CHAPTER 12:

Medication Administration in Community

Settings
Health and illness care has shifted from traditional institutions to
community settings. The faces of a community are many, varied and ever-
changing. With the movement of health care into the community, nurses –
more than any other health care provider-have the opportunity to shape the
health care of society. This chapter describes selected aspects of medication
administration of prescription, over the counter (OTC), and herbal
preparations within each of the major community settings: home, school,
and work. In all settings, client safety is the primary concern. Chapter 3 of
this book provides a detailed presentation on medication administration.
The process of medication administration in the home, school, and work
site must be consistent with professional, legal and regulatory requirements.
In each setting it must first be determined what the nursing personnel will
teach clients about medications and then the routes by which the
medications can be administered. Once these decisions have been made,
criteria for administration, instruction and client teaching, and ongoing
supervision need to be developed, implemented, and evaluated. Mechanisms
for communication and “paper tracking” must be in place to promote
efficacy of the medication and avoidance of untoward responses and
medication errors.
With the sky rocketing costs of medications, the nurse in any community
setting is likely to become aware of clients who need assistance paying for
their prescriptions. Ready resources for the nurse and client are
pharmaceutical companies’ assistance programs.
The backbone of health promotion and disease prevention is the
knowledge client base. The role of the nurse in establishing this base is
critical. A comprehensive discussion of client teaching is offered in Chapter
2. Assessment of learning needs and styles is another essential component
to achieving the identified teaching goal.

Client Teaching
Regardless of the state and agency regulations related to medication
administration in community settings, the following hints for client teaching
are associated with medication administration. These hints are grouped into
five categories: (1) general, (2) diet, (3) self-administration, (4) side effects,
and (5) cultural considerations.

General
Within the general area, client safety is of primary concern, so a client’s
physical abilities require ongoing assessment. Capabilities of the client may
be temporarily impaired with the use of certain drugs (e.g., narcotics,
selected eye medications, psychotropics). It is essential that clients be
advised not to operate hazardous machinery during such times and to use
caution at all other times. It is appropriate to discuss with clients and families
what situations in the daily routine require full alertness and cannot be
inenced by medication for the sake of safety.
Numerous safety concerns are associated with the stage of medications.
Medications should be kept in the original labelled containers, with childproof
caps when needed.
The client or family should be provided with written instructions (audio
instructions if client is sight impaired) about the drug regimen. Large print
may be helpful or necessary. Another part of the teaching plan is to advise
the client or family about any necessary laboratory tests to monitor the
blood level of the medication and any possible drug laboratory test
interactions. This information should be included in the written instructions
as well.
An important yet frequently misunderstood component of the written
instructions is the expected therapeutic effect and the length of time
required to achieve a therapeutic response from the medication. These vary
widely among different medications (e.g., most narcotics act within 30
minutes; many antibiotics act within 24 hours; some psychotropics act within
6 weeks). Having clients understand the expected time frame for results can
markedly diminish their concerns and promote adherence to the therapeutic
plan.
The client or family must also be aware of the need to have an adequate
supply of necessary medications available at all times- at home, school,
work, and while travelling. It is best to order prescription refills in advance. If
the pharmacy is local, at least 1 week should be allowed; several weeks
should be allowed if drugs are ordered through the mail. It is a good idea to
pack extra medication when going on trips, both short and extended. This is
preferred at all times and is essential for foreign travel.
Impress on the client or family to first contact the health care provider
before using OTC preparations that may cause problems are laxatives, diet
aids, cold and cough preparations, and overdose of fat-soluble vitamins.
Reinforce with the client or family the importance of follow-up appointments
with health care providers. Encourage wellness checkups, including
preventive and restorative dental care, because the presence of other
conditions may impact on the current therapeutic regimen. In addition,
advise clients of the need to complete laboratory studies in a timely manner.
Encourage clients to wear Medic-alert bands that indicate medications taken
and any allergies (Herbal Alert 12-1).
When disposing of medications, remember to protect the environment.
The White House Office of National Drug Control advises to “take unused,
unneeded, or expired prescriptions out of their original containers and throw
them in the trash’. Prior to throwing in the trash, mix them in litter or used
coffee grounds and place in empty cans or sealed bags. Flushing meds down
the toilet is not recommended; some drug can kill helpful bacteria in the
 sewer/septic systems. The same procedure should be followed with OTC
preparations.
Some pharmacies, health care providers and governmental sites have
programs providing for safe disposal of medications; contact your local
resources. Refer to federal drug disposal guidelines at
www.whitehousedrugpolicy.gov/drugfact/proper_disposal.html.
Reinforcement of the availability of community resources is important.
Availability does not always equate with accessibility, so the client or family
needs to know how to mobilize resources according top individual needs.
Matching community resources and client needs is a prerequisite. While
acknowledging the variability of each, the following are offered as examples:
• The telephone book is a frequently overlooked resource that can
direct clients and families to contacts and addresses of associations of
relevant health conditions (e.g., written, audiocassettes, videotapes,
occasionally Braille).
• Churches may have outreach groups in which volunteers pick up
prescriptions and deliver them to homebound clients.
• Pharmacists can frequently clarify a client’s or family’s concern
over the telephone.
• Meals on Wheels enable clients to remain at home and adhere to
taking medications with food.
• In a college town, students of the health professions may be
motivated caregivers to assist clients or families in the community.
Clients or families need to be encouraged to have a contact person for
their concerns and questions, frequently a nurse. Use of appropriate
resources is likely to increase compliance with and effectiveness of the
therapeutic regimen.

