Florida Heart CPR*
Medication Administration
1 hour
Purpose
The administration of medication is often a chief responsibility of the nurse. The practice
of administering medication involves providing the patient with a substance prescribed
and intended for the diagnosis, treatment, or prevention of a medical illness or
condition.
Description
The central action of medication administration involves actual and complete
conveyance of a medication to the patient. However, there is a wider set of practices
required to achieve safe, effective patient outcomes and to prepare for and evaluate the
outcome of medication administration.
Laws regarding medication administration vary from state to state. Doctors, physicians,
physician assistants, nurse practitioners, and nurses are generally trained and
authorized to administer medication, while other medical disciplines may have a limited
responsibility in this area. In certain circumstances, unlicensed personnel may be
trained and authorized to administer medication in residential care settings. State and
federal laws also restrict the distribution of and access to medications that can be
abused (called controlled substances). Responsibility for controlled substances includes
accountability for any discarded substances, double-locked storage, and counting of
medication supply at regular intervals by clinician teams.
Preparation for medication administration begins with the order for medication, in most
circumstances written by the physician. Nurse practitioners and physician assistants are
also often authorized to write prescriptions. State laws vary regarding these privileges.
A record of orders for medication and other treatments is kept in the medical chart.
Universally accepted safe clinical practice guidelines and state laws govern the
components of medication orders in order to ensure consistency and patient safety. All
orders should contain the patient's name, the date and time when the order is written,
and the signature of the ordering clinician. Caregivers administering medication are
responsible for checking that these components are present and clear. The name of the
medication is accompanied by the dosage, or how much of the drug should be given;
the route of administration, or how the medication should be given (ie, intramuscular
injection); and frequency, or how often the drug is to be given. Common routes of
administration are discussed below.
The most common route of administration is the oral route, or swallowing of medication.
This is the easiest and safest route. The physical position and swallowing abilities of the
Florida Heart CPR*
Medication Administration
patient should be evaluated to avoid choking. Patients may also receive medication by
the buccal route (through the inner cheek or gum) or the sublingual route (under the
tongue).
Administration involving a needle or syringe occurs with several drug routes. These
routes are referred to as parenteral. Care must be taken to maintain asepsis with all
injections and injection sites. Intramuscular medications are injected into the muscle. A
special injection technique called Z-track can be used when administering intramuscular
medications that can be damaging to the tissue. All intramuscular injections involve the
practice of landmarking, or identifying anatomical markers that indicate the correct
injection site and avoid damage to bone or nerves. Subcutaneous injections are
administered under the skin. Insulin is a common medication that is usually given
subcutaneously. Intradermal medications are used much less frequently than
subcutaneous or intramuscular injections. They are injected into the skin. Intravenous
medications are given through an intravenous line into the vein. These medications may
be mixed with a large amount of solution that is being infused, given in a small solution
through a port in the intravenous tubing (bolus), or attached in smaller infusion
containers to the larger infusion (piggyback). In all cases of administration with a needle
or syringe, rotation of injection sites is required to prevent damage to tissue. It is also
important that the size of the needle is selected based on the thickness of the
medication to be given and the depth of the injection, while maximizing the patients
level of comfort during insertion. Needle sticks with contaminated needles are a hazard
to both health professional and patient. Care is taken to dispose of needles and
syringes rapidly in impervious containers. Protective systems that sheath the needle
after use are commonly used to prevent inadvertent needle sticks.
Medication can also be instilled via the mucous membranes. Asepsis must be used to
avoid introduction of infection. Rectal or vaginal medications are most often given in
suppository form and must be introduced gently to avoid tearing or bleeding of tissue.
Nasal medications are often instilled via spray or drops and often involve closing one
nostril and asking the patient to inhale gently. The head should be tilted back to avoid
aspiration. Ear or otic medications are given in liquid form. The patient's head is tilted to
the side. Instruments should never enter the ear. If the medication is not instilled
correctly, the patient may experience nausea or vertigo. Eye or ophthalmic medications
may be given via drops or ointment. The container for the medication should not touch
the eye, and drops are introduced into the inner canthus or corner of the eye.
Inhalational medications are inhaled via the respiratory tract, most often to treat
respiratory conditions. Metered dose inhalers (MDI) are often used. MDIs involve
pressing a specially designed canister to release a mist.
