Medication Administration (Basics in Nursing)

Terms Definitions

a tablet shaped like a capsule

a small soluble container, usually made of gelatin, used for enclosing a dose of medication for swallowing

a layer added to oral medications that allows the medication to pass through the stomach and be absorbed in the intestinal tract
enteric coating

a clear liquid containing water, alcohol, sweeteners, or flavors, used primarily as a vehicle for the oral administration of a drug

method used to absorb medication administered as a vapor or gas

in the skin

an easily melted medicated mass for insertion into the rectum, urethra, or vagina

a small, solid dosage form of medication

method of applying a drug to unbroken skin; drug is absorbed through the skin via a disk or patch
transdermal drug delivery (TDD)

a small oval, round, or oblong tablet containing a medicinal agent incorporated in a flavored, sweetened mucilage or fruit base that dissolves in the mouth, releasing the drug
troche (lozenge)

a plant extract made by soaking herbs in a liquid for a specified length of time, then straining and discarding the plant material

pertaining to treatment other than through the digestive tract
What act establishes the guidelines of medication administration that nurses must follow?
State Nurse Practice Act
Can student nurses administer medications?
Yes, under the direct supervision of their instructor

After your instructor has verified that your medications have been drawn correctly, you are able to administer them to your client by yourself.

You must be supervised by your instructor while drawing up medications AND administering them.
What is the Doctor's responsibility regarding medications for the client?
The doctor writes the orders
What is the Pharmacist's responsibility regarding medications for the client?
The pharmacist dispenses the medication
What is the Nurse's responsibility regarding medications for the client?
The nurse prepares, administers, evaluates effectiveness, and teaches the client about the medication

A doctor must be directly involved in the care of a patient to write a prescription for that patient

If a nurse prepares an injection and verifies that it is correct, another nurse can administer that medication.
False - the medication MUST be administered by the nurse who prepared the injection
What form is used to verify and keep track of client medications and the administration of those medications?
MAR (Medication Administration Record)
If you are in doubt regarding a medication, who is the ultimate person you should contact?
The doctor who wrote the order
How many patient identifiers must you verify before administering medications? (Give a common example for each)
2 identifiers (Name and DOB commonly used)
How long after preparation should medications be administered?
Medications should be administered as soon as they are prepared (within agency window)
Are medications ever verified by 2 nurses? Why or why not?
Yes, some medications (ex. heparin and insulin) require dual verification depending on agency policy
What are the 5 rights?
Right Patient
Right Dose
Right Medication
Right Route
Right Frequency
What are the &quot;additional&quot; 5 rights?
Right Documentation
Right Education (of the client)
Right to Refuse
Right Assessment
Right Evaluation
What are the 7 parts of a medication order?
Client's name, date &amp; time, drug, dose, route, frequency, MD name (signature)
An 86 year old client is admitted for renal disease. 6 days after admission, the client decides that he no longer wants to take his medication. The nurse decides to hide the medication in a small amount of pudding. What this the correct action?
No. There was no indication that the client was not competent. Age is NOT an indication of competency. The next correct action would be communication!
You are administering an antihypertensive medication. What type of assessment should precede the administration of this drug?
Where should physician's orders be written?
On the doctor's order sheet
Where should verbal orders be written? When should these orders be signed by the doctor?
Verbal/Phone orders must be written on the doctor's order sheet. The dr. has 24 hours to sign the orders
What should you do to ensure accuracy when receiving verbal orders from a doctor?
Repeat the orders back to the doctor for verification

A student nurse can take verbal orders from a doctor as long as a supervising nurse is present.
FALSE - a student nurse never takes verbal orders
What must accompany a medical student's medication order?
The supervising doctor's signature

Medications suggested on the progress sheet must be administered immediately.
False- progress notes are not orders. The only orders that can be followed are on the doctor's order sheet.
What measurement system should medication orders be written in?
Should generic or trade names be used when writing orders?

Medications ordered under the trade name should not be administered until the doctor writes the order using the generic name.

Many doctors will order medications using trade names. It is our responsibility to familiarize ourselves with the medications.

