Medication Administration

Components of medication orders
– PT’s name
– Date/time
– Drug name
– Drug dose
– Drug route
– Time/frequency
– MD’s signature
ways to receive medication orders
– Written order
– Verbal order (VO)
– Telephone order (TO)
Written order
– Written onto a prescription
– Written onto physician’s order sheet and then transcribed onto MAR
– Best type from a safety/legal standpoint
Verbal order (VO)
– Should only be used in emergencies
– Can only be taken by a licensed nurse
– Followed up with a written order onto the physician’s order sheet
– MD must co-sign order
Telephone order (TO)
– Can only be taken by a licensed nurse
– Repeat order back word by word
– Followed up with a written order onto the physician’s order sheet
– MD must co-sign order
Types of medication orders
– PRN
– Routine order
– Single order
– Standing order (written unit policy)
– STAT order
PRN
Medication that is meant to be given as needed
Routine order
– Medication that is meant to be given one or more times a day on a set schedule (QD, TID)
– Can be given w/in an hour of scheduled time
Single order
Medication that is meant to be given at a certain time but only once.
Standing order (written unit policy)
Medication that can be given in emergency w/out first calling MD
STAT order
Medication that is meant to be given immediately, but only once
Deciphering the medication order
– Nurse receives order decides if it is acceptable
– Order is transcribed onto MAR
– Bedside nurse administers drug from MAE after determining that it is safe to give based on pt’s current condition
– If MAR seems unclear, go back to original order on physician’s order sheet.
Medication record forms
– Physician’s order sheet
– Pharmacy pt profile
– MAR
– Nursing notes
– Controlled substance inventory
Physician’s order sheet
Where all medication orders get written in black ink
Pharmacy pt profile
Record kept by pharmacist of all current pt medications
MAR
– Where all medications get transcribed onto from MD’s oder sheet
– Must include pt allergies
– Discontinued drugs are highlighted
Nursing notes
– Response to medications (PRN drugs)
– Any suspected adverse drug reactions and that MD was notified
Controlled substance inventory
– Narcotic drugs must be kept locked up in a drawer or automated machine
– Narcotic inventory sheet lists drug name and the number present
– All narcotics are counted at beginning and end of each shift by 2 nursed from different shifts
– Discrepancies are researched immediately
– Every narcotic drug that is didensed is recorded on an inventory sheet
Medication distribution systems
– Unit dose
– Emergency floor stock
Unit dose
– Dose of medication remeasured and individually wrapped
– Placed into medication cart or automated machine
– Pharmacy dispenses doses for 24 hours, drugs are replaced daily
Emergency floor stock
– Supply of certain drugs kept in a cart or in unit medication room
– Used in emergencies when there isn’t time for pharmacy delivery
– Needs to be periodically inventoried and restocked
Nursing process
– Assessment
– Nursing diagnosis
– Planning
– Implementation
– Evaluation
Assessment
– check for known drug allergies
– know pertinent information (Hx)
– Look up all unfamiliar drugs
– Check pt’s ability to take medication
– Check recent related lab values
– Check appropriate VS before giving drug
Nursing diagnosis (NANDA)
– Knowledge deficit related to lack of information
– Noncomplicance with medications related to lack of funds
Planning (Outcomes)
Plan what equipment will be needed to administer medication
Implementation
– Procure and prepare the medication
– Administer medication safely
– Document drug on MAR
– Provide PT teaching
Evaluation
– Assess drug response
– Chart abnormal/PRN drug responses
– Watch for adverse/toxic drug reactions
Eight rights
1) Right PT
2) Right drug
3) Right dose
4) Right route
5) Right time
6) Right reason/ Right education
7) Right to refuse
8) Right documentation
Types of medication errors
– Wrong time
– Omitted dose
– Wrong dose
– Wrong drug
Medication error procedure
– Recognize that an error has been made
– Report error to nursing supervisor and MD
– Asses pt condition
– Record error on incident report
Oral route
– Capsule
– Tablet
– Liquid
– Powder
Oral route (Capsule)
– Contains dry powder, liquid, gel, or drug-impregnated beads
– Should be swallowed whole
Oral route (Tablet)
– Contains compressed powder
– Can be swallowed whole, chewed or crushed
– LAYERED TABLET- Contains 2 or more layers of ingredients
– SCORED TABLET- has groove in center that makes it easy to break in half
– ENTERIC-COATED TABLET- Hard coating allows it to dissolve past the stomach in the small intestine
Oral route procedure (Tablet)
– Dispense 1 pill into bottle cap and then transfer into soufflé cup.
