Medications

Objectives

1. Define selected terms related to the administration of medications.

2. Describe legal aspects of administering medications.
3. Describe actions of drugs on the body.
4. Identify factors affecting medication action.
5. Describe various routes of medication administration.

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 Objectives

6. Identify essential parts of a medication order.

7. List examples of various types of medication orders.
8. State systems of measurement that are used in the administration
of medications.
9. Describe four formulas for calculating drug dosages.

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 Objectives

10. List six essential steps to follow when administering medication.

11. State the “rights” to accurate medication administration.
12. Describe the physiologic changes in older adults that alter
medication administration and effectiveness.

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 Objectives

13. Recognize when it is appropriate to delegate medication

administration to unlicensed assistive personnel.
14. Demonstrate appropriate documentation and reporting of
medication administration skills.

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 Terminologies

× Medication
× Substance administered for diagnosis, cure, treatment, or relief
of symptom or for prevention of disease
× Drug
× Same as medication but also refers to illicitly obtained
substance

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 Terminologies

× Prescription
× Written direction for preparation and administration of a drug
× Generic name
× Name used throughout the drug’s lifetime Rx
× Trade (brand) name
× Given by drug manufacturer
× Identifies it as property of that company

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 Terminologies

× Official name
× Name by which drug is listed in official publications
× Chemical name
× Name by which a chemist knows it
× Describes constituents of the drug precisely

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 Terminologies

× Pharmacology
× Study of effect of drugs on living organisms
× Pharmacy
× Prepares, makes, and dispenses drugs as ordered
× Pharmacist
× Person who prepares, makes, and dispenses drugs as ordered

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 Drug Standards

× Drugs can be made from plants, minerals, or animals, or be

produced synthetically.
× Standards ensure drugs are pure and of uniform strength, uniform
quality.
× U . S. Pharmacopeia describes drug sources, properties, tests done,
storage methods, assay category, normal dosages.
× pharmacopoeia (also spelled pharmacopeia) is a book containing a list of
products used in medicine, with descriptions of the product, chemical tests
for determining identity and purity, and formulas and prescriptions.

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× Food and Drug Administration
× It is responsible for protecting the public health by ensuring the
safety, efficacy, and security of human and veterinary drugs,
biological products and medical devices, and by ensuring the
safety of our nation’s food supply, cosmetics, and products that
emit radiation. www.fda.gov

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 Legal Aspects of Administering Medications

× Nursing practice acts

× Recognizing limits of own knowledge and skill
× Take responsibility for actions
× Question any order that appears unreasonable
× Refuse to give medication until order is clarified

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 Legal Aspects of Administering Medications

× Controlled substances
× Kept under lock
× Special inventory forms
× Documentation requirements
× Procedures for discarding
× End-of-shift counts of controlled substances

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 Effects of Drugs

× Therapeutic effect
× Desired effect
× Reason drug is prescribed
× Side effect
× Secondary effect
× Unintended, usually predictable
× May be harmless or harmful

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 Effects of Drugs

× Adverse effect
× More severe side effect
× May justify discontinuation of a drug
× Drug toxicity
× Results from overdose, ingestion of external-use drug, or
buildup of drug in blood

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 Effects of Drugs

× Drug allergy
× Immunologic reaction to drug
× Mild to severe reactions
× Anaphylactic reaction, anaphylaxis
× Drug tolerance
× Unusually low physiological response
× Requires increases in the dosage to maintain a given
therapeutic effect

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 Effects of Drugs

× Drug tolerance
× Cumulative effect
× Increased effect resulting from rate of dosage being higher
than rate of excretion
× Idiosyncratic effect
× Unexpected; may be individual to client
× Drug interaction
× One drug alters effect of other drug(s).

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 Effects of Drugs

× Potentiating effect
× One or both drugs is increased.
× Additive
× Two of same types of drugs increase action of each other.
× Synergistic
× Two different drugs increase action of one or another.

