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Patients with acute or chronic health problems restore or maintain their health using a variety of

strategies. One of these strategies is medication, a substance used in the diagnosis, treatment,
cure, relief, or prevention of health problems. No matter where they receive their health care
hospitals, clinics, or homenurses play an essential role in safe medication preparation,
administration, and evaluation of medication effects. When patients cannot administer their own
medications at home, family members, friends, or home care personnel are often responsible for
medication administration. In all settings, nurses are responsible for evaluating the effects of
medications on the patients ongoing health status, teaching them about their medications and
side effects, ensuring adherence to the medication regimen, and evaluating the patients and
family caregivers ability to selfadminister medications.
!edications are fre"uently used to manage diseases. #ecause medication administration and
evaluation are a critical part of nursing practice, nurses need to have $nowledge about the actions
and effects of the medications ta$en by their patients. %dministering medications safely re"uires
an understanding of legal aspects of health care, pharmacology, pharmaco$inetics, the life
sciences, pathophysiology, human anatomy, and mathematics.
Pharmacological Concepts
e!ication Names"
&ome medications have as many as three different names. 'he chemical name of a medication
provides an e(act description of its composition and molecular structure. Nurses rarely use
chemical names in clinical practice. %n e(ample of a chemical name is Nacetylpara
aminophenol, which is commonly $nown as 'ylenol. 'he manufacturer who first develops the
medication gives the generic or nonproprietary name, with )nited &tates %dopted Names
*)&%N+ ,ouncil approval. %cetaminophen is an e(ample of a generic name. It is the generic
name for 'ylenol. 'he generic name becomes the official name listed in official publications
such as the )&P. 'he trade name, brand name, or proprietary name is the name under which a
manufacturer mar$ets a medication. 'he trade name has the symbol *-+ at the upper right of the
name, indicating that the manufacturer has trademar$ed the name of the medication *e.g.,
Panadol,- 'empra,- and &t. .oseph %spirin/ree /ever 0educer for ,hildren-+.
!anufacturers choose trade names that are easy to pronounce, spell, and remember. !any
companies produce the same medication, and similarities in trade names are often confusing.
'herefore be careful to obtain the e(act name and spelling for each medication you administer to
your patients. #ecause similarities in drug names are a common cause of medical errors,
Classi#ication" !edication classification indicates the effect of the medication on a body system,
the symptoms the medication relieves, or its desired effect. )sually each class contains more
than one medication that is used for the same type of health problem. /or e(ample, patients who
have asthma often ta$e a variety of medications to control their illness such as beta1adrenergic
agonists. 'he beta2-adrenergic classification contains at least eight different medications
*2ehne, 1343+. &ome are part of more than one class. /or e(ample, aspirin is an analgesic, an
antipyretic, and an
antiinflammatory medication.
e!ication Forms" !edications are available in a variety of forms, or preparations. 'he form of
the medication determines its route of administration. 'he composition of a medication enhances
its absorption and metabolism. !any medications come in several forms such as tablets,
capsules, eli(irs, and suppositories. When administering a medication, be certain to use the
proper form
Forms o# e!ication
e!ication Forms Commonl% Prepare! #or A!ministration &% Oral $o'te
Solid Forms
,aplet &haped li$e capsule and coated for ease of swallowing
,apsule !edication encased in gelatin shell
'ablet Powdered medication compressed into hard dis$ or cylinder5 in addition
to primary medication, contains binders *adhesive to allow powder to
stic$ together+, disintegrators *to promote tablet dissolution+, lubricants
*for ease of manufacturing+, and fillers *for convenient tablet si6e+
7ntericcoated tablet ,oated tablet that does not dissolve in stomach5 coatings dissolve in
intestine, where medication is absorbed
Liquid Forms
7li(ir ,lear fluid containing water 8 or alcohol5 often sweetened
7(tract &yrup or dried form of pharmacologically active medication, usually
made by evaporating solution
%"ueous solution &ubstance dissolved in water 8 syrups
%"ueous suspension /inely divided drug particles dispersed in li"uid medium5 when
suspension is left standing, particles settle to bottom of container
&yrup !edication dissolved in a concentrated sugar solution
Other Oral Forms and Terms Associated with Oral Preparations
'roche *lo6enge+ /lat, round tablets that dissolve in mouth to release medication5 not
meant for ingestion
%erosol %"ueous medication sprayed and absorbed in mouth and upper airway5
not meant for ingestion
&ustained release 'ablet or capsule that contains small particles of a medication coated
with material that re"uires a varying amount of time to dissolve
e!ication Forms Commonl% Prepare! #or A!ministration &% Topical $o'te
Ointment *salve or cream+ &emisolid, e(ternally applied preparation, usually containing one or
more medications
2iniment )sually contains alcohol, oil, or soapy emollient applied to s$in
2otion 2i"uid suspension that usually protects, cools, or cleanses s$in
Paste 'hic$ ointment5 absorbed through s$in more slowly than ointment5
often used for s$in protection
'ransdermal dis$ or patch !edicated dis$ or patch absorbed through s$in slowly over long period
of time *e.g., 19 hours, 4 wee$+
e!ication Forms Commonl% Prepare! #or A!ministration &% Parenteral $o'te
&olution &terile preparation that contains water with one or more dissolved
Powder &terile particles of medication that are dissolved in a sterile li"uid *e.g.,
water, normal saline+ before administration
e!ication Forms Commonl% Prepare! #or Instillation Into Bo!% Ca(ities
Intraocular dis$ &mall, fle(ible oval *similar to contact lens+ consisting of two soft, outer
layers and a middle layer containing medication5 slowly releases
medication when moistened by ocular fluid
&uppository &olid dosage form mi(ed with gelatin and shaped in form of pellet for
insertion into body cavity *rectum or vagina+5 melts when it reaches
body temperature, releasing medication for absorption
Pharmaco)inetics As the Basis o# e!ication Actions
/or medications to be therapeutic they must be ta$en into a patients body5 be absorbed and
distributed to cells, tissues, or a specific organ5 and alter physiological functions.
Pharmaco)inetics is the study of how medications enter the body, reach their site of action,
metaboli6e, and e(it the body. )se $nowledge of pharmaco$inetics when timing medication
administration, selecting the route of administration, considering the patients ris$ for alterations
in medication action, and evaluating the patients response.
A&sorption is the passage of medication molecules into the blood from the site of medication
/actors that influence absorption are the route of administration, ability of the medication to
dissolve, blood flow to the site of administration, body surface area *#&%+, and lipid solubility of
Route of Administration.
7ach route of medication administration has a different rate of absorption. When applying
medications on the s$in, absorption is slow because of the physical ma$eup of the s$in.
!edications placed on the mucous membranes and respiratory airways are absorbed "uic$ly
because these tissues contain many blood vessels. #ecause orally administered medications pass
through the gastrointestinal *:I+ tract, the overall rate of absorption is usually slow. Intravenous
*I;+ in*ection produces the most rapid absorption because medications are immediately
available when they enter the systemic circulation.
Ability of the Medication to issol!e
'he ability of an oral medication to dissolve depends largely on its form or preparation. 'he
body absorbs solutions and suspensions already in a li"uid state more readily than tablets or
capsules. %cidic medications pass through the gastric mucosa rapidly. !edications that are basic
are not absorbed before reaching the small intestine
"lood Flow to the Site of Administration.
!edications are absorbed as blood comes in contact with the site of administration. 'he richer
the blood supply to the site of administration, the faster the medication is absorbed.
