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PRINCIPLES OF DRUG ADMINISTRATION

I. The “Five Plus Five Rights” of Drug Administration

5 Traditional Rights 5 Additional Rights


1. right client 1. right assessment
2. right drug 2. right documentation
3. right dose 3. client’s right to education
4. right time 4. right evaluation
5. right route 5. client’s right to refuse

A. Right Client
Nurse must do:
 verify client  check ID bracelet & room number
 have client state his name
 distinguish bw 2 client’s with same last names

B. Right Drug
 medication order may be prescribed by:
a. Physician
b. Dentist
c. Podiatrist
d. Advanced practice registered nurse (APRN)

 Components of a drug order:


1. date & time the order is written
2. drug name (generic preferred)
3. drug dosage
4. frequency & duration of administration
5. any special instructions for withholding or adjusting dosage
6. physician or other health care provider’s signature or name if TO or VO
7. signature of licensed practitioner taking TO or VO

 Nurse must do:


• check med order is complete & legible.
• know general purpose or action, dosage & route of drug
• compare drug card with drug label three times.
1. at time of contact with drug bottle/ container
2. before pouring drug
3. after pouring drug

 4 Categories of Drug Orders:


1. Standing Order / Routine Order
 ongoing order
 may have special instructions to base administration
 include PRN orders
ex. digoxin 0.2 mg PO q.d., maintain blood level at 0.5 – 2.0 ng/ml

2. One-time (single) order


 given only once, at a specific time

ex. Cefixime 2mg IM at 7 AM on 12-1-05

3. PRN order
 given at client’s request & nurse’s judgement for need & safety

ex Mefenamic Acid 500mg q 4h PRN for pain

4. STAT order
 given once, immediately

ex. Morphine 2mg IV STAT

C. Right Dose
 Nurse must do:
• Calculate and check drug dose accurately.
• Check PDR, drug package insert or drug handbook for recommended range of
specific drugs.
• Check heparin, insulin and IV digitalis doses with another nurse.

 Stock- method vs Unit-dose method

D. Right Time
 Nurse must do:
• Administer drugs at specified times.
• Administer drugs that are affected by foods, before meals.
• Administer drugs that can irritate stomach, with food.
• Drug administration may be adjusted to fit schedule of client’s lifestyle, &
activities. & diagnostic procedures.
• Check expiration date.
• Antibiotics shld be administered at even intervals.

E. Right Route
 Nurse must do:
• assess ability to swallow before giving oral meds.
• Do not crush or mix meds in other substances before consultation with
physician or pharmacist
• Use aseptic technique when administering drugs.
• Administer drug at appropriate sites.
• Stay with client until oral drugs have been swallowed.

F. Right Assessment
 get baseline data before drug administration.

G. Right Documentation
 Immediately record appropriate info
• Name, dose, route,time & date, nurse’s initial or signature

 Client’s response:
• narcotics
• analgesics
• antiemetics
• sedatives
• unexpected reactions to meds.

 Use correct abbreviations & symbols.

H. Right to Education
 Client teaching :
• therapeutic purpose
• side-effects
• diet restrictions or requirements
• skill of administration
• laboratory monitoring

 Principle of Informed Consent

I. Right Evaluation
 client’s response to meds.
o effectiveness
o extent of side-effects or any adverse reactions.

J. Right to Refuse
 Nurse must do:
• determine, when possible, reason for refusal.
• facilitate px’s compliance.
• explain risk for refusing meds & reinforce the reason for medication.
• Refusal shld be documented immediately.
• Head nurse or health care provider shld be informed when omission pose
threat to px.
ALL MEDICATION ERRORS ARE SERIOUS OR POTENTIALLY SERIOUS!!!!!!!!

Medication Misadventures include:


1. administration of wrong medication & IV fluid.
2. incorrect dose or rate
3. administration to the wrong patient
4. incorrect route
5. incorrect schedule interval
6. administration of known allergic drug or IV fluid
7. omission of dose or discontinuation of med or IV fluid that was not discontinued.

II. Guidelines for Correct Administration of Medications

A. Preparation
1. Wash hands before preparing meds.
2. Check for allergies.
3. Check medication order with physician’s orders, medicine sheet, & medication card.
4. Check label on drug container 3 times.
5. Check expiration date on drug label.
6. Recheck drug calculation with another nurse.
7. Verify doses of drugs that are potentially toxic with another nurse or pharmacist.
8. With unit dose, open packet at bedside after verifying client identification.
9. Pour liquid at eye level.
10. Dilute drugs that irritate gastric mucosa or give with meals.

B. Administration
11. Administer only those drugs that you have prepared.
12. Identify the client by ID band or ID photo.
13. Offer ice chips when giving bad tasting medicine.
14. Assist client to appropriate position.
15. Provide only liquids allowed on the diet.
16. Stay with client until meds are taken.
17. Administer no more than 2.5 to 3 ml of solution by IM at one site.
18. Infants receive no more than 1 ml of solution by IM at 1 site & no more than 1 ml
subcutaneously. NEVER recap needles.
19. Give drugs last to client who need extra assistance.
20. Discard needles & syringes in appropriate containers.
21. Follow appropriate drug disposal based on institution policy.
22. Discard unused solutions from ampules.
23. Store appropriately unused solutions from open vials.
24. Write date & time opened & initials on label.
25. Keep narcotics in a double-locked drawer or closet. Med cart – locked at all times
when nurse is not around.
26. Keys to narcotics drawer must be kept by the nurse & not stored in drawer.
27. Avoid contamination of one’s own skin or inhalation to minimize chances of allergy.

