drug preparation.

Implementation: 1. Arrange supplies at bedside. 2. Check the patient’s identification by asking the patient’s name. 3. Ask the patient to lie supine or sit back in a chair with the head slightly hyperextended. 4. 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 few minutes. Always wipe clean from inner to outer canthus. 5. Hold cotton ball or clean tissue in no dominant hand just below lower eyelid. 6. With tissue or cotton resting below lower lid, gently press downward with thumb or forefinger, against bony orbit. 7. Ask the patient to look up toward ceiling. 8. Instill eye drops: a) hold an eye dropper in a dominant hand approximately 1–2 cm (1/2 to 3/4 in) above a conjunctival sac; b) drop the prescribed number of medication drops into the conjunctival sac; c) if patient blinks or closes an eye, or if drops land on outer lid margins, repeat the procedure;

d) when administering drugs that cause systemic effects, protect your finger with clean tissue and apply gentle pressure to a child’s nasolacrimal duct for 30–60 sec; e) after instilling drops ask the child to close the eye gently. 9. Instill eye ointment: a) holding an ointment applicator above the lid margin, apply thin stream of ointment evenly along inside edge of a lower eyelid, on conjunctiva; b) ask a patient to look down. In children have the hand that holds a dropper rest on child’s forehead so that the hand will move synchronously with the child’s head and not into an eye if the child moves suddenly; c) apply thin stream of ointment along the upper lid margin on inner conjunctiva; d) have the patient close the eye and rub lid lightly in circular motion with a cotton ball. 10. If there is excess medication on eyelid, gently wipe it from inner to outer canthus. 11. If a patient had an eye patch, apply the clean one by placing it over affected eye so entire eye is covered. Tape securely without applying pressure to eye. 12. Dispose of soiled supplies in proper receptacle and wash hands.

Otic Administration Ear drops are instilled, with the child restrained in the supine position and the head turned to the appropriate side. For children younger than 3 years of age, the external auditory canal is straightened by gently pulling the pinna downward and straight back. The pinna is pulled upward and back in children older than 3 years of age. After instillation, the child should remain lying on the unaffected side for a few minutes. Gentle massage of the area immediately anterior to the ear facilitates

the entry of drops into the ear canal. The use of cotton pledges prevents medication from flowing out of the external canal. However, they should be loose enough to allow any discharge to exit from the ear. Internal ear structures are extremely sensitive to temperature extremes. Failure to instill a solution at room temperature can cause vertigo (severe dizziness) or nausea and debilitate a patient for several minutes. Although structures of the outer ear are not sterile, it is wise to use sterile drops and solutions in case the eardrum is ruptured. Entrance of nonsterile solutions into the middle ear can cause serious infection. The nurse must not occlude the ear canal with a medicine dropper because this can cause pressure within the canal during instillation and subsequent injury to the eardrum.

Administering Eardrops Remember: 1. Principles of medical asepsis. 2. Anatomy of the ear. 3. Principles of drug preparation. Implementation: 1. Arrange supplies at bedside. 2. Have the patient assume side-lying position with the ear to be treated facing up. 3. Identify a child by asking patient’s name. 4. If cerumen or drainage occludes outermost portion of ear canal, wipe out gently with cotton tipped applicator. Do not force wax inward to block or occlude canal. 5. Straighten a patient’s ear canal by pulling pinna down and back (children) or upward and outward (adult). 6. Instill prescribed drops holding the dropper 1 cm (1/2 in) above the ear canal.

7. Ask the patient to remain in side-lying position 2–3 min. Apply gentle massage or pressure to tragus of ear with finger. 8. At times physician orders insertion of portion of cotton ball into outermost part of canal. Do not press cotton into canal. 9. Remove cotton in 15 min. 10. Dispose of soiled supplies and wash hands. 11. Assist the patient to comfortable position once drops are absorbed.

