TheSixRightsofMedicationAdministration Procedure Merged PDF

Mosby's Nursing Video Skills
Procedure Guideline for Ensuring the Six Rights of Medication Administration

1. Perform hand hygiene.
2. To prevent medication errors, keep in mind the six rights of medication administration each
time you prepare to administer a drug: right medication, right dose, right patient, right
route, right time, and right documentation. Depending on the agency, some or all of the
preparation may occur in the medication room and/or at the patient’s bedside.
3. Bring medications to the patient’s room. Introduce yourself to the patient and family if
present. Provide for the patient’s privacy. Obtain any pre-assessments necessary for
medication administration.
4. Review the Medication Administration Record (MAR) to make sure it is clear and
complete. The order must include:
A. Patient’s full name

B. Drug ordered
C. Dosage
D. Route of administration
E. Time of administration
5. Observe the six rights of medication administration:
A. Right medication:
(1) Check the medication label against the MAR three times:
a. Once when you take the medication out of the dispensing system, or
before removing medication from the drawer or shelf
b. Once before placing medicaiton in the medicine cup or taking it to the

patient’s room
c. Once before administering medication at the patient's bedside.
(2) If the medication requires preparation and it is not in its original container,
be sure to label it. Include the name of the drug, its strength, the amount, and
expiration date or time.
(3) If you must prepare a dose from a larger volume or strength, or if the
prescriber orders the medication in a system of measurement that is different
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

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from what the pharmacy supplies, calculate the dose. Double-check all
medication calculations and ask another nurse to calculate the dose
independently. Compare your calculations and confirm that you have
calculated the dose correctly.
B. Right dose
(1) When administering insulin, a narcotic, a sedative or an anticoagulant,
follow current guidelines for administering high-alert medications.
(2) To help ensure the right dose for a liquid medication, prepare it using a
standard measuring device, such as a syringe or graduated medication cup.
(3) Ask the pharmacy to split tablets, or use a pill-splitting device to administer
part of a tablet. Only scored tablets should be split. Discard any pill that
doesn't break evenly.
(4) Mix crushed tablets with a small amount of food or liquid to make it easier
to swallow.
(5) Never crush sublingual, enteric-coated or extended-release medications.
C. Right patient:
(1) When you’re ready to administer a medication, ensure that you have the
right patient, using two identifiers. For example, check his identification
band, compare it to the MAR, and ask the patient to state his full name and
birth date.
(2) Do not use the patient’s room number for identification.
(3) Some agencies use a wireless bar-code scanner to help identify the right
patient.
D. Right route:
(1) Next, ensure that the medication is for the right route, based on the
prescriber’s order. If the route is missing from the order or if it’s not the
recommended route for the medication, consult the prescriber immediately.
(2) For an injection, be sure to use only a preparation intended for parenteral
use. Injection of an oral medication can be life threatening. To prevent this
problem, remember that parenteral medications are labeled “for injectable
use only.”
E. Right time:
(1) Follow your agency’s recommended schedule for routine medications. In
general, give non–time-critical medications within 1 to 2 hours of the
scheduled time.

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(2) For time-critical medications:

a. Give STAT doses immediately.
b. Give NOW doses within 60 minutes of receiving the order.
c. As needed, use your clinical judgment about the timing of other doses.
For example, if a drug must be given with food, administer it within 30
minutes after a meal.
d. Give an “on call” drug when the operating room or treatment area
requests it.
e. Give a PRN (pro re nata, Latin for “when necessary”) drug according
to circumstances, per the patient’s request. Check the MAR to see
when the last PRN medication was administered to ensure that an
additional dose is appropriate.
F. Right documentation:
(1) Document the medication’s name, dose, route, time given, and any
preassessments obtained, immediately after giving the medication. (Refer to
the video skill, "Documenting Medication Administration").
(2) Document the patient’s response to PRN medications.
(3) Teach the patient about his medication.
(4) To review your rights and responsibilities as a nurse, refer to the video skill,
"Preventing Medication Errors."
6. Dispose of sharps in a sharps container immediately. Dispose of other supplies if necessary.
7. Remove clean gloves, if used, and perform hand hygiene.
8. Help the patient into a comfortable position, and place toiletries and personal items within
reach.
9. Place the call light within easy reach, and make sure the patient knows how to use it to
summon assistance.
10. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed
to the lowest position.
11. Leave the patient’s room tidy.

Procedure Guideline for Administering Oral Medications

1. Verify the health care provider’s orders.
2. Gather the necessary equipment and supplies.
4. Prepare the medication:
A. As you work, avoid interruptions. Keep the door to the medication room closed, and
do not accept telephone calls. Follow your agency’s “No Interruption Zone” policy.
B. Arrange the medication tray and cup in a drug preparation area. Access the automated
dispensing system, or unlock the medicine drawer or cart.
C. Prepare medications for one patient at a time. Follow the six rights of medication
administration. (Refer to the video skill "Ensuring the Six Rights of Medication
Administration").
D. Select the correct drug from the automated dispensing system, unit-dose drawer, or
stock supply. All medications must be verified three times. Confirm the name of the
medication by comparing the label with the Medication Administration Record
(MAR). This is your first check.
E. If the dosages on the label do not match the dosage prescribed, check or calculate the
correct amount of medication to give. Double-check any calculation. Check the
expiration date of all medications, and return outdated medication to the pharmacy.
F. To prepare a unit-dose tablet or capsule, compare the packaged tablet or capsule with
the MAR, and then put it into the medication cup without removing the wrapper.
Administer a unit-dose medication only from a clearly labeled container. If any
medication is not clearly labeled, do not administer it.
G. If you are giving tablets and capsules, use a single medication cup. Medications that
require a pre-assessment, such as apical pulse or blood pressure measurement, should
be placed in a separate medication cup as a reminder to perform the assessment.
H. If your patient only needs half of a tablet or pill, ask the pharmacy to split, label,
package, and send the medication to the unit. If you must split a scored tablet, use a
clean pill-cutting device. Split the tablet and discard the other half. Do not split a
tablet or caplet that has not been scored by the manufacturer.
I. If the patient has difficulty swallowing, crush each medication separately using a pill-
crushing device. Mix the ground tablet into a small amount (about a teaspoon) of soft
food, such as custard or applesauce. Remember to give each crushed medication
separately.

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J. Controlled substances will be stored in a secured locked compartment of the

dispensing unit. When you retrieve a controlled substance, check the controlled drug
record for the previous count, and compare it with the supply remaining to be sure
they match. Never leave any medication unattended.
K. Before going to the patient's room, verify the patient's name on the MAR with the
labels on the prepared drugs to confirm the drug name and the patient's name. This is
your second check. If using an automated dispensing system, log out after you
remove the drugs.
5. Take oral medication to the patient at the correct time (see agency policy). Give time-
critical medications (i.e., STAT and NOW doses) at the precise time ordered. During
administration, apply the six rights of medication administration.
6. Administer the medication:
A. Perform hand hygiene.
B. Provide for the patient's privacy.
C. Introduce yourself to the patient and family, if present.
D. Identify the patient using two identifiers.
E. For highly acidic medications (e.g., aspirin), offer the patient a nonfat snack (e.g.,
crackers) if not contraindicated by the patient’s condition.
F. At the patient’s bedside, again compare the MAR with the names of the medications
on the medication labels and with the patient’s name. This is your third check.
G. Perform necessary pre-administration assessment (e.g., blood pressure, pulse) for
specific medications.
H. Discuss the purpose of each medication, its action, and possible adverse effects.
Allow the patient to ask questions.
I. Administer tablets or capsules with the patient in a sitting or side lying position. The
patient may wish to hold solid medications in his or her hand or in the cup before
placing them in his or her mouth. Offer water or the patient’s preferred liquid to help
swallow the medications, as long as it is compatible with the medication
7. For liquid medications:
A. Thoroughly mix liquids before administration by shaking the container gently. If a

drug is in a unit-dose container with the correct volume, shaking is not necessary. If
the drug is in a multi-dose bottle, remove the bottle cap from the container and place
the cap upside-down on your work surface.

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B. Hold the label of the bottle against the palm of your hand as you pour to protect the
label's integrity.
C. Place a medication cup one a level surface where it can be read at eye level, and pour
the liquid to the desired level. The printed or embossed line indicating the correct
dosage should be even with the bottom of the fluid meniscus or the surface of the
liquid.
D. Wipe the lip and neck of the bottle with a paper towel, and recap the bottle.
E. If you’re giving less than 10 mL of liquid, prepare the medication in an oral syringe.
Do not use a hypodermic syringe or a syringe with a needle or syringe cap.
8. For orally disintegrating formulations (tablets or strips): Remove the medication from the
packet just before administering it. Tear the package open carefully. Do not push the tablet
through the foil. Place the medication on top of the patient’s tongue. Caution him or her
against chewing the medication.
9. For buccally administered medications: Have the patient place the medication in his or her
mouth against the mucous membranes of the cheek and gums until it dissolves.
10. For sublingually administered medications: Have the patient place the medication under the
tongue and allow it to dissolve completely. Caution the patient against chewing or
swallowing the tablet. Caution the patient against chewing or swallowing lozenges
11. For powdered medications: Mix with liquids at the bedside and give the mixture to the
patient to drink.
12. If the patient is unable to hold medications, place the medication cup to his or her lips and
gently introduce each drug into the mouth, one at a time. Be patient and do not rush or force
medication administration. A spoon can also be used to place the pill in the patient’s mouth.
If necessary, using a gloved hand, place the medication directly into the patient’s mouth.
13. Stay until the patient completely swallows each medication or takes it by the prescribed
route. Ask the patient to open his or her mouth if you are not certain whether he or she has
swallowed the medication.
14. Help the patient return to a comfortable position.
15. Dispose of soiled supplies, and perform hand hygiene.
16. Place toiletries and personal items within reach.
summon assistance.

