Chapter 22 Perry & Potter

Order: ½ NS @ 125cc/hr• Drop factor: 15 gtt/ml• Drop rate: – 31.25 gtt/min (31-32)125 cc/hr x 15 gtt/ml = 31.23 (31-32)

60 min

Order: D5 ½ NS @ 100 ml/hr• Drop factor: 10 gtt/ml• Drop rate: – 16.6 gtt/min (16-17)

Order: Maxeran 10 mg IVPB ½ hour ac meals

Available: 10 mg/ml Further dilute: 50 ml NS, infuse over 15 min What is the rate:

◦ 200 ml/hr◦ 50 ml X ? = 200 ml/hr 15 min 60 min

What is the drip rate (drop factor 15 gtt/ml): ◦ 50 gtt/min

Order: Pantoprazole 40 mg IV now

• Available: 40 mg vial• Reconstitute with 10 ml NS (final concentration 4 mg/mL).

Reconstituted solution may be given intravenously (over 2 minutes) or may be added to 100 mL D5W, NS, or LR (for 15-minute infusion).

• Stable in D5W, LR, NS. • Y-site administration: Incompatible: Midazolam, zinc.

• How much do you add to the minibag: – 10 ml

• What is the rate: – 440 ml/hr

• What is the drip rate with drop factor of 15 gtt/ml: – 110 gtt/min (this will be difficult to count)

Primary line: NS with 40 meq KCL @ 75 ml/hrOrder: Pantoprazole 40 mg IV now

What do you need to know before you begin?• Reason for primary infusion & reason for

IV med• Drug information (expected &

unexpected)• Client’s history & allergies• Client’s knowledge of medication• IV compatibility!!!

IV therapy◦ Monitoring an IV Site, checking Infusion Rate, and

Changing an IV Solution Container◦ Replacing IV Solution Container and

Administration Tubing IV Medications

◦ Administrating IV Medications by Piggyback Infusion

Order: Lovenox 40 mg SC OD

• Available: 300mg/3ml (100mg/ml)• Info: Lovenox is a sterile aqueous solution containing

enoxaparin sodium, a low molecular weight heparin. Lovenox® is indicated for the prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE)

• How much do you withdrawl? – 0.4 ml

• Identify the appropriate syringe: – 1 ml

• Where are you going to administer this medication? – Outer aspect of abdomen (never arms)

• Mixing Two Insulin's in One Syringe

• Important information you need to know?– If insulin’s are compatible– Is it safe to give (know clients blood sugar)– Insulin(s) information (onset, peak, duration)–Draw up rapid acting insulin first (unmodified)– Check dose with RN/instructor– Know S&S of hyper/hypoglycemia – Injections sites

• Faster absorption • Less danger of causing tissue damage • Risk of injecting into blood vessels exists • Muscle is less sensitive to irritating and

viscous drugs • Large well developed muscles (adults) can

tolerate as much as 5 ml of medication (infants 0.5-1ml, toddler 1-2ml, preschool 2-3ml, adolescents 3-5ml)

• Usual max dose: 3mL in adult

Vastus lateralis and ventraogluteal sites used in infants

Deltoid used in well developed children and adolescents

In estimating needle length in children, grasp muscle between thumb and index, needle length showed be half the distance between fingers.

Insert needle as close to 90 degrees as possible

Rotate sites to decrease risk of hypertrophy

Gauge often determined by length Most water soluble medications use:

◦ 22-27 gauge needle More viscous medications use:

◦ 18-25 gauge needle Older or cachectic clients may need shorter

smaller gauge needle

Average length:◦ Children: 5/8 – 1 inch◦ Adults: 1- 1 ½ inches

Assess integrity of a muscle prior to injection

Help client assume a position that reduces strain on the muscle.

Area must be free of infection or necrosis, bruising or abrasions, underlying bones, nerves & major blood vessels.

Review order (medication rights) Obtain medication information Review history and assess factors

contraindicating injection (muscle atrophy, shock, impaired circulation)◦What would you do if contraindicated?