Performing Bulb Syringe Suctioning A bulb syringe is a soft, flexible, plastic device constructed with only one small opening to which air and mucus pass. The bulb syringe is traditionally used to suction infants and children. A bulb syringe is easy to use, requires minimal equipment, exerts gentle controlled pressure making it less traumatic than traditional suction catheters, does not require the use of surgical asepsis, and can be performed rapidly. However, use of the bulb syringe is limited to the upper airway. A bulb syringe is standard equipment in most delivery rooms and newborn nurseries. The bulb syringe is initially used to aspirate amniotic fluid and mucus from the infant’s oral and nasal passages immediately after delivery. Position of an infant or small child. Hold a child in arms tucking one arm closest to nurse around back and holding his free arm with a cradling arm. Bundle the child in a blanket or large towel to restrain his arms and hold him on nurse’s lap. For a bigger child, lay on bed or couch face up with his arms at his sides. Sitting next to the child, nurse lays upper torso lightly across his chest. If additional restraint is needed, the child can be bundled in a blanket or large towel.

Remember: 1. Upper airway anatomy of infants, children, and adults. 2. Mechanism of gas exchange. 3. Principles of medical asepsis.

Implementation: 1. Wash hands. 2. Holding bulb in free hand, firmly squeeze the bulb end of syringe forcing air out of syringe. 3. Insert a small tip into the client’s airway (nose or mouth) while keeping pressure on a bulb and gently release pressure from the bulb to suction secretions. 4. When all pressure is released from the bulb, remove it from airway and rapidly squeeze the bulb in and out several times over soft tissue. 5. Reassess the patient’s respiratory status. 6. Repeat steps 2–5 as needed to clear patient’s airway. 7. Clean the patient’s face and nares with soft tissue. 8. Place the patient in comfortable position after soothing him. 9. Discard the tissue and bib into appropriate waste receptacles. 10. Rinse the syringe under warm running water. Squeeze the bulb several times to remove secretions. After rinsing, squeeze the bulb in and out (in air) with tip pointed downward several times to remove excess water. 11. Loosely wrap the syringe in the second cloth and store at the patient’s bedside within easy reach. 12. Wash hands.

Nasal administration Patients with nasal sinus alterations may receive drug solutions by spray, drops or tampons. Severe nosebleeds often require packing with tampons. Sprays and drops are safer and easier to administer. Nasal decongestants, supplied in sprays and drops, are available without prescription and used widely by persons to treat common cold symptoms. Since they are in direct contact with nasal mucosa, the drugs act rapidly. Decongestants cause blood vessels within the mucosa to constrict, thus opening swollen nasal passages. Potentially serious systemic side effects can occur, particularly if the drugs are used too frequently. The most common effect is drug rebound. Decongestants eventually irritate nasal mucosa to cause worsening of congestion. The drugs should be used no longer than 3–5 days and no more frequently than package directions indicate. Nose drops are instilled in the same manner as in the adult patient. Unpleasant sensations associated with medicated nose drops are minimized when care is taken to position the child with the head ended well over the edge of the bed or a pillow. Depending on the age of the infant, he can be positioned in the football hold, in the nurse’s arm with the head extended and stabilized between the nurse’s body and elbow and the arms and hands immobilized with the hands, or with the head extended over the edge of the bed or pillow. Strangling sensations are caused by medication trickling to the throat rather than up into the nasal passages. Following instillation of the drops, the child should remain in position for 1 minute to allow the drops to come in contact with the nasal surfaces.

Administering Nasal Instillations Remember: 1. Principles of medical asepsis. 2. Principles of drug preparation. 3. Anatomy of sinuses and nose. Implementation: 1. Arrange supplies and medications at bedside. 2. Check the patient’s identification by reading identification elect and asking client’s name. 3. Instruct the patient to blow his nose (unless contraindicated, risk of intracranial pressure or nose bleeds). 4. Administer nasal spray: a) assist the patient to a comfortable sitting position; b) have the patient tilt neck backward, slightly hyperextended; c) patient may hold spray or a nurse may administer. In infant gently wipe nose and clean nares with moistened wash cloth, patient to lightly occlude one nostril by holding his finger on side of nostril. Then place tip of spray applicator just inside opening of other nostril; d) instruct the patient to quickly squeeze applicator once and inhale simultaneously; e) repeat procedure for opposite nostril; f) offer facial tissue to blot runny nose but caution child against blowing nose for several minutes. 5. Administer nasal drops: a) assist a patient to supine position; b) infant will require restraining. Optional positions: hold in arms with football hold; position supine with head extended and stabilized between nurse’s arms and hands; position supine with arms and hands restrained at sides and head extended over edge of a bed or pillow; c) instruct the client to breathe through his mouth;

