09/27/18
NRSG 2220
Nursing Interventions, Assessment and Community Care
CRN: 12301
Medication Administration
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Medication knowledge
o Actions and indications
o Appropriate dosage
 Onset, peak, and duration
 Age
 Weight or body surface area (BSA)
o Administration guidelines
 Black box warnings
 Ibuprofen
o “NSAIDs increased risk of serious and potentially fatal
cardiovascular thrombotic events, including MI and stroke;
risk may occur early in treatment and may increase with
duration of use; contraindicated for CABG peri-operative
pain”
o Drug-drug interactions
o Contraindications and cautions
 Ex: there are certain drugs you would NOT give to a pregnant woman
o Nursing considerations
 Patient teaching
Factors Affecting Pharmacokinetics
o Age
o Organ system dysfunction
 Liver
 Kidney
o Height and weight
 Body surface area
o Route of administration
Medication Effects
o Therapeutic effects
o Adverse effects (side effects)
 A little more benign vs. a toxic effect
o Toxic effects
o Allergic effects
Know your patient
o Medical history
o Medication history
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o Allergies
o Check the Medication Administration Record (MAR)
o Diet and fluid orders
 NPO – not per oral
 Fluid restriction
o Laboratory values
 Blood levels
 Medication effectiveness vs. toxicity
6 Patient ‘Rights’
o The right drug
o The right dose
o The right patient
o The right route
o The right time
o The right documentation
3 Checks
o When nurse reaches for medication in drawer
o After picking it up, compare with the MAR
Before giving the medication to the patient
Pre-administration Assessment
o Patient identification
 2 forms
 Long term care
o Patient assessment
 Vital signs
Documentation
o Document as soon as given
o Document is not given a reason
 Patient refusal
 Medication held
o Document response to medication
Patient education
o Purpose of med and dose
o Time of administration
o Potential side effects
o When med can be stopped
o When med needs to be gradually stopped
o What adverse effects to report
QUESTION:
o A nurse is conducting an interview for a medication history. Which of the
following questions would be used to ensure safe medication administration?
 a. “Have you noticed any change in your bowel habits?”
 b. “How do you feel about taking medications?”
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 c. “Do you have any allergies to medications?”
 d. “At what times do you take your medications?”
o When administering medications to a patient, the priority nursing action is
to:
 Help the patient to swallow by keeping the head in a neutral position
 Identify the patient by checking the ID band and asking his name
 Keep all prepared medications in sight
 Check the patient for the desired or undesired drug effects within an hour
after administration of the medication
o Acetaminophen (Tylenol) is ordered for a 9-year-old child with a temperature
of 102F. The nurse realizes that the patient looks very thin for his age. What
action would the nurse take first?
 Give him ½ the ordered dose
 Give the prescribed dose
 Measure his weight and calculate the dosage
 Call the doctor and question the dosage
Names of Drugs
o Generic Name
 Ibuprofen
o Trade Name
 Advil
 Motrin
Drug Classification
o Antipyretic
 Reduces fever
o Antihypertensive
 Reduces BP
o Antiemetic
 Reduces nausea/vomiting
o Diuretic
o Analgesic
 Reduces pain
o Anticoagulant
 Blood thinner
o Antihistamine
 Stops histamine release
o Bronchodilator
 Dilates bronchioles (easier breathing)
o Schedule I – Schedule V
 Based on abuse potential and medical usefulness
 Most narcotics are schedule II
 Special handling requirements for narcotics
 Schedule III is a lower dose of the narcotic schedule II
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 Benzodiazepines/sedatives are schedule IV
 Codeine (cough syrup) are schedule V
FDA: Food and Drug Administration
o Responsible for public safety
o Regulates the manufacture, sale and effectiveness of drugs
o Prevents unsafe drugs from being marketed
o Identifies which medications require a prescription
o Controls drug advertisement
o Medwatch Voluntary Reporting
Drug Order Components
o Patient’s name
o Date and time order written
o Medication name
o Medication dose
o Route of administration
o Frequency of administration
o Signature
o EXAMPLE: Tylenol 650mg po q4h prn
 Q4h = every 4 hours
 Prn = as needed
Types of Orders
o Standing
o Prn – pro re nata
o Stat
o Now
o One time
o Repeat
Dose Conversions
o 1 g = 1000 mg
o 1000 mg = 1,000,000 mcg
o 1000 mcg = 1 mg
o 1000 g = 1 kg
o 1 kg = 2.2 lbs
o 1mL = 1 g
o 1 mL = 15 gtts
o 5 mL = 1 tsp
o 15 mL = 3 tsp = 1 tbl
o 30 mL = 1 fl oz
o 240 mL = 8 fl oz = 1cup
o 16 oz = 1 lb
o 1000 mL = 1 L
Drug Calculations
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Dose on hand - 1, 10 mg pill
Quantity on hand - 1, 10 mg pill
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QUESTION:
o An order reads: Amoxicillin 250mg every 6 hours. What should the nurse
question further?