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20. Document the medication administration immediately after administration, not before.
21. As follow up care, keep an eye on the patient to see his or her response to the medication.


Procedure Guideline for Documenting Medication Administration
1. Documenting completely and accurately before and after administering a drug is the
6th right of medication administration.
2. Begin by reviewing the order carefully against the medication administration record
(MAR).
3. Verify that the order is complete and accurate. Make sure it includes the following
information: (query any items that are missing or unclear)
B. Drug name ordered
C. Dosage
D. Route
E. Frequency or timing of administration, including the time interval if it is a PRN
order
4. Consult the prescriber in the following circumstances:
A. The dosage is unusually large or small.
B. A route of administration other than the recommended route has been specified.
C. The order seems incorrect or inappropriate for the patient in any way.
D. The handwritten order is illegible.
5. If you have doubt about any of the six rights (right medication, right dose, right
patient, right route, right time or right documentation), it is your right as a nurse to
withhold the medication while you consult the prescriber, the pharmacist or a current
drug guide. Refer to the video skill “Ensuring the Six Rights of Medication
Administration.”
6. If you receive a telephone or verbal order, enter it into the MAR and read the entire
order back to the prescriber. At the end of the order, write TO for telephone order or
VO for verbal order. Include the prescriber’s name. Indicate that the order was read
back. The prescriber must countersign the order later, usually within 24 hours (refer
to agency policy).
7. Due to a high risk for errors, telephone and verbal orders should only be done for
emergent reasons. Another nurse should listen in if possible. Follow agency policy.
8. Before administering medication, identify the patient using two identifiers according
to agency policy. Verify the identification against the MAR.
9. Ask the patient if he has any allergies.
10. In addition, use a bar code scanner if your agency has such a system.
11. Immediately after medication administration, document the following in the patient’s
MAR:
A. Drug name
B. Dosage
C. Route of administration and location of the injection site, if applicable
D. Actual time the medication was given
E. For PRN medications, include the indication for administration and the patient’s
therapeutic response.

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F. For medications that were held, document the time, and reason for withholding
the medication, and any additional action taken, such as notifying the prescriber.
G. For medications that require a preassessment, include information on the MAR
such as BP, heart rate, or pertinent lab values.
H. Mark each entry with your initials or signature per agency policy.
12. Guidelines for documenting the medication administration:
A. Enter only medications you yourself administered or witnessed the patient self-
administer.
B. If handwriting, comply with the standardized list of abbreviations, acronyms,
symbols, and dose designations approved by your agency policy.
C. Use Tall Man lettering (a mix of capital and lower case letters) to help emphasize
dissimilarities between look-alike and sound-alike drugs, such as TEGretol and
TRENtal.
D. When entering a drug dosage, never add a trailing zero after a whole number (e.g.,
1.0 mg) and always include a zero preceding a decimal value of less than 1 (e.g.,
0.5 mL).
E. Record allergy information in several places including the MAR, electronic
medical record or the front of the patient’s chart. The patient must also wear a
color coded allergy band.
13. Document drugs dispensed by a medication dispensing system the same as you would
document drugs dispensed by other means.
14. If a patient refuses a medication, document the reason for refusal and if the prescriber
was notified. If a narcotic was wasted, record this on the narcotic administration form
(or enter it in the appropriate computer document) and have the witnessing nurse sign
it to indicate that the drug was discarded properly. Follow agency policy.
15. As part of your follow-up care, observe and document the patient’s therapeutic
response to the medication, and monitor for side effects. Notify the provider of any
serious adverse events.

Procedure Guideline for Handling Variations in Medication Administration
1. Before administering any medication, check the medication administration record

(MAR) against the provider’s orders.
2. Compare the label of the medication with the information in the MAR twice, and do a
third check at the bedside. Also check the expiration date of the medication.
3. As you proceed, observe the six rights of medication administration; right medication,
right dose, right patient, right route, right time and right documentation. Refer to the
Video Skill “Ensuring the Six Rights of Medication Administration.”
4. Perform hand hygiene, ensure patient privacy and introduce yourself to the patient.
5. Identify the patient using two identifiers according to agency policy.
6. If a patient refuses a medication, carefully assess his or her reason for refusing and
intervene appropriately:
A. Patient refuses medication due to allergy:
(1) If the patient is allergic to the medication, withhold it and check the medical
record for documentation. Document the allergy as required by agency policy,
and obtain an allergy ID band for the patient. Notify the health care provider,
and request a change to the medication order.
B. Patient refuses medication due to side effects:
(1) If the patient is unwilling or unable to tolerate the drug’s unpleasant or
inconvenient side effects, assess the patient to determine that the symptoms he
or she describes are side effects, and not a life-threatening adverse reaction.
(2) Try to eliminate or reduce the side effects by suggesting he take the
medication with food or at a different time.
(3) Explain your reasoning and emphasize the importance of taking the
medication as prescribed and the possible consequences of not taking the
medication.
(4) Since side effects can be dose dependent, ask the prescriber if it is possible to
give a smaller dose, or to give lower doses at more frequent intervals.
(5) Respect the patient’s right to refuse. Withhold the medication, and notify the
health care provider.
C. Patient questions the medication or dosage:
(1) If the patient questions the medication, stop and recheck to be certain there is
no mistake. An alert patient or family caregiver will know whether a
medication is different from those he or she has received before.
(2) A patient may question you if the medication looks unfamiliar (e.g., a gel
capsule instead of a tablet, or a blue tablet instead of a green tablet).
(3) If the patient questions the medication, do not give it until it has been verified
with the health care provider’s order.
(4) Once the medication has been verified, address the patient’s concern by
explaining the new drug form. For example, a generic drug may have been
substituted for a brand name. Be aware that look-alike and sound-alike
medications may contribute to drug errors. When in doubt, withhold the drug
until you can confirm it.

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7. A patient may make an inappropriate request for a medication. If you have a PRN
order for a medication, use your clinical judgment. Do not give medications
automatically without assessing the patient’s need.
8. Become familiar with the onset and duration of action for each medication you
administer.
9. Be aware of how long it will take to reach its peak and begin to plateau.
10. If a patient requests a PRN analgesic and it is too early to administer the next dose, do
the following:
A. Assess the patient’s pain.
B. Check the medication administration record (MAR) to determine the time of the
previous dose.
C. If it is too early for additional pain medication, enhance the patient’s comfort with
nonpharmacologic measures, such as distraction, a back massage, or
repositioning.
D. Give the pain medication as soon as the prescribed time interval has elapsed.
(1) Identify the patient using two identifiers according to agency policy.
(2) Help the patient sit up and watch him/her take the medication.
(3) Help the patient back into a comfortable position.
E. Document the dose in the patient’s MAR.
F. Notify the health care provider if the pain medication order does not seem to provide
appropriate pain management.
11. If a medication was refused, document that it was not given, the reason for refusal
and the time at which the health care provider was notified according to agency
policy.
12. If a medication is held, document the time and reason for holding the medication and
notify the health care provider if necessary according to agency policy.
13. As part of your follow-up care, monitor the patient’s response to determine whether
the interventions have relieved his pain. Notify the health care provider when a
patient refuses medication, complains of intolerable side effects, or reports that the
medication does not provide the expected therapeutic effect. The dose, drug, or drug
form may need to be changed.

Procedure Guideline for Preventing Medication Errors
1. Before administering any medication, check the medication administration record

(MAR) against the provider’s order.
2. The best way to prevent medication errors is to ensure the six rights of safe
medication administration as shown in the Video Skill “Ensuring the Six Rights of
Medication Administration.”
3. Begin by reviewing the medication order which should include:
1. Patient’s full name
2. Name of the drug
3. Dosage
4. Route of administration
5. Frequency or time of administration
6. Indication for use (PRN orders only)
7. Date of order expiration
8. Prescriber’s signature
4. To avoid medication errors, consult the prescriber about any illegible handwriting, an
unusually large or small dose, or an order that seems incomplete, incorrect or
inappropriate for the patient.
5. Once you begin the medication administration process, do not let anything
interrupt the process.
6. ERROR PREVENTION TIPS FOR THE SIX RIGHTS:
A. Right medication:
(1) When administering the drug, compare the label on the drug container with the
MAR three times:
a. Once before removing the drug from the drawer or shelf
b. Once before placing the drug in a medicine cup or taking it to the patient’s
room
c. Once again before administering the drug at the bedside
(2) If the patient questions the medication you have prepared, withhold it until you
can recheck the preparation against the order.
(3) If the drug ever seems inappropriate with the patient’s condition, check with the
prescriber.
(4) Never assume that the pharmacy has sent the correct form or dose of the
medication. Refer to drug reference material if the medication name is different
from that which appears on the order.
B. Right dose:
(1) If you must calculate a dose or conversion, double-check your calculations. Then
verify them with another registered nurse, especially if it is a high-alert
medication.
(2) Use standard measurement devices, such as medication cups or syringes.
(3) Avoid splitting medication that has not been scored by the manufacturer. If
possible, send the pill to the pharmacy to be split and repackaged with an accurate
label or encourage the provider to order medications that do not require splitting.

