FUNDAMENTALS – MEDICATION
Warm ear drops to room
ADMINISTRATION
EARDROPS
• When administering an otic medication to
an adult or child age 3 and older,
the pinna is pulled upward and back to
straighten the external ear canal.
• For an infant, the pinna is pulled downward
and straight back.
• The child should be placed in the prone or
supine position with the head turned to the
appropriate side.
• Otic medication should be warmed to room
temperature if removed from a refrigerator
prior to administration. Holding the bottle in
the palm of the hand is an effective method
of warming. Instilling cold drops into the
ear can cause a vestibular reaction,
resulting in dizziness and vomiting.
• The medication dropper should be held
near the entrance to the ear canal without
touching it. This technique allows the drops
to fall against the wall of the canal, reducing
discomfort while avoiding contamination of
the dropper.
• After instilling the drops, the child should
remain with the affected ear up for several
minutes to allow full coverage of the
medication.
• Otic medications are used to treat infection,
soften cerumen for later removal, and
facilitate removal of an insect trapped in the
ear canal. They are contraindicated in a
client with a perforated eardrum.
• The general procedure for instilling ear
drops includes the following steps:
1. Perform hand hygiene and don clean
gloves. The ear canal is not sterile, but
aseptic technique is used
2. Position the client side-lying with the
affected ear up (if not
contraindicated). This facilitates
administration and prevents drops from
leaking out of the ear
3.
temperature (ie, use hand or warm
water) to help avoid vertigo, dizziness,
or nausea as the internal ear is
sensitive to temperature extremes
4. Pull the pinna up and back to straighten
the ear canal in clients >4 years old and
adults. Pull the pinna down and back in
clients <3 years old
5. Support hand on the client's head and
instill the prescribed number of drops
by holding the dropper 1 cm (1/2 in)
above the ear canal. This avoids
damaging the ear canal with the
dropper
6. Apply gentle pressure to the tragus
(fleshy part of external ear canal) if it
does not cause pain, which facilitates
the flow of medication into the ear canal
7. Instruct the client to remain side-lying
for at least 2-3 minutes to facilitate
medication distribution and prevent
leakage
8. Place a cotton ball loosely in the
client's outermost ear canal for 15
minutes, only if needed, to absorb
excess medication. Perform this with
caution and avoid in infants or very
young clients as it is a choking hazard
PARENTERAL ADMINISTRATION
• When reconstituting a powdered medication
for parenteral administration, the nurse
should:
1. Perform hand hygiene and don clean
gloves prior to handling medication. This
is a universal practice for aseptic
handling of any medication. Cleanse
the vial top with alcohol and let it dry to
prevent possible microbial
contamination.
2. Withdraw an amount of air from the vial
equal to the prescribed amount of
diluent to create negative pressure that
will be equalized when the diluent is
injected into the vial. The medication
manufacturer will specify the needed
amount and type of diluent
 3. Inject the appropriate diluent (eg,
sterile saline, sterile water) into the
vial. The diluent reconstitutes the
medication by dissolving the
powder Roll the vial
4. between the palms of the hands to
gently mix the solution. Avoid
shaking the vial as bubbles may
develop, making withdrawal of the
reconstituted medication difficult
5. Withdraw the
reconstituted medication from the vial
into a sterile syringe for
administration. Verify the dosage by
checking the prepared medication
against the medication administration
record and medication label.
6. Label the syringe with the medication
name and dosage to prevent medication
errors at the bedside
• Parenteral medications are administered
via injection into body tissues using
aseptic technique (eg, intradermal,
intramuscular, subcutaneous, IV).
Intradermal
• Administer injections at a 5- to 15-
degree angle to reduce risk of injection
into subcutaneous tissue
• Apply firm pressure to the injection site
to reduce bleeding. Massaging the site
introduces medication into deeper
tissues and should be avoided
Subcutaneous
• Administer injections at 90 degrees if 2
in (5 cm) of subcutaneous tissue can be
grasped or at 45 degrees if only 1 in
(2.5 cm) can be grasped
Intramuscular
• Acceptable sites include the deltoid,
vastus lateralis, and ventrogluteal. The
ventrogluteal is preferred as fewer large
blood vessels and nerves are present.
• Position the client supine, prone, or
side-lying with the knee and hip flexed
when administering ventrogluteal
injections. Flexing the knee and hip
reduces muscle tension, improves
access, and promotes client comfort
• A filter needle must be used when
withdrawing medication from a glass
ampule to prevent aspiration and
injection of glass shards. After the
medication is withdrawn, the filter
needle is discarded and an injection
needle (eg, 20-gauge, 1-in [2.5-cm]
needle) is attached to the syringe.
