Medications – Administration of the First Dose of Medication SECTION: 16.01 Strength of Evidence Level: 3 PURPOSE: 13. Physician should be available by telephone for To describe the limitations associated with the first dose consultation during first dose administration as of an intravenous or injectable medication to be needed. administered in the home. 14. The First Dose Checklist will be completed whenever a patient receives a first does in the CONSIDERATIONS: home. 15. The nurse must observe the patient for a minimum 1. The term “first dose” shall refer to a patient’s first of one-half hour after the completion of the infusion. known exposure to a medication. 2. All options for having the first dose of a medication EQUIPMENT: administered in a hospital setting, or a physician’s office under the supervision of a physician or the None physician’s designee should be considered before administering the medication in the home. PROCEDURE: 3. Several criteria must be considered in order to make 1. Adhere to Standard Precautions. the decision regarding whether the first dose of a 2. Explain procedure to patient. medication can be administered in the home. The 3. Follow appropriate procedures. (See Medications nurse should consult appropriate drug reference and/or Infusion Therapy for Administration of books and/or a pharmacist to become familiar with Medication). the medication. 4. Discard soiled supplies in appropriate containers. a. The patient will be evaluated for any history of an allergy or adverse response to: AFTER CARE: (1) The medication. 1. Document in patient’s record: (2) A medication in that classification. a. Medication administered, dose, time, rate and (3) A medication that has a known cross- route. allergenicity with any medication in that b. Patient’s response to procedure, side effects classification (e.g., penicillin and and management. cephalosporin). c. Instructions given to patient/caregiver. b. Medication to which a patient has a known or d. Communication with physician. suspected allergy or sensitivity may not be administered. c. The physician must be readily available by telephone during administration of the first dose. d. Emergency transport services and treatment must be available to the patient in the patient’s home. 4. If all the above criteria are met, then the medication will be considered appropriate for the first dose administration in the home. 5. The physician order must be obtained that specifies that the first dose is to be administered in the home. The physician order shall include orders for allergic or anaphylactic reaction, if appropriate. 6. If the criteria are not met for first dose administration in the home, the nurse’s supervisor is to be notified. 7. Use at least 2 patient identifiers prior to administering medications. 8. See MAH Policy 3-13 (Medication Administration) for list of medications that are not appropriate for first dosing in the home. 9. The patient is at least one year old and weighs at least 10 kg. (Except for the administration of palivizumab (synagis) to infants less than one year of age.) 10. The patient is clinically stable. 11. The patient is alert, cooperative and able to respond appropriately to body symptoms. 12. There is ready access to EMS personnel. Medications – Aerosolized Pentamidine Isethionate Administration SECTION: 16.02 Strength of Evidence Level: 3 PURPOSE: CONSIDERATIONS FOR HEALTHCARE WORKERS: To administer pentamidine isethionate in aerosolized 1. To effectively control aerosolized medication form in the home in a safe manner. ambient air mist, the treatment should take place in a well-ventilated room. It is desirable to have a fan CONSIDERATIONS: blowing away from patient and nurse. 1. Pentamidine isethionate administered in an 2. A NIOSH-approved (at least N95) respiratory mask, aerosolized form is indicated in the prevention of disposable gown and goggles with side shields must pneumocystis carinii pneumonia (PCP) in high-risk, be worn during the treatment. immuno-compromised patients, such as HIV- 3. Registered nurses who are pregnant, have infected patients. respiratory problems, external eye problems or 2. Administration of pentamidine in the aerosolized diabetes should be offered alternate work form is contraindicated in patients with a history of assignments or medical screening by a physician. an anaphylactic reaction to parenteral pentamidine. 