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(4) To crush a tablet, pulverize it and mix it with a small amount of food or liquid. If
mixing with food, ensure there is no incompatibility.
a. Sublingual, enteric coated and time release medications must never be
crushed.
b. The medication crusher should be thoroughly cleaned after each use.
C. Right patient:
(1) Use at least two patient identifiers when administering a medication. For example,
check the name band, and ask the patient to state his or her full name and birth
date. Compare this information with the MAR. If the patient’s ID band is illegible
or missing, obtain a new one.
(2) If your patient is confused or unresponsive, compare the information in the MAR
with that printed on the patient’s ID band.
D. Right route:
(1) Use oral syringes for oral and enteral medications. Use parenteral syringes for
injectable medications. Label all syringes at the point of preparation with the
drug, dose, and route.
(2) Contact the prescriber immediately if the specified route is missing or if the route
is not recommended or contraindicated for the patient’s condition.
E. Right time:
(1) Do not give PRN medications automatically. Check the documentation to see
when the medication was last given, and allow an appropriate time interval to
elapse.
(2) Administer time-critical medications (antibiotics, insulin, anticoagulants) within
the 30-minute window before or after the scheduled time or according to agency
policy.
(3) Give non–time-critical drugs within 1 to 2 hours of the scheduled time or
according to agency policy.
(4) Remember that a Q8H drug must be given around the clock to maintain a
therapeutic blood level.
(5) Remember a TID medication may be given during waking hours and scheduled
around the patient’s activities.
F. Right documentation:
(1) Document your preparation for medication administration, and document all
medications as soon as you administer them, as shown in the Video Skill
“Documenting Medication Administration.”
(2) Follow agency policy for documenting held or refused medications.
(3) Document the name of the drug and the dose, route, and time of administration in
the MAR. Include the site when you give an injection.
(4) Document the patient’s response to all PRN medications.
7. Remember if a medication error occurs despite your best efforts, follow up by
reporting it according to agency policy. Follow agency policy for appropriate
interventions for the patient such as administering an antidote, withholding the next
dose, and monitoring the patient as appropriate.


Procedure Guideline for Using Automated Medication Dispensing Systems
1. Before using a medication dispensing system, review your patient’s medication

administration record (MAR) for the following:
B. Drug’s name, dosage, and form (e.g., tablet, liquid, or suppository)
C. Route and frequency or timing of administration
D. Reason for administration (for a PRN medication)
E. Expiration date
2. Follow the six rights of medication administration:
A. Right medication
B. Right dose
C. Right patient
D. Right route
E. Right time
F. Right documentation
3. Follow the correct procedure for using your agency’s medication dispensing system:
A. To access the computer, enter your security code or perform bioidentification
using your fingerprint.
B. Once you have logged in, select a patient’s name and medication profile.
C. Using the touch screen, select the appropriate medication, as indicated on the
MAR. Remove the medication from the dispensing compartment.
D. Check that you have the right drug and dose for your patient, comparing it again
with the MAR. As an additional safety check, some dispensing systems require
that the medication be scanned when it is removed.
E. Repeat these steps for all additional medications.
F. Log off the system and lock the storage area before walking away.
4. Report immediately any discrepancies between what the physician ordered or what
was requested from the dispensing system, and what was supplied.


Procedure Guideline for Applying Topical Medications
1. Verify the health care provider’s orders and compare it with the medication
administration record (MAR) twice.
4. Introduce yourself to the patient and family, if present.
5. Provide for the patient’s privacy.
6. Identify the patient using two identifiers, such as name and date of birth or name and
account number, according to agency policy. Compare these identifiers with the
information on the patient’s identification bracelet.
7. Verify the patient’s allergies and check the expiration date of the medication.
8. Take the medication to the patient at the correct time (refer to agency policy). Give
time-critical medications (i.e., STAT and now doses) at the precise time ordered.
During administration, apply the Six Rights of medication administration. Review the
video “Six rights of medication administration” if needed.
9. Apply clean gloves. If the patient has any open skin areas, use sterile gloves.
10. Help the patient into a comfortable position.
11. Discuss the purpose of each medication, its action, and possible adverse effects.
Allow the patient to ask questions about the drugs.
12. Apply topical creams, ointments, and oil-based lotions:
A. Expose the affected area while keeping unaffected areas covered.
B. Wash, rinse, and dry the affected area before applying medication.
C. If the skin is excessively dry and flaking, apply the topical agent while the skin is
still damp.
D. Remove your gloves, perform hand hygiene, and apply new clean gloves.
E. Place the required amount of medication in the palm of your gloved hand, and
warm it by rubbing it briskly between your gloved hands. Spread the medication
evenly over the patient’s skin using long strokes in the direction of hair growth.
You may need to use cotton-tipped applicators for small areas.
F. Do not vigorously rub the skin. Apply to the thickness specified by the
manufacturer’s instructions.
G. Explain to the patient that the skin may feel greasy after application.
13. Applying a transdermal patch:
A. Apply clean gloves and remove the old patch.
B. Fold the sticky sides of the patch together and dispose according to agency policy.
Policy may require that the patch be cut in half prior to disposal.
C. Use a felt tip marker to note the date, time, and initials of the person applying the
new patch.
D. Apply clean gloves.
E. Apply new patch to a clean, dry area, avoiding the previous site for at least a
week. The new site must be relatively free of hair, burns, cuts, or any kind of skin
irritation, and must not be too oily.

F. To apply the new patch, carefully remove the plastic liner by holding the patch
around the edges without touching the adhesive.
G. Apply the patch immediately to the selected site, pressing it firmly with your hand
for 10 seconds to ensure that it is adheres well.
H. Remove gloves and perform hand hygiene.
14. Administer aerosol sprays (e.g., local anesthetic sprays):
A. If the area of application is near the face, ask the patient to turn his or her face
away from the spray or briefly cover the face with a towel.
B. Shake the container vigorously. Read the container label for the recommended
distance at which to hold the spray away from the area—usually 15 to 30 cm (6 to
12 inches).
C. Spray the medication evenly over the affected site (in some cases, the spray is
timed for a period of seconds).
15. Apply a suspension-based lotion:
A. Put on clean gloves. Shake the container vigorously.
B. Apply a small amount of lotion to a small gauze dressing or pad, and apply it to
the skin by stroking evenly in the direction of hair growth. Dab the affected area
and avoid rubbing vigorously.
C. Explain to the patient that the area will feel cool and dry.
16. Apply a powder:
A. Be sure the skin surface is thoroughly dry. With your nondominant hand, fully
spread apart any skin folds, such as between the toes or under the axilla, and dry
with a towel.
B. If the area of application is near the face, ask the patient to turn his or her face
away from the powder or briefly cover the face with a towel.
C. Dust the skin site lightly with a dispenser so that the area is covered with a fine,
thin layer of powder. Option: Cover the skin area with a dressing if ordered to do
so by the health care provider.
17. Dispose of soiled supplies in the appropriate trash receptacle, remove and dispose of
your gloves, and perform hand hygiene.
18. Help the patient into a comfortable position, and place toiletries and personal items
within reach.
19. Place the call light within easy reach, and make sure the patient knows how to use it
to summon assistance.
20. To ensure the patient’s safety, raise the appropriate number of side rails and lower the
bed to the lowest position.
22. Document and report the patient’s response and expected or unexpected outcomes.

Procedure Guideline for Applying an Estrogen Patch or Nitroglycerin Ointment

1. Take the medication to the patient at the correct time (refer to agency policy). Give time-
critical medications (that is, stat and “now” doses) at the exact time ordered. During
administration, apply the Six Rights of Medication Administration
2. Refer to the video skills “Applying Topical Medication” and “Ensuring the Six Rights of
Medication Administration” before performing this skill.
6. Identify the patient using two identifiers according to agency policy. Compare these
identifiers with the information in the patient’s MAR or medical record. Ask the patient if
he or she has allergies.
7. Before applying a topical medication, verify the health care provider’s orders.
8. Assist the patient into a comfortable position.
9. Compare the MAR or computer printout with the names of the medications on the
medication labels, twice. Do a third check at the bedside. Notice the expiration date on the
medication.
10. Discuss the purpose of each medication, its action, and possible adverse effects. Allow the
patient to ask questions about the drugs.
11. To apply an estrogen patch:
A. Put on clean gloves.
B. Remove the used patch. It may be necessary to check between the skin folds to find it.
C. Fold the used patch in half with sticky sides together. Dispose of the used patch in the
appropriate trash receptacle.
D. If needed, wipe the skin clean.
E. Remove gloves and discard in appropriate receptacle.
F. Using a soft-tip or felt-tip marker, write the date, time, and your initials on the new
patch.

