the different routes of medicine administration.
There are various routes of administration available, each of which has associated advantages and disadvantages. All the routes of drug administration need to be understood in terms of their implications for the effectiveness of the drug therapy and the patient??™s experience of drug treatment.
Routes of administration
* Parenteral ??“ Intravenous, intramuscular, subcutaneous
This is the most frequently used route of drug administration and is the most convenient and economic. Solid dose forms such as tablets and capsules have a high degree of drug stability and provide accurate dosage. The oral route is nevertheless problematic because of the unpredictable nature of gastro-intestinal drug absorption. For example the presence of food in the gastrointestinal tract may alter the gut pH, gastric motility and emptying time, as well as the rate and extent of drug absorption.
The extent to which patients can tolerate solid dose forms also varies, particularly in very young and older patients. In such cases the use of liquids or soluble formulations may be helpful. Many drugs, however, are not stable in solution for liquid formulation and in such cases careful consideration should be given to the option of switching to alternative drug treatment.
Difficulties frequently arise with patients who are prescribed modified-release preparations as these must not be crushed or broken at the point of administration. Modified-release formulations can delay, prolong or target drug delivery. The aim is to maintain plasma drug concentrations for extended periods above the minimum effective concentration.
For patients, their main advantage is that doses usually only need to be taken once or twice daily. Damage to the release controlling mechanism, for example by chewing or crushing, can result in the full dose of drug being released at once rather than over a number of hours. This may then be absorbed leading to toxicity or may not be absorbed at all leading to sub optimal treatment.
Nurses should seek advice from a pharmacist or the prescribing doctor if they are uncertain about a formulation of solid dose forms and whether or not they are suitable for crushing.
The sublingual mucosa offers a rich supply of blood vessels through which drugs can be absorbed. This is not a common route of administration but it offers rapid absorption into the systemic circulation. The most common example of sublingual administration is glyceryl trinitrate in the treatment of acute angina.
The pharmaceutical industry has formulated and marketed ???wafer??™-based versions of tablets that dissolve rapidly under the tongue. These are aimed at particular markets where taking tablets may be problematic, such as the treatment of migraine (rizatriptan) where symptoms of nausea may deter patients from taking oral treatments. The formulation is also used to treat conditions where compliance with prescribed drug regimens may be problematic, for example, olanzapine used to treat schizophrenia can be administered by the sublingual route.
The rectal route has considerable disadvantages in terms of patient acceptability (in the UK at least) and unpredictable drug absorption but it does offer a number of benefits. It offers a valuable means of localised drug delivery into the large bowel, for example the use of rectal steroids in the form of enemas or suppositories in the treatment of inflammatory bowel disease. Antiemetics can be administered rectally for nausea and vomiting and paracetamol can be give to treat patients with a pyrexia who are unable to swallow.
The topical application of medicines has obvious advantages in the management of localised disease. The drug can be made available almost directly at the intended site of action, and because the systemic circulation is not reached in great concentration, the risk of systemic side-effects is reduced. For example:
* The use of eye drops containing beta blockers in the treatment of glaucoma;
* The application of topical steroids in the management of dermatitis;
* The use of inhaled bronchodilators in the treatment of asthma;
* The insertion of pessaries containing clotrimazole in the treatment of vaginal candidiasis.
Topical administration has also become a popular way of introducing drugs into the systemic circulation through the skin. The development of transdermal patches that contain drugs began with the introduction of a hyoscine-based product for the treatment of nausea in the early 1980s.
The market for such products has since grown to include a wide range of disease management areas including the prophylaxis of angina (glyceryl trinitrate), the treatment of chronic pain (fentanyl) and hormone replacement (oestrogens). While the use of transdermal drug administration is not without its problems – for example, some preparations can cause local skin reactions – many patients find it a welcome alternative to taking tablets.
Parenteral drug administration can be taken literally to mean any non-oral means of drug administration, but it is generally interpreted as relating to injection directly into the body, by-passing the skin and mucous membranes. The common routes of parenteral administration are intramuscular (IM), subcutaneous and IV.
