ANGELES UNIVERSITY FOUNDATION

COLLEGE OF NURSING

NCM 0106 - PHARMACOLOGY

First Semester, Academic Year 2020 – 2021

Handout Number 5
DIFFERENT ROUTE FOR MEDICATION ADMINISTRATION

OBJECTIVES:
At the end of the discussion, the students will be able to:
 Understand the major routes of medication administration
 Identify the advantages and disadvantages of the different route of
administration
 Distinguish which drugs should be given oral or parenteral
 Integrate knowledge in the administration of medications

I. ORAL/ENTERAL ADMINISTRATION

The most desirable way to give drugs is by mouth. The oral route is the most
practical, economical, convenient and safe way to administer a drug that is why it is
most commonly used. Oral medications may be absorbed in the mouth and the
stomach, but they are generally absorbed in the small intestines. Chewing or
swallowing such preparations is the simplest way to get the drug into the body and
on its way to the bloodstream and other tissues. Forms of oral medications include
tablets, capsules, pills, syrups, elixirs and other forms of oral liquid drugs

Advantages:
1. The easiest and convenient way of giving medication
2. It is more economical. Less costly than injectable forms
3. It is relatively safe, since it does not involve breaking through the body’s defenses.
e.g., skin
4. Drugs given by mouth produce an effect that is more readily controlled than when
it is administered by injection

Disadvantages:
1. Possible vomiting due to the taste of drugs, and/or irritation of the gastric mucosa
2. Destruction of the drug by presence of digestive enzymes
3. The relative inability to accurately assess absorption of some drugs
4. The necessity for the cooperation of the patient

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Contraindications:
1. Those patients with dysphagia
2. Infants and small children who cannot swallow pills, tablets or capsules
3. Irrational, unconscious, uncooperative, restless patients
4. Patients on NPO
5. Patients recovering from anesthesia
6. Diarrhea or vomiting
7. Diseases of the oral cavity or have undergone oral surgery

Special considerations during oral administration of drugs:

1. Try to avoid mixing drugs with food when the patient is an infant or child. In the
future, the child is apt to refuse a food that he associates with drug administration

2. Explain to the child when the medication has an objectionable taste if the child is
likely to decrease his trust

3. Use a dropper to give infants or very small children liquid medications while
holding them in a sitting or semi-sitting position. Place the medication between
the gums and cheeks, to prevent aspiration

4. Do not tilt the head backward when the patient has difficulty in swallowing in
giving liquid medication. Tilting the head can cause aspiration

5. To disguise the objectionable taste of the medicine, the following techniques are
suggested:

 Give the medication with generous amounts of water or other liquids such as
juices if permitted
 Allow the patient to suck on a small piece of ice for a few minutes before
giving the medication
 Pour a liquid medication over crushed ice and offer it to the patient with
drinking straw
 Place the medication in a dropper or syringe and place the syringe well back
on the tongue while being careful not to cause the patient to gag
 Offer oral hygiene immediately after giving the medication with objectionable
taste or offer the patient sugarless gum if permitted

Procedure:
1. Check the written medication order for completeness. It should include the drug
name, dosage, route of administration, frequency and duration of the therapy

2. Check to see if there are any special circumstances surrounding administration of

the dose to the patient. For example, a nasogastric tube may be attached to
suction or the patient may be instructed nothing by mouth (NPO). Check with the
prescriber to determine if the medication should be administered by another route

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3. Be certain that you know the expected action, safe dosage range, special
instructions for administration and adverse effects associated with drug orders

4. Prepare the necessary equipment like the medication tray, cart, medication card,
water and pestle

5. Wash your hands

6. Prepare the dosage as ordered. Remember not to crush or tamper with sustained-
action dosage forms. Scored tablets may be broken along score marks if
necessary. If dosage forms other than those available on the nursing unit are
required for the patient, contact the pharmacist

7. Check the label on the medications three times before administering any drug

8. Do not touch labels or capsule with your hands. Pour the required number into the
bottle cap then into the medication cup. Unit dosage packages should not be
opened until the nurse is ready to administer the dosage to the patient. For liquid
medication, remove the cap and place it at eye level and fill it to the desired level

9. Never prepare a dosage of medication, which is discolored, has precipitated, and

is contaminated or outdated

10. If the patient expresses any doubt about the medication; always re-check the
order, drug label and dosage on the container

