Route of Drug Administration

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A route of drug administration is the path by which a drug or other substance is brought into contact with the body. Drugs are introduced into the body by several routes. When administering a drug, the nurse should ensure that the pharmaceutical preparation is appropriate for the route specified.

Route	Advantages	Disadvantages
Oral	· Most convenient · Usually least expensive · Safe, does not break skin barrier · Administration usually does not cause stress	· Inappropriate for patients with nausea and vomiting · Drug may have unpleasant taste or odor · Inappropriate when gastrointestinal tract has reduced motility · Inappropriate if patient cannot swallow or is unconscious · Cannot be used before certain diagnostic tests or surgical procedures · Drug may discolor teeth, harm tooth enamel · Drug may irritate gastric mucosa · Drug can be aspirated by seriously ill patients
Sublingual	· Same as oral route, plus · Drug can be administered for local effect · More potent than oral route because drug directly enters the blood and bypasses the liver	· If swallowed, drug may be inactivated by gastric juice · Drug must remain under tongue until dissolved and absorbed · Drug is rapidly absorbed into the bloodstream
Buccal	· Same as sublingual	· Same as sublingual
Rectal	· Can be used when drug has objectionable taste or odor · Drug released at slow, steady rate	· Dose absorbed is unpredictable
Vaginal	· Provides a local therapeutic effect	· Limited use
Topical	· Provides a local effect · Few side effects	· Maybe be messy and may soil clothes · Drug can enter body through abrasions and cause systemic effects
Transdermal	· Prolonged systemic effect · Few side effects · Avoids gastrointestinal absorption problems	· Leaves residue on the skin that may soil clothes
Subcutaneous	· Onset of drug action faster than oral	· Must involve sterile technique because breaks skin barrier · More expensive than oral · Can administer only small volume · Slower than intramuscular administration · Some drugs can irritate tissues and cause pain · Can produce anxiety
Intramuscular	· Pain from irritating drugs is minimized · Can administer larger volume than subcutaneous · Drug is rapidly absorbed	· Breaks skin barrier · Can produce anxiety
Intradermal	· Absorption is slow (this is an advantage in testing for allergies)	· Amount of drug administered must be small · Breaks skin barrier
Intravenous	· Rapid effect	· Limited to highly soluble drugs · Drug distribution inhibited by poor circulation
Inhalation	· Introduces drug throughout respiratory tract · Rapid localized relief · Drug can be administered to unconscious client	· Drug intended for localized effect can have systemic effect · Of use only for the respiratory system

Conduction Anesthesia

Spinal, Epidural, Caudal

Definition:

Central nerve blocks performed by injecting anesthetic solutions intrathecally (into the subarachnoid space), into the epidural space, or into the caudal canal (an extension of the epidural space).

Discussion:

These anesthetics are employed for procedures on the lower abdomen and lower extremities. The composition and concentration of the anesthetic solution will determine the duration of the block. The position of the patient immediately following the injection of the anesthetic solution influences the level and distribution of the block.

Preparation of the Patient:

Position of the patient is determined by the type of block being administered, procedure being performed, condition of the patient, and preference of the anesthetist. Position may be sitting, lateral, or prone.

• Sitting: With back arched and feet supported on a stool (spinal or epidural)
• Lateral: With knees, hips, back, and neck flexed (spinal or epidural)
• Prone: Flexed at the waist (caudal or hypobaric spinal)

Following the injection of the agent (after an interval determined by anesthetist), the patient is placed in the selected operative position.

For prolonged procedures or for post-operative analgesia, continuous epidural or caudal anesthesia is established by inserting a catheter into the appropriate space at the time of the initial needle placement. Increments of anesthetic solution may then be administered.

Skin Preparation and Draping:

Usually performed by the anesthetist. These materials may be included in the prepackaged disposal tray.

