Removing Medication From an Ampule

Skill 5-3

Removing Medication From an Ampule

An ampule is a glass flask that contains a single dose of medication for parenteral administration. Because there is no way to prevent contamination of any unused portion of medication after the ampule is opened, discard any remaining medication if not all the medication is used for the prescribed dose. You must break the thin neck of the ampule to remove the medication.

Delegation Considerations

The preparation of medication from an ampule is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the preparation of medication from an ampule may be delegated to a licensed practical/vocational nurse (LPN/LVN). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Sterile syringe and filter needle
New needle for replacing filter needle, if indicated
Ampule of medication
Antimicrobial swab
Small, sterile gauze pad
Gloves
Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR)

Assessment

Assess the appropriateness of the drug for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Assess the medication in the ampule for any particles or discoloration. Assess the ampule for any cracks or chips. Check the expiration date before administering the medication. Assess the patient's knowledge of the medication. If the patient has a knowledge deficit about the medication, this may be the appropriate time to begin education about the medication. If the medication may affect the patient's vital signs, assess them before administration. If the medication is for pain relief, assess the patient's pain level before and after administration. Verify patient name, dose, route, and time of administration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Infection risk
Knowledge deficiency
Injury risk

Outcome Identification and Planning

The expected outcomes to achieve when removing medication from an ampule are that the medication is removed in a sterile manner, the medication is free from glass shards and contamination, and the proper dose is prepared.

Implementation

Action	Rationale
1. Gather equipment. Check each medication prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Perform hand hygiene.	Hand hygiene prevents the spread of microorganisms.
4. Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.	Organization facilitates error-free administration and saves time.
5. Unlock the medication supply system or drawer. Enter the passcode and scan employee identification, if required.	Locking the medication supply system or drawer safeguards each patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use. Entering the passcode and scanning ID allows only authorized users into the computer system and identifies the user for documentation by the computer.
6. Prepare medications for one patient at a time.	This prevents errors in medication administration.
7. Read the eMAR/MAR and read the label when selecting the proper medication from the medication supply system or the patient's medication drawer.	This is the first check of the label.
8. Read the label and compare the label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.	This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary.
9. Tap the stem of the ampule (Figure 1) or twist your wrist quickly (Figure 2) while holding the ampule vertically.	This facilitates movement of medication in the stem to the body of the ampule.
10. Put on gloves. Using the antimicrobial swab, scrub the neck of the ampule. Wrap a small sterile gauze pad around the neck of the ampule.	Gloves reduce risk of injury to hands from glass (Innovation Compounding, 2020). Scrubbing the neck is necessary to reduce the risk of contamination (Dolan et al., 2016; Innovation Compounding, 2020). Wrapping the neck of the ampule with gauze protects your fingers from the glass as the ampule is broken.
11. Breaking away from your body, use a snapping motion to break off the top of the ampule along the scored line at its neck (Figure 3). Always break away from your body.	This protects your face and fingers from any shattered glass fragments.
12. Attach the filter needle to the syringe. Remove the cap from the filter needle by pulling it straight off.	Use of a filter needle prevents the accidental withdrawing of small glass particles with the medication (Innovation Compounding, 2020). Pulling the cap off in a straight manner prevents accidental needlestick.
13. Withdraw the medication in the amount ordered plus a small amount more (approximately 30% more). Do not inject air into the solution. While inserting the filter needle into the ampule, be careful not to touch the rim. Use either of the following methods to withdraw the medication:	By withdrawing an additional small amount of medication, any air bubbles in the syringe can be displaced once the syringe is removed while allowing ample medication to remain in the syringe. The contents of the ampule are not under pressure; therefore, air is unnecessary and will cause the contents to overflow. The rim of the ampule is considered contaminated.
a. Insert the tip of the needle into the ampule, which is upright on a flat surface, and withdraw fluid into the syringe (Figure 4). Touch the plunger only at the knob.	Handling the plunger only at the knob will keep the shaft of the plunger sterile.
b. Insert the tip of the needle into the ampule and invert the ampule. Keep the needle centered and not touching the sides of the ampule. Withdraw fluid into the syringe (Figure 5). Touch the plunger only at the knob.	Surface tension holds the fluids in the ampule when inverted. If the needle touches the sides or is removed and then reinserted into the ampule, surface tension is broken, and fluid runs out. Handling the plunger only at the knob will keep the shaft of the plunger sterile.
14. Wait until the needle has been withdrawn to tap the syringe and expel the air carefully by pushing on the plunger. Check the amount of medication in the syringe with the medication dose and discard any surplus, according to facility policy.	Ejecting air into the solution increases pressure in the ampule and can force the medication to spill out over the ampule. Ampules may have overfill. Careful measurement ensures that the correct dose is withdrawn.
15. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, read the label and recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.	This third check ensures accuracy and helps to prevent errors. Note: Many facilities require the third check to occur at the bedside, after identifying the patient and before administration.
16. Label the syringe with the medication name, dose, and amount (The Joint Commission, 2021).	Unlabeled syringes are unidentifiable and may lead to a medication administration error (The Joint Commission, 2021).
17. Engage the safety guard on the filter needle and remove the needle. Discard the filter needle in a suitable container. Attach the appropriate administration device to the syringe.	The filter needle used to draw up medication should not be used to administer the medication. This will prevent any glass shards from entering the patient during administration.
18. Discard the ampule in a suitable container. Remove gloves and perform hand hygiene.	Any medication that has not been removed from the ampule must be discarded because sterility of contents cannot be maintained in an opened ampule. Removing gloves and performing hand hygiene deters the spread of microorganisms
19. Log out of and/or lock the medication supply system before leaving it.	Locking the medication supply system safeguards the patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use.
20. Perform hand hygiene.	Hand hygiene deters the spread of microorganisms.
21. Proceed with administration, based on prescribed route.	See appropriate skill for prescribed route.

Evaluation

The expected outcomes have been met when the medication was removed from the ampule in a sterile manner, it remained free from glass shards and contamination, and the proper dose was prepared.

Documentation

Guidelines

It is not necessary to record the removal of the medication from the ampule. Prompt recording of administration of the medication is required immediately after it is administered.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

You cut yourself while trying to open the ampule: Discard the ampule and medication in case contamination has occurred. Clean and bandage the wound and obtain a new ampule. Communicate the incident according to facility policy.
All of medication was not removed from the stem and insufficient medication remains in body of ampule for dose: Discard the ampule and drawn medication. Obtain a new ampule and start over. Medication in the original ampule stem is considered contaminated once the neck of the ampule has been placed on a nonsterile surface.
You inject air into inverted ampule, spraying medication: Wash your hands to remove any medication. If any medication has gotten into your eyes, perform eye irrigation. Obtain a new ampule for medication dose. Communicate the incident according to facility policy.
Plunger becomes contaminated before inserted into ampule: Discard the needle and syringe and start over. If the plunger is contaminated after medication is drawn into the syringe, it is not necessary to discard and start over. The contaminated plunger will enter the barrel of the syringe when pushing the medication out, will not come in contact with the medication, and will not contaminate the medication.

Special Considerations

When mixing medications in one syringe, preparation of medications in one syringe depends on how the medication is supplied. When preparing medications from an ampule and a vial, prepare the medication in the vial first. Draw up the medication in the ampule after the medication in the vial (see Skill 5-4).

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Skill 5-3