- MEDICATION PREPARATION AND ADMINISTRATION |
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OBJECTIVES:
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1. To prepare the appropriate delivery device for the purpose of administering medications
2. To prepare the appropriate delivery device for the purpose of administering fluids
3. To prepare the appropriate delivery device for the purpose of administering a medication via a nebulizer
4. To administer medication enteral and parenteral routes
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IMPORTANT POINTS:
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1. Use appropriate body substance isolation precautions
2. Medication must be administered in compliance with local protocols and medical direction
3. A comprehensive assessment must be performed on all patients to whom medications will be administered to determine:
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Indication for medication
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Contraindication(s) for medication
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Appropriate dose for patient
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Response to medication
4. All skills in this section assume the patient is being provided with supplemental oxygen as appropriate
5. Before administering any medication, always be certain you have:
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The right patient
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The right medication
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The right dose
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The right time
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The right route
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The right documentation
6. Prior to medication preparation and delivery, inspect the medication to insure it:
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Contains the correct medication
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Contains the correct dose
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Has not expired
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Has not been contaminated in any manner. Non-intact packaging may indicate loss of sterility
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7. Documentation should include (per local protocol):
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Medication
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Dose delivered
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Route
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Site/method
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Time given
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Physician ordering medication
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EMT delivering medication
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I. ORAL, SUBLINGUAL AND BUCCAL MEDICATIONS
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A. PREPARATION OF ORAL, SUBLINGUAL AND BUCCAL MEDICATIONS
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1. Tablets
a. Inspect the medication
b. Shake out the proper number of tablets to obtain the proper dose
c. Recheck the label for proper medication and dosage information
d. Give directions to patient for medication administration
e. The medication is now ready to be administered
2. Sublingual spray
a. Inspect the medication
b. Give directions to patient for medication administration
c. The medication is now ready to be administered
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The tablets should be placed in the lid of the medication bottle or an appropriate container
The medication should be transferred from the lid to the patient’s hand or to the rescuer’s gloved hand for administration
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3. Buccal (between cheek and gum):
a. Inspect the medication
b. Give directions to patient for medication administration
c. The medication is now ready to be administered
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B. ADMINISTRATION OF ORAL, SUBLINGUAL AND BUCCAL MEDICATIONS
1. Prepare medication as previously described in this section
2. Recheck medication label for the rights
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3. Explain procedure to the patient:
a. Oral: Swallow the medication with a small amount of water
b. Chewed: Chew the medication and do not swallow for about 10 seconds
c. Sublingual: Place the medication under the tongue and do not swallow for 10 seconds
d. Sublingual spray: Spray on or under the tongue; be careful the patient does not inhale medication
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e. Buccal: Apply medication between patient’s cheek and gum
4. Give the medication to the patient to take or place medication in the patient’s mouth
5. Assure the medication is swallowed, chewed or dissolved
6. Document medication administration
7. Provide an ongoing assessment of your patient to identify any effects of the
medication
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Buccal medication may be applied to a tongue depressor for administration
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II. INHALED MEDICATIONS
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A. PREPARATION OF INHALED MEDICATIONS
1. Metered dose inhaler
a. Inspect the medication
b. Shake the inhaler canister vigorously
c. Wait 1-2 minutes between inhalations; shake canister before each inhalation
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2. Nebulizer
a. Select a nebulizer delivery method
1) If using the hand held delivery, attach the reservoir hose and mouthpiece to opposite ends of the “T” fitting
2) If using a mask delivery, use a nebulizer mask or remove the reservoir bag and the one-way valves (flaps) from a non-rebreather mask
b. Assemble the medication cup by screwing the top and bottom sections together
c. Inspect the medication
d. Place the ordered dose of medication(s) into the medication cup and attach it to the bottom of the “T” fitting or mask
e. Attach the oxygen tubing to the inlet port of the medication cup. Attach the other end to an oxygen source capable of delivering a 4-6 lpm flow
f. Turn on oxygen and adjust flow for best results
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Choosing between the “T” piece and mask is based on the patient’s ability to hold the device and coordinate inhalation and breathing technique
