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MEDICATION ADMINISTRATION NOTES

1. DRUG NOMENCLATURE

Every drug has four names, with a focus on the generic name in NCLEX. These are:

1.1 Chemical Name

• Identifies the drug's atomic and molecular structure.

• Notable for being very complex.

• Example: 4-chloro-N-furfuryl-5-sulfamoylanthranilic acid (C12H11CIN2O5S).

1.2 Generic Name

• Assigned by the manufacturer that first develops the drug.

• This is the NCLEX-tested name.

• Example: furosemide.

1.3 Official Name

• The name by which the drug is identified in official publications such as the United States Pharmacopeia (USP) and the National Formulary (NF).

1.4 Trade / Brand Name

• Copyrighted by the company that sells the drug.

• Example: Lasix (which is a memory trick: 'Lasts six hours').

2. DRUG PREPARATIONS & FORMS

Drugs can be prepared and administered in various forms:

2.1 Oral Preparations

• Solid forms: capsule, pill, tablet, extended release.

• Liquid forms: elixir, spirit, suspension, syrup, solution.

2.2 Topical Preparations

• Liniment, lotion, ointment, suppository, transdermal patch, inunction (rubbing in an ointment).

2.3 Injectable Preparations

• Types of injection: ID (intradermal), SQ (subcutaneous), IM (intramuscular), IV (intravenous).

• Key Measurement Tip: Read liquid medication at the bottom of the concave meniscus curve for accurate measurement.

• Oral Medication Tips:
    1. Keep oily medications in the refrigerator.
    2. Crush medications with food or drink for easier swallowing.
    3. Have patient suck on ice prior to swallowing a pill.
    4. Offer oral hygiene right after administration.
    5. Give with extra fluids.
    6. Note: Do not crush potassium pills; request a liquid alternative from the pharmacist/MD as necessary.

3. DRUG CLASSIFICATIONS & MECHANISMS

3.1 How Drugs are Classified

• By effect on body system: e.g., cardiovascular, respiratory.

• By chemical composition.

• By clinical indication or therapeutic action: This defines why a patient is receiving the medication.

3.2 Mechanisms of Drug Action

• Drug-receptor interaction: Drug interacts with cellular structures to alter cell function.

• Drug-enzyme interaction: Drug combines with enzymes to achieve desired effects.

• Acting on cell membrane or altering the cellular environment.

4. PHARMACOKINETICS (ADME) ★ MEMORIZE

Overview of Pharmacokinetics

• Absorption (A): How the drug enters the bloodstream. Affected by:
    - Route of administration (PO, IV, IM, SQ).
    - Lipid solubility (drugs more effectively absorbed in lipid environments).
    - pH (acidic drugs are better absorbed).
    - Blood flow/perfusion and local conditions at the site of administration.
    - Drug dosage.

• Distribution (D): How the drug moves through body compartments to reach target tissues, influenced by:
    - Blood flow, plasma protein binding, and drug's ability to cross membranes.

• Metabolism (M): Primarily occurs in the liver. Hepatic impairment may slow metabolism, posing higher risks for toxicity and drug accumulation.

• Excretion (E): Primarily through the kidneys (renal). Renal impairment increases the risk of drug accumulation and toxicity. Excretion can also occur via lungs, bile, feces, and sweat.

- Half-Life (T1/2): The half-life of a drug is the duration required for the plasma concentration to be reduced by half.

4.1 Half-Life Examples

4.2 Peak & Trough Levels

• Peak: The highest drug level in the blood, drawn approximately 30-60 minutes after IV infusion is complete.

• Trough: The lowest drug level, drawn just before the next scheduled dose.

• Therapeutic Ranges:
    - Sub-therapeutic: below the therapeutic range — continue administering until therapeutic levels are achieved.
    - Therapeutic: within the effective range — maintain.
    - Supra-therapeutic (toxic): above the therapeutic range — hold medication and notify the physician.

• Prophylaxis: Administering a drug preventatively, like antibiotics prior to surgery.

5. VARIABLES INFLUENCING DRUG EFFECT

• Developmental considerations: Differences based on age (infants vs. geriatrics).

• Weight: Affects dosing calculations.

• Sex: Hormonal differences can influence metabolism.

• Genetic and cultural factors.

• Psychological factors: Mental state can alter drug effects.

• Pathology: Conditions such as kidney or liver disease significantly change drug processing.

• Environment and timing of administration.

6. ADVERSE EFFECTS & DRUG INTERACTIONS

6.1 Types of Effects

• Side Effect: Predictable, unavoidable secondary effects at usual therapeutic doses. Common examples include nausea/vomiting, dry mouth, drowsiness, and constipation.

