Medication Administration

Principles of Medication Administration

I. “Six Rights” of drug administration

1. The Right Medication – when administering medications, the nurse compares the label of the medication container with medication form.

The nurse does this 3 times:

1. Before removing the container from the drawer or shelf
2. As the amount of medication ordered is removed from the container
3. Before returning the container to the storage

2. Right Dose –when performing medication calculation or conversions, the nurse should have another qualified nurse check the calculated  dose

3. Right Client – an important step in administering medication safely is being sure the medication is given to the right client.

1. To identify the client correctly:
2. The nurse checks the medication administration form against the client’s identification bracelet and asks the client to state his or      her name to ensure the client’s identification bracelet has the correct information.

4. Right Route – if a prescriber’s order neither does nor designates a route of administration, the nurse consult the prescriber. Likewise, if the specified route is not recommended, the nurse should alert the prescriber immediately.

5. Right Time

1. The nurse must know why a medication is ordered for certain times of the day and whether the time schedule can be altered
2. Each institution has are commended time schedule for medications ordered at frequent interval
3. Medication that must act at certain times are given priority (e.g insulin should be given at a precise interval before a meal)

6. Right Documentation –Documentation is an important part of safe medication administration

1. The documentation for the medication should clearly reflect the client’s name, the name of the ordered medication, the time, dose, route and frequency
2. Sign medication sheet immediately after administration of the drug

Client’s Right Related to Medication Administration

A client has the following rights:

1. To be informed of the medication’s name, purpose, action, and potential undesired effects.
2. To refuse a medication regardless of the consequences
3. To have a qualified nurses or physicians assess medication history, including allergies
4. To be properly advised of the experimental nature of medication therapy and to give written consent for its use
5. To received labeled medications safely without discomfort in accordance with the six rights of medication administration
6. To receive appropriate supportive therapy in relation to medication therapy
7. To not receive unnecessary medications

II. Practice Asepsis

• Wash hand before and after preparing the medication to reduce transfer of microorganisms.

III. Nurse who administers the medications is responsible for their own action

• Question any order that you considered incorrect (may be unclear or appropriate)

IV. Be knowledgeable about the medication that you administer

• A fundamental rule of safe drug administration is: “Never administer an unfamiliar medication”

V. Keep the Narcotics in locked place

VI. Use only medications that are in clearly labeled containers. Relabeling of drugs is the responsibility of the pharmacist.

VII. Return liquid that is cloudy in color to the pharmacy.

VIII. Before administering medication, identify the client correctly

IX. Do not leave the medication at the bedside. Stay with the client until he actually takes the medications.

X. The nurse who prepares the drug administers it. Only the nurse prepares the drug knows what the drug is. Do not accept endorsement of medication.

XI. If the client vomits after taking the medication, report this to the nurse in charge or physician.

XII. Preoperative medications are usually discontinued during the postoperative period unless ordered to be continued.

XIII. When a medication is omitted for any reason, record the fact together with the reason.

XIV. When the medication error is made, report it immediately to the nurse in charge or physician

• To implement necessary measures immediately. This may prevent any adverse effects of the drug.

Oral Administration

Advantages

1. The easiest and most desirable way to administer medication
2. Most convenient
3. Safe, does nor break skin barrier
4. Usually less expensive

Disadvantages

1. Inappropriate if client cannot swallow and if GIT has reduced motility
2. Inappropriate for client with nausea and vomiting
3. Drug may have unpleasant taste
4. Drug may discolor the teeth
5. Drug may irritate the gastric mucosa
6. Drug may be aspirated by seriously ill patient.

Drug Forms for Oral Administration

1. Solid– tablet, capsule, pill, powder
2. Liquid– syrup, suspension, emulsion, elixir, milk, or other alkaline substances.
3. Syrup– sugar-based liquid medication
4. Suspension– water-based liquid medication. Shake bottle before use of medication to properly mix it.
5. Emulsion– oil-based liquid medication
6. Elixir– alcohol-based liquid medication. After administration of elixir, allow 30 minutes to elapse before giving water. This allows maximum absorption of the medication.

