MEDICATION ADMINISTRATION

Right medication to right patient in the right dosage through the right route
at the right time

A. MEDICATION ORDERS
- no medication may be given to a patient without a medication order
from a physician or, in some
states, a nurse practitioner
- orders are written on a form designed specifically for a physician’s
order, which becomes a
permanent part of the patient’s record
- many facilities use a computer-generated pharmacy order system and
can receive a medication
order by fax from the physician
- physician enters drug order into computer
- computer sends order directly to pharmacy and enters order into
patient’s permanent record
- prevent any guessing when handwriting is illegible or drug names
are similar
- provides physicians with recommended doses of medication,
indicates laboratory tests that
monitor action of drug, and lists potential interactions that
may occur
- in certain circumstances (emergencies), a verbal order from physician
may be given to RN or
pharmacist
- unless specific orders to the contrary are written, all drugs that may
have been ordered while at
home are discontinued
- explain to patient and family how the patient’s drug plan is to be
implemented
- in some inpatient facilities, patients keep medications at bedside and
learn or continue to administer
as they would at home
- promotes patient’s independence
- nurse should be aware when patients are allowed to do this
- notation should be made on patient’s care plan
- when patient has had surgery or is transferred to another clinical
service or another health agency, it
is general practice that all orders related to drugs are discontinued
and new ones written
- check that all medications are appropriately reordered

1. Types of Orders
- physician writes a standing order and its cancellation
simultaneously
- specifies a certain order is to be carried out for a stated
number of days or times
- after stated period, order is cancelled automatically
 p.r.n. (“as needed) – patient receives medication when it is
requested or needed
- commonly written for postoperative pain meds

single order – directive is carried out only once, at a time

specified by physician

stat order – carried out immediately

2. Parts of Medication Order

- patient’s name - date and time order is written
- drug name - drug dosage
- route of administration - administration frequency
- signature of person writing the order

3. Questioning Medication Order

- any drug order suspected to be in error should be questioned
- suspected error should be noted and reported
- on occasion, nurse may not think there is an error but may not
understand why medication
has been prescribed
- ask how order relates to patient’s care plan
- may prevent medication error if wrong med has been
ordered
- confusion over placement of decimal point can be prevented by
always having a zero
precede the decimal for clarity (no need for zero after
decimal – can cause confusion
if decimal is unclear or missed completely)
- drug to which patient is allergic may inadvertently be prescribed
- notation should be made in patient’s record of past adverse
reactions
- do not administer and question when, in nurse’s judgment,
patient is allergic
- patient may wear wristband indicating specific allergies
- drug may be ordered that would potentially interact with another
med patient is taking
- all unfamiliar meds should be verified before administering
- guessing is a gross carelessness action – checking with
person that wrote the order
is the only safe procedure
- nurses have the right to refuse to administer any medication that,
based on their knowledge
and experience, may be harmful to patient
- must notify physician of refusal

B. USING SAFETY MEASURES WHILE PREPARING DRUGS

1. Three Checks and Five Rights
- label on medication should be checked 3 times during preparation
 - when nurse reaches for container or unit dose package
- immediately before pouring or opening medication
- when replacing container to drawer or shelf or before giving
unit dose medication

Right medication to right patient in the right dosage through the

right route at the right time

2. Caring for Controlled Substances Safely

- controlled substances are kept in a locked drawer or container as
a safety measure
- narcotics or controlled substances may be ordered only by
physician (sometimes, nurse
practitioners registered with Dept. of Justice)
- record must be kept for each narcotic administered
- forms are kept with narcotics
- information required: - receiving patient’s name
- hour narcotic was given
- name of physician prescribing narcotic
- name of nurse administering narcotic
- narcotics are checked daily
- amount on hand is counted and each dose used must be
accounted for on the
narcotic record
- nurse has a secure i.d. code that provides access into the
system, identifies patient
by name or i.d. number, and verifies count for each
drug as it is removed
- count that does not check properly must be reported
immediately
- if for any reason a narcotic prepared for administration has to be
discarded, a 2 nurse
nd

should act as witness, and that person should also sign the
narcotic sheet
- also document with a witness any time a full dosage is not
given and some of the
narcotic needs to be disposed of