Advantages of parenteral administration:
* Drugs that are poorly absorbed, inactive or ineffective if given orally can be given by this route
* The intravenous route provides immediate onset of action
* The intramuscular and subcutaneous routes can be used to achieve slow or delayed onset of action
* Patient compliance problems are largely avoided .
Disadvantages of parenteral administration:
* Requires trained staff to administer
* Can be costly
* Can be painful
* Aseptic technique is required
* May require supporting equipment for example, programmable infusion devices
NB: The correct administration of parenteral doses requires the use of appropriate injection technique. If performed incorrectly, for example using the wrong sized needle it can cause damage to nerves, muscle and vasculature and may adversely affect drug absorption.
Intramuscular and subcutaneous injection:
In general the injection of drugs into the muscle or the adipose tissue beneath the skin allows a deposit or ???depot??™ of drug to become established that will be released gradually into the systemic circulation over a period of time. By altering the formulation of the drug, the period over which it is released can be influenced. For example, the formulation of antipsychotic agents such as flupentixol in oil allows them to be administered once a month or every three months.
In many respects the administration of medicines via the IV route is an admission that the use of other routes will not allow for an intended therapeutic outcome or goal of the treatment to be met. Not only is the IV route inconvenient for the patient and practitioner, but it carries the greatest risk of any route of drug administration. By administering directly into the systemic circulation either by direct injection or infusion, the drug is instantaneously distributed to its sites of action.
Such administration is frequently complex and confusing. It may require dose calculations, dilutions, information to be gathered on administration rates and compatibilities with other IV solutions, and the use of programmable infusion devices.
Moreover the preparation of IV medicines requires the use of an aseptic technique, often in a ward environment that is unsuited for such work. It is imperative that to minimise the risk of errors occurring in the administration of IV medicines that practitioners can demonstrate their competence to practice safely in this area, and have access to appropriate sources of expert information and advice.
Also visit this website??™s Practical Procedures section.
Considerations when preparing an intravenous injection or infusion
* Is the drug suitable for preparation at ward level or should it be prepared in pharmacy
* Does the drug require initial dilution
* If so what diluent is required and in what volume
* Does the drug require further dilution
* If so to what volume and with what diluent
* Is the drug suitable for direct injection or must it be infused over time
* What length of time can it be administered over
* Is an infusion device required
* Is the drug compatible with other drugs or fluids to be administered at the same time
* Does the drug cause any local reaction when given
* Is any monitoring required during or after administration
Administration of drugs via enteral feeding tubes
Drugs should only be administered via fine-bore enteral feeding tubes as a last resort and other routes of administration should be considered first. Most drugs are not licensed for administration via enteral feeding tubes.
Interaction can occur between drugs and the enteral feed. Clinically significant interactions include, phenytoin, digoxin, ciprofloxacin and rifampicin. A pharmacist should therefore be involved in any decision to administer drugs via this route.
The British Association for Parenteral and Enteral Nutrition has produced a step-by-step guide for administration of drugs via enteral feeding tubes as well as information leaflets for GPs and patients. This is available at www.bapen.org.uk/res_drugs.html.
For many years the standard method of medicines administration in the healthcare settings such as hospitals and nursing homes has been based on nurses interpreting a prescription and giving the relevant medicine in the required dose via the required route. The patient??™s role in the process has been passive.
Self-administration as an alternative means of administering medicines is based on the patient being encouraged to play a central and active part in their drug treatment, just as they would be expected to do if at home.
The safety and success of a self-administration scheme is based on an ongoing nursing assessment that measures individual patients??™ ability to interpret and participate in their prescribed treatment regimen.
This assessment must initially evaluate whether or not patients administer any prescribed treatment at home, whether or not they are able to read medicine labels, can understand dose instructions and open medicine containers or packaging (Box 1). The assessment must also reflect events that take place during the hospital stay.
For example a patient judged to be capable of self-administration before surgery is unlikely to be able to do so in the immediate postoperative period. Such changes in patient capability must be reflected in the patient??™s care plan, and any indications that the ability to self-administer is compromised should trigger a return to nurse-administered treatment.
