ADMINISTRATIONS OF MEDICATIONS

ADMINISTRATIONS OF MEDICATIONS

Drugs given for therapeutic purposes are called medications. Giving medications to clients is an important nursing responsibility in many health care settings, including ambulatory care, hospitals, long-term care facilities, and clients’ homes.

The basic requirements for accurate drug administration are often called the “Nine rights”: When one of these rights is violated, medication errors can occur. Nurses need to recognize circumstances in which errors are likely to occur and intervene to prevent errors and protect clients. This chapter is concerned with safe and accurate medication administration.

GENERAL PRINCIPLES OF DRUG ADMINISTRATION

1.      Avoids distraction and interruption when preparing and administering the medication to prevent medication error.

2.      Verifies order in the patient's medical record by checking it against the doctor’s order.

3.      Chooses equipment appropriate to the prescribed medication, and make sure it works properly.

4.      Compares medication label with the order in the patient’s medical record.

5.      Checks the patient’s medical record for an allergy or contraindication to the prescribed medication. If an allergy or a contraindication exists, don’t administer the medication; instead, notify the doctor.

6.      The checks expiration date on the medication. If the medication is expired, return it to the pharmacy and obtain new medication.

7.      Visually inspects prescribed medication for particles, discoloration, or other loss of integrity; don’t administer the medication if its integrity is compromised. (Remember that for some drugs (such as suspensions), the presence of drug particles is normal. If in doubt check with the pharmacist and the manufacturer’s instruction).

8.      Discusses, any unresolved concerns about the medication with the patient’s doctor.

9.      Performs hand hygiene.

10.    Put on the gloves.

11.    Confirms the patient’s identity as per policy.

12.    If the patient is receiving the medication for the first time, teach patients about potential adverse reactions and discuss any other concerns related to the medication.

13.    Verifies medication is being administered at the proper time, in the prescribed dose, and by the correct route to reduce the risk of medication errors.

14.    If your facility uses a bar code scanning system, scan your identification badge, the patient’s identification badge bracelet, and the medications bar code.

        15.  Performs hand hygiene.

DRUG DOSE FORMS

Dosage Forms and Their Routes of Administration	Characteristics	Considerations/Precautions
Tablets
Regular: PO, GI tube (crushed and mixed with water) Chewable: PO	• Contain active drug plus binders, dyes, preservatives • Dissolve in gastric fluids Colorful and flavored, mainly for young children who are unable to swallow or who refuse regular tablets	8 oz of water recommended when taken orally, to promote dissolution and absorption Colors and flavors appeal to children; keep out of reach to avoid accidental overdose.
Enteric coated: PO	Dissolve in small intestine rather than stomach; mainly used for medications that cause gastric irritation	Do not crush; instruct clients not to chew or crush
Extended-release (XL): PO	• Also called sustained release (SR), long-acting (LA), and others • Formulated for slow absorption and prolonged action • Effects of most last 12–24 hours • Contain relatively large doses of active drug	Warning: Crushing to give orally or through a GI tube administers an overdose, with potentially serious adverse effects or death!! Never crush; instruct clients not to chew or crush
Sublingual: Under the tongue Buccal: Held in cheek	• Dissolve quickly • Medication absorbed directly into the bloodstream and exerts rapid systemic effects	Few medications formulated for administration by these routes
Capsules
Regular: PO	• Contain active drug, fillers, and preservatives in a gelatin capsule • Gelatin capsules dissolve in gastric fluid and release medication	As with oral tablets, 8 oz of fluid recommended promoting dissolution of capsule and absorption of medication
Extended-release (XL): PO	• Also called sustained release (SR), long-acting (LA), and others • Formulated for slow absorption and prolonged action • Effects of most last 12–24 hours • Contain relatively large doses of active drug	Warning: Emptying a capsule to give the medication orally or through a GI tube administers an overdose, with potentially serious adverse effects or death!! Instruct clients not to bite, chew or empty these capsules.
Solutions
Oral: PO, GI tube	• Absorbed rapidly because of they do not need to be dissolved	Use of appropriate measuring devices and accurate measurement are extremely important.
Parenteral: IV, IM SC, intradermal	• Medications and all administration devices must be sterile • IV produces rapid effects; SC is used mainly for insulin and heparin; IM is used for only a few drugs; intradermal is used mainly to inject skin test material rather than therapeutic drugs.	Use of appropriate equipment (eg, needles, syringes, IV administration sets) and accurate measurement is extremely important. Insulin syringes should always be used for insulin and tuberculin syringes are recommended for measuring small amounts of other drugs.
Suspensions
PO, SC (NPH and Lente insulins)	• These are particles of active drug suspended in a liquid; the liquid must be rotated or shaken before measuring a dose.	Drug particles settle to the bottom on standing. If not remixed, the liquid vehicle is given rather than the drug dose.
Dermatologic Creams, Lotions, Ointments
Topically to skin	• Most are formulated for minimal absorption through the skin and local effects at the site of application; medications in skin patch formulations are absorbed and exert systemically effects.	Formulations vary with intended uses and are not interchangeable. When removed from the client, skin patches must be disposed of properly to prevent someone else from being exposed to the active drug remaining in the patch.
Solutions and Powders for Oral or Nasal Inhalation, Including Metered Dose Inhalers (MDIs)	• Oral inhalations are used mainly for asthma; nasal sprays for nasal allergies (allergic rhinitis) • Effective with less systemic effect than oral drugs • Deliver a specified dose per inhalation	Several research studies indicate that patients often do not use MDIs correctly and sometimes are incorrectly taught by health care providers. Correct use is essential to obtaining therapeutic effects and avoiding adverse effects.
Eye Solutions and Ointments	• Should be sterile • Most are packaged in small amounts, to be used by a single patient	Can be systemically absorbed and cause systemic adverse effects
Vaginal Creams and Suppositories	• Used for cough and sore throat	Effects somewhat unpredictable because absorption is erratic
Rectal Suppositories and Enemas	• Used mainly for ear infections	Effects somewhat unpredictable because absorption is erratic

