Medication Administration
Chapter 35: MEDICATION ADMINISTRATION
Terminology
Drug: Any substance that either positively or negatively alters physiologic function.
Medication: A drug specifically administered for its therapeutic effect on physiologic function.
Medication Designations:
Chemical Name: Describes elements of the molecular structure of the drug.
Generic Name: Generally not capitalized; may have a suffix or prefix to help identify the drug class; used in healthcare to reduce errors.
Trade/Brand Name: Capitalized drug name; registered by the manufacturer; uses a trademark symbol after the drug name.
Medications and Regulations
Governmental Agencies and Standards: Ensure uniform quality and predictable effects of medications.
The Pure Food and Drug Act of 1906: Established standards for food and drug safety.
United States Pharmacopeia (USP) and National Formulary (NF): The only official authorities that can establish drug standards for quality and purity.
U.S. Food and Drug Administration (FDA): Responsible for enforcing medication legislation; mandates that all medications undergo safety testing before being released to the public.
Medications and Regulations (Continued)
Controlled Substances:
Comprehensive Drug Abuse Prevention and Control Act (1970): Established five categories of scheduled drugs (C I – C V) and mandates regulations for handling and distributing controlled substances.
Drug Enforcement Administration (DEA): Monitors compliance for the prescribing and use of controlled substances.
Healthcare Facilities: Must keep accurate logs of controlled substances inventory and dispensing records. Report to the DEA every 2 years.
Counting Narcotics Inventory: Conducted by nurses at the start and end of each shift; requires two licensed nurses to witness if a controlled drug needs to be wasted.
Medications and Regulations (Continued)
State and Local Medication Regulations:
Healthcare facilities develop policies that comply with federal, state, and local regulations, which may be more restrictive than those by the government.
Nurse Practice Act: Defines functions and professional responsibilities of nurses; cannot be modified or expanded by healthcare facilities.
Principles of Drug Actions
Therapeutic Effect: Desired result or action of a medication.
To achieve a therapeutic effect, medication must:
Be taken into the body.
Be absorbed and distributed in cells and tissues.
Alter physiologic functioning.
Effectiveness Influenced By:
Medication dose
Route of administration
Frequency of administration
Function of metabolizing organs (liver and kidneys)
Age of patient
Principles of Drug Actions (Continued)
Absorption: Passage of drug from administration site into the bloodstream; affected by blood flow and route of administration.
Distribution: Process of delivering medication to the specific site of action within tissues and organs; affected by chemical properties of the drug and the cardiovascular system effectiveness.
Metabolism: Process by which the drug is altered to a less active form for excretion, primarily through liver function.
Excretion: Removal of the drug from the body, usually through the kidneys.
Principles of Drug Actions (Continued)
Drug Action Factors:
Onset of Action: Time the body takes to respond to a drug, affected by the route of administration.
Duration of Action: Time drug exerts an effect on the body, usually dictates dosing schedule.
Peak Plasma Level: Highest serum concentration of drug.
Trough: Lowest serum concentration of drug.
Serum Laboratory Tests: Monitor peak and trough levels to ensure therapeutic drug levels and check for toxicity.
Principles of Drug Actions (Continued)
Side Effects: Predictable, unwanted reactions to a medication; usually harmless or minor; the responsibility of nurses to monitor.
Adverse Effects: Severe, unintended, unwanted, and often unpredictable reactions to a medication; reported by providers to the FDA’s MedWatch Program.
Toxic Effects: Result from an overdose of medication due to impaired liver or kidney function or incorrect dosing; potentially lethal.
Allergic Reactions: Immune responses to medications or their components (binders/fillers), ranging from minor to severe.
Principles of Drug Actions (Continued)
Medication Interactions: Occurs when the drug action is altered by another medication, herbal supplement, or food, impacting absorption, metabolism, or elimination.
Drug Incompatibility: Potentially adverse chemical reactions when mixing medications; compatibility must be verified.
Polypharmacy: Taking multiple medications can lead to negative effects, prevalent in older adult populations.
Nonprescription Medications (OTC)
Definition and Regulation: Medications that do not require a prescription and are regulated by the FDA; must be accounted for in medication reconciliation.