“Never crush Enteric-Coated or Sustained Release Tablet”

Sublingual Administration

• A drug that is placed under the tongue, where it dissolves.
• When the medication is in capsule and ordered sublingually, the fluid must be aspirated from the capsule and placed under the tongue.
• A medication given by the sublingual route should not be swallowed, or desire effects will not be achieved

Advantages

1. Same as oral
2. Drug is rapidly absorbed in the bloodstream

Disadvantages

1. If swallowed, drug may be inactivated by gastric juices.
2. Drug must remain under the tongue until dissolved and absorbed

Buccal Administration

• A medication is held in the mouth against the mucous membranes of the cheek until the drug dissolves.
• The medication should not be chewed, swallowed, or placed under the tongue (e.g sustained release nitroglycerine, opiates, antiemetic, tranquilizer, sedatives)
• Client should be taught to alternate the cheeks with each subsequent dose to avoid mucosal irritation

Advantages

1. Same as oral
2. Drug can be administered for local effect
3. Ensures greater potency because drug directly enters the blood and bypass the liver

Disadvantages

• If swallowed, drug may be inactivated by gastric juice

Topical Administration

• Application of medication to a circumscribed area of the body.

1. Dermatologic – includes lotions, liniment and ointments, powder.

1. Before application, clean the skin thoroughly by washing the area gently with soap and water, soaking an involved site, or locally debriding tissue.
2. Use surgical asepsis when open wound is present
3. Remove previous application before the next application
4. Use gloves when applying the medication over a large surface. (e.g. large area of burns)
5. Apply only thin layer of medication to prevent systemic absorption.

2. Ophthalmic – includes instillation and irrigation

1. Instillation – to provide an eye medication that the client requires.
2. Irrigation – To clear the eye of noxious or other foreign materials.
3. Position the client either sitting or lying.
4. Use sterile technique
5. Clean the eyelid and eyelashes with sterile cotton balls moistened with sterile normal saline from the inner to the outer canthus
6. Instill eye drops into lower conjunctival sac.
7. Instill a maximum of 2 drops at a time. Wait for 5 minutes if additional drops need to be administered. This is for proper absorption of the     medication.
8. Avoid dropping a solution onto the cornea directly, because it causes discomfort.
9. Instruct the client to close the eyes gently. Shutting the eyes tightly causes spillage of the medication.
10. For liquid eye medication, press firmly on the nasolacrimal duct (inner cantus) for at least 30 seconds to prevent systemic absorption of    the medication.

3. Otic Instillation – to remove cerumen or pus or to remove foreign body

1. Straighten the ear canal:
2. Perform hand hygiene. Apply gloves if drainage is present.
3. Have the client assume a side-lying position (if not contraindicated) with ear to be treated facing up.
4. Warm the solution at room temperature or body temperature, failure to do so may cause vertigo, dizziness, nausea and pain.
   • 0-3 years old: pull the pinna downward and backward
   • Older than 3 years old: pull the pinna upward and backward
5. Instill eardrops on the side of the auditory canal to allow the drops to flow in and continue to adjust to body temperature
6. Press gently bur firmly a few times on the tragus of the ear to assist the flow of medication into the ear canal.
7. Ask the client to remain in side lying position for about 5 minutes
8. At times the MD will order insertion of cotton puff into outermost part of the canal. Do not press cotton into the canal. Remove cotton after 15 minutes.

4. Nasal – Nasal instillations usually are instilled for their astringent effects (to shrink swollen mucous membrane), to loosen secretions and facilitate drainage or to treat infections of the nasal cavity or sinuses. Decongestants, steroids, calcitonin.