Most cups must be kept upright to avoid spilling the medication
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B. ADMINISTRATION OF INHALED MEDICATIONS
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1. Metered dose inhaler
a. Inspect the medication
b. Verify the inhaler belongs to the patient
c. Shake the inhaler canister vigorously
d. Explain procedure to the patient:
1) Forcibly exhale
2) Place lips around the inhaler
3) Activate inhaler with deep inhalation
4) Hold breath as long as comfortably able
e. Remove supplemental oxygen from the patient if needed for the medication administration
f. Assist with medication administration as needed
g. Replace oxygen and encourage patient to take several deep breaths
h. Repeat steps c-g to obtain ordered dosage(s). Wait 1-2 minutes between inhalations
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2. Nebulizer
a. Assemble nebulizer delivery device as previously described in this section
b. Recheck medication label for the rights
c. Explain procedure to the patient:
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1) Seal lips around the mouthpiece of the hand held nebulizer or place mask on patient
2) Take slow breaths and inhale as deep as possible
3) Hold breath as long as comfortably able, up to 10 seconds
4) Continue until the medication is gone; there is no misting
d. Remove supplemental oxygen from patient
e. Start nebulizer with oxygen at 4-6 lpm – adjust until it makes a fine mist
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The mist should "disappear" with each breath. Much of the mist that can actually be seen is too large to actually be absorbed
Follow manufacturer’s recommendation for liter flow
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f. Encourage patient to take slow, deep breaths until the medicine is gone from the
medication cup
g. Replace supplemental oxygen when the treatment is completed
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As the medication is administered and the level drops in the medication cup, the cup may need to be tapped to deliver all the medication
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III. INJECTABLE MEDICATIONS
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IMPORTANT POINTS
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1. Maintain sterility of needles and medication for injections
2. Utilize safety engineered devices to minimize risk of needle sticks (mandatory except for auto-injectors)
3. Always ensure that all sharps are properly disposed of in a timely manner in an approved sharps disposal container
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4. Route of administration and size of the patient are used to determine the appropriate size needle
a. A 23- to 25-gauge, 5/8-inch-long needle is appropriate for subcutaneous injections.
b. The needle gauge for I.M. injections should be larger to accommodate viscous solutions and suspension. Recommend 21G to 23G needles 1” to 2” in length
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As a rule of thumb, a 200-lb (90-kg) patient requires a longer needle (i.e. 2” ) for an IM injection; a 100-lb (45-kg) patient will require a 11⁄4” to 11⁄2” needle
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Pre-filled systems may have an air bubble that will need to be purged prior to medication administration
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When drawing up medication from a vial or ampule, draw up a little extra that can be wasted when purging air bubbles
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7. Assure the proposed site for injection is free of inflammation, swelling, infection and any skin lesions
8. Never recap used needles
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9. If blood is present when aspirating, withdraw the needle and discard the medication. Start over with new medication and a new site
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A. PREPARATION OF INJECTABLE MEDICATIONS
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SYRINGE AND VIAL
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1. Inspect the medication
2. Select an appropriate size syringe for the medication to be delivered
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3. Remove the protective “flip-off” cap from the top of the vial
4. Wipe the rubber stopper with an alcohol prep or other suitable antiseptic swab
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5. a. If reconstituting a medication:
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Pierce the center of the medication vial’s stopper with the needle on the syringe of diluting solution
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Inject diluting solution
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Remove the needle/syringe from the vial
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Gently shake the vial to assure the medication dissolves
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Continue with drawing up the medication with a new needle and syringe repeating steps #1-4
b. If drawing a medication or diluting solution from a vial:
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Draw up the same volume of air as the volume to be withdrawn
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Pierce the center of the vial’s stopper with the needle on the syringe
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Inject air
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Common practice is to use a larger needle for drawing up the drug, smaller needle for injecting
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6. Holding the vial upside down in one hand and being careful to keep the end of the needle within the fluid level of the vial, pull back gently on the plunger to draw the medication or diluting solution into the syringe
7. Withdraw the needle and syringe from the vial
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8. Replace the needle with an appropriate size safety engineered needle for subcutaneous or IM injections
9. With the needle pointing upward, gently tap the syringe to move any air bubbles to the top
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For comfort, change the needle prior to injection. Most needles have a fine silicon coating to facilitate easy entry into muscle mass. This may be lost when drawing up the medication. Also, literature has shown some rubber stoppers to contain trace amounts of latex that may cause a sensitivity reaction