Selecting OTC Medications:
Consider desired effects, potential side and adverse effects, possible allergic reactions, interactions with other medications and herbs, and warnings/directions/dosage.
Types of Nonprescription Medications:
Pain medicines, cold and flu medicines, vitamins, herbal supplements (regulated by the FDA through the Dietary Supplement Health and Education Act).
Prescription Medications
Administration: Can be legally prescribed by various healthcare providers, including physicians and nurse practitioners; dispensed by pharmacists upon receipt of a prescription.
Medication Order Components:
Patient's name
Date and time
Drug name
Dosage
Drug route
Administration frequency
Provider's signature.
Prescription Medications (Continued)
Administration Times: Determined by facility’s pharmacy, not within nurses' scope of practice to determine.
Common Types of Medication Orders in Acute Care Settings:
Routine
PRN (as needed)
One-time orders
On-call
Stat
Now
Medication Documentation
Medication Administration Record (MAR):
Includes patient’s name, medication name, administration time, dose, route, frequency, site of administration for parenteral medications, and nurses' initials/signatures.
Specifies when and by whom each dose was administered.
Medication Documentation (Continued)
Specific Documentation Needs:
Required when a medication is not administered as prescribed.
For instance, if a medication is held or declined, the nurse must document the drug name and reason for not administering.
Forms of Medication
Administration Responsibility: Nurses must ensure the correct form of medication is administered by the correct route for optimal effectiveness and patient safety.
Forms Include:
Oral (tablets, liquids)
Intravenous
Injectable (IM, SQ, ID)
Intraarticular (for joints)
Routes of Administration
Oral Administration:
Abbreviated as PO (from Latin, "per os", meaning “by mouth”).
Considered the safest, least expensive, and most convenient route.
Assess for nausea; ensure the patient can swallow.
Routes Include:
Swallowed
Sublingual: absorbed under the tongue through the oral mucosa (do not swallow or chew).
Buccal: absorbed against cheek through oral mucosa (do not swallow or chew).
Nasogastric, gastric, intestinal, jejunal tubes; check tube placement before administration.
Routes of Administration (Continued)
Topical Medications:
Formulations for application and absorption through the skin or mucous membranes; affected by site vascularity.
Types include transdermal patches, ointments, creams.
Inhaled Medications:
Administered through respiratory tract (nebulizer, MDI inhaler, DPI inhaler).
Routes of Administration (Continued)
Parenteral Medications:
Administered by injection (faster and more complete than oral).
Aseptic Technique: Must be used to avoid infection.
Major Sites of Injection:
Intradermal (ID): shallow injection into dermis; typically for local anesthetics or allergy testing.
Subcutaneous (Subcut): below the skin's surface.
Intramuscular (IM): into a muscle (for larger volumes).
Intravenous (IV): directly into the bloodstream.
Routes of Administration (Continued)
Filter Needles: Used for drawing medications from glass ampules.
Needleless Delivery Systems: Aim to reduce needlestick injuries and exposure to bloodborne pathogens.
Safe Medication Administration
Interpreting the Order: Use clinical judgment to evaluate if the medication, dose, and route are safe for the patient. Clarify unclear orders.
Abbreviations: Use approved abbreviations to reduce errors; consult The Joint Commission's Do Not Use list.
Measurement Systems: Knowledge of metric, apothecary, and household measurement systems is essential for nurses.
Safe Medication Administration (Continued)
Medication Errors: Defined as any preventable event leading to inappropriate medication administration or harm. Awareness of common causes is crucial for prevention.
Common causes include interruptions, misinterpretations of handwriting or verbal orders, calculation errors, and not performing necessary checks.
Systems such as Computerized Provider Order Entry (CPOE), electronic MARs (eMARs), smart IV pumps, and barcoding reduce error occurrences.
Safe Medication Administration (Continued)
Administering Medications Using Six Rights:
Verify right drug, right dose, right time, right route, right patient, and right documentation before administration.
Confirm the order for safety; check drug expiration dates; perform three safety checks; identify patient using two identifiers and check for allergies.
Only administer medications you have prepared; verify doses of high-risk drugs (e.g., insulin, heparin) with another nurse.