Most medications are considered given on time 30-60 minutes before/after the scheduled time.
True - the exact time frame will depend on the agency

four times during the day

two times a day

once every day

once every other day

before meals

hour of sleep

nothing by mouth

every hour

every three hours
A medication that is given at 5 every day might be abbreviated how? How should it be abbreviated?
It may be abbreviated QD, however it should be written as &quot;daily&quot;
If a medication is ac, how long before eating should it be given?
at least 30 minutes before the meal is due to be served
What is a standing order?
an order that is given repeatedly and continues everyday
What is the time frame for a STAT order?
Within 30 minutes (sooner if possible)
What is the time frame for a NOW order?
Within 60 minutes (sooner if possible)
What is a single order?
a one time order
What is a PRN order?
given as needed
What is a combination order?
A combination of two types of orders (ex. a combination of a NOW order followed by a standing order)
What does a bracket around 2 orders indicate?
that the 2 medications must be given together
A bracket order for phenergan and demerol has been issued for pain. The client complains of nausea and asks you if they can have the phenergan only. Can you do this? Why or why not?
No, you cannot. A bracket order must be administered together for it's specific purpose. A new order for phenergan would need to be written specifically for &quot;nausea&quot; not &quot;pain&quot;.
What's wrong with this order?

Demerol PO 25-50 mg as needed for pain q4h
The order should specify the dosage rating - example 25 mg for pain rated 1-5 and 50 mg for pain rated 6-10
Would you administer a medication that is listed on the MAR as 126544532v4?
No, this is likely an investigational drug and nurses do not administer investigatinal drugs.
Can you leave a medication with a patient?
No, you must administer and witness the patient taking the medication.
What is the protocol for omitted medications?
Notify the staff nurse/supervisor, document, and depending on the situation, notify the doctor

(in minor situations, documentation may be all that is required)
What are examples of situations where orders would be automatically stopped?
- When the client is referred from one service to another
- When the client is going to surgery
- When the order has expired
- When the drug has a pre-determined expiration (ex. narcotics, antibiotics, etc.)
What is the protocol for medications brought by the patient to the hospital?
The medications are documented by the admit nurse and then sent home with the family. The client cannot take any medications brought from home unless the dr. specifically writes that the client can continue these medications.
What are your first 3 steps following a medication error?
1. Report immediately
2. Document on the client's chart
3. Complete an incident report
Describe the Triple Check System.
1. Check when you remove the medication from where it is stored
2. When you begin to prepare the medication
3. After you have prepared the medication
Route of Administration:

The medication is swallowed
Route of Administration:

A medication is placed under the tongue where it dissolves
Route of Administration:

Route of Administration:

Medication administration along any portion of the GI tract; includes nasogastric tubes, PEG tubes, duodenostomy, jejuostomy, rectal
Route of Administration:

A medication is administered by injection
What are examples of parenteral routes of administration?
- Subcutaneous
- Intramuscular
- Intradermal
- Intravenous
- Intrathecal or Intraspinal
- Intra-arterial
- Epidural
Route of Administration:

parenteral route given just below the skin
Route of Administration:

parenteral route given into a muscle
Route of Administration:

parenteral route under the epidermis (into the dermis)
Route of Administration:

parenteral route into a vein
Route of Administration:

parenteral route into the spinal canal
intrathecal or intraspinal
Route of Administration:

parenteral route into an artery
Route of Administration:

parenteral route into the epidural space
Route of Administration:

medications applied to the skin and mucous membranes; these affect the area to which they are applied

Topical drugs only affect local areas.
FALSE- although these drugs generally only affect the local region, systemic effects can occur
What are examples of topical routes of administration?
- ophthalmic
- otic
- nose drops
- inhalation of drugs through the nose and mouth into the respiratory tract
- cream applied to the skin
- insertion of a rectal suppository
How long should you hold the nasolacrimal duct closed after applying ophthalmic drops?
at least 1 minute
Route of Administration:

