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Файл:Clinical nursing practice. Study aid for foreign students of medical university
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151
Table 13
Types of injection
Injection
Description
Intramuscular
injection
Probably the most common and the most useful route for parenteral
administration. The drug is injected into a muscle, usually
of the outer aspects of the thigh; the upper, outer quadrant
of the buttock; or (only if necessary) the mid-deltoid region
of the arm. Correct needle length is important, thus avoiding abscess
formation due to inadequate penetration of the muscle. The skin
may be cleaned before administration, but research has questioned
the value of this. There is no experimental evidence that skin
bacteria are introduced into the deeper tissues by injection.
The muscle must be relaxed so that the injected fluid can spread
through the muscle fibers and less force will be required to inject
Subcutaneous
injection
The drug is injected directly under the surface of the skin.
Administration may be by intermittent injection or continuous
infusion. This method is often taught to patients/clients who need
to administer drugs such as insulin at home. The procedure is fairly
easy and relatively safe to perform. Inadvertent intravenous
administration must be avoided by use of the correct sized needle.
Rotation of subcutaneous sites decreases the likelihood of irritation
and improves absorption
Intravenous
injection
The drug is injected directly into a vein and therefore, directly into
the bloodstream. Drugs given by this route act more quickly than
drugs given by other types of injection. They may be administered
by intermittent (bolus) injection or continuous infusion. Dangerous
effects may result if the drug is administered too quickly,
or in an incorrect dilution or concentration. Should the wrong dose
be injected, there is very little time for an error to be rectified
By rectum. Drugs intended to have a systemic effect may be given in
the form of suppositories inserted into the rectum, from where they are absorbed into the bloodstream. Absorption is slower and more sustained than
by mouth, and reduces gastric irritation. This is sometimes the route of
choice for people who cannot take medication by mouth, such as those suf-
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fering from nausea and vomiting. This method may also be used to give
drugs that could be inactivated by gastric secretions. Drugs may also be
given rectally for local effect, either as suppositories to relieve hemorrhoids or as enemas for ulcerative colitis.
When administering drugs per rectum, the nurse should always wear
clean gloves and lightly lubricate the suppository before insertion. The
person needs to be assisted into a comfortable and relaxed position, with
a protective covering placed underneath the pelvis.
By topical application. This route is used when it is preferable to
administer a drug in a form that has a local rather than a systemic effect,
for example, in treating localized disorders, such as skin infections and nasal congestion. This is because it is much easier to control the effects of
drugs administered topically and to ensure they produce the maximum
benefit, with minimum side-effects. Some drugs, however, such as glycerin triturate or estrogen, are used topically to produce systemic effects.
Topical preparations are available in a variety of forms, from skin
creams, ointments and lotions, to vaginal pessaries, inhalers, nasal sprays
and ear and eye drops. It is important when using topical preparations to
follow instructions carefully, avoiding a higher dose than recommended or
application for longer than necessary. This will help avoid adverse systemic effects caused by the absorption of large amounts into the bloodstream.
When administering topical drugs, wear clean gloves, where appropriate, to avoid absorption through your own skin. Sometimes it helps if
lotions, creams or solutions are warmed before administration.
By inhalation. Drugs may be inhaled to produce either a systemic effect or a local effect on the respiratory tract. Gases used in general anesthesia are administered by inhalation and are absorbed into the bloodstream through the lungs to produce a general effect on the body, particularly the brain. Bronchodilators used to treat certain types of asthma, emphysema and bronchitis are common examples of drugs administered by
inhalation for direct action on the respiratory tract, although some of the
drug also reaches the bloodstream. It is important to be especially careful
that all of the drug has been administered when using this route. If a per-
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son is discharged home with an inhaler, it is vital that he or she is proficient in the technique.
By slow release preparations. A number of disorders can be treated
with drug preparations specially formulated to release their active ingredient
slowly, over a given period of time. Such preparations may be beneficial
when it is inconvenient for a person to visit the doctor on a regular basis to
receive treatment by injection, or when it is necessary to control accurately
the release of small amounts of drugs into the body.
Slow release of drugs can be achieved by depot injections, transdermal patches, slow-release capsules and tablets, as well as implants (pellets
containing the drug which are implanted under the skin). Implants slowly
release the drug into the bloodstream over a period of months.
7.6. TEACHING PATIENTS AND CLIENTS
Another important factor influencing the person's confidence in their
treatment, and ultimately their self-care abilities, is how effective nurses
are in teaching patients and clients about the medications they taking. This
requires an individualized, planned approach and involves assessing the
person's capacity to learn and tailoring and presenting information accordingly. This will include:
• Why a particular medication has been prescribed.
• What effects and side-effects it may have.
• How to recognize any side-effects and what to do about them if
they occur.
• The method of administration, for example whether to take the
medication with food or drink.
• The frequency of administration.
• Any substances (such as alcohol) that should be avoided while the
medication is being taken.
• The likely duration of treatment.
• Any consequences of non-compliance.