Understanding the medication's purpose and performing necessary assessments before and after administration is critical.
Safe Medication Administration (Continued)
Patient Rights: Under the Patient Care Partnership program:
Right to refuse medication.
Right to have an accurate medication history taken.
Right to receive medications as per the Six Rights.
Right to have any questions or concerns about the medication addressed respectfully and appropriately.
Medication Documentation
Documentation Concerns:
Do not document medication administration until it is given.
Compliance with emergency documentation guidelines if the computer system fails.
Ensure legibility of orders and documentation, correct ink color based on facility policy, and avoid leaving blanks.
Medication Documentation (Continued)
Ensure documentation is done in appropriate places and times; log on as the actual caregiver.
Address manual overrides and document appropriately.
Medication Documentation (Continued)
**Documentation Guidelines: **
Use appropriate abbreviations, but avoid those listed on The Joint Commission’s Do Not Use list.
Use correct grammar, spelling, and prompt documentation of adverse effects.
Assessment
Initial Assessment: Produces baseline data from medical history and physical exams.
Ongoing Assessment: Evaluates medication effectiveness to identify side effects/adverse effects early.
Important data includes:
Allergy information
Medication history (prescription, vitamins, herbal supplements, OTC)
Relevant laboratory results
Vital sign measurements before and after administration
Ability to swallow if oral medication.
Nursing Diagnosis
Common ICNP® Nursing Diagnoses Related to Medication Administration:
Lack of Knowledge
Supporting Data: Lack of exposure to information; double dosing; unaware of possible side effects.
Constipation
Supporting Data: Use of opioid pain medication; reported hard stools; painful defecation.
Impaired Health Maintenance
Supporting Data: Lack of expressed knowledge about the therapeutic regimen; refusal of prescribed medications.
Planning
Patient Goals Related to Medications: Examples include the patient:
Will verbalize side effects before discharge.
Will demonstrate understanding of fluid and fiber intake to prevent constipation during outpatient visits.
Will commit to taking medications daily until the next appointment.
Medication Administration
Six Rights of Medication Administration: Must be administered appropriately and safely:
The right medication
The right dose
The right time
The right route
The right patient
The right documentation
Medication Administration (Continued)
Interprofessional Collaboration and Delegation: Medication administration may not be delegated to unlicensed assistive personnel (UAP); however, UAP should report vital sign changes and medication-related inquiries.
Collaborate with the dietary staff regarding meal timings; collaborate with pharmacists for medication inquiries; collaborate with physical and occupational therapists regarding medication timing for therapy sessions.
Oral Medication Administration
Considered the easiest and most convenient route.
Assess the patient's ability to swallow; position them sitting upright.
Alternate routes for NPO patients or those with nausea (e.g., intravenous, suppository).
Verify that the medication was swallowed post-administration; cut, crush, or dissolve tablets in water for large tablets.
Liquid Medications: Administer using calibrated syringes or cups; do not return unused medications to multidose containers.
Oral medication may also be delivered via enteral route (nasogastric tube).
Oral Medication Administration (Continued)
After administration, offer oral hygiene for medications with unpleasant tastes.
Sublingual and Buccal Medications Administration
Allows rapid absorption of medications.
Sublingual: Place under the tongue and allow to dissolve without swallowing.
Buccal: Place against the inner cheek and allow to dissolve; also ensure nothing is eaten or drunk until dissolved.
Example: Nitroglycerin for chest pain related to angina.
Topical Medication Administration
Medications are placed on skin surfaces, mucous membranes, or body cavities; types include lotions, creams, ointments, etc.
Cleanse the skin before applying; use gloves to avoid skin absorption.
Common topical medications: hormones, narcotics, cardiac medications.
Transdermal Patches
Designed for systemic effect absorption via skin; remove old patch before applying a new one, rotating sites to avoid skin irritation.
Apply over intact, hairless skin; write date, time, and initials on the patch before placement.
Document patch removal and changes in skin condition in MAR.
Ophthalmic Instillation
Used to treat eye issues like irritation, infections, and glaucoma.
Avoid cross-contamination; wear gloves, and do not touch the applicator tip to the eye.