• Adverse Effect: Unintended and undesirable, often unpredictable, ranging from mild to potentially fatal.

• Toxicity: When a drug accumulates in the blood due to impaired metabolism or excretion, leading to possible lethality. Countermeasure: Hold medication and notify the physician.

• Allergic Reaction: Unpredictable immune-mediated responses that may cause anaphylaxis; signs include rash, urticaria, fever, diarrhea, nausea, or vomiting.

• Idiosyncratic Effect: Unpredictable responses that are unique to the patient, which could be an over-response or qualitatively different from expected.

• Iatrogenic Disease: A condition caused by medical treatment or diagnostic procedures.

6.2 Drug Interaction Types

• Accumulation: Drug accumulates in the bloodstream leading to toxicity.

• Potentiation: The effects of the primary drug are increased by another drug.

• Synergism: Combined action of drugs is greater than the sum of their individual effects (1 + 1 = 3 effect).

• Antagonism: One drug decreases the response to another drug.

• Inhibition: The decrease of drug effect due to interaction.

6.3 Dependence, Tolerance & Addiction

• Dependence: Physiologic adjustment where withdrawal symptoms occur upon sudden cessation of the drug; the time for development varies.

• Tolerance: Physiologic adaptation requiring increasingly larger amounts of the drug to achieve the same effect; this occurs rapidly with opioids.

• Addiction: Psychological dependence characterized by compulsive drug use and continued craving for non-analgesic reasons.

7. TYPES OF MEDICATION ORDERS

• Standing Order: Carried out until cancelled by another order.

• PRN Order: Administered 'as needed' based on specific documentation of the reason and patient's response.

• STAT Order: Carried out immediately, treated as highest priority.

• Protocol Order: Based on a specific clinical protocol (e.g., ICU sepsis protocol).

• Pharmacy Order: Written by a pharmacist.

• Nursing Order: Standardized orders that a nurse can write, such as MOM, Tylenol, Mylanta, etc.

7.1 Parts of a Complete Medication Order (★ MEMORIZE ALL 7)

1. Patient's name

2. Date and time order is written

3. Name of drug

4. Dosage

5. Route of administration

6. Frequency

7. Prescriber signature/computer login
   
   Example Order: John Smith | March 15, 2025 0835 | Lasix 40 mg PO every AM × 3 days | TORB Dr. Jones / SSnyder RN (TORB = Telephone Order Read Back, always read back and document).

7.2 Right Frequency

• Always verify: When was the last time this medication was administered?

• Common frequencies include: Q1h, Q2h, Q3h, Q4h, Q6h, Q12h, Q24h (daily), BID (twice daily), TID (three times daily), QID (four times daily).

8. MEDICATION SUPPLY & ADMINISTRATION SYSTEMS

• Stock supply.

• Individual unit dose supply.

• Medication cart.

• Computerized automated dispensing system (e.g., Pyxis).

• Bar code-enabled medication cart (scan patient's armband and medication).

9. THREE CHECKS OF MEDICATION ADMINISTRATION

1. Check 1: When the nurse reaches for the container or unit dose package.

2. Check 2: After retrieval, compare it with the clinical medication administration record (CMAR) or immediately before pouring from a multidose container.

3. Check 3: When replacing the container to the drawer/shelf, or before giving a unit-dose package to the patient.

9.1 Documentation Requirements

• Name of the medication.

• Dosage.

• Route and time of administration.

• Nurse's initials / computer ID.

• Intentional or inadvertently omitted drugs.

• Refused drugs (document refusal).

9.2 Patient Refusal of Medications

1. Step 1: Ask the patient the reason for refusal.

2. Step 2: Educate the patient regarding the medication's importance.

3. Step 3: Document patient refusal.

10. MEDICATION ERRORS

10.1 Types of Medication Errors

• Inappropriate prescribing of the drug.

• Extra, omitted, or wrong doses.

• Administration to the wrong patient.

• Administration by the wrong route or rate.

• Failure to give medication within the prescribed time.

• Incorrect preparation of the drug.

• Improper technique during drug administration.

• Administration of a drug that has deteriorated.

10.2 Response to a Medication Error (IN ORDER)

1. Check the patient immediately and observe for adverse effects (this is the priority).

2. Notify the nurse manager and physician.

3. Document the description of the error and steps taken in the medical record.

4. Complete the special incident/error report form.

11. PARENTERAL MEDICATION ADMINISTRATION - INJECTION REFERENCE

Parenteral administration bypasses the intestines and includes SQ, IM, ID, IV, intraarterial, intracardial, intraperitoneal, intraspinal, and intraosseous routes.

11.1 Injection Methods

11.2 Injection Site Documentation

Always document injection sites on a grid, and alternate/rotate sites for injection.