 Common Abbreviations 

Routes of Drug Administration
IM	intramuscular
IV	intravenous
OD	right eye*
OS	left eye*
OU	both eyes*
PO	by mouth, oral
SC	subcutaneous
SL	sublingual
Drug Dosages
cc	cc
g	g
gr	gr
gt	gt
mg	mg
mL	mL
oz	oz
tbsp	tbsp
tsp	tsp
Times of Drug Administration
ac	before meals
ad lib	as desired
bid	twice daily
hs	bedtime
pc	after meals
PRN	when needed
qd	every day, daily
q4h	every four hours
qid	four times daily
qod	every other day
stat	immediately
tid	three times daily

*Because of errors made with the abbreviations, some authorities recommend spelling out the site (eg, right eye). †drops = gtt.

Equivalents 

Metric                                        Apothecary                       Household

1 mL = 1 cc                          = 15 or 16 minims              = 15 or 16 drops 

4 or 5 mL                              =  1 fluid dram                   = 1 tsp 

60 or 65 mg                          = 1 gr 

30 or 32 mg                          = 1/2 gr 

30 g = 30 mL                        = 1 oz                                = 2 tbsp 

250 mL                                 = 8 oz = 1 cup 

454 g                                     = 1 lb 500 mL = 

500 cc                                    = 16 oz                             = 1 pint 

1 L = 1000 mL                      = 32 oz                             = 1 quart 

1000 mcg*                            = 1 mg 

1000 mg                                = 1 g 

1000 g = 1 kg                        = 2.2 lb                            = 2.2 lb

 0.6 g = 600 mg or 650 mg   = 10 gr

*mcg = microgram.

Sites for Injections

Common sites for subcutaneous injections are the

  Upper arms

  Abdomen

  Back

  Thigh

Sites for intramuscular injections are the

   Deltoid

  Dorsogluteal

  Ventrogluteal

  vastus lateralis

Common sites for intravenous injections are the veins subclavian and jugular veins used (mainly in critically ill clients) 

Additional parenteral routes include injection into layers of the skin

   Intradermal

  Arteries (intra-arterial),

  Joints (intraarticular), and

  Cerebrospinal fluid (intrathecal). 