 The medication
 The dose
 The route
 The frequency
o Your patient is being discharged on Augmentin 10mg po TID (three times a
day). The label says 5mg/5 mL. How many teaspoons do you tell your patient
to take?
 ½ teaspoon
 1 teaspoon
 2 teaspoons
 3 teaspoons
General Administration Guidelines
o Infection control
 Wash hands before and after
 Do not touch medications
o Safe practice
 Prepare medications for 1 patient at a time
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 Never give a medication prepared by someone else
 Do not allow interruptions
 Double check all calculations
 Check expiration date
 Do not use unmarked or illegible containers
 Be aware of changes in liquid clarity and sediment
 Administer within 30 minutes of designated time
o ‘Do not crush’ Medications
 Medication released over time
 SR: sustained release
 ER: extended release
 XL: long acting
 Delayed release
 EC: enteric coated
o For sensitive stomachs, more protective coat
 DR: delayed release
o Administration Precautions
 Drug name pairs with Tall Man Letter
 buPROPion and busPIRone
 hydrALAZINE and hydrOXYzine
 glypiZIDE and glyBURIDE
 High alert meds
 Double check with a second nurse when feasible
o Prevent dosage errors
 Use leading zeros
 0.52 mg NOT .52 mg
 No trailing zeros
 2.5 mL NOT 2.50 mL
o Dose Accuracy
 Pour liquid medications at eye level
 Read dose at base of meniscus
 Pour away from label
Oral Medication Administration
o PO
 Tabs
 Capsules
 Caplets
 Spansules
 Liquids
 Suspensions
o Sublingual
 Under the tongue
o Buccal
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 In the gum, inside cheek
Metered dose inhalers
Guidelines:
 Ensure patient can swallow
 Position patient properly
 Explain purpose of medication
 Open unit doses at bedside
 Do not leave medication at bedside
 Remain with patient while taking meds
QUESTION:
 The nurse is preparing multiple medications for administration. Of
the following actions, which would be inappropriate.
 Prepare medications for one client at a time
 Calculate correct drug dosage
 Open unit tablets and place medications in medication cup at the
dispensary location
 Avoid touching tablets or capsules with the hands
 What would a nurse instruct a patient to do immediately after
administration of a sublingual medication?
 a. “Drink some water and swallow the pill.”
 b. “Try not to swallow until the pill dissolves.”
 c. “Swallow frequently to get the best benefit.”
 d. “Chew the pill so it will dissolve faster.”
