NurseAchieve

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• Objectives • Intramuscular
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• Pharmacokinetics • Intravascular
• The Six Rights Of Medication • Intraosseous
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Administration • Controlled Substances

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• Evaluating Medication Orders •

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Total Parenteral Nutrition

• Unit Conversions • Route
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• Calculating Medication Doses • Timing

• Calculating Medication Rates • Complications
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• Medication Administration • Administration

• Oral • Preventing Needle-stick Injuries
• Rectal • Summary
• Topical • References
• Subcutaneous

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 • Understand the pharmacokinetics of medication’s movement through the
body
• Apply the six rights of medication administration

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• Evaluate medication orders

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• Calculate medication doses

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• Administer medication – oral, rectal, topical, subcutaneous, intramuscular,

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intravascular, and intraosseous
• Handling controlled substances

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• Administering Total Parenteral Nutrition
• Preventing needle-stick injuries

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Medication goes through

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ABSORPTION DISTRIBUTION
four phases in the body,
• Instant by IV, slower by other • Time to reach target tissues
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all of which affect its

routes and receptors varies
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efficacy and duration

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Foods or medications
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that inhibit liver

enzymes can reduce
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metabolism rates and METABOLISM

increase toxicity risk • Slowed breakdown increases
the risk of toxicity EXCRETION
Grapefruit is a • Liver and kidneys are key
major culprit! sites for metabolism

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MEDICATION DOSE CLIENT

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ROUTE TIME DOCUMENTATION

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• Is this the medication indicated on the order?

• Is this medication appropriate for the client’s
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condition?
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MEDICATION
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• Consult a medication guide for any medications

you are unfamiliar with
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 • Is this the dosage indicated on the order?
• Is this dosage appropriate for the client’s

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condition?
DOSE • Is this dose within the therapeutic range from the

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medication guide?
• Have I performed any necessary conversions to

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ensure this is the correct dose?

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• Is the order for this client?

Confirm with at least two unique identifiers like
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Name and Client ID number

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CLIENT
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• Does the client have any allergies to this

medication, any of its components, or any similar
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medications or foods?
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• Is this medication indicated for my client’s condition?

• Does my client know the purpose of this medication and what to watch for?
• Complete any assessments like blood pressure, apical heart rate, prior to
administration as needed.

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 • What route does the order give for this
medication?
• Is this medication suited for this route of

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ROUTE administration?

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• Can the medication be crushed if necessary (for

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ease of swallowing or administration via tube)?

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• Is this the time of administration specified on the

order? Is this a single time dose or a continuing
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order?
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TIME
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• Has the client received other medications likely to

interact with this medication within the washout
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window?
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• Organizational policies on acceptable windows for

medication administration vary – nurses use
clinical judgement to determine which are most
time-sensitive.

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 • Complete the medication administration record
(MAR)
• Monitor for therapeutic effect

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DOCUMENTATION
• Monitor for adverse effects

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• Nurses are responsible for critically reading

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and understanding medication orders

ORDER • Orders need to be complete with every
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• Date
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element listed here – any missing element

• Client’s name
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MUST be clarified before administration

• Reading an order together with a
• Medication name
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medication guide can assist the novice

• Dose nurse to confirm the suitability of the
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• Route medication order for their client

• Reading medication orders thoughtfully is
• Frequency crucial to protecting client safety
• Special instructions
• Signature of prescriber

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 To convert grams to milligrams, multiply by 1000 or
move decimal three spaces to the right

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i.e. 3 grams = 3000 mg

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To convert milligrams to grams, divide by 1000 or

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move decimal three spaces to the left
i.e. 3000 mg = 3 grams
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1 kilo = 2.2 pounds

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Weight in pounds / 2.2 = weight in kilograms

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Milliequivalent (mEq) is a ratio measuring the

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concentration of a substance (grams per Litre)

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 Consistent application of a formula makes dose calculation straightforward.
Prescriptions based on weight, requiring unit conversions, or divided doses over the
day require additional calculations before determining the prescribed dose

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Dose prescribed

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Quantity (i.e. tabs or mLs)
Dose available

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Nursing Perform calculations somewhere quiet and
without any interruptions to maintain focus and to

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The medication order calls for 500 mg of acetaminophen for a client. There are 250 mg
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tablets available. Solve for X.