Nursing Action	Rationale
For oral medications:
Adults
To give tablets or capsules, open the unit-dose wrapper, place the medication in a medicine cup, and give the cup to the client. For solutions, hold the cup at eye level, and measure the dosage at the bottom of the meniscus. For suspensions, shake or invert containers to mix the medication before measuring the dose.	To maintain a clean technique and measure doses accurately. Suspensions settle on standing, and if not mixed, the diluent may be given rather than the active drug.
Have the client in a sitting position when not contraindicated.	To decrease risks of aspirating medication into the lungs. Aspiration may lead to difficulty in breathing.
Give before, with, or after meals as indicated by the specific drug	Food in the stomach usually delays drug absorption and action.
Give most oral drugs with a full glass (8 oz.) of water.	To promote dissolution and absorption of tablets and capsules.
Children	Children under 5 years of age are often unable to swallow tablets or capsules.
Measure and give liquids to infants with a dropper or syringe slowly.	Giving slowly decreases risks of aspiration.
Medications are often mixed with juice, applesauce.	To increase the child’s ability to take the medication.
Do not give oral drugs if the client is: NPO	Oral drugs and fluids may interfere with diagnostic tests or be otherwise contraindicated.
Vomiting	Oral drugs and fluids increase vomiting. Thus, no benefit results from the drug.
Excessively sedated or unconscious	To avoid aspiration of drugs into the lungs.
For medications given by nasogastric tube: Use a liquid preparation when possible. If necessary, crush a tablet or empty a capsule into about 30 mL of water and mix well Use a clean bulb syringe Before instilling the medication, aspirate gastric fluid. Clamp off the tube from suction or drainage for at least 30 minutes.	Particles of tablets or powders from capsules may obstruct the tube lumen. The syringe allows aspiration and serves as a funnel for installation of medication To be sure the tube is in the stomach To avoid removing the medication from the stomach
For subcutaneous (SC) injections: Use only sterile drug preparations labeled or commonly used for SC injections. Use a 25-gauge, 5⁄8-inch needle for most SC injections.  Select an appropriate injection site, based on client preferences, drug characteristics, and visual inspection of possible sites. In long-term therapy, such as with insulin, rotate injection sites. Avoid areas with lumps, bruises, or other lesions. Cleanse the site with an alcohol sponge. Tighten the skin or pinch a fold of skin and tissue between thumb and fingers. Hold the syringe like a pencil, and insert the needle quickly at a 45-degree angle. Release the skin so that both hands are free to manipulate the syringe. Pull back gently on the plunger. If no blood enters the syringe, inject the drug. If blood is aspirated into the syringe, remove the needle, and reprepare the medication. Remove the needle quickly and apply gentle pressure for a few seconds	Many parenteral drugs are too irritating to subcutaneous tissue for use by this route. This size needle is effective for most clients and drugs. Increase client comfort and cooperation To prevent infection If the client is obese, tightening the skin may be easier. If the client is very thin, the tissue fold may keep the needle from hitting bone. To give the drug correctly with minimal client discomfort To prevent accidental injection into the bloodstream.
For intramuscular (IM) injections: Use only drug preparations labeled or commonly used for IM injections. Check label instructions for mixing drugs in powder form. Use an 11⁄2-inch needle for most adults and a 5⁄8- to the 11⁄2-inch needle for children, depending on the size of the client. Use the smallest-gauge needle that will accommodate the medication. A 22-gauge is satisfactory for most drugs; a 20-gauge may be used for viscous medications. Select an appropriate injection site, based on client preferences, drug characteristics, anatomic landmarks, and visual inspection of possible sites. Cleanse the site with an alcohol sponge. Tighten the skin, hold the syringe like a pencil and insert the needle quickly at a 90-degree angle. Aspirate. Remove the needle quickly and apply pressure for several seconds.	Some parenteral drug preparations cannot be given safely by the IM route. A long needle is necessary to reach muscle tissue, which underlies subcutaneous fat. To decrease tissue damage and client discomfort To increase client comfort and participation and to avoid tissue damage. To prevent infection To give the drug correctly with minimal client discomfort To prevent bleeding
