Week 8: RN Medication Administration

Medication Administration

• Nurses are the final check in medication safety
• Medication errors are preventable but common
• Medication safety includes systems, interprofessional teamwork, and nurse education

Pharmacokinetics (ADME) Study

• The study includes how the body processes drugs through: Absorption, Distribution, Metabolism, Excretion.
• Influences of pharmacokinetics are: age, route, pH, blood flow, lipid solubility, surface area, and disease states.

Absorption

• It is the movement from the entry site to bloodstream
• Absorption is faster with: high blood flow, large surface area, high lipid solubility
• Routes affect speed in the following order: IV > IM > SC > oral

Distribution

• It is the transport to target tissues
• Distribution is affected by: circulation, membrane permeability, and protein binding

Metabolism

• It mostly occurs in the liver
• It converts drugs for excretion
• "First-pass effect" lowers oral drug concentration

Excretion

• Eliminated mainly by kidneys
• Other routes include liver (bile), lungs (exhalation), skin (sweat)

Medication Preparations and Reactions

• Therapeutic Effect: Intended outcome
• Adverse Drug Reaction (ADR): Unintended, harmful
• Allergic Reaction: Immune-based, may lead to anaphylaxis (life-threatening)
• Interactions: Drug-drug or drug-food interactions

Factors Affecting Medications

• These include: age, weight, gender, genetics, comorbidities
• Children and older adults are at higher risk of errors due to organ function and dosing complexities

Client Rights

• Every client has rights to know, to refuse, to be educated, to be evaluated
• There are 10 Rights of Medication Administration

The Medication Prescription

• Must include: client name, date/time, drug name, dose, route, frequency, indication, provider signature.

Medication Reconciliation

• Process of comparing current medications with new orders during transitions in care
• Helps prevent omissions, duplications, and errors

Medication Errors

• Most errors occur at the administration stage
• Errors must be reported, the patient assessed, the provider notified, and documentation completed

Routes of Administration

• These include: Enteral, Parenteral, Topical
• Enteral: GI tract (oral, NG, PEG) has slower absorption
• Parenteral: Injection (IM, IV, SC, ID) faster absorption, bypasses GI tract
• Transdermal/Topical: applied to skin for local/systemic effect (e.g., patches, ointments)
• Other: Inhaled (MDI), Otic (ear), Ophthalmic (eye), Vaginal, Rectal, Nasal

Oral Medication Administration

• It is the most common and preferred route
• GI function, aspiration risk, and food interactions need to be considered

Subcutaneous Injection

• Maximum volume is No more than 1.5 mL
• Use a 3/8 to 5/8 inch length needle with 25 to 27G
• For insulin, use a 28 to 31G insulin syringe
• Pinch the skin and insert at a 45° to 90° angle
• The angle should be 90° for clients who are obese
• Rotate sites

Intramuscular Injection

• For Ventrogluteal, the volume is 3 mL with a 1½ inch length needle, between 18 to 25G
• The ventrogluteal site is a relatively safe site because of the lack of major nerves
• For the Deltoid, the volume is 2 mL with a 1½ inch length needle, between 18 to 25G
• The deltoid site is used frequently for immunizations in adults due to its easy access
• For Vastus lateralis, the volume is 1 to 3 mL with a 1½ inch length needle, between 18 to 25G
• Injections should be given at a 90° angle
• The needle length may need adjustments based on weight/size.

Intradermal Injection:

• Use the ventral aspect of forearm for 0.1 mL
• Use a ¼ to ⅝ inch length needle with 25 to 27G
• Use a 1-mL TB syringe
• Insert at a 5° to 15° angle
• Insert the needle with the bevel up to produce a small bleb

Various Routes of Administration

• Oral (PO) is safer and less costly, it's convenient since there are a variety of forms, it's painless, and clients are able to self-administer
• The oral route has a slow onset of action since it is subject to the first-pass effect
• The oral route may have an unpleasant taste and is not appropriate for unconscious clients or for clients with excessive vomiting and/or diarrhea

Sublingual (SL)

• Rapid onset of action as it bypasses first-pass effects.
• It can be self-administered by the client
• The route is not appropriate for children and may cause membrane irritation

Rectal (PR)

• It can be administered to children, unconscious clients, or clients who are unable to swallow
• Increased concentration is achieved quickly
• It also has absorption varies, and rectal mucosa can become irritated or swollen

Intravenous (IV)

• Rapid onset for clients who are unconscious, noncompliant, or unable to tolerate oral medications
• Sterilization and aseptic technique are essential, invasive technique is required, and high cost
• It can injure nerves, tissues, or vessels

Buccal Route

• Rapid onset of action , it bypasses first-pass effects, and can be self-administered by the client
• Irritation to open sores in the mouth, exact site location can be difficult, and decrease in the medication effect if swallowed
• Client may experience nausea and vomiting if the medication has an undesirable taste

Inhalation route

• Rapid action since a smaller dose is required and medication dosage can be regulated
• Local irritation can precipitate respiratory secretions or bronchospasms

Intramuscular (IM)