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Dose prescribed
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500 mg Quantity (i.e. tabs or mLs)

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First add the values to the formula

Dose available 1 tablet
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250 mg
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500 mg 2 Then perform the calculations

Quantity (i.e. tabs or mLs)
250 mg 1 1 tablet

= 2 x 1 tablet 2 tablets

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 A slightly more complex example is a dose based on weight. You receive an order
for 0.2 mg/kg morphine sulfate for your client who weighs 70 kg.
Morphine sulfate is available in a vial that says “10 mg/mL”

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Dose prescribed

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0.2 mg x 70 kg

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Quantity (i.e. tabs or mLs) First add the values to the formula
Dose available 1 mL

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10 mg

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14 mg 2
1 mL
10 mg 1 Then perform the calculations

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= 1.4 x 1 mL 1.4 mL ng
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Calculating the dose may require converting the unit of weight. For this example, a
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child weighing 74.8 lbs (pounds) is prescribed medication 0.05 mg/kg. It is available
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in 5 mg/mL. Remember that one kilogram = 2.2 pounds

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Client weight = 74.8 lbs /2.2 = 34 kg

First convert the weight to kgs, then
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Dose prescribed = 34 kg x 0.05 mg/kg use it to calculate the dose prescribed

Dose prescribed = 1.7 mg
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1.7 mg
1 mL Then perform the calculations
5 mg
= 0.34 x 1 mL 0.34 mL

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 IV medications are delivered over time, so the nurse must calculate either the
mL/hour (for electronic infusion pumps) or the drops per minute (gtt/min) for
infusion by gravity. This client is to receive 450 mL of blood over 2 hours.

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Total Volume x Drop Factor gtts/min

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This is the formula for
Time in minutes (drops per gravity infusion.

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minute) Drop factor is the number
of drops per mL, it is

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450 mL x 10 gtts/mL marked on the infusion
4500 drops / 120 min set. In this example, the
2 hours x 60 min/hr
macroset has 10 gtt/mL

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37.5 gtt/min, rounded to 38 gtts/min ng
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An electronic IV pump is programmed with the number of mL/hour. This client is

supposed to receive 1 L normal saline over the next 8 hours.
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Total Volume in mL
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Rate in mL/hr
Time in hours Drops/min and mL/hour
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both express a volume

over time but use
1 L x 1000 = 1000 mL different units.
1000 mL / 8 hours
8 hours
125 mL / hour

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 • PO medications include tablets, liquid suspensions and capsules
• Oral suspension doses are calculated based on their concentration and
are measured in medication cup (at eye level) or in a syringe (for children

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or small amounts)

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• Coated, extended release and enteral

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preparations should not be crushed,

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check with a pharmacist or the
prescriber for alternatives

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• PR medications are a safe option for clients

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unable to swallow or who have nausea and

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vomiting
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• Administer with client in the Sim’s position.

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Ask them to exhale, and gently place the

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lubricated medication beyond the anal-

rectal ridge
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 • Topical mediations can be
• applied to the skin
• administered through inhalation
• instilled into a space in the body

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• Transdermal patches are used to provide slow release

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of medication into systemic circulation
• The nurse should distinguish between medication

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intended to act locally and those intended for

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distribution into the circulation

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• SC medication often prescribed for anticoagulants,

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insulin, vaccines and some vitamins

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• Use a short (1.5 cm) fine needle (23 – 26 gauge) to

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deliver medication to the deepest layer of skin

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• To administer, pinch the skin and administer at 90°

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for obese clients, 45° for people of average build,

or less than 45° for thin clients
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• Use a cotton swab to prevent bleeding and apply

band aid on top.

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 • Muscles suited for injecting medication include:
• Ventrogluteal
• Vastus lateralis
• Deltoid

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• To deliver the medication deep into the muscle, a

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larger (2.5 – 3.5 cm, 20 – 23 gauge) needle is used,

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using a 90° angle and a smooth, dartlike motion
• The choice of needle length and gauge is based on

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the client’s muscularity, characteristics of the

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medication, and comfort

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• IV medications are immediately distributed and available

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throughout the vasculature; this method provides the

quickest onset of all routes
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• Intravenous medication administration also has hazards.

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Injecting directly into the bloodstream can be a portal for

infection and the medication is irretrievable
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Nursing Alert!
Monitor clients receiving IV medications for infection and
adverse effects. Have antidote or reversal agents available for
high-alert medications.

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 • Intraosseous access is sometimes used for clients
where intravenous access is NOT feasible Nursing Alert!
e.g. pediatric, critically ill or very dehydrated clients
Practical Nurses can not

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• A needle is inserted through the hard cortex of the administer intraosseous

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bone and into the rich, vascular marrow. This medications.