The system requires that safe and secure arrangements are in place for patients??™ medicines and that local policies and procedures are in place to guide practice (NMC, 2006).
A number of factors have stimulated hospital practitioners to look at the benefits of self-administration for patients and carers. There is now widespread acknowledgement that traditional methods of medicines administration in hospitals do little to encourage patient compliance and often leave patients being discharged with a bewildering bag of medicines that they may never have seen before and may not be sure how to take.
Encouraging those patients who are able to administer their own medicines, as they would do at home, raises the possibility of identifying their education needs and improving concordance. For those assessed as unable to self-administer, consideration needs to be given prior to discharge to the problems this may present.
Criteria for patient assessment for self-administration:
* Is the patient receiving medicines and willing to participate
* Does the patient appear confused or forgetful
* Does the patient have a history of drug / alcohol abuse / self harm
* Does the patient self-administer at home
* Can the patient read medicines labels
* Can the patient open medicines containers
* Can the patient open his or her medicines locker
* Do the patient know what his or her medicines are for (and dosage, instructions, side-effects)
The successful operation of an extensive self-administration scheme throughout an acute hospital offers insights into the complexities and contradictions of modern medicines management which may have been hidden by the drug trolley approach.
It requires an acknowledgement that the traditional manner of working does not meet the needs of most patients, and for ward-based practitioners to be committed to adopting this approach in their practice. It also requires a truly integrated multi-professional approach that focuses on ensuring patients gain the maximum benefit from their medicines.
3.1:? Explain the types, purpose and function of materials and equipment needed for the administration of medication via the different routes.
Self administration is where the Individual wishes to have full responsibility to take his or her own medicine. All Individual??™s should be encourage to administer their own medication and must be fully supported by carer to ensure they do it safely. Most medicines are administered orally either in a solid dose formulated or liquid preparation. All materials and equipment can only be used once and then thrown away, always wear gloves when administrating drugs with equipment or not. ? Some medicine are applied to the skin and always use new gloves and throw them away after use.? ? The majority of medicines are formulated for oral administration this means they are to be taken via the mouth in the form of liquid or suspension. These medicines comes in a variety shapes and sizes, colours and taste solid dose oral formulation are made either as tablets or capsules and are formulated to aid compliance. Inhalation pump, syringes, drugs trolley, medication pots, spoons, syringes, water jugs, drinking glasses, prescription charts, disposal bags and packets. Make sure that all equipment are sterile and washed. There are two steps to processing items that are used during clinical andsurgical procedures. Cleaning is the first and the most important step.Cleaning is followed by either sterilization or disinfection and by immediate use or proper storage of the item.
3.2:? Identify the required information from prescriptions / medication administration charts.
Medicines are all classified by the medicine act 1968. It is important when working with medicine that the carers know and understand the type of medicine the service user is taking.? What medication is required And Identifying all medication that need to be ordered and which ones are on repeat prescription. The carer should know the dose required and record the quality of the medicines received on the (MAR) chart and the correct dose. The route of administration: must know how to give. The carer must know the time and frequency of administration and they must know how long the service user should take the medicine and what the purpose are. If the carer or or person who administer medication fail to know how long the service user should take the medicine the service user may be overdosed or not be treated if medication are stopped before it should or if given the wrong way the medication would not work or be dangerous.The MAR? chart is an official record of administration of medicines to the Individual. The MAR chart needs to be filled in whenever medication is given even if it is refused it has to be written down. If there is any change in medication from doctor it has to be recorded and written down.
I will send you copy with my forms Viorela
4.1:? Apply standard precautions for infection control.