2
G. Apply clean gloves.
H. Select a clean, dry site with intact skin that is away from the previous site and free of
hair. Avoid previous used sites for at least a week. Avoid sites where the skin in oily,
burned, cut or irritated.
I. Estrogen patches are commonly applied to the flat areas of the abdomen, hips, and
thighs. They should never be applied on or near to the breast or waistline.
J. Carefully remove the patch from its protective cover, holding it by the edge without
touching the adhesive.
K. Immediately apply the patch and press it firmly with your hand for 10 seconds. Make
sure the patch adheres well, especially around the edges.
L. Explain precautions for patch use. Stress that the patient must not: cut the patch (to
lower the dose), use a heating pad on or near the patch, reuse the same site within 1
week, or use other forms of the drug simultaneously with the patch.
12. Nitroglycerin ointment is available as a transdermal patch or as an ointment. To apply an

antianginal (nitroglycerin) ointment:
A. Apply clean gloves.
B. Remove the previous dose measuring paper. Fold the used paper containing any
residual medication with used sides together. Wipe off any residual medication with a
tissue, and discard it in an appropriate trash receptacle with your gloves.
C. With a felt-tip pen, write the date, time, and initials on the new application paper.
D. Apply clean gloves.
E. Measure the ointment on the dosing paper according to the health care provider’s
orders.
F. Antianginal (nitroglycerin) ointments are usually ordered in inches measured on

application dosing paper marked off in half-inch increments. Unit-dose packages are
available. Apply the desired number of inches of ointment to the paper measuring
guide.
G. Select a new application site: Apply nitroglycerin ointment to the chest, back,
abdomen, or anterior thigh. Do not apply on hairy surfaces or over scar tissue, which
may interfere with absorption.
H. Be sure to rotate application sites.

3
I. Apply ointment to the skin surface by holding the edge or back of the paper
measuring guide and placing the ointment and wrapper directly on the skin. Do not
rub or massage the ointment into the skin.
J. Secure the ointment and paper with a transparent dressing or strip of tape. Plastic
wrap may be used as an occlusive dressing.
13. Remove and dispose of gloves. Perform hand hygiene.
14. With all transdermal applications, remind the patient to keep a journal/diary of doses and
application sites.
reach.
16. Place the call button within easy reach, and make sure the patient knows how to use it to
summon assistance.
18. Dispose of used supplies and equipment. Leave the patient’s room tidy.
Document on the MAR that medication was administered and the site of application
according to agency policy.

Procedure Guideline for Administering Eye Medications
4. Introduce yourself to the patient and family if present.
5. Identify the patient using two identifiers. Compare these identifiers with the information in
the patient’s medication administration record (MAR) or medical record.
6. Ask the patient if he or she has any allergies.
7. Before applying any eye medication, check the patient's MAR against the provider's orders.
During administration, follow the "Six Rights of Medication Administration." Perform the
third medication check at the patient’s bedside. Compare the MAR or computer printout
with the medication labels and with the patient’s name. Check the expiration of the
medication. (For review, refer to the video skill, "Ensuring the Six Rights of Medication
Administration.")
patient to ask questions about the drugs. Patients who wish to self-instill medications may
be allowed to do so under a nurse’s supervision (check agency policy). Tell patients who
are receiving eye drops (mydriatics) that vision will be blurred temporarily and that
sensitivity to light may occur.
9. For all eye medications:
A. Perform hand hygiene and apply clean gloves.

B. Help the patient into a comfortable position. Ask the patient to lie supine or sit back
in a chair with the neck slightly hyper-extended. Raise the bed and lower the side rail.
C. If drainage or crusting is present along the eyelid margins or inner canthus, gently
wash it away. Soak any dried crusts by holding a warm, damp washcloth or cotton
ball over the eye for several minutes. Always wipe from the inner canthus to the outer
canthus using a clear corner of the cloth each time. Do not scrub the eyelid.
D. Remove your gloves, and perform hand hygiene. Reapply clean gloves.
10. Instill eyedrops:

2
A. Using your non-dominant hand, hold a clean tissue or cotton ball on the patient's
cheekbone, just below the lower eyelid. Gently press downward with your thumb or
forefinger against the bony orbit, exposing the conjunctival sac. Never press directly
against the patient’s eyeball.
B. Ask the patient to look up. Resting your dominant hand gently on the patient’s
forehead, hold the filled medication eyedropper approximately 1 to 2 cm (½ to ¾
inch) above the conjunctival sac.
C. Drop the prescribed number of drops into the conjunctival sac.
D. If the patient blinks or closes his or her eye, causing the drops to land on the outer lid
margins, repeat the procedure.
E. When administering drops that may have systemic effects, apply gentle pressure to
the patient’s nasolacrimal duct with a clean tissue for 30-60 seconds per eye. Avoid
putting pressure directly on the patient’s eyeball. Ask the patient to close his or her
eyes gently and briefly.
F. Dispose of used tissues in the proper trash receptacle. Remove your gloves, and
perform hand hygiene.
11. Instill eye ointment:
A. With the thumb of your nondominant hand, pull the patient’s eyelid down, exposing
the conjunctival sac. Have the patient look up. Holding an applicator above the lower
margin of the eyelid, apply a thin ribbon of ointment evenly along the inner edge of
the lower eyelid on the conjunctiva, from the inner canthus to the outer canthus.
B. Have the patient close his or her eye and rub the lid gently with a cotton ball, using a
circular motion, if doing so is not contraindicated.
C. If excess medication is on the eyelid, gently wipe it away, moving from the inner to
the outer canthus.
D. Dispose of used tissues in the proper trash receptacle. Remove your gloves, and
perform hand hygiene.
12. If the patient needs an eye patch, apply a clean one by placing it over the affected eye, so
that the entire eye is covered. Tape the patch securely without applying pressure to the eye.
13. As part of your follow up care, encourage the patient to demonstrate self-administration of
his or her eye medication. Reinforce teaching as needed.
reach.

3
summon assistance.

Procedure Guidelines for Administering Ear Medications
6. Identify the patient using two identifiers. Ask the patient about allergies.
7. Take the medication to the patient at the correct time (refer to agency policy). Give time-
critical medications (e.g., stat and “now” doses) at the exact time ordered. As you proceed,
apply the Six Rights of medication administration.
patient to ask questions about the drugs. Patients who wish to self-instill medications may
be allowed to do so under a nurse’s supervision (check agency policy).
9. Instill ear medication:
A. Apply clean gloves if drainage is present.

B. Position the patient on his or her side (if not contraindicated) with the ear to be
treated facing up. Alternately the patient may sit in a chair or at the bedside. Tilt
the patient’s head toward the unaffected side, and stabilize it with the patient’s
own hand.
C. For an adult or child older than 3 years of age, straighten the ear canal by pulling
the pinna up and back to the 10 o’clock position. For a child younger than 3 years
of age, pull the pinna down and back to the 6 o’clock or 9 o’clock position.
D. If cerumen or drainage occludes the outermost portion of the ear canal, wipe it out
gently with a cotton-tipped applicator. Take care not to force cerumen into the
canal.
E. Instill the prescribed drops by holding the dropper 1 cm (½ inch) above the ear
canal.
F. Ask the patient to remain in a side-lying position, on the unaffected side, for a few
minutes. Gently massage or put pressure on the tragus of the ear with your finger.

2
G. If ordered, gently insert a portion of a cotton ball into the outermost part of the ear
canal. Do not press cotton into the canal. Remove the cotton after 15 minutes.
10. Dispose of your used supplies in the appropriate trash receptacle, remove and dispose of
your gloves (if used), and perform hand hygiene.
11. After the drops have been absorbed, help the patient into a comfortable position and place
toiletries and personal items within reach.
summon assistance.


Procedure Guideline for Using a Metered-Dose Inhaler (MDI)
1. Perform hand hygiene and ensure privacy.

3. Identify the patient using two identifiers.
4. Ask if the patient if he or she has any allergies.
5. A metered dose inhaler (MDI) is a small handheld device that delivers a measured
dose of medication to the airways. With each puff, a propellant in the canister
disperses the drug in the form of an aerosol spray or mist.
6. Compare the label of the MDI medication with the information in the medication
administration record (MAR) twice. Do a third check at the patient’s bedside. Check
the expiration date of the medication. Apply the Six Rights of Medication
Administration. Refer to the Video Skill "Ensuring the Six rights of Medication
Administration."
7. Assess the patient's respirations and breath sounds. Ask the patient about subjective
symptoms such as shortness of breath.
8. Discuss the purpose and action of each medication, as well as its possible adverse
effects. Allow the patient to ask questions about the drug. Explain what a metered-
dose inhaler (MDI) is and how to use it. Caution not to use medication more than
what the health care provider has specified. Warn the patient about potential side
effects related to overuse of the inhaler.
9. Explain the steps for administering an MDI without a spacer (demonstrate for the
patient).
A. Remove the mouthpiece cover from the inhaler after inserting the MDI canister
into the holder.
B. Shake the inhaler well for 2 to 5 seconds (five or six shakes).
C. Have the patient hold the inhaler in his or her dominant hand.
D. Instruct the patient to position the inhaler in one of two ways:
(1) Place the inhaler's mouthpiece in the mouth, with the opening toward the back
of the throat, closing the lips tightly around it. This technique is the best way
to deliver medication without the use of a spacer device.
(2) Alternately, have the patient hold the mouthpiece 2 to 4 cm (1 to 2 inches) in
front of his or her wide-opened mouth, with the opening of the inhaler facing
the back of the throat. The patient’s lips should not touch the inhaler. Have the
patient take a deep breath and exhale completely.
(3) With the inhaler in either of the above positions, have the patient hold the
inhaler with the thumb at the mouthpiece and the index finger and middle
finger at the top. Instruct the patient to tilt his or her head back slightly and
inhale slowly and deeply through the mouth for 3 to 5 seconds while
depressing the medication canister completely.
(4) Have the patient hold his or her breath for about 10 seconds.
(5) Instruct the patient remove the MDI from the mouth before exhaling, and
exhale slowly through the nose or pursed lips.