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 Effects of Drugs

× Inhibiting effect
× Effect of one or both drugs is decreased.
× Iatrogenic disease
× Disease unintentionally caused by medical or drug therapy

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 Drug Misuse

× Improper use of common medications

× Drug abuse
× Drug dependence
× Physiological dependence
× Psychological dependence
× Drug habituation
× Illicit drugs

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 Actions of Drugs on the Body

× Half-life
× Time interval required for body’s elimination processes to
reduce the concentration of the drug in the body by one-half
× Onset of action
× Peak plasm level
× Drug half-life (elimination half-life)
× Plateau

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 Figure 35-2 A Graphic Plot of Drug Concentration in the Blood Plasma
Following a Single Dose

For long description see slide 210, Appendix 1.

 Pharmacodynamics

× Mechanism of drug action and relationships between drug

concentration and the body’s responses
× Receptor
× Drug’s target
× Agonist
× Same response as endogenous substance
× Antagonist

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 Pharmacokinetics

× Study of absorption, distribution, biotransformation, and excretion

of drugs
× Absorption
× Process by which drug passes into bloodstream
× Rate is variable
× Depends on food, acid medium
× Drug bypassed if injected

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 Pharmacokinetics

× Distribution
× Transportation of a drug from its site of absorption to its site of
action
× Biotransformation
× Also called detoxification or metabolism
× Process by which a drug is converted to a less active form
× Metabolites
× Products of this process

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 Pharmacokinetics

× Excretion
× Process by which metabolites eliminated
× Mostly through urine

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 Quick Quiz!

× Select the statements that are true about the absorption of drugs.
Select all that apply.
A. Food can delay or enhance
B. Movement to site of action
C. Slower in stomach than large intestine
D. Occurs first in vascular organs
E. Rate depends on site
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 Factors Affecting Medication Action

× Developmental factors
× Risks during pregnancy
× Infants require smaller dosages.
× Older adults experience decreased gastric motility
× Gender
× More drug research done on men

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 Factors Affecting Medication Action

× Cultural, ethnic, and genetic factors

× Pharmacogenetics
× Ethnopharmacology
× Study of the effect of racial, ethnic responses to prescribed
medication
× Diet
× Nutrients can affect action of a medication

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 Factors Affecting Medication Action

× Environment
× Especially affects drugs used to alter behavior and mood
× Psychological factors
× Expectations

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 Factors Affecting Medication Action

× Illness and disease

× Action altered in clients with circulatory, liver, or kidney
dysfunction
× Time of administration
× Some drugs absorbed more quickly if stomach is empty, some
when stomach is full

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Allergy Identification
 Routes of Administration

× Oral
× Most common, least expensive, most convenient
× Sublingual
× Not to be swallowed, but dissolved
× Buccal
× Cheek

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× Oral Medications
× N P O “nothing by mouth” or Latin “nil per os”
× Oral most common route
× Preferred unless digestive problem (e.g., nausea and vomiting)

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× Nasogastric and Gastrostomy Medications
× Nasogastric tube, gastrostomy tube
× Practice guidelines
× Check with pharmacist a liquid form
× Check to see if medication can be crushed
× Crush tablet into fine powder and dissolve in at least 30
milliLiter of warm water
× Open capsules and mix contents with water only if pharmacist
says it is safe
× Do not administer whole or undissolved medications
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 Routes of Administration

× Parenteral
× Subcutaneous (hypodermic)
× Intramuscular (I M)
× Intradermal (I D)
× Intravenous (I V)
× Less common
× Intrathecal/intraspinal
× Epidural
× Intracardiac

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× Parenteral Medications
× Parenteral administration is a common nursing procedure.
× Absorbed more quickly than oral route
× Careful and accurate administration
× Aseptic technique

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Figure 35-14 The Three Parts of a Syringe
 Figure 35-15 Three Kinds of Syringes

For long description see slide 223, Appendix 14.

A, 3-m L syringe marked in tenths (0.1) of milliliters and in minims; B, insulin syringe marked in 100 units; C, tuberculin
illi iter

syringe marked in tenths and hundredths (0.01) of 1 milliliter (mL) and in minims.
 Figure 35-18 Tips of Syringes

A, Luer-Lok syringe (note threaded tip); B, non-Luer-Lok syringe (note the smooth graduated tip).
Figure 35-19 A 60-mL Non-Luer-Lok Syringe, Which Can Be Used for
Irrigation of Tubes or Wounds
Figure 35-22 The Parts of a Needle
× Preventing needlestick injuries
× Needles and sharps present one of greatest dangers to health
care workers.
× Passive devices
× Retracts immediately
× Active devices
× Requires nurse to activate safety feature
 Figure 35-26 Passive Safety Device

For long description see slide 224, Appendix 15.