Most eye medications are placed inside the conjunctival sac (lower eyelid).
Document the eye treated and patient response.
Otic Instillation
Used to treat ear infections, soften earwax, and apply local anesthetics.
Eardrops should be at room temperature.
Document the ear treated and patient response.
Procedures should be sterile if the tympanic membrane is compromised.
Nasal Medication Administration
Administered by drops or nebulizers into the nose; used to treat allergies, sinus infections, and nasal inflammation.
Wear gloves; have the patient blow their nose before administration.
Most common medications: decongestants which can have systemic side effects.
Document which nares were treated and patient responses.
Inhaled Medication Administration
Administered using MDIs, DPIs, or nebulizers; spacers can be used with MDIs to assist inhalation. Assess lung sounds, respiratory rate, and oxygen saturation before and after administration.
Indications include promoting bronchodilation or decreasing inflammation.
Inhaled Medication Administration (Continued)
In many facilities, respiratory therapists are responsible for administering inhaled medications; collaboration with them is encouraged.
Medication administration cannot be delegated, but patients may self-administer under nurse supervision.
Vaginal Medication Administration
Includes creams, foams, tablets, liquids, and gels; usually administered with applicators.
Patients positioned supine; refrigeration may be needed for vaginal suppositories.
Document the patient’s response and any side effects observed.
Rectal Medication Administration
Produces local or systemic effects; used for patients unable to swallow or who require rapid action.
Common forms: suppositories (antipyretics, antiemetics, laxatives).
Administer using lubricated suppositories, document patient response, and how long they retained the medication.
Parenteral Medication Administration
Administered by injection; requires standard precautions and sterile technique. Observing patients closely is critical post-administration.
Equipment: Syringes, needles, vials/ampules.
Parenteral Medication Administration (Continued)
Syringe Sizes & Types: Ranges from 0.5 to 60 ml; types include standard, tuberculin, and insulin syringes.
Needle lengths vary from ¼ to 3 inches; gauges from 14 to 30.
Parenteral Medication Administration (Continued)
Ampules: Single-dose glass containers; require filter needles/straws for drawing medication.
Vials: Can be single or multi-dose; must label multi-dose vials appropriately.
Parenteral Medication Administration (Continued)
Reconstitution of Powdered Medications: Requires specific diluent types and amounts as indicated; Act-O-Vial systems facilitate this process.
Parenteral Medication Administration (Continued)
Prefilled Cartridges: Single-dose medications in reusable devices; proper management before and post-administration is essential.
Single-dose Vials: Preferred to prevent contamination, infections; caution must be exercised to avoid spreading microorganisms.
Intradermal Injections
Administered into the dermis; used for local anesthetics and allergy testing.
Common sites include hairless areas like the inner forearm; use a 1-mL tuberculin syringe and 25-27 gauge needle.
Mixing Medications in One Syringe
Compatible medications should be prepared in one syringe to minimize patient discomfort; compatibility needs to be verified via pharmacy resources.
Insulin Administration
Administered subcutaneously; timing is crucial in relation to meals; immediate administration post-preparation is needed to maintain mixture integrity.
Multidose Insulin Pens
Devices that facilitate multiple doses; they need to be primed before use.
Ensure correct rotation of injection sites and aftercare duration of needle in skin.
Subcutaneous Injections
Best administered into fatty layers above muscle tissue; common medications include insulin and heparin.
Use insulin syringes or 0.5-1 mL syringes with a 25-31 gauge needle.
Intramuscular Injection
Administered into muscle mass; preferred sites are ventrogluteal or vastus lateralis.
Use 1-3 mL syringes; document injection site accurately.
EpiPens
Devices for emergency treatment of anaphylaxis containing a single dose of epinephrine; stored at room temperature; must check expiration dates and document uses.
Medication Teaching
Nurses must educate patients about their medications, ensuring understanding around doses and side effects.
Discuss missed doses, disposal of unused medications, and the importance of not sharing medications.
Document all patient teaching performed, including return demonstrations if injections are involved.
Evaluation
Clinical observations provide insight into medication effectiveness; nurses must assess for side effects and utilize laboratory tests for response indications.
Significant deviations from expected responses are to be reported to healthcare providers.