2
10. Explain the steps to administer an MDI using a spacer device (demonstrate for the
patient).
A. Remove the mouthpiece cover from the MDI and from the mouthpiece of the
spacer device.
B. Shake the inhaler well for 2 to 5 seconds (five or six shakes).
C. Insert the MDI into the end of a spacer device.
D. Instruct the patient to place the spacer device mouthpiece into his or her mouth
and close the lips around it. Advise the patient not to insert the device beyond the
raised lip of the mouthpiece, and to avoid covering the small exhalation slots with
the lips.
E. Have the patient breathe normally through the mouthpiece of the spacer device.
F. Instruct the patient to depress the medication canister, spraying one puff into the
spacer device.
G. Ask the patient to breathe in slowly and fully for 5 seconds.
H. Instruct the patient to hold this full breath for 10 seconds.
11. When using a MDI, with or without a spacer, instruct the patient to wait 20 to 30
seconds between inhalations of the same medication and 2 to 5 minutes between
inhalations of different medications. When two different medications are given, a
bronchodilator should be used before a steroid medication.
12. Instruct the patient not to repeat the inhalations before the next scheduled dose.
13. Inform the patient that droplets of medication on the pharynx or tongue may cause a
gagging sensation. Advise the patient of the importance of rinsing with warm water
and then spitting out the water about 2 minutes after each dose.
14. For daily cleaning, instruct the patient to remove the medication canister and rinse the
inhaler and cap with warm running water. Tap to remove any remaining drops of
water and allow to dry. Caution the patient to be sure the inhaler is completely dry
before reusing it. Instruct the patient not to get the valve mechanism of the canister
wet.
16. Show the patient how to keep track of how many doses he has used by noting the first
day of use on the canister and calculating the number of doses the patient uses per
day.
17. For follow up care, assess the patient's respirations and breath sounds and compare
with the assessment made prior to giving the medication. Include patient teaching and
encourage self-administration of medication using the MDI. Observe the patient's
technique and offer reinforcement as necessary.
18. Encourage the patient to report any adverse effects of the medication, such as
tremors, anxiety, palpitations, and/or lightheadedness. Help the patient into a
comfortable position, and place toiletries and personal items within reach. Place the
call light within easy reach, and make sure the patient knows how to use it to summon
assistance.
21. Document the medication in the MAR after administration and not before. Report the
patient’s response and expected or unexpected outcomes.


Procedure Guidelines for Using a Dry Powder Inhaler

6. Identify the patient using two identifiers. Compare these identifiers with the
information in the patient’s MAR or medical record.
7. Compare the label on the medication with the information in the MAR twice when
preparing for administration. At the patient’s bedside, again compare the MAR or
computer printout with the names of the medications on the medication labels and the
patient’s name. Check the expiration date on the medication.
time-critical medications (e.g., stat and “now” doses) at the exact time ordered.
9. Assess the patient’s respirations and lung sounds. Ask the patient about subjective
symptoms, such as shortness of breath. During administration, apply the Six Rights of
medication administration. Refer to the Video Skill “Ensuring the Six Rights of
Medication Administration.”
10. Allow adequate time for the patient to manipulate the dry powder inhaler (DPI).
Explain why the medication is being given, and demonstrate how to properly load the
DPI. Advise the patient not to use the inhaler more often than the health care provider
has ordered and to be aware of possible side effects. Determine the patient’s ability to
hold, manipulate, and activate the DPI. Point out the external counter that indicates
the remaining number of doses. This number should be one less after the
administration of a dose.
11. Explain the steps for administering the dose; demonstrate when possible:
A. Some DPIs require rotation of a lever, insertion of a capsule, or insertion of a disk
into the inhaler device. Always follow the manufacturer’s directions. Have the
patient breathe all the way out.
B. Next, have the patient place his or her lips over the mouthpiece of the DPI and
inhale deeply and at the rate recommended by the manufacturer. Remove the
inhaler from the mouth as soon as inhalation is complete.
C. Have the patient hold his or her breath for a minimum of 10 seconds, or longer if
possible, and then exhale through pursed lips. Advise the patient not to exhale
into the DPI.
D. Return the DPI to the closed position, or remove the loaded capsule or disk if
necessary.
E. Remind the patient to clean the device after each use.
12. Inform the patient that he or she might not taste the powder.
13. Advise the patient of the importance of rinsing with warm water and then spitting out
the water about 2 minutes after each dose.
14. Instruct the patient not to repeat the inhalation before the next scheduled dose.
15. Dispose of any used supplies in an appropriate receptacle.

2
within reach.
21. As part of follow up care, assess the patient’s respiration and breath sounds,
comparing them with the assessments you made before the medication was
administered. Note the patient’s response to the medication. Monitor the patient for
adverse effects, such as tremors, anxiety, palpitations, and/or lightheadedness.


Procedure Guidelines for Inserting a Rectal Suppository
time-critical medications (stat and “now” doses) at the exact time ordered. During
administration, apply the Six Rights of medication administration (See “Six Rights of
Medication Administration” video, if needed).
3. Introduce yourself to the patient and family, if present. It may be appropriate to ask
family and/or visitors to leave the room.
4. Perform hand hygiene. Arrange supplies at the bedside.
6. Identify the patient using two identifiers, according to agency policy. Compare these
identifiers with the information in the patient’s MAR or medical record. Ask the
patient if he has allergies to any medications.
7. Ask the patient if he or she has any gastrointestinal problems such as constipation,
diarrhea, itching, burning, rectal bleeding or discomfort.
8. Before inserting the suppository, verify the health care provider’s orders against the
MAR.
9. Compare the MAR or computer printout with the name of the medication on the label
and with the patient’s name, twice. Do a third check at the bedside. Check the
expiration date on the suppository. As you proceed, keep in mind the six rights of
medication administration.
10. Discuss the purpose of the suppository, its action, and possible adverse effects. Allow
the patient to ask questions
11. Ask the patient if he or she is comfortable with you inserting the suppository or if he
wishes to insert the suppository themselves. If he or she chooses to do so themselves,
explain the procedure carefully to him or her and ensure their understanding of the
procedure. Remind him or her to remove the suppository’s wrapper before insertion.
12. Help the patient assume a left side-lying Sims’ position, with his or her right leg
flexed.
13. If the patient has mobility impairment, help him or her into a left lateral position. If
needed, obtain assistance to turn the patient, and use pillows to support the upper arm
and leg.
14. Apply clean gloves. Keep the patient draped; expose only the anal area.
15. Examine the condition of the anus. Notice any rectal bleeding or hemorrhoids. If
impaction is suspected, palpate the rectal walls and then dispose of gloves by turning
them inside out and placing them in the appropriate trash receptacle. Do not palpate if
there is a recent history of rectal surgery.
16. Apply a new pair of clean gloves if your previous gloves were soiled and discarded.
17. Remove the suppository from its wrapper, and lubricate the rounded end with water-
soluble lubricant. Lubricate the gloved index finger of your dominant hand. If the
patient has hemorrhoids, use a liberal amount of lubricant and handle the area gently.
18. Ask the patient to take slow, deep breaths through the mouth and relax the anal
sphincter.

2
19. Retract the patient’s buttocks with your nondominant hand. With the gloved index
finger of your dominant hand, insert the suppository gently through the anus, past the
internal anal sphincter, and against the rectal wall to a depth of 10 cm (4 inches) for
adults or 5 cm (2 inches) for infants and children. DO NOT PLACE
SUPPOSITORY DIRECTLY INTO STOOL.
20. NOTE: If ordered, a suppository may be given through a colostomy (but not through
an ileostomy). The patient should lie supine. Use a small amount of water-soluble
lubricant to insert the suppository.
21. Withdraw your finger, and wipe the patient’s anal area.
22. Discard your gloves by turning them inside out. Dispose of them and your other used
supplies in the appropriate trash receptacle. Perform hand hygiene.
23. Ask the patient to remain flat or on his or her side for 5 minutes.
24. If the suppository contains a laxative or stool softener, place the call light within
reach so the patient can request assistance to use the bedpan or toilet.
25. If the suppository was given for constipation, remind the patient not to flush the toilet
after the bowel movement.
within reach.
27. To ensure patient safety, raise the appropriate number of side rails and lower the bed
Watch for adverse effects. Evaluate the patient to see if the constipation or other
symptoms were relieved. Document results and medication administration according
to agency policy.


