Medication Administration

1. Medication Administration November 2009 CE Advocate Condell Medical Center Objectives prepared by: Mike Higgins, FF/PM Grayslake Fire Department Power point prepared by Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this module, the EMS provider will be able to: • 1. Identify the six rights of drug administration correctly • 2. Identify medical control’s role in drug administration • 3. Identify knowledge of proper use of standard precautions • 4. Identify knowledge of proper disposal of contaminated equipment • 5. Identify the importance of maintaining a sterile and clean environment

3. Objectives • 6. Accurately calculate the drug dosage for a pt with weight stated in pounds, converting weight to kilograms • 7. Identify the various routes used to administer medication • 8. Identify the proper technique for drawing up meds from an ampule • 9. Identify the proper technique for drawing up meds from a vial • 10. Identify the proper administration of a medication from a prefilled syringe

4. Objectives • 11. Identify the proper administration of sub-lingual medications • 12. Verbalize the proper administration of rectal medications • 13. Identify the proper administration of IV piggy-back medications • 14. Identify the proper administration of in-line nebulizer medications • 15. Identify the proper administration of endotracheal medications

5. Objectives • 16. Identify proper documentation of medication administration • 17. Demonstrate the proper administration of subcutaneous medications • 18. Demonstrate the proper administration of intramuscular medications • 19. Demonstrate proper administration of intravenous medications / IO meds • 20. Demonstrate the insertion of the EZ-IO correctly

6. 6 Right of Medication Administration • The RIGHT patient • In the field this is the patient lying in front of you • When doing clinical in the hospital, it is extremely important to check wrist bands for identifying the right patient • The RIGHT drug • Check all medications 3 times prior to administration • Did you grab the correct medication?

7. 6 Rights • The RIGHT dose • Most field medications can be easily calculated in your head • Double check if you are ever unsure of the dose • The RIGHT time • In the field the time is now

8. 6 Rights • The RIGHT route • IV/IO • Injected • IM • SQ • Inhaled • IVPB

9. 6 Rights • The RIGHT documentation • Drug name • Dose – verify order in mg • Dose often stated in ‘amps”, “tab” • Route of delivery • Time administered • Person administering the medication • Use skill check box • Patient response to the medication

10. Allergies • Important to screen all patients for their allergy status prior to medication administration • If you are in doubt regarding an allergic reaction versus side effect (ie: abdominal distress), contact medical control for clarification

11. Facts and Allergies • Lidocaine and Novocain • These are different “caine” families so allergy to one does not cross over to the other • Morphine sulfate • This is NOT a sulfa drug • Lasix – furosemide • There is a low risk of patients allergic to sulfa drugs having a reaction to Lasix • Monitor the patient receiving Lasix if they have a sulfa allergy

12. Medical Control • You operate under the license of the Medical Director • You are still individually responsible for having knowledge of the medications you are delivering • Inappropriate delivery of medications, even when the patient does not suffer harm, may result in legal ramifications

13. Medical Control • Medical control is available as an on-line resource • Clarification regarding indications • Clarification regarding dosage • Clarification regarding orders received from a physician on the scene • In an acute care center, clinic, doctor’s office, you cannot accept orders unless that physician is willing to go with to the hospital

14. Standard Precautions • Establishing routes for drug administration creates the potential exposure to blood and body fluids • Decrease risk of exposure by following standard precautions • Gloves • Goggles • Mask • The best standard precaution often forgotten: • HANDWASHING

15. Sterile vs Clean Environment • Sterile – free from all forms of life • Generally uses extensive heat or chemicals • Difficult in the field to maintain sterile environments • Most packages are sterile until opened • Clean environment • Minimize risk of infection • Careful handling of equipment to prevent contamination

16. Disposal of Equipment • Minimize tasks done in a moving ambulance • Need to decrease risk of EMS exposure • Immediately dispose of sharps in a sharps container • Rigid, puncture-resistant container • Recap needles only as a last resort • Use one handed technique