HERBAL ALERT 12-1

Community:
-Encourage client/ family to consult the health care provider before taking herbal preparations;
some products may interact with prescription or OTC medications they are taking.

Diet
Diet is the second area that requires the nurse’s attention. There is an
overall need to advise clients or families about possible drug-food
interactions, detailing which foods are to be avoided and which foods are
encouraged for specific nutrient value. For example, tyramine-rich foods
contraindicated with monoamine oxidase (MAO) inhibitors, and potassium-
rich foods are recommended for clients taking potassium-wasting diuretics.
Alcohol may be contraindicated with selected medications. Lists of foods-
and pictures when appropriate- may be helpful to clients and others involved
with their diet.
Self-Administration
The area of concern is self-administration of medications. Based on the
level of the client’s or family’s knowledge, instructions should be given on all
skills related to the drug regimen. Examples are: how to take the pulse for
clients who take digitalis preparations, correct use and cleaning of inhalers,
techniques for successful administration of parenteral medications, and how
to decrease risks of infection for clients taking immunosuppressants. The
nurse should allow time for instruction and questions, including
demonstration of the skill and return demonstration. Clients should be given
graphic illustrations for future reference as appropriate. It is essential that
the nurse provide the client or family member to return-demonstrate a skill
(e.g., administration of insulin, use of inhaler) with relative ease and then
forget information or become confused when trying self-administration of the
drug when alone.

Side Effects
Side effects are the fourth area for client teaching. The client or family
should be advised about general side effects of the medications. This is not
done to scare clients but rather to inform them about the more commonly
occurring side effects. Clients need to know when to notify their health care
provider if they experience an adverse reaction.

Cultural Considerations
Cultural considerations are the fifth general area concern. Initially the
nurse assesses the client’s personal beliefs. Based on these beliefs, the
nurse then modifies communications to meet client or family cultural
practices. The nurse needs to communicate respect for the client or family
cultural practices. The nurse needs to communicate respect for the client or
family culture at all times. It is incumbent on the nurse to assess his or her
own beliefs and biases related to cultural competence and diversity. Then
one needs to evaluate the effectiveness of interactions and their
acceptability within the cultural realm.
Culturally sensitive and competent health care promotes client or family
compliance with the therapeutic regimen. Respect for cultural diversity may
be demonstrated by inclusion of traditional and folk practices into the plans
for improved communication, health promotion, and disease prevention.
Although applicable to multiple settings, the following are some common
cultural concerns presented as examples for illustrative purposes (Purnell
2003).