11.3 Z-Track Technique (IM Only)

• Pull skin laterally 1-1.5 inches before inserting the needle.

• Insert the needle at a 90-degree angle.

• Inject medication slowly, and hold for 10 seconds after injection.

• Release the skin to create a 'Z' pathway that seals the medication in the muscle and prevents tracking back into subcutaneous tissue.

• Important Note: The dorsogluteal site is no longer recommended; use the ventrogluteal site instead.

11.4 Preparing Medications for Injection

• Ampules: Break away at the scored neck using a barrier (e.g., gauze); use a filter needle to draw up; change the needle before administering to the patient.

• Vials: Use a blunt draw-up needle, then change to the appropriate injecting needle (e.g., 25-gauge).

• Prefilled cartridges: Used as is.

11.5 Heparin / Enoxaparin (Lovenox) - SQ Administration

• Used to prevent or treat clots.

• Side effect: Decreased platelets (thrombocytopenia).

• Monitor for bleeding (e.g., blood in stool, urine, or sputum).

• Administer at a 90-degree angle into the abdomen; do not aspirate for SQ injections or rub the site after injection.

• Antidote for Heparin: Protamine Sulfate.

11.6 Insulin Administration

• Use a 50-unit syringe for small doses; a 100-unit syringe for large doses.

• For sliding scale insulins such as Lispro (Humalog), Regular (Humulin R / Novolin R), and Aspart (Novolog), always check if the scheduled insulin is ordered alongside the sliding scale.

11.7 Insulin Mixing Rule (Regular + NPH ONLY)

1. Inject air equal to NPH dose into the NPH vial first.

2. Inject air equal to Regular dose into the Regular vial.

3. Draw up Regular first (R before N; remember N first for air).

4. Draw up NPH.

• Only Regular and NPH insulins can be mixed.

11.8 Nitroglycerine Sublingual

• Always check B/P first prior to administering.

• Used for management of angina (chest pain).

• Comes in a dark bottle (light-sensitive).

• Administer one pill sublingually; do not swallow.

• Can repeat one pill under the tongue every 5 minutes for a total of 3 pills — if pain persists after the 3rd pill, call emergency services.

12. TOPICAL & ROUTE-SPECIFIC MEDICATION ADMINISTRATION

12.1 Transdermal Patches - General Rules

• Always wear gloves when applying or removing patches.

• Remove the old patch before placing a new one.

• Wipe off excess medication from the old site with a damp paper towel.

• Clean the new site if needed.

• Always check the dose (there may be more than one patch).

• Write on the patch before placing it on the patient: date, time, and initials (e.g., 4/11/25 09 SS).

• Check MAR for patch removal documentation requirements.

12.2 Medications

12.3 Inhalers

• A spacer may be needed for effective delivery of medication to the lungs.

• Example: Advair (fluticasone/salmeterol) is a bronchodilator and steroid—rinse mouth to prevent oral thrush.

• Example: Spiriva is an anticholinergic bronchodilator.

12.4 Eye Drops Administration

• Position the patient lying supine or sitting with the head slightly hyperextended.

• Provide a tissue for blottage, instruct not to rub eyes; blot cheeks if drops roll down.

• Pull down the lower eyelid to create a pocket (conjunctival sac).

• Place medication in the lower conjunctival sac.

• Avoid touching the tip of the bottle to the eye (maintain sterility).

• If blinking excessively, hold both upper and lower eyelids open.

• Instruct the patient to close their eye gently after the drop is placed.

12.5 Ear Drops Administration

• The patient should lie on the unaffected ear with the affected ear facing up.

• ADULTS: Pull the auricle up and back.

• SCHOOL-AGED CHILDREN: Pull the auricle straight back.

• YOUNG CHILDREN: Pull the auricle down and back.

12.6 Nasal Spray Administration

• Provide a tissue for the patient.

• Instruct the patient to blow their nose first.

• Position: supine or sitting with the head tilted back.

• New bottle: prime the air out first and agitate gently.

• Insert the tip into one nostril; close the other nostril and have the patient inhale gently while releasing the spray.

• After using the spray, instruct the patient to blot their nose without blowing.

12.7 Rectal Suppository Administration

• Position: lateral, side-lying, or Sim's position.

• Use gloves and lubricate the suppository.

• Insert at least 4 inches past the internal sphincter.

12.8 Vaginal Medication Administration

• Position: dorsal recumbent.

• Wear gloves when administering.

• Insert along the posterior vaginal wall for the entire length of the finger.

• For suppositories: insert 3-4 inches; for an applicator: 2-3 inches, depositing the medication as instructed.