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10. Gently depress the plunger of the syringe until air is expelled and only the desired amount of medication remains in the syringe
11. The medication is now ready to be delivered
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SYRINGE AND AMPULE
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Inspect the medication
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Select a syringe of appropriate size for the volume of medication to be delivered
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3. Select a filter needle of appropriate size and length to withdraw the medication and attach to the syringe
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Also called a “filter straw”
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4. Hold the ampule upright and gently “flick” it to move any medication trapped in the head of the ampule to the base
5. Wipe the area between the head and base of the ampule with an alcohol prep or other suitable antiseptic swab
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6. Once the medication is removed from the head of the ampule, use a commercially available device or a gauze square to grasp the head of the ampule and break the head from the base
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Hold the ampule at arms length and break by snapping the top toward you. This will cause any glass shards to be directed away rather than toward you when the ampule breaks
If the ampule fails to break cleanly and glass shards can be observed, dispose of the ampule and replace with another
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7. Using the filter needle and syringe withdraw medication for administration. Discard any remaining medication and properly dispose of both portions of the ampule in a sharps container
8. Remove the filter needle used to withdraw the medication from the ampule and properly dispose of the filter needle in an sharps container
9. Replace the filter needle with an appropriate size safety engineered needle for subcutaneous or IM injections
10. With the needle pointing upward, gently tap the syringe to move any air bubbles to the top of the syringe
11. Gently depress the plunger of the syringe until air is expelled and only the desired amount of medication remains in the syringe
12. The medication is now ready to be delivered
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PRE-LOADED SYRINGES
1. Pre-filled Systems
a. Inspect the medication
b. Remove the protective caps from the medication cartridge and the barrel of the syringe assembly
c. Insert the medication cartridge into the barrel assembly and rotate clockwise until the medication cartridge is secure in the barrel. The medication cartridge is now the plunger
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d. With the unit now fully assembled, remove the protector from the distal tip and gently depress the plunger until air is expelled and only the desired amount of medication remains in the syringe
e. Attach an appropriate size safety engineered needle for subcutaneous or IM injections
f. The medication is now ready to be delivered
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2. Syringe Cartridge Systems (e.g. Carpuject and Tubex)
a. Inspect the medication cartridge
b. Insert and secure the syringe cartridge into the cartridge holder following the manufacturer’s directions
c. Attach an appropriate size safety engineered needle for subcutaneous or IM injections
d. With the unit now fully assembled, remove the protector from the distal tip and gently depress the plunger of the syringe until air is expelled and only the desired amount of medication remains in the syringe
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e. The medication is now ready to be delivered
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3. Auto-injector systems
a. Inspect the medication
b. Remove the safety cap only after placing the device against the previously prepared injection site
c. The medication is now ready to be administered
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Never place your thumb or finger over the ends of the auto-injector
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B. ADMINISTRATION OF INJECTABLE MEDICATIONS
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INTRAMUSCULAR INJECTION
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1. Prepare medication as previously described in this section
2. Recheck medication label for the rights
3. Ensure the correct size safety needle is attached for administration route (not applicable for auto-injector)
4. Select an injection site
a. Deltoid
b. Vastus lateralis (lateral thigh)
5. Cleanse the injection site with an alcohol prep or other suitable antiseptic swab in an outward circular motion for about 2 inches
6. Hold the syringe in dominant hand and remove the needle cover
7. Stabilize the injection site with your non-dominant hand using:
a. “Pinch“ technique
b. Stretch technique
8. Holding the syringe like a dart, quickly but not forcefully, insert the needle into the injection site at a 90 degree angle until the proper depth is reached
9. Release the skin while continuing to hold the syringe in place with the dominant hand
10. Grasp the plunger with one hand and the barrel of the device with the other. Pull back (aspirate) slightly on the plunger and wait five seconds
11. If no blood aspirates into the syringe, proceed with the injection. Slowly depress the plunger to administer the injection (10 seconds per mL)
12. Once the medication has been administered, wait ten seconds, then withdraw the needle using appropriate safety features and/or activating the needle safety engineering device
13. Cover the injection site with an alcohol or gauze pad and apply gentle pressure to the area to help reduce pain and improve absorption
14. Properly dispose of the syringe and needle assembly in an appropriate sharps container
15. Place a bandage over the injection site
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After selecting the injection site, gently tap it to stimulate the nerve endings which will minimize pain when the needle is inserted.
Using the stretch technique may accomplish this also
Allow alcohol to dry for 30 seconds for bacteria to be killed and to minimize discomfort of the injection
Prior to injection, tell the patient that they will feel a poke.