"ody Surface Area.
When a medication comes in contact with a large surface area, it is absorbed at a faster rate. 'his
helps e(plain why the ma<ority of medications are absorbed in the small intestine rather than the
Lipid Solubility.
#ecause the cell membrane has a lipid layer, highly lipidsoluble medications cross cell
membranes easily and are absorbed "uic$ly. %nother factor that often affects medication
absorption is whether or not food is in the stomach. &ome oral medications are absorbed more
easily when administered between meals because food changes the structure of a medication and
sometimes impairs its absorption. When some medications are administered together, they
interfere with one another, which impairs the absorption of both medications. &afe medication
administration re"uires $nowledge of factors that alter or impair absorption of prescribed
medications. =ou need an understanding of medication pharmaco$inetics, the patients health
history, the physical e(amination, and $nowledge gained through daily interactions with patients.
)se this $nowledge to ensure that you administer medications at the correct time for best
absorption. When medications interact with food, $now which medications must be administered
before or between meals or on an empty stomach. When medications interact with one another,
ensure that they are not given at the same time. ,onsult and collaborate with the patients
prescribers to ensure that the patient achieves the therapeutic effect of all medications. #efore
administering any medication, chec$ pharmacology boo$s, drug references, or pac$age inserts or
consult with pharmacists to identify medicationmedication or medicationfood interactions.
%fter a medication is absorbed, it is distributed within the body to tissues and organs and
ultimately to its specific site of action. 'he rate and e(tent of distribution depend on the physical
and chemical properties of the medication and the physiology of the person ta$ing it.
#irculation. Once a medication enters the bloodstream, it is carried throughout the tissues and
organs. >ow fast it reaches the site depends on the vascularity of the various tissues and organs.
,onditions that limit blood flow or blood perfusion inhibit the distribution of a medication. /or
e(ample, patients with heart failure have impaired circulation, which slows medication delivery
to the intended site of action. 'herefore the efficacy of medications in these patients is often
delayed or altered.
Membrane Permeability.
!embrane permeability refers to the ability of the medication to pass through tissues and
membranes to enter target cells. 'o be distributed to an organ, a medication has to pass through
all of the tissues and biological membranes of the organ. &ome membranes serve as barriers to
the passage of medications. /or e(ample, the bloodbrain barrier allows only fatsoluble
medications to pass into the brain and cerebral spinal fluid. 'herefore central nervous system
infections often re"uire treatment with antibiotics in<ected directly into the subarachnoid space in
the spinal cord. &ome older patients e(perience adverse effects *e.g., confusion+ as a result of the
change in the permeability of the bloodbrain barrier, with easier passage of fatsoluble
medications. 'he placental membrane also has a nonselective barrier to medications. /atsoluble
and nonfatsoluble agents often cross the placenta and produce fetal deformities. %fter birth
neonates often e(perience respiratory depression and withdrawal symptoms when their mothers
use or abuse narcotics.
Protein "indin$.
'he degree to which medications bind to serum proteins such as albumin affects their
distribution. !ost medications partially bind to albumin. !edications bound to albumin cannot
e(ert pharmacological activity. 'he unbound or ?free@ medication is its active form. Older adults
have a decrease in albumin, probably caused by a change in liver function. 'he same is true for
patients with liver disease or malnutrition. In both e(amples patients are at ris$ for an increase in
medication activity, to(icity, or both.
%fter a medication reaches its site of action, it becomes metaboli6ed into a less active or inactive
form that is easier to e(crete. Biotrans#ormation occurs under the influence of en6ymes that
!eto+i#%, brea$ down, and remove biologically active chemicals. !ost biotransformation occurs
within the liver, although the lungs, $idneys, blood, and intestines also metaboli6e medications.
'he liver is especially important because its speciali6ed structure o(idi6es and transforms many
to(ic substances. 'he liver degrades many harmful chemicals before they become distributed to
the tissues. If a decrease in liver function occurs such as with aging or liver disease, a medication
is usually eliminated more slowly, resulting in its accumulation. Patients are at ris$ for
medication to(icity if organs that metaboli6e medications are not functioning correctly. /or
e(ample, a small sedative dose of a barbiturate sometimes causes a patient with liver disease to
lapse into a coma.
%fter medications are metaboli6ed, they e(it the body through the $idneys, liver, bowel, lungs,
and e(ocrine glands.
'he chemical ma$eup of a medication determines the organ of e(cretion. :aseous and volatile
compounds such as nitrous o(ide and alcohol e(it through the lungs. Aeep breathing and
coughing help patients eliminate anesthetic gases more rapidly after surgery. 'he e(ocrine
glands e(crete lipidsoluble medications. When medications e(it through sweat glands, the s$in
often becomes irritated, re"uiring you to instruct patients in good hygiene practices. If a
medication is e(creted through the mammary glands, there is a ris$ that a nursing infant will
ingest the chemicals. ,hec$ the safety of any medication used in breastfeeding women.
'he :I tract is another route for medication e(cretion. !edications that enter the hepatic
circulation are bro$en down by the liver and e(creted into the bile. %fter chemicals enter the
intestines through the biliary tract, the intestines resorb them. /actors that increase peristalsis
*e.g., la(atives and enemas+ accelerate medication e(cretion through the feces, whereas factors
that slow peristalsis *e.g., inactivity and improper diet+ often prolong the effects of a medication.
'he $idneys are the main organs for medication e(cretion. &ome medications escape e(tensive
metabolism and e(it unchanged in the urine. Others undergo biotransformation in the liver before
the $idneys e(crete them. If renal function declines, a patient is at ris$ for medication to(icity.
When the $idney cannot ade"uately e(crete a medication, it is necessary to reduce the dose.
!aintenance of an ade"uate fluid inta$e *B to C cups, or about 1 2 of waterDday+ promotes proper
elimination of medications for the average adult.
T%pes o# e!ication Action
!edications vary considerably in the way they act and their types of action. Patients do not
always respond in the same way to each successive dose of a medication. &ometimes the same
medication causes very different responses in different patients. 'herefore it is essential to
understand all the effects that medications have on patients.
Therape'tic E##ects"
'he therape'tic e##ect is the e(pected or predicted physiological response that a medication
causes. 7ach medication has a desired therapeutic effect. /or e(ample, nitroglycerin reduces
cardiac wor$load and increases myocardial o(ygen supply. &ome medications have more than
one therapeutic effect. /or e(ample, prednisone, a steroid, decreases swelling, inhibits
inflammation, reduces allergic responses, and prevents re<ection of transplanted organs.
Enowing the desired therapeutic effect for each medication allows you to provide patient
education and accurately evaluate its desired effect.
Si!e E##ects-A!(erse E##ects"
7very medication has a potential to harm a patient. Si!e e##ects are predictable and often
unavoidable secondary effects produced at a usual therapeutic dose. 'hey are either harmless or
cause in<ury. /or e(ample, some antihypertensive medications cause impotence in men. If the
side effects are serious enough to negate the beneficial effects of the therapeutic action of the
medication, the prescriber discontinues the medication. Patients often stop ta$ing medications
because of side effects. A!(erse e##ects are unintended, undesirable, and often unpredictable
severe responses to medication. &ome adverse effects are immediate, whereas others ta$e wee$s
or months to develop. 7arly recognition is important. When adverse responses to medications
occur, the prescriber discontinues the medication immediately.
>ealth care providers report adverse effects to the /A% using the !edWatch program.