Procedure Guideline for Preparing Injections from a Vial
1. To prepare an injection from a vial, first verify the health care provider’s orders.
2. Perform hand hygiene, and prepare your supplies.
3. Prepare medications:
A. If you are using an automated medication dispensing system, log on and access
the patient’s profile.
B. When preparing medications, it is important to avoid becoming distracted. Follow
your agency’s “No Interruption Zone” policy. Prepare medications for only one
patient at a time.
C. Select a vial of the prescribed drug from the medication cart or automated
dispensing system. Compare the name of the drug on the label of the vial with the
name in the MAR.
D. Check the expiration date and drug concentration or dose on the vial. Calculate
the correct volume to withdraw. Double-check your calculation. Ask another
registered nurse to check your calculation if needed.
E. Check agency policy to note which high alert medications require validation by a
second RN.
4. Prepare the vial containing a solution:
A. Remove the cap on an unused vial to expose the rubber seal. If a multidose vial
has been used before, the cap will have been removed already. Firmly wipe the
surface of the rubber seal with an alcohol swab. Allow it to dry.
B. Select a syringe, and attach a needle or needleless access device. If the syringe is
capped, remove the cap first. A filter needle may be needed to withdraw certain
medications from the vial. Review your agency’s policy or the drug insert to
determine if it is necessary to use a filter needle.
C. Pull back on the plunger to draw an amount of air into the syringe equivalent to
the volume of medication to be aspirated from the vial.
D. With the vial on a flat surface, apply pressure to insert the tip of the needle or
needleless device through the center of the rubber seal.
E. Inject the air you drew into the syringe into the air space of the vial, firmly
holding the plunger to prevent its being forced backward by air pressure in the
vial.
F. Hold the vial with your nondominant hand. Hold the syringe barrel and plunger
with your dominant hand. Invert the vial securing the plunger to continue
counteracting pressure within the vial. Keep the tip of the needle or needleless
device below the level of the fluid.
G. Allow the air pressure from the vial to fill the syringe gradually. If necessary, pull
back slightly on the plunger to hasten the process.
H. When the level of medication in the syringe reaches the desired volume, position
the tip of the needle or needleless device into the air space of the vial. Tap the
syringe barrel gently to dislodge any air bubbles. If air remains at the top of the
syringe, eject any remaining air into the vial.
I. Recheck the volume in the syringe.

2
J. Finally, remove the needle or needleless access device from the vial.
K. Hold the syringe vertically, needle up, at eye level, and ensure the correct volume
and the absence of air bubbles. Remove the remaining air by tapping the barrel to
dislodge the air bubbles. If air remains, draw back slightly on the plunger, and
then push it upward to eject the air. Do not eject any fluid. Recheck the volume of
the drug in the syringe. Cover the needle with a safety sheath or cap.
L. If you need to inject medication into the patient’s tissue, change the needle to the
appropriate gauge and length according to the route of medication administration.
M. If you are preparing the medication away from the patient’s bedside, clearly label
the syringe with the name of the medication and the dose in the syringe.
N. For a new multidose vial, write the date on which it was opened and your initials
on the vial label. Remove the cap and swab the rubber seal with an alcohol swab.
Let it dry.
O. If a multidose vial is already open, wipe the surface of the rubber seal with an
alcohol swab and let it dry.
P. Discard single dose vials after use even if there is medication remaining in the
vial.
5. Prepare a vial containing a powder (reconstituting medications):
A. Remove the cap on the vial of powdered medication and the cap on a vial of the
proper diluent. Be sure to check the manufacturer’s guideline for the correct
diluent and volume of diluent to use, and if use of a filter needle is recommended.
Wipe both rubber seals with an alcohol swab, and allow the alcohol to dry.
B. Use a needle or needleless device to draw the volume of diluent suggested by the
manufacturer into the syringe as you would medication from a vial.
C. To mix the diluent with a powered medication, insert the tip of the needle or the
needleless device through the center of the rubber seal of the vial of powdered
medication. Inject the measured diluent into the vial containing the powder.
Withdraw and dispose of the syringe or access device in a puncture proof
container.
D. Roll the vial between the palms of your hands to mix the powder and diluents
thoroughly. Do not shake the vial.
E. The reconstituted medication in the vial is now ready to be drawn into a new
syringe. Read the label carefully to determine the concentration of the drug.
F. Wipe off the top with an alcohol swab and allow it to dry. Draw up the
appropriate volume of medication based on its concentration in the reconstituted
formulation into a syringe.
G. Some medications are now available in vials that contain both the medication and
diluent separated by a gasket.
a. To combine, press down on the plastic activator to force the diluent into the
lower compartment.
b. Remove the top and gently agitate the vial to mix the solution.
c. Swab the gasket with alcohol. Then insert the needle through the center of the
stopper.
d. Invert the vial and withdraw the dose.
6. Again compare the label of the prepared medication with the MAR, computer screen,
or printout.

3
7. Remember, if you are drawing up medication away from the patient’s bedside, label
the syringe with the name of the medication and the amount of medication or dose in
the syringe.
8. Dispose of used supplies. Place the used vials and used needle or needleless device in
a puncture-proof, leak-proof container. Clean your work area, and perform hand
hygiene.

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Procedure Guidelines for Preparing Injections from an Ampule

2. Perform hand hygiene, and prepare your supplies.
3. Prepare the medications:
A. If you are using a medication cart, move it outside the patient’s room. Unlock the
cart.
B. If you are using an automated medication dispensing system, log on to the unit.
C. Follow your agency’s “No Interruption Zone” policy. Prepare medications for one
patient at a time.
D. Select the ampule containing the correct drug from the medication cart or
automated dispensing system. Compare the label of the medication with the
MAR.
E. Check the expiration date and drug dose on the ampule.
F. Calculate the drug dose as necessary. Double-check your calculation. Ask another
registered nurse to check your calculation if needed.
4. Prepare the ampule:
A. Tap the top of the ampule lightly and quickly with your finger until the fluid
moves out of the neck of the ampule.
B. Place a small gauze pad or unopened alcohol swab around the neck of the ampule.
C. Quickly and firmly snap the neck of the ampule, pulling the top of the ampule
toward you, with the opening of the ampule facing away from your hands and
face.
D. To draw up the medication:
(1) Attach a filter needle or filter straw long enough to reach the bottom of the
ampule to the appropriate sized syringe.
(2) Hold the ampule upside down, or set it on a flat surface. Insert the filter
needle or straw into the center of the ampule opening. Do not allow the
needle tip or the shaft to touch the rim of the ampule.
(3) Aspirate the medication into the syringe by gently pulling back on the
plunger.

2
(4) Keep the needle tip under the surface of the liquid. Tip the ampule to bring
all of the fluid within reach of the needle.
(5) If you aspirate air bubbles, do not expel the air into the ampule.
(6) To expel excess air bubbles, remove the needle from the ampule. Hold the
syringe vertically, with the needle pointing up. Tap the side of the syringe,
so that the air bubbles rise toward the needle. Draw the plunger back
slightly, and push the plunger upward to eject the air. Do not eject the
fluid.
(7) If the syringe contains excess fluid, use the sink for disposal. To do so,
hold the syringe vertically with the needle tip up and slanted slightly
toward the sink. Slowly eject the excess into the sink. Recheck the fluid
level in the syringe by holding the syringe vertically.
(8) Cover the filter needle with its safety sheath or cap, and remove it from
the syringe. Replace the filter needle with a regular safety needle of the
appropriate gauge and length for the injection.
5. Compare the label of the medication with the electronic MAR or a printout.
6. If you draw up medication away from the patient’s bedside, label the syringe with the name
of the medication and the amount of medication it contains.
7. Dispose of soiled supplies. Place the broken ampule and used filter needle/straw in a
puncture-proof and leak-proof container. Clean your work area, and perform hand hygiene.

Procedure Guideline for Preparing Insulin
1. Perform hand hygiene and ensure privacy.

3. Identify the patient using two identifiers.
4. Verify the health-care provider’s orders.
5. Determine the patient's blood glucose level and when the patient's next meal will be.
6. Preparation and administration must be timely, taking into consideration mealtimes.
Usually the time between injecting rapid-acting insulin and eating a meal is no more
than 5 to 15 minutes. For short-acting insulin, the time interval is 20 to 30 minutes
before a meal.
A. Rapid-acting types, such as insulin lispro, aspart, and glulisine:
(1) Begin to act in 15 to 30 minutes
(2) Peak effects occur in 1 to 3 hours
(3) Last 3 to 6½ hours
B. Short-acting types, such as regular insulin:
(1) Begin to act in 30 minutes to 1 hour
(3) Last 6 to 10 hours
C. Intermediate-acting types, such as isophane (NPH) insulin suspension:
(1) Begin to act in 1 to 2 hours
(3) Last 16 to 24 hours
D. Long-acting types, such as Detemir or Levemir:
(1) Begin to act in 0.8 to 2 hours
(2) Are non-peaking.
(3) Last up to 24 hours
7. The various types of insulin are not interchangeable and cannot be substituted for one
another without the approval of the prescriber.
8. Select the ordered insulin from the medication cart or automated medication
dispensing unit. Follow your agency’s “No Interruption Zone” policy.
9. Compare the insulin label with the medication administration record.
10. Check the expiration date on the vial.
11. If the medication has been refrigerated, allow it to come to room temperature before
administering it. Inspect the insulin for changes that may indicate a loss of potency
such as clumping, frosting, precipitation or altered color or clarity.
12. If a correction scale or sliding scale is used, obtain a current bedside blood glucose.
Check the MAR and note the correct amount to draw up based on the patient’s
current blood glucose reading.
13. Select an injection site: in an upper arm, the anterior or lateral aspect of the thigh, the
buttocks, or the abdomen. Avoid the 2-inch radius around the umbilicus.
A. When choosing a site, consider the expected absorption rate. Insulin is absorbed
fastest when injected into the abdomen, followed by the arms, thighs, and
buttocks.