– Leave unit doses in package
– Keep drugs that require special assessment separate
– Crush tablets with a mortar and pestle, between souffle cups, or in their own package
– Mix w/ liquid or food
– Have water at bedside
– Place into high-fowler’s position
– Remain until all medicine is taken
Oral route (Liquid)
– Pourable medicine: syrups, elixir, emulsions, and suspensions
– Can be swallowed or given as a swish and swallow
Oral route procedure (Liquid)
– Shake liquids before opening
– Uncap and place lid with mouth up
– Pour liquid at eye level into plastic medicine cup to desired line
Oral route powder
– Fine particles of medicine
– Mix with water or other liquid just before administering to pt
Sublingual route (Tablet)
Placed under tongue where it dissolves
Sublingual route procedure
Have pt lift tongue and drop tablet under tongue from gloved hand or soufflé cup
Buccal route (Lozenge/Troche)
Hard disk that contains medicine in a candy-like base placed against inner cheek where it dissolves
Buccal route procedure
Have pt place lozenge into their own cheek or don clean gloves and place it in position
NG/G tube route
– LIQUID- Use this form whenever possible and dilute with 15-30 mL water
– TABLET- Crush and dissolve in water
– POWDER- Mix with water
NG/G tube route procedure
– Prepare medicine in plastic cup
– Stop any tube feeding
– Check for correct tube placement
– Flush tube with water
– Instill medication into tube using syring
– Flush tube afterwards with water
– Clamp tube for 30 mins or resume tube feeding
– Keep HOB elevated
Ophthalmic route
– DROPS- Liquid drops placed into eye
– OINTMENT- Tube of oil base semisolid placed into eye
Ophthalmic route procedure (Drops)
– Review order for number of drops and eye to be medicated (O.D.= R eye, O.S.= L eye, O.U.= both eyes)
– Don clean gloves
– Have pt tilt head slightly back and look up
– Pull down lower lid and drop prescribed number of drops into center of conjuctival sac
– Allply gently pressure with finger to inner can thus to prevent systemic absorption
– replace dropper, never rinse
Ophthalmic route procedure (Ointment)
Apply thin ribbon of ointment into lower canjuctival sac from inner to outer canthus
Otic route
Liquid drops placed into ear
Otic route procedure
– Review order for number of drops and ear to be medicated
– Don clean gloves
– Have pt lie on side with ear to be medicated up
– Hold dropper 1/4″ from ear and instill prescribed number of drops
Nasal route
– DROPS- Liquid drops placed into nose
– SPRAY- Liquid sprayed into nose
Nasal route procedure (Drops)
– Tell pt to tilt their head back and aim dropper towards the upper nose
– Breathe through mouth
– Drop prescribed number of drops into nostril
Nasal route procedure (Spray)
When using sprays, occlude opposite nostril during delivery
Inhalation route
Hand-held canister with a mouthpiece through which aerosol medication is inhaled into lungs
Inhalation route procedure
– Shake canister first and exhale
– Place canister 1″ from mouth
– Compress while inhaling deeply
– Hold breath for 5-10 secs
– 1″ between puffs
– Round inhalers and those with a spacer should be placed into mouth
– Children under age 6 may need to use a spacer with face mask
Topical route
– LOTION- Water based liquid applied to the skin
– CREAM- Water based semisolid applied to the skin
– OINTMENT- Oil base semisolid applied to the skin
– PASTE- Drug contained in a thick base meant to be applied to the skin but not rubbed in
– PATCH- Drug bonded to an adhesive bandage applied transdemally
– SPRAY- Liquid or powder medication in an aerosol can that is sprayed onto the skin
Topical route procedure (Lotion)
– Always wear gloves to prevent absorbing medication into your skin
– Shake bottle as need
– Briefly warm lotion in your hands
– Rub into skin thoroughly
Topical route procedure (Cream)
– Always clean off old medication from entie area before applying new
– Apply cream thinly with floved hand, sterile seab, or tongue blade
Topical route procedure (Ointment)
– Squeeze ointment from tube and spread evenly with gloved hand or sterile swab
– Cover with telfa dressing as ordered
Topical route procedure (Paste)
Spread the ordered amount of NTG paste onto the paper applicator in an even line
Topical route procedure (Patch)
Peel off clear plastic backing and press adhesive side of patch against the skin, rotate sites
Topical route procedure (Spray)
– Shake can well
– Hold can about 6″ from skin
– Spray a thin even layer over affected area
Vaginal route
– Foam
– Jelly
– Cream
– Suppository
Vaginal route procedure