C. Recording
28. Report drug error immediately to nurse manager & physician. Complete an incident
report.
29. Charting: record drug given, dose, time, route & your initials.
30. Record drugs promptly after given, esp STAT doses.
31. Record effectiveness & results of meds given, esp PRN meds.
32. Report to physician & record drugs that were refused with reason for refusal.
33. Record amount of fluid taken with medications on input & ouput chart.

 Behaviors to Avoid During Medication Administration:


• Do not be distracted when preparing meds.
• Do not give drugs poured by others.
• Do not pour drugs from containers whose labels are partially removed or have fallen off.
• Do not transfer drugs from one container to another.
• Do not pour drugs into the hand.
• Do not give expired medications.
• Do not guess about drugs & drug doses. Ask when in doubt.
• Do not use drugs that have sediment, are discolored, or are cloudy (& shld not be).
• Do not leave medications by the bedside or with visitors.
• Do not leave prepared medications out of sight.
• Do not give drugs if the px says he has allergies to the drug or drug group.
• Do not call the px’s name as the sole means of identification.
• Do not give drug if the client states the drug is different from drug he has been
receiving. Check the order.
• Do not recap needles. Use universal precautions.
• Do not mix with large amount of food or beverage that are contraindicated.

III. Forms & Routes for Drug Administration

A. Tablets & Capsules

• oral meds not given to pxs who are:


o vomiting
o lack gag reflex
o comatose
• Do not mix with large amt of food or beverage or contraindicated food or infant formula
• Enteric- coated & timed-release capsules must be swallowed whole.
• Administer irritating drugs with food to lessen GI discomfort.
• Administer drugs on empty stomach if food interferes with absorption.
• Drugs given sublingually or bucally must remain in place until fully absorbed.
• Encourage use of child-resistant caps.

B. Liquids
• Forms : elixir, emulsions, suspensions
• read label if dilution or shaking is required.
• read the MENISCUS.
• refrigerate once reconstituted.

C. Transdermal
• systemic effect
• more consistent blood levels & avoid GI absorption problems associated with oral
products.
• patches should NOT be cut.

D. Topical
• Applied to skin with a glove, tongue blade or cotton - tipped applicator.
• Apply to clean dry skin when possible.
• Do not contaminate the medication in a container.
• Do not “double dipped” .
• Observed sterile technique when skin is broken.
• Use firm strokes if medication is to be rubbed in.

E. Instillations
• Eyedrops
1. wash hands
2. lie or seat down and look up towards ceiling
3. remove any discharge by wiping out from inner canthus
4. rest hand holding the dropper against the client’s head.
5. gently draw skin down below affected eye to expose conjunctival sac
6. administer drops into center of the sac
7. gently press lacrimal duct with sterile cotton ball or tissue for 1 to 2
mins after instillation
8. keep eyes closed for 1 to 2 mins following application

• Eye Ointment
1, 2, 3, 4,- same as above
5 . squeeze strip of ointment (abt ¼ inch, unless stated otherwise).
5. keep eyes close for 2-3 mins.
6. instruct px for blurred vision for a short time.
7. apply at bedtime, if possible.
• Ear Drops
1. wash hands.
2. med shld be at room temp.
3. sit up with head tilted slightly toward unaffected side.
4. child: pull auricle down & back. (after 3yo ,same as adult)
adult: pull up & back.
5. instill prescribed drops.
6. do not contaminate dropper.
7. maintain position for 2-3 minutes.

• Nose Drops & sprays


1. have client blow nose.
2. tilt head back for drops to reach frontal sinus.
tilt head to affected side to reach ethmoid sinus.
3. Administer prescribed number of drops or sprays.
Some sprays, close 1 nostril, tilt head to closed side & hold breath or breathe
thru nose for 1 minute.
4. Keep head tilted backward for 5 minutes after instillation.

F. Inhalations
• Semi-fowlers or high-fowler’s position.
• Teach correct use of nebulizer & metered-dose inhalers.

G. Parenteral

Action site
1. ID > local effect > ventral midforearm,
> small amt clavicular / scapular area
> for tuberculin / skin test

2. SC > systemic effect > abdomen, upper hips/ back,


> slow, sustained effect upper arms, lateral thighs
> small amt of non-irritating, water
soluble

3. IM > systemic effect > ventrogluteal, dorsogluteal,


> rapid effect than SC deltoid, vastus lateralis
> for irritating, aqueous suspensions,
oil solutions

4. IV > systemic effect > cephalic vein, median cubital v.


> more rapid than IM or SC dorsal vein of the hand

Remember!!!!
 Ventrogluteal site – preferred for IM inj. in adults & infants >7 mos old.
 DONOT use DORSOGLUTEAL site for IM inj in children.
 Vastus lateralis - infants < 7 mos old
Developmental needs:
 Stranger anxiety – infant
 Hospitalization/ ilness viewed as punishment – 3-6 yo
 Fear of mutilation – 3- 6 yo

Technological advances:
• Patient- Controlled Anesthesia (PCA) systems
• Eutectic mixture of local anesthetics (EMLA)