• Faster absorption as compared to the oral route, soluble and suspension substances can be administered
• Aseptic technique must be administered, and it can be painful and cause nerve damage

Subcutaneous (subcut) route

• Can be self-administered by the client
• Maximum volume delivery is 1.5 mL with slow absorption

Transdermal Route

• Effects can last for several days and Medication dosing varies due to client factors

Otic Route

• Can be administered by the client
• Blockage of the ear canal will decrease absorption, so ear irrigation of the ear canal must occur before instilling drops
• Positioning of the ear canal is different for children and adults

Ophthalmic Route

• Can be administered by the client, though the client's contact lens must be removed before instilling medication
• Bradycardia and hypotension can occur with specific ophthalmic medications (i.e. beta blockers)

Nasal Route

• Can be administered by the client
• Permanent swelling of tissue within the nose can develop with continued use

Feeding Tube Medication

• Flush before and after with sterile water and administer one medication at a time.

Parenteral Administration

• Use aseptic technique with the correct syringe and needle size and rotate sites

Preventing Infection and Needlestick Injury

• Use sharps containers and safety syringes while avoid recapping used needles

Pediatric and Geriatric Considerations

• Pediatrics: Use weight-based dosing with appropriate tools (dropper, oral syringe)
• Geriatrics: Monitor for polypharmacy and reduced metabolism/excretion

Measurement Systems and Calculations

• Metric is preferred
• Household systems may be inaccurate
• Conversions are needed (e.g., mg to g)

Nurse Education Role

• Assess literacy, use plain language, provide information about all medications
• Apply teach-back, repeat, and reinforce

Medication Reconciliation

• It is an important part of client safety
• The Joint Commission emphasizes keeping an accurate and current list of every client's medications.
• Conduct medication reconciliation at admission, during transfers, when moving between facilities, and at discharge home

Medication Reconciliation Process

• This process updates and communicates the medication list during transitions of care
• Get a complete list of all home medications (name, dose, route, frequency, and purpose)
• Compare home medications with newly prescribed ones
• Look for omissions, duplications, interactions, and discrepancies
• Include OTC and herbal meds in the process and involve the interprofessional team (nurses, providers, pharmacists)

Client and caregiver education upon discharge

• Educate the client and caregivers upon discharge

Preventing Medication Errors

• A medication error is any preventable event that could cause inappropriate medication use or harm
• Most common causes are not following the rights of med admin, distractions/interruption during preparation, skipping standard procedures, and incorrect calculations

Strategies for preventing medication errors

• Follow the 10 Rights of medication administration, use barcode scanners and Automated Medication Dispensing Systems (AMDS)
• Avoid workarounds, watch for sound-alike medications (e.g., dopamine/dobutamine), and clarify questionable orders

High-Alert Medications

• High alert medications can cause severe harm if used incorrectly.
• They require manual double-checks (e.g., insulin, heparin, potassium), verified by two RNs confirming the correct medication, dose, route, time, patient, etc.

Actions if a Med Error Happens :

• Assess the client, notify the provider and supervisor, document facts only, and complete an incident report

Barcode and AMDS Systems

• Barcode scanning includes scanning the wristband and med label to prevent mismatches
• AMDS is a password-protected system that dispenses medications
• Both systems track what has been given and by whom

Causes of Medication Errors (3 I's)

• Identification: lack of drug knowledge
• Interruption: distractions during prep/admin
• Information Overload: ignoring alerts

Workarounds and Overrides

• A Workaround is bypassing safety steps (e.g., not scanning medications)
• An Override is taking medications from AMDS before pharmacist review, only acceptable in true emergencies

Routes of Medication Administration

• Oral (PO): Easy, safe, slow onset, first-pass metabolism
• Sublingual (SL): Under the tongue, fast-acting, bypasses first-pass
• Buccal: Between cheek/gum
• Rectal (PR): Good for vomiting/unconscious clients
• IV: Fastest acting, direct to the bloodstream
• IM: Into muscle (e.g., deltoid, vastus lateralis)
• SC: Beneath the skin (e.g., insulin)
• ID: Just under the skin (e.g., TB test)
• Transdermal: Patch (e.g., nicotine, pain medications)
• Ophthalmic: Eye drops
• Otic: Ear drops
• Nasal: Nasal sprays
• Vaginal/Rectal: Local or systemic effect
• Inhalation: MDIs or nebulizers

Enteral Tube Medications (NG, PEG, J-tube)

• Use liquid medications when possible and crush only if safe to do so
• Flush tube with 30-60 mL before/after, and 15-30 mL between medications. Never mix medications in formula and check placement and residuals

Parenteral Medication Administration

• Use correct syringe and needle size
• IM: 1½ inch, 18–25G
• SC: ⅝-⅝ inch, 25-27G
• ID: ¼-⅝ inch, 25–27G
• Use a filter needle for ampules
• Vials = inject air before withdrawing. Apply aseptic technique always

Safety Tips

• Perform hand hygiene and wear gloves while refrain from recapping used needles
• Use sharps container properly and engage the safety device after injection