medication is stored in a patch placed on the skin and absorbed through the skin; has a systemic effect
Why aren't nasogastric tubes used for long periods?
because they cause corrosion to the nares/pharynx
If a person must have long-term feedings, what type of tube would you expect to see?
PEG tube
What type of educational information would you supply a patient who has been prescribed a transdermal patch?
- apply to a hairless, clean, immobile site
- apply to a new location when you change it
- remember to remove the old patch
How much absorption occurs in the mouth with oral medications (excluding sublingual/buccal)?
very little absorption
Where specifically should eye drops/ointments be placed in the eye?
conjunctival sac
How much absorption occurs in the mouth with sublingual and buccal medications?
near complete absorption with proper technique
How quickly might you see the effects of a sublingual drug?
within 2 minutes
What is an example of a common sublingual drug?
What are 2 examples of buccal drugs?
- hormones
- enzyme preparations
Buccal drugs are absorbed quickly and and enter general circulation without passing through what system? Why is this important?
They avoid passing through the Hepatic Portal system; this avoids drug destruction by GI fluid and the liver
In the stomach the pH is low and drugs that are _______ are rapidly absorbed.
What happens to drugs that are weak bases (alkaline) in regards to absorption in the stomach?
these drugs are not readily absorbed by the stomach, however are absorbed upon entry to the small intestine because of the alkaline pH environment
Are Sublingual/Buccal drugs subject to first-pass effects?
No, these drugs are absorbed directly into the bloodstream
An empty stomach _________ (enhances/decreases) absorption as the drug passes into the small intestine.
Where does absorption occur in the small intestine?
In the upper portion of the small intestine
What is the average pH of the small intestine?
The intestines are highly vascular. How does this affect absorption of medications in the small intestine?
Medications that are not absorbed by the stomach are readily absorbed by the small intestine

Rectal medications typically lose 1/2 of their potency due to first pass effect.

1. blood that perfuses the rectal area bypasses the liver

2. the extent of first-pass effect depends on the drug and dosage, therefore blanket measurements are not accurate
What is the procedure for inserting a rectal suppository.
Place client on left side, lubricate gloved finger and tip of suppository, use index finger and insert 4 inches. Hold in place until you feel internal muscle relax (may take a few minutes)
What are 4 advantages of oral medications?
1. convenient
2. least expensive
3. safe
4. acceptable; causes minimal anxiety
What are 2 nursing solutions for an oral medications that have an unpleasant taste?
1. allow the client to suck on ice to numb the taste buds
2. Use fruit juices, milk, and applesauce to mix medications if possible (use a small amount
What are 3 possible solutions when giving medications that are irritating to the gastric mucosa (if not contraindicated or unavailable)?
- give medication with enteric coating
- dissolve and dilute before administration
- give along with food or immediately after a meal
How should a medication that is harmful to the teeth be administered, such as an iron preparation (if not contraindicated)?
- mix well with water or other liquid
- Use a drinking straw followed by drinking water
- rinse mouth after taking medication
Will increased peristalsis increase or decrease the absorption of a drug?
decreases absorption

Medications can not be destroyed by GI secretions.
False - certain medications can be destroyed by GI secretions

Circulation affects the rate of absorption
Would you readminister a drug if the client vomits after receiving the medication?
Questionable -

Depends on whether the amount lost can be determined. ex. identifiable pills would be readministered
Does first-pass increase or decrease a drugs effect?
What are 5 examples of clients who could not take oral medications?
- unconscious client
- vomiting
- swallowing impairments
- gastric suction

When administering oral medications, you should never give the client water before taking the medications.

Water may be offered before hand to wet the GI tract

All medications may be crushed if a patient has difficulty swallowing

Enteric coated and time released medications are 2 examples of medications that should NEVER be crushed
How soon after dissolving effervescent powders and tablets in water should you wait to administer?
Would you allow a patient to drink water after receiving medication in syrup form?
No, many of these drugs exert local effects on the oral mucosa and water decreases this
How can you prevent a client from aspirating when receiving oral medications?
- Give one pill at a time
- Position the client in a sitting or side-lying position
What is the first thing you do prior to administering a medication enterally?
auscultate for bowel sounds
Describe the 2 procedures for checking the tube placement of NG tubes?
1. (evidence-based practice method) states to aspirate gastric contents and measure pH to ensure acidity (as should be found in the stomach)
2. Inject 5-10mL of air through the tube while auscultating over the left upper quadrant
What is the purpose of administering medications in a liquid form (crushing tablets/opening capsule &amp; adding water) when giving them enterally?
prevents tube obstruction
What type of water &quot;should&quot; you use when mixing medications for tube/enteral feedings? Is this the procedure in most hospitals.
- sterile water

- No, this is not the procedure in most settings. Normally, you will see it mixed with tap water (the GI tract is not sterile)
What type of medications should not be administered enterally?
- buccal
- sublingual
- enteric coated
- sustained action medications