• Any helpful tips which may increase the effectiveness of the medi-
cation. For example, the therapeutic effect of antibiotics is increased if the
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person rests and has an adequate fluid intake; the effectiveness of antacids
is increased if the diet is bland and adequate relaxation is encouraged at
the same time.
• The effects of adding new drugs to the person's existing drug re-
gime. This may be particularly important if the person adds a nonprescription
medicine themselves.
Exercise. Developing a patient/client teaching plan
Identify a patient/client that you are currently caring for, -who is receiving medication. Using the points made above as a guide, try to identify
the person's learning needs in relation to his or her medication. If possible
discuss these with the person, and ask what he or she feels that they know
and what else they need or would like to know about their medications.
From what you know of the patient/client, devise a teaching plan to
improve the person’s understanding or confidence in his or her drug regime and capacity for self-administration, where appropriate.
7.7. EVALUATING CARE
Evaluating care in relation to the administration of medications is
concerned with:
1. Whether or not the patient/client received or has taken his or her
prescribed medication, and if not what the reasons were:
Missed doses. Missing a dose of prescribed medication should be
recorded and reported as soon as possible. It may produce a recurrence of
symptoms or a change in the action of the drug. Local policies may vary
and it is best to get advice on what problems may occur with missed doses
of any particular drug.
With some drugs, the timing of doses depends on how long then- actions last. A missed dose will lower the amount of drug within the body
and the effect of the drug may be diminished. Missed doses are especially
important with insulin, anticoagulants and drugs for epilepsy.
Discontinued drug treatment. Ending drug treatment too soon can be
a problem. Advice on stopping regular drugs should be offered only with
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medical support. The disappearance of symptoms does not necessarily mean
that a condition has been cured. This mistake is frequently made with antibiotics, when the frill course is not taken.
Non-compliance. Where a patient/client has chosen not to take pre-
scribed medications, it is important to discuss this openly and honestly
with the person in order to elicit the reasons and to find clues as to what
would make compliance easier for the person. It is inappropriate to patronize or scold the person. It is also important that when a drug does not have
the desired effect, health care workers do not assume non-compliance.
Non-compliance is frequently associated with inadequate or inaccessible patient/client information, so that the person may not have had the
necessary understanding to comply with the prescription. Psychological
adjustment to long-term chronic illness can be particularly difficult for
some people. Adolescents, for example, with conditions such as diabetes
or asthma, may use non-compliance as a way of expressing their feelings
of anger, frustration and powerlessness because of the limitations the illness is placing on their lives.
Drug administration errors. A drug dose may be missed or the cor-
rect dose may be given at the wrong time or by the wrong route. Alternatively, the correct drug may be given, but the dose may be incorrect. A patient/client may receive the wrong drug entirely. Whatever the error, any
administration errors could have an adverse effect on the patient/client and
a mistake could have legal consequences. If a drug administration error
does occur, the patient/client should be observed for any effects and the
relevant medical and nursing personnel should be contacted immediately
the mistake is discovered.
There are basically two types of medication errors: errors of omission
and errors of commission. An error of omission occurs when a nurse unintentionally fails to give a prescribed drug. An error of commission is when
a drug that was not prescribed, or an excessive dose of a prescribed medication, is given.
Different degrees of harm can occur to a patient/client when errors
are made. Death is the most serious, but there are many other symptoms,
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declining in severity. Sometimes there are no noticeable results following
an error and, rarely, the patient's condition actually improves.
Exercise. The safe administration of medications by nurses
• Spend a few minutes thinking about your answers to the following
questions. You may find it useful to discuss some of the questions with
work colleagues, or with someone else who is using this pack.
1. How would you define a drug error? How close have you ever
come personally to making an error?
2. What do you think the policy should be in your hospital/area for
dealing with nurses who make a drug error?
3. Which do you think is most important, the seriousness of an error
in terms of the danger to the patient/client or the degree to which a nurse
has failed to follow the safety standards laid down in the local policy?
• Try to obtain a copy of your local policy on the safe administration of medications and the policy for reporting drug errors. Using the
material in this section as a guide try to identify the strengths and weaknesses of your local policies. How could they be improved?
• Try to find out the answers to the following questions:
What training and education do nurses receive in relation to new
drugs and new techniques for administration? How often are updating
sessions held and do nurses attend them? If not, how do nurses in your
area find out about developments in this aspect of their role?
If nurses in your area undertake intravenous injection, what training and support do they receive in support of this role?
If you can, try to find out what the incidence of drug errors by
nurses is in your area. Has this figure increased over time or has it
stayed the same? How would you account for this?
2. The effects of the prescribed medication (beneficial or otherwise).
It is suggested that the effect of any medication on an individual (its
“total drug effect”) depends on a number of elements in addition to its
pharmacological properties. These are:
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• The attributes of the drug itself (taste, shape, colour, name).
• Those of the patient/client receiving the drug (experience, educa-
tion, personality, socio-cultural background).
