Medication Administration Basics

Purpose
The administration of medication is often a chief responsibility of the nurse. The practice of administering medication involves providing the patient with a substance prescribed and intended for the diagnosis, treatment, or prevention of a medical illness or condition.

Description
The central action of medication administration involves actual and complete conveyance of a medication to the patient. However, there is a wider set of practices required to achieve safe, effective patient outcomes and to prepare for and evaluate the outcome of medication administration.

Laws regarding medication administration vary from state to state. Doctors, physicians, physician assistants, nurse practitioners, and nurses are generally trained and authorized to administer medication, while other medical disciplines may have a limited responsibility in this area. In certain circumstances, unlicensed personnel may be trained and authorized to administer medication in residential care settings. State and federal laws also restrict the distribution of and access to medications that can be abused (called controlled substances). Responsibility for controlled substances includes accountability for any discarded substances, double-locked storage, and counting of medication supply at regular intervals by clinician teams.

Preparation for medication administration begins with the order for medication, in most circumstances written by the physician. Nurse practitioners and physician assistants are also often authorized to write prescriptions. State laws vary regarding these privileges. A record of orders for medication and other treatments is kept in the medical chart. Universally accepted safe clinical practice guidelines and state laws govern the components of medication orders in order to ensure consistency and patient safety. All orders should contain the patient's name, the date and time when the order is written, and the signature of the ordering clinician. Caregivers administering medication are responsible for checking that these components are present and clear. The name of the medication is accompanied by the dosage, or how much of the drug should be given; the route of administration, or how the medication should be given (ie, intramuscular injection); and frequency, or how often the drug is to be given. Common routes of administration are discussed below.

The most common route of administration is the oral route, or swallowing of medication. This is the easiest and safest route. The physical position and swallowing abilities of the patient should be evaluated to avoid choking. Patients may also receive medication by the buccal route (through the inner cheek or gum) or the sublingual route (under the tongue).

Administration involving a needle or syringe occurs with several drug routes. These routes are referred to as parenteral. Care must be taken to maintain asepsis with all injections and injection sites. Intramuscular medications are injected into the muscle. A special injection technique called Z-track can be used when administering intramuscular medications that can be damaging to the tissue. All intramuscular injections involve the practice of landmarking, or identifying anatomical markers that indicate the correct injection site and avoid damage to bone or nerves. Subcutaneous injections are administered under the skin. Insulin is a common medication that is usually given subcutaneously. Intra dermal medications are used much less frequently than subcutaneous or intramuscular injections. They are injected into the skin. Intravenous medications are given through an intravenous line into the vein. These medications may be mixed with a large amount of solution that is being infused, given in a small solution through a port in the intravenous tubing (bolus), or attached in smaller infusion containers to the larger infusion (piggyback). In all cases of administration with a needle or syringe, rotation of injection sites is required to prevent damage to tissue. It is also important that the size of the needle is selected based on the thickness of the medication to be given and the depth of the injection, while maximizing the patients level of comfort during insertion. Needle sticks with contaminated needles are a hazard to both health professional and patient. Care is taken to dispose of needles and syringes rapidly in impervious containers. Protective systems that sheath the needle after use are commonly used to prevent inadvertent needle sticks.

Medication can also be instilled via the mucous membranes. A sepsis must be used to avoid introduction of infection. Rectal or vaginal medications are most often given in suppository form and must be introduced gently to avoid tearing or bleeding of tissue. Nasal medications are often instilled via spray or drops and often involve closing one nostril and asking the patient to inhale gently. The head should be tilted back to avoid aspiration. Ear or otic medications are given in liquid form. The patient's head is tilted to the side. Instruments should never enter the ear. If the medication is not instilled correctly, the patient may experience nausea or vertigo. Eye or ophthalmic medications may be given via drops or ointment. The container for the medication should not touch the eye, and drops are introduced into the inner can thus or corner of the eye.

Inhalational medications are inhaled via the respiratory tract, most often to treat respiratory conditions. Metered dose inhalers (MDI) are often used. MDIs involve pressing a specially designed canister to release a mist.

Topical medications are applied to the surface of the skin. The skin needs to be cleansed and assessed for breaks before administering topical medications. Topical patches that gradually release medication need to be labeled with date and time in case a second patch is inadvertently applied without removal of the first. Ointments are applied evenly. The clinician should avoid touching the topical medication, as medications that are absorbed into the system via the skin, such as nitroglycerin paste, may affect the clinician. As with all medication techniques, asepsis must be maintained to avoid introduction of microorganisms.

Frequency of administration is most often ordered on a repeating schedule (ie, every 8 hours). At times the order may be written as a STAT (give right away) order, a one-time order (give just once) or a prn (give as needed) order. Standing orders are routine hospital orders that doctors in specialized areas prescribe on admission.

Many abbreviations are used in writing medication orders. Other common abbreviations include:

p.o.: by mouth
IM: intramuscular injection
SC: subcutaneous injection
IV: intravenous
PR: per rectum
h.s.: at hour of sleep (bedtime)
ac: before meals
pc: after meals
q: every, ie, q 8 h means every 8 hours
q.d.: every day
b.i.d.: twice/day
t.i.d.: three times/day
q.i.d.: four times/day
q.o.d.: every other day
Some examples of medication orders using these abbreviations are:

digoxin 0.25 mg p.o. q.d.
diphenhydramine 25 mg p.o. q h.s. prn.
If orders are illegible, ambiguous, or confusing, the author of the order should be consulted to clarify the order before any medication administration occurs. When the order is clear, it often needs to be transcribed to another document reserved for recording administration of medications. Health care institutions have specific policies regarding methods with which to check medication orders and ensure proper transcription. Policies also dictate parameters for order renewal or medication discontinuation. Poor penmanship, misunderstanding of penmanship, and errors in transcription often contribute to medication errors. It is increasingly common for medical facilities to use a computerized system that lowers the risk of error by reducing steps in the process and validating information automatically.

