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Medication Administration: Part I
N225 Health Assessment and
Nursing Clinical Skills
Medication Management
System for Patients
Automated Dispensing Systems
Automated Dispensing Systems for
medications are storage areas for
patient medications that are located
on the unit near the patient’s point of
care.
Controls, tracks, and documents
medication distribution to the patient
Example of an Automated
Dispensing System “Pyxis” and
Scanning a Medication
Example of Scanning Device to
Check Patient Name Band and
Label on Medication
Key Aspects to Safe
Medication Administration
With Administration of any medication you need to check the
healthcare provider’s order against medication administration
record (MAR).
Next you will retrieve the medication from the patient’s
drawer and inspect the label.
Prepare the medication; any wasted medication are witnessed
and scanned by another nurse to validate it.
Check the Medication against the patient’s MAR
You will need to look up the medication and verbalize the
indication, drug classification, contraindication, usual dose
range, side effects, and nursing considerations.
3 SAFETY CHECKS! See CLC Skill Validation
The 10 Rights
Right
Right
Right
Right
Right
Patient
Medication
Dose
Time
Route
Right Education
Right to Refuse
Right Assessment
Right Evaluation
Right
Documentation
Medication Orders
Standing orders- continue until
discontinued. Some automatically
discontinued after 7 days
One time ordersSTAT- single dose within 30 minutes
Now – single dose within 90 minutes
prn- as needed, must have reason
Order for unfamiliar drug
If unfamiliar
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“look it up” ;
“ask the pharmacist”
or discuss with MD
Would it be NEGLIGENCE if you
administered an unfamiliar drug while
remaining ignorant of its actions, intended
effects & side effects, or adverse
reactions?
Parts of Medication Orders to
Check For
1. Patient’s name and date of birth
2. Date and time medication ordered
3. Name of medication (generic and/or brand)
4. Medication dosage
5. Route of administration
6. Frequency e.g. every 6 hours
7. Duration
8. IF prn medication, needs to include reason
9. Signature of individual ordering the drug
Oral Medications
 Slightly flex head, chin down to prevent aspiration
 Route of choice- if patient can swallow safely and
tolerate medication in the stomach
 Contraindicated if client is nauseated, vomiting,
has gastric or intestinal suction or NPO
 Class Practice:
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Oral medications
Tablets and capsules
Liquid/Elixir Medications
If unable to swallow pills
Works faster than pills
Usually more expensive
Use clear plastic medicine
cup with measurements
Always place med cup on
flat surface to measure
accurate amount
If giving less than 10 mL,
draw up liquid with a
syringe- LABEL IT!
Liquid Amounts Read at the
Bottom of the Curved Meniscus
Crushing Oral Medications
Used for clients who
cannot swallow whole
pills
Need to verify if the
med can be crushed
Extended release
meds and enteric
coated meds cannot be
crushed
Always use a clean
mortar and pestle or
other crushing utensil
Can be mixed with
apple sauce, ice cream,
jam, etc. (small
amount)
Capsules can usually be
opened & mixed with
small amount of food
Dispensing oral medications
Cannot be delegated
Check swallow, gag, cough reflexes
Check available labs, e.g. liver function?
Do not touch medication
Keep meds in wrapper until dispensing
Do not split tablet unless scored
Stay with patients until pill swallowed
Record reasons for refusal or failure to
dispense
Medications
Sublingual (SL)- under tongue and allow to dissolve
completely
 Hold fluids until completely dissolved
 Caution client against swallowing
Buccal- against mucus membranes of cheek until
dissolved
Powdered- mix with liquids at bedside
Lozenges- don’t chew or swallow- avoid oral fluids
Sublingual medications are placed
under a patient’s tongue for rapid
absorption e.g. nitroglycerin for chest
pain
Topical medications
Applied locally to skin
Transdermal patch- sustained action medications e.g.
nicotine, estrogen
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Apply to clean, hairless skin in areas without wrinkling &
excessive movement
Don’t apply heat to patch
Don’t massage
Remove old patch before applying new one
Wear gloves to apply and remove
Dispose of properly
Document when and where applied.
Topical medications
Ointments, creams, powders applied to clean, dry skin.
Thin layer. Wear gloves or use applicators. May cover
with gauze etc. Check orders,
Parts of a Syringe
Luer-Lock Syringe tip
Attach the needle securely to
the syringe by twisting to the right firmly.
Standard syringe tip
Needles
Most made of stainless steel
Most are disposable
3 parts
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Hub-fits into the syringe tip
Cannula or shaft-attaches to the hub, length
varies from 1/4 to 5 inches
Bevel-slanted part at needle tip
Length – ¼ to 3 inches
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Choose depending on clients size, weight and
location of injection
Longer for IM
Shorter for subcutaneous
Needles
Gauge (diameter)
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varies from #18 to #33
larger the number, the smaller the needle
diameter
Pick gauge depending on size of client and
how viscous medication is. Examples :
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Adult needing a subcutaneous injection - use
#24 to #26 gauge needle that is 3/8 to 5/8”
long
For an obese adult – subcutaneous -use 1 inch
#24 to #26 gauge needle
For children and thin elderly clients –
subcutaneous use a #24 to #26 gauge shorter
needle
Safety Needles for Safety
Healthcare facilities do have safety
needles for use to promote and
safety and prevent needle injuries
Ampule Medications
Some medications are solutions that
are packaged in glass ampules
Before opening ampule flick the top
so the medication moves down to the
main portion
Use an ampule opener or alcohol swab
to break the neck to remove the top
portion
Breaking the Ampule Neck
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Scored for easy opening, usually this band is colored
at the neck band
Snap neck AWAY from you
Don’t inject air into vial
Ampule Medications
To withdraw the medication invert the
ampule and use a syringe with a filter needle
to withdraw fluid or place the ampule at a
45 degree angle.
Discard syringe in Biohazard
Container
Vials
Vial
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Small bottle with rubber seal
Seal needs to be pierced & air injected equal to
what you are withdrawing
Single dose and multi-dose vials available. Date
multi dose vials
May use a filter needle to aspirate- then change
needles
Class activity:
 Snap cap off, do not handle rubber seal, alcohol top-
wait for the ETOH to dry (some agencies policies are
to not alcohol rubber seal with 1st dose removed)
 Withdraw 0.8 mL of fluid- which syringe would you use?
 Now, try to withdraw 2 mL without injecting air first
Vials
Tuberculin syringe (1 mL capacity)
Measurement is in hundreds of a mL on one side of
the syringe (and may have minims (apothecary system)
on the other side).
Compare this syringe to the insulin syringe in your bag.
Insulin Syringe
Measurement is in units. Most syringes are U100 per
mL
(BE CAREFUL!)
Come in different sizes never more than one mL. Can
NOT substitute tuberculin syringes!
Take out a 1 ml syringe and compare to the insulin
syringes in your bag.
Mixing Meds in One Syringe:
Example Mixing Two Types of Insulin
Example of mixing meds:
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Intermediate acting NPH insulin—cloudy
Fast acting Regular insulin—clear
REMEMBERcloudy (NPH)-clear (Regular)-clear (Regular)-cloudy
(NPH)
 Air goes first in cloudy, then air in clear. Withdraw
medication from clear and then cloudy
Injected Parenteral Medications
Intradermal (ID): this injection places the medication
into the dermis under the epidermis.
Subcutaneous (SC): this injection places the
medication into the loose connective tissue under the
dermis
Intramuscular (IM): this injection places the
medication into the body of a muscle
Intravenous (IV): this injection places the
medication/solution into a vein through an existing IV
line or a short venous access device (saline lock).
Intravenous route medications may be ordered as an IV
bolus, an intermittent (piggyback) medication, or in a
large volume continuous infusion (IV bag).
Safety Considerations
Always wash your hands
Keep sterile parts of the needle and
syringe sterile
Use new, sterile equipment with each
injection
Needle Length
Correct needle length allows for correct delivery of
medication into the correct site and can reduce
complications such as abscesses, pain, and bruising.
Needle selection should be based on size of patient,
gender, injection site, and amount of medication
injected
Needles of varying length, with and without
retractable caps extended.
Injection Tips
With all injections, the needle should be
inserted all the way up to the hub
For injections, use a sharp, beveled needle and
place bevel side up
Enter the skin smoothly and quickly to help
reduce pain during injection.
Hold the syringe steady once the needle is in
the tissue to prevent tissue damage. Withdraw
the needle at the same angle used for
insertion.
Rules of Thumb for SQ or IM
Parenteral Medications
Wash your hands- before and after procedure.
Wear gloves.
Check medication vial at least 3 times- when
removing from drug cart, when drawing up, before
administering
Clean injection site in a circular motion, start at
center and move out~ 2 inches.
Insert needle quickly and smoothly. Hold needle
still when in tissue
Inject medication slowly to allow time for
medication to disperse through the tissue
Hold needle in place for 10 seconds to prevent leak
back
Massage site after injecting to aid in absorption
Subcutaneous Injection
Injected into the loose connective tissue under
dermis. Less vascular, absorbs slower than IM
Some vaccines, insulin, heparin
45 to 90 degree angle to the skin (depends on
patient size; book states 90 degree, and you will
do this on your CLC skill validation)
Needle length 1.25-1.5 cm (1/2-5/8 in.)
25-27 gauge
1 mL or less is injected
Subcutaneous Injection continued
Sites: usually inject into fatty tissue
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Outer posterior aspect of the upper arm
Abdomen, below the costal margins to the ileac
crest
Anterior aspect of the thighs
Scapular areas of upper back
Upper ventral or dorsal gluteal area
Rotate sites
Abdominal site preferred for insulin injection
because the absorption is more predictable
Sites for SQ Injections
SQ Administration
Heparin (LMWH)
Injections (SQ)
Select site on
abdomen at least 2
inches from umbilicus
& above iliac crests
Needle length depends
on client
#25 gauge needle or
smaller
90 degree angle or if
very thin 45 degree
angle with >3/8 needle
length
SQ Heparin Injection
To prevent tissue damage and bruising, do not
aspirate or massage anticoagulant injections
Heparin and low molecular weight heparin, Lovenox
(LMWH) does come in a prefilled syringe
Pre-filled syringe and Carpuject
holder
Intradermal Injections
Usually for skin testing- allergy, TB tests
(Manitou test), lidocaine injections
Administered into the dermal layer of the
epidermis- (decreased blood supplydecreased med absorption). In area free
of rashes, hair, etc.
Small amount of solution is used (0.01 to
0.1 mL)
Used frequently for allergy or TB testing
1mL syringe with a #25, #26 or #27
gauge needle that is 3/8 to 1/2 inch long
INTRADERMAL INJECTION
Syringe—1mL (or a
tuberculin [TB] syringe)
Needle
 Short ¼ – ½ inch
 Fine gauge (#26#27)
Amount injected 0.01 –
0.1 mL
Insert needle at 15
degree angle, bevel up,
and inject solution to
form a wheal on the skin
(if no wheal, you
probably went too deeply
Intradermal Wheal
Intramuscular Injections
Faster absorptiongreater blood supply
Syringe 3 mL syringe
most common
Needle –
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Length 1.5 -3.8 cm (1
– 1½ inch)
Gauge #19 – #25
gauge depends on the
muscle and fat at the
site
Intramuscular Injections
3 mL syringe
Note syringe is marked to measure tenths of a mL
(CLC may have syringe that measures
Note you cannot measure medication in this syringe
to more than tenths)
IM injections
Clean site using a circular motion- start at
center and move out ~ 2 inches. Wait till
alcohol dries (less burning, more effective)
Muscle relaxed, area free of rash etc.
Insert quickly but inject steadily & slowly
(10 seconds/ml)
Wait 10 seconds then withdraw smoothly
at same angle as injection
Z-Track Method of IM
Injection
Preferred method for all IM’s but not used
much in practice, best for meds that
irritate or discolor tissue, e.g. iron
injections, progesterone injections
Less painful –seals medication in muscle
tissue
New needle on syringe
Pull skin to the side (1-1 ½ inches)
Z-Track
Insert needle at 90 degrees deep into
muscle
Aspirate, if no blood return, inject med
After 10 seconds-withdraw needle and let
skin go back to natural position
When the skin returns, it forms a natural
seal over the site, preventing the seepage
of the med. into the subcutaneous tissue
Z-track
Ventrogluteal Site
Deep in the gluteus muscles (gluteus medius) of
the lateral hip
** Preferred site- No large nerves or blood
vessels
Side lying easiest to find landmarks
Right hand/left hip Left hand/right hip
Heel of hand rests on Greater Trochanter
Index finger- Anterior Superior Iliac Spine
Middle finger –below Posterior Iliac Crest to form
V (triangle) inject into middle of triangle
Ventrogluteal Site
Ventrogluteal Injection Site
Locate greater trochanter and anterior
superior iliac spine.
Place palm at trochanter and index finger
at anterior superior iliac spine; fan
remaining fingers posteriorly.
Vastus Lateralis
Infants, children &
adults
Anterior lateral aspect
of thigh
Use middle third of
muscle
Divide into 1/3 area
between the top and
bottom of femur,
select middle
Vastus Lateralis Injection Site
Select site 1 hand-breadth below greater trochanter
and 1 hand-breadth above knee for vastus lateralis
injection.
Site is middle third and anterior lateral aspect of
thigh.
Inject medications at 90-degree angle directly into
muscle.
Deltoid IM Injection Site
Needle
 Length –
5/8 – 1 1/2 inch
 Gauge 19-25
Use 3 ml syringe
3-5 cm (1-2 inches) below acromion process
Relax & flex elbow
Rapid absorption
HepB, flu shots
Apply pressure for 10 seconds before injecting to decrease
pain
Deltoid IM Injection Site
Reconstitution of Medication
Reconstituting vial- powdered med
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Label will tell you what to mix with the powderusually 0.9 NS or sterile water (diluent)
Draw up amount needed of diluent and inject
into bottle. Mix by gently rotating (rolling) vial
until all powder dissolved
Remove needed amount
Label with date/time/diluent/concentration
Syringe with Attached Needle and
Safety Shield
Review of Injection Types
What we hope to avoid when
administering medications!!!
Use this to Practice in the CLC
Open a patient chart in the EHRgo (Practice
Patient only)
Open the Physician order and verify the order
against the MAR for any of the oral medications
Look up the medication in your drug book
Do your first and second check of the medication
at the medication cart
Scan the medication/ or hit the pencil icon
Follow prompts for giving the medication
Make sure to hit the blue save icon when finished
Document date, time, site, patient’s tolerance.