Comprehensive Medication Administration Lecture Notes

Types of Medication Orders

• Routine / Standing
  • Begins when written and continues until a specific stop date/time or until the provider discontinues it.
  • Ex: “Acetaminophen 650\;mg PO q6h.” Nurse continues until an order to stop or the patient is discharged.
• PRN (As-Needed)
  • Given only when the stated condition exists or the patient requests.
  • Order must contain the explicit indication.
  • Ex: “Metoprolol 25\;mg PO PRN for HR > 100” or “Ondansetron 4\;mg IV PRN nausea/vomiting.”
  • Nurse must document the assessment data that justifies administration (e.g., actual HR or nausea scale).
• One-Time Orders
  • Now – must be administered within 60–90 min; disappears from the MAR after one dose.
  • Stat – give immediately, drop everything else; used for true emergencies (e.g., epinephrine, naloxone).
  • Both are non-recurring.

Mandatory Components of a Medication Order

• Two client identifiers (hospital standard = name & date of birth).
• Date and exact time the order starts.
• Generic name of the drug (trade names are not used in hospitals).
• Dose (usually in mg; pharmacy converts to mL).
• Route (PO, IV, IM, etc.).
• Frequency or specific schedule.
• Provider signature & credentials (first + last name; specialty if duplicates exist).
• Optional but ideal: indication, stop date, parameters (e.g., “hold for SBP < 90”).

Common Abbreviations & the “Do-Not-Use” List

• Hundreds of acceptable abbreviations (pp. 523-528 of text).
• Students are primarily tested on prohibited abbreviations (short “black-board” list).
• Goal: reduce interpretation errors (e.g., “U” for units, “q.d.” for daily). Review the official ISMP list.

Automated Dispensing Cabinets (ADC/Pyxis)

Advantages

• Computerised profiling = real-time order updates, client-specific drawers.
• Biometric/password access restricts who can remove meds.

Risks / Disadvantages

• Restock errors by pharmacy techs (wrong drug in right bin).
• Removal errors when distracted.
• Overrides / work-arounds: only for true emergencies; otherwise call pharmacy rather than bypass safety.
• Power outages → backup generators & manual keys; still risky because all drawers open.

Barcode Medication Administration (BCMA)

Advantages

• Scanning patient wristband + drug barcode verifies right patient & right drug.
• Auto-documents date/time/dose → decreases charting errors.

Disadvantages

• Nurses can bypass by manual entry (unsafe).
• Requires full staff compliance & functioning scanners; call IT—not skip—when hardware fails.

The Three Medication Checks

1. When selecting the drug on the ADC screen (compare to order).
2. When removing the drug from the drawer/vial.
3. At bedside: scan patient, scan drug, visually verify label vs. MAR.

The “Ten Rights” (+ 5) of Medication Administration

1. Right Drug – matches order & patient diagnosis.
2. Right Reason – especially for PRN; Tylenol ordered for fever ≠ headache.
3. Right Dose – confirm via pharmacy or drug reference if unsure.
4. Right Route – adjust for NPO, swallowing issues, speed of onset.
5. Right Patient – 2 identifiers every time.
6. Right Time – hospital window = \pm 1 hr; call pharmacy to reschedule if procedure delays.
7. Right Assessment – HR before beta-blocker, temp before antipyretic, pain score before opioid.
8. Right Education – concise purpose/SE; maintain autonomy.
9. Right to Refuse – educate first; notify provider if refusal endangers care.
10. Right Documentation – scan = done; include effect evaluation.
    11-15. Response, Evaluation, Compatibility, Expiry, Allergies (institution-specific additions).

Overview of Medication Routes

• Slowest onset: Oral
• Fastest onset: IV push
• Intermediate/extended: IM, Sub-Q, transdermal, SL/buccal.

Oral Route

Advantages

• Most convenient, comfortable, inexpensive; minimal equipment.

Disadvantages

• Unsuitable if NPO, vomiting, unconscious, severe dysphagia.
• Slow onset → not for emergencies.

Forms & Key Rules

• Tablets: scored line = may split; no score → consult pharmacy.
• Enteric-coated (EC): shiny; never crush (protects stomach lining).
• Capsules: do not open unless pharmacy specifically okays (altered time-release).
• Time-release labels:
  • ER/XL = Extended Release
  • CR = Controlled Release
  • LA = Long Acting
  All are no-crush / no-open.
• Liquids: measure in medicine cup on a flat surface; read the bottom of the meniscus.
• Alcohol may be ordered medically (e.g., withdrawal); nurse must stay in room while consumed.

Enteral-Tube Meds

• Prefer commercial liquids; otherwise crush finely, mix with water.
• Stop NG suction 30 min pre-dose; clamp tube 30 min post-dose to prevent immediate removal.
• Flush before & after each med.

Sublingual & Buccal

• Give after all other PO meds.
• Do not chew or swallow; allow complete dissolution.
• Ex: Nitroglycerin SL for chest pain → bypasses GI, rapid systemic absorption.