1. Have the client blow the nose prior to nasal instillation
2. Assume a back lying position, or sit up and lean head back.
3. Elevate the nares slightly by pressing the thumb against the client’s tip of the nose. While the client inhales, squeeze the bottle.
4. Keep head tilted backward for 5 minutes after instillation of nasal drops.
5. When the medication is used on a daily basis, alternate nares to prevent irritations

5. Inhalation – use of nebulizer, metered-dose inhaler

1. Semi or high-fowler’s position or standing position. To enhance full chest expansion allowing deeper inhalation of the medication
2. Shake the canister several times. To mix the medication and ensure uniform dosage delivery
3. Position the mouthpiece 1 to 2 inches from the client’s open mouth. As the client starts inhaling, press the canister down to release one dose of the medication. This allows delivery of the medication more accurately into the bronchial tree rather than being trapped in the oropharynx then swallowed
4. Instruct the client to hold breath for 10 seconds to enhance complete absorption of the medication.
5. If bronchodilator, administer a maximum of 2 puffs, for at least 30 second interval. Administer bronchodilator before other inhaled medication. This opens airway and promotes greater absorption of the medication.
6. Wait at least 1 minute before administration of the second dose or inhalation of a different medication by MDI
7. Instruct client to rinse mouth, if steroid had been administered. This is to prevent fungal infection.

6. Vaginal – drug forms: tablet liquid (douches), jelly, foam and suppository.

1. Close room or curtain to provide privacy.
2. Assist client to lie in dorsal recumbent position to provide easy access and good exposure of vaginal canal, also allows suppository     to dissolve without escaping through orifice.
3. Use applicator or sterile gloves for vaginal administration of medications.

• Vaginal Irrigation – is the washing of the vagina by a liquid at low pressure. It is also called douche.
  1.  Empty the bladder before the procedure
  2. Position the client on her back with the hips higher than the shoulder (use bedpan)
  3. Irrigating container should be 30 cm (12 inches) above
  4. Ask the client to remain in bed for 5-10 minute following administration of vaginal suppository, cream, foam, jelly or irrigation

Rectal Administration

• Can be use when the drug has objectionable taste or odor.

1. Need to be refrigerated so as not to soften.
2. Apply disposable gloves.
3. Have the client lie on left side and ask to take slow deep breaths through mouth and relax anal sphincter.
4. Retract buttocks gently through the anus, past internal sphincter and against rectal wall, 10 cm (4 inches) in adults, 5 cm (2 in) in children and infants. May need to apply gentle pressure to hold buttocks together momentarily.
5. Discard gloves to proper receptacle and perform hand washing.
6. Client must remain on side for 20 minute after insertion to promote adequate absorption of the medication.

Parenteral Administration

• Administration of medication by needle.

Intradermal – under the epidermis.

1. The site are the inner lower arm, upper chest and back, and beneath the scapula.
2. Indicated for allergy and tuberculin testing and for vaccinations.
3. Use the needle gauge 25, 26, 27: needle length 3/8”, 5/8” or ½”
4. Needle at 10–15 degree angle; bevel up.
5. Inject a small amount of drug slowly over 3 to 5 seconds to form a wheal or bleb.
6. Do not massage the site of injection. To prevent irritation of the site, and to prevent absorption of the drug into the subcutaneous.

Subcutaneous– Vaccines, heparin, preoperative medication, insulin, narcotics.

Sites:

• outer aspect of the upper arms
• anterior aspect of the thighs
• Abdomen
• Scapular areas of the upper back
• Ventrogluteal
• Dorsogluteal

1. Only small doses of medication should be injected via SC route.
2. Rotate site of injection to minimize tissue damage.
3. Needle length and gauge are the same as for ID injections

• Use 5/8 needle for adults when the injection is to administer at 45 degree angle; ½ is use at a 90 degree angle.

1. For thin patients: 45 degree angle of needle
2. For obese patient: 90 degree angle of needle
3. For heparin injection: do not aspirate.
4. Do not massage the injection site to prevent hematoma formation
5. For insulin injection: Do not massage to prevent rapid absorption which may result to hypoglycemic reaction.
6. Always inject insulin at 90 degrees angle to administer the medication in the pocket between the subcutaneous and muscle layer. Adjust the length of the needle depending on the size of the client.
7. For other medications, aspirate before injection of medication to check if the blood vessel had been hit. If blood appears on pulling back of the plunger of the syringe, remove the needle and discard the medication and equipment.

Intramuscular

• Needle length is 1”, 1 ½”, 2” to reach the muscle layer
• Clean the injection site with alcoholized cotton ball to reduce microorganisms in the area.
• Inject the medication slowly to allow the tissue to accommodate volume.