– Vaginal medications are usually self-administered
– Best used at bedtime
– Place drug into vaginal applicator
– Lie supine/dorsal recumbent
– Insert applicator 2-4″ into vagina and depress plunger
– Insert suppository into vagina as deep as possible
Rectal route
– OINTMENT- Oil base semisolid applied to the anal area
– SUPPOSITORY- Drug combined with cocoa butter, shaped like a cylinder or cone and wrapped in foil
Rectal route procedure (Ointment)
– Don clean gloves
– Position pt on side
– Apply ointment to anal area with gloved hand, sterile gauze or swab
Rectal route procedure (Suppository)
– Don clean gloves
– Position pt into L sims
– Lubricate pinted end of suppository
– Insert into rectum with finger as high as possible
– Instruct to retain medicine for 20 mins or as long as possible
Parenteral medications
– Syringes
– Hypodermic needes
Syringe parts
– Barrel holds the med, has graduated scale on it for measuring dose
– Luer- Lock tip is end of barrel where needle is attached
– Flange is end of barrel where plunger is inserted
– Plunger is moveable cylinder that puches medicine out of barrel
– Top of rubber stopper needs to line up with dose line
– Inside of barrel, Luer-Lock tip, and rubber stopper end of plunger must be kept sterile
Hypodermic needles
– Disposable stainless steel needles
– Opening at slanted tip is the bevel
Parenteral dosage forms
– Ampule
– Vial
– Pre-filled cartridge
Ampule
– Sealed glass container used for a single dose of medication
– Tap stem to remove any trapped medicine
– Cover stem with gauze and break open
– Withdraw drug and discard ampule into sharps
Vial
– Glass or plastic bottle of medication with self-sealing rubber stopper used for 1 or more doses
– Clean rubber top with alcohol
– Inject in air equal to required dose and withdraw drug
Pre-filled cartridge
– Sealed glees cylinder pre-filled with medication used for 1 dose
– Puch down on needle hun to puncture rubber stopper
– Used with tubex injector for delivery
Parenteral route
– Intradermal route
– Subcutaneous route
– Intramuscular route
Intradermal route
– Used most often for diagnostic tests
– EQUIPMENT- 1cc TB syringe with 25-27G needle, 3/8-5/8″ long
– SOLUTION VOLUME- 1cc or less
– SITES- Upper arm, anterior thigh, upper buttocks, abdomen except 1″ around the navel
– PROCEDURE- Insert needle at a 45-90 angle
Procedure for heparin
– Change needle after withdrawing and before giving the dose
– Insert needle into abdomen at a 45-90 angle (pinch up with 90)
– Never massage site
– Rotate sites
Procedure for insulin
– Roll cloudy bottle of insulin to mix
– Draw up clear before cloudy after displacing air into cloudy
– Insert needle at a 45-90 angle (may pinch up with 90)
– Rotate sites
Intramuscular route
– EQUIPMENT- 3cc syringe with 21-23G needle, 1-2″ long
– SOLUTION VOLUME- 3cc or less can be given into a single muscle
– SITES- Ventrogluteal site, Dorsogluteal site, Deltoid site, Vastus laterals site, Rectus femoris site
– PROCEDURE- After filling syringe, add 0.2mL of air behind drug to flush out needle
Ventrogluteal site
– Hip area for all ages
– Position on side
– Place palm on greater trochanter with thumb facing towards navel
– Point index finger to ant iliac spine
– Move middle finger along iliac crest
Dorsogluteal site
– Upper outer quadrant of buttocks
– Used for pt over age 3
– Position on side or prone
– Divide buttocks into 4 quadrants, then divide upper outer quadrant again into 4
– Inject into top upper outer quadrant
Deltoid site
– Lateral aspect of upper arm
– Used only for adults and if medication volume is 2cc or less
– Position lying, sitting, or stanging
– Find acromion process
– Draw imaginary line at axilla
– Inject between these 2 points
Vastus lateralis site
– Outer thigh area
– Used for all ages
– Best site for infants and children
– Position supine or sitting
– Divide thigh into thirds
– Inject into middle area on top of thigh
Rectus femoris site
– Anterior thigh area
– Used for self-injections
– Divide thigh into thirds
– Inject into middle area on top of thigh
Blood glucose testing equipment
– Glucose meter
– Glucose test strip
– Lancet
– Clean gloves
– Alcohol wipe
– Dry gauze
Blood glucose testing procedure
– Don clean gloves
– Wipe side of fingertip with alcohol and let dry
– Insert strip into meter
– Compare number on strips bottle to number on meter
– Stick finger with lancet
– Apply blood to strip
– Hold gauze to finger
– Read results in 5 sec
– Remove strip from meter and discard
– Discard lancet into sharps
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