For intravenous (IV) injections: Use only drug preparations that are labeled for IV use. Check label instructions for the type and amount of fluid to use for dissolving or diluting the drug. Prepare drugs just before use, as a general rule. For venipuncture and direct injection into a vein, apply a tourniquet, select a site in the arm, cleanse the skin with an antiseptic, insert the needle, and aspirate a small amount of blood into the syringe to be sure that the needle is in the vein. Remove the tourniquet, and inject the drug slowly. Remove the needle and apply pressure until there is no evidence of bleeding For administration by an established IV line: Check the infusion for patency and flow rate. Check the venipuncture site for signs of infiltration and phlebitis before each drug dose. For direct injection, cleanse an injection site on the IV tubing, insert the needle, and inject the drug slowly. To use a volume-control set, fill it with 50–100 mL of IV fluid, and clamp it so that no further fluid enters the chamber and dilutes the drug. Inject the drug into an injection site after cleansing the site with an alcohol sponge and infuse, usually in 1 hour or less. Once the drug is infused, add the solution to maintain the infusion. To use a “piggyback” method, add the drug to 50–100 mL of IV solution in a separate container. Attach the IV tubing and a needle. Insert the needle in an injection site on the main IV tubing after cleansing the site. Infuse the drug over 15–60 minutes, depending on the drug. When more than one drug is to be given, flush the line between drugs. Do not mix drugs in syringes or in IV fluids unless the drug literature states that the drugs are compatible.	Others are not pure enough for safe injection into the bloodstream or are not compatible with the blood Ph. Some drugs require special preparation. Some drugs are unstable in solution. For safe and accurate drug administration with minimal risk to the client. The solution must be flowing freely for accurate drug administration. Most of the tubings have injection sites to facilitate drug administration. This method is used for the administration of antibiotics on an intermittent schedule. Dilution of the drug decreases adverse effects. This the method is also used for intermittent administration of antibiotics and other drugs. Physical and chemical interactions between the drugs may occur and cause precipitation, inactivation, or increased toxicity.
For application to skin: Use drug preparations labeled for dermatologic use. Cleanse the skin, remove any previously applied medication, and apply the drug in a thin layer. For broken skin or open lesions, use sterile gloves, tongue blade, or cotton-tipped applicator to apply the drug.	To promote therapeutic effects and minimize adverse effects
For instillation of eye drops: Use drug preparations labeled for ophthalmic use. Wash your hands, open the eye to expose the conjunctival sac, and drop the medication into the sac, not on the eyeball, without touching the dropper tip to anything. Provide a tissue for blotting any excess drug. If two or more eye drops are scheduled at the same time, wait for 1–5 minutes between instillations. With children, prepare the medication, place the child in a head-lowered position, steady the hand holding the medication on the child’s head, gently retract the lower lid, and instill the medication into the conjunctival sac.	Careful positioning to avoid sudden movements are necessary to decrease risks of injury to the eye.
For installation of nose drops and nasal sprays: Have the client holds his or her head back, and drop the medication into the nostrils. Give only as ordered With children, place in a supine position with the head lowered, instill the medication, and maintain the position for 2–3 minutes. Then, place the child in a prone position.	When nose drops are used for rhinitis and nasal congestion.
For installation of ear medications: Open the ear canal by pulling the ear up and back for adults, down and back for children, and drop the medication on the side of the canal.	To straighten the canal and promote maximal contact between medication and tissue
For rectal suppositories: Lubricate the end with a water-soluble lubricant, wear a glove or finger cot, and insert into the rectum the length of the finger. Place the suppository next to the mucosal wall. If the client prefers and is able, provide supplies for self-administration.	To promote absorption. Allowing self-administration may prevent embarrassment to the client. Be sure the client knows the correct procedure.
For vaginal medications: Use gloves or an applicator for insertion. If an applicator is used, wash thoroughly with soap and water after each use. If the client prefers and is able, provide supplies for self-administration.	Some women may be embarrassed and prefer self-administration. Be sure the client knows the correct procedure.