Topical medications are applied to the surface of the skin. The skin needs to be
cleansed and assessed for breaks before administering topical medications. Topical
patches that gradually release medication need to be labeled with date and time in case
a second patch is inadvertently applied without removal of the first. Ointments are
applied evenly. The clinician should avoid touching the topical medication, as
Florida Heart CPR*
Medication Administration
medications that are absorbed into the system via the skin, such as nitroglycerin paste,
may affect the clinician. As with all medication techniques, asepsis must be maintained
to avoid introduction of microorganisms.
Frequency of administration is most often ordered on a repeating schedule (ie, every 8
hours). At times the order may be written as a STAT (give right away) order, a one-time
order (give just once) or a prn (give as needed) order. Standing orders are routine
hospital orders that doctors in specialized areas prescribe on admission.
Many abbreviations are used in writing medication orders. Other common abbreviations
include:
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p.o.: by mouth
IM: intramuscular injection
SC: subcutaneous injection
IV: intravenous
PR: per rectum
h.s.: at hour of sleep (bedtime)
ac: before meals
pc: after meals
q: every, ie, q 8 h means every 8 hours
q.d.: every day
b.i.d.: twice/day
t.i.d.: three times/day
q.i.d.: four times/day
q.o.d.: every other day
Some examples of medication orders using these abbreviations are:
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digoxin 0.25 mg p.o. q.d.
diphenhydramine 25 mg p.o. q h.s. prn.
If orders are illegible, ambiguous, or confusing, the author of the order should be
consulted to clarify the order before any medication administration occurs. When the
order is clear, it often needs to be transcribed to another document reserved for
recording administration of medications. Health care institutions have specific policies
regarding methods with which to check medication orders and ensure proper
transcription. Policies also dictate parameters for order renewal or medication
discontinuation. Poor penmanship, misunderstanding of penmanship, and errors in
transcription often contribute to medication errors. It is increasingly common for medical
facilities to use a computerized system that lowers the risk of error by reducing steps in
the process and validating information automatically.
Once the order has been read and verified, the care-giver needs to evaluate the order in
the context of the individual patient. Some factors to consider include:
Florida Heart CPR*
Medication Administration
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pharmacodynamics: how the drug works in the body
interactions: possible effects of other medication or food on the ordered
medication
allergies: patient history of hypersensitivity to drug or drug class
contraindications: medical conditions that preclude the use of the ordered drug
side effects: potential adverse reactions to the drug
toxic effects: dangerous effects that often occur due to build up of drug in body or
impaired metabolism
tolerance: certain drugs require increasing doses over time to achieve the same
effect
physiological variables: sex, age, size, and physical condition may alter how a
drug is processed in the body
diet: certain foods, liquids, or nutritional states may alter the drug's effect on the
body
Due to the large number of medications available and the large body of information
required for appropriate drug administration, it is important to have access to a current
medication reference such as the Physician's Desk Reference or other reference
handbooks about medication. The package insert that comes with every medication is
also a good resource. Pharmacists are knowledgeable resources and can answer many
questions regarding medication. It is important to be familiar with the medication
ordered before attempting to administer it. Procedural manuals by the institution or
medical reference publishers detail the step-by-step techniques for administering
various types of medication.
The patient should be notified of the order for the drug and provided with education
about the medication they are to receive. Before administration, five factors often
referred to as the "five rights" should be addressed. Medication records should be on
hand at time of administration to ensure safe administration.
Right patient. Identify patient by name badge or bracelet. Avoid simply asking patient's
name or checking the name on the door as miscommunications can sometimes occur.
Right drug. Check record for name of drug and compare with drug on hand. As many
drugs have similar spellings, this needs to be checked carefully. For prevention of error,
it is often recommended that three checks of the drug to be administered are made:
when reaching for the package that contains the drug, when opening the drug, and
when returning the packaging to its storage area. It is also recommended that clinicians
only administer drugs that they have prepared, versus those prepared by another
clinician.
Right route. Check medication record for how to administer the drug and check
labeling of drug to ensure it matches prescribed route.
Right dose. Compare ordered dose to dose on hand. At times, calculations may need
to be performed to ascertain the correct dose. For example, a scored tablet, or one that
Florida Heart CPR*
Medication Administration
is designed and intended for dividing, may need to be halved or quartered in order to
administer the correct oral dose. This requires simple division. Common situations
requiring calculation include calculation of intravenous infusion rates and the conversion
of measurement units, for example, determining how many milliliters (mL) are required
to give the ordered number of milligrams.