The needle retracts immediately into the barrel after injection.

Figure 35-27 Active Safety Device. the Nurse Manually Pulls the Sheath or
Guard over the Needle after Injection
Figure 35-28 A Needleless System Can Extract Medication
from a Vial
 Box 35-8 Avoiding Puncture Injuries (1 of 2)

For long description see slide 225, Appendix 16.

 Box 35-8 Avoiding Puncture Injuries (2 of 2)

For long description see slide 226, Appendix 17.

× Preparing Injectable Medications
× Ampules and vials
 Skill 35-2 Preparing Medications from Ampules (4 of 4)

For long description see slide 230, Appendix 21.

 Skill 35-3 Preparing Medications from Vials (2 of 4)

For long description see slide 232, Appendix 23.

 Skill 35-3 Preparing Medications from Vials (3 of 4)

For long description see slide 233, Appendix 24.

 Skill 35-3 Preparing Medications from Vials (4 of 4)

For long description see slide 234, Appendix 25.

× Preparing Injectable Medications
× Mixing medications in one syringe
× Can be done with compatible drugs (e.g., two types of insulin)
× Push amount of air equal to dose into first vial
× Push amount of air equal to dose of second drug into second
vial
× Withdraw correct amount of drug from second vial
× With newly attached, sterile needle, carefully withdraw correct
amount of drug from first vial
 Skill 35-4 Mixing Medications Using One Syringe (4 of 4)

For long description see slide 239, Appendix 29.

× Intradermal Injections
× Very small amounts
administered just below
epidermis
× Allergy testing
× Tuberculosis

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 Skill 35-5 Administering an Intradermal Injection for Skin
Tests (4 of 4)

For long description see slide 244, Appendix 33.

× Subcutaneous Injections
× Injected just beneath skin
× Vaccines, insulin, heparin
× Syringe depends on medication given,
thickness of skin fold
× Sites need to be rotated in an orderly fashion to
minimize tissue damage, aid absorption
× Aspiration no longer recommended

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Skill 35-6 Administering a Subcutaneous Injection (3 of 6)

For long description see slide 249, Appendix 37.

Skill 35-6 Administering a Subcutaneous Injection (4 of 6)

For long description see slide 250, Appendix 38.

× Intramuscular Injections
× Absorbed more quickly than subcutaneous because muscle more
vascular
× Large volumes can be tolerated.
× Size of syringe varies.
× Adult standard is 1.5 inches, 21 or 22 gauge.
× Factors determining size and length
× Muscle
× Type of solution
× Adipose tissue
× Age of client 67
× Intramuscular Injections
× Ventrogluteal site
× Preferred
× No large nerves, vessels
× Sealed off by bone
× Side-lying position most accessible
× Vastus lateralis site
× Best for infants, young children

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 Figure 35-35 Landmarks for the Ventrogluteal Site for an
Intramuscular Injection

For long description see slide 254, Appendix 41.

 Figure 35-37 The Vastus Lateralis Muscle of an Infant’s Upper Thigh, Used
for Intramuscular Injections

For long description see slide 255, Appendix 42.

 Figure 35-40 Landmarks for the Rectus Femoris Muscle of the Upper
Right Thigh, Used for Intramuscular Injections

For long description see slide 256, Appendix 43.

× Intramuscular Injections
× Dorsogluteal site
× Not preferred, should be avoided
× Close to sciatic nerve and superior gluteal nerve
× Complications have occurred.
× Numbness
× Pain
× Paralysis
× Subcutaneous tissue

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× Intramuscular Injections
× Rectus femoris site
× Easily accessible to clients who administer their own injection
× May cause discomfort for some people
× Deltoid site
× Close to radial nerve, artery
× No more than 1 milliLiter of solution can be administered
× Hepatitis B vaccine

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 Figure 35-41 A Method of Establishing the Deltoid Muscle Site for an
Intramuscular Injection

For long description see slide 257, Appendix 44.