Sites:

1. Ventrogluteal site

1. The area contains no large nerves, or blood vessels and less fat. It is farther from the rectal area, so it less contaminated.
2. Position the client in prone or side-lying.
3. When in prone position, curl the toes inward.
4. When side-lying position, flex the knee and hip. These ensure relaxation of gluteus muscles and minimize discomfort during injection.
5. To locate the site, place the heel of the hand over the greater trochanter, point the index finger toward the anterior superior iliac spine, and then abduct the middle (third) finger. The triangle formed by the index finger, the third finger and the crest of the ilium is the site.

2. Dorsogluteal site

1. Position the client similar to the ventrogluteal site
2. The site should not be use in infant under 3 years because the gluteal muscles are not well developed yet.
3. To locate the site, the nurse draw an imaginary line from the greater
4. trochanter to the posterior superior iliac spine. The injection site id lateral and superior to this line.
5. Another method of locating this site is to imaginary divide the buttock into four quadrants. The upper most quadrant is the site of injection. Palpate the crest of the ilium to ensure that the site is high enough.
6. Avoid hitting the sciatic nerve, major blood vessel or bone by locating the site properly.

3. Vastus Lateralis

1. Recommended site of injection for infant
2. Located at the middle third of the anterior lateral aspect of the thigh.
3. Assume back-lying or sitting position.

4. Rectus femoris site –located at the middle third, anterior aspect of thigh.

5. Deltoid site

1. Not used often for IM injection because it is relatively small muscle and is very close to the radial nerve and radial artery.
2. To locate the site, palpate the lower edge of the acromion process and the midpoint on the lateral aspect of the arm that is in line with the axilla. This is approximately 5 cm (2 in) or 2 to 3 fingerbreadths below the acromion process.

* IM injection – Z tract injection

1. Used for parenteral iron preparation. To seal the drug deep into the muscles and prevent permanent staining of the skin.
2. Retract the skin laterally, inject the medication slowly. Hold retraction of skin until the needle is withdrawn
3. Do not massage the site of injection to prevent leakage into the subcutaneous.

Intravenous

• The nurse administers medication intravenously by the following method:
  1. As mixture within large volumes of IV fluids.
  2. By injection of a bolus, or small volume, or medication through an existing intravenous infusion line or intermittent venous access (heparin or saline lock)
  3. By “piggyback” infusion of solution containing the prescribed medication and a small volume of IV fluid through an existing IV line.
• Most rapid route of absorption of medications.
• Predictable, therapeutic blood levels of medication can be obtained.
• The route can be used for clients with compromised gastrointestinal function or peripheral circulation.
• Large dose of medications can be administered by this route.
• The nurse must closely observe the client for symptoms of adverse reactions.
• The nurse should double-check the six rights of safe medication.
• If the medication has an antidote, it must be available during administration.
• When administering potent medications, the nurse assesses vital signs before, during and after infusion.

Nursing Interventions in IV Infusion

1. Verify the doctor’s order
2. Know the type, amount, and indication of IV therapy.
3. Practice strict asepsis.
4. Inform the client and explain the purpose of IV therapy to alleviate client’s anxiety.
5. Prime IV tubing to expel air. This will prevent air embolism.
6. Clean the insertion site of IV needle from center to the periphery with alcoholized cotton ball to prevent infection.
7. Shave the area of needle insertion if hairy.
8. Change the IV tubing every 72 hours. To prevent contamination.
9. Change IV needle insertion site every 72 hours to prevent thrombophlebitis.
10. Regulate IV every 15-20 minutes. To ensure administration of proper volume of IV fluid as ordered.
11. Observe for potential complications.

Types of IV Fluids

1. Isotonic solution – has the same concentration as the body fluid
   • D5 W
   • Na Cl 0.9%
   • Plain Ringer’s lactate
   • Plain Normosol M
2. Hypotonic – has lower concentration than the body fluids.
   • NaCl 0.3%
3. Hypertonic – has higher concentration than the body fluids.
   • D10W
   • D50W
   • D5LR
   • D5NM

Complication of IV Infusion

1. Infiltration – the needle is out of nein, and fluids accumulate in the subcutaneous tissues.

Assessment:

• Pain, swelling, skin is cold at needle site; pallor of the site, flow rate has decreases or stops.