To%ic &ffects.
To+ic e##ects develop after prolonged inta$e of a medication or when a medication accumulates
in the blood because of impaired metabolism or e(cretion. 7(cess amounts of a medication
within the body sometimes have lethal effects, depending on its action. /or e(ample, to(ic levels
of morphine, an opioid, cause severe respiratory depression and death. %ntidotes are available to
treat specific types of medication to(icity. /or e(ample, nalo(one *Narcan+, an opioid antagonist,
reverses the effects of Opioid to(icity.
'diosyncratic Reactions.
!edications sometimes cause unpredictable effects such as an i!ios%ncratic reaction, in which
a patient overreacts or underreacts to a medication or has a reaction different from normal. /or
e(ample, a child who receives diphenhydramine *#enadryl+, an antihistamine, becomes
e(tremely agitated or e(cited instead of drowsy. It is not always possible to predict if a patient
will have an idiosyncratic response to a medication.
Aller$ic Reactions.
%llergic reactions also are unpredictable responses to a medication. &ome patients become
immunologically sensiti6ed to the initial dose of a medication. With repeated administration the
patient develops an allergic response to it, its chemical preservatives, or a metabolite. 'he
medication or chemical acts as an antigen, triggering the release of the antibodies in the body. %
patients me!ication allerg% symptoms vary, depending on the individual and the medication
*'able F41+. %mong the different classes of medications, antibiotics cause a high incidence of
allergic reactions. &evere or anaph%lactic reactions, which are life threatening, are
characteri6ed by sudden constriction of bronchiolar muscles, edema of the pharyn( and laryn(,
and severe whee6ing and shortness of breath. Immediate medical attention is re"uired to treat
anaphylactic reactions. % patient with a $nown history of an allergy to a medication needs to
avoid e(posure to that medication in the future and wear an identification bracelet or medal,
which alerts nurses and physicians to the allergy if the patient is unconscious when receiving
medical care.
e!ication Interactions
When one medication modifies the action of another, a me!ication interaction occurs.
!edication interactions are common in individuals ta$ing several medications. &ome
medications increase or diminish the action of others and may alter the way another medication
is absorbed, metaboli6ed, or eliminated from the body. When two medications have a s%nergistic
e##ect, their combined effect is greater than the effect of the medications when given separately.
/or e(ample, alcohol is a central nervous system depressant that has a synergistic effect on
antihistamines, antidepressants, barbiturates, and narcotic analgesics. &ometimes a medication
interaction is desired. Prescribers often combine medications to create an interaction that has a
beneficial effect. /or e(ample, a patient with high blood pressure ta$es several medications such
as diuretics and vasodilators that act together to control the blood pressure when
one medication is not effective on its own
Timing o# e!ication Dose $esponses
!edications administered intravenously enter the bloodstream and act immediately, whereas
medications given in other routes ta$e time to enter the bloodstream and have an effect. 'he
"uantity and distribution of a medication in different body compartments change constantly.
!edications are ordered at various times, depending on when their response begins, becomes
most intense, and ceases. 'he minimum effective concentration *!7,+ is the plasma level of a
medication below which the effect of the medication doesnot occur.
Terms Associate! .ith
e!ication Actions
Onset 'ime it ta$es after a medication is administered for it to produce a response
Pea$ 'ime it ta$es for a medication to reach its highest effective concentration
'rough !inimum blood serum concentration of medication reached <ust before the ne(t
scheduled dose
Auration 'ime during which the medication is present in concentration great enough to
produce a response
Plateau #lood serum concentration of a medication reached and maintained after repeated
fi(ed doses
$o'tes o# A!ministration
'he route prescribed for administering a medication depends on the properties and desired effect
of the medication and the patients physical and mental condition. Wor$ with the prescriber in
determining the best route for a patients medication.
Oral $o'tes"
'he oral route is the easiest and the most commonly used route. !edications are given by mouth
and swallowed with fluid. Oral medications have a slower onset of action and a more prolonged
effect than parenteral medications. Patients generally prefer the oral route
Sublin$ual Administration.
&ome medications are readily absorbed after being placed under the tongue to dissolve. %
medication given by the s'&ling'al route should not be swallowed because the medication does
not have the desired effect. Nurses often give nitroglycerin by the sublingual route. 'ell the
patient not to drin$ anything until the medication is completely
"uccal Administration.
%dministration of a medication by the &'ccal route involves placing the solid medication in the
mouth against the mucous membranes of the chee$ until it dissolves. 'each patients to alternate
chee$s with each subse"uent dose to avoid mucosal irritation. Warn patients not to chew or
swallow the medication or to ta$e any li"uids with it. % buccal medication acts locally on the
mucosa or systemically as it is swallowed in a persons saliva.
Parenteral $o'tes"
Parenteral a!ministration involves in<ecting a medication into body tissues. 'he following are
the four
ma<or sites of in<ectionG
4. Intra!ermal /ID01 In<ection into the dermis <ust under the epidermis
1. S'&c'taneo's1 In<ection into tissues <ust below the dermis of the s$in
F. Intram'sc'lar /I01 In<ection into a muscle
9. Intra(eno's /I201 In<ection into a vein
&ome medications are administered into body cavities other than the four types listed here. 'hese
additional routes include epidural, intrathecal, intraosseous, intraperitoneal, intrapleural, and
intraarterial. Nurses usually are not responsible for the administration of medications through
these advanced techni"ues. Whether or not you actually administer the medication, you remain
responsible for monitoring the integrity of the medication delivery system, understanding the
therapeutic value of the medication, and evaluating the patients response to the therapy.
7pidural medications are administered in the epidural space via a catheter, which is placed by a
nurse anesthetist or an
anesthesiologist. 'his route is used for the administration of regional analgesia for surgical
procedures. Nurses who have advanced education in the epidural route can administer
medications by continuous infusion or by a bolus dose.
Physicians and specially educated nurses administer intrathecal medications through a catheter
placed in the subarachnoid space or one of the ventricles of the brain. Intrathecal administration
is often associated with longterm medication administration through surgically implanted
'his method of medication administration involves the infusion of medication directly into the
bone marrow. It is most commonly used in infants and toddlers who have poor access to their
intravascular space and when an emergency arises
and I; access is impossible.
!edications administered into the peritoneal cavity are absorbed into the circulation.
,hemotherapeutic agents, insulin, and antibiotics are administered in this fashion.
% syringe and needle or a chest tube is used to administer intrapleural medications directly into
the pleural space. ,hemotherapeutic agents are the most common medications administered via
this method. Physicians also instill medications that help resolve persistent pleural effusion. 'his
is called pleurodesis, which promotes adhesion between the visceral and parietal pleura.
Intraarterial medications are administered directly into the arteries. Intraarterial infusions are
common in patients who have arterial clots. 'he nurse manages a continuous infusion of clot
dissolving agents and carefully monitors the integrity of the infusion to prevent inadvertent
disconnection of the system and subse"uent bleeding. Other methods of medication
administration that are usually limited to physician administration are intracar!iac, an in<ection
of a medication directly into cardiac tissue, and intraartic'lar, an in<ection of a medication into
a <oint.
Topical A!ministration"
!edications applied to the s$in and mucous membranes generally have local effects. =ou apply
topical medications to the s$in by painting or spreading the medication over an area, applying
moist dressings, soa$ing body parts in a solution, or giving medicated baths. &ystemic effects
often occur if a patients s$in is thin or bro$en down, the medication concentration is high, or
contact with the s$in is prolonged. % trans!ermal !is) or patch *e.g., nitroglycerin,
scopolamine, and estrogens+ has systemic effects. 'he dis$ secures the medicated ointment to the
s$in. 'hese topical applications are left in place for as little as 41 hours or as long as H days.