Equipment:

• Stool (for patient’s feet, sitting position)
• Sitting tool (for anesthetist)

Supplies:

• Appropriate sterile disposable tray (spinal, epidural, caudal)
• Additional agents, needles, catheters, etc (as requested)

Nursing Considerations:

• The circulator may be requested to set up an intravenous line.
• The circulator is usually requested to assist in maintaining the patient’s position during administration of the block.
• The circulator (in addition to anesthetist) should closely observe the patient for signs of respiratory distress caused by the sedation or by the inadvertent administration of a “high” spinal, which would result in depression or paralysis of the respiratory muscles and require immediate intubations and ventilation.
• Special care must be taken to protect the patient in order to avoid injuries, that is, burns, neurological damage, pressure sores, or other traumas to the patient who is unable to sense the injuries while receiving an anesthetic.
• According to some authorities, in order to avoid post spinal headache, patients may be instructed preoperatively and reminded postoperatively that they should remain at bedrest without raising their heads for 24 to 48 hours.
• Adhesive tape secures intravenous line and anesthetic catheter.
• Do not dispose of the tray until the anesthetist has the appropriate information needed for the anesthetic record.
• The patient, although often sedated, may be alert enough to hear; therefore, discussion of the diagnosis, other medical information, and idle conversation should be limited accordingly.
• The patient’s privacy should always be maintained.

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Procedure: Oxygen Therapy

Oxygen therapy – is the administration of oxygen as a therapeutic modality. It is prescribed by the physician, who specifies the concentration, method of delivery, and liter flow per minute.
Benefits of Oxygen Therapy:

Additional Benefits of Oxygen Therapy:

• Increased clarity
• Relieves nausea
• Can prevent heart failure in people with severe lung disease
• Allows the bodies organs to carry out normal functions

Long-Term Benefits of Oxygen Therapy:

• Prolongs life by reducing heart strain
• Decreases shortness of breath
• Makes exercise more tolerable
• Results in fewer days of hospitalization

Oxygen Delivery Systems
1. Nasal Cannula

• Also called nasal prongs.
• Is the most common inexpensive device used to administer oxygen.
• It is easy to apply and does not interfere with the client’s ability to eat or talk.
• It delivers a relatively low concentration of oxygen which is 24% to 45% at flow rates of 2 to 6 liters per minute.

2. Face Mask

• It cover the client’s nose and mouth may be used for oxygen inhalation.
• Exhalation ports on the sides of the mask allow exhaled carbon dioxide to escape.

Types of Face Masks:

1. Simple Face Mask - Delivers oxygen concentrations from 40% to 60% at liter flows of 5 to 8 liters per minute, respectively.
2. Partial Rebreather Mask – Delivers oxygen concentration of 60% to 90% at liter flows of 6 to 10 liters per minute, respectively.
3. Non Rebreather Mask – Delivers the highest oxygen concentration possible 95% to 100% – by means other than intubation or mechanical ventilation, at liter flows of 10 to 15 liters per minute.
4. Venturi Mask – Delivers oxygen concentrations varying from 24% to 40% or 50% at liter flows of 4 to 10 liters per minute.

3. Face Tent

• It can replace oxygen masks when masks are poorly tolerated by clients.
• It provide varying concentrations of oxygen such as 30% to 50% concentration of oxygen at 4 to 8 liters per minute.

4. Transtracheal Oxygen Delivery

• It may be used for oxygen-dependent clients.
• The client requires less oxygen (0.5 to 2 liters per minute) because all of the low delivered enters the lungs.

Oxygen Therapy Safety Precautions:

1. For home oxygen use or when the facility permits smoking, teach family members and roommates to smoke only outside or in provided smoking rooms away from the client.
2. Place cautionary signs reading “No Smoking: Oxygen in use” on the clients door, at the foot or head of the bed, and on the oxygen equipment.
3. Instruct the client and visitors about the hazard of smoking with oxygen use.
4. Make sure that electric devices (such as razors, hearing aids, radios, televisions, and hearing pads) are in good working order to prevent the occurrence of short-circuit sparks.
5. Avoids materials that generate static electricity, such as woolen blankets and synthetic fabrics. Cotton blankets should be used , and client and caregivers should be advised to wear cotton fabrics.
6. Avoid the use of volatile, flammable materials such as oils, greases, alcohol, ether, and acetone(e.g. nail polish remover), near clients receiving oxygen.
7. Ground electric monitoring equipment, suction machines and portable diagnostic machines.
8. Make known the location of the fire extinguishers, and make sure personnel are trained in their use.