All medicines that are no longer required must be disposed at the earliest opportunity and not kept at the premises, it should be returned to the pharmacy where they will dispose of it. Needles and syringes must be put in a sharp box and made sure it does not overflow and that it is thrown out in the sleuce in the proper place for syringes and needles and then bagged in the yellow bag. Gloves and aprons should be used when administrating medication and put new gloves on for every medication. Make sure to wash hands before and after. Once used to reduce the risk of needle tick injuries and cross contamination the transdermal patches should be folded in half to render them ineffective. When using eye drops on both eyes make sure there is one for the left eye and one for the right eye so there will be no cross infection from eye drops as well as nose drops. Hands should always be washed in the proper way before and after and you should not touch the pills but use gloves when touching the pills. Ask the service user to wash hands before and after as well.
4.2:? Explain the appropriate timing of medication eg check that the individual has not taken any medication recently.
It is very important to give medication at the right time and that there is a time gap when the Individual has taken medicine Why What might happen if you dont give medication in time, what might happen is the medication is given too early. Always keep record of when, how and what type of medication was taken on the medicine administration record. It is important that it is accurately recorded. All information must be hand written with the signature of the person who gave the medicine if the patient did not want to take the medicine you should put on the form they refused and not leave it open. Make sure that all information is on the administrating medication chart can be used in court evidence. If the person did not write down they gave the medication and then someone els give the medication when the individual already took it could be highly dangerous and could mean the Individual has an overdose and even death. Some medicines need to be given at specific times, for example:
??? Before, with or after food ??” the absence/presence of food in the stomach can affect how the medicine works and may cause unwanted effects
??? Some illness can only be controlled with very precise dose timings, e.g. some medicines for Parkinson??™s disease have to be taken five times during the day, some people??™s fits are only controlled if they take their tablets at set times.
Be able to administer and monitor individuals??™ medication
The learner can:
5.1: Select the route for the administration of medication, according to the patient??™s plan of care and the drug to be administered, and prepare the site if necessary.
My service user used to be on Flexon Patches. I made sure I read the side effects and dosage which was explained by her doctor and Pharmacist. I administrated the patch after she had a bath and breakfast at 8:30am in morning. I made sure the part of her skin I was going to put it on was not irritated and was dry. I then put my gloves on and removed the old patch, I took my gloves off and put new gloved on, I then put the patch on a part of her skin without the sticky part touching my glove, I made sure to put it on another part of the skin every day.
5.2: Safely administer the medication:
in line with legislation and local policies
LEGISLATION AND GUIDANCE
Legislation ??“ Medicinal Act 1968
Care Standards Act 2000
CSCI medication guidance
??? Immunisation in care homes (nursing)
??? Medicine Administration records in care homes and domiciliary care
??? The Administration of medicines in care homes
??? The Administration of medicines in domiciliary care
??? The safe disposal of waste medicines from care homes (nursing)
??? The safe management of controlled drugs in care homes
??? Training care workers to safely administer medicines in care homes
??? Palliative and end-of-life care within all care home setting
National Service Framework for mental health
National Service Framework for Older People
Regulations and National Minimum Standards, England
in a way which minimises pain, discomfort and trauma to the individual
5.3: Describe how to report any immediate problems with the administration.
What if there is a mistake or incident
Errors can occur in the prescribing, dispensing or administration of medicines. Most medication errors do not harm the individual although a few errors can have serious consequences. It is important that errors are recorded and the cause investigated so that we can learn from the incident and prevent a similar error happening in the future.
Examples of administration errors are:
??? Wrong dose is given, too much, too little
??? Medication is not given
??? Medication is given to the wrong child or adult.
Should not ignore errors but encourage a culture that allows their staff to report incidents without the fear of an unjustifiable level of recrimination. To achieve this they must:
??? Have a clear incident reporting system
??? Investigate reports and decide whether they need to offer training to an individual or review existing procedures
??? Record any action taken
??? Report serious incidents to the regulatory body.
??? You must immediately report any error or incident in the administration of medicines. This would usually be to your line manager or person in charge of the setting. If you work as a live in carer the GP has to be told immediately.
5.4: Monitor the individual??™s condition throughout, recognise any adverse effects and take the appropriate action without delay.