2
B. Remember to rotate sites within a selected anatomical region, such as the

abdomen.
C. When all sites have been used, the patient may select another region, such as the
thigh, or start the rotation pattern over again in the same region.
14. Draw up the insulin, as shown in the Video Skill “Preparing Injections from a Vial,”
or mix a combination of insulin, as shown in the Video Skill “Drawing Up More
Than One Type of Insulin.”
15. Compare the vial of the insulin and the amount drawn up in the syringe with the
MAR.
16. Have another registered nurse verify the correct type and amount of insulin drawn up.
17. If you draw up insulin away from the patient’s bedside, label the syringe with the
insulin indicating the type and amount of insulin it contains.
18. When teaching patients to use an insulin administration pen, demonstrate how to
remove the cap, insert and secure the disposable needle, and dial the prescribed
number of units.
19. Have the patient demonstrate the insulin injection, as shown in the Video Skill,
“Administering Subcutaneous Injections.” Patients should demonstrate insulin self-
administration whenever possible.
20. Dispose of used supplies, clean up your work area, and perform hand hygiene.
within reach.
22. Place the call button within easy reach, and make sure the patient knows how to use it
24. Document insulin administration immediately afterwards.

Procedure Guideline
1. Review the Medication Administration Record (MAR). Review the types of insulin
ordered including the onset, peak, duration of action, nursing implications, and
compatibility when mixed. Refer to the Video Skill “Preparing and Administering
Insulin” to review onset, peak, and duration of insulins. Long-acting insulin should
never be mixed with another type of insulin.
2. For subcutaneous injections, assess the patient’s body build, muscle size, and weight.
3. Preparation and administration must be timely, taking into consideration mealtimes.
Usually the time between injecting a rapid-acting insulin and eating a meal is no more
than 5 to 15 minutes. For short-acting insulins, the time interval is 20 to 30 minutes
before a meal.
4. Perform hand hygiene, and prepare supplies.
5. Follow your agency’s “No Interruption Zone” policy.
6. Select the ordered insulins from the medication cart or automated dispensing system.
Compare insulin vial labels with the MAR.
7. Check the expiration date on the vials.
8. If it has been refrigerated, allow the insulin to come to room temperature before the
injection.
9. Prepare insulin for one patient at a time, and follow the Six Rights of Medication
Administration. Refer to the Video Skill “Ensuring the Six Rights of Medication
Administration.”
10. Verify the labels of the insulins and the amounts drawn up in the syringe with the
MAR.
11. When mixing rapid- or short-acting insulin with intermediate-acting insulin, prepare
the injection as follows:
A. First calculate the total volume of insulin you will need.
B. Ask another registered nurse to verify the types of insulins and your calculations.
C. Roll the vial between your hands.
D. Wipe off the top of the rapid or short-acting insulin with an alcohol swab.
E. For insulin suspension preparations, roll the vial between your palms to
redistribute any medication that settles out. Wipe off the insulin with a new
alcohol swab.
F. Pick up the insulin syringe with a preattached needle. Aspirate a volume of air
equal to the total amount of intermediate insulin to be administered.
G. Insert the needle of the syringe into the longer-acting insulin. Do not allow the
needle tip to touch the solution in the vial. Inject a volume of air equal to the
amount of intermediate insulin that will be given. Immediately withdraw the
needle, without aspirating any medication.
H. Insert the needle of the same syringe into the short- or rapid-acting insulin. Inject
the remaining amount of air (equal to the prescribed dose of short-acting insulin)
into the vial. Invert the vial of the rapid- or short-acting insulin, with the needle
still inserted, and draw up the ordered amount of the rapid- or short-acting insulin.
I. Remove the syringe from the vial of rapid- or short-acting insulin, eliminating any

2
air bubbles to ensure an accurate dose.

J. Verify the short-acting insulin dosage with the MAR. Show the insulin prepared
in the syringe to another nurse to verify that the correct dosage has been prepared.
K. Determine the point on the syringe scale to which the combined units of insulin
should reach, by adding the number of units of both insulins together. Verify the
combined dose.
L. Place the needle of the syringe back into the vial of intermediate- or long-acting
insulin. As you do, be careful not to push the plunger and inject insulin from the
syringe into the vial.
M. Invert the vial and carefully withdraw the desired amount of insulin into the
syringe. Do not overdraw or push any insulin in the syringe back into the vial.
Either of these actions could cause the wrong volume of either insulin to be drawn
up.
N. Withdraw the needle, and check the volume in the syringe. Verify the volume
with another registered nurse. Keep the needle of the prepared syringe sheathed or
capped until you are ready to administer the medication.
12. If insulin is prepared away from the patient’s bedside, label the syringe with the name
and volume of each insulin in the syringe.
13. Remember to do a third accuracy check against the MAR at the patient’s bedside.
14. Dispose of your used supplies. Clean up the work area.

Procedure Guideline for Administering Intradermal Injections
1. Verify the health care provider's orders.

2. Prepare medications for one patient at a time, using aseptic technique; avoid
distractions. Keep together all pages of the MAR or computer printouts for one
patient, or look at only one patient’s electronic MAR at a time. Check the label of
the medication carefully against the MAR or the computer printout twice during
preparation of the medication. You will do a third check at the patient’s bedside.
3. Take the medication to the patient at the correct time (see agency policy). During
administration, apply the six rights of medication administration. Refer to the Video
Skill “Ensuring the Six Rights of Medication Administration.”
4. Gather the necessary equipment and supplies. When preparing an injection away
from the patient’s bedside, be sure to label the syringe properly.
6. Provide for the patient's privacy.
8. Identify the patient using two identifiers. Compare these identifiers with the
information in the patient’s MAR or medical record. Ask the patient if he or she has
allergies.
9. At the patient’s bedside, again compare the MAR or the computer printout with the
names of the medications on the medication labels and with the patient’s name.
10. Discuss the purpose of the intradermal injection, its action, and its possible adverse
effects. Allow the patient to ask questions. Tell the patient that the injection will
cause a slight burning or stinging sensation. Instruct the patient to report any itching
or shortness of breath.
11. Raise the bed to a comfortable working height.
12. Keep a sheet or gown draped over portions of the body that do not require exposure.
13. Select an appropriate site. Note any lesions or skin discoloration. If possible, select a
site three to four finger-widths below the antecubital space and one hand-width
above the wrist. If you cannot use the forearm, inspect the upper back. If necessary,
use sites that are appropriate for subcutaneous injection.
14. Help the patient into a comfortable position. Have the patient extend his or her
elbow, and support the elbow and forearm on a flat surface.
15. Apply clean gloves.
16. Clean the site with an antiseptic swab. Starting from the center of the injection site,
rotate the swab outward in a circular direction for about 5 cm (2 inches). Option:
Use a vapocoolant spray, such as ethyl chloride, before the injection.
17. Hold a swab or a piece of gauze between the third and fourth fingers of your
nondominant hand.
18. Remove the needle cap from the needle by pulling it straight off.
19. Hold the syringe between the thumb and forefinger of your dominant hand, with the
bevel of the needle pointing up.
20. Administer the injection:
A. Using your nondominant hand, stretch the skin over the site with your forefinger

2
or thumb.
B. With the needle almost against the patient’s skin, insert it slowly at a 5- to 15-
degree angle until you feel resistance. Advance the needle through the
epidermis to a depth of about 3 mm (⅛ inch) beneath the skin. You will see the
bulge of the needle tip through the skin.
C. Inject the medication slowly. You should feel resistance. If you do not, the
needle is too deep. Withdraw it and begin the procedure again.
D. As you inject the medication, a small bleb (approximately 6 mm [¼ inch])
resembling a mosquito bite will form on the skin surface.
E. Withdraw the needle, and apply an alcohol swab or gauze pad gently to the site.
Do not massage.
21. Discard the uncapped needle, or needle enclosed in a safety shield and attached
syringe, in a puncture-proof and leak-proof receptacle.
22. Help the patient into a comfortable position.
23. Remove your gloves, and perform hand hygiene.
24. Stay with the patient for several minutes to watch for any allergic reaction.
27. To ensure the patient's safety, raise the appropriate number of side rails and lower
the bed to the lowest position.
28. Leave the patient's room tidy.