SUBCUTANEOUS INJECTION
• The injection should be made on the right
or left side of the abdomen, at least 2 in
from the umbilicus. An inch of skin
should be pinched up and the injection
made into the fold of skin with the needle
inserted at a 90-degree angle.
• When
administering subcutaneous anticoagulant
injections (eg, heparin, enoxaparin), the
nurse must select the appropriate needle
length and angle to avoid accidental
intramuscular injection, especially in
clients with insufficient adipose
tissue (eg, cachexia).
• Intramuscular injection of heparin would
cause rapid absorption, resulting in a
hematoma and painful muscle irritation.
• The nurse should administer subcutaneous
injections at 90 degrees if 2 in (5 cm) of
subcutaneous tissue can be grasped, or
at 45 degrees if only 1 in (2.5 cm) can be
grasped.
• Anticoagulants are best absorbed if
administered in the abdomen at least 2 in (5
cm) away from the umbilicus.
INJECTION
NG TUBE MEDICATION ADMINISTRATION
CASE: The nurse plans to administer 9:00
AM medications via the nasogastric (NG)
route to a client with an NG tube. The nurse
contacts the primary health care provider
(PHCP) to clarify which prescriptions that are
contraindicated using this route?
ANS:
ENTERIC COATED IBUPROFEN 200MG
TABLET
METOPROLOL EXTENDED RELEASE
50MG TABLET
TAMSULOSIN 0.4MG SLOW RELEASE
CAPSULE
• Enteric-coated drugs have a barrier
coating that dissolves at a slower rate
(usually in the small intestine) to protect the
stomach from irritant effects. Crushing
enteric-coated medications (eg, ibuprofen)
disrupts the barrier coating and may
cause stomach irritation. In addition, the
particles from the coating may clog the NG
tube, particularly small-bore NG tubes.
• Slow-, extended-, or sustained-
release drug formulations are designed to
dissolve very slowly within a specific time
frame. Crushing these medications alters
this property and introduces the risk of
adverse effects from toxic blood levels due
to more rapid drug absorption. Therefore,
the nurse should first contact the PHCP for
clarification.
• Double- and extra-strength drugs such as
sulfamethoxazole and acetaminophen may
be crushed and administered separately
through an NG tube as long as they are not
enteric-coated. The nurse should flush the
tube with water before and after each drug
administration.
PATIENT CONTROLLED ANALGESIA
• Patient-controlled analgesia (PCA) delivers
a set amount of IV analgesic each time the
client presses the administration
button. With many PCA pumps,
a continuous IV solution (eg, normal
saline) is required to keep the vein
open and flush the PCA
medication through the line so that the
boluses reach the client.
• Many facilities have a policy regarding IV
fluid for use with PCA; however, a
prescription may be required.
• To ensure uninterrupted delivery of this
client's PCA, the nurse should contact the
health care provider to clarify the
prescription to discontinue the normal
saline.
• A "keep-vein-open" rate (eg, 5-20 mL/hr)
may be appropriate; however, a
prescription is necessary before the nurse
can implement this.
• This client is still receiving PCA, so it is
inappropriate to convert the IV to a saline
lock. In addition, this does not address the
 need to flush the PCA medication through
the line.
• Continuous IV fluids may be required to
deliver the PCA boluses; before
discontinuing the normal saline, the nurse
should receive clarification from the health
care provider.
RECTAL SUPPOSITORY
• Pediatric administration of rectal
suppositories is similar to the adult
technique, with a few key modifications due
to the small size of a child's colon and
varying developmental needs.
• Age-appropriate explanations and/or
distractions should be implemented to
reduce distress.
• Toddlers and infants may benefit from
distraction with a toy; preschoolers and
older children can be instructed to take
deep breaths or count during the
procedure.
• Basic steps for suppository administration
include the following:
1. Apply clean gloves and position the
client appropriately based on age and
size (eg, infant supine with knees and
feet raised, older child side-lying with
knees bent)
2. Lubricate the tip of the suppository
with water-soluble jelly. Petroleum-
based products can reduce absorption.
3. Insert the suppository past the internal
sphincter using the fifth finger if the
child is under 3 years. Use of the index
finger may cause injury to the colon or
sphincters in children younger than age 3
years.