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Article: Concept of Family

The family is the basic unit of society. Families exist in all sizes and configurations and are essential to the health and survival of the individual members and to society as a whole. As the primary group for the individual, the family serves as a buffer between the needs of the individual and the demands and expectations of society. The role of the family is to meet the needs of society (Taylor, et. Al., 1989).
The family is a unity of interacting persons related by ties of marriage, birth or adoption, whose central purpose is to create and maintain a common culture which promotes the physical, mental, emotional and social development of each of its members (Duval, 1971).
In today’s society, Friedman defines the family as composed of two or more people who are emotionally involved with each other and live in close geographical proximity.
The family provides a set of functions important to the needs of the individual members and to society as a whole. The family provides the individual with the necessary environment for development and interactions; it also provides new and socialized members for society.
4 Major Functions of a Family: (Friedman, 1981)

1. Physical Function – carried out by providing a safe, comfortable environment necessary to growth, development and rest/recuperation.
2. Economic Function – provide financial aid for members, as well as, meeting monetary needs of society.
3. Reproductive Function – it is met by the birth of children.
4. Socialization Function – this is of major importance and includes teaching; transmitting beliefs, values, attitudes and coping mechanisms; providing feedback and guiding problem – solving.

Family Structure
Family Stages and Tasks

STAGES	TASKS
Beginning Family	• establishing a mutually satisfying marriage • planning to have or not have children
Child – bearing Family	• having and adjusting to infant • supporting the needs of all three members • renegotiating marital relationship
Family with Pre – school Children	• adjusting to costs of family life • adapting to needs of pre-school children to simulate growth and development • coping with parental loss of energy and privacy
Family with Pre – school Children	• adjusting to the motivity of growing children • promoting joint decisions between children and parents • encouraging and supporting children’s educational achievements
Family with Teenagers and Young Adults	• maintaining open communication among members • supporting ethical and moral values within the family • balancing freedom with responsibility for teenagers • releasing young adults with appropriate ritual and assistance • strengthening marital relationship • maintaining supportive home base
Post – parental Family	• preparing for retirement • maintaining ties with older and younger generations
Aging Family	• adjusting to retirement • adjusting to loss of spouse • closing family house

Case Study: Ectopic Pregnancy

• Implantation of a fertilized ovum outside the uterine cavity, most commonly in the fallopian tube.
• Good maternal prognosis with prompt diagnosis, appropriate surgical intervention, and control of bleeding.
• Poor fetal diagnosis (rare incidence of survival to term with abdominal implantation).
• About 33 % chance of giving birth to a live neonate in a subsequent pregnancy.
• Incidence: about 1 to 200 pregnancies in whites; about 1 of 120 pregnancies on nonwhites.
• Complications: rupture of fallopian tube, hemorrhage, shock, peritonitis, infertility, disseminated intravascular coagulation, and death.

Pathophysiology

• Transport of a blastocyst to the uterus is delayed.
• The blastocyst implants at another available vascularized site, usually the fallopian tube lining.
• Normal signs of pregnancy are initially present.
• Uterine enlargement occurs in about 25% cases.
• Human chorionic gonadotropin (hCG) hormonal levels are lower than in uterine pregnancies.
• If not interrupted, internal hemorrhage occurs with rupture of the fallopian tube.