12.9 Tube Medications (NGT / G-tube / J-tube)

• Never check residual on a J-tube.

• Allow 60 minutes between medications if necessary.

• Silent Knight: A pill crusher for tube medications.

• Pantoprazole (Protonix) delayed release can be given via NGT/G-tube/J-tube with apple juice (or apple sauce for swallowed patients).

• Important Note: Do not crush potassium pills; consult pharmacy/MD for liquid alternatives as required.

12.10 Chlorhexidine (Peridex/Periogard)

• This mouthwash (oral rinse USP 0.12%) should not be confused with topical antiseptic. Use Yankauer suction if necessary after oral care.

13. NPO MEDICATION RULES

• NPO (Nil Per Os) = Nothing by mouth; hold all medications that require ingestion.

• HOLD (PO Route): All oral (PO) medications.

• CONTINUE (Bypass GI tract): Transdermal patches, IV push medications, IVPB, IM, ID, SQ.

• Dialysis Day: Hold blood pressure medications in the morning unless very high (consult with the dialysis nurse).
  

14. HIGH ALERT MEDICATIONS

Characteristics and Documentation

The acronym CHIP represents medications that require co-signature by two licensed persons:

• Chemotherapy

• Heparin

• Insulin

• PCA pumps
  Also includes Magnesium (notably used in obstetrics).

15. CONTROLLED SUBSTANCES

Required Documentation for Narcotics

• Name of the physician prescribing the narcotic.

• Name of the nurse administering the narcotic.

• Name of patient (including DOB) receiving the narcotic.

• Amount used, with double signature for any waste.

• Hour narcotic was last given.

• Frequency of ordered medication.

• Vital signs prior to administration, particularly respirations for benzodiazepines/opioids, along with HR and BP.

• Labs if required.

• Always check for allergies.

Controlled Substance Schedules

16. REVERSAL AGENTS & ANTIDOTES ★ MEMORIZE

17. MEDICATION SAFETY CONCEPTS

LASA/SALAD Drugs

• SALAD: Sound Alike Look Alike Drugs.

• LASA: Look Alike Sound Alike medications that are visually or phonetically similar, which increases the risk of errors.

• Examples: Klonopin vs. Clonidine | Hydralazine vs. Hydroxyzine.

Tall Man Lettering

• Uses capitalized and bolded portions of look-alike drug names to emphasize differences and draw attention to potential errors.

• Examples: glipiZIDE vs. glyBURIDE | hydrALAZINE vs. hydrOXYzine.

BEERS Criteria

• A specific list of medications that are dosed differently for geriatric patients; essential for elderly patient care.

Ceiling Dose

• The maximum dose beyond which there is no additional analgesic effect; higher doses only increase side effects without added benefit.

• Tylenol (Acetaminophen) Ceiling Dose: > 150 lbs: MAX 4 grams (4,000 mg) per 24 hours; < 150 lbs or in liver disease: MAX 3 grams (3,000 mg) per 24 hours, watch for acetaminophen in combination products.

Black Box Warning

• The most serious FDA warning regarding potentially life-threatening side effects, found on package inserts of prescription drugs.

• Example: Fluoroquinolones (levofloxacin, ciprofloxacin) carry warnings of increased risk of tendonitis and tendon rupture in all age groups.

18. PREGNANCY DRUG CATEGORIES

Classification of Teratogenic Drugs

• Category A: No known risk to fetus based on adequate human studies confirming safety.

• Category B: Animal studies indicate no harm to fetus; no adequate human studies.

• Category C: Adverse effects seen in animal studies; risks may outweigh benefits in humans.

• Category D: Positive evidence of human fetal risk; may be used if benefits outweigh risks.

• Category X: Positive evidence of fetal abnormalities; contraindicated in pregnancy.

• Category Z: Studies, recommendations, or alerts provided by expert committees or regulatory agencies for healthcare professionals.

Combination Drugs (Know these examples)

• Norco 5/325: Hydrocodone 5 mg + Acetaminophen 325 mg.

• Fiorinal: Aspirin 325 mg + Caffeine 40 mg + Butalbital 50 mg.

• Benicar 20-12.5: Olmesartan 20 mg + Hydrochlorothiazide 12.5 mg.

• Clinical Tip: Monitor for acetaminophen (Tylenol) in combination medications to prevent exceeding the ceiling dose of 4 g/24 hrs for patients receiving both Norco and Tylenol separately.

19. PATIENT TEACHING

• Review medication administration techniques with the patient.

• Remind patients to take medications as prescribed for the entire duration of the prescription.

• Instruct patients not to alter dosages without consulting their physician.

• Caution patients against sharing their medications with others.

Good luck on your exam!