An adverse drug reaction as ???an appreciably harmful or unpleasant reaction, resulting from an intervention related to the use of a medicinal product, which predicts hazard from future administration and warrants prevention or specific treatment, or alteration of the dosage regimen, or withdrawal of the product.??? Such reactions are currently reported by use of WHOs Adverse Reaction Terminology, which will eventually become a subset of the International Classification of Diseases. Adverse drug reactions are classified into six types (with mnemonics): dose-related (Augmented), non-dose-related (Bizarre), dose-related and time-related (Chronic), time-related (Delayed), withdrawal (End of use), and failure of therapy (Failure). Timing, the pattern of illness, the results of investigations, and rechallenge can help attribute causality to a suspected adverse drug reaction. Management includes withdrawal of the drug if possible and specific treatment of its effects. Suspected adverse drug reactions should be reported. Surveillance methods can detect reactions and prove associations. It should be recorded, the purpose of documenting is to prevent future injuries for your patients and for others.
Mild adverse drug reaction: Drowsiness, dizziness, dry mouth, constipation, diarrhee, skin rashes etc.
Serious adverse drug reaction: Reactions might be difficulty breathing, wheezing, blood ulcers, kidney damage, fever, joint pain, swelling etc it should be assessed by a physician.
Anapyhlactic shock: It is a allergic reaction to that severely affects body functions that includes symptoms of swelling, confusion, fainting and difficulty breathing. Emergency care is imperative.
5.5: Explain why it may be necessary to confirm that the individual actually takes the medication and does not pass the medication to others.
People may not get the medicines they need and these may be vital to their health and well being. Alternatively, care staff may give entirely the wrong medicine by mistake if there are gaps in the information and that can be devastating not only for the person involved but also for the care worker. A care worker forgets to sign that she has given furosemide to Mrs Jones. The next care worker who comes on duty sees that there is no signature and gives Mrs Jones another dose. Although this may not be a disaster, the drug error could make Mrs Jones very unwell. In this case the lady would have to go to the toilet more often. This could cause her problems if she could not walk very well and she might fall.
5.6: Maintain the security of medication and related records throughout the process and return them to the correct place for storage.
Medication can heal but never forget they can also harm. By storing your medications safely you can maintain their effectiveness and quality as well as protect children and vulnerable adults from access. All medication must be locked in a locked store / box/ cupboard and only trained members of the staff and managers should be granted access to it. In certain cases the medication may need to be refrigerated. If this is the case you should ensure to stick to the policy concerning the storage and cross contamination of food product etc. Ideally medication will be stored in its own cold storage between 15-30 degrees depending on the requirements. You should check the patient??™s information leaflet. Related records should be kept secure in the patients files and returned when used at all times and locked again in special cupboard where the files are kept. Medicines need to be stored so that the products are not damaged by:
??? Heat or dampness
??? They cannot be mixed up with other people??™s medicines
??? They cannot be stolen
??? They do not pose a risk to anyone else.
A good rule of thumb is that medicines need to be treated like valuables. Just because many people do not have to pay for their medicines does not mean that they have no value
5.7: Describe how to dispose of out of date and part-used medications in accordance with legal and organisational requirements.
All care settings should have a written policy for the safe disposal of surplus, unwanted or expired medicines. When care staff are responsible for the disposal, a complete record of medicines should be made. The normal method for disposing of medicines should be by returning them to the supplier. The supplier can then ensure that these medicines are disposed of in accordance with current waste regulations. In England, care homes (nursing) must not return medicines to a community pharmacist but use a licensed waste management company.
Special arrangements apply to the disposal of Controlled Drugs in care homes registered to provide nursing care in England & Wales:
??? If supplied for a named person: denature CDs using a kit designed for this purpose and then consign to a licensed waste disposal company
??? If supplied as a ???stock??™ for the care home (nursing): an authorised person must witness the disposal.
For all other social care settings, the CDs should be returned to the pharmacist or dispensing doctor who supplied them at the earliest opportunity for safe denaturing and disposal. When CDs are returned for disposal, a record of the return should be made in the CD record book. It is good practice to obtain a signature for receipt from the pharmacist or dispensing doctor.