4. Angle suppository and guide it along the
rectal wall. The suppository should
remain in contact with the rectal mucosa
(and not be buried inside stool) to ensure
systemic absorption
5. Hold the buttocks together for several
minutes, or until the urge to defecate has
passed, to prevent immediate expulsion
6. If a bowel movement occurs within 10-30
minutes, observe for the presence of the
suppository.
• The suppository must be inserted past both
the external and internal sphincters for
proper placement. If not inserted far
enough, it may be expelled before
achieving a therapeutic effect.
TIOTROPIUM MEDICATION
• Tiotropium (Spiriva) is a long-acting, 24-
hour, anticholinergic, inhaled medication
used to control chronic obstructive
pulmonary disease (COPD).
• It is administered most commonly using
a capsule-inhaler system called the
HandiHaler. The powdered medication
dose is contained in a capsule. The client
places the capsule in the inhaler device and
pushes a button on the side of the device,
which pokes a hole in the capsule. As the
client inhales, the powder is dispersed
through the hole.
• Unlike most inhaled medications, tiotropium
looks like an oral medication because it
comes in a capsule. Therefore, it is
important to teach the client proper
administration prior to the first dose,
emphasizing that the capsule should not
be swallowed and that the button on the
inhaler must be pushed to allow for
medication dispersion. During future
appointments, the nurse should
assess/reassess the client's ability to use
this medication correctly.
• Clients should rinse the mouth after using
tiotropium and inhaled steroids (eg,
beclomethasone, budesonide, fluticasone)
to remove any medication remaining in the
mouth, which decreases the risk of
developing thrush.
• Tiotropium is a controller medication for
COPD with a peak effect of approximately 1
week; therefore, it should not be used as a
rescue medication. Instead, short-acting
bronchodilators (eg, albuterol and/or
ipratropium) should be used for symptom
rescue. Clients must discontinue
ipratropium before taking tiotropium as both
are anticholinergic.
• Anticholinergic inhaled medications
(eg, ipratropium, tiotropium, umeclidiniu
m) do not reduce inflammation in the
airway. Instead, they relax the airway by
blocking parasympathetic
bronchoconstriction. They also help dry up
airway secretions.
CLONIDINE PATCH PLACEMENT
• Clonidine is a potent antihypertensive agent
and is available as a transdermal
patch. The patches should be replaced
every 7 days and can be left in place during
bathing.
• Instructions for using the clonidine
(transdermal) patch:
o Apply the patch to a dry hairless
area on the upper outer arm or chest
once every 7 days
o Do not shave the area before applying
the patch. The skin should be free from
cuts, scrapes, calluses, or scars
o Wash hands with soap and water before
and after applying the patch as some
medication may remain on the hands
after application.
o Wash the area with soap and water,
then rinse and wipe with a clean, dry
tissue.
o Remove the patch from the
package. Do not touch the sticky side.
o Rotate sites of patch application with
each new patch. Remove the old patch
only when applying a new one. Do not
wear more than 1 patch at a time unless
directed by your health care provider
(HCP).
o When removing the patch, fold it in half
with the sticky sides together. Discard
the patch out of the reach of children
and pets. Even after it has been used,
the patch contains active medicine that
may be harmful if accidentally applied or
ingested
o Notify the HCP if you are experiencing
side effects such as dizziness or slow
pulse rate. Do not remove the patch
without discussing this with the HCP as
rebound hypertension can occur
IV SOLUTIONS
FENTANYL PATCHES
• Fentanyl, a potent opioid analgesic, is
administered IV to treat acute pain and as
a transdermal patch (Duragesic) dosed in
mcg/hr to treat chronic pain.
• When given via transdermal patch, fentanyl
is absorbed systemically through the skin
to provide continuous analgesia.
• Patches are replaced every 72 hours, and
the used patch must be removed before
applying a new one
• Used patches must be folded and
discarded immediately, as some medication
remains in a used patch.
• Opioid medications must be stored
and disposed of securely (eg, flushed
down the toilet, discarded in a sharps
container) as accidental exposure
is potentially fatal for children, pets, and
caregivers
• Heat (eg, heating pad) should not be placed
over a patch as this accelerates absorption.
• Cutting a transdermal patch damages the
drug-delivery system, results in
administration of an imprecise dose, and
risks exposure to the person cutting the
patch.
• Transdermal patches should be applied to
an area of flat, intact skin (eg, upper back,
chest) to prevent accidental removal. The
site should be clean, with little hair. Unlike
transdermal patches, topical analgesic
patches (eg, lidocaine, capsicum) deliver
drug locally and are placed near the site of
pain.
