Non-Parenteral Medications

Medication standards of safety

Legislation and pharmacological concepts

Legislation

FDA regulations, state and local regulations, health care organizations/institutions, professional organizations

FDA regulations

All medications on the market undergo vigorous testing for safety

State and local regulations

Additional controls, including alcohol and tobacco

Healthcare organizations/institutions

Policies and procedures on medication administration

Professional organizations

Defining the scope of practice for nurses

Pharmacological concepts

Medication names, classification, forms, medication actions

Medication names

Chemical vs. generic vs. proprietary

Medication classification

Effect on body system, symptoms it relieves, desired effect

Medication route in body

Absorption, distribution, metabolism, excretion

Medication forms

Solid, liquid, powder, ointment, cream, paste, powder, patch, gum, suppository, parenteral

Medication actions

Therapeutic effect, adverse effect, side effect, toxic effect, idiosyncratic effect, allergic reactions, interactions, tolerance, dependence

Therapeutic effect

Expected or predicted physiological effect

Adverse effect

Undesired, unpredicted & unpredictable responses

Side effects

Predictable and unavoidable effects

Toxic effects

Impaired metabolism or excretion

Idiosyncratic effects

Under/overreaction

Allergic reactions

Unpredictable immune response

Medication interactions

When one medication modifies the action of another (antidote vs. synergistic effect)

Medication tolerance

Body's decreased response to a medication after prolonged use

Medication dependence

When a person experiences withdrawal symptoms when a medication is stopped abruptly

Routes of drug administration

Enteral, topical, inhalations, parenteral, other routes

Enteral routes

Oral, sublingual, buccal, NG tube, orogastric tube, gastrostomy tube, jejunostomy tube, rectal

Topical routes

Skin preps, transdermal patches, mucous membranes

Inhalation routes

Aerosol therapy, metered dose inhalers

Parenteral

Intradermal, subcutaneous, intramuscular, intravenous

Other routes

Intrathecal, epidural, intraperitoneal, intrapleural, intraosseous

Prescribers

NPs, physicians, physician’s assistants, nurses do not prescribe

Orders

Written (hand or electronic), verbal, telephone

Types of HCP orders

Standing/routine, PRN, single, now, STAT, prescriptions

Standing/routine orders

Administered until dosage is changed or another med is prescribed

PRN orders

Given when patient requires it

Single (one-time) orders

Given one time only for a specific reason

STAT orders

Given immediately in an emergency

Now orders

When a medication is needed right away, but not STAT

Prescription orders

Medications to be taken outside of the hospital

Seven rights of medication

Right medication, dose, patient, route, time, documentation, reason

Right documentation (5 W’s)

When, why, what, where, was

Safety for all meds

Two patient identifiers, check allergies and 7 rights, avoid distractions, use clinical judgement, right assessment, right evaluation

Nursing diagnoses

Impaired health maintenance, knowledge deficit related to medication, non adherence to medication regimen, adverse reaction or adverse interaction, complex medication regimen (Polypharmacy)

Oral, sublingual, and buccal route

Easiest and most desirable route, taken with fluid, food sometimes affects absorption

Buccal medication administration

Placed between the cheek and the gum

Sublingual medication administration

Placed under the tongue

Topical medication application

Use gloves and applicators, clean skin first, use sterile technique if the patient has an open wound, apply evenly, cover as ordered

Transdermal patch medication administration

Remove old patch before applying new, wash skin, document location of new patch, apply a label to patch if it is difficult to see, write date/time of placement, document removal of patch

Types of topical medications

Creams, ointments, pastes, lotions, transdermal patches

Small-bore feed medication administration

Verify tube location is compatible with medication absorption, use elixirs/liquid when possible, crush/dissolve other tablets, DO NOT open extended release capsules, 30ml water flush before and after, prepare each med in separate cup, if medication is to be given on empty stomach, allow 30 minutes before or after feeding, risk of drug-drug interactions is higher

Types of inhalation medication administration

Metered dose inhalers, dry powder inhalers

Ophthalmic medication administration

Wash hands/wear gloves, let drops warm up to room temperature, position patient semi fowlers or supine, clean eyelid margins as needed, roll bottle between palms, do not lay cap down, drop into conjunctival sac

Ear medication instillation

Instill at room temperature, use sterile solutions, check for eardrum rupture if patient has ear drainage, never occlude ear canal with dropper or syringe, instill 1cm above ear canal, apply gentle massage to tragus, remain side lying for 2 min, document drainage or pain

Rectal instillation medication instillation

Place on anal-rectal ridge so body can absorb

Preparing an injection from an ampule

Snap off ampule “neck” with an alcohol pad, aspirate medication into syringe using filter needle, replace filter needle with appropriate size needle, administer injection

Preparing an injection from a vial (closed system)

If dry, reconstitute with solvent or diluent as needed, calculate correct volume to withdraw, remove cap, pull back plunger to fill with air (same as medication amount), push needle tip into cap, inject air into vial, invert vial and allow air pressure to fill syringe gradually, tap barrel to get rid of bubbles once needed amount is reached (eject remaining air into vial if needed), cover needle with safety sheath or cap

Intradermal route

Medicine introduced in the dermis, 10-15 degree angle, <0.5 ml, forms a bleb or wheal, used for TB or allergy testing

Subcutaneous route

Medicine administered to the fat, 45-90 degree angle, 1 ml max, give slowly

Intramuscular injection sites

Deltoid, ventrogluteal, vastus lateralis, dorsogluteal

Z-track method

Prevents medication from tracking back along needle path

Intramuscular injections

Identify appropriate landmarks, cleanse area with alcohol swab, make skin taunt with nondominant hand, inject at appropriate angle with dominant hand, aspirate (not for immunizations), continue with injection, remove needle, activate needle safety, apply bandage, document

Medication safety

Keep narcotics locked in place, return cloudy liquids to pharmacy, nurse who prepares med administers it, do not leave medication at the bedside, prepare medications for one patient at a time, do not label meds by patient room or bed number

Sharps safety

Never recap used needles, dispose of sharps in marked containers, use puncture- and leak-proof containers, never force needles into receptacle or place used needles into wastebaskets, pockets, or patient’s tray or bedside

Medication errors

Report all errors, patient safety is top priority, documentation required, nurse is responsible for preparing a written occurrence or incident report (accurate, factual description of what occurred and what was done)

Nurse’s role in medication administration

Determining if medications ordered are correct, assessing patient’s ability to self-administer, determining if patient should receive medications at a given time, administering medications correctly, closely monitoring effects and side effects, communication with healthcare team/advocacy, cannot be delegated, includes patient/family teaching