11. Elevate the head of bed to aid the patient in swallowing the medication

12. Stay with the patient as he/she swallows the medication. Provide necessary
assistance, e.g., positioning and/or obtaining fluids to aid in swallowing. Instruct
the patient not to chew any tablets or capsules except those, which are to be
chewed

13. If the patient refuses the medication, determine why. Report the refusal and
reason given to the head nurse. Note it on the patient chart

14. If the patient vomits within 20-30 minutes of taking the medication, the physician
must be promptly notified. Also note the details on the patient’s chart. Save
vomitus for inspection, if possible

15. If the dosage is to be administered sublingually, instruct the patient to place the
tablet under the tongue. Buccal tablets are placed between the gum and the
cheek preferably next to an upper molar. The patient should also be advised not
to chew the tablet or drink while the tablet is being absorbed

16. If the fluid intake and output are being monitored, record the amount of fluid taken
with the drug on the patient's intake sheet

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17. Following administration, be certain that the patient is comfortable, then
immediately record the procedure. This should include the name of the drug,
dosage, special factors related to oral administration (e.q. nasogastric tube
clamped following administration), time of administration and your name or initials

For patients with nasogastric tube:

 Some patient with nasogastric tube will have orders for medication to be
given through the tube. Liquid preparations of the drug should be used when
available. In other cases, the nurse will have to reduce the tablet to fine
powder as possible using mortar and pestle. Soft gelatin capsule may have a
pinhole pricked in one end and the liquid squeezed out into a plastic medicine
container or cup. Most capsules, which contain powder, may be emptied of
their contents. The resulting powder form capsules or pulverized tablets is
mixed with a small amount of fluid, usually 20-30 ml of water or normal saline
and taken to the patient’s bed at 30 – 45 degrees to avoid aspiration during
and following the administration of the drug

 Before administering the medication, the nurse check the placement of the
nasogastric tube to be certain that the medication administered through it will
reach the stomach

 Several techniques can be used to determine the proper placement of the

nasogastric tube:

 X-ray
 Auscultate
 Aspirate a small amount of gastric contents

 The patency of the tube is also checked, particular when the tube has not
been connected to a suction device. Patency can be checked by aspirating a
small amount of gastric contents and by flushing the tube with a small amount
of normal saline (about 20-30 ml). Always return fluid removed from the
stomach to maintain electrolyte balance

After placement and patency have been established, the previously prepared
medication can be administered through a syringe barrel (without the plunger)
connected to the tubing. Hold the barrel of the syringe approximately 6 inches higher
than the patient’s nose and allow the medication to flow into the stomach by gravity.
If it is hard to get the medication flowing gently, insert the bulb or plunger in to the
syringe. When the medication begins to flow remove the plunger or bulb and allow
the medication to flow by gravity. The administration of medication is followed by a
small amount of fluid, 20-30 ml for children and 30-35 ml for adults and the tube is
clamped for about 20-30 minutes. Clamping is necessary; otherwise the medication,
which has just been administered, will be withdrawn from the stomach by the suction
apparatus. The patient’s head should remain elevated for 20-30 minutes following the
installation of the medication

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II. PARENTERAL ROUTE

This refers to the route other than the oral, but current usage has restricted them
to mean “injections”. Parenteral route refers ordinarily to all the various ways by
which a solution or suspension of a drug is injected beneath or under the skin and
deposited within the body. Thus, this route is the administration of drugs through the
use of the needle and syringe by injection (forcing a fluid into a cavity, blood vessel
or body tissues through a needle).

Injection of drugs requires skill and special care, because parenteral

administration is more hazardous than the oral dosage form. This is mainly the result
of rapidly and efficiency with which drugs are absorbed from most injection sites.
Once a drug is injected, it is usually difficult to keep being fully absorbed and from
producing all of its effects including adverse ones.