OPHTHALMIC OINTMENT
• Ophthalmic lubricants (drops, ointment, gel)
replace tears and add moisture to the
eyes. They are prescribed to treat dry
eyes, a common symptom in clients with
Sjögren's syndrome, an autoimmune
disorder.
• Administering an ophthalmic ointment by
tightly closing the eyes and rubbing the lid
for 2-3 minutes can squeeze the ointment
out of the eye and cause injury. The client
is taught to gently close the eyes for 2-3
minutes to distribute the medication after
applying the ointment.
• This statement indicates the client's
understanding that when self-administering
the medication, the client should squeeze a
thin strip of ointment onto the lower eyelid,
from the inner to the outer edge, and
without letting the tube touch the eye to
prevent contamination.
• This statement indicates the client's
understanding that when self-administering
the medication, the client tilts the head
back, pulls the lower lid down, and looks
toward the ceiling to help decrease blink
reflex.
• Some clients use the ophthalmic ointment
at bedtime and the eye drops during the
day due to blurred vision that ointments and
gels can cause.
• If applicable, the nurse requests that the
client remove contact lenses. The nurse
then dons clean gloves and uses aseptic
technique to administer ophthalmic
medications (eg, eye drops, lubricant) that
lubricate the eye and treat eye conditions
(eg, glaucoma, infection). The Joint
Commission disallows the use of
abbreviations for right eye (OD), left eye
(OS), and both eyes (OU). The nurse must
verify the prescription if the health care
provider (HCP) uses these abbreviations.
• The general procedure for the
administration of ophthalmic medications
includes the following steps in sequence:
1. Remove dried secretions with
moistened (warm water or normal
saline) sterile gauze pads by wiping
from the inner to outer canthus to
keep eyelid and eyelash debris from
entering the eye and to prevent transfer
of debris into the lacrimal (tear) duct
2. Place client in the supine or sitting
position with head tilted back toward
side of the affected eye to prevent
excess medication from flowing into the
lacrimal duct and minimize systemic
absorption through the nasal mucosa
3. Rest hand on client's forehead and hold
dropper 1-2 cm (1/2-3/4 in) above the
conjunctival sac, which keeps the
dropper away from the eye globe and
avoids contamination
4. Pull lower eyelid down gently with
thumb or forefinger against bony orbit to
expose the conjunctival sac
5. Instruct client to look upward and then
instill drops of medication into the
conjunctival sac. This minimizes the
blink reflex and retracts the cornea up
 and away from the conjunctival sac to washing will be completed after checking
avoid instillation onto the cornea for drug compatibility.
6. Instruct client to close the eyelid and NASAL SPRAY ADMINISTRATION
move the eye around (if
able). Then apply pressure to the • The proper positioning and administration
lacrimal duct for 30-60 seconds if of nasal sprays allow the medication to
medication has systemic effects (eg, reach the nasal passages. When educating
beta blocker, timolol maleate a client on how to self-administer nasal
[Timoptic]). This will distribute the sprays, the nurse teaches the client to:
medication, prevent overflow into the o Assume a high Fowler's position with
lacrimal duct, and reduce possible head slightly tilted forward
systemic absorption o Insert the nasal spray nozzle into an
open nostril, occluding the other nostril
7. Remove excess medication from each with a finger
eye with a new tissue or gauze pad to o Point the nasal spray tip toward the side
prevent cross-contamination and away from the center of the nose
o Spray the medication into the nose while
8. Wait 5 minutes before instilling a
inhaling deeply
different medication into the same eye
o Remove the nozzle from the nose and
breathe through the mouth
o Repeat the above steps for the other
IV ADMINISTRATION nostril
• The priority when administering 2 IV o Blot a runny nose with a facial tissue,
medications concurrently is to determine but avoid blowing the nose for several
drug compatibility. Incompatible drugs minutes after instillation
given through the same IV line
will deteriorate or form a precipitate. This
change is visualized through either a color
change, a clouding of the solution, or the
presence of particles.
• If 2 or more drugs are not compatible, the
nurse may consider inserting a second IV
or consulting the pharmacist and the health
care provider to determine the safest and
most beneficial plan for the client.
• Assessing the IV site for complications (eg,
infiltration, phlebitis) should always be
performed before giving any IV
medication. This will be completed after
determining drug compatibility.
• Verification using 2 client identifiers pertains
to the "right client" in the "6 rights" of
medication administration. Drug
compatibility should be determined prior to
entering the client's room and verifying
identity.
• Hand hygiene is a standard precaution
taken before any type of client interaction to
prevent contamination and infection; hand