4. Materials contaminated with aerosolized medication 3. The potential for the development of acute PCP still should be handled as hazardous waste. exists in patients receiving aerosolized pentamidine prophylaxis. The recommended dose of aerosolized EQUIPMENT: pentamidine for prevention of PCP is insufficient to Oxygen flow meter with nipple adaptor treat acute PCP. Air compressor 4. Patients receiving aerosolized pentamidine should be closely monitored for the development of serious Wright-type nebulizer system adverse reactions that have occurred in patients Micronebulizer receiving parenteral pentamidine. (See Medication Considerations, Administration of Intravenous Pentamidine Isethionate.) The nurse should remain Sterile water for injection, USP with the patient throughout the treatment. Syringes with 18-gauge needles or needle less adaptors 5. The most frequent adverse experiences to Alcohol prep pads aerosolized pentamidine are bronchospasm and Puncture-proof container cough. Other adverse experiences include: fatigue, burning sensation in back of throat and dizziness. Protective eye wear 6. Aerosolized pentamidine is most efficiently delivered Disposable gown in particle sizes varying from 0.5-4 microns to reach Mask (HEPA Respirator) the desired alveolar regions. The Wright-type nebulizer is designed with a series of one-way PROCEDURE: valves that act both as a baffle to trap large particles 1. Check physician order. and direct exhalation to a bacterial filter. This 2. Adhere to Standard Precautions. system prevents aerosolized medication from being 3. Gather equipment. dispersed in the surrounding environment. 4. Identify patient and explain procedure. Respirgard II is an example of a Wright-type 5. Position the patient: nebulizer and is recommended by the Food and a. Patient should be seated on a chair with both Drug Administration for delivery of aerosolized feet on the floor. If confined to bed, place in pentamidine. high-Fowler's position. 7. Never use the nebulizer to administer a b. Instruct patient to take several slow, deep bronchodilator. breaths through his/her mouth. 8. Aerosolized pentamidine must be dissolved only in 6. Reconstitute medication. When administering sterile water for injection, USP. DO NOT use saline pentamidine use the following: solution. Reconstitution with saline will cause the a. 30 mg Pentamidine: drug to precipitate. DO NOT mix the aerosolized (1) Draw up 6 mL sterile water and inject 6 mL pentamidine solution with any other drugs. into the 300 mg pentamidine vial. 9. Follow manufacturer's guidelines for stability of (2) Shake vial until all solute dissolves. reconstituted pentamidine. (PDR recommends using (3) Withdraw 0.6 mL from pentamidine vial and freshly prepared solutions and the solution is stable place in nebulizer. Add 5.4 mL of sterile 48 hours in the original vial at room temperature, if water to nebulizer. Total amount of solution protected from light.) in nebulizer is 6 mL (may be premixed by 10. Instructions given to patient/caregiver. pharmacy). 11. Use at least 2 patient identifiers prior to b. 150 mg Pentamidine: administering medications. (1) Draw up 6 mL sterile water and inject 6 mL into the 300 mg pentamidine vial. (2) Shake vial until all solute dissolves. Medications – Aerosolized Pentamidine Isethionate Administration SECTION: 16.02 Strength of Evidence Level: 3 (3) Withdraw 3 mL from pentamidine vial and place in nebulizer. Add 3 mL of sterile water to nebulizer. Total amount of solution in nebulizer is 6 mL (may be premixed by pharmacy). c. 300 mg Pentamidine: (1) Draw up 6 mL sterile water and inject 6 mL into the 300 mg pentamidine vial. (2) Shake vial until all solute dissolves. (3) Withdraw 6 mL of solution from pentamidine vial and place in nebulizer. 7. Instruct patient to put mouthpiece in place, adjust gas flow for a full mist (6 liters/minute). 8. POSSIBLE ADVERSE REACTIONS: a. If bronchospasm occurs, stop therapy and administer bronchodilator per physician's order, then continue therapy. Prior to next therapy, pretreat patient with a bronchodilator per physician's order. [Note: Epinephrine must also be available for possible anaphylaxis.] b. If coughing continues, treat as above. c. If fatigue occurs, allow the patient to rest. During rest breaks, the gas flow is to be turned off. d. If a burning sensation occurs, stop therapy and have the patient drink some liquid, then resume aerosolization. At the end of therapy have the patient drink more liquid. e. If dizziness occurs, stop therapy until episode has passed. 9. Instruct the patient to inhale and to exhale through the mouth into the mouthpiece. 10. Continue treatment until all medication is absorbed. Treatment time varies from 30 to 45 minutes depending upon patient tolerance. 11. Discard soiled supplies in appropriate containers. AFTER CARE: 1. Document in patient's record: a. Medication administered, dose, time, rate and route. b. Vital signs. c. Patient's response to procedure, side effects and management. d. Instructions given to patient/caregiver. e. Communication with the physician. Medications – Antithrombotic Therapy: Fragmin Administration SECTION: