Communication \
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> Medication Administration
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Definition (Giddens)
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Medication Administration
I. Medication and Regulations
A. Drugs and medications
-drug vs medication. Drug is any substance that positively or negatively alters physiologic
function , while medications are used for a therapeutic effect on physiologic function
-chemical name-describes the elements of the medication’s molecular structure
-generic name-official name assigned by a council, which is usually simpler than the
chemical name. Generic name is not capitalized and often contains a prefix or suffix that
helps identify the drug class {beta blockers- (-olol) }
-trade name-registered name assigned by drug manufacturer. Because one type of
medication can be manufactured by several companies, it can have several different trade
names while having a common generic and chemical name.
B. Medication standards and regulations
-United States Pharmacopeia(USP) since 1820 and the National Formulary(NF) since
1898-official medication lists have been reported to these two to help protect public safety
by identifying medication properties that show an appropriate range of quality and purity.
The Pure Food and Drug Act of 1906 designated the USP and NF as the only official
authorities to establish drug standards, including the requirement that medications be free
of impurities
-Controlled substances are types of medications that have government-regulated
manufacturing, prescribing, and dispensing requirements
-Enforcement of medication legislation in the US is the responsibility of the US Food and
Drug Administration(FDA), which mandates that all medications undergo safety testing
before being released to the public.
C. Controlled substances
-Controlled Substances Act(CSA) established five categories of scheduled drugs. One
objective of the CSA was to reduce opportunities for drugs to be diverted from legitimate
sources to drug abusers. The CSA mandates regulations for the handling and distributing
of controlled substances by manufacturers, distributors, pharmacists, nurses, and care
providers. Compliance with these regulations is monitored by the Drug Enforcement
Administration(DEA).
-A written record is required to track all transactions involving controlled substances that
originate from legitimate sources. An inventory must be kept of all controlled substances in
stock, and this inventory must be reported to the DEA every 2 years. Many hospitals and
clinics require that floor stock of controlled substances be accounted for at the beginning
and end of shit.
-If a controlled drug needs to be wasted (e.g. only a partial amount is needed for a
prescribed dose), two licensed clinical staff members must witness the appropriate
dispensal of the substance and document the wasting of the drug.
Controlled Substances
CATEGORY DESCRIPTION
Schedule I
Schedule II
Schedule
III
High potential for
abuse
No currently accepted
medical use in
treatment in the
United States
High potential for
abuse; may lead to
severe psychological
or physical
dependence
Has a currently
accepted medical use
with severe
restrictions
EXAMPLES
Heroin, lysergic acid
diethylamide (LSD), and
methaqualone
Morphine, cocaine,
methadone, and
methamphetamine
Lower potential for
abuse compared to
Anabolic steroids, narcotics
the drugs in schedules
such as codeine or
I and II in regard to
hydrocodone with aspirin
moderate dependence
or acetaminophen, and
Has a currently
accepted medical use
Controlled Substances
CATEGORY DESCRIPTION
EXAMPLES
some barbiturates
Schedule
IV
Schedule V
Lower potential for
abuse relative to the
drugs in schedule III;
may lead to limited
dependence
Has a currently
accepted medical use
Pentazocine, meprobamate,
diazepam, and alprazolam
Low potential for abuse
relative to the drugs
Over-the-counter (OTC) cough
in schedule IV
medicines with codeine
Has a currently
accepted medical use
in treatment in the
United States.
D. State and local medications regulations-The goal of these regulations is to prevent adverse
patient outcomes. Health care facilities cannot expand or modify the nurse practice act; it is the
nurse’s responsibility to understand and follow the nurse practice act and policies of the facility when
administering any medication, particularly controlled substances. Violations of regulations can result
in fines, imprisonment, and the loss of nurse licensure.
II Principles of drug actions
A. Pharmokinetics-study of how a medication enters the body, moves through the body, and
ultimately leaves the body
a. Therapeutic effect (or intended effect)-desired result or action of a medication.
Effectiveness is influenced by medication dose, route of administration, frequency,
function of metabolizing organs(such as liver or kidneys), and age of patient.
Prescribing practitioners and nurses providing care monitor the patient’s response to
the med & lab and diagnostic studies measure medication effects. Medication
actions depend on absorption, distribution, metabolism, and excretion properties.
b. Older adults: Age-related changes, such as increased fat deposits, decreased
gastric mobility, decreased renal and liver function, and changes in the blood–brain
barrier; can lead to increased side effects of medications. Comorbidities,
polypharmacy, potential drug interactions, and adverse drug side effects (such as
falls and delirium) increase dramatically in older adults
c. Women have slower gastric motility than do men, which affects plasma
concentration and absorption of oral medications. Glomerular filtration rate and renal
blood flow are higher in men than in women, which contributes to faster clearance of
medications eliminated via the kidneys in men
1. Absorption-process by which the drug is transferred from site of entry into the
bloodstream
Affected by: route of administration, ability to dissolve, blood flow to site of
administration, body surface area, lipid solubility of medication, drug dosage,
serum drug levels(therapeutic levels-peak, trough, half-life), age
Route of admin that is faster-IV, sublingual, buccal
Serum drug levels-digoxin, lithium, warfarin(protime & INR drawn daily if in the
hospital, dose is altered by the result of INR), heparin drip (PTT and aPTT),
vancomycin(BUN and creatinine)
2. Distribution-how the drug is dispersed throughout the body-tissues, organs, specific
sites of action. Distribution depends on circulation, membrane permeability, protein
binding, blood-brain barrier
a. Yoost- Distribution is affected by the chemical properties of the drug, the
effectiveness of the cardiac system, the ability to pass through tissue and
organ membrances, and the extent to which the drug binds to proteins or
accumulates in fatty tissue.
3. Metabolism-meds are metabolized into a less potent or an inactive form to prepare
for excretion. The products of this process are called metabolites. Most metabolism takes place in the
liver, and it may be slowed in elderly individuals or anyone with impaired liver function. Care is taken
in administering to these populations, because toxic levels of a medication can build up if the liver is
not able to break the drug down to a less active form.
4. Excretion-process by which the drug or its metabolites are removed from the body.
Kidneys excrete most drugs, but some be excreted by liver, bile in the GI tract, lungs for excretion of
gaseos, exocrine glands-sweat, salivary, and mammary glands
B. Pharmacodynamics-the process by which the drug alters cell physiology, and affect the
body. Drugs turn on, turn off, promote, or block responses that are part of normal body responses.
-The biochemical response can be systemic(such as the nervous system(sedation),
respiratory system(change in resp rate), and GI system(constipation) after receiving a pain medicine),
or can be local(when a antipruritic lotion is applied to an insect bite).
-The biochemical response is typically evaluated on the basis of changes in the
patient’s clinical condition. Diff patients may respond differently to the same medication.
-The desired drug action is produced by maintaining a constant drug level in the body
and is based on the half-life of the drug. A drug's half-life is the expected time it takes for the blood
concentration to measure one-half of the original drug dose due to drug metabolism and excretion.
For example, if a drug has a half-life of 12 hours, 50% of the drug's original dose remains in the
bloodstream 12 hours after administration. Repeated doses are usually required to maintain the
desired drug level. Correct spacing of doses to maintain consistent drug levels and obtain therapeutic
effects is based on the drug's half-life and is an important consideration when medications are
prescribed.
Nurses must account for other drug action factors. Onset of action is the time the body takes to
respond to a drug after administration. Onset is affected by the administration route, drug formulation,
and pharmacokinetic factors. For example, the onset of action for insulin varies greatly, depending on
the route (intravenous versus subcutaneous) and on the type of insulin (e.g., lispro versus
glargine). Peak plasma level indicates the highest serum (blood) concentration. After the peak is
reached, serum levels decrease until another dose is administered. Conversely, the trough is the
lowest serum level of the medication. The peak and trough levels of a medication are measured with
serum laboratory tests, and results are used to adjust dose amounts and monitor for toxicity. Blood
samples for peak serum levels are drawn at specified times after administration on the basis of the
drug half-life; samples for trough levels are drawn just before the administration of a scheduled dose.
C. Side effects, Adverse effects, drug interactions
1. Side effects-Unintended, secondary effect. Can be harmless or harmful. Common
effects that may happen when a patient takes a certain medication. Patients may refuse to continue a
medicine because of side effects. Patient education regarding how to handle expected side effects
can offset this reaction(e.g. medicine taken with a light meal to prevent nausea)
2. Adverse effects-Severe, unintended, unwanted, and often unpredictable drug
reactions. An adverse effect may occur after one dose, such as a severe allergic response, or it may
develop over time, such as the development of anemia associated with a medication. When an
adverse reaction occurs, the medication is immediately stopped.
3. Toxic effects-medication accumulates in the blood stream due to impaired
metabolism and excretion. Results from overdose, ingestion of external use drug,
buildup of drug in blood. Carry the risk of permanent organ damage
-toxic levels of a pain med(such as morphine sulfate) may cause respiratory
depression, leading to respiratory arrest.
-Other organs that can be damaged from drug toxicity include the
kidneys(nephrotoxicity), liver(hepatotoxicity), organs of hearing(ototoxicity), and
heart(cardiotoxicity). Most drug toxicity is avoidable with careful patient
monitoring, esp. of kidney and liver function.
4. Allergic effects- unpredictable response to a medication; an immune response.
Signs and symptoms of drug allergy-rash, urticaria(hives), fever, diarrhea, nausea,
vomiting
-When a patient is first exposed to a foreign substance(antigen), the body
produces antibodies. The medication, a chemical preservative, or one of the
metabolites can initiate the immune response. On exposure, the patient reacts to
the antigen with an allergic reaction that ranges from minor to severe. Minor
allergic reactions include a rash, itching of the skin, inflammation of the nasal
passages causing swelling and a clear discharge, and raises skin
eruptions(hives).
a. Anaphyllactic reaction-Medical emergency!!!-severe allergic reaction.
Anaphylaxis can occur immediately after admin of medication and can
be fatal. Treatment includes immediate discontinuation of the drug and
administration of epinephrine(an antagonist), IV fluids, steroids, and
antihistaminces while providing respiratory support. Possible severe
bronchospasm and cardiovascular collapse
5. Idiosyncratic reaction-over- or under-reaction to a medication (e.g. patient receiving
an antihistamine may become overly alert and unable to sleep, rather than being drowsy, as
expected)
6. Medication interaction-occurs when the drug action is modified by the presence of a
certain food, herb, or another medication. The interaction can alter the way the medication is
absorbed, metabolized, or eliminated.
a. synergesic effect-Occurs when the combined effect of two medications is
greater than the effect of the medications given separately. Alcohol, is a CNS depressant that has an
increased effect when taken with antihistamines, antidepressants, or barbiturates. Providers may
purposely prescribe two synergistic drugs to create a response(e.g. a patient with hypertension may
receive a diuretic and a vasodilator to achieve a greater antihypertensive response than would be
achieved by either drug alone.)
b. antagonism-when the drug effect is decreased by taking the drug with another
substance, including herbs. For example, antibiotics can lessen the effect of birth control medications
and grapefruit juice alters the absorption of statins, a class of lipid-lowering drugs.
c. compatibility-Special care is taken when administering parenteral medications.
Mixing medications in a solution that causes precipitation or combining a drug with another drug that
causes an adverse chemical reaction is called drug compatibility. Compatibility must be verified
before mixing or administering medications with a syringe or through IV tubing. If medications that are
not compatible are prescribed, they must be administered separately with appropriate safety
measures, such as flushing the IV tubing between medications.
Medication dose responses-----vancomycin-check therapeutic levels during the trough
III. Nonprescription medications-examples are cold medicines, mild analgesics, diet and nutrition
supplements, sleep aids. Factors to consider when selecting an OTC medication include: 1) clearly
understanding the desired effect and potential side and adverse effects of all ingredients in the
medication, 2) possible allergic reactions, 3) potential interactions with other medications and herbs,
4) warnings, 5) directions and dosage, and 6) features (such as safety caps).
A. Vitamins- Vitamins needed by the body are usually acquired from food that is eaten. The
body uses vitamins for the biologic processes of growth, digestion, and nerve function. Water-soluble
vitamins are excreted by the body through the kidneys. The water-soluble vitamins are the B complex
and C vitamins. Fat-soluble vitamins are stored by the body for use as needed; however, excess can
build up in the liver, so they must be used with caution. The fat-soluble vitamins are the A, D, E, and
K vitamins. There are certain conditions in which vitamins should be considered for use. They include
pregnancy, breastfeeding, a vegetarian or vegan diet, an illness or condition that prevents oral
consumption of foods, and the need for dietary supplements.
B. Alternative therapies pg 788- Herbs are often taken for specific symptoms and for a limited
period of time. Because they act in the body similar to the way that prescription medications act, they
should be used with caution, and many need to be discontinued several days before a surgical
procedure. Many consumers are reluctant to inform or do not understand the importance of telling
their PCP about their use of herbal supplements, and this increases the possibility of an adverse
reaction among prescribed medications and the supplements
HERB
USES
SIDE EFFECTS AND DRUG INTERACTIONS
HERB
USES
SIDE EFFECTS AND DRUG INTERACTIONS
Echinacea
Stimulates the immune
system; facilitates
wound healing; fights
flu and colds
Possible liver inflammation and damage if used with
anabolic steroids or methotrexate
Garlic
Lowers blood pressure and
cholesterol and
triglyceride levels
Increased bleeding; potentiates action of anticoagulants
Ginkgo
bilob
a
Improves memory and
mental alertness
Increased bleeding; potentiates action of anticoagulants
Ginseng
Increases physical stamina
and mental
concentration
Can increase heart rate and blood pressure; decreases
effectiveness of anticoagulants; may cause
hypoglycemia in patients taking oral hypoglycemics
or insulin
Saw
Helps with enlarged
prostate and urinary
inflammation
Interacts with other hormones
Alleviates mild to moderate
depression, anxiety,
and sleep disorders
Interacts with anti-anxiety medications, antidepressants,
anticoagulants, birth control pills, cyclosporine,
digoxin, statins, and human immunodeficiency virus
(HIV) and cancer medications
palm
etto
St. John's
wort
-The nurse must be vigilant in obtaining an accurate patient medication history that includes the use
of herbs, extracts, teas, tinctures, and dietary supplements. Because many herbs have the same
properties as prescription medications, the patient taking an herb and prescription medication for the
same effect could experience a toxic reaction.
IV. Prescription medications
A. Components of a prescription
---Parts of the medication order----- Patient’s name, date and time order is written,
name of drug to be administered, dosage of drug, route by which drug is to be
administered, frequency of administration, signature of person writing the order
- Nurses need to know why a medication is ordered for certain times and whether the times can be
altered. For example, there is a difference between medications ordered every 6 hours (q 6 hr) and
those ordered four times per day (qid), even though the four doses of medication are administered in
a 24-hour period. A medication ordered q 6 hr is given at regular intervals around the clock (e.g., at 6
a.m., 12 p.m., 6 p.m., and midnight) to maintain a constant blood level. A medication given qid (e.g.,
at 9 a.m., 1 p.m., 5 p.m., and 9 p.m.) is administered during waking hours.
Medication orders can change on the basis of the status of the patient. For example, a sudden
change in condition, an adverse reaction to a medication, or a patient transfer to a different care unit
can necessitate a change in medication orders. Medication orders may need to be adjusted by the
prescriber after surgical procedures or on discharge. Insulin is often prescribed to be taken at a
specific time before meals; other medications may be ordered to be taken after meals to ensure that
they are not taken on an empty stomach.
The five common types of medication orders in acute care settings are based on administration
frequency or urgency: routine, PRN (as needed), one-time or on-call, stat, and now orders. Stat
medications are given immediately. The instructions regarding when to give an on-call medication are
included in the order; the time is based on when a treatment or procedure is scheduled to start, such
as when the operating room staff is ready to transport a patient to the surgical department for surgery.
A PRN medication is administered as needed but still within identified time constraints. Each facility's
pharmacy has guidelines for medication administration times. It is not within the scope of practice for
a nurse to determine medication administration times. The hours of administration per pharmacy
protocol must be adhered to, unless ordered differently by the PCP.
Routine order-administered until HCP discontinues the order or until a prescribed number of doses or
days have occurred.
PRN-given only when the patient requires it . Use determined by objective and subjective assessment
and clinical judgement of nurse.
One-time or on-call order-given only once at a specified time, often before a diagnostic or surgical
procedure
Stat order-given immediately and only once in a single dose; frequently given for emergency
situations
Now order-used when a medication is needed quickly but not as immediately as a stat med; given
one time
V. Forms of medication
-solid, liquid, other oral forms, topical, parenteral, instillation into body cavities
VI. Routes of med administration and method of administration-Common routes of administration
include oral, buccal, sublingual, parenteral, topical, by inhalation, and through a medical tube(e.g. NG
tube, PEG tube)
A. Oral-Oral meds can often be administered through nasogastric, gastric, intestinal, and
jejunal tubes when they are ordered to be given that route. Tube placement is checked before med
admin and special safety precautions need to be taken to prevent aspiration or clogging of the tube.
Enteric-coated, time-release, sublingual, buccal, and other medications with special coatings cannot
be administered through a tube, Contact the PCP to safely change the prescribed med to an alternate
administration route or formulation, if needed.
1. Tablets-medication is compressed with binding substances and disintegrating
agents; may have flavoring added to improve taste; used for oral, sublingual, and buccal routes.
Enteric coated tabs have a special outer covering that delays absorption as it dissolves in the
intestines. || inappropriate for pts with N&V, contraindicated for patients with swallowing difficulty,
cannot be used with simultaneous gastric suctioning or before various diagnostic or surgical
procedures
2. Capsules-meds are enclosed in cylindrical gelatin coatings. Time-release capsules
have medication particles encased in smalled casings that deliver meds over an extended period
3. Liquids—solutions are medications already dissolved in liquid. Syrups are mixed with
sugar and water. Suspensions are finely crushed medications in liquid. Elixirs are medications
dissolved in alcohol and water with glycerin or other sweeteners. Drops are a sterile solution or
suspension administered directly into the eye, outer ear canal, or nose or sublingually. Injectable
solutions are sterile suspensions supplied in ampuled, prefilled syringes, bags, or bottles.
4. Sublingual-under the tongue, more potent than oral because the drug bypasses the
liver and enters bloodstream directly. Example of sublingual med is nitroglycerin.
5. Buccal-against the cheek, more potent than oral because the drug bypasses the liver
and enters bloodstream directly. Some examples of buccal meds are antiemetics and opiate pain
meds.
B. Topical-Ointments(spreadable, greasy preparations), creams(not greasy but used on skin
only), and lotions(solutions or suspensions used on skin and not as sticky as creams or ointments),
Absorption may be irregular if skin breaks are present, and it may be slow.
C. Inhaled-medications inhaled or sprayed into the mouth or nose; may have local or systemic
effects. Some are delivered in fixed doses. Advantage-rapid localized effect, may be administered to
unconscious patients, but disadvantage-may cause serious systemic effects. Inhaled meds are
effectively used to induce anesthesia and to treat respiratory disorders. Nurses administer inhaled
medications through nasal passages, oral passages, an endotracheal tube, or a tracheostomy tube.
Means of delivery include small amounts of fluids, metered-dose inhalers(MDIs), turbo-inhalers, and
nebulizers.
D. Parenteral-by injection or infusion. Common forms-intradermal, subcutaneous, IM, IV).
More rapid response than the oral or topical route, can be used for critically ill patients or
for long-term therapy. Sterile technique must be used as the skin barrier is compromised.
Intradermal, Subq and IM are useful for small volumes only.
-Parenteral medications are administered by injection into tissue, muscle, or vein.
Absorption is usually faster and more complete by a parenteral route than the oral route.
Aseptic technique is used b/c protective skin barrier is compromised with this route. Tissue
damage is another risk when meds are administered parenterally.
-Syringes have a barrel, plunger, and syringe tip. With a Luer-Lok syringe, the needle is
secured onto the end of the syringe with a twisting motion. A Luer-Lok syringe can be
directly attached to an access port on the IV tubing or aline lock without the use of a
needle. Nurse may touch the outside of the syringe and the handle of the plunger, but a
nonsterile object should not touch the tip of the barrel, inside of the barrel, shaft of the
plunger, or needle.
-Common syringes range from very small, 0.5 mL sizes for intradermal and subcutaneous
injections to 60 mL for irrigations and tube feedings. The three common types of syringes
are standard, tuberculin, and insulin.
-Common gauges range from 18-30; the larger gauges, such as 16 or 14 are used in EDs
or ORs. 18 is large, 25 is small. The nurse selects a needle gauge based on the viscosity,
or thickness, of the medication to be injected and the route of administration. Long-acting
medications formulated in an oil base for sustained release require a large gauge needle
than thinner, water-based medications.
-Needle length varies from 1/3 to 3 inches-size depends on age and size of patient.
-Syringe sizes are 1, 3, 5, and 10 mL.
-insulin U-100(meaning there are 100 units/mL) syringes are calibrated in units and
millimeters and are supplied in 3 sizes—30 units(0.3 mL), 50 units(0.5 mL), and 100 units(1
ml), each with a 26-31 gauge needle.
1. Intradermal; Shallow injection into the dermal layer just under the epidermis
a. Syringe selection-1 mL tuberculin syringe
b. Needle size (gauge and length)- ¼ to 5/8 inch needle, 25-27 gauge
c. Angle of injection-15 degrees
d. Site selection-inner forearm, upper arm, and across the scapula
2. Subcutaneous-Injection into the subcutaneous tissue just below the skin
a. Syringe selection-0.5-3 ml
b. Needle size (gauge and length)-3/8-5/8 inch, 25 to 31 gauge needle
b. Angle of injection-45-90 degrees
c. Site selection-abdomen, lateral aspects of the upper arm and thigh, scapular
area of the back, and upper ventrodosal gluteal area
3. Intramuscular-injection into the muscle of adequate size to accommodate the
amount and type of medication
a. Syringe selection-1-5 mL, depending on site and muscle mass
b. Needle size (gauge and length)- 1-3 inch, 19 to 25 gauge needle(adult) ||| 5/81 inch, 19-25 gauge(pediatric). Oil based solutions: 18-20 gauge
c. Angle of injection-90 degrees
c. Site selection-Ventrogluteal, vastus lateralis, deltoid
Age of patient and corresponding site- Infant: vastus lateralis, children: vastus
lateralis or deltoid, adult: ventrogluteal or deltoid
4. Intravenous-Injection or infusion directly into the bloodstream via a vein
a. Syringe selection-depends on amount of medication to be infused
b. Needle size (gauge and length)-Typically, a large-gauge, 1 inch needle.
c. Angle of injection
d. Site selection-vein
5. Preparing Parenteral medications
a. Ampules and vials-Filter needles or straws are used when medication are
being withdrawn from a glass ampule. The filter traps glass gragments. A filter needle or straw must
be replaced with a regular needle before injecting the medication into the patient.
b. Reconstituting powdered medications-Some medications are supplied as a
powder in a vial. They are reconstituted by adding a liquid, or diluent, to the powder. Powdered
medications are carefully reconstituted by adding only the proper amount and type of diluent identified
by the manufacturer. Sterile normal saline and sterile distilled water are common diluents used for
reconstituting medications. Specific directions printed on the vial or package insert identify the type
and amount of diluent needed for reconstitution and the resulting concentration of medication.
An Act-O-Vial system (i.e., dual-compartment vial) is another approach for administering powdered
medication. In this system, the medication powder (e.g., methylprednisolone sodium succinate) and
diluent are in two compartments of a single vial, separated by a rubber stopper. To prepare the ActO-Vial for administration, the nurse depresses the stopper to combine the diluent and medication,
gently mixes the solution, and withdraws the prescribed dose.
c. Prefilled cartridges and syringes-A single dose of medication may be supplied
in a prefilled cartridge or syringe. A cartridge is placed into a reusable injection device or holder. Care
is taken to lock the cartridge into the injection holder to stabilize it during administration. Before
injection, the cartridge is cleared of air and excess medication because products may be overfilled,
risking overdose, or the dose ordered may be smaller than the amount of medication contained in the
cartridge. After administration, the cartridge is removed from the holder and placed in the appropriate
disposal container. The holder is retained and is reusable. Examples of prefilled cartridge holders
include Tubex and Carpuject appliances.
Some medication supplied in cartridges is withdrawn using a different syringe and is then
administered with that syringe. The transfer of medication from a prefilled cartridge to a different
syringe is done if a needleless system is in place or a safety needle is available for use instead of the
needle supplied with the cartridge. Withdrawing medication from a cartridge is similar to using a vial,
except that no air is injected into the cartridge before the medication is withdrawn.
Prefilled syringes are similar to prefilled cartridges. A single dose of medication is in a syringe with a
needle attached. Excess air or medication may need to be expelled from the syringe; however, some
prefilled medication syringes, such as enoxaparin, contain air that should not be removed before
administration.
E. Ophthalmic
F. Otic
G. Nasal
H. Vaginal
I. Rectal
VII. Safe medication administration-Before administering a medication, the nurse should check the
patient’s MAR or the primary care provider’s prescription, review diet and fluid orders, review relevant
laboratory values, and perform a brief physical assessment.
-safe practice standards dictate that the nurse should follow only written orders. In an
emergency situation, a verbal order from the PCP may be given to nurse or pharmacist, but the order
must be put in writing ASAP. Nurses are legally accountable for medications they administer and for
recognizing side effects and adverse reactions. Questions regarding the purpose, dose, route, time,
abbreviations, relation to laboratory values, potential interactions, allergies, or patient response must
be resolved with the PCP or pharmacist before the nurse administers the medication. The nurse has
the right and responsibility to refuse to administer a medication if he or she feels that the prescribed
medication endangers the safety of the patient, but the PCP must be notified of the refusal to
administer the medication.
A. Interpreting order-Clinical judgement is needed to evaluate whether the medication, amount
prescribed, and route are safe for the patient. The nurse must understand the purpose, typical
dosage, route, and side effects of the med before administration. The nurse assumes legal
responsibility for all meds he or she administer. The nurse should clarify orders with the prescriber
that are hard to read, do not contain all of the critical information needed for safe administration, or
contain prohibited or unfamiliar abbreviations.
B. Medications Error-Common causes of errors include poor communication,
misinterpretation of writing, and the use of improper techniques. A medication error is “any
preventable event that may cause or lead to inappropriate medication use or patient harm
while the medication is in the control of the HCP, patient, or consumer.”
-Multidisciplinary collaboration for med admin helps safeguard against errors. Because the
nurse is typically the last person in the sequence of administering meds in a health care
facility, the nurse is the patient’s last line of defense against mistakes. Many facilities have
a “No Interruption Zone” policy for med admin, requiring the nurse to prepare medications
in a quiet setting without interruptions by other staff, patients, or phone calls. Focusing only
on preparing the correct meds helps decrease errors.
-Dieticians may consult with patients taking medications that are effected by specific food
intake. Patients with diabetes, cardiac disorders, undergoing chemotherapy, or taking
anticoagulants are some examples of individuals who would benefit from meeting with
dieticians.
-If a medication error occurs, the nurse's priorities are to determine the effect on the patient
and intervene to offset any adverse effects of the error. Actions include immediate and ongoing
assessment, notification of the prescribing PCP, initiation of interventions as prescribed to
offset any adverse effects, and documentation related to the event. Error reporting is an
essential component of patient safety and should be completed as soon as the patient is
assessed and stable. The nurse should follow facility guidelines for medication error reporting.
C. Abbreviations
a. Joint Commission “Do Not Use” list-list of abbreviations that were identified as
contributing to med errors.
b. Abbreviations
1. Ac-before meals
2. Pc-after meals
3. H or hr- hour
4. Bid-two times per day
5. Tid-three times per day
6. Qid-four times per day
7. q-every
8. g or gm-gram
9. mcg-microgram
10. mg-milligram
11. mL-milliliter
12. IM-intramuscular
13. IV-intravenous
14. PO or po-by mouth, orally
15. NPO or npo-nothing by mouth
16. PRN or prn-as needed
17. SL-sublingual
18. STAT-immediately
C. Dosage calculations-A teaspoon is 5 ml. A tablespoon is 15 mL.
-start the equation with the dose to be given, then the concentration or supply available.
D. 6 Rights of medication administration-right drug, right dose, right time, right route, right
patient, right documentation
-check prescriber order, check patient’s allergies, check medication expiration date.
-never administer medication you did not prepare.
-verify that the drug is the right drug- 1)when taking it out of the drawer, 2)when comparing
it with the MAR as the drug is being prepared, 3)at the bedside immediately before
administration
-administer meds within the appropriate time frame(usually between the half hour before
and the half hour after the scheduled time for oral med) or administer as specified(e.g.
before meals).
-Before administering parenteral meds, check compatibility, need for dilution, and rate of
admin.
-When meds are mixed in the same syringe, there may be a time limit between when the
drugs are mixed and when they are administered. Always verify time of admin.
-Patient has right to refuse. The nurse investigates the patient’s reason for refusing the
med and provides, reinforces, or clarifies information to ensure that the patient understands
the risks of refusing the meds. The prescriber needs to be notified of the patient’s refusal of
the ordered med. Documentation of refusal of med should include the patient’s concern, the
information provided by the nurse, and the name of the prescriber who was notidfied of the
patient’s refusal.
Patients rights-the right to be informed of the name, purpose, and potential side effects of meds
-the right to refuse a med
-the right to have an accurate med history taken by a qualified person
-the right to receive meds in accordance with the 6 rights of meds
-Common laboratory tests monitored to assess medication responses include electrolytes, serum
glucose, complete blood count (CBC), white blood cell (WBC) count, bleeding time, blood urea
nitrogen (BUN), creatinine, and serum levels of specific medications.
The nurse completes a physical assessment to identify body systems that may be affected by
prescribed medications. For example, a respiratory assessment is performed before the
administration of a bronchodilator treatment for a patient having an asthma attack. This assessment
includes respiratory rate, auscultation of lung sounds, use of accessory muscles, and oxygen
saturation levels. The assessment is repeated after medication administration to determine the
effectiveness of the intervention.
Because medications may affect temperature, pulse, respirations, and blood pressure, vital signs that
may be affected should be measured before and after administering a medication. For example, the
apical pulse for 1 minute is obtained before administering digoxin (i.e., cardiac medication that slows
the heart rate), because it is common to withhold administration if the patient's heart rate is less than
60 beats/min; blood pressure is monitored before and after an antihypertensive is administered; the
patient's temperature is measured before and after an antipyretic (medication to decrease fever) is
administered; and respiratory rate and blood pressure are measured before administration of an
opiate (narcotic) that can decrease these vital signs.
Assessing the patient's ability to swallow is important before administration of an oral medication.
Adequate muscle mass is needed for proper absorption of IM medications, and functioning IV access
must be available for intravenously administered medications. The skin site for topical medications
must be inspected.
The most important steps for the nurse to take when preparing to administer medications are
assessment of the patient and adherence to the Six Rights of Medication Administration
-Assessment before and after administration of inhaled medications includes assessment of breathing
status, breath sounds, respiratory rate, and use of accessory muscles. The nurse assesses the
patient's use of inhalers, because the MDI is often used incorrectly. Important patient education
includes determining when the inhaler is empty and needs to be replaced. It is recommended that the
number of doses in the container be divided by the number of doses the patient takes in a day. The
patient should keep a record of doses to obtain a refill of the medication canister before it runs out.
Proper use of the medication ensures optimal outcomes. The ability to compress the inhaler is
affected by hand strength, flexibility, and the hand size of a child or adult.
**Not in Medication Administration chapter:
Safe Medication Administration via enteric tube
A. Enteric coated and Time release -Enteric-coated or sustained-release tablets should
never be crushed. The enteric coating protects the oral and gastric mucosa from irritating
medications. Crushing a sustained-release medication allows absorption to occur all at
once rather than the desired absorption over time.
B. Steps of administering medication via enteric tube
-Medication may be administered by the enteral route (i.e., through a gastrointestinal
tube). Liquid medication is preferred, although some tablets may be finely crushed and
dissolved in sterile water. Care is taken that the tube is flushed before and after
administration with 15 mL of sterile water (or in accordance with facility policy) to clear the
tube of medication and prevent clogging of the tube. Having the patient sit as upright as
possible decreases the risk of aspiration. The patient should remain with the head elevated
for at least 30 minutes after administration. To allow absorption time, gastric suction
should not be used for 20 to 30 minutes after administration