Procedure Guideline for Administering a Subcutaneous Injection

2. Before administering a subcutaneous injection, perform hand hygiene and prepare the
medication using aseptic technique.
3. Check the medication label twice against the medication administration record (MAR).
4. Take the medication to the patient at the correct time, according to your agency’s policy.
Give time-critical medications, such as “stat” and “now” doses, at the exact time specified in
the order.
5. Perform hand hygiene, ensure patient privacy and introduce yourself to the patient.
6. Identify the patient using two identifiers according to agency policy. Compare these
identifiers with the MAR or medical record. Ask the patient if he has any allergies.
7. Access the electronic MAR.
8. At the patient’s bedside, again compare the MAR or computer printout with the names of the
medications on the medication labels and with the patient’s name.
9. Discuss the purpose of each medication with the patient, including its action and possible
adverse effects. Allow the patient to ask questions. Find out where the last injection was
given by checking the MAR and/or asking the patient. Determine which site you will use.
Tell the patient that the injection may cause a slight burning or stinging sensation.
10. Shift the patient’s bed linen to expose only the potential injection site and surrounding areas.
11. Select an injection site, and inspect the skin for bruises, inflammation, or edema. Choose
another site if bruising or signs of infection are evident.
12. The best sites for a subcutaneous injection include the outer aspect of the upper arm, the
abdomen from below the costal margin to the iliac crest and the anterior aspect of the thigh.
These areas are easily accessible and large enough to allow for multiple injections.
13. Palpate the site. Select a new site if you find a mass or tenderness. Be sure the needle is the
correct size by grasping a skinfold of tissue at the injection site with your thumb and
forefinger. Measure the fold from top to bottom. Make sure the needle is one-half this length.
A. When administering insulin or heparin, abdominal injection sites are preferred, followed
by injection sites on the thigh.
B. When administering low-molecular weight heparin (LMWH) subcutaneously, choose a
site at least 5 cm (2 inches) to the right or left of the umbilicus. If an abdominal area is
not available, look for a site on the thigh.
C. Systematically rotate insulin injection sites within one anatomical region, such as the
abdomen or thigh.
14. Help the patient into a comfortable position. Have the patient relax the area of the injection
site.
15. Apply clean gloves. Clean the site with an antiseptic swab, wiping in a circular pattern from
the center of the site outward about 5 cm (2 inches).
16. Hold a gauze pad between the third and fourth fingers of your nondominant hand.
17. Remove the needle cap or protective sheath on the syringe by pulling it straight off.
18. Hold the syringe between the thumb and forefinger of your dominant hand, as though you
were holding a dart.

2
A. For an average-size patient, hold the skin across the injection site or pinch a fold of skin
with your nondominant hand.
B. Insert the needle quickly and firmly at a 45- to 90-degree angle. Release the skin if it is
pinched. Rest your nondominant hand on the patient and use it to stabilize the syringe.
When using an injection pen or giving heparin, continue to pinch the skin during the
injection.
C. For an obese patient, pinch the skin at the site and inject the needle at a 90-degree angle
below the tissue fold.
D. Move your dominant hand to the end of the plunger and slowly inject the medication over
several seconds. Retain your grasp on the syringe to keep it still.
E. With the thumb and middle finger of your nondominant hand, pull the skin taut, quickly
withdraw the needle and place a swab or gauze pad on the site and apply gentle pressure.
F. Do not massage the site. If heparin was administered, hold a gauze pad on the site for 30
to 60 seconds.
20. Activate the needle safety and help the patient into a comfortable position.
21. Discard the needle and syringe in a puncture-proof, leak-proof container.
22. Dispose of used supplies. Remove and discard your gloves, and perform hand hygiene.
23. Document the injection immediately in the MAR including the medication name, dose given
and the site in which it was injected.
24. As part of your follow up care, stay with the patient for several minutes, observing for any
allergic reaction.
summon assistance.
27. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed to
the lowest position.
29. Return to the patient’s room in 15-30 minutes to see if the patient has any acute pain,
tingling, burning or numbness at the injection site.

Procedure Guideline for Administering an Intramuscular Injection
1. When you administer an intramuscular injection or give any agent, remember to prepare
medications for only one patient at a time.
2. Use aseptic technique. Avoid distractions and interruptions.
3. Check the medication label twice against the order in the medication administration record
(MAR). Be sure to check the medication expiration date when you retrieve the medication.
5. Take the medication to the patient at the correct time according to your agency’s policy. Give
time-critical medications, such as “stat” and “now” doses, at the exact time specified in the
order.
9. Identify the patient using two identifiers according to agency policy. Compare this
information to the MAR or medical record. Ask the patient if she has any allergies.
10. Access the electronic MAR again. At the patient’s bedside, again compare the MAR or
computer printout with the names of the medications on the medication labels and with the
patient’s name. This is your third check.
11. Discuss the purpose of each medication with the patient, including its action and possible
adverse effects. Allow the patient to ask questions. Tell the patient that the injection may
cause a slight stinging or burning sensation.
12. Select an appropriate injection site. The vastus lateralis and deltoid muscles are possible sites
for an intramuscular injection. The ventrogluteal site is preferred. Note the integrity and size
of the patient’s muscle. Palpate for tenderness or hardness, and avoid such areas. If the
patient receives frequent injections, rotate the site selection.
13. Inspect the area for bruising, inflammation or edema. If the skin is bruised or shows signs of
infection, use a different site.
14. Help the patient into a comfortable position, according to the site being used. Expose only
that portion of the body.
15. Apply clean gloves. Use anatomical landmarks to find the site again.
16. For a ventrogluteal injection:
A. Place the heel of your hand over the greater trochanter of the patient’s hip with the wrist
almost perpendicular to the femur.
B. Point the thumb toward the patient’s groin.
C. Point the index finger to the anterior superior iliac spine.
D. Extend the middle finger back along the iliac crest towards the buttocks.
E. The index finger, middle finger and iliac crest form a V shaped triangle. The injection
site is the center of the triangle.
F. Once you locate the site, it may help to mark it with an unopened alcohol wipe.
17. Cleanse the site with an antiseptic swab. Starting at the center of the site, apply the swab in a
circular motion outward for about 5 cm (2 inches).

2
A. Optional: Apply EMLA (eutectic mixture of local anesthetics) cream to the injection site
about 1 hour before the intramuscular injection, or if you use a vapocoolant spray, such
as ethyl chloride, spray it on the site just before giving the injection.
18. Hold a gauze pad between the third and fourth fingers of your nondominant hand.
19. Remove the needle cap or protective sheath by pulling it straight off.
20. Hold the syringe between the thumb and forefinger of your dominant hand, as though you
were holding a dart.
21. Remind your patient to try and relax.
A. Position the ulnar side of your nondominant hand just below the injection site, and pull
the patient’s skin laterally 2.5 to 3.5 cm (about 1 to 1½ inches). Hold this position until
you have inserted the needle.
B. If the patient has little muscle mass, grasp the body of the muscle between your thumb
and forefinger.
C. With your dominant hand, quickly pierce the muscle at a 90-degree angle.
D. After the needle has pierced the muscle, continue to pull the skin taught with your
nondominant hand. Stabilize the syringe by grasping the lower end of the barrel with the
fingers of your nondominant hand as they are resting on the patient.
E. Attempt to aspirate by pulling back on the plunger with your dominant hand. If blood
appears, you are not in the muscle. Remove and discard the needle and syringe and start
over.
F. If no blood appears, you are ready to proceed. Inject the medication slowly, at a rate of
1mL/10 sec.
G. Wait 10 seconds, and then smoothly and steadily withdraw the needle. Engage the needle
safety sheath. Release the skin, and apply a gauze pad over the site.
23. Apply gentle pressure. Do not massage the site. Apply a bandage to the injection site if
needed.
24. Discard the needle and its attached syringe in a puncture-proof, leak-proof container.
25. Help the patient into a comfortable position. Dispose of used gauze. Remove your gloves,
and perform hand hygiene.
26. Document the injection immediately in the MAR. Include the medication name, the dosage
given and the site in which it was injected.
27. As part of your follow up care, stay with the patient for several minutes, observing for any
allergic reaction.
summon assistance.
30. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed to
the lowest position.
32. Return to the patient’s room in 15-30 minutes to see if she has had any acute reaction at the
injection site.

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Mosby's Nursing Video Skills

Procedure Guideline for Ensuring the Six Rights of Medication Administration

A. Patient’s full name

b. Once before placing medicaiton in the medicine cup or taking it to the

c. Once before administering medication at the patient's bedside.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

(2) For time-critical medications:

b. Give NOW doses within 60 minutes of receiving the order.

7. Remove clean gloves, if used, and perform hand hygiene.

11. Leave the patient’s room tidy.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Procedure Guideline for Administering Oral Medications

2. Gather the necessary equipment and supplies.

3. Perform hand hygiene.

4. Prepare the medication:

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

J. Controlled substances will be stored in a secured locked compartment of the

6. Administer the medication:

A. Perform hand hygiene.

B. Provide for the patient's privacy.

C. Introduce yourself to the patient and family, if present.

D. Identify the patient using two identifiers.

A. Thoroughly mix liquids before administration by shaking the container gently. If a

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

14. Help the patient return to a comfortable position.

15. Dispose of soiled supplies, and perform hand hygiene.

16. Place toiletries and personal items within reach.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

19. Leave the patient’s room tidy.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mosby's Nursing Video Skills

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mosby's Nursing Video Skills

Procedure Guideline for Handling Variations in Medication Administration

1. Before administering any medication, check the medication administration record

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Procedure Guideline for Preventing Medication Errors

1. Before administering any medication, check the medication administration record

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mosby's Nursing Video Skills

1. Before using a medication dispensing system, review your patient’s medication

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mosby's Nursing Video Skills

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Procedure Guideline for Applying an Estrogen Patch or Nitroglycerin Ointment

3. Perform hand hygiene.

4. Provide for the patient’s privacy.

5. Introduce yourself to the patient and family, if present.

8. Assist the patient into a comfortable position.

11. To apply an estrogen patch:

A. Put on clean gloves.

D. If needed, wipe the skin clean.

E. Remove gloves and discard in appropriate receptacle.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

G. Apply clean gloves.

12. Nitroglycerin ointment is available as a transdermal patch or as an ointment. To apply an

A. Apply clean gloves.

D. Apply clean gloves.