3. Identifying the Patient

- positive identification of patient is essential to safe drug
administration
- check carefully to see that right drug is being given to right
patient
- patients usually wear identification bracelets
- as patient to state his/her name, if possible
- check current photograph of resident, if available, which is usually
displayed above
resident’s bed
- verify patient i.d. with other healthcare providers
C. ADMINISTERING ORAL MEDICATIONS
- check patient to ensure medication was they actually take meds (make
sure they don’t “cheek” it
- preparation forms include
solid (tablets, capsules, pills)
- some tablets are scored for easy breaking if partial quantity
is needed
- enteric-coated tablets and extended-release forms (SR =
sustained release, XL =
extended release, CR/CT = controlled release, SA =
sustained action, LA =
long-acting) should not be chewed or crushed
- certain narcotics can be administered in a lollipop or oral-
transmucosal form
liquids (elixirs, spirits, suspensions, syrups)
- water-based and alcohol-based solutions
- can be administered via syringe between gum and cheek
- if label becomes difficult to read or accidentally comes off, container
should be returned to pharmacy
- never give a medication from a bottle without a label
- care should be taken when pouring to prevent unnecessary loss
- do not transfer medication from one container to another

1. Steps / Rationales
a. Know actions, special nursing considerations, safe dose ranges,
purpose of administration,
and adverse effects of medication to be administered.
- aids nurse in evaluating therapeutic effect, can also be used
to educate patients
about their medication
b. Prepare medication for administration in medication area
- facilitates error free administration and saves time
c. Prepare medications for one patient at a time
- prevents errors in medication administration
d. Hold liquid medication bottles with label against the palm. Use
appropriate measuring device when pouring, read amt. of
medication at bottom of meniscus at eye level
- label is needed for additional safety check, also may
indicate monitoring of certain
vital signs
- liquid may drip onto label making it difficult to read
e. When all medications for one patient have been prepared recheck
once again with medication
order before taking them to patient – keep medications in sight at
all times
- 3rd check to ensure accuracy and to prevent errors
f. Identify patient carefully: check name on i.d. band, ask patient
his/her name, verify patient’s
i.d. with staff members who know patient
- most reliable method, requires an answer from patient
 - do not use name on door or over bed – these may be
inaccurate
g. Check allergy bracelet or ask patient about allergies – explain
purpose and action of each
medication to patient
- assessment is prerequisite to administration of medication
h. Offer water or other permitted fluids with pills, capsules, tables,
and some liquid measures – If
capsule or tablet falls to floor, it must be discarded and a new one
administered
- facilitates swallowing of solid drugs
- encourages patient’s participation
- prevents contamination
i. Remain with patient until each medication is swallowed
- only by physician’s order can medication be left at bedside
j. Record each medication given on medication chart – record refused
or omitted drugs, record
narcotic administration and any additional required forms
- prompt recording avoids possibility of accidentally repeating
administration
- verifies reason medication was omitted and ensure
physician is aware of patient’s
condition
k. Check patient within 30 minutes to verify his/her response to
medication

D. ADMINISTERING MEDICATIONS TO CHILDREN

- children younger than 5 yrs have difficulty swallowing tablets and
capsules
- in addition to understanding medication order and reason for
medication, caregiver should be able to
demonstrate any special techniques involved in administering
prescribed drugs
- use dropper for infants or very young children
- place medication between gum and cheek to prevent aspiration
- crush uncoated tablets or empty soft capsule and mix med with soft
food (potatoes, pudding, cooked
or hot cereal)
- proper absorption may not occur
- if med has objectionable taste, warn child
- failing to warn is likely to decrease child’s trust in nurse
- take care when selecting food – item should not be essential part of
child’s diet
- child may refuse food associated with meds
- offer child flavored ice pop or frozen fruit bar immediately before taking
meds
- numbs tongue, making take less evident
- praise child for job well done after administration

E. ADMINISTERING MEDICATIONS THROUGH ENTERAL FEEDING TUBE

 - use liquid meds or meds that can be crushed and combined with liquid
- bring liquid med to room temp
- remove clamp from tube, checking for tube placement before
administering drug
- flush tube with 15 – 30 mL water (5 – 10 mL for children) before giving
meds and immediately after
- give meds separately and flush with water between each drug
- disconnected from suction and clamped 20 – 30 minutes after
administration
- disconnect continuous tube feeding, leaving tube clamped for short
period of time
- document water intake and liquid med on I & O chart

F. ADMINISTERING INTRADERMAL INJECTION

- if necessary, withdraw med from ampule or vial
- select area on inner aspect of forearm that is not heavily pigmented or
covered with hair
- forearm is convenient and easy, hair or lesions may interfere with
assessments
- cleanse area using aseptic technique
- use nondominant hand to spread skin taut over injection site
- place needle almost flat against patient’s skin, bevel side up, and insert
needle into skin so that point
can be seen through skin (approx. 1/8”)
- inject agent while watching for small wheal or blister – if none, withdraw
needle slightly
- do not massage area
- assess patient for comfort
- chart administration as well as site of injection
- observe area for reaction at ordered intervals (usually 24- to 72-hours)
- aspiration is not recommended