17. Metric System • Pharmacology’s principle system of measurement • Widely used in science and medicine • 3 fundamental units • Grams – weight or mass • Liters – volume • Meters – distance • To avoid use of multiple zero’s , usually change the prefixes (ie: kilo, centi, milli, micro)

18. Drug Administration and Mathematical Skills • To properly prepare and administer medications, need understanding of: • Multiplication • Division • Fractions • Decimal fractions • Proportions • Percentages

19. Converting Pounds to Kilograms • Many medications are dosed based on patient weight • Adults – acceptable to be “close enough” • Can round off the adult weight • Pediatrics – must practice a more precise formula • Less room for error in calculation

20. Pounds to Kilograms • 1 kilogram = 2.2 pounds • In the field, usually acceptable to take the adult patient’s weight in pounds and divide in half to be close enough to the kilograms • In peds, need to take the weight in pounds and divide by 2.2

21. Exercise • Convert 150 pounds to kilograms • 150/2.2 can be written as 150  2.2 • As a fraction, top number (numerator) is divided by the bottom number (denominator) • 150 = dividend • 2.2 = divisor • The divisor must always be a whole number • Answer = quotient

22. Exercise 2.2 150 • Need to make 2.2 a whole number • In the metric system, you are multiplying by “10” • When multiplying with any derivative of 10, count the zeros and move the decimal that many numbers to the right • What you do with the divisor, you must do with the dividend (actions inside and outside the box must match)

23. Example – 150# = ? kilograms 2.2 150 = 22 1500 68.1 22 1500.0 132 180 176 40 22 18

24. Medication By Patient Weight • Most typical order is Lidocaine (mg/kg) and pediatric drugs (mg/kg) • Calculate the patient’s kilogram • Divide pounds by 2.2 • Acceptable to divide the adult weight by 2 • Multiply the kilogram by the number of mg per kilogram • Then you need to calculate the volume (ml) to draw up in the syringe

25. Example • Give your 132 pound patient 1.5mg/kg Lidocaine • Lidocaine is packaged as 100 mg/5ml • Steps to calculate • Convert pounds to kilograms • Based on the kilograms, calculate the number of mg required • Multiply kilograms by mg/kg required • Calculate the ml volume to draw up

26. Answer • 132  2.2 = 1320  22 = 60 kg • 1.5 mg/kg = 1.5 mg x 60 kg = 90mg • Now, draw up 90 mg (Lidocaine comes 100 mg/5ml) • Formula #1: x ml = desired dose x vol on hand dose on hand • Formula #2: mg in bottle = mg ordered ml in bottle x ml

27. Formula #1 • Formula #1: x ml = desired dose x vol on hand dose on hand x ml = 90 mg x 5 ml 100 mg x ml = 450 (this fraction means 450  100) 100 (top number divided by bottom number) x ml = 4.5 ml

28. Formula #2 • Formula #2: mg in bottle = mg ordered ml in bottle x ml 100 mg = 90 mg 5 ml x ml (cross multiply) 100 x = 450 (divide by 100 to get 100 x = 450 x by itself) 100 100 (divide top by bottom #) 450 / 100 = 450100 4.5 ml is answer

29. Do Brain Check • Give 90 mg Lidocaine • Lidocaine packaged 100 mg / 5 ml • Your answer was to give 4.5 ml • Brain check • 90 mg is slightly smaller than the total amount of 100 mg • 4.5 ml is slightly smaller than 5 ml • So our math must be correct

30. Routes of Medication Administration • 4 basic categories • Percutaneous • Applied or absorbed thru the skin • Pulmonary • Absorbed via inhalation or injection • Enteral • Absorbed thru the gastrointestinal (GI) tract • Parenteral • Administration outside the GI tract • Generally includes the use of needles

31. Percutaneous Medication Routes • Meds absorbed through skin or mucous membranes • Sublingual route • Medication absorbed through the mucous membrane under the tongue • Sub = below; lingual = tongue • Area extremely vascular • Moderate to rapid rate of absorption • Avoids the digestive tract