Aspiration takes longer with smaller needles
A slow, steady injection rate allows the muscle to distend gradually and accept the medication under minimal pressure.
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AUTO-INJECTOR
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1. Prepare medication as previously described in this section
2. Recheck medication label for the rights
3. Select the vastus lateralis (lateral thigh) injection site
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4. Cleanse the injection site with an alcohol prep or other suitable antiseptic swab in an outward circular motion for about 2 inches
5. Grasp the auto-injector by wrapping fist around the unit
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Allow alcohol to dry for 30 seconds for bacteria to be killed and to minimize discomfort of the injection
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6. Place black end of auto-injector against the prepared site on the lateral thigh at a 90 degree angle
7. Remove the gray protective cap
8. Stabilize the patient’s leg to prevent pulling away
9. Apply a gentle pressure against leg with auto-injector until it clicks
10. Hold in place for 10 seconds before removing auto-injector
11. Properly dispose of the auto-injector in an appropriate sharps container
12. Place a bandage over the injection site
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Never place your thumb or finger over the ends of the auto-injector
Prior to injection, tell the patient that they will feel a poke
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SUBCUTANEOUS INJECTION
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1. Prepare medication as previously described in this section
2. Recheck medication label for the rights
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3. Insure the correct size safety needle is attached for administration route (not applicable for auto-injector)
4. Select an injection site
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5. Cleanse the injection site with an alcohol prep or other suitable antiseptic swab in an outward circular motion for about 2 inches
6. Hold the syringe in dominant hand and remove the needle cover
7. Stabilize the injection site with your non-dominant hand using the “pinch” technique
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Allow alcohol to dry for 30 seconds for bacteria to be killed and to minimize discomfort of the injection
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8. Holding the syringe like a dart, quickly but not forcefully, insert the needle into the injection site at a 45-90 degree angle until the proper depth is reached
9. Release the skin while continuing to hold the syringe in place with the dominant hand
10. Slowly depress the plunger to administer the injection (10 seconds per mL)
11. Once the medication has been administered, wait ten seconds, then withdraw the needle using appropriate safety features
12. Cover the injection site with an alcohol or gauze pad and put gentle pressure on the area to help reduce pain and improve absorption
13. Properly dispose of the syringe and needle assembly in an appropriate sharps container
14. Place a bandage over the injection site
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Shorter needles or patient size may affect the angle of injection
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INTRAVENOUS BOLUS MEDICATIONS (IVP) - Assumes a patent IV is present
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1. Prepare medication as previously described in this section
2. Recheck medication label for the rights
3. Insure the correct size safety needle is attached for administration route (not applicable for auto-injector)
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3. Use an alcohol prep or other suitable antiseptic swab to wipe the surface of the IV tubing med-port closest to the patient
4. Remove the protective cap from the syringe
5. Connect the syringe to the prepared med-port by:
a. Twisting clockwise for luer lock connections
b. Inserting blunt cannula for ports designed for this safety device
c. Inserting needle through self-sealing ports designed for needle puncture
6. Kink off the IV tubing between the selected med-port and the IV solution bag
7. Inject the medication at the proper rate
8. Disconnect syringe from med-port
9. Following injection of the medication, flush the IV tubing
a. Bolus flush by syringe
b. Open flow of IV
10. Properly dispose of the syringe and needle assembly in an appropriate sharps container
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Allow alcohol to dry for 30 seconds for bacteria to be killed and to minimize injecting alcohol with the medication
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IV. INTRAVENOUS ADMINISTRATION AND CARE
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IMPORTANT POINTS
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1. Maintain sterility of needles, ends of IV tubing and medication for injections
