Order Entry and Processing Study Guide for the PTCB Exam

Equipment and Supplies

There are specific types of equipment and supplies used to help facilitate adequate drug delivery and administration. These supplies ensure patients accurately get the medication they need.

Package Size

Some medications are supplied by the manufacturer in a specific unit-of-use bottle. This may be done for a variety of reasons, including stability, photosensitivity, moisture restrictions, and so on. For example, Aggrenox is dispensed in a 60-count unit-of-use bottle and should not be repackaged. By contrast, nitroglycerin sublingual tablets come in a small amber vial. These tablets must remain in their container until needed by the patient for photosensitivity and stability purposes.

Unit Dose

Medication in a hospital or within the inpatient setting is unit-dosed into single small packages. This helps with ease of administration, in addition to the fact that a patient’s stay within the inpatient setting is usually relatively short. This means only a few days of medication will be used, as opposed to an entire bottle. In the retail setting, some pharmacies may offer their customers the ability to get their medications blister-packaged or pouched, which helps support medication management and compliance. These services are especially beneficial for caregivers or those with memory impairment who have a hard time setting up their own pill boxes.

Diabetic Supplies

Diabetic supplies include prefilled insulin pens and calibrated insulin syringes used to administer a patient’s insulin. Prefilled insulin pens have the ability to be dialed up to the necessary units of insulin needed for subcutaneous injection. A pen needle is screwed onto the tip of the prefilled syringe. Pen needles are for a single use only and should be discarded thereafter in a sharps container.

Insulin syringes used to draw up and administer insulin from a vial are not calibrated by milliliters, like an oral or standard injection syringe. Instead, they are calibrated in units, since insulin is measured that way as opposed to milliliters. Some patients may use an insulin pump that administers short-acting insulin at a specific rate depending on the patient’s needs. These pumps are for those who have their diabetes well controlled and are able to strictly manage their diet.

Diabetic supplies also include those elements used to draw and test a patient’s blood sugar. A diabetic tests their blood sugar using a lancet device with an associated lancet. This lancet device pricks the patient’s finger to draw a small amount of blood. A glucose meter (glucometer) is used with an associated test strip that takes the patient’s sample of blood and tests it for a glucose level. Typically, diabetics test prior to meals.

There are many different types of meters, testing strips, and lancets currently on the market. It is important that patients receive lancets that fit their lancet device and test strips that are compatible with their glucometer. Also, a control solution should be used periodically on a glucometer as it tests the accuracy of the device.

Examples of common diabetic supplies include the following:

prefilled insulin syringe—Novolog KwikPen
insulin syringe/needles—BD SafetyGlide Insulin Syringe with Needle
lancets—Accu-Chek SoftClix lancets
glucometer—OneTouch Ultra Blue meter
test strips—OneTouch Ultra Blue test strips

Inhaler Spacers

Spacers are used on the end of a metered-dose inhaler (MDI) to create a chamber between the inhaler and a patient’s mouth. This facilitates a better inhalation technique, as it holds the medication until the patient breathes in. Spacers also increase the amount of medication that reaches the lungs. When a spacer is not used, there is a greater chance of improper technique, which will result in the majority of medication reaching the back of the throat, with only limited amounts reaching the lungs. Commonly used inhaler spacers include the OptiChamber and the AeroChamber Plus.

Oral and Injectable Syringes

There are three distinct parts of an injectable syringe: the plunger, barrel, and needle. The plunger is used to move medication through the barrel and out the tip through the needle. The internal aspect of the plunger is sterile and should not be touched during product manipulation. All needles should be discarded in the sharps container.

Syringes come in multiple standard sizes, which include one milliliter, three milliliters, five milliliters, 10 milliliters, 20 milliliters, 40 milliliters, and 60 milliliters. The syringe barrel has calibrated measurement tick markings to accurately measure a solution. When a syringe is selected to draw up and/or administer medication, it is important to note that you should use a syringe around double the volume of the required amount. This is because you do not want the plunger completely extended, as it increases the risk of contamination. For instance, if you were to draw up one milliliter of cyanocobalamin for your pharmacist to administer to a patient, you would use a three-milliliter syringe to do so.

An oral syringe is structured the same as an injectable syringe; however, it does not have a needle. Oral syringes are used to accurately administer oral solutions or liquids. Typically, these are used for ease of administration to infants, children, and those in hospice care.

Filters

Filters are commonly used in pharmacy practice when preparing a medication for both sterile and nonsterile compounding. Filters are available as a small apparatus that is placed between a syringe and a needle. They also come built into a needle, called a filter needle. Filters and filter needles are used to separate out any large particles, particulates, or possible contaminants. Filters and filter needles should only be used in a singular direction, to either draw up a medication from the syringe or push out the medication from the syringe. If the same filter is used to do both, it defeats the purpose of filtering. Medications that are commercially available as a sterile formulation (e.g., hydromorphone 50 mg/5 mL solution vial) do not require filtration.

There are a few scenarios when a filter is used. One such scenario is preparing a medication that comes as a bulk powder formulation. You would follow these steps:

Weigh out the appropriate amount of medication (in powder form).
Wet and dilute the medication using the proper diluent. The medication will be in solution form following dilution.
Draw up the solution into a syringe and then filter it into an IV bag.