Once the order has been read and verified, the care-giver needs to evaluate the order in the context of the individual patient. Some factors to consider include:

pharmacodynamics: how the drug works in the body
interactions: possible effects of other medication or food on the ordered medication
allergies: patient history of hypersensitivity to drug or drug class
contraindications: medical conditions that preclude the use of the ordered drug
side effects: potential adverse reactions to the drug
toxic effects: dangerous effects that often occur due to build up of drug in body or impaired metabolism
tolerance: certain drugs require increasing doses over time to achieve the same effect
physiological variables: sex, age, size, and physical condition may alter how a drug is processed in the body
diet: certain foods, liquids, or nutritional states may alter the drug's effect on the body
Due to the large number of medications available and the large body of information required for appropriate drug administration, it is important to have access to a current medication reference such as the Physician's Desk Reference or other reference handbooks about medication. The package insert that comes with every medication is also a good resource. Pharmacists are knowledgeable resources and can answer many questions regarding medication. It is important to be familiar with the medication ordered before attempting to administer it. Procedural manuals by the institution or medical reference publishers detail the step-by-step techniques for administering various types of medication.

The patient should be notified of the order for the drug and provided with education about the medication they are to receive. Before administration, five factors often referred to as the "five rights" should be addressed. Medication records should be on hand at time of administration to ensure safe administration.

Right patient. Identify patient by name badge or bracelet. Avoid simply asking patient's name or checking the name on the door as miscommunications can sometimes occur.

Right drug. Check record for name of drug and compare with drug on hand. As many drugs have similar spellings, this needs to be checked carefully. For prevention of error, it is often recommended that three checks of the drug to be administered are made: when reaching for the package that contains the drug, when opening the drug, and when returning the packaging to its storage area. It is also recommended that clinicians only administer drugs that they have prepared, versus those prepared by another clinician.

Right route. Check medication record for how to administer the drug and check labeling of drug to ensure it matches prescribed route.

Right dose. Compare ordered dose to dose on hand. At times, calculations may need to be performed to ascertain the correct dose. For example, a scored tablet, or one that is designed and intended for dividing, may need to be halved or quartered in order to administer the correct oral dose. This requires simple division. Common situations requiring calculation include calculation of intravenous infusion rates and the conversion of measurement units, for example, determining how many milliliters (mL) are required to give the ordered number of milligrams.

The formula for this calculation can be applied to many situations:

dose ordered/dose on hand × amount on hand = amount to administer
Using the above medication question, 25 mg/100 mg × 2 ml = 0.5 ml (amount to administer)

Intravenous medications also require frequent calculation. For example, an intravenous anticoagulant such as heparin may be ordered as "1000 units per hour," and the clinician may need to calculate how many drops are needed per minute or hour based on how the intravenous solution is prepared. These calculations may vary according to the infusion equipment used, for example, varying drop factor ratings or use of a device called a buretrol that carefully measures infused medication. Often a mechanical pump is used to control intravenous infusion rates.

Right time. Verify that frequency or time ordered matches current time.

All medications should be handled to ensure that they do not come into contact with potentially contaminated objects or surfaces. Medications of any sort should not be left unattended, and patients should be observed taking the medication. This avoids the disposal, hoarding, abuse, or misuse of the medication, and assures the safety of the patient.

Documentation of medication administration is an important responsibility. The medication record tells the story of what substances the patient has received and when. Like other health care records, it is also a legal document. Various institutions have policies and procedures regarding documentation. The initials of the administering nurse or other health care provider and the time and date should be documented on the record next to the appropriate order. Other information may be required, such as location and severity of pain when administering a pain medicine (analgesic) or pulse rate when administering certain heart medications (i.e., digoxin). Patient refusals of medication also need to be documented, and the prescribing clinician should be informed.

Medication errors need to be documented as well. The prescribing clinician should be notified of errors. Institutional policies usually require filing a separate form to document errors. Errors can include administering the wrong drug, wrong dose, at the wrong time, or via the wrong route. Omissions of medication are also considered errors.

It is important to evaluate the patient following medication administration and document effect. For example, many hospitals dictate that a note be written regarding pain relief within several hours after analgesic administration. Any adverse effects from medication should be reported.

Preparation
Preparation for safe medication administration requires a background of education and hands-on training. New nurses and other professionals should be supervised until they demonstrate an appropriate level of knowledge and competent skills for independent medication administration.

Aftercare
The patient should be monitored to make sure the medication has had the desired effect.

Health care team roles
In addition to the clinician who administers medication, other members of the health care team play vital roles surrounding the medication administration process. Doctors or other prescribing clinicians are responsible for writing clear, legible orders and for monitoring the response of the patient to medication. They are also responsible for responding to potential adverse effects and concerns by the patient or other clinicians. Pharmacists are responsible for evaluating the medication order for potential problems, correctly filling the order, and monitoring the medication supply. All health care professionals are responsible for complying with medication-related policies designed to protect the patient and/or staff and for maintaining current knowledge regarding medication and medication administration.
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