Parenteral Overview

Advantages

• Use when PO not possible; predictable absorption; dose control.
• IV = immediate; IM/Sub-Q = depot effect possible; avoids first-pass metabolism.

Disadvantages

• Pain, invasive, infection risk, need for aseptic technique & equipment.
• Harder to reverse once injected; placement errors can cause nerve/bone injury.

Needles & Syringes

• Gauge (diameter): larger number = smaller bore (e.g., 25 G tiny; 14 G large).
• Length determined by route & patient build:
  • ID: \approx 3/8 in
  • Sub-Q: \frac{1}{2}–\frac{5}{8} in (45°) or \approx1 in (90° with skin pinch).
  • IM: 1–1.5 in; tailor to muscle mass.
• “Needle-less” connectors for IV admi­nistration in modern hospitals.

Subcutaneous Injections

• Common sites: abdomen (best absorption), posterior upper arm, anterior thigh, scapula, love-handle area.
• Rotate sites; stay >5 cm from the umbilicus.
• Angle: 45^{\circ} (thin) or 90^{\circ} (pinch an inch).
• Typical meds: insulin, heparin/enoxaparin.

Intramuscular Injections

Landmarks & Volumes

• Deltoid: 3-finger widths below acromion; max 1 mL (maybe 2 mL in adults).
• Vastus Lateralis: middle third between greater trochanter & knee; preferred for peds.
• Ventrogluteal (gluteus medius/minimus): palm on greater trochanter, fingers toward iliac crest; safest, can take \le 3 mL viscous meds (ceftriaxone, Toradol).
• Insert at 90^{\circ} swiftly; steady hand prevents muscle spasm.

Topical & Transdermal

• Wear gloves to protect yourself (esp. lidocaine, nitro).
• Remove old patch, clean site, document location/date/time; rotate to prevent irritation.
• Watch for adhesive allergies, variable absorption with fever/sweating.

Ophthalmic (Eye) Drops/Ointment

• Don gloves; pull lower conjunctival sac, drop into sac without touching tip to eye/skin.
• Apply gentle pressure to nasolacrimal duct 30 s to reduce systemic absorption.
• Wipe excess from inner → outer canthus.

Otic (Ear) Drops (Adults)

1. Side-lying with affected ear upward.
2. Pull pinna up & back to straighten canal.
3. Instill along canal wall, not directly on tympanic membrane.
4. Gently pump tragus; remain side-lying \approx5 min.

Nasal Sprays

• Have patient blow nose first.
• Head slightly tilted; avoid deep sniffing (prevents throat runoff).
• If sneeze occurs, consult provider before re-dosing.

Rectal & Vaginal Suppositories

• Rectal: left-side Sims; lubricate generously; insert past internal sphincter (≈4 cm).
• Vaginal (dorsal recumbent / lithotomy): water-soluble lube; remain supine 10–15 min.
• Provide privacy, explain sensations.

Inhalation Therapies

• Metered-Dose Inhaler (MDI): exhale, seal lips, depress canister during slow deep inhalation, hold breath 5–10 s, exhale slowly.
• Dry-Powder Inhaler (DPI): load capsule/lever, forceful deep breath.
• Rinse mouth after steroid-containing products to prevent thrush.

Documentation & Error Reporting

• Chart immediately after administration (BCMA time-stamp).
• If dose omitted, supply a clear rationale and notify pharmacy/provider for reschedule.
• Incident reports are internal; they are not charted in the medical record but must be completed objectively.
• Transparency improves system safety; do not fearfully conceal errors.

Legal Case Study: RaDonda Vaught / Vanderbilt (2017-2022)

Summary

• Patient with subdural hematoma awaiting MRI; ordered midazolam 2 mg IV for anxiety.
• ADC override used; vecuronium (paralytic) 10\;mg reconstituted & given instead.
• Patient arrested & died; initial hospital settlement sealed with gag order; error unreported to state.
• Whistle-blower (grandson) alerted regulators; CMS investigation; nurse fired, criminally charged (reckless homicide, impaired adult abuse).
• 2022 verdict: guilty; \approx3 yrs supervised probation, $3,000 fine; nursing license revoked.
  Ethical / Practical Lessons
• Overrides only for life-saving drugs with pharmacist unavailability.
• Vigilant drug–name, form, and route verification (vecuronium is powder vs. liquid midazolam).
• System failures (policy gaps) + human factors (distraction, haste) converge → “Swiss-cheese” error.
• Importance of personal liability insurance for nurses.
• Culture of safety requires non-punitive, transparent reporting; criminalization may drive errors underground.

Study Tips & Key Takeaways

• Practice matching order → MAR → drug label aloud to build muscle memory.
• Memorize do-not-crush list (EC, SR, XR, CR, LA).
• Re-draw IM landmarks on peers; verbalize inches & angles.
• Use drug reference apps (Lexicomp, Micromedex) for dose range checks.
• Ask “Why am I giving this?” every single time—links Right Drug & Right Reason.
• Slow down: a 10-second double-check can avert a lifetime consequence.