You would also use a filter when preparing a medication that is commercially available in an ampule. An ampule is a small, single-use glass container that contains medication. An ampule must be broken where indicated to get access to the liquid medication inside it. Since ampules are glass, a filter needle on a syringe is used to obtain the medication and ensure it is free of any glass shards or particles.

Examples of medications that are available in ampules include fentanyl, vitamin K, and epinephrine.

Dilution Solutions

A diluent is a solution that is used to dilute an active ingredient. Diluents do not have any active pharmaceutical ingredients or therapeutic benefit. They are used to mix and/or dissolve a drug prior to its use or administration. Many medications are available in powder form, which allows them to be shelf-stable for longer. However, medications in powder form require a diluent to dissolve them into a uniform concentration prior to use or administration.

Once diluted, the medication is no longer as stable as it was in powder form and must be used within the manufacturer’s guidelines and specifications. The most common dilution solutions include sterile water, normal saline (0.9% sodium chloride [NaCl]) and bacteriostatic water.

Here are some examples of medications that require dilution prior to use:

amoxicillin 400 mg/5 mL oral suspension—The 50-milliliter bottle size must be diluted/reconstituted with 35 milliliters of sterile water and mixed well. Once mixed, the suspension should be discarded after 14 days.
ceftriaxone 2 g vial—This is commonly diluted with 19.2 milliliters of sterile water or 0.9% NaCl to yield a 100 mg/mL solution that must be further diluted for IV administration. Once reconstituted, the 100 mg/mL solution is stable for two days at room temperature or 10 days refrigerated.
Shingrix vaccine—The manufacturer provides the proper diluent that must be used to reconstitute the vaccine itself prior to administration. Once the vaccine has been reconstituted with the diluent, it must be administered within six hours.

Medications that are used for IV administration (e.g., ceftriaxone) must be further diluted to proper concentrations. For intravenous administration within the hospital setting, ceftriaxone is commonly further diluted into an IV bag of normal saline or dextrose (dextrose 5% in water).

Now, you might be asking yourself, why are medications further diluted in normal saline or dextrose 5% for IV administration? Well, let’s break it down.

normal saline (0.9% NaCl)
- same salt concentration as blood (isotonic)
- will not cause any blood electrolyte imbalances
- will not shock the patient’s system
dextrose 5% in water (D5W)
- also isotonic
- may be used in cases of patients with hypernatremia (high salt levels) or hypoglycemia (low sugar levels)

Note: Any two solutions are isotonic if they have the same concentration of salt and water.

Immunization Supplies

Certain supplies are needed to properly administer an immunization, which go beyond the vaccine itself. Here is a list of common items needed during the preparation and administration of an immunization:

vaccines—The vaccine being given will typically come as a prefilled syringe (e.g., Afluria) or as a powder in a vial that needs to be diluted with the proper diluent prior to administration (e.g., MMR).
diluent—The manufacturer of the vaccine will provide the pharmacy with the proper diluent when it is ordered from the wholesaler or will specify in the package insert what should be used (e.g., normal saline or sterile water).
sharps container—Once the vaccine is administered, the syringe and needle used for administration must be properly disposed of in a sharps container.
needle—A needle is placed on the end of the syringe containing the vaccine and is used to penetrate the muscle for proper administration. Vaccines being given intramuscularly (IM) require at least a one-inch needle. Vaccines being given subcutaneously (SUB-Q) require a 1/2- to 5/8-inch needle.
alcohol pads—Alcohol pads containing 70% isopropyl alcohol are used to clean the surface of the injection site. They are also used to clean the tops of the vials (vaccine and diluent) during preparation. Vaccines that come in prefilled syringes do not need to be cleaned with an alcohol pad.
bandage/cotton balls—These are necessary to cover the injection site after administration and clean up any drops of blood.
gloves—Gloves are not necessary but are considered good hygiene. Not only do they protect the patient, but they also protect the immunizer from any bodily fluids (e.g., drops of blood) that may result from vaccine administration
prescription/standing order—An immunization can only be dispensed and administered pursuant to a valid prescription or standing order. Most retail pharmacies have standing orders with a local provider to administer common vaccines (e.g., a flu shot) to ensure they are available to the general public.
emergency kit—This contains items that may need to be used in the event of an allergic reaction or post-patient monitoring. The most common items in a vaccine emergency kit include diphenhydramine, epinephrine autoinjector, and a blood pressure cuff.

Nebulizers

A nebulizer (often referred to as a “breathing machine” by patients) is an apparatus that is used to convert a medication from liquid form into a mist that can be easily inhaled. Nebulizers are commonly used with medications that are used to treat asthma, chronic obstructive pulmonary disease (COPD), chronic cough, and other lung conditions. Nebulizers come in many different shapes and sizes, depending on the manufacturer. Some require being plugged into a power supply, while others may run on batteries. A nebulizer may be preferred over an inhaler in the hospital setting (for critically ill patients) or in patient populations that may have trouble using inhalers (e.g., the elderly or small children).

In general, a nebulizer machine consists of the following elements:

mouthpiece or mask—what the patient uses to breathe the medication into the lungs
air compressor—what converts the liquid medication into a mist
reservoir—where the medication is stored
tubing—what connects the compressor to the medication reservoir and mouthpiece

Medications that are commercially available in a nebulizer solution include the following:

albuterol—opens the bronchial airways
ipratropium/albuterol—relaxes/opens the bronchial airways
budesonide—reduces airway inflammation
normal saline—helps break up mucus and soothe the airway
levalbuterol—opens the bronchial airways