d) hold a dropper 1 cm (1/2 in) above nares and instill the prescribed number of drops; e) have the patient remain in supine position for 5 min; f ) offer facial tissue to blot runny nose, but caution the child against lowing nose for several minutes. 6. Assist the patient to a comfortable position after drug is absorbed. 7. Dispose of soiled supplies in proper container and wash hands.

Parenteral methods of medicinal agents introduction Intracutaneous, intramuscular, hypodermic, and intravenous injections belong to parenteral methods of medicinal agents introduction. Intracutaneous, hypodermic, and intramuscular injections are given by a nurse; intravenous injections are given by a doctor. One must wash hands with warm water and soap thoroughly, dry them with sterilized napkins or, not wiping them, process hands with spirit, and water fingertips with 3–5 % iodine spirit solution. Then open a sterilized syringe package from the side of the needle, placed on the syringe cylinder cone and kept in a box. Two needles are necessary for an injection – one needle to place solution into the syringe, and the other to give the injection. The sides of an ampoule are wiped with a sterilized cotton tampon moisture with spirit, then one makes an incision on the ampoule and breaks its narrow side. The needle is put into the ampoule and solution is placed into the syringe. After this the syringe is put vertically, the needle looks up, and with a piston stroke the air and foam are removed, thus leaving the necessary quantity of solution. The syringe ready for the injection is put onto a sterilized basin. Intracutaneous injection technique: usually an agent is introduced through skin on the front part of a forearm. The

place of an injection is wiped with spirit. The child’s forearm is taken from below with left hand; the skin is stretched a bit. The needle is stricken into the skin at the maximum sharp angle to a minor depth in order to allow the needle to penetrate the corneal layer (stratum corneum) only. In case of correct injection the agent creates a white “tumour” on skin, which looks like a lemon skin. There must be no blood when the needle is removed. Syringes of 1 ml capacity and needles of 2–3 cm length with small diameter are used for injections. Solution quantity for injection is 0.2–0.3 ml. Hypodermic injection technique: syringes of 0.1–2.0 ml capacity with needles of different diameter are used for hypodermic injections. The most suitable places for such injections are on the front external part of a shoulder or hip, the side surface of the abdominal wall and the lower part of inguinal region (regio in-guinalis). The place of injection is wiped with spirit. The skin is folded in a triangle form with a forefinger and a thumb, the base down: the syringe is taken with three middle fingers and a thumb, and, with the needle and piston fixation, the needle is stricken into the triangle’s base at an angle of 45° with a quick movement to a 1–2 cm depth. After that the syringe is taken with left hand, the piston is moved back a bit with right hand (if there is blood in the cylinder (the needle penetrated a vessel), it is strictly prohibited to push the solution – the needle location must be changed); pressing the piston the solution is gradually introduced. The needle is removed with a sharp back movement; the place of the needle penetration is pressed with a new sterilized cotton tampon moistured with spirit. This place must be massaged for better medicinal agent’s distribution without removing the cotton tampon. Intramuscular injection technique. Such injections are made with a needle 6–8 cm long into buttocks muscles (the

high external quadrant) or into hip muscles (the front external district at the middle one third). The place of injection is wiped with spirit. The syringe is taken with right hand; the second finger supports the piston, the fourth supports the needle sleeve, other fingers support the cylinder. The syringe is on the right angle to the patient’s body surface in case of a buttocks injection, and is on the angle to the patient’s body in case of a hip injection. The skin in the place of penetration is pressed and stretched with left hand. With a sharp movement the needle is stricken into muscles, leaving not less than 1 cm space under the sleeve. It is necessary to pull the piston back in order to be sure the needle is not in a vessel, and only in case of correct penetration the solution is introduced. The needle is removed with a sharp movement; the cotton tampon moisture with spirit is to be pressed to skin.