× Intramuscular Injection Technique
× Also called Z - track
× Less painful
× Decreases leakage of irritant medication into subcutaneous tissue
× Traps medication in muscle layer

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Skill 35-7 Administering an Intramuscular Injection (4 of 6)

For long description see slide 262, Appendix 48.

 Skill 35-7 Administering an Intramuscular Injection (5 of 6)

For long description see slide 263, Appendix 49.

 Skill 35-7 Administering an Intramuscular Injection (6 of 6)

For long description see slide 264, Appendix 50.

× Intravenous Medications
× Route appropriate for rapid effect (direct to bloodstream) or for
medication that irritates tissue
× Large-volume infusions
× Safest, easiest
× Main danger is hypervolemia
× Intermittent intravenous infusions
× Tandem
× Piggyback

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 Figure 35-45 Secondary Intravenous Lines

For long description see slide 265, Appendix 51.

A, a tandem intravenous alignment; B, an intravenous piggyback (I VPB) alignment.

 Skill 35-8 Adding Medications to Intravenous Fluid
Containers (3 of 5)

For long description see slide 269, Appendix 54.

 Skill 35-8 Adding Medications to Intravenous Fluid
Containers (4 of 5)

For long description see slide 270, Appendix 55.

× Intravenous Medications
× Volume-controlled infusions
× Often used with children, older clients when volume
administered is critical and must be carefully monitored
× Intravenous push
× Or bolus
× Intermittent infusion devices
× For clients receiving long-term therapy

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 Skill 35-9 Administering Intravenous Medications Using I V
Push (5 of 8)

For long description see slide 277, Appendix 61.

 Routes of Administration

× Topical
× Dermatologic
× Installations and irrigations
× Inhalations

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× Topical Medications
× Percutaneous
× Transdermal patch
× Skin applications
× Clean skin before applying
× Wear gloves
× Use surgical asepsis in presence of open wound
× Ophthalmic medications
× Liquid or ointment medication into eye
× Irrigation
× Instillation 90
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 Skill 35-10 Administering Ophthalmic Instillations (4 of 6)

For long description see slide 287, Appendix 68.

× Topical Medications
× Otic medications
× Administer medication to external
auditory canal
× Irrigation
× Instillation
× Position of canal varies with age.

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× Topical Medications
× Nasal medications
× Shrink swollen mucus membranes
× Loosen secretions and facilitate drainage
× Treat infections of nasal cavity and sinuses
× For self-administration:
× Suggest that client should blow nose first
× Client in seated position with head tilted back
× Client holds tip of container just inside the nares
× Inhales as spray enters the nasal passage
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 Figure 35-51 Position of the Head to Instill Drops into the
Ethmoid and Sphenoid Sinuses

For long description see slide 297, Appendix 76.

 Figure 35-52 Position of the Head to Instill Drops into the
Maxillary and Frontal Sinuses

For long description see slide 298, Appendix 77.

× Topical Medications
× Vaginal medications
× Creams, jellies, foams, or suppositories
× Infections or discomfort

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 Skill 35-12 Administering Vaginal Instillations (2 of 4)

For long description see slide 301, Appendix 79.

× Topical Medications
× Rectal medications
× Inserting a rectal suppository
× Assist client to left lateral or left Sims position
× Upper leg flexed
× Expose buttocks
× Put glove on hand used to insert the suppository
× Unwrap suppository

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× Topical Medications
× Rectal medications
× Inserting a rectal suppository
× Lubricate smooth rounded end
× Lubricate gloved index finger
× Encourage client to relax by breathing through the mouth
× Insert suppository gently into the anal canal
× Avoid embedding in feces
× Press buttocks together for a few minutes
× Ask client to remain in left lateral or supine position for at
least 5 minutes
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Figure 35-53 Inserting a Rectal Suppository beyond the Internal Sphincter
and along the Rectal Wall
× Inhaled Medications
× Nebulizers
× Fine spray (fog or mist)
× Metered-dose inhaler
× Extender, extender spacer

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× Irrigations
× Irrigation (lavage)
× Stream of water or other fluid
× Clean body cavity
× Remove foreign object, secretions
× Apply heat/cold
× Apply antiseptic
× Reduce inflammation
× Relieve discomfort

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 Figure 35-59 Four Types of Syringes Used for
Irrigations

For long description see slide 305, Appendix 82.