Nurses administer medications to mucous membranes in a variety of ways, including the
following, byG
4. Airectly applying a li"uid or ointment *e.g., eyedrops, gargling, or swabbing the throat+.
1. Inserting a medication into a body cavity *e.g., placing a suppository in rectum or vagina or
inserting medicated pac$ing into vagina+.
F. Instilling fluid into a body cavity *e.g., eardrops, nose drops, or bladder and rectal instillation
Ifluid is retainedJ+.
9. Irrigating a body cavity *e.g., flushing eye, ear, vagina, bladder, or rectum with medicated
fluid Ifluid is not retainedJ+.
K. &praying a medication into a body cavity *e.g., instillation into nose and throat+.
Inhalation $o'te"
'he deeper passages of the respiratory tract provide a large surface area for medication
absorption. Nurses administer inhaled medications through the nasal and oral passages or
endotracheal or tracheostomy tubes. 7ndotracheal tubes enter the patients mouth and end in the
trachea, whereas tracheostomy tubes enter the trachea directly through an incision made in the
nec$. Inhaled medications are readily absorbed and wor$ rapidly because of the rich vascular
alveolar capillary networ$ present in the pulmonary tissue. !any inhaled medications have local
or systemic effects.
Intraoc'lar $o'te"
Intraoc'lar medication delivery involves inserting a medication similar to a contact lens into the
patients eye. 'he eye medication dis$ has two soft outer layers that have medication enclosed in
them. 'he nurse inserts the dis$ into the patients eye, much li$e a contact lens, and it can remain
there for up to 4 wee$.
%dvantages Aisadvantages
Oral, B'ccal, S'&ling'al $o'tes
,onvenient and comfortable for patient
7asy to administer
Often produce local or systemic effects
0arely cause an(iety for patient.
Oral route is avoided when patient has
alterations in gastrointestinal function *e.g.,
nausea, vomiting+, reduced motility *after
general anesthesia or bowel inflammation+, and
surgical resection of gastrointestinal tract.
Oral administration is contraindicated in
patients unable to swallow *e.g., patients with
neuromuscular disorders, esophageal strictures,
mouth lesions+.
Oral administration is contraindicated in
unconscious or confused patient who is unable
or unwilling to swallow or hold medication
under tongue.
Oral medications cannot be administered when
patients have gastric suction5 are
contraindicated before some tests or surgery.
Oral medications sometimes irritate lining of
gastrointestinal tract, discolor teeth, or have
unpleasant taste.
:astric secretions destroy some medications.
S'&c'taneo's, Intram'sc'lar /I0, Intra(eno's /I20, Intra!ermal /ID0 $o'tes
Provide means of administration when oral
medications are
!ore rapid absorption than with topical or oral
I; infusion provides medication delivery when
patient is
critically ill or longterm therapy is necessary5
if peripheral
perfusion is poor, I; route preferred over
&ome patients e(perience pain from repeated
&ubcutaneous, I!, and IA routes are avoided
in patients with bleeding tendencies.
'here is ris$ of tissue damage.
I! and I; routes have higher absorption rates,
thus placing patient at higher ris$ for reactions.
'hey often cause considerable an(iety in many
patients, especially children.
Primarily provides local effect
2imited side effects
Patients with s$in abrasions are at ris$ for rapid
medication absorption and systemic effects.
!edications are absorbed through s$in slowly
Prolonged systemic effects with limited side
!edication leaves oily or pasty substance on
s$in and sometimes soils clothing.
Mucous MembranesL
'herapeutic effects provided by local
application to involved
%"ueous solutions readily absorbed and
capable of causing
systemic effects
Potential route of administration when oral
medications are
!ucous membranes are highly sensitive to
some medication concentrations.
Patient with ruptured eardrum cannot receive
ear irrigations.
Insertion of rectal and vaginal medication often
causes embarrassment.
0ectal suppositories contraindicated if patient
has had rectal surgery or if active rectal
bleeding is present.
Provides rapid relief for local respiratory
)sed for introduction of general anesthetic
&ome local agents cause serious systemic
N'rse3s $ole
%dministering medications to patients re"uires $nowledge and
a set of s$ills that are uni"ue to a nurse. =ou first assess that
the medication ordered is the correct medication. Ao not assume
that all medications that are in the patients ?drawer@ or pillbo(
are to be given to him or her. %ssess the patients ability to selfadminister
medications, determine whether a patient should
receive a medication at a given time, administer medications
correctly, and closely monitor their effects. Patient and family
education about proper medication administration and monitoring
is an integral part of your role. Ao not delegate any part of the
medication administration process to nursing assistive personnel
*N%P+ and use the nursing process to integrate medication therapy
into care.
e!ication Errors
% me!ication error can cause or lead to inappropriate medication
use or patient harm. !edication errors include inaccurate prescribing,
administering the wrong medication, giving the medication
using the wrong route or time interval, and administering e(tra
doses or failing to administer a medication. Preventing medication
errors is essential. 'he process of administering medications has
many steps and involves many members of the health care team.
#ecause nurses play an essential role in preparing and administering
medications, they need to be vigilant in preventing errors
*#o( F49+. %dvances in technology have helped to decrease the
occurrence of medication errors *#o( F4K+.
!edication errors are related to practice patterns, health care
product design, or procedures and systems such as product labeling and distribution. When an
error occurs, the patients safety and
wellbeing become the top priority. 'he nurse first assesses and
e(amines the patients condition and notifies the health care provider
of the incident as soon as possible. Once the patient is stable,
the nurse reports the incident to the appropriate person in the
institution *e.g., manager or supervisor+. 'he nurse is responsible
for preparing a written occurrence or incident report that usually
needs to be filed within 19 hours of the error. 'he report includes
patient identification information5 the location and time of the
incident5 an accurate, factual description of what occurred and
what was done5 and the signature of the nurse involved. 'he occurrence
report is not a permanent part of the medical record and is
not referred to anywhere in the record *see ,hapters 1F and 1M+.
'his legally protects the nurse and institution. %gencies use occurrence
reports to trac$ incident patterns and initiate "uality
improvement programs as needed.
Prepare medications for one person at a time.
/ollow the si( rights of medication administration.
#e sure to read labels at least three times *comparing medication administration record
I!%0J with label+ before administering the medication.
)se at least two patient identifiers and review the patients allergies whenever
administering a medication.
Ao not allow any other activity to interrupt administration of medication to a patient *e.g.,
phone call, pager, discussion with other staff+.
N Aoublechec$ all calculations and other highris$ medication administration processes
*e.g., patientcontrolled analgesia+ and verify with another nurse.
Ao not interpret illegible handwriting5 clarify with prescriber.
Ouestion unusually large or small doses.
Aocument all medications as soon as they are given.
When you have made an error, reflect on what went wrong and as$ how you could have
prevented the error.
7valuate the conte(t or situation in which a medication error occurred. 'his helps to
determine if nurses have the necessary resources for safe medication administration.
%ttend inservice programs that focus on the medications commonly administered.
7nsure that you are well rested when caring for patients. Nurses ma$e more errors when
they are fatigued.
Involve and educate the patient when administering medications. %ddress patients
concerns about medications before administering them *e.g., concerns about their
appearance or side effects+.