Metered Dose Inhalers
 Uses
 Administer medications
o Bronchodilators
o Mucolytic agents
o Corticosteroids
 Rinse mouth after
 Document response
 MDI
o Dry powder
o Liquid
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Spacer
o Aerochamber
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Administration pearls
 Exhale with pursed lips
 Wait 30 seconds - 1 minute between puffs
 Rinse mouth after use particularly with steroids
 Reassess and document
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Transdermal Medication Administration
o Remove previous patch and any remaining traces of medication
o Avoid touching med - Fold patch to be discarded into itself
o Apply new patch to a clean, hairless, dry intact area of skin
o Note date, time and your initials on patch
o Dispose of patch properly
o Rotate sites
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Ophthalmic
o Eye drops, ointment, or disks
o Procedure pearls
 Give tissues
 Anchor dominant hand on patient’s foreharm - pull down lower lid
pressing on lower bony orbit
 Instill ointment from inner to outer canthus
 Insert disk before bed usually
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Apply slight pressure to lacrimal duct
Instruct patient to close eyes
Otic (Ear)
o Turn head to unaffected side
o Ensure drops are at room temperature
o Pull pinna up and back in older children and adults
o Instill ordered number of drops ½ inch above ear canal
o Release pinna and gently massage tragus
o Wait 2-3 minutes before instilling drops in opposite ear
Nasal Medications
o Atomizer and drops
o Have patient sit up and lean head back
o Place tip of bottle just inside nare
o Aim spray or dropper toward the midline of the nose
o When the patient inhales, squeeze the bottle once
o Instruct patient to keep heard tilted back for 2-3 minutes
Rectal Medications
o Suppositories or enema
o Place patient on left side
o Don gloves
o Lubricate suppository or enema catheter tip
o Insert past the internal anal sphincter against the rectal wall
Vaginal Medications
o Foams, jellies, liquids (douches), creams, tablets, suppositories
o Position patient in dorsal recumbent or side lying position
o Don gloves
o Insert medication using an applicator
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QUESTION:
o Ampicillin (Antibiotic) 0.75 g PO q8h
(Available in 250 mg capsule and 500 mg capsules)
 Which capsules would you give?
 You have a choice
o How would you dispose of a transdermal patch with a narcotic medication?
 In the patient’s waste basket
 In the waste basket at the nurses’ station
 In the sharps container
 Return it to the pharmacy
o Tetracycline (Broad spectrum antibiotic) 1g daily po in two divided doses
(Available as oral suspension 125 mg/5ml)
 How many mg would the patient receive per dose?
 500 mg per dose
 How many ml would the patient receive per dose?
 20 mL (x 4)
 How would you schedule the doses?
 Morning and night
 This drug is nephrotoxic; what does this mean and what nursing
considerations would it present?
 Check labs for kidney function before and after
 Input output of urine (if damaged- output will go down)
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Parenteral Administration Routes
o IM
o SC
o ID (slowest)
o IV (fastest)
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Prep Techniques
o Drawing up medications
 Vial
 Ampule
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 Prefilled syringe Tubex
o Mixing medications
 Check compatibility
Injection guidelines
o Patient control
o Position to reduce muscle tension
o Divert client’s attention
o Rotate sites
 1 inch rule
o Inject slowly but smoothly (0.1 mL/sec)
o Do not rub: apply pressure
Prevent needle stick injuries
o Bloodborne pathogen exposure
 Hepatitis B and C
 HIV
o Safety syringes
o Sharps container not filled beyond ‘fill’ line
o Dispose of used needle immediately
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o Never leave syringe at bedside
o Never place syringe in your pocket
o Never cap, bend or break used needle
Needle Selection
o Use shortest length & smallest gauge needed
o Length (1/4 inch to 3 inch)
 Muscle mass
 Adipose tissue
o Diameter (gauge) 14 - 29
 Lower number = larger diameter needle
 Viscosity of fluid to be administered
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Tuberculin Syringe
o Maximum 1ml
o Calibrated by 1/100
o 25-28 gauge
o ¼ " or ½ " needle
o Increases dosage
 accuracy for SC & IM injections <1mL