2. Utilize safety engineered devices to minimize risk of needle sticks (mandatory)
3. Always insure that all sharps are properly disposed of in a timely manner in an approved sharps disposal container.
4. Assure the proposed site for cannulation is free of inflammation, swelling, infection and any skin lesions
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Never recap used needles
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When drawing up medication from a vial or ampule, draw up a little extra that can be wasted when purging air bubbles
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A. IV ADMINISTRATION SET PREPARATION
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1. Select the appropriate solution
a. Inspect the solution
b. Open outer packaging by tearing pre-cut slit at either end of the bag
1) Recheck clarity
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Solution choice should be based on patient condition and local protocols
A slight amount of moisture inside the outer bag is normal and not cause for concern
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2. Select an appropriate IV administration set
3. Open the administration set
a. Check to be certain the end caps that preserve the sterile field of the administration set remain in place
b. Uncoil the tubing in preparation for spiking the IV bag
c. If adjunct devices such as extensions or flow meters are to be used, they should be opened and attached to the administration set at this time
4. Move the flow control clamp to a convenient location and close off the IV tubing by:
a. Rotating the control knob (roller clamp)
b. Sliding the clamp (slide clamp)
c. Pinching the clamp (pinch clamp)
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Choose between macro and micro infusion sets based on patient condition
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5. Spike the IV bag
a. Method one
1) If not previously done, hang the IV bag with the tail ports extending downward
2) Grasp the IV port just above the plastic tab. With the other hand, pull the plastic tab from the port. Be careful to maintain sterility of the port
3) Remove the protective cap from the IV tubing spike being careful to protect the sterile field
4) Insert the IV tubing spike into the IV port by pushing and twisting the spike until it punctures the seal of the port
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Whenever possible, the IV bag should be hung in a vertical position to facilitate preparation
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5) Squeeze the drip chamber to fill it approximately half full of fluid
b. Method two
1) Holding the IV bag at its base, invert the bag so the tail ports extend upward
2) While continuing to hold the IV bag, grasp its IV port just below the plastic tab. With the other hand, pull the plastic tab from the port. Be careful to maintain sterility of the port
3) Remove the protective cap from the IV tubing spike being careful to protect the sterile field
4) Insert the IV tubing spike into the IV port by pushing and twisting the spike until it punctures the seal of the port
5) Invert the bag so it is in an upright position and hang the IV bag
6) Squeeze the drip chamber to fill it approximately half full of fluid
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If too much fluid enters the drip chamber, invert the bag and drip chamber and squeeze some of the fluid back into the bag
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6. Place the end of the tubing in a convenient location while preserving sterility by keeping protective cap in place
7. Open the flow control clamp and allow the IV fluid to completely fill the line. It is often necessary to invert and “flick” med-ports with your fingers to remove larger air bubbles
8. Once the line is completely filled with fluid, and larger air bubbles removed, close the flow clamp and place the “primed” line in position for use
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Some fluid may be flushed into the environment
Some protective caps do not allow fluid to flow once they are wet. If the protective cap needs to be removed to complete priming, maintain sterility and replace cap when tubing is primed
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B. INITIATING VENOUS ACCESS
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1. Prepare IV administration system as previously described in this section
2. Prepare the necessary equipment and supplies
a. Sharps container
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b. Tape and/or commercially available device for securing the IV
c. Alcohol prep pads or other suitable antiseptic swab
d. Gauze pads
e. Site dressing
f. Tourniquet (latex free)
g. Catheter(s)
h. Band-aid
4. Select a venipuncture area (hand, wrist, forearm or antecubital space)
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If tape is used, it should be torn to appropriate size and length prior to beginning the procedure
Use antiseptics per local protocol
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5. Apply a venous tourniquet approximately 4 to 8 inches above the selected area
6. Select a vein for cannulation and cleanse the intended venipuncture site with an alcohol prep or other suitable antiseptic swab in an outward circular motion for at least 2 inches
7. Based on the intent of the IV and the size of the vein selected, choose an appropriate size IV catheter
8. Remove the catheter from its packaging and the protective plastic sheath
9. Being careful to maintain the sterility of the needle and catheter, visually inspect the end of each for any defects, such as burred edges
10. Slightly twist the catheter on the needle to insure the catheter moves freely on the needle (optional step)
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Allow alcohol to dry for 30 seconds for bacteria to be killed and to minimize discomfort of the insertion
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11. Grasp the patient’s extremity near the area where the IV will be started using your non-dominant hand in order to stabilize the vein at the venipuncture site. This may be accomplished by:
a. Pulling traction distal
b. Holding extremity circumferentially so area is taut
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Avoid placement that would shut off the blood supply and cause the vein to collapse.