A, Asepto; B, rubber bulb; C, piston syringe; D, Pomeroy.

 Medication Orders

× Ordered by physicians
× Sometimes nurse practitioners, physician assistants depending
on state laws and agency policies
× Verbal and telephone orders
× Abbreviations, acronyms, and symbols

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 Types of Medication Orders

× Stat order
× Such as morphine sulfate 10 milligrams I V stat
× Single order
× Such as Seconal 100 milligrams hs before surgery
× Standing order
× Indefinitely, such as multiple vitamins daily
× Specified number, such as K Cl twice daily × 2 days
× P R N order
× Such as Amphojel 15 milliLiter prn

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 Essential Parts of a Medication Order

× Full name of client

× Date and time order is written
× Name of drug to be administered
× Dosage of drug
× Frequency of administration
× Route of administration
× Signature of person writing the order

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 Figure 35-5 A Prescription Filled out by a Primary Care
Provider

“take thou”

For long description see slide 211, Appendix 2.

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 Quick Quiz!

× Which of the following items does not need to be included in the

medication​ order?
A. Medication to be administered
B. Signature of prescriber
C. Drug manufacturer
D. Client​’s
E. Name
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 Communicating Medication Orders

× Written on chart, provided by phone or verbally

× Copied to Kardex or M A R, or on computer printout
× If an order seems inappropriate
× Contact primary care provider
× Document in notes when P C P called, what was
communicated, how P C P responded
 Communicating Medication Orders

× If an order seems inappropriate

× Or, document attempts to reach P C P and reason for
withholding drug
× If medication given, document client condition before and after
dose
× If needed, document factual information on incident report
 Systems of Measurement

× Metric system
× Devised by the French
× Logically organized into units of 10
× Meter, liter, gram basic units
× Apothecaries’ system
× Older than metric system
× Grain, minim basic units
× Do not use; unfamiliar to many

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 Figure 35-7 Basic Metric Measurements of Volume and
Weight

For long description see slide 212, Appendix 3.

 Systems of Measurement

× Household system
× May be used when more accurate systems not required
× Drops, teaspoons, tablespoons, cups, and glasses
× Pints and quarts defined as apothecaries’ measures

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 Converting Units of Weight and Measure

× Converting weights within the metric system

× Gram (g), milligram (mg), and microgram (mcg) only units
used for dosages
× Divide or multiply and move decimal points
× Put a 0 in front of decimal point if less than 1 (0.5g)

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 Converting Units of Weight and Measure

× Converting weights and measures between systems

× Nurse may need to convert from systems used by pharmacies
× Converting units of volume
× Fluid drams, ounces used in liquid medications
× Liters, milliliters used for enemas, irrigations, and solutions for
wounds

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 Converting Units of Weight and Measure

× Converting units of weight

× Milligrams to grains
× Milligram is smaller than a grain
× 1 grain = 60 milligrams
× Pounds to kilograms
× 2.2 l b = 1 kilograms

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The table is as follows.
Appendix 4
Metric Apothecaries Household

1 milliliter 15 minims, m i n or m 15 drops, g t t

4 to 5 milliliters 1 fluid dram 1 teaspoon

15 milliliters 4 fluid drams 1 tablespoon, T b s p

30 milliliters 1 fluid ounce same

500 milliliters 1 pint, p t same

1,000 milliliters 1 quart, q t same

4,000 milliliters 1 gallon, g a l same

 Methods of Calculating Dosages

× Basic formula
× (D × V) / H
× D (desired dose)
× H (dose on hand)
× V (vehicle or form of drug)
× Ratio and proportion method
× H : V :: D : x
× Considered to be the oldest method
 Methods of Calculating Dosages

• Fractional equation method

×
× Cross multiply and solve for x

* Dimensional analysis

1. 1. Identify dose on hand

2. 2. Identify desired dose
3. 3. Write down conversion factor
4. Set up equation
5. Cancel units that appear in numerator and denominator
6. Multiply numerator; multiply denominator; divide the products
 Methods of Calculating Dosages