Enteral medications should be mixed together in one batch to reduce the amount of fluid you administer.
False - Each medication should be mixed separately and administered separately
Why is it important to keep track of the amount of fluid used to administer medications enterally in addition to fluid used to rinse the tube?
Because this will be recorded as intake for the patient
Adding fluid in between enteral medications ensures that the tube stays open. This refers to the __________ of the tube.
You should rinse a tube with at least _____ mL of water between medications when administering medications enterally.
If an NG or PEG tube becomes obstructed during administration of medications, what 2 things may be used to flush the tube?
- warm water
- coca cola
During the administration of medications enterally, you should hold the syringe ___ -___ inches above the head or abdominal area depending on tube type.
Why is it so important to check the residual stomach contents before administering medications enterally?
because a large residual amount could indicate that the stomach is not emptying (and the meds may not be administered)
What should you do with residual stomach contents after aspirating them to measure?
return them to the stomach
How long should you keep the head of the bed elevating after administering medications enterally (unless contraindicated)?
20-30 minutes after (keep HOB elevated during administration as well)
When administrating medications enterally, you should flush the tube before and after with ___-___ mL of warm water (or follow agency policy).
30-50 mL
When administering medications parenterally, what is the logic behind injecting medications slowly?
injecting medications too quickly may cause a sterile abscess
What may occur if you penetrate bone when giving an injection?
periostitis (inflammation of the bone)
What is the most likely IM injection site for accidental penetration of the underlying bone?
Which parenteral route:

Used for non-irritating drugs; approximately 1-2 mL of drug diffused into capillary per hour
Subcutaneous (sc)
Which parenteral route:

used for irritating drugs; absorption rate varies depending on site
Intramuscular (IM)
Which parenteral route:

into vein; medication acts immediately when it enters the blood
Intravenous (IV)
Which parenteral route:

under the epidermis
Which parenteral route would have a faster effect, SC, IM, or IV? Which would be the slowest?
IV = fastest
SC = slowest
What are 4 reasons for administering medications parenterally?
1. Precise Dosage
2. Rapid Absorption
3. Rapid Drug Action
4. Nature of the medication
What is an example of a medication that must be given parenterally due to destruction by gastric secretions?
List the advantages of parenteral drug administration. (6)
- accurately measure the amount absorbed
- complete absorption
- can be administered to a client with altered LOC
- administered to clients with difficulty swallowing (dysphagia)
- administered to clients with vomiting/diarrhea, gastric suction, NPO
What alternative route can be used for a medication that is irritating to SC tissue?
can be given IM
Would you be able to inject a larger volume of medication IM or SC?
What are the 6 potential disadvantages of parenteral drug administration?
- infection (to skin or bone)
- damage to blood vessels/major nerves
- sterile abscess
- hypertrophy
- lipodystrophy
- pain/discomfort

collection of undissolved medication at injection site
sterile abscess

thickening of skin

atrophy of adipose tissue
What guidelines should you follow for intradermal injections?
- bevel up
- 15 degree angle
- inject into lighter pigmented area of skin
- skin should be absent of lesions and have minimal hair
What indicator lets you know that you have properly performed an intradermal injection?
a &quot;bleb&quot; (bubble) will form under the skin
What are 6 locations for SC injections?
- abdomen
- anterior thigh
- flank
- scapular
- buttocks
- outer aspects of the arm

If SC injection is not possible in any of the 6 traditional sites, you can use any other body site as long as there is no bone beneath or lesions on the skin.