Nursing Intervention:

• Change the site of needle
• Apply warm compress. This will absorb edema fluids and reduce swelling.

2. Circulatory Overload – Results from administration of excessive volume of IV fluids.

Assessment:

• Headache
• Flushed skin
• Rapid pulse
• Increase BP
• Weight gain
• Syncope and faintness
• Pulmonary edema
• Increase volume pressure
• SOB (shortness of breath)
• Coughing
• Tachypnea
• Shock

Nursing Interventions:

• Slow infusion to KVO
• Place patient in high fowler’s position. To enhance breathing
• Administer diuretic, bronchodilator as ordered

3. Drug Overload – the patient receives an excessive amount of fluid containing drugs.

Assessment:

• Dizziness
• Shock
• Fainting

Nursing Intervention:

• Slow infusion to KVO.
• Take vital signs
• Notify physician

4. Superficial Thrombophlebitis – it is due to o0veruse of a vein, irritating solution or drugs, clot formation, large bore catheters.

Assessment:

• Pain along the course of vein
• Vein may feel hard and cordlike
• Edema and redness at needle insertion site.
• Arm feels warmer than the other arm

Nursing Intervention:

• Change IV site every 72 hours
• Use large veins for irritating fluids.
• Stabilize venipuncture at area of flexion.
• Apply cold compress immediately to relieve pain and inflammation; later with warm compress to stimulate circulation and promotion absorption.
• “Do not irrigate the IV because this could push clot into the systemic circulation’

5. Air Embolism – Air manages to get into the circulatory system; 5 ml of air or more causes air embolism.

Assessment:

• Chest, shoulder, or back pain
• Hypotension
• Dyspnea
• Cyanosis
• Tachycardia
• Increase venous pressure
• Loss of consciousness

Nursing Intervention

• Do not allow IV bottle to “run dry”
• “Prime” IV tubing before starting infusion.
• Turn patient to left side in the trendelenburg position. To allow air to rise in the right side of the heart. This prevent pulmonary embolism.

6. Nerve Damage – may result from tying the arm too tightly to the splint.

Assessment

• Numbness of fingers and hands

Nursing Interventions

• Massage the are and move shoulder through its ROM
• Instruct the patient to open and close hand several times each hour.
• Physical therapy may be required

Note: apply splint with the fingers free to move.

7. Speed Shock – may result from administration of IV push medication rapidly.

• To avoid speed shock, and possible cardiac arrest, give most IV push medication over 3 to 5 minutes.

General Principles of Parenteral Administration

1. Check doctor’s order.
2. Check the expiration for medication – drug potency may increase or decrease if outdated.
3. Observe verbal and non-verbal responses toward receiving injection. Injection can be painful; client may have anxiety, which can increase the pain.
4. Practice asepsis to prevent infection. Apply disposable gloves.
5. Use appropriate needle size to minimize tissue injury.
6. Plot the site of injection properly to prevent hitting nerves, blood vessels, and bones.
7. Use separate needles for aspiration and injection of medications to prevent tissue irritation.
8. Introduce air into the vial before aspiration. To create a positive pressure with in the vial and allow easy withdrawal of the medication.
9. Allow a small air bubble (0.2 ml) in the syringe to push the medication that may remain.
10. Introduce the needle in quick thrust to lessen discomfort.
11. Either spread or pinch muscle when introducing the medication. Depending on the size of the client.
12. Minimized discomfort by applying cold compress over the injection site before introduction of medicati0n to numb nerve endings.
13. Aspirate before the introduction of medication. To check if blood vessel had been hit.
14. Support the tissue with cotton swabs before withdrawal of needle. To prevent discomfort of pulling tissues as needle is withdrawn.
15. Massage the site of injection to haste absorption.
16. Apply pressure at the site for few minutes. To prevent bleeding.
17. Evaluate effectiveness of the procedure and make relevant documentation.