/ollow established policies and procedures when using technology to administer
medications *e.g., automated medication dispensing systems I%!A&sJ and barcode
scanning+. !edication errors occur when nurses ?wor$ around@ the technology *e.g.,
override alerts without thin$ing about them+.
&tandards are actions that ensure safe nursing practice. &tandards
for medication administration are set by individual health care
agencies and the nursing profession. %gency policy usually sets
limits on the nurses ability to administer medications in certain
units of the acute care setting. &ometimes nurses are limited by
certain medication routes or dosages. !ost institutions have
nursing procedure manuals that contain policies that define the
types of medications nurses can and cannot administer. 'he types
and dosages of medications that nurses deliver often vary from unit
to unit within the same facility. /or e(ample, phenytoin *Ailantin+,
a powerful medication for treating sei6ures, may be administered
by mouth or I; push. In large dosages phenytoin affects heart
rhythm. 'herefore some agencies place limits on how much nurses
can give to a patient on a nursing unit that does not have the ability
to monitor the patients heart rate and rhythm. Not all prescribers
are aware of all of the limitations and sometimes prescribe medications
that nurses cannot give in a particular health care setting.
0ecogni6e these limitations and inform the prescriber accordingly.
'a$e appropriate actions to ensure that patients receive medications
as prescribed and within the time prescribed in the appropriate
Professional standards such as Nursing: Scope and Standards of
Practice *%merican Nurses %ssociation I%N%J, 1343+ *see ,hapters
4 and 1F+ apply to the activity of medication administration. 'o
prevent medication errors, follow the si( rights of medication
administration consistently every time you administer medications.
!any medication errors can be lin$ed, in some way, to an
inconsistency in adhering to these si( rightsG
4. 'he right medication
1. 'he right dose
F. 'he right patient
9. 'he right route
K. 'he right time
M. 'he right documentation
$ight e!ication" % medication order is re"uired for every
medication that you administer to a patient. &ometimes prescribers When preparing
medications from bottles or containers, compare the label
of the medication container with the !%0 three timesG *4+ before
removing the container from the drawer or shelf, *1+ as the amount
of medication ordered is removed from the container, and *F+ at
the patients bedside before administering the medication to the
patient. Never prepare medications from unmar$ed containers or
containers with illegible labels *'.,, 1343+. With unitdose prepac$aged
medications, chec$ the label with the !%0 when ta$ing
medications out of the medication dispensing system. /inally verify
all medications at the patients bedside with the patients !%0 and
use at least two identifiers before giving the patient any medications
*'.,, 1344a+.
Patients who selfadminister medications need to $eep them in
their original labeled containers, separate from other medications,
to avoid confusion. !any hospitals re"uest that all medication
administration in the hospital setting be completed through nurses
rather than letting patients selfadminister to ensure that patients
are not receiving double doses. #ecause the nurse who administers
the medication is responsible for any errors related to it, nurses
administer only the medications they prepare. =ou cannot delegate
preparation of medication to another person and then administer
the medication to the patient. If a patient "uestions the medication,
do not ignore these concerns. %n alert patient or a family caregiver
familiar with a patients medications $nows whether a medication
is different from those received before. In most cases the patients
medication order has changed5 however, some patient "uestions
reveal an error. When this occurs, withhold the medication and
rechec$ it against the prescribers orders. If a patient refuses a medication,
discard it rather than returning it to the original container.
)nitdose medications can be saved if they are not opened. If a
patient refuses narcotics, follow proper hospital procedure by
having someone else witness the ?wasted@ medication.
$ight Dose" 'he unitdose system is designed to minimi6e
errors. When preparing a medication from a larger volume or
strength than needed or when the prescriber orders a system of
measurement different from that which the pharmacy supplies, the
chance of error increases. When performing medication calculations
or conversions, have another "ualified nurse chec$ the calculated
doses. %fter calculating doses, prepare the medication using
standard measurement devices. )se graduated cups, syringes, and
scaled droppers to measure medications accurately. %t home have
patients use $itchen measuring spoons rather than household teaspoons
and tablespoons, which vary in volume.
$ight Patient" !edication errors often occur because one
patient gets a drug intended for another patient. 'herefore an
important step in safe medication administration is being sure that
you give the right medication to the right patient. It is difficult to
remember every patients name and face. #efore administering a
medication, use at least two patient identifiers *'.,, 1343+. %cceptable
patient identifiers include the patients name, an identification
number assigned by a health care agency, or a telephone number.
Ao not use the patients room number as an identifier. 'o identify
a patient correctly in an acute care setting, compare the patient
identifiers on the !%0 with the patients identification bracelet
while at the patients bedside. If an identification bracelet becomes
smudged or illegible or is missing, obtain a new one. In health care
settings that are not acute care settings, '., *133B+ does not re"uire
the use of armbands for identification. >owever, nurses still need
to use a system that verifies the patients identification with at least
two identifiers before administering medications.
Patients do not need to state their names and other identifiers
when administering medications. ,ollect patient identifiers reliably
when the patient is admitted to a health care setting. Once the
identifiers are assigned to the patient *e.g., putting identifiers on
an armband and placing the armband on the patient+, the nurse
uses the identifiers to match the patient with the !%0, which lists
the correct medications. %s$ing patients to state their full names
and identification information provides a third way to verify that
the nurse is giving medications to the right patient.
In addition to using two identifiers, some agencies use a wireless
barcode scanner to help identify the right patient */ig. F4B+. 'his
system re"uires the nurse to scan a personal bar code that is commonly
placed on the nurses name tag first. 'hen he or she scans a
bar code on the singledose medication pac$age. /inally the nurse
scans the patients armband. %ll this information is then stored in
a computer for documentation purposes. 'his system helps eliminate
medication errors because it provides another step to ensure
that the right patient receives the right medication.
$ight $o'te" %lways consult the prescriber if an order does
not designate a route of administration. 2i$ewise, if the specified
route is not the recommended route, alert the prescriber immediately.
0ecent evidence shows that medication errors involving the
wrong route are common. /or e(ample, enteral and parenteral
medications are at ris$ for confusion in the pediatric population
because li"uid medications are fre"uently given orally. When oral
medications are prepared in parenteral syringes, there is a high ris$
for giving an oral medication through the parenteral route *I&!P,
$ight Time" In addition, you need to $now why a medication
is ordered for certain times of the day and whether you are able to
alter the time schedule. /or e(ample, two medications are ordered,
one "Bh *every B hours+ and the other F times a day. #oth medications
are scheduled for F times within a 19hour period. 'he prescriber
intends the "Bh medication to be given aroundthecloc$
to maintain therapeutic blood levels of the medication. In contrast,
the nurse needs to give the Ftimesaday medication during the
wa$ing hours. 7ach agency has a recommended time schedule for
medications ordered at fre"uent intervals. =ou can alter these recommended
times if necessary or appropriate.
$ight Doc'mentation" Nurses and other health care providers
use accurate documentation to communicate with one
another. !any medication errors result from inaccurate documentation.
