tion and is a common method for tuberculosis and allergy testing. Intramuscular administration facilitates rapid systemic access via abundant capillary regions. Intramuscular injections are inserted at a 90-degree angle. Common administration areas include the deltoid, dorsogluteal, ventrogluteal and vastus lateralis. The gen- eral standard for deltoid injections limits needle length to 1 inch, and pharmaceutical dosage to 1 milliliter (mL) (Watkins, 2013, p. 175). Dorsogluteal injections present a risk of insulting the sciatic nerve, and should be administered in a superolateral quadrant. A topographic boundary line for the sciatic nerve may be drawn from the greater trochanter to the posterior superior iliac spine. Vastus lateralis is a common injection site for patients under the age of 2. Subcutaneous injections are indicated for medications that are best suited for decreased rate of absorption and prolonged systemic circulation. Subcutaneous injection sites are regions of increased adipocytes, decreased vascular potential and limited nerve supply, such as the abdomen and fleshy segments of the arm and thigh (Watkins, 2013, p. 180). Common medications ad- ministered subcutaneously include insulin and heparin. Consid- eration must include rotation of subcutaneous injection sites in order to prevent complications such as drug accumulation and/ or abscess formation. Intravenous (IV) medication administration is the fastest way to administer drugs into the bloodstream, making it the method of choice in an emergency and/or critical situation. Intravenous ad- ministration also delivers the most rapid relief of acute symptoms. Intravenous medications and fluids are directly administered into the venous system to treat a disease, prevent illness and provide nutrition and/or hydration, and as part of a diagnostic procedure (Watkins, 2013, p. 183). Peripheral IV lines may be placed in veins of the arms, hands, feet or scalp. Central IV lines are placed in larger veins such as the subclavian or internal jugular veins, with the catheter tips terminating in the superior vena cava. This posi- tion allows for medications to mix with larger amounts of blood closer to the heart. A peripherally inserted central catheter (PICC) line is inserted from a peripheral site, often the arm, and extends to larger veins proximal to the heart (Watkins, 2013, p. 184). Al- though the majority of intravenous lines are administered during hospital admission, many patients are discharged with these lines still in place for continued treatment. Routine inpatient medi- cal treatment may include intravenous administration of fluids, electrolytes, blood or total parenteral nutrition. Common fluids include dextrose, saline and lactated ringers. Dextrose is a vari- able solution of sugar and water. Saline is a solution of sodium chloride. Lactated ringers are solutions of dextrose, potassium chloride, sodium, lactate and calcium. Each one is an example of crystalloids. Crystalloids are simple solutions that can increase fluid volume and are employed for patients presenting with de- hydration and possible physiologic shock (Watkins, 2013, p. 183). Medications administered through intravenous lines are allotted via infusion, piggyback line or intravenous push. Infusion may be gravity assisted, with the medication bag hung above the patient’s heart. Medications are commonly infused via rate-controlled infu- sion pump; additional technology allows for infusion pumps to regulate the infusion rate as well as infusion pressure. Under cer- tain circumstances, analgesic medication may be administered via patient-controlled analgesia (PCA) pumps, which allow for pa- tients to induce medication release by pressing a control button. PCA pumps are highly regulated, with release parameters preset by the prescribing physician (Watkins, 2013, p. 183). A piggyback solution consists of a series of IV bag and tube branches connected to a primary line. This formation facilitates administration of multiple medications over short durations and is commonly used when medications are prescribed for use multiple times per day alongside IV solutions. An IV push denotes instant delivery of a limited amount of medication by way of attaching a syringe to the distal IV port. IV push must be administered slowly in order to reduce opportunities for venous irritation. Total paren - teral nutrition (TPN) is an IV nutrition solution consisting of fluid, electrolytes, fats, proteins and vitamins. TPN administration is in-
Solid topical medications are often formed into a powder or patch. Powders commonly reduce moisture and are applied to localized fungal infections. A common example is Desenex, or miconazole, which is applied to treat tinea pedis, or athlete’s foot. Transder- mal patches include specific solid medication doses and are ap- plied directly over skin. The pharmaceutical is then absorbed into the skin at a consistent rate, i.e. time release. Transdermal patch medications are widely variable. Common examples include Ni- coDerm for smoking cessation, Dramamine or scopolamine for nausea and/or motion sickness, fentanyl for pain relief, and cloni- dine for hypertension. While transdermal patches are easy to apply, the risk of cumulative effects and overdose are present if the application area is not cleansed between doses. In addition, patch application can be affected by excessively dry or oily skin. In turn, skin can become irritated when patch locations are not changed. Clinicians applying patches should wear gloves in order to prevent the pharmaceutical from affecting his or her body. Ophthalmic medications are drops or ointments that are applied directly onto the eye to lubricate the surface, treat infections and glaucoma, and prime the eye for further examination and/or treat- ment. Ophthalmic drop medications are widely variable. Com- mon examples include Visine to constrict dilated blood vessels, anti-allergen drops, lubricant drops, and bacitracin to treat con- junctivitis, i.e. “pink eye.” Multiple ophthalmic drops can be used to manage glaucoma symptoms. The primary therapeutic effect for these drugs is to reduce ophthalmic pressure, thereby safe- guarding the integrity of the optic nerve (Radhakrishnan, 2016). Mechanisms of action for glaucoma drops may include increased fluid production, reduced fluid production and/or enhanced fluid drainage. Otic medications are drops applied directly into the ear canal to treat irritation and/or infection of the inner and outer ear, as well as to decrease cerumen impaction, i.e. earwax (Watkins, 2013, p. 166). Common examples include ofloxacin to treat bacterial infec- tions of the middle and outer ear and associated with treatment of otitis externa, or “swimmer’s ear,” as well as various antibiotic drops applied for otitis media, i.e. middle ear infections. Vaginal medications are composed of gels, foams, lotions and jellies. Common application includes treatment of local bacterial and fungal infections, as well as contraception. Nasal medications are applied treat various sinus conditions in- cluding congestion, asthma and seasonal allergies (Watkins, 2013, p. 168). Methods of use include inhalers, sprays, drops and installation. Administration by inhalation reaches systemic circulation quickly and efficiently, and may provide additional therapies by dilating and/or breaking up congestion in the lungs. Metered-dose in- halers provide a specified dosage of an aerosol pharmaceutical through a hand-held inhalation device. Sterile water or sodium chloride is often added to facilitate inhalation of a powder form of medication (Watkins, 2013, p. 169). A spacer is a plastic chamber that may be attached to an inhaler in order to suspend a medica- tion dosage until a patient is ready to inhale. Inhalers require sani- tary measures to prevent infection. Nebulizers are relatively small machines that condense air or oxygen to aerosolize medication into minute particles within a light mist for inhalation. Nebuliz- ers are used often to administer bronchodilators and hypertonic saline for patients with asthma and cystic fibrosis. Oxygen may also be inhaled by way of nasal cannulas, masks and positive air- way pressure devices. Machine choice depends on the amount of oxygen required, as well as the patient’s ventilatory capacity. Pro- longed oxygen delivery can dry out mucus membranes and must be supplemented with distilled water for humidification (Watkins, 2013, p. 172). Injectable medications are liquids, or powder compounds mixed with sterile water or bacteriostatic sodium chloride solution, ad- ministered by needle or syringe. Medication may be injected via intradermal, intramuscular, subcutaneous or intravenous routes (Watkins, 2013, p. 173). Intradermal administration reaches the dermis of the skin by way of a 10- to 15-degree angled injec-
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