Various suggestions can be made concerning ways to reduce the pain of injection: 1. The antiseptic should be dry before the needle is inserted to avoid carrying the solution into body tissues. 2. The needle should be sharp and have the smallest diameter that will permit the solution to flow freely. The length should be appropriate for the size of the muscle so that the fluid is deposited only within the muscle mass, where it can be absorbed properly. 3. The medication should be at room temperature. 4. The volume of solution should be no more than 1.0 ml for older infants and small children and 2.0 ml for older children when injected into a site. Adolescents may be given nearly adult dosages because of their larger muscle mass. The medication should be injected slowly into the tissues so that the muscle can accommodate the fluid.

5. The plunger should not be depressed while the needle is being inserted, because the solution injected into the tissues may cause an irritation alone the needle track. 6. The sites should be rotated when multiple injections are given over a period of time. If the thigh is used repeatedly, fibrosis of the muscle may occur resulting in quadriceps contracture – the loss of ability to flex the knee. This can occur in both premature and full-term infants who are on long-term intramuscular antibiotic therapy. When the nurse charts the medication, the site of the injection is noted. 7. The nurse should have someone available who can restrain the child as necessary so that if the child pulls away, no injury from the needle will occur. 8. The nurse can reduce the psychological discomfiting of an intramuscular injection by carrying out the procedure as quickly and skillfully as possible. Delay or postponement will only increase the child’s anxiety.

Selection of the Site of Injection The intramuscular injection should be given at a site away from major blood vessels and nerves, one that has adequate muscle tissue to retain and absorb the injected solution, and has minimal sensory innervation. Addition factors to consider include the type and amount medication, the ability of the child to assume necessary position so that the injection can be given and the possibility of contamination of the site. Injection sites in older children and adolescents are the same as for adults: the posterior gluteal, ventrogluteal deltoid, and quadriceps femoral muscles. The preferred sites for infants and small children are, in order of preference, the ventrogluteal, vastus lateralis, deltoid muscle. Ventrogluteal Muscle. The muscle mass in area is sufficiently developed to absorb fluid, and these are no major

nerves or blood vessels nearby. To the site, the nurse palpates the anterior iliac silica crest, and greater trochanter of the femur. The intramuscular injection is given inside the triangle formed by these landmarks. This site is easily accessible in the supine, prone, standing, and lateral recumbent positions. The needle is held perpendicular to the skin, and the medication is inserted into the muscle. Vastus Lateralis Muscle. The muscle mass in this area is well developed, and there are no major nerves or blood vessels nearby. The belly of the muscle can be found in the middle third of the distance between the greater trochanter and the knee. The injection is given lateral to the midline of the anterior thigh. This site is readily accessible in the supine, prone, lateral recumbent, sitting, or standing positions. The needle inserted perpendicular to the skin or at a 45-degree angle toward the knee. If a hypersensitivity reaction occurs when a drug is injected, a tourniquet may be applied. Dorsogluteal Muscle (Upper Outer Quadrant of Gluteal Muscles). The muscle mass in this area is well developed after the child has been walking for at least a year. Prior to this time the area consists largely of fatty tissue. To find the site, the nurse palpates the head of the greater trochanter and the posterior iliac spine. The gluteal region is divided into an upper outer and a lower inner portion when a line is drawn between these two points. The injection site is superior and lateral to this imaginary line. With the child in a full prone position from which the needle cannot be seen, the needle is inserted perpendicularly at a 90-degree angle to the table or bed. The needle must not be inserted inferiorly or medially because of the danger of injury to the sciatic nerve. Damage to the sciatic nerve is usually caused by the mechanical trauma of an injection near or into the nerve. Sciatic neuropathy may result in paralytic foot drop and sensory and anatomic deficits in the