'herefore always document medications accurately at the
time of administration and verify any inaccurate documentation
before giving medications.
aintaining Patients3 $ights" In accordance with The
Patient Care Partnership *%merican >ospital %ssociation, 133F+
and because of the potential ris$s related to medication administration,
a patient has the following rightsG
N 'o be informed of the name, purpose, action, and potential
undesired effects of a medication
N 'o refuse a medication regardless of the conse"uences
N 'o have "ualified nurses or physicians assess a medication
history, including allergies and use of herbals
N 'o be properly advised of the e(perimental nature of medication
therapy and give written consent for its use
N 'o receive labeled medications safely without discomfort in
accordance with the si( rights of medication administration
N 'o receive appropriate supportive therapy in relation to
medication therapy
N 'o not receive unnecessary medications
N 'o be informed if medications are a part of a research study
Enow these rights and handle all in"uiries by patients and families
courteously and professionally. Ao not become defensive if a
patient refuses medication therapy, recogni6ing that every person
of consenting age has a right to refusal.
Auring the assessment process, thoroughly assess each patient and
critically analy6e findings to ensure that you ma$e patientcentered
clinical decisions re"uired for safe nursing care.
Thro'gh the Patient3s E%es" )se professional $nowledge,
s$ills, and attitudes to provide compassionate and coordinated
care. 'his re"uires you to ta$e the patients preferences, values, and
needs into consideration while determining his or her need for and
potential response to medication therapy. %ssess patients e(periences
and encourage them to e(press their beliefs, feelings, and
concerns about their medications. Putting patients in the center of
their care helps you to see the situation through their eyes and
contributes to safe medication administration. #egin your assessment
by as$ing a variety of "uestions that help you better understand
your patients current medication management routine, the
ability to afford medications, and beliefs and e(pectations about
medications *#o( F4B+.
4istor%" #efore administering medications, obtain or review
the patients medical history. % patients medical history provides
indications or contraindications for medication therapy. Aisease or
illness places patients at ris$ for adverse medication effects. /or
e(ample, if a patient has a gastric ulcer, medications containing
aspirin increase the li$elihood of bleeding. 2ongterm health problems
*e.g., diabetes or arthritis+ re"uire specific medications. 'his
$nowledge helps the nurse anticipate the type of medications
that a patient re"uires. % patients surgical history indicates use of
medications. /or e(ample, after a thyroidectomy a patient re"uires
thyroid hormone replacement.
Aller$ies. Inform the other members of the health care team if
the patient has a history of allergies to medications and foods.
!any medications have ingredients also found in food sources. /or
e(ample, propofol *Aiprivan+, which is used for anesthesia and
sedation, includes egg lecithin and soybean oil as inactive ingredients.
'herefore patients who have an egg or soy allergy should not
receive propofol *&$idmore0oth, 1344+. In some health care settings
patients wear identification bands listing medication and
food allergies. 7nsuring that all allergies and the patients reactions
are noted on the patients admission notes, medication records, and history and physical
e(amination facilitates communication of this
essential information to members of the health care team.
Medications. %ssess information about each medication that
the patient ta$es, including length of time the medication has been
ta$en, the current dosage, and whether or not the patient e(periences
side effects or has had adverse effects from the medication.
In addition, review the action, purpose, normal dosage, routes, side
effects, and nursing implications for administering and monitoring
each medication. Often you need to consult several resources to
gather necessary information. Pharmacology te(tboo$s and handboo$s5
electronic medication manuals available on a computer,
handheld computer, or %!A&5 nursing <ournals5 the Physicians
Desk eference *PA0+5 medication pac$age inserts5 and pharmacists
are valuable resources. Nurses are responsible for $nowing as
much as possible about each medication given.
iet )istory. % diet history reveals a patients normal eating
patterns and food preferences. %n effective dosage schedule is
planned around them. 'each the patient to avoid foods that interact
with medications. In addition, some medications are more
effective when ta$en with meals5 teach patients about specific
medications that must be ta$en with food.
Patient*s Perceptual or #oordination Problems. % patient with
perceptual finemotor or coordination limitations has difficulty
selfadministering medication. /or e(ample, a patient who ta$es
insulin to manage blood glucose and has arthritis has difficulty
manipulating a syringe. %ssess the patients ability to prepare doses
and ta$e medications correctly. If the patient is unable to selfadminister
medications, assess if family or friends are available to
assist or ma$e a home care referral.
Patient3s C'rrent Con!ition" 'he ongoing physical or
mental status of a patient affects whether a medication is given or
how it is administered. !ssess a patient carefully before gi"ing any
#edication$ /or e(ample, chec$ the patients blood pressure before
giving an antihypertensive. % patient who is nauseated is probably
unable to swallow a tablet. Notify the patients health care provider
if he or she is unable to ta$e a medication. %ssessment findings
serve as a baseline in evaluating the effects of medication therapy.
Patient3s Attit'!e A&o't e!ication 5se" 'he patients
attitude about medications sometimes reveals a level of medication
dependence or drug avoidance. &ome patients do not e(press their
feelings about ta$ing a particular medication, particularly if dependence
is a problem. Observe the patients behavior for evidence of
dependence or avoidance. %lso be aware that his or her cultural
beliefs about Western medicine sometimes interfere with medication
compliance *#o( F4C5 see ,hapter C+.
Patient3s 5n!erstan!ing o# an! A!herence to e!ication
Therap%" 'he patients $nowledge and understanding of
medication therapy influence the willingness or ability to follow a
medication regimen. If the patient has a history of poor adherence
*e.g., fre"uently missed doses or failure to fill prescriptions+, investigate
if he or she can afford prescribed medications and review
resources available for purchase of medications if indicated. %lso
determine if the patient understands the purpose of the medication,
the importance of regular dosage schedules, proper administration
methods, and the possible side effects. Without ade"uate
$nowledge and motivation, adherence to medication schedules is
Patient3s Learning Nee!s" >ealthrelated information is difficult
to understand because of the use of technical terminology.
&erious errors can occur when patients do not understand information
about their medications. %ssess patients health literacy
regarding medication administration to determine their need for instruction *,ornett, 133C+ *see
,hapter 1K+. ,onsider patient
responses to assessment "uestions that you as$ about medications
such as those listed in #o( F4B. When a patient is unable to answer
"uestions about medications appropriately, assess him or her for
challenges in health literacy.
,O!PON7N'& O/ !7AI,%'ION O0A70
% medication order is incomplete unless it has the following partsG
Patient3s #'ll name1 'he patients full name distinguishes the patient from
other persons with the same last name. In the acute care setting patients
are sometimes assigned special identification numbers *e.g., medical
record number+ to help distinguish patients with the same names. 'his
number is often included on the order form.
Date an! time that the or!er is .ritten1 'he day, month, year, and time
need to be included. Aesignating the time that an order is written helps
clarify when certain orders are to start and stop. If an incident occurs
involving a medication error, it is easier to document what happened when
this information is available.
e!ication name1 'he health care provider orders a medication by its
generic or trade name. ,orrect spelling is essential in preventing confusion
with medications with similar spelling.
Dose1 'he amount or strength of the medication is included.
$o'te o# a!ministration1 'he health care provider uses accepted
abbreviations for medication routes. %ccuracy is important to ensure that
patients receive medications by the intended route.
Time an! #re6'enc% o# a!ministration1 'he nurse needs to $now what
time and how fre"uently to administer medications. Orders for multiple
doses establish a routine schedule for medication administration.
Signat're o# health care pro(i!er1 'he signature ma$es an order a legal
% sound $nowledge base is re"uired for medications to be administered
safely. Nurses need to be prepared to administer medications
using a variety of routes. 'he following sections e(plain the steps
involved in administering medications using various routes.
