The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [538]
8 With the second Registered Nurse, take the prepared dose to the patient and check the patient’s identity by asking them to verbally identify themselves (where possible) and check against the patient’s identification wristband. Also ask and check allergy status. To prevent error and confirm patient’s identity (NPSA 2005, C; NPSA 2007b, C).
9 Administer the drug after checking the prescription chart again. If given orally, wait until the patient has swallowed the medication. To ensure the patient receives the medicines (DH 2003b, C).
Postprocedure
10 Once the drug has been administered, the prescription chart is signed by the nurse responsible for administering the medication and the Registered Nurse who witnessed the administration. To prevent duplication of treatment. To comply with hospital policy (DH 2003b, C; NMC 2008a, C; NPSA 2006, C). To maintain accurate records, provide a point of reference in the event of any queries and prevent any duplication of treatment (NMC 2008a, C; NMC 2008b, C; NMC 2009, C).
11 The nurse should check the patient after administration to check for effectiveness and/or toxicity. To ensure that the drug has been effective and to administer a breakthrough dose if necessary. To check that the patient has not experienced any toxicity that may require interventions. E
12 If drug given via a syringe driver/pump, the nurse should return to check the infusion and site and document in the appropriate records. To ensure that the infusion is infusing at the correct rate and the site is suitable. E
Postprocedural considerations
Ongoing care
Patients should be monitored for signs of adverse effects from opioids and for signs of toxicity.
The most common side-effects are constipation, nausea and vomiting and drowsiness. All patients who are prescribed an opioid regularly should be prescribed laxatives concurrently to prevent constipation. Nausea and vomiting should subside after a few days but patients should be prescribed antiemetics and given reassurance. Drowsiness due to opioids should also subside after a few days so patients should be given reassurance. (Regnard and Hockley 2004)
The warning signs of toxicity due to opioids are:
drowsiness
confusion
myoclonus
hallucinations and nightmares
respiratory depression.
If patients are showing signs of toxicity the opioid dose should be reduced or stopped and as-required opioid pain relief given (Regnard and Hockley 2004). Changing to an alternative opioid can also be considered (Regnard and Hockley 2004).
Naloxone, a specific opioid antagonist, has a high affinity for opioid receptors and reverses the effect of opioid analgesics. It is rarely needed in palliative care but may be needed in the case of opioid-induced respiratory depression (with respiration rate of 8 or below).
Care must be taken not to give naloxone to patients who have opioid-induced drowsiness, confusion or hallucinations that are not life threatening due to the risk of reversing the opioid analgesic effect (Twycross and Wilcock 2007).
Naloxone should be given in stat doses every 2 minutes until respiratory function is satisfactory and doses should be titrated against respiratory function and not consciousness in order to avoid total reversal of the analgesic effect (Twycross and Wilcock 2007). Flumazanil may be required for reversal of midazolam.
Routes of administration
The three basic routes of administration are enteral, parenteral and topical. The enteral route uses the gastrointestinal (GI) tract for absorption of drugs. The parenteral route bypasses the GI tract and is associated with all forms of injections. The topical route also bypasses the GI tract and is associated with drugs that are administered to the skin and mucous membranes (see Table 13.8).
Table 13.8 Advantages and disadvantages of the routes of administration
Route Advantages Disadvantages
Oral Convenient
Easy to administer
Least expensive Compliance
Some drugs not suitable for oral route
May not be able to swallow or take oral medications
Topical Easy to apply
Local