Advantages:
1. Rapid absorption of drugs in comparison with the oral route
2. Best method to administer drugs in times of emergency
3. Desired dosage can be determined with greater accuracy
4. It can be used to unconscious, uncooperative and irrational patients

Disadvantages:
1. The use for strict asepsis when using this route
2. Limited opportunity for the patient to medicate himself
3. Breaking the continuity of the body’s defenses against infection
4. It is always associated with physical discomforts – painful
5. Expensive than oral medications
6. Requires rigid instructions to the patients in case he or she will be discharged
7. In case of error, it is difficult to take back the medicine because of its rapid
absorption in the bloodstream

Contraindications:
1. Sites with signs of inflammation such as redness, heat, edema, tenderness or pain
2. Presence of scar tissue

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TYPES OF PARENTERAL ROUTES OF ADMINISTRATION

A. INTRADERMAL INJECTION

Intradermal injections are made into the dermal layer of the skin just below the
epidermis. Small volumes, usually 0.01 - 0.1ml, are injected to produce a wheal. The
absorption from intradermal sites is slow, making it the route of choice for allergy
sensitivity tests, desensitization injections, local anesthetics and vaccinations

Site: Preferred areas are lightly pigmented, thinly keratinized and hairless such as
the ventral midforearm, clavicular area of the chest and scapular area of the back

Equipment: Needle: 25 –27 gauge

Syringe: 1ml calibrated in 0.01ml increments

Procedure:

1. Check with the patient before starting testing to be sure that he/she has not taken
anti-histamine or anti-inflammatory agents (such as aspirin, ibuprofen, and
corticosteroids) for 24- 48 hours preceding the tests

2. Wash your hands and assemble the needed equipment (1cc tuberculin syringe
with a 26 – 27 gauge, 5/8 or ¼ inch needle, alcohol swabs, and vial or ampoule and
medication card)

3. Locate the antecubital space. Select a site one (young child) to several (adult)
finger-widths distal to this landmark. Select a site without skin blemishes and with
little hair

4. Cleanse the site with an alcohol swab circular motion. Do not use iodine solution to
cleanse the skin since the residual iodine may interfere with interpretation of the skin
test. Allow the skin top dry thoroughly
5. Holding the patient’s forearm in one hand, stretch the skin taut

6. Position the syringe with the bevel of the needle pointing upward so that the
needle is almost flat against the patient’s skin (about 15 degrees)

7. Insert the needle through the epidermis so that the point of the needle is visible
through the skin

8. Gradually inject the medication. Observe for the development of a small blister
(wheal)

9. When the wheal appears, withdraw the needle. When the intradermal injection is
given for diagnostic purposes e.g. to determine sensitivity to allergens, a control
wheal is also made. The solution injected is the same fluid without the allergen and
the wheal is made on the opposite arm

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10. Using blue or black ball pen, mark the wheal that was formed. Write the time the
medication was injected and the time for you to check the skin test result, which is 30
minutes after the injection

11. Chart the name of the medication, the amount given, the time and the location of
the test and control sites. Always observe the patient for local (redness, itchiness)
and systemic reactions (anaphylaxis)

B. SUBCUTANEOUS INJECTION

Subcutaneous injections are made into the loose connective tissue between the
dermis and the muscle layer. Absorption is slower and drug action is generally longer
with subcutaneous injections. If the circulation is adequate, the drug is completely
absorbed from the tissue.

Many drugs cannot be administered by this route since no more than 2 ml can
ordinarily be deposited at a subcutaneous site. The drugs must be quite soluble and
potent enough to be effective in small volume without causing significant tissue
irritation. Drugs commonly injected into the subcutaneous tissue are heparin and
insulin.

Site: Locations are chosen for adequate fat pad size and include the abdomen, upper
hips, upper back, lateral upper arms and lateral thighs

Equipment: Needle: 25 – 27 gauge, ½ to 5/8 inches in length

Syringe: 1 to 3 ml (usually 0.5 – 1.5 ml injected)

Procedure:

1. Identify the patient and explain the procedure

2. Position the patient for maximum comfort, privacy and exposure of the injection
site

3. Identify the anatomical landmarks by inspection and palpation

4. Identify the injection site. In an ideal site, you should be able to pinch at least 1-
inch subcutaneous tissue between the thumb and forefinger

5. Cleanse the injection site with an antiseptic solution using a circular motion
working from the site outward. Place the swab between the fingers of the hand not
holding the syringe

6. Remove the protective needle cap

7. Grasp the skin firmly between the thumb and forefinger to elevate the
subcutaneous tissue

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8. Holding the syringe firmly and at 45-degree angle to the skin, thrust the needle into
the tissue

9. Once the needle is inserted, release the grasp on the patient’s tissue

10. If no blood appears in the syringe, slowly introduce the medication. This allows
time for distention of space within the tissue to accommodate the fluid and prevent
the forcing of medication back up the needle tract.