× Calculating for individualized drug dosage

× Clients receiving chemotherapy, critically ill clients required
individualized dosages
× Body weight
× Convert pounds to kilograms.
× Determine drug dose per body weight by multiplying drug
dose × body weight × frequency
 Methods of Calculating Dosages

× Calculating for individualized drug dosage

× Body weight
× Choose method of drug calculation to determine amount to
administer
× Body surface area
× Ratio of child’s body surface area to that of an average
adult
× (Surface area of child (meter2) / 1.7meter2) × normal
adult dose
 Administering Medications Safely

× Always assess health status

× Take medication history
× Include O T C drugs and supplements, allergies, normal eating
habits
× Include client’s illness or current condition, intended drug and route
× Assess ability to self-administer
× Assess socioeconomic factors
× Transportation
× Money for medication
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 Medication Reconciliation

× Most accurate list possible of all drugs taken compared to primary

care provider’s orders to provide continuity of care
× Inadequate communication during transitions accounts 50% of med
errors and 20% of adverse drug events
× Completed list provided to client and next health care provider

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 Medication Dispensing Systems

× Medication cart
× Mobile
× Medication cabinet
× Locked, in client’s room
× Medication room
× Accessed by key, code
× Automated dispensing cabinet The Medication Cart is Kept Locked
× Reduces risk of error, theft When Not in Use

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 Process of Administering Medications

× Identify the client

× Inform the client
× Administer the drug
× Provide adjunctive interventions as indicated
× Record the drug administered
× Evaluate the client’s response to the drug

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 Ten “Rights” of Medication Administration

1. Right Medication
• The medication given was the medication ordered.
2. Right Dose
• The dose ordered is appropriate for the client.
3. Right Time
• Give the medication at the right frequency and at the time ordered
according to agency policy.
4. Right Route
• Give the medication by the ordered route.
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 Ten “Rights” of Medication Administration

5. Right Client
• Medication is given to the intended client.
6. Right Client Education
• Explain information about the medication to the client
7. Right Documentation
• Document medication administration after giving it, not before.
8. Right to Refuse
• Adult clients have the right to refuse any medication.

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 Ten “Rights” of Medication Administration

9 Right Assessment
• Some medications require specific assessments prior to
administration (e.g., apical pulse, blood pressure, lab results).
10. Right Evaluation
• Conduct appropriate follow-up (e.g., was the desired effect
achieved or not? Did the client experience any side effects or
adverse reactions?).

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Figure 35-13A A Sample Bar Code
Figure 35-13B The Nurse Scans the Bar Code on the
Medication Package
Figure 35-13C The Nurse Scans the Bar Code on the Client’s Wristband
before Administering the Medication
 Developmental Considerations

× Growth and development especially important in administering

medication to very young and very old
× Infants and children
× Most often provided in sweetened liquid form
× Do not mix into milk or orange juice

👪
× Be honest about injections hurting

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 Developmental Considerations

× Older adults
× Altered memory
× Decreased visual acuity
× Decrease in renal function
× Less complete and slower absorption from gastrointestinal tract
× Increased proportion of fat to lean body mass
× Decreased liver function
× Decreased organ sensitivity
× Altered quality of organ responsiveness
× Decrease in manual dexterity
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 Quick Quiz!

× A client tells the nurse, “This pill is a different color than the one
that I usually take at home.” Which is the best response by the
nurse?
1. “Go ahead and take your medicine.”
2. “I will recheck your medication orders.”
3. “Maybe the doctor ordered a different medication.”
4. “I’ll leave the pill here while I check with the doctor.”

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� Summary

�
× Medications have several names. Nurses need to know the
generic and trade names of a medication and be aware of both its
therapeutic and side effects.
× Nurse practice acts define limits on the nurse’s responsibilities
regarding medications.
× Nurses must always assess a client’s physical status before giving
any medication and obtain a medication history.

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 Summary

× When administering medications the nurse observes specified

“rights” to ensure accurate administration. When preparing
medications, the nurse checks the medication container label
against the MAR three times.
× The nurse always identifies the client appropriately before
administering a medication and stays with the client until the
medication is taken.
× Medications, once given, are documented as soon as possible
after administration.

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 Place your screenshot here

REFERENCE
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