Home Care
Hispanics and Asians/Pacific Islanders frequently say they agree with the
plan of care out of respect for health care providers, although they may not
intend to follow it. This practice may have dangerous or life-threatening
outcomes. Egyptians are accustomed to the oral tradition of communication
and thus may not keep reliable written records for medication schedules and
glucose monitoring results. A call from an Amish family is probably a true
emergency because of their religious and cultural obligations to care for
themselves first before seeking outside resources. Food rituals are important
to the Appalachian, Jewish, Muslim, and Asian/Pacific Island people and must
be incorporated into the plan of care if a prescription is to be followed. Self-
medication and self-diagnosis are common among Asians.

School
African-American grandmothers play a significant role in dealing with
health care concerns and must be included in the plans for care. Because
being overweight is seen as positive to many African Americans, the health
care provider may need to reeducate clients (children and families) in this
cultural group frequently and carefully explain the health risks associated
with obesity.

Worksite
African Americans have increased risk for development of hypertension.
They prefer to be addressed formally. For Asian/Pacific Islanders,
confidentiality is especially important, and they may not provide needed
information if they perceive that the information might be shared and other
community members may obtain knowledge about their health problems. It
may be difficult for outsiders to develop rapport with Appalachian people
because of past inequities from government agencies.

COMMUNITY BASED SETTINGS:

Home Setting:
The home setting provides nurses with many challenges related to
medication administration. A major question that quickly arises is, “Who can
administer medications in the home setting?” The response does not develop
so quickly.
In general, medications are administered by licensed nurses in the
home setting according to the order of the health care provider. Drugs that
are administered by the nursing personnel in the home must be approved by
the Food and Drug Administration. The nurse also initiates instructions about
the medication to the client or family. The licensed nurse may also
administer the medication on the short-term basis for a disease-related
condition if a caregiver with an order from the health care provider is unable
to do so.
The order from the health care provider must be current and complete.
The medication must be labelled by the pharmacist or health care provider.
The nurse should not administer any medication that is not properly labelled.
It is the nurse’s responsibility to contact the health care provider, pharmacist
or other group identified by the agency with any concerns about the
medication for a specific client. The expiration date must be checked at the
time of each administration. Storage and deterioration of the medication are
 also evaluated. Significant side effects, allergies, and adverse reactions are
reported promptly to the health care provider. Each client is assessed for
allergies before administering the drug.
The establishment of policy and procedures for medication
administration promotes safety and consistency; however, errors do occur.
When a medication error occurs, it is reported to the health care provider
and nursing supervisor. The client and family are instructed when to notify
the nurse or the health care provider if an adverse drug reaction is
suspected. Ultimately, the health care provider should be notified of all
adverse drug reactions.
An agency policy for medication administration generally addresses
guidelines for specific medications. Example of these agents include allergy
vaccines, chemotherapy, gamma globulins, gold, experimental drugs, and
narcotics. The guidelines are agency-specific and may include that the first
dose of allergy vaccine may be given by the health care provider in a
controlled environment or that family members be taught how to administer
narcotics to the client by the parenteral route if the order is so written by the
health care provider. When the order is discontinued, the health care
provider
Box 12-1 needs to be notified if any unused narcotics are in the home.
Licensedofpractical
Summary nurseshints
client teaching mayabout
not administer
medications gamma
use andglobulin intravenously,
administration in the
community:
and family members may not be taught to administer selected drugs (eg.iron
dextran). Chemotherapy for cancer commonly presents a special challenge.
GENERAL:
The -client’s blood
Client safetywork must be
is of primary current before the administration of the
concern.
chemotherapeutic
- drugs,
Client’s physical the client
abilities requiremust
ongoingbe assessment.
under regular and ongoing care
of the- physician, and medications
Keep or store safety requirements may be
in original labelled identified.
containers (eg. Gloves
with childproof capsand
when needed.
goggles may be used.)
- Provide client or family with written instructions about the drug regimen.
Certified home health aides work under the supervision of the
- Advise the client or family about the expected therapeutic response from the
registered nurse. Home health aides are commonly asked to administer
medication.
medications
- to aclient
Advise client by the
or family client,
about family,
possible or friends.interaction.
drug-laboratory In the current health
care -environment,
Advise client theor home
family tohealth aide may
have adequate receive
supply pressure
of necessary to administer
medications
available. but legally home health aides may only assist with medications
medications,
- Caution against the use of OTC preparations without first contacting the health
the client customarily self-administers.
care provider.
- Additional
Reinforce challenges
the importance related to medication
of follow up appointmentsadministration in providers.
with health care the home
setting
- include
Reinforceadherence
that community to the therapeutic
resources regimen,
are available especially
and need the right
to be mobilized
drug,according
right dose and
to the right
client time. needs.
or family Some clients need but do not have a primary
care giver to oversee follow-up with medications and other aspects of care.
DIET:
The quality and preparation of meals may also be a factor related to
- Advise client/family/student/employee about possible drug-food interaction.
medication
- administration,
Advise such as what
client/family/student/employee what foods
foods aretocontraindicated.
avoid with certain
medications
- and what foods complement a medication.
Advise client/family/student/employee regarding alcohol use. In addition, it may be
difficult for their clients to get their medications and to get them in a timely
SELD ADMINISTRATION:
manner. Coordinated skill may be required by the client or family, for
example, Instruct
-
with the client/family/student/employee regarding drug dose and dosing schedule.
use of an inhaler or administration of insulin. In all these
- Instruct client/family/student/employee on all psychomotor skills related to the
situations, the
drug regimen. nurse is frequently the person who coordinated the resources.
- Provide client/family/student/employee with contact person and telephone
number for questions and concerns.