Oral A!ministration
'he easiest and most desirable way to administer medications is by
mouth *&$ill F44 on pp. M41M4K+. Patients usually are able to
ingest or selfadminister oral medications with a minimum of
problems. /ood delays stomach emptying, which may decrease the
therapeutic effects of oral medications. 'herefore most oral medications
reach their therapeutic action best if given F3 minutes to 4
hour before meals. In addition, some medications must be ta$en
with food. &ome situations contraindicate the patients receiving
medications by mouth *see 'able F4K+. !any medications interact
with nutritional and herbal supplements. =ou need to be $nowledgeable
about these interactions to determine the best time to give
oral medications.
%n important precaution to ta$e when administering any oral
preparation is to protect patients from aspiration. %spiration
occurs when food, fluid, or medication intended for :I administration
inadvertently enters the respiratory tract. Protect the patient
from aspiration by assessing his or her ability to swallow. #o( F449
provides techni"ues that protect patients from aspirating. Proper
positioning is essential in preventing aspiration. Position a patient
in a seated position at a C3degree angle when administering oral
medications if not contraindicated by his or her condition. )sually
having the patient slightly fle( the head in a chindown position
reduces aspiration. )se a multidisciplinary approach *e.g., speech
therapist, dietitian, and occupational therapist+ with patients who
have difficulty swallowing.
Topical e!ication Applications
'opical medications are medications that are applied locally, most
often to intact s$in. 'hey come in many forms *see 'able F44+.
'hey are also applied to mucous membranes.
S)in Applications" #ecause many locally applied medications
such as lotions, pastes, and ointments create systemic and local
effects, apply these medications using gloves and applicators. )se
sterile techni"ue if the patient has an open wound. &$in encrustation
and dead tissues harbor microorganisms and bloc$ contact of
medications with the tissues to be treated. #efore applying medications,
clean the s$in thoroughly by washing the area gently with
soap and water, soa$ing an involved site, or locally debriding tissue.
%pply each type of medication according to directions to ensure
proper penetration and absorption. When applying ointments or
pastes, spread the medication evenly over the involved surface and
cover the area well without applying an overly thic$ layer. Prescribers
sometimes order a gau6e dressing to be applied over the medication
to prevent soiling clothes and wiping away the medication.
2ightly spread lotions and creams onto the surface of the s$in5
rubbing often causes irritation. %pply a liniment by rubbing it
gently but firmly into the s$in. Aust a powder lightly to cover the
affected area with a thin layer.
&ome topical medications are applied in the form of a transdermal
patch that remains in place for an e(tended amount of time
*e.g., 41 hours or H days+. #efore applying a new patch, remove the
old one. !edication remains on the patch even after its recommended
duration of use. Nurses and patients have inadvertently
left old transdermal patches in place, resulting in the patient receiving
an overdose of the medication. /or e(ample, patients who use
fentanyl transdermal patches for pain management can e(perience
respiratory depression, coma, and death when the patches are not
removed. !any patches are clear, which ma$es them difficult to
see. 'herefore carefully assess the patients s$in and be sure to
remove the e(isting patch before applying a new patch. /ollow
these guidelines to ensure safe administration of transdermal or
topical medications *I&!P, 133Hb+G
N Aocument the location on the patients body where the
medication was placed on the !%0.
N When applying a transdermal patch, as$ the patient if he or
she has an e(isting patch.
N When ta$ing a medication history or reconciling medications,
specifically as$ the patient if he or she ta$es any medications
in the forms of patches, topical creams, or any route
other than the oral route.
N If the dressing or patch is difficult to see *e.g., clear+, apply
a noticeable label to the patch.
N Aocument removal of the patch or medication on the !%0.
Nasal Instillation" Patients with nasal sinus alterations sometimes
receive medications by spray, drops, or tampons *#o( F44M+.
'he most commonly administered form of nasal instillation is
decongestant spray or drops, used to relieve symptoms of sinus
congestion and colds. ,aution patients to avoid abuse of medications
because overuse leads to a rebound effect in which the nasal
congestion worsens. When e(cess decongestant solution is swallowed,
serious systemic effects also develop, especially in children.
&aline drops are safer than nasal preparations that contain sympathomimetics
*e.g., %frin or Neo&ynephrine+ as a decongestant for
It is easier to have the patient selfadminister sprays because he
or she is able to control the spray and inhale as it enters the nasal
passages. /or patients who use nasal sprays repeatedly, chec$ the
nares for irritation. Nasal drops are effective in treating sinus infections.
Position patients to permit the medication to reach the
affected sinus. &evere nosebleeds are usually treated with pac$ing
or nasal tampons, which are treated with epinephrine, to reduce
blood flow. )sually a physician or advanced practice clinician
places nasal tampons.
E%e Instillation" ,ommon medications used by patients are
eyedrops and ointments, including O', preparations such as artificial
tears and vasoconstrictors *e.g., ;isine and !urine+. !any
patients, especially older adults, receive prescribed ophthalmic
medications for eye conditions such as glaucoma or after cataract
e(traction. %gerelated problems, including poor vision, hand
tremors, and difficulty grasping or manipulating containers, affect
the older adults ability to selfadminister eye medications. Instruct
patients and family members about the proper techni"ues for
administering them *&$ill F41 on pp. M4MM4C+. Aetermine the
patients and familys ability to selfadminister through a return
demonstration of the procedure. &howing patients each step of the
procedure for instilling eyedrops can improve adherence. /ollow
these principles when administering eye medicationsG
N %void instilling any form of eye medications directly onto
the cornea. 'he cornea of the eye has many pain fibers and
thus is very sensitive to anything applied to it.
N %void touching the eyelids or other eye structures with eyedroppers
or ointment tubes. 'he ris$ of transmitting infection
from one eye to the other is high.
N )se eye medication only for the patients affected eye.
N Never allow a patient to use another patients eye medications.
'ntraocular Administration. 'he nurse administers some medications
intraocularly *see &$ill F41+. !edications delivered this
way resemble a contact lens. Place the medication into the con<unctival
sac where it remains in place for up to 4 wee$. !edications
such as pilocarpine are administered this way. Patients re"uire
teaching about monitoring for adverse reactions to the dis$. 'hey
also need to $now how to insert and remove the dis$.
Ear Instillation" Internal ear structures are very sensitive to
temperature e(tremes. Instill eardrops at room temperature to
prevent vertigo, di66iness, or nausea. %lthough the structures of
the outer ear are not sterile, sterile solutions are used in case the
eardrum is ruptured. 'he entrance of nonsterile solutions into
middle ear structures can result in infection. If a patient has ear
drainage, be sure that the eardrum has not ruptured. Never occlude
or bloc$ the ear canal with the dropper or irrigating syringe.
/orcing medication into an occluded ear canal creates pressure that
in<ures the eardrum. #o( F44H provides guidelines for administering
2aginal Instillation" ;aginal medications are available as suppositories,
foam, <ellies, or creams. &olid, ovalshaped suppositories come individually pac$aged in foil
wrappers and are sometimes
stored in the refrigerator to prevent them from melting. %fter a
suppository is inserted into the vaginal cavity, body temperature
causes it to melt and be distributed and absorbed. /oam, <ellies,
and creams are administered with an applicator inserter *#o(
F44B+. :ive a suppository with a gloved hand in accordance
with standard precautions *see ,hapter 1B+. Patients often prefer
administering their own vaginal medications and need privacy.
#ecause vaginal medications are often given to treat infection, discharge
is usually foul smelling. /ollow aseptic techni"ue and offer
the patient fre"uent opportunities to maintain perineal hygiene
*see ,hapter FC+.