11. When the syringe is empty, smoothly and quickly withdraw the needle and use
the swab to immediately place pressure over the puncture site. Unless
contraindicated, as in heparin administration, massage the injection site to
facilitate the absorption of the medication

12. Position the patient comfortably

13. Chart date, time route and site of injection and the dosage of the medication

C. INTRAMUSCULAR INJECTION

Penetrating a needle through the dermis and subcutaneous tissue, into the muscle
layer, makes intramuscular injections. The injection deposits the medication deep
within the muscle mass. Absorption is more rapid than from the subcutaneous
injections because muscle tissue has a greater blood supply. Site selection is
especially important with IM injections because incorrect placement of the needle
may cause damage to the nerves or blood vessels. A large, healthy free of infection
or wounds should be used.

Site: Locations are chosen for adequate muscle size and minimal major nerves and
blood vessels in the area. Locations include ventrogluteal, dorsogluteal, deltoid, and
vastus lateralis (pediatrics)

Equipment: Needle: 20 – 23 gauge, 1 to 1.5 inches in length

Procedure:

1. Identify the patient and explain the procedure

2. Position the patient for maximum comfort, privacy and exposure of the injection
site

3. Identify the anatomical landmarks by inspection and palpation

4. Identify the injection site

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5. Cleanse the injection site with an antiseptic solution using a circular motion
working from the site outward. Place the swab between the fingers of the hand not
holding the syringe

6. Remove the protective needle cap

7. Holding the syringe firmly and perpendicularly to the skin, thrust the needle into the
muscle at 90-degrees angle. Do not insert the needle up to the hub but leave ¼ to
½ inch to allow identification in case the needle should break

8. Holding the syringe with the left hand, aspirate by pulling back on the plunger with
the right hand. If blood appears in the syringe, remove the needle and replace it
with a sterile needle before repeating the procedure

9. If no blood appears in the syringe, slowly introduce the medication. This allows
time for distention of space within the muscle to accommodate the fluid and
prevent the forcing of the medication back up the needle tract into the
subcutaneous tissue. Another way to ensure that the medication does not leak out
of the injection site is to draw an air bubble of 0.3 ml into the syringe after the
medication is injected, the bubble follows the medication into the needle tract and
subcutaneous tissue

10. Smoothly and quickly withdraw the needle and use the swab to immediately
place the pressure over the puncture site. Unless contraindicated, massage the
injection site to facilitate the absorption of the medication

11. Position the patient comfortably

12. Chart the date, route and site of injection and the name and the dosage of the
medication

D. INTRAVENOUS METHOD OF ADMINISTERING DRUGS

Intravenous (IV) administration of medication places the drug directly into the
bloodstream, by passing all barriers to drug absorption. Large volumes of
medications can be administered into the vein; there is usually less irritation, and the
onset of action is the most rapid of all parenteral routes. Drugs may be given by
direct injection with a needle and syringe, but more commonly drugs are given
intermittently or by continuous infusion through an established peripheral or central
venous line, or via an implantable venous access device, also referred to as
“implantable subcutaneous port”

Purpose: To provide a rapid onset of drug action

Equipment: ordered drug, syringe and needle, IV fluid, cotton swab with alcohol,
medication card

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Site: Accessible peripheral veins (e.g. cephalic or cubital vein of arm, dorsal vein of
hand)

Equipment: Needle: Adults: 20 – 21 gauge, 1 to 1.5 inches

Infants: 24 gauge, 1 inch
Children: 22 gauge, 1 inch
*Larger bore for viscous drugs, whole blood or fractions

Procedure
1. Apply a tourniquet

2. Cleanse the area using aseptic technique

3. Insert butterfly or a catheter, and feed up into the vein until blood returns. Remove
tourniquet

4. Stabilize the needle and dress site

5. Monitor the flow rate, distal pulses, skin color, temperature, and insertion site

6. Consult agency policy regarding the addition of medications to bottle or bag,

piggyback technique and IV push

Special considerations:
1. Wash hands thoroughly

2. Prepare the prescribed drug in the syringe

3. Always observe aseptic technique in preparing and administering drugs

4. Explain the procedure to the patient

5. Always check the needle of the intravenous infusion if it is in the vein before
administering the drug by any of the following method:

> bring the IV bottle lower than the patient’s arm

> pinch the IV tubing

*** if the needle is in the vein, the nurse must observe for the backflow
of the blood in the distal portion of the IV tubing

6. Record the drug after its administration

8. Observe the patient for possible untoward reaction

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INTRAVENOUS PUSH OR BOLUS

1. Close the IV tubing by: (as the case may be)

> Pinching the tubing above the injection site
> Closing the flow regulator or clamps

2. Clean the injection port (rubberized portion) with a cotton swab with alcohol

3. Insert the needle into the injection port and inject the drug slowly for a period of 1
to 7 minutes. Observe the patient for any untoward reaction

4. When the administration is completed, withdraw the needle and open the clamp of
the tubing
5. Regulate the IV fluid through its proper rate of flow

6. Chart the procedure including the time, name and dosage of drug and the patient’s
response to the administration

INCORPORATION – this method is used when the drug is mixed to an IV line

whether an on-going or follow-up line

Initial line or Follow-up line

1. Remove the metal cover from the IV bottle

2. Clean the rubber stopper of the IV bottle with an alcohol swab

3. Inject the prepared drug into the larger whole of the rubberized stopper since the
smaller hole serves as an airway

4. Invert the bottle several times to mix the IV solution and the drug

5. Label the IV bottle with a card indicating the name of the drug, dosage, time of
administration and the signature of the nurse

6. If it is an initial line, run a small amount of fluid to remove the air on the tubing

* If the bottle is used as follow-up, close the clamp of the IV tubing and remove the
bottle that was consumed. Insert the tip of the IV tubing into the hole of the rubber
stopper of the IV bottle intended for follow-up

7. Open the clamp and regulate the proper flow rate

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Ongoing line

1. Close the clamp of the IV tubing

2. Remove the needle of the syringe and inject the prepared drug into the injection
port of the drip chamber

3. Invert the bottle several times to mix the drug and the IV fluid

4. Label the bottle with card containing the name of the drug, dosage, time drug was
administered and the signature of the nurse

5. Open the clamp and regulate the proper flow rate

PIGGYBACK OR SIDE-DRIP
1. Prepare the medication to be administered in the required amount of fluid or obtain
the medication already prepared

2. Connect the bottle containing the medication to an intravenous administration pack

3. Place a needle, usually 20G, on the end of the tubing designed for it

4. Invert the bottle and run a small amount of fluid in the tubing to remove the air

5. Take the administration set-up to the bedside and invert the bottle next to the
primary intravenous administration set-up

6. Clean the injection site on the primary set with alcohol and insert the needle, being
careful not to puncture the tubing of the primary set

7. Tape the needle securely in place

8. Open the clamp on the piggy set and establish the correct flow rate

9. Check the flow rate frequently to reestablish the flow once the piggyback set-up
has emptied

10. Complete the charting of the information to the drug administration including the
drug, its dosage, amount of fluid, administration time and the patient’s response to
the procedure. Be certain to chart the amount of fluid infused on the intake and
output record (I&O)

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ADMINISTRATION THROUGH A SPECIAL CHAMBER
(SOLUSET OR BURETOL)
1. Clamp the administration tubing below the drip chamber

2. Allow 10-15 ml of the fluid being administered intravenously to flow into the drug
administration chamber (soluset)

3. Close the clamp between the bottle and the administration chamber

4. Cleanse the injection site on the administration chamber with alcohol

5. Inject the medication to be administered into the chamber

6. Open the clamp between the bottle and the drug administration chamber and add
the appropriate amount of fluid to the administration chamber

7. Clamp the tubing above the administration chamber

8. Gently agitate the drug administration chamber to mix the fluid

9. Open the clamp below the chamber

10. Establish the flow rate appropriate to permit administration of the required
amount of medication within the specified time period

11. Once the medication has been administered, open the clamp above the
administration chamber to resume administration of the fluid ordered

12. Chart the procedure including the time, dosage and patient’s reaction to the
procedure

Prepared by:

Pharmacology Instructors

Noted by:

Jennie C. Junio, RN, MAN

Level 2 Coordinator

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