Causes

• Congenital defects in the reproductive tract
• Diverticula
• Ectopic endometrial implants in the tubal mucosa
• Endosalpingitis
• Intrauterine device
• Previous surgery, such as tubal ligation or resection
• Sexually transmitted tubal infection
• Transmigration of the ovum
• Tumors pressing against the tube

Assessment findings

• Amenorrhea
• Abnormal menses (after fallopian tube implantation)
• Slight vaginal bleeding
• Unilateral pelvic pain over the mass
• If fallopian tube ruptures, sharp lower abdominal pain, possibly radiating to the shoulders and neck.
• Possible extreme pain when cervix is moved and adnexa palpated.
• Boggy and tender urine
• Possible enlargement of adnexa

Test Results

• Serum hCG is abnormally low; when repeated in 49 hours, the level remains lower than the levels found in a normal intrauterine pregnancy.
• Ultrasonography may show an intrauterine pregnancy or ovarian cyst.
• Culdocentesis shows free blood in the peritoneum
• Laparoscopy may reveal a pregnancy outside the uterus.

Treatment

• Initially, in the event of pelvic-organ rupture, management of shock
• Diet determined by clinical status
• Activity determined by clinical status
• Transfusion with whole blood or packed red blood cells
• Broadspectrum I.V. antibiotics
• Methotrexate (Rheumatrex)
• Laparotomy and salpingectomy if culdocentesis shows blood in the peritoneum; possibly after laparoscopy to remove affected fallopian tube and control bleeding.
• Micro-surgical repair of the fallopian tube for patients who wish to have children.
• Oophorectomy for ovarian pregnancy
• Hysterectomy for interstitial pregnancy
• Laparotomy to remove the fetus for abdominal pregnancy.

Nursing Interventions

• Determine the date and description of the patient’s last menstrual period.
• Monitor vital signs for changes.
• Assess vaginal bleeding, including amount and characteristics
• Assess pain level
• Monitor intake and output
• Assess for signs of hypovolemia and impending shock
• Prepare the patient with excessive blood loss for emergency surgery.
• Administer prescribed blood transfusions and analgesics.
• Provide emotional support.
• Administer Rh (D) immune globulin (RhoGAM), as ordered, if the patient is Rh negative.
• Provide a quiet, relaxing environment
• Encourage the patient to express feelings of fear, loss, and grief.
• Help the patient develop effective coping strategies.
• Refer the patient to a mental health professional, if necessary, prior to discharge.

Case Study: Meconium Aspiration Syndrome

• Aspiration of meconium (the neonate’s first feces) into the lungs.
• Typically occur with the first breath or while the neonate is in utero.
• Thick, sticky, and greenish black substance; may be seen in the amniotic fluid after 34 weeks gestation.

Pathophysiology

• Asphyxia in utero leads to increased fetal peristalsis, relaxation of the anal sphincter, passage of meconium into the amniotic fluid, and reflex gasping of amniotic fluid into the lungs.
• Neonates with meconium aspiration syndrome (MAS) increase respiratory efforts to create greater negative intrathoractic pressures and improve air flow to the lungs.
• Hyperinflation, hypoxemia, and academia cause increased peripheral vascular resistance.
• Right-to-left shunting commonly follows.
• Meconium creates a ball-valve effect, trapping air in the alveolus and preventing adequate gas exchange.
• Chemical pneumonitis results, causing the alveolar walls and interstitial tissues to thicken, again preventing adequate gas exchange.
• Cardiac efficiency can be compromised from pulmonary hypertension.

Causes

• Commonly related to fetal distress during labor.
• Advance gestational age (greater than 40 weeks)
  
  • Difficult delivery
  • Fetal distress
  • Intrauterine hypoxia
  • Maternal diabetes
  • Maternal hypertension
  • Poor intrauterine growth
  • Risk factors for MAS:
  
  

Assessment Findings

• Fetal hypoxia as indicated by altered fetal activity and heart rate.
• Dark greenish staining or streaking of the amniotic fluid noted on rupture of membranes.
• Obvious presence of meconium in the amniotic fluid
• Greenish staining of the neonate’s skin (if the meconium was passed long before delivery) or placenta.
• Signs of distress at delivery, such as the neonate appearing limp, an Apgar score below 6, pallor, cyanosis, and respiratory distress.
• Coarse crackles when auscultating the neonate’s lungs.

Test Results

• Arterial blood gas analysis shows hypoxemia and decreased pH.
• Chest X-ray may show patches or streaks of meconium in the lungs, air trapping, or hyperinflation.