Call prescriber for alternative route! Medical history, allergies, medication

history Client’s knowledge/concerns

6 rights, 3 checks Prepared correct dose from vial/ampule Replace needle with needle for injection

◦ Children: 5/8 – 1 inch ◦ Adults: 1- 1 ½ inches (22-27 gauge)

: 1 ½ inch (18-25 gauge) viscous medications Check arm band/compare with MAR Explain procedure, locate site, BE

CONFIDENT

A deep site, situated away from major nerves and blood vessels, less chance of contamination in incontinent clients or infants because it is away from rectum.

Easily identified by prominent bony landmark.

Safe for all clients

Land marking (p. 599):

◦ Place heel of hand over the greater trochanter of the client's hip right hand over left hip left hand over right hip

Point thumb towards client's groin Index finger over anterior superior iliac

spine Extend middle finger back along the iliac

crest toward the buttock Create a triangle between index finger,

middle finger and the iliac crest (towards the buttocks)

Inject in the middle of this triangle Flexing of the knee and hip helps person to

relax

Vastus Lateralis - lacks major nerves and blood vessels, rapid drug absorption, developed muscle

◦ Site used for giving children IM medication (preferred for immunizations)

◦ Client should lie with the knee slightly flexed or in a sitting position

Land marking (p.600):

Located on the anterior lateral aspect of the thigh◦ Handbreadth above the knee to a handbreadth

below the greater trochanter of the femur. ◦ In width, from the midline of the thigh to the

midline of the thighs outer side. ◦ Inject into the middle third of the muscle.

Not well developed in most adults & children (not recommended for use in infants or children)

Radial & ulnar nerves & brachial artery lie within the upper arm along the humerus

Used when other injection sites are inaccessible

Used for small amount of drugs (1 ml or less)

Landmarking (p. 600):

Expose upper arm Palpate lower edge of the acromion process

(base of triangle) Inject in the middle of the triangle (3-5 cm

below the acromion process)

No longer a recommended site Runs risk of striking underlying sciatic

nerve, greater trochanter, major blood vessel.

Often used by nurses in hospitals (4 quadrant landmarking), practice is slowly changing

Minimizes tissue irritation by sealing the drug within the muscle tissues anddecreasing pain.

Recommended technique for all IM’swhen possible

Privacy Wash hands Expose only required area Select appropriate injection site & ensure client is

comfortable Landmark site Cleanse site with antiseptic (center and rotate

outward ~ 5 cm) With nondominant hand, pull skin 2.5-3.5 cm down or

lateral (Z track), hold this position until medication is administered.

Gauze in nondominant hand

Remove cap (pull straight off) Hold syringe like a dart Inject quickly at 90 degrees Hold lower part of syringe to stabilize syringe Pull back on plunger 5-10 sec, if no blood inject

medication slowly (1 ml/10 sec) Wait 10 sec, slowly withdrawl needle, place

gauze over site Assess site Observe response to medication Record on MAR, record response (i.e prn/STAT) Document and report undesirable effects

Video: Intramuscular Injection

1. Order: Demerol 50 mg IM q4h, prn Order: Gravol 25 mg IM, q4h, prn

Supplied :◦ Demerol 50 mg / ml (ampule)◦ Gravol 50 mg / ml (vial)

How much do you need of each?◦ Demerol: 1 ml◦ Gravol: 0.5 ml

(Draw up medication from vial first, using filtered needle)

2. Order: Diphenhydramine 25mg IM stat

Supplied: 50 mg/ml

3. Order: Dimenhydrinate 50mg IM/IV/PO q4-6 h prn

Supplied 50 mg/ml

Order: Solumedrol 100 mg IM statDirections for ReconstitutionAvailable 40 mg: Aseptically add 1 mL Bacteriostatic Water for InjectionAvailable 125 mg: Aseptically add 2 mL Bacteriostatic Water for Injection

How much do you draw up in the syringe? ◦ 1.6 ml

125 mg X 100 mg = 1.6 ml2 ml ?

Or

Dose X Stock 100 mg X 2ml = 1.6 mlHave 125 mg

Next Lab: Sterile Dressings

Perry & Potter: Chapter 38 & 39