$ectal Instillation" 0ectal suppositories are thinner and more
bulletshaped than vaginal suppositories. 'he rounded end prevents
anal trauma during insertion. 0ectal suppositories contain
medications that e(ert local effects such as promoting defecation
or systemic effects such as reducing nausea. 0ectal suppositories
are often stored in the refrigerator until administered. &ometimes
it is necessary to clear the rectum with a small cleansing enema
before inserting a suppository.
A!ministering e!ications &% Inhalation
!edications administered with handheld inhalers are dispersed
through an aerosol spray, mist, or powder that penetrates lung
airways. 'he alveolarcapillary networ$ absorbs medications
Press'ri7e! metere!8!ose inhalers /pDIs0, breathactuated
metered dose inhalers *#%Is+, and dry powder inhalers *APIs+
deliver medications that produce local effects such as bronchodilation.
&ome medications create serious systemic side effects. p!AIs
use a chemical propellant to push the medication out of the inhaler
and re"uire the patient to apply appro(imately K to 43 pounds of
pressure to the top of the canister to administer the medication.
,hildren or older adults with chronic respiratory diseases often use
p!AIs. 'hese two populations have diminished hand strength.
'herefore it is essential to assess if patients in these groups have
enough strength to use the p!AI.
A!ministering e!ications &% Irrigations
&ome medications irrigate or wash out a body cavity and are delivered
through a stream of solution. Irrigations most commonly use
sterile water, saline, or antiseptic solutions on the eye, ear, throat,
vagina, and urinary tract. )se aseptic techni"ue if there is a brea$
in the s$in or mucosa. )se clean techni"ue when the cavity to be
irrigated is not sterile, as in the case of the ear canal or vagina.
Irrigations cleanse an area, instill a medication, or apply hot or cold
to in<ured tissue *see ,hapter 9B+.
Parenteral A!ministration o# e!ications
Parenteral administration of medications is the administration of
medications by in<ection into body tissues. When medications are
administered this way, it is an invasive procedure that is performed
using aseptic techni"ues *#o( F413+. %fter a needle pierces the
s$in, there is ris$ of infection. 7ach type of in<ection re"uires
certain s$ills to ensure that the medication reaches the proper location.
'he effects of a parenterally administered medication develop
rapidly, depending on the rate of medication absorption. 'he nurse
closely observes the patients response.
E6'ipment" % variety of syringes and needles are available,
each designed to deliver a certain volume of a medication to a
specific type of tissue. )se nursing <udgment when determining the
syringe or needle that will be most effective.
Syrin$es. &yringes consist of a cylindrical barrel with a tip
designed to fit the hub of a hypodermic needle and a closefitting
plunger. In general syringes are classified as being 2uer2o$ or
nonQ2uer2o$. 'his nomenclature is based on the design of the tip
of the syringe. 2uer2o$ syringes have needles that are twisted onto
the tip and loc$ themselves in place */ig. F443, ! and %+. 'his
design prevents the inadvertent removal of the needle. NonQ2uer
2o$ syringes */ig. F443, , and D+ have needles that slip onto the
tip. &yringes have safety devices to prevent needlestic$ in<ury.
&yringes come in a number of si6es, from 3.K to M3 m2. It is
unusual to use a syringe larger than K m2 for an in<ection. % 4 to
Fm2 syringe is usually ade"uate for a subcutaneous or I! in<ection.
% larger volume creates discomfort. )se larger syringes to
administer certain I; medications and irrigate wounds or drainage
tubes. &yringes often come prepac$aged with a needle attached.
>owever, you sometimes change a needle based on the route of
administration and si6e of the patient.
a minim and hundredths of a milliliter and has a capacity of
4 m2. )se a tuberculin syringe to prepare small amounts of medications
*e.g., intradermal or subcutaneous in<ections+. % tuberculin
syringe is also useful when preparing small, precise doses for
infants or young children.
Insulin syringes */ig. F443, D+ are available in si6es that hold
3.F to 4 m2 and are calibrated in units. !ost insulin syringes are
)433s, designed to be used with )433 strength insulin. 7ach
milliliter of )433 insulin contains 433 units of insulin.
/ill a syringe by pulling the plunger outward while the needle
tip remains immersed in the prepared solution. Only touch the
outside of the syringe barrel and the handle of the plunger to
maintain sterility. %void letting any unsterile ob<ect touch the tip
or inside of the barrel, the hub, the shaft of the plunger, or the
needle */ig. F444+.
+eedles. &ome needles come pac$aged in individual sheaths to
allow fle(ibility in choosing the right needle for a patient, whereas
others are preattached to standardsi6e syringes. !ost needles are
made of stainless steel, and all are disposable. % needle has three partsG the hub, which fits onto
the tip of a syringe5 the shaft, which
connects to the hub5 and the bevel, or slanted tip.
A!ministering In*ections
7ach in<ection route differs based on the type of tissues the medication
enters. 'he characteristics of the tissues influence the rate of
medication absorption and thus the onset of medication action.
#efore in<ecting a medication, $now the volume of the medication
to administer, the characteristics and viscosity of the medication,
and the location of anatomical structures underlying in<ection sites
*&$ill F4K on pp. M1MMF4+.
If a nurse does not administer in<ections correctly, negative
patient outcomes result. /ailure to select an in<ection site in relation
to anatomical landmar$s results in nerve or bone damage during
needle insertion. Inability to maintain stability of the needle and
syringe unit can result in pain and tissue damage. If you fail to
aspirate the syringe before in<ecting an I! medication, the medication
may accidentally be in<ected directly into an artery or vein.
In<ecting too large a volume of medication for the site selected
causes e(treme pain and results in local tissue damage.
!any patients, particularly children, fear in<ections. Patients
with serious or chronic illness often are given several in<ections
daily. !inimi6e the patients discomfort in the following waysG
N )se a sharpbeveled needle in the smallest suitable length
and gauge.
N Position the patient as comfortably as possible to reduce
muscular tension.
N &elect the proper in<ection site, using anatomical
N %pply a vapocoolant spray *e.g., /luori!ethane spray
or ethyl chloride+ or topical anesthetic *e.g., 7!2% cream+
to the in<ection site before giving the medication when
N Aivert the patients attention from the in<ection through
conversation using openended "uestioning.
N Insert the needle "uic$ly and smoothly to minimi6e tissue
N >old the syringe steady while the needle remains in tissues.
N In<ect the medication slowly and steadily.
S'&c'taneo's In*ections" &ubcutaneous in<ections involve
placing medications into the loose connective tissue under the
dermis *see &$ill F4K+. #ecause subcutaneous tissue is not as richly
supplied with blood as the muscles, medication absorption is
somewhat slower than with I! in<ections. >owever, medications
are absorbed completely if the patients circulatory status is normal.
#ecause subcutaneous tissue contains pain receptors, the patient
often e(periences slight discomfort.
'he best subcutaneous in<ection sites include the outer posterior
aspect of the upper arms, the abdomen from below the costal
margins to the iliac crests, and the anterior aspects of the thighs
*/ig. F44H+. 'he site most fre"uently recommended for heparin
in<ections is the abdomen */ig. F44B+. %lternative subcutaneous
sites for other medications include the scapular areas of the upper
bac$ and the upper ventral or dorsal gluteal areas. 'he in<ection
site chosen needs to be free of s$in lesions, bony prominences, and
large underlying muscles or nerves.