the method of using alternating patterns of injection sites commonly seen in patients who have injections often (such as those on insulin)
intrasite rotation
What determines whether or not you will go on a 45 degree or 90 degree angle when giving a SC injection?
the amount of tissue that is pinched (one inch or less is 45 degree, more than one inch is 90 degree)
What are the 3 common sites for IM injections?
- Ventrogluteal
- Vastus lateralis
- Deltoid
Of the 3 common IM injection sites, which require the Z track method?
- Ventrogluteal
- Vastus lateralis
What IM injection site is discouraged because of the risk of striking the underlying sciatic nerve?
What is considered the preferred IM site?
What specific benefit does the ventrogluteal IM site have over the Dorsogluteal site in incontinent clients?
offers lower chance of contamination
Is the blood flow slower or faster in the ventrogluteal site vs. the deltoid and thigh?
If the ventrogluteal IM site is considered safer than the dorsogluteal site, why isn't it seen more often in a healthcare setting?
many healthcare professionals are unfamiliar with this site
What is the preferred IM site for infants and children?
vastus lateralis
What is the purpose of bending a client's leg slightly when giving a ventrogluteal IM injection?
to relax the muscle
Which IM site would be used for a small dose of medication?
Which IM site would likely be the most painful?
vastus lateralis
Which IM site(s) are situated away from major blood vessels and nerves?
vastus lateralis
Which IM site offers the fastest rate of absorption?
Z track method is not used on the deltoid. What is the procedure for displacement in this location?
spread the skin prior to injection
The deltoid is heart shaped. You never go beneath what anatomical landmark when injecting here?
axillary line
With IM injections, what should always be done after inserting the needle but prior to injecting the medication?
aspirate the muscle to ensure that you have not penetrating a vein/vessel
What are 2 types of parenteral medication preparations (how they are stored by the manufacturer)?
1. vials (single and multiple doses)
2. ampules
List the sterile parts of the syringe. (4)
- tip
- plunger
- inside of the barrel
- shaft and bevel of the needle
List the non-sterile parts of the syringe. (2)
- outside of the barrel and flange
- outside of the hub of the needle
How many mL does a TB syringe hold?
1 mL
What is the needle gauge range for SC injections? What gauge is used for the average adult.
24-30 gauge range

25 for the average adult
What is the gauge range for IM injections? What gauge is used for the average adult?
20-23 range

22 used for average adult
What is the range for SC needle lengths? What length is used for the average adult?
3/8&quot; - 5/8&quot; range

5/8&quot; is the norm
What is the range for IM needle lengths? What length is used for the average adult?
1&quot; - 3&quot; range

1 1/2&quot; is the norm
What are the 2 angles of insertion for SC injections?
45 degree or 90 degree
What is the angle of insertion for IM injections?
90 degree
What is the maximum amount of medication allowed for a SC injection? What is the range that is normally injected?
1 mL maximum

0.5 - 1 mL is normally injected
What is the maximum amount of medication allowed for an IM injection in the deltoid?
1 mL maximum
What is the maximum amount of medication that can be safely tolerated in a well developed gluteus medius, maximus or vastus lateralis muscle?
4 mL
You have to give 4mL of medication via IM. Would you need to split this injection if you were using the vastus lateralis muscle?
This is situational. You will have to determine if the client can handle this dose. While the maximum is 4mL in this muscle, keep in mind that this refers to a well developed muscle. Therefore, an weakened, thin, malnourished (etc.) patient may require 2 separate injections.
Describe the method for cleaning the top of a vile.
Begin in the center with an alcohol swab and go ONCE around
You need to withdraw 1mL of medication from a vile. What should you do prior to withdrawing the medication to displace it?
Inject 1mL of air into the vile. Remember to inject air to air!
If a medication is known to discolor or irritate the skin (IM injection), what 2 things need to be done to reduce irritation?
1. change the needle
2. use z-track technique
Describe the Z track technique.
Hold skin to the side with the ulnar side of the hand, aspirate, wait 10 seconds after injecting the medication before withdrawing the needle

You should always date a single dose vial after opening to ensure that future doses are not given after expiration.
False - you should always date and time MULTI-dose vials! Single dose vials are disposed of after use.
What are 3 situations where needles may need to be changed?
1. when the medication is a known irritant or stains the skin
2. after puncturing the rubber stopper of the vial multiple times, as this may dull the needle
3. if the needle becomes contaminated
Describe the procedure for changing the needle when necessary.
1. Prepare the injection
2. Pull plunger down to draw the medication out of the needle
3. Change the needle
4. Push plunger up to remove the air and replace the medication in the needle
5. follow the procedure for administering the injection
What should you do if you aspirate an IM site and blood enters the needle?
Remove the needle. Do NOT administer. Dispose of medication and prepare new syringe.
List examples of ways to reduce injection pain. (13)
- talk with client to reduce anxiety
- change the needle after withdrawing medication from the vial
- avoid sensitive areas
- avoid tracking
- position properly, inject into a relaxed muscle
- unless contraindicated, allow refrigerated meds to warm to room temp
- allow alcohol to dry
- do not give more volume than allowed
- insert and remove needle quickly and smoothly
- hold skin firmly when removing
- insert medication slowly
- apply firm pressure to site
- rotate sites
When administering medications to older adults, you should always allow time for what?
assessment, explanation, and administration
Why should you always observe for drug toxicity in older adults even when the suggested medication dosage is taken?
many physiologic changes are associated with aging. This may enhance the possibility of cumulative effects and toxicity.