SIDE EFFECTS:
- Advise client/family/student/employee about general side effects and adverse
reactions of the medication.
- Advise client /family/student/employee when to notify the health care provider.

CULTURAL CONSIDERATIONS:
- Assess personal beliefs of client/family/student/employee.
 PREVENTING MEDICATION ERRORS:
Safety alert:
-Do not give or take medications in the dark; proper lighting is important to
avoid errors.
-dispose all medications in a safe manner.

SCHOOL SETTING:
Health and education are natural partners. The ability to learn is
influenced by health factors.
 The Centers for Disease Control and Prevention (CDC) summarized the
benefits of care of chronic health conditions such as: improved attendance,
alertness and physical stamina; fewer symptoms and restrictions on taking
part in physical activities; and decreased number of emergencies.
Administration of medications in the school setting is of special
concern. A recent study reports that in any given 2-week time interval, about
13 million children in grades K-12 take medications. The most frequently
taken medications were drugs for ADHD, OTC preparations, and medications
for treatment of asthma. In addition, there was a dramatic increase in the
kinds of medications taken at school: from 58 in the late 1980s to 200
currently. School health services are not immune from the phenomenon of
downsizing personnel, and many school systems are dealing with the
questions “Where are the nurses?” and “Who is responsible for the
administration of medication?”
In the absence of federal and state law, some school districts have
elected not to employ school nurses. The average national caseload for a
school nurse is an alarming 3098 students. This is reality despite the long-
standing recommendation of having one registered nurse for every 750
students. Coupled with this is the impact of a federal law that entitles
children with handicaps to attend public schools in their residential areas. It
is not unreasonable to assume that these children have special needs that
may require professional nursing services.
In 1990 the Office of School Health Policy of the University of
Colorado Health Sciences Center recognized that medication administration
was a serious policy issue. Massachusetts developed its model with a goal
“to develop regulations that provided minimum standards for the safe and
proper administration of prescription medications in the Commonwealth
schools”. The development of this model has many strengths, including
representation of professional associations, community groups, and
regulatory bodies. Consistent consent forms were designed and adopted,
and orientation and training programs were instituted for all personnel in
school health positions. The established regulations apply to both public and
non public schools. This model appears to have applicability to other states
that are grappling with the important child health issue of medication
administration in schools.
The Minnesota Guidelines for Medication administration in Schools
(May 2005) are organized as follows: legal considerations; roles; staffing;
delegation of medication administration by the licensed school
nurse/registered nurse; general procedures for medication administration ;
education and training policies and procedures; quality assurance,
monitoring and assessment; school and family relationships; and finances.
It is essential that nurses be aware of the policies and procedures for
medication administration in their own state, country, and school system.
Standardized policies for medication administration are necessary for safe
practice and should promote self-management programs for students with
chronic conditions such as asthma and diabetes. Nurses must get actively
involved in developing these policies and in ensuring that the needs of the
individual students are met. In some states or school systems, persons who
are not nurses may be responsible for medication administration. This
presents additional concerns that need to be addressed, such as adherence
to the instructions and to the principle that medication administration is a
process, more than merely “giving the student a pill.” A major component of
medication administration is assessment of the need for the medication and
its effectiveness of action. The effectiveness of action includes being alert to
side effects and adverse reactions that the client may experience.
While recognizing the variability among policies on medication
administration, Igoe and Speer (1996) identified the following basic
requirement for medication administration in schools:
1. Medications are given only with parents’ written permission.
2. Medications requiring prescription are given only on the written
authorization of the health care provider.
3. For medications requiring a prescription, there must be an
individual pharmacy-labelled bottle for each student.
4. Medications must be recorded by the school personnel who
administer them. This record states the student’s name, medication, dosage,
time, and the name of the person administering the medication.
5. Medications must be stores in as secure, locked, clean container or
cabinet.

Child care and adult day care services have similar rules for
medication administration. In general, these facilities administer medications
or supervise self-administration within the Nurse Practice Act of the specific
state. In addition, most facilities require labeling of medications in
accordance with the Pharmacy Rules and Regulations of the specific state.
Guidelines for safe storage of medications must be followed, including the
rule that the medications be accessible only to personnel responsible for
their administration or for distribution of self-administered medications.
Some states require that internal and external medications be stored
separately. Care must be taken to ensure that prescription medications be
used only for whom the medication was prescribed.
The national Association of School Nurses is a good resource of
information on the many-faceted aspects of school nursing.
BOX 12-2
Guideline #5: General procedures for medication administration
1. Guarantee that medication administration is a clean procedure by
washing hands.
2. Give medication exactly as ordered by the health care provider.
3. Everything should be done to avoid “no shows,” especially for seizure
medications and antibiotics.
4. Prevent errors! Do not allow to be distracted. Do not use one student’s
medication for another.
5. Keep individual student information private.
6. Apply child development principles when working with students.
7. If there is an error or medication incident, it must be reported. Follow
district procedure. Complete documentation. It is important to act as soon
as the errors are discovered. The school administrator or supervisor should
evaluate errors by all persons administering medications.
WORK SETTING:
Most adult Americans and many youth are employed and spend a
significant amount of time at the work site on a regular basis; thus the work
site is an ideal setting to promote personal health behaviours and decrease
environmental hazards.
Healthy employees are more productive than unhealthy employees.
This fact, coupled with the escalating costs of health care and insurance, has
inspired many businesses to offer some type of health care at the work site.
This care may range from emergency first aid and work-related health and
safety problems to the provision of primary care and referral services.
Occupational and environmental health nursing is a specialty practice
that provides for and delivers health care services to workers and workers
populations. The practice is autonomous and focuses on the promotion,
protection, and restoration of workers’ health within the context of a safe
and healthy environment. According to the American Association of
Occupational health Nurses (AAOHN) occupational and environmental health
nurses may function in a variety of roles, including solo practitioner, case
manager, and corporate director, and these nurse often work together with
the other members of an occupational health and safety team.,
The nurse needs to be aware of the policies and procedure for
medication administration at the specific work site. There is great diversity in
policy and procedure among settings. For example, the following are the two
of the many current practices at work sites:
• at one setting the registered nurse essentially follows protocols for
selected employee complaints. Each protocol includes the following areas
with relevant information for the specific complaint: assessment,
treatment/medications, client education, referral and follow up. Medications
are identified as appropriate and noted under the treatment section with the
stated drug, dosage, frequency, and route.
 • Another work site has established self care stations for minor
illnesses and injuries. Each station has designated criteria for use. Employees
are familiarized with this service as part of the orientation process. Upon
arrival at the stations, employees note date, time, and signature on the sign-
in sheet posted at each station. They indicate their chief complaint or reason
for seeking medication and the specific OTC preparations at each station.
An excellent source for care of clients in the work setting is the AAOHN
website: www.aaohn.org.