foot and leg, and possibly a permanent disability. Another problem in the use of this site is the difficulty in maintaining cleanliness of the skin. Deltoid Muscle. The deltoid muscle should be used for intramuscular injections in children only when the other areas are not available for injection, such as when they are burned or covered with a dermatitis. It may be used for injections in older children whose muscles are better developed. The injection is given into a rectangle bound by the acromion process on the top and a point opposite the axilla on the bottom. With the arm held beside the trunk parallel to the longitudinal axis of the body, the needle is inserted perpendicular to the skin surface. Only a small amount of fluid, usually less than 1.0 ml, should be injected into this area. Following an injection into any site, the area should be massaged to ensure the absorption of the medication. This should not be prolonged, because the preschool child especially may consider this a further intrusion. The drug is recorded along with the site so that injection sites can be rotated.

Intravenous injection technique Syringes of 10–20 ml capacity and needles of corresponding diameter (with a short microscopic section) are used for such injections. Injections can be given into different veins: head hypodermic veins of children of the first year of life, ulnar surface veins of older children, more rarely, injections are made into hand or foot veins. Vein cannulation is made for prolonged and recurring injections. A child must lie for an intravenous stream injection of liquids. The vein must be pressed above the place of injection for the vein to fill better; the vein is pressed with a finger on the child’s head and with a tourniquet on a hand or leg. Vein perforation is made by a needle without a syringe or by a

needle put on a syringe. The needle movement must correspond to the blood circulation direction; perforation is made on the sharp angle to the skin surface. The skin perforation is made with a quick movement to a minor depth. Then carefully moving the needle the vein is perforated, one must be careful not to perforate the back side of the vein. After this the needle is moved along the vein. In case of correct perforation blood appears on the external end of the needle. It is also possible to check blood appearance with a cotton tampon. If the needle is not in the vein, it is moved back without removing it, and the next attempt is made. In case of correct puncture the solution is introduced. After the procedure the needle is quickly removed from the vein in a parallel to the skin surface direction. The place of puncture is processed with spirit and a sterilized pressure bandage is put. For intravenous drop infusion systems for infusion are used. Two needles are needed for infusion from small bottles – a short one and a long one, or two short ones. The central small bottle is released from the metal curfew, processed with spirit, and perforated by two needles. The system is equipped with a clamp in the funnel-shaped opening, while the small bottle is turned over down the cork. In order to let the air out of the system, at first the small bottle is put lower at the end of the tube with a needle cone, and then, when the clamp is opened, the small bottle is slowly lifted. The liquid replaces the air, flows into the system, so the infusion can be started. The vein is perforated in a usual way. The needle is connected with the needle cone, the presence of air in the system must be checked before, and the speed of drops falling per minute is regulated at the funnel-shaped opening of the infusion system. Infusion lasts a definite period of time. That is why the extremity must be fixed. A sterilized cotton tampon is

placed under the needle for its fixation; the tampon is fixed with plaster. The extremity is fixed in a splint or V-splint, sometimes it is tied to the bed, in case of necessity other parts of body can be fixed. In order to preserve the vein for further infusions one must use “butterfly” needles or sleeved catheters. To prevent fibrillation the “heparin lock” is made, if it is necessary to re-use the needles or catheters. This “heparin lock” consists of the following ingredients: 1 ml of heparin is mixed with 9 ml of natrium chloride isotonic solution, and then 1 ml of the obtained mixture is introduced with the following catheter or “butterfly” needle corking. The nurse should know the following information concerning each drug given to children by the intravenous route: 1. The expected action of the drug, untoward reactions, side effects, and their antidotes. 2. The amount of the prescribed drug. 3. The solution in which the drug is to be diluted. 4. The compatibility of the drug and the intravenous solution. 5. The precise dilution of the drug for effectiveness. 6. The rate of infusion necessary to provide the optimal blood level of the drug. 7. The length of time needed to infuse the drug. 8. The hours when this and other drugs are to be infused. 9. The compatibility of the intravenous drugs given.

The nurse must also be aware of the following factors when giving drugs intravenously: 1. The drug must be designed for intravenous administration.