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provides RAPID, DIRECT, NON-COLLAPSIBLE
ACCESS TO THE VASCULATURE Only a Registered Nurse

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can carry out this task

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• Most common site is the proximal

tibia
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• Intraosseous access is used to provide

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fluid resuscitation and has SIMILAR Most common site for

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VOLUMES, FLOW AND ABSORPTION intraosseous access is the

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RATES TO THE IV ROUTE PROXIMAL TIBIA

• Monitor for pain, fractures, signs of
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fluid buildup (possible dislodgement)

and compartment syndrome

Image adapted from BruceBlaus License

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 Nurses are responsible for administering medications within regulatory
guidelines, this includes substances considered to have abuse potential, such
as narcotics

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As per organizational policy and local regulations, when

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administering controlled substances, nurses must:

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• have another nurse CHECK and COSIGN wastage of
medication

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• have a nurse WITNESS waste of controlled
substances

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• perform NARCOTICS COUNTS when withdrawing
medication and at the start/end of each shift, and
• maintain substances in a CONTROLLED

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ENVIRONMENT (e.g. a locked narcotics cupboard)
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• Controlled substances are often under- TOLERANCE

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used for pain management, even Escalating doses

when appropriately prescribed
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required to achieve
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• The “illicit” designation of a the same effect.

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controlled substance should not

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deter the nurse from providing DEPENDENCE

adequate pain relief. To provide
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Physiological adaptation to a
good care, nurses must substance precipitates
distinguish between ADDICTION
withdrawal
dependence, Psychological symptoms
tolerance and addiction dependence often when d/c
rooted in trauma

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 • Used to ensure nutrition when the gastrointestinal system
is not working or needs rest
• Mix of fats, carbohydrates, protein, vitamins and minerals

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is delivered directly into the bloodstream
• Invasive and introduces several risks for complications

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including infection, air embolism, hyperglycemia or

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hypervolemia and potential for rebound hypoglycemia

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Nursing Alert!

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Practical Nurses can not initiate TPN
for a client or monitor a client on

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TPN. This task can only be completed
by a Registered Nurse
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PERIPHERAL
• Via subclavian or internal jugular vein
• If short term (under 1 month)
• For less concentrated solutions (isotonic
or mildly hypertonic)
CENTRAL
• Via implanted vascular access devices,
PICC, tunneled catheter
• If long term (over 1 month)
• For more concentrated hypertonic
solutions high in glucose or protein

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Intermittent
• Used at home for longer periods of Continuous

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time to promote independence • Used in hospital for short term
• Higher risk of rebound hypoglycemia durations

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• Usually 12 hrs/day (overnight) • Reduced risk of rebound
hypoglycemia

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PERIPHERAL CENTRAL BOTH

•Risk for swelling and •Placement must be •Allergy to eggs in lipid
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phlebitis from hypertonic confirmed by x-ray solution

solution •Air embolism risk – use
•Increased infection risk caution, Valsalva maneuver
and positioning to manage
•Infection due to bacterial
growth in sugary solution
•Refeeding syndrome,
hyperglycemia and
hypervolemia

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 Monitor Follow with 10%
Monitor blood
temperature and dextrose solution
glucose for
WBCs for to avoid rebound
hypoglycemia
infection hypoglycemia

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Don’t discontinue
Monitor weight for Monitor liver
abruptly, refeed
hypervolemia enzymes

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gradually

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Never try to catch
Examine solution,
Use an electronic up with a delayed
should be

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increasing flow rate
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NEEDLESTICK INJURIES CAN KILL

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• Have a sharps container nearby when you gather your materials for a
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procedure. Move the container with you (e.g. avoid walking across a room)
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• Concentrate on completing procedures safely through to disposal, and

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reduce interruptions as much as possible

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• Advocate for needleless systems and/or safety

needles that retract or can be placed in a safety
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sheath
Image: William Rafti (License)

• Avoid recapping needles, but if necessary, scoop lid

back on, one-handed to keep fingers away from tip
• Reporting injuries and near-misses is a part of
developing safer processes
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 To summarize, in this presentation the fundamentals of mediation
administration have been reviewed, including:
• The movement of medication through the body

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• Applying the six rights of medication administration

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• Evaluating medication orders

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• Calculating medication doses
• Administering medication by oral, rectal, topical, subcutaneous,

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intramuscular, intraosseous and intravascular routes

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• Handling controlled substances
• Total Parenteral Nutrition

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• Preventing needle stick injuries ng
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1. Adams M, Holland L, Urban C. (2019). Pharmacology for Nurses: A

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Pathophysiologic Approach (6th edition). Pearson.

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2. Bauldoff G, Gubrud P, Carno M. (2019). LeMone and Burke’s Medical-Surgical

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Nursing: Clinical Reasoning in Patient Care. (7th edition). Pearson.

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3. Harding MM, Kwong J, Roberts D, Hagler D, Reinisch C. (2019). Lewis’s

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Medical-Surgical Nursing: Assessment and Management of Clinical Problems,

(11th edition). Mosby.
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4. Perry A, Potter P, Ostendorf W, Laplante N. (2021). Clinical Nursing Skills and

Techniques. (10th edition). Mosby.

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