o Change needle for SC or IM use
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Standard Syringe
o Choose based on volume to be administered
o 3mL, 5mL, or 10mL
 3mL calibrated by 1 tenths
 5mL calibrated by 2 tenths
o 3mL is typical for SC or IM injections
o Syringes come with and without needles
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Insulin Syringe Selection
o ORANGE TIP
o Marked in units
o Small doses use U30 or U50
o U100 is the most common
o Nondetachable needles
 28-30 gauge
 1/2" or 5/8 " needle
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Insulin PENS
o Insulin pen
 Guideline 28-1 in textbook
 Pre-filled syringe
 Individual dose
Epipen
o Treatment for severe allergic reactions and anaphylaxis
o Only inject into thigh
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Intradermal Injection
o Purpose:
 PPD or allergy testing
o Use Tb syringe
o Give into the dermis
 Inner forearm
 Upper arm
 Across scapula
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o Technique:
 Bevel of needle up
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 Insert needle at 5-15 ° angle
 Inject to form a wheal/bleb
 Remove needle after a brief delay
 Do NOT massage site
 Measure induration
Subcutaneous Injection
o Inject into connective (sc) tissue
o Small doses (0.5 – 1.0 ml)
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o Absorbs less quickly than IM route
o Typically use a 25-27 gauge needle
o Common sites
Subcutaneous
o Amount of adipose tissue influences:
 Needle length (3/8 to 5/8 inch)
 Needle insertion angle (45° to 90°)
 Tissue grasp rule
o Holding techniques
 Bunching
 Spread flat
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Insulin
o SC injection
o Administered in units
 Only use Insulin syringes
o Agitate suspensions only
o Site rotation
 Observe for lipodystrophy
 Abdomen is best for absorption
o When mixing insulin: draw up Regular Insulin FIRST
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R before the N
Heparin (anticoagulant)
o SC injection
o Use small gauge needle 25g-28g
o 5/8”-7/8” needle length
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o Measured in units (10,000 U/ml)
o Administration technique:
 Ensure needle is free of heparin drips
 Roll or bunch tissue to stabilize
 Insert the needle at a 90° angle
 Inject slowly
 Do not rub or massage site after giving
QUESTION
o Humulin Regular insulin 6 units and Humulin NPH insulin 40 units SC daily
(available U 100/ml)
 What type of syringe would you use?
 Insulin syringe
 50 mL
 Regular insulin is clear. What action would you take if the regular insulin
were cloudy or contained sediment?
 You would not use it
 Call pharmacy
 How many total units of insulin would the patient receive?
 46 unites
Intramuscular Injections
o Give into muscle layer
o Use a 3ml – 5ml syringe
o 19g – 25g needle
o 5/8" - 3" needle length
o Do not give more than 3mL in 1 injection
o Inject at a 70-90 degree angle
o Inject slowly
IM Guidelines
o Aspirate with intramuscular injections?
 No longer required per CDC (2009)
 May be required by agency
o Z tracking
 Recommended for all IM injections
 Change needle after drawing up med prior to injection
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Deltoid
o A recommended site for adults
o Toddlers, children and adults. Not infants
 Vaccines
 Hepatitis B
 Rabies
o Med is rapidly absorbed
o Close to radial nerve and brachial artery
o Maximum 1 ml
o Use 5/8” – 1.5” needle
Vastus Lateralis
o Safe for all age groups
 Preferred site for infants & toddlers (vaccines)
o Not near large blood vessels or nerves
o Divide anterior thigh into 3 equal parts horizontally and vertically.
 Administer injection into outer middle third
o Use 5/8 – 1” needle unless there is a lot of adipose tissue
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Ventrogluteal
o A recommended site for adults
 Not recommended for the older adults and debilitated patients
o Free from major blood vessels and nerves
o Landmarks:
 Greater trochanter
 Anterior superior iliac spine
 Iliac crest
o Can give up to 4mL
o Typically use 1.5” needle
o Used for irritating, viscous or oily solutions
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Dorsogluteal
o Not used anymore
o Not a recommended site!
 Sciatic nerve
 Superior gluteal artery
 Thick layer of fat
 Slow and inconsistent absorption
o Do not use! But you will see it used by others
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