• Those of the person prescribing or dispensing the drug (personali-
ty, professional status or sense of authority).
• The setting in which the drug is administered — the “drug situa-
tion” (such as a doctor's office, laboratory or social occasion).
Because the “total drug effect” is dependent on the mix of these in-
fluences in a particular case, there can be wide variation in how different
people respond to the same medication. In the case of very powerful drugs,
though, such as certain poisons, the effect is entirely due to its pharmacological actions.
The effects of a particular medication need to be reviewed in relation
to the these points, as well as to the extent of the desired effects of the
medication. Any undesired or unexpected effects also need to be reviewed.
The person's prescription may need to be reviewed with the prescribing
doctor and the pharmacist in order to make any adjustments or alterations.
The person should be involved in judging the effectiveness or otherwise of
medications and in any decisions to alter the medication, whenever
possible.
The nursing role in this evaluation is one of making judgements based
on both observation of and interaction with the patient/client. It may be
necessary to adopt an advocacy role on behalf of the patient/client where
medications are having distressing side-effects or where the person finds it
difficult to put his or her perspective to medical staff.
Exercise
Earlier in this section, you were asked to devise a teaching plan for
a patient/client in respect of their drug regimen.
Hopefully, you will have identified the expected outcomes, against
which you will evaluate success (or otherwise) as part of that plan. If not,
try to work out now the criteria by which you would evaluate the teaching plan.
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Now systematically review the plan and how far you have got with
putting it into practice (if you have not yet had an opportunity to work with
the patient/client since drawing up the plan, leave this exercise for now
and return to it at a future time).
• Which goals or expected outcomes were achieved?
• Which were not achieved? Why do you think that this was? If you
had an opportunity to start again, would your goals be any different?
Which ones would you keep the same?
• How much did having a plan of care make a difference to your
practice in teaching this patient/client, compared with others you are educating at present? Did you find yourself developing plans with them
as well?
• How does the patient/client feel now about their drug regime?
• What new learning needs does your patient/client now have and
how will you meet them?
7.8. CONCLUSION
Nurses are responsible for the correct administration of prescribed
drugs to the patients/clients in their care. To achieve this, they must have
a sound knowledge of the use, action, usual dose and side-effects of the
drugs being administered. Various studies have shown that this is not always the case. One study concluded that both doctors and nurses in the
hospital surveyed needed to upgrade their knowledge of the drugs they
prescribed or administered. A lack of a sound knowledge base possibly
contributes towards the number of preventable adverse drug reactions in
hospitals.
Other studies have attempted to look at the issue of medication errors. In one survey, it was found that nurses made ten times more errors
than they reported. There is an unfortunate belief among many nurses that
just one error can lead to severe disciplinary problems. As a result, many
nurses admit privately that they have neglected to report less serious mistakes at least once in their careers.
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We have been brought up to believe that because there is no tolerance of medication mistakes within the profession, all errors are shameful.
This can lead to the creation of a climate in which secrecy and covering up
are common; yet unreported incidents can result in potentially serious risks
for patients.
Rightly, statutory nursing bodies and hospital managers see the protection of patients/clients from harm as their primary responsibility. There
should, however, be a system that can allow medication errors to be reported and acted on by the appropriate staff without promoting a climate of
fear and secrecy. Some hospitals have set up “medical error hotlines”,
where calls are treated in confidence. An attempt to cover up a mistake
under these circumstances would result in the most severe disciplinary and
professional charges.
When a mistake occurs it is best to notify the nurse in charge and the
doctor as quickly as possible. It may also be appropriate, depending on local policy, to inform the pharmacist. Medication errors should be documented in the patient/client's records as well as on an incident form, including the names of staff involved as well as details of the incident itself.
In this section we have examined the role and responsibilities nurses
have in relation to the safe administration of medications. From the discussion above, we can see that maintaining standards in relation to the safe
administration of medications requires nurses to be supported in their role.
The attitudes and responses within a particular health care setting should
be concerned primarily with patient/client safety, within a climate that fosters honesty and prompt action in the case of error, rather than one which
creates fear and defensiveness in staff who make mistakes.
While an individual may bear the primary responsibility for an error
in the administration of medications, there is much that mangers can do to
review any circumstances which contributed towards the breach in safety.
Policy changes required and training and education needs can be highlighted by such an approach, with the long-term outcome being improved
safety standards in the administration of medications.
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8. CONCLUSION
In this chapter we explored the nurse's function in relation to developing clinical nursing practice. We also looked at a model for using critical
thinking, theoretical understanding, research findings and the identification
of standards for practice to improve the quality of nursing care. Obviously
this chapter is not a complete overview of all you should know for your
clinical nursing practice. We encourage you to apply the model mentioned
above to your current practice and to new areas of practice you may encounter in the future.
Finally, before you go on to the next chapter, take the time to go back
to the learning objectives at the beginning of each section of the chapter. If
you are not sure whether you have reached all the objectives, read the relevant sections in the text once more.
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