SUMMARY:
This chapter discusses only a minute, but significant, portion of the
nurse’s role in a variety of community settings. Especially the focus is on the
selected concerns associated with the administration of medications and the
need to practice in accordance with the Nurse Practice Act of a specific state.
The role of the nurse in the drug administration is growing in complexity. The
nurse in the twenty-first century must have a strong knowledge base.
NURSING PROCESS:

Assessment:
- Obtain vital signs and relevant laboratory results for future
comparisons and evaluation of the therapeutic response.
- Obtain drug history including drug allergies.
- Identify high risk clients/students/employees for reactions.
- Assess clients/students/employees’ capability to follow therapeutic
regimen.
- Determine clients/students/employees learning needs.

Nursing Diagnosis:
- Risk for injury related to possible adverse reactions
- Risk for ineffective therapeutic regimen management.
- Deficient knowledge related to therapeutic regimen
- Effective therapeutic regimen management related to medication
administration.

Planning:
- Identify goals
- Promote therapeutic response and prevent or minimize adverse
reactions
- Identify strategies to promote adherence
- Identify interventions

Nursing Interventions:
- Prepare equipment and environment; wash hands
- Determine allergies and other assessment data
- Check drug label three times; check expiration date
- Be certain of drug calculation; verify dose with another registered
nurse as necessary.
- Pour liquids at eye level on flat surface
- Keep all drugs stored properly; especially to light, temperature and
moisture.
- Avoid contact with topical and inhalation preparations.
 - Document properly
- Record effectiveness of drugs administered and reason for any drugs refused.

CULTURAL CONSIDERATIONS:
- When language barriers are present, use literature and videos in client’s preferred
language and with pictures of that group to promote compliance with health
interventions.
- Obtain an interpreter when necessary; do not rely on family members. Provide
interpreter with the same ethnic background and gender if possible
- When offering a prescription. Instructions to Asians and Pacific Islanders, use both
hands to show respect.
- Include grandmothers when providing support and health teaching in the African
American population.
- Encourage clients to disclose the use of folk healers and treatment prescribed.
Incorporate harmless and non-conflicting practices into the therapeutic plan.

Evaluation:
- Evaluate effectiveness of medication administered
- Identify expected time frame of desired drug response; consider need for
modification of therapy.
- Determine clients/students/employee satisfaction with regimen
- Determine clients/students/employee knowledge of treatment regimen.

CRITICAL THINKING CASE STUDY:

The Rivera family (Jose, age 30; wife Maria, 29, 7 months pregnant;
children Jose Jr. Age 11; Angel, age 8; Tony, age 7) recently moved into a
new community. Jose is employed full time by a large credit card corporation,
and Maria handles the child care and works part time as a cashier.

1. Give examples of culturally sensitive and competent care for the

Rivera children in the school setting.
2. Identify culturally sensitive and competent care for the parents at the
work site.
3. What modifications would you suggest for a family of Afro-American
heritage?

NCLEX study questions

1. You are preparing for a health teaching session with your client. The
most important information in the general area is:
a. foods to avoid
b. client safety
c. storage of medication
d. lab test results
 2. Teaching related to OTC preparations in all settings includes the
importance of contacting the health care provider:
a. if using products
b. if symptoms persist
c. when meds run out
d. when adding an herbal product

3. Grandmothers from what culture are known to play a significant role

in dealing with health care issues?
a. Pacific Islanders
b. Asians
c. African Americans
d. Europeans

4. In general, who administers medications when working in the home

care setting?
a. neighbours
b. nurses aides
c. advanced practice nurses
d. licensed nurses

5. Guidelines for use of interpreters do not include:

a. do not reply on the family members
b. same ethnicity
c. same gender
d. do rely on family members