You should always aspirate SC sites.
False - you only aspirate IM sites
The client states that he will no longer take the medication because it is nauseating and makes him sick. The medication is essential to his recovery. What should your next action be?
Notify the MD and check with the pharmacy to see if the medication comes in a different form
You check the MAR to the client's chart and realize that the client is allergic to one of the ordered medications. What should your next action be?
Do NOT administer the medication and notify the MD.
You are administering a medication and the client states that he believes that you are giving him the wrong pill. What should your next action be?
Recheck the MD orders to make sure you did not make a mistake - always listen to what the client tells you
As you begin to administer medications to a patient, she states &quot;I believe my doctor was supposed to change that medication&quot;. What is your next action?
Check the doctor's orders.
The client complains that the SQ injections he's been receiving all week are painful to him. What is your next action?
- Determine if a different size needle can be used
- Determine if you can use a less painful site
- Place ice on the area prior to injection
The client tells you he will not take a medication because it has a horrible taste. What is your next action?
Research literature to see if the medication can be mixed with something to reduce the unpleasant taste
A client tells you that he doesn't want to take a medication because he is scared and doesn't understand how it works. What is your next action?
Ask client what he does know, explain and teach about the medication

When preparing medications, the nurse must wear clean gloves.
False- gloves do not need to be worn during preparation of medications

Liquid oral medication should be poured into a medicine cup held at eye level.
False- it should be poured at eye level on a flat surface, not held in the hand

Single dose capsules and tablets should be opened and placed into a cup before entering the client's room
False- this should be done at the bedside (in case the client refuses, etc.)
Describe the procedure for finding the deltoid injection site.
one or two finger breaths below the acromion process on the lateral side of the arm
Describe the procedure for finding the anterior thigh injection site.
one hands breath below the greater trochanter and one hands breath above the knee. Inject between these areas into the top of the thigh.
Describe the procedure for finding the abdomen injection site.
below the ribs, above the synthesis pubis, not past the anterior superior iliac spines, not within 2 inches of the umbilicus
Describe the procedure for finding the ventrogluteal injection site.
thumb towards the abdomen, index finger on the asis, palm on the greater trochanter. Spread middle finger back along iliac crest to form a V. Located between index and middle finger.
Describe the procedure for finding the scapula injection site.
place a hand under the apex of the scapula, inject into the area covered by the hand
Describe the procedure for finding the buttocks injection site.
Place a hand under the iliac crest, inject into the area covered by the hand
Describe the procedure for finding the vastus lateralis injection site.
one hands breath below the greater trochanter and one hands breath above the knee. Inject between these areas into the lateral side of the thigh
Describe the procedure for finding the posterior aspect of the arm injection site.
one hands breath below the acromian process and one hands breath above the elbow, inject between these two areas into the posterior aspect of the arm
Describe the procedure for locating the flank injection site.
below the lower aspect of the ribs and above the iliac crest on the lateral side of the body
IM, SQ, or both?

hold syringe at a 90 degree angle
IM always, SQ if more than 1&quot; of tissue is pinched
IM, SQ, or both?

pinch the skin
IM, SQ, or both?

administer a maximum of 1 mL
SQ and deltoid IM
IM, SQ, or both?

aspirate before injecting
IM, SQ, or both?

expect a more rapid response to the medication
IM, SQ, or both?

average gauge is 25
IM, SQ, or both?

average needle length is 1 1/2&quot;
IM, SQ, or both?

use an insulin syringe
IM, SQ, or both?

inject at a 45 degree angle
IM, SQ, or both?

Stretch the skin
IM, SQ, or both?

use a tuberculin syringe
both for amounts lower than 0.5 mL
IM, SQ, or both?

Use Z tract
IM (vastus lateralis and ventrogluteal)
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