Treatment

• Respiratory assistance via mechanical ventilation
• Maintenance of a neutral thermal environment
• Administration of surfactant and an antibiotic
• Extracorporeal membrane oxygenation (in severe cases).

Nursing Interventions

• During labor, continuously monitor the fetus for signs and symptoms of distress.
• Immediately inspect any fluid passed with rupture of the membrane.
• Assist with immediate endotracheal suctioning before the first breaths, as indicated.
• Monitor lung status closely, including breath sounds and respiratory rate and character.
• Frequently assess the neonate’s vital signs.
• Administer treatment modalities, such as oxygen and respiratory support as ordered.
• Institute measures to maintain a neutral thermal environment.
• Provide the family with emotional support and guidance.

Case Study: Encephalitis

• Is an inflammation of cerebral tissue typically accompanied by meningeal inflammation, caused by an infection or other source.
• It can present as acute viral encephalitis, most frequently caused by herpes virus and most commonly occurring in children.
• Cytomegalovirus (CMV) and toxoplasma are common causes in patients with acquired immunodeficiency syndrome.
• It may also present as post-infectious encephalitis, which follows a viral or bacterial infection, usually of the respiratory or GI tract.
• It may also present as an anthropod-borne infection such as West Nile Virus.
• The disease, which is commonly fatal, causes lymphocytic infiltration of the brain, which leads to cerebral edema, basal ganglia degeneration, and diffuse nerve cell destruction.
• Complications include motor and sensory deficits, amnesia syndrome, syndrome of inappropriate antidiuretic hormone (SIADH), coma, and death.

Assessment

1. Fever, headache, nausea and vomiting, mental status changes.
2. Meningeal signs – nuchal rigidity (stiff neck), photophobia.
3. Seizures, motor deficits, personality changes.
4. Signs of brain stem involvement, such as nystagmus, extraocular nerve palsies, hearing loss, dysphagia, and respiratory dysfunction.
5. Patients with hypothalamic-pituitary involvement may develop diabetes insipidus, hypothermia, or SIADH.

Diagnostic Evaluation

1. Lumbar puncture evaluates cerebrospinal fluid (CSF) for increased cell count; polymerase chain reaction analysis of CSF for viral antibodies.
2. Electroencephalogram may reveal abnormalities.
3. Gadolinium-enhanced magnetic resonance imaging can detect different patterns of inflammation to differentiate type of encephalitis.
4. Blood cultures rarely identify causative organism, but brain-tissue biopsy may indicate presence of microorganism.
5. West Nile virus serologic testing on blood or CSF.

Pharmacologic Interventions

1. Antiviral agent acyclovir given I.V. for 10 days to 3 weeks for herpes simplex virus.
2. Blood cultures and foscarnet I.V. for CMV encephalitis.
3. Anticonvulsants to treat seizures, corticosteroids to reduce cerebral edema, and sedatives and analgesics as supportive therapy.

Nursing Interventions

1. Monitoring pupils and vital signs frequently for increased intracranial pressure (ICP; irregular pupils, widening pulse pressure, tachycardia, irregular breathing hyperthermia).
2. Monitor the patient’s response to medications and observe for adverse reactions.
3. Monitor neurologic status closely. Watch for subtle changes, such as behavior or personality changes, weakness, or cranial nerve involvement.
4. Monitor fluid intake and output to ensure adequate hydration.
5. Maintain quiet environment and provide care gently, to avoid excessive stimulation and agitation, which may cause increase ICP.
6. Maintain seizure precautions; pad side rails of bed and have airway and suction equipment available at bedside.
7. Maintain standard precautions and additional isolation according to hospital policy to prevent transmission.
8. Administer antipyretics and other cooling measures as indicated.
9. Provide fluid replacement through I.V. lines as needed.
10. Reorient patient frequently.
11. Provide supportive care if coma develops; may last several weeks.
12. Encourage significant others to interact with patient with even while in coma and to participate in care to promote rehabilitation.