32. Mucous Membranes cont’d • Nasal route • Uses a medication atomization device (MAD) • Coming soon to Region X • Relatively rapid absorption rate in the absence of IV access • MAD provides a fine mist that allows even and widespread distribution of medication across the nasal mucosa • The Region is preparing to incorporate use of the MAD device in the near future

33. Pulmonary Medication Route • To administer medications into the pulmonary system via inhalation or injection • Generally include gases, fine mists, or liquids • Most medications used for bronchodilation for respiratory emergencies • Inhalation also used for humidification

34. Nebulizer • Uses pressurized oxygen to disperse a liquid into a fine aerosol spray or mist • Inhalation carries the aerosol to the lungs

35. Enteral Route - Rectally • Medication absorbed through the GI tract • Extreme vascularity promotes rapid drug absorption • Absorption more predictable • Medications administered rectally do not pass through the liver so are not subject to alteration in the liver • Advantageous for the unconscious patient

36. Parenteral Route • Any drug administration outside of the GI tract • Typically, this route involves the use of needles • Medication is injected into the circulation or into tissues • Some parenteral forms (ie: IVP) are the most rapid for drug delivery

37. Syringes • Plastic or glass tube for drawing up medications • Range of sizes • Medications are given in dosages by weight (ie: mg) • Syringes represent volume (ie: ml) • Weights (ie: mg) must be mathematically converted to volume (ie: ml)

38. Syringe Markings • Plunger • Barrel • Hash marks • Use most appropriate sized syringe for higher accuracy TB Syringe

39. Medications in Ampules • Breakable vessel with liquid medication • Cone-shaped top with thin neck • Thin neck is the vulnerable point for intentionally breaking open the ampule • Contains a single dose of med

40. Withdrawing From an Ampule • Confirm the medication and dosage • Hold the ampule upright • Tap the top to dislodge trapped liquid • Place gauze (or alcohol wipe package) around thin nick • Snap top off away from you • Place tip of needle into ampule and withdraw liquid • Dispose of ampule into sharps container

41. Medications in Vials • Plastic or glass containers with self-sealing rubber top • Rubber top prevents leakage from punctures • May contain single or multiple doses • Liquid is vacuum packaged

42. Withdrawing From a Vial • Confirm the medication and dosage • Prepare the syringe and needle based on volume of liquid to draw up • Use 1 ml TB syringe for any dose < 1 ml • Because of the vacuum, draw up the same amount of air as volume to be removed • Cleanse rubber top with an alcohol wipe • Insert needle straight into rubber top

43. Vial cont’d • Inject the air from the syringe into the vial • Withdraw the desired volume of liquid • Watch to keep tip of needle in liquid • Helpful to draw a small amount of extra fluid to accommodate removing air bubbles • Hold syringe with needle pointing upward • Tap side of syringe with finger to displace bubbles to distal end of syringe • Expel air bubbles and confirm exact volume required in syringe

44. Medications in Prefilled Syringes • Tamperproof containers packaged with medication already in the syringe • Generally contain standard dosages • May require assembly

45. Prefilled Syringe • Confirm the medication and dosage • Assemble syringe • Pop off protective caps • Twist glass tube containing liquid into syringe • Glass tube becomes the plunger • Expel excess air • Confirm dosage volume required • Lidocaine cap is twisted to unlock and then remove the cap

46. Nonconstituted Medications • Extends viability and storage of time for drugs with short shelf life or instability in liquid form • Consists of 2 vials • Powdered medication • Liquid mixing solution

47. Reconstituting Medications • Confirm medication and dosage • Prepare syringe with liquid • Cleanse off top of powder vial • Inject liquid into powder vial • Gently roll vial between palms to dilute powder • Check that ALL particles have dissolved • Redraw up liquid into syringe, expel excess air

48. Medication Administration

49. Medication Administration • Just because you administer medications now, does not mean your technique is accurate • The first rule in medicine: Primum non Nocere Hippocrates First, do no harm!

50. Sublingual Medication Route • Use Standard Precautions • Confirm medication and dosage 3 times • Have patient lift their tongue • Place the tablet between the tongue and the floor of the oral cavity • Instruct the patient to allow the pill to dissolve