The formula for this calculation can be applied to many situations: dose ordered/dose
on hand × amount on hand = amount to administer. Using the above medication
question, 25 mg/100 mg × 2 ml = 0.5 ml (amount to administer)
Intravenous medications also require frequent calculation. For example, an intravenous
anticoagulant such as heparin may be ordered as "1000 units per hour," and the
clinician may need to calculate how many drops are needed per minute or hour based
on how the intravenous solution is prepared. These calculations may vary according to
the infusion equipment used, for example, varying drop factor ratings or use of a device
called a buretrol that carefully measures infused medication. Often a mechanical pump
is used to control intravenous infusion rates.
Right time. Verify that frequency or time ordered matches current time.
All medications should be handled to ensure that they do not come into contact with
potentially contaminated objects or surfaces. Medications of any sort should not be left
unattended, and patients should be observed taking the medication. This avoids the
disposal, hoarding, abuse, or misuse of the medication, and assures the safety of the
patient.
Documentation of medication administration is an important responsibility. The
medication record tells the story of what substances the patient has received and when.
Like other health care records, it is also a legal document. Various institutions have
policies and procedures regarding documentation. The initials of the administering
nurse or other health care provider and the time and date should be documented on the
record next to the appropriate order. Other information may be required, such as
location and severity of pain when administering a pain medicine (analgesic) or pulse
rate when administering certain heart medications (i.e., digoxin). Patient refusals of
medication also need to be documented, and the prescribing clinician should be
informed.
Medication errors need to be documented as well. The prescribing clinician should be
notified of errors. Institutional policies usually require filing a separate form to document
errors. Errors can include administering the wrong drug, wrong dose, at the wrong time,
or via the wrong route. Omissions of medication are also considered errors.
It is important to evaluate the patient following medication administration and document
effect. For example, many hospitals dictate that a note be written regarding pain relief
within several hours after analgesic administration. Any adverse effects from medication
should be reported.
Florida Heart CPR*
Medication Administration
Preparation
Preparation for safe medication administration requires a background of education and
hands-on training. New nurses and other professionals should be supervised until they
demonstrate an appropriate level of knowledge and competent skills for independent
medication administration.
Aftercare
The patient should be monitored to make sure the medication has had the desired
effect.
Health care team roles
In addition to the clinician who administers medication, other members of the health
care team play vital roles surrounding the medication administration process. Doctors or
other prescribing clinicians are responsible for writing clear, legible orders and for
monitoring the response of the patient to medication. They are also responsible for
responding to potential adverse effects and concerns by the patient or other clinicians.
Pharmacists are responsible for evaluating the medication order for potential problems,
correctly filling the order, and monitoring the medication supply. All health care
professionals are responsible for complying with medication-related policies designed to
protect the patient and/or staff and for maintaining current knowledge regarding
medication and medication administration.
Resources
BOOKS
Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing: Concepts,
Process, and Practice, 4th ed. St Louis: Mosby-Year Book, Inc., 1997.
Taylor, Carol, Carol Lillis, and Priscilla LeMone. Fundamentals of Nursing: The Art of
Science of Nursing, 3rd ed. Philadelphia: Lippincott-Raven Publishers, 1997.
Katherine Hauswirth, APRN
Florida Heart CPR*
Medication Administration
Florida Heart CPR*
Medication Administration Assessment
1. Who is authorized to administer medications?
a. Doctors
b. Nurses
c. Nurse practitioners
d. All of the above
2. Preparation for administration of medications begins with an order for medication
from:
a. The nurse
b. The CNA
c. The Physician’s Assistant
d. The Doctor
3. The most common route of drug administration is:
a. Rectal
b. Oral
c. Intramuscular
d. IV
4. IV routes of drug administration are referred to as:
a. IV
b. IM
c. Parenteral
d. Oral
5. Asepsis must be used to avoid:
a. Swelling
b. Necrosis
c. Infection
d. Overdose
6. Topical medications are administered to the:
a. Surface of the skin
b. rectum
c. tongue
d. eyes
7. If an order is ambiguous or confusing, the administrator of the medication should:
a. Give it anyway
b. Ask another CNA or HHA
c. Confirm with the doctor
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Medication Administration
d. Not give the medication
8. Before giving the medication, the caregiver should ask the patient:
a.
b.
c.
d.
What day it is
To confirm their allergies
Ask the patient if they would like something to drink
Tell the patient to go to the bathroom
9. The five rights include:
a. Right patient
b. Right drug
c. Right route and dose
d. Right time
e. All of the above
10. After the patient has been given the medication, the patient should:
a. Be seen by the physician
b. Taken outside for a walk
c. Monitored for signs of reaction
d. Told to lie down
Florida Heart CPR*
Medication Administration