In order to maintain sterility while placing IV, keep stabilizing hand and fingers out of the way of the catheter assembly
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12. Insure the bevel of the needle is facing upward in relation to the patient’s skin
13. Holding the catheter assembly with fingers of your dominant hand, and in such a manner as to be able to visualize the flash chamber, approach the injection site with the needle held at approximately a 15 – 20 degree angle
14. Inform the patient they will feel a slight “pinch” as the needle enters their skin
15. While continuing to apply traction to the skin to hold the vein steady, quickly, but carefully, enter the skin with the needle and continue until the needle tip is against the wall of the vein itself. Maintain traction and vein stabilization until catheter is in the lumen of the vein
16. Slowly advance the needle through the vein wall and into the lumen of the vein
17. Once you have entered the vein, continue to advance the needle and catheter assembly slightly (0.5 cm further) so the tip of the catheter enters the vein
18. When the catheter tip is within the lumen of the vein, slowly advance the catheter along the needle until the hub meets the patient’s skin. Slide the catheter while holding the needle steady
19. After the catheter has been threaded into the vein, slightly pull back the needle from the catheter, but DO NOT withdraw it completely
20. If not drawing blood via the IV catheter, release the tourniquet. If blood draws are to be made using the IV catheter, leave the tourniquet in place and obtain blood samples before releasing tourniquet
21. Palpate the end of the catheter beneath the patient’s skin and occlude the vein just proximal to the end of the catheter with direct pressure
22. Remove the needle and activate any safety features before disposing of it in an approved sharps container
23. With your free hand, remove the protective cap from the end of the IV tubing and attach it to the catheter hub, making sure not to push the catheter further in or pull it out
24. Open the IV flow clamp and observe the flow of fluid into the drip chamber
a. If the IV does not flow:
1) Insure the tourniquet has been released
2) Carefully withdraw the catheter slightly while observing the drip chamber since the tip may be occluded by a valve or the side of the vein
3) Determine if the IV is positional and troubleshoot as necessary
2) Begin the process anew using another site
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Consideration may be given to a bevel down approach for pediatric and geriatric patients with small veins
A “pop” may be felt as the needle enters the vein.
The flash chamber should fill with blood when entering the vein.
Smaller catheters will be slower to have a flash
Patients with poor perfusion may not have a significant flash
No more than one-half the length of the catheter should be below the skin at the point the needle enters the vein or only a small portion of the catheter will actually be within the vein for the finished IV
Review “luer lock” versus “slip tip” connections
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b. With the IV running, and before securing the IV catheter in place, inspect the venipuncture site for signs of infiltration
c. If an IV can not be made to flow properly or infiltration is observed, discontinue the IV immediately
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25. If the IV is observed to flow properly:
a. Using a gauze pad or alcohol prep pad as necessary, wipe away any fluid or blood that may be present in order to dry the site sufficiently that tape will adhere
b. Secure the IV and the IV tubing in place; cover insertion site with a sterile dressing or commercially available device
26. Secure the patient’s extremity as appropriate to maintain flow
27. Adjust the flow rate by closing flow clamp or other flow-metering device to the appropriate setting
28. Continue to monitor the patient for:
a. Signs of a fluid overload
b. Other complications resulting from the IV
c. Appropriate flow rate
d. Infiltration
29. Continue to monitor the IV to insure appropriate flow rate is maintained and the venipuncture does not infiltrate
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Many taping methods and commercial securing devices are available. Follow local protocols
Consideration must be given to maximum and/or ordered quantities of fluids
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C. CHANGING THE SOLUTION BAG OF AN ESTABLISHED IV
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1. Select and inspect the IV solution
2. Open outer packaging by tearing pre-cut slit at either end of the bag
3. Shut off the flow clamp on the nearly empty IV bag to prevent air from entering the IV tubing as the solution bag is being changed
4. Invert the nearly empty bag to prevent any remaining fluid from running out, and remove the IV tubing spike from the bag
a. Use extreme care to ensure the IV tubing spike does not touch anything to contaminate the sterile field
b. Follow one of the methods previously described in this section to puncture the bag
c. Discard the used solution bag after noting the approximate amount of any remaining fluid
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4. Reestablish the IV flow rate
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D. DISCONTINUING AN IV
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1. Prepare the necessary materials
a. Gauze square(s)
b. Tape
c. Band-Aid
d. Disposal container
2. Close the flow clamp of the IV administration set
3. Gently remove the tape and/or securing device to expose the venipuncture site
4. Cover the venipuncture site with a gauze square and apply gentle pressure as you remove the IV catheter
5. Inspect the catheter to insure it is complete, noting any abnormalities
6. Affix an adhesive bandage that will continue to apply pressure until bleeding has stopped
7. Properly dispose of all materials
8. Monitor venipuncture site for bleeding
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