G. ADMINISTERING SUBCUTANEOUS INJECTION

- if necessary, withdraw med from ampule or vial
- identify patient carefully
- have patient assume appropriate position: injection into tense extremity
causes discomfort
- outer aspect of upper arm = patient’s arm should be relaxed and
at body’s side
- anterior thighs = patient may sit or lie with leg relaxed
- abdomen = patient may lie in semirecumbent position
- ensure site of choice is not tender and is free of lumps or nodules
- clean area
- grasp and bunch area surrounding injection site or spread skin at site
- provides easy, less painful entry
- thin patients should have their skin bunched to create skin fold
- with dominant hand, inject needle at 45 - 90° angle with dart-like action
- after needle is in place, release tissue
- aspirate if recommended - if blood appears, withdraw needle
- do not aspirate when giving insulin or any form of heparin
 - massage area gently, except with heparin or insulin, apply small
bandage if necessary
- chart administration including injection site
- evaluate patient’s response within specified times

H. ADMINISTERING INTRAMUSCULAR INJECTION

- if necessary, withdraw med from ampule or vial
- do not add air to syringe
- identify patient carefully
- have patient assume appropriate position:
- ventrogluteal = patient may lie on back or side with hip and knee
flexed
- vastus lateralis = patient may lie on back or may assume sitting
position
- deltoid = patient may site or lie with arm relaxed
- dorsogluteal = patient may lie prone with toes pointing inward or
on side with upper leg
flexed and placed in front of lower leg
- ensure site is not tender and is free of lumps or nodules
- spread skin at site using nondominant hand
- quickly dart needle into tissue at 72- to 90° angle
- aspirate – if blood is present, discard needle, syringe, and med - -
prepare new sterile setup and
inject at another site
- gently apply pressure at site with small, dry sponge
- chart administration including injection site
- evaluate patient within appropriate time frame

I. EYE INSTILLATIONS AND IRRIGATIONS

- applications to eye seldom are placed directly onto eyeball
- applications intended to act on eye or lids are placed onto, or instilled or
irrigated into, lower
conjunctival sac
- sterile application

1. Eyedrops – instilled for local effects (pupil dilation or constriction when

examining, for treatment, or
controlling intraocular pressure for glaucoma)
- type and amt of solution depend on purpose of instillation
- hold dropper close to eye but avoid touching eyelids or lashes
- administer prescribed number of drops
- apply gentle pressure to inner canthus to prevent eyedrops from
flowing into tear duct
- instruct patient not to rub
- chart administration
- evaluate for response

2. Eye Irrigation
- have patient sit or lie with head tilted toward side of affected eye
 - clean from inner toward outer canthus to prevent debris entering
lacrimal ducts
- expose lower conjunctival sac, hold irrigator about 2.5 cm (1”)
from eye, direct flow from
inner to outer canthus
- irrigate until solution is clear or all of the solution has been used
- use only enough force to remove secretions gently
- avoid touching any part of eye
- dry area with cotton balls or gauze sponge
- chart irrigation, appearance of eye, drainage, and patient’s
response

J. ADMINISTERING SUBLINGUAL AND BUCCAL MEDICATIONS

sublingual – tablet is placed under patient’s tongue
buccal – medication is administered between the cheek and gum

- these areas are rich in superficial blood vessels, allowing relatively rapid
absorption into the
bloodstream for quick systemic effect
- should not be swallowed but rather held in place so that complete
absorption can occur

K. ADMINISTERING TOPICAL MEDICATIONS

topical – drug is applied directly to body site

- applied for direct action at particular site, although some systemic

effect may occur
- if application site is a cavity (nose) or is enclosed (eye), mechanical
applicator is needed to introduce
drug

inunction - ointment preparation is rubbed into skin for absorption

- cleaning skin thoroughly with soap or detergent to enhance
absorption
- when indicated, apply local heat to improve blood circulation and
promote absorption

L. RECTAL SUPPOSITORIES
suppository – conical or oval solid substance shaped for easy insertion
into body cavity and designed
to melt at body temperature

- functions include fecal softener (constipation), direct action on nerve

endings in rectal mucosa (weak
muscle tone or poor intervention), and carbon dioxide when
moistened (liberates gas,
distends, stimulates elimination impulses)
- have patient lie on either side and pie-fold top lines over him/her
- lubricate suppository and fingertips to reduce irritation
 - separate buttocks and have patient relax by breathing through mouth
during insertion
- introduce suppository well beyond internal sphincter (4” – adults, 2” –
children and infants)
- avoid embedding suppository in fecal mass
- correct placement is between stool and rectal mucosa
- be sure patient understand he/she is to retain suppository, usually 30 –
40 minutes after insertion