2. Some drugs given intravenously are very toxic or irritating to body tissues outside the intravascular system. It is important to check the site of infusion for proper placement and signs of infiltration. 3. Drug mixtures should be administered within the stability time period. 4. Intravenous drugs generally are not administered with blood or blood products. 5. Only one antibiotic at a time should be given. 6. Antibiotics should not be mixed with vitamins or other substances that may inactivate them. Control over a drug that has been given intravenously is limited; therefore, continuous monitoring to watch for drug reactions is essential.

Possible Complications of Parenteral Drugs Introduction: 1. Infiltration in the place of introduction. 2. Hemorrhage and bleeding. 3. Nerve fibers damage. 4. Allergic reactions. 5. Air embolism. 6. Suppuration in the place of injection. 7. Phlebitis. 8. Tissues necrosis when the technique of introduction is violated. Rectal administration of medicines is also popular. It is especially important in cases where peroral administration is unfeasible due to difficult swallowing, in burns of the esophagus, incoercible vomiting, when the patient is unconscious, and in some other cases. In some diseases (heart failure, diseases of the gastrointestinal tract) absorption of medicines in the stomach and intestine is either slow or incomplete. Rectal

administration is preferred in such cases because due to anastomosis of the hemorrhoid veins with the iliac veins, the medicine enters the inferior vena cava bypassing the system of the portal vein and the liver. It should be remembered that the absorption power of the rectal mucosa is about 25 per cent lower than that of the small intestine. The rectal dose should therefore be slightly higher than a median therapeutic one, but it should not exceed the permissible single dose. The absence of enzymes in the rectum is a disadvantage: medicines contained in a protein, fat or polysaccharide base cannot penetrate the rectal wall and should therefore be given only locally. Rectal suppositories are shaped like small cigars or cones, 1–1.5 cm in diameter, and are 2.5–4 cm long. A suppository weighs 1.1–4 g. When inserted into the rectum, the suppository base has to overcome the resistance of the sphincter muscles. The base material should therefore be solid at normal temperature but melt and dissolve at the temperature of the body, so that the active substance can be absorbed by the rectal mucosa. Commonly used bases are cocoa butter, polyethylene glycols, glycerinated gelatin, etc. Suppositories should be wrapped in water-proof paper and kept in a refrigerator.

List of Literature: A. Main: 1. Nelson Textbook of Pediatrics / edited by Richard E. Behrman, Robert M. Kliegman, Ann M. Arvin; senior editor, Waldo E. Nelson. – 15th ed. – W. B. Saunders Company, 1996. – 2200 p. 2. Pediatric Nurse Practitioner Certification Review Guide / editor, Virgina layng Milloing: contributing authors, Ellen Rudy Clore and all. – 2nd ed., 1994. – 628 p. 3. Ambulatory pediatric care / edited by Robert A. Dershewitz; with 141 contributors. – 2nd ed., 1993. – 834 p. 4. Critical care of infants and children / I. David Todres, John H. Fugate [editors]; 1996. – 725 p. 5. Current Pediatric Diagnosis and Treatment 14th ed. / Edited by William W Hay, Jr., M D and others, 1999. – P. 19– 26, 31. B. Additional: 1. Ambulatory pediatric care / edited by Robert A. Derchewitz. – 2nd ed. – Lippincot – Raven, 1992. 2. Neonatology: Pathophysiology and Management of the Newborn / G. B. Avery– 5th ed. Lippincot Williams & Wilkins; 1999. 3. Manual of Neonatal Care / J. P. Cloherty – 4th ed. Lippincot Raven; 1997. 4. Jaundice and hyperbilirubinemia in the newborn. In: Nelson Textbook of Pediatrics / J. Bergman – 15th ed. W. B. Saunders Co; 1996. – 493 р. 5. Caring For Your Baby And Young Child: Birth To Age 5 / S. P. Shelov, et al. – New York, N.Y. : Bantam; 2009. – 747 р. 6. Accuracy of pacifier thermometers in young children. Pediatric Nursing / C. A. Braun. – 2006. – 413 р.

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