Special Populations

• Older Adults: Prone to polypharmacy with decreased liver and kidney function. There may be slow metabolism and excretion
• Pediatric Clients: Use weight-based dosing(kg only) and oral syringes, droppers, flavoring. Use limited IM sites in infants (vastus lateralis preferred)

Client Education

• Use the teach-back method with simple language (6th-grade reading level)
• Include the drug name, purpose, dose, and timing

Safety Considerations for Medication Administration

• Determine whether the client has allergies by identifying them first to prevent allergic reactions
• Verify client identification to ensure the correct procedure and medication
• Use standard/infection control precautions to prevent the transmission of infectious organisms
• The rights of medication administration must be followed

Equipment/Supplies

• These include: Nonsterile gloves and PPE (if indicated),Medication Administration Record (MAR),Medication(s), Irrigation kit, Medicine cup, 60-mL syringes labeled for enteral use, Sterile water, Towel or pad

Skills Setup (for All Routes)

• Each skill is performed using the nursing process
• Assessment: verify orders, allergies, and client readiness
• Planning: gather equipment and verify medications
• Implementation: administer medication using correct technique and safety protocols
• Evaluation: monitor response and document

Common Skills Requiring Setup and Rationales

• Oral Medications (PO, SL, Buccal): Use liquids or tablets and position upright
• Enteral Tube Medications: Confirm placement, flush, and use correct syringes
• IM Injections: Choose appropriate site and needle while using the Z-track method
• Subcutaneous Injections: Rotate sites and use pinch technique
• Intradermal Injections: Bevel up with a small volume for TB/allergy testing
• Transdermal Medications: Remove old patch while rotating sites and wear gloves
• Ophthalmic (Eye) Drops: Avoid cornea and use punctal occlusion
• Otic (Ear) Drops: Warm to room temperature and position properly
• Nasal Sprays: Clear nostrils and avoid overuse
• Intravaginal Medications: Wear gloves and position supine
• Rectal Medications: Use lubrication and encourage holding
• MDI (Inhalers): Shake, press and inhale slowly, and use a spacer if needed
• IV Push: Know drug dilution and rate while monitoring closely
• IV Piggyback: Check compatibility with the primary line and monitor the site

Key Terms to Know

• Adverse Drug Event (ADE): Injury caused by medication use, requiring intervention.
• Adverse Drug Reaction (ADR): Unintended, harmful effect from a medication.
• Anaphylaxis: Life-threatening allergic reaction with difficulty breathing and low BP.
• Ampule: Small glass container of medication that must use a filter needle to draw up medications.
• Automated Medication Dispensing System (AMDS): Machine that stores and dispenses medications with password access and barcode linkage.
• Barcode Medication Administration (BCMA): Technology that scans the client ID and medication label to match orders.
• Buccal Route: Medication placed between cheek and gum for absorption.
• Enteral Route: Administered through the GI tract (oral, NG tube).
• Enteric-Coated: Tablet with a special coating that dissolves in the intestines, not the stomach.
• First-Pass Effect: Oral drugs are metabolized in the liver before reaching systemic circulation.
• High-Alert Medication: Medications with a high risk of causing harm (e.g., insulin, heparin).
• Infiltration: IV fluid leaks into surrounding tissues causing swelling, pain, and cool skin.
• Intradermal (ID): Injection into the skin (e.g., TB test).
• Intramuscular (IM): Injection into a muscle (e.g., vaccines).
• Intravenous (IV): Direct injection into a vein for fast absorption.
• Lipohypertrophy: Lumps under the skin from repeated insulin injections at the same site.
• Medication Reconciliation: Process of verifying and updating a client's medication list during transitions in care.
• Parenteral Route: Medications given by injection (IM, IV, SC, ID).
• Polypharmacy: Use of multiple medications, common in older adults.
• Subcutaneous (SC): Injection into fat tissue under the skin (e.g., insulin).
• Sublingual Route: Medication placed under the tongue for fast absorption.
• Teach-Back Method: Patient repeats back medication instructions to confirm understanding.
• Transdermal: Medication patch absorbed through the skin (e.g., nicotine, hormone patches).
• Trough Level: The lowest concentration of a drug in the bloodstream.
• Workaround: Unsafe shortcut that bypasses medication safety protocols.

Actions That Support Safe Medication Administration

• Among the nurse responsibilities is to always verify the right client, medication, dose, time, route, documentation, assessment, education, the right to refuse, and evaluation
• Avoid workarounds like overriding systems or skipping double checks

Common Error-Prone Situations

• Interruptions during medication prep/administration
• Similar sounding/look-alike medications
• High-alert medications (e.g., insulin, heparin, potassium chloride) requires independent double checks by two nurses
• Polypharmacy and comorbidities in older adults increase risk and incorrect weight units (e.g., using lbs instead of kg) in pediatric dosing

Reduce Risk of Medication Errors

• Use automated dispensing systems and barcoding to reduce human error
• Perform medication reconciliation at every transition of care (admission, discharge, and transfer)
• Document errors factually in incident reports, not in the client's chart
• If an error occurs, assess the client, notify the provider and nursing supervisor, document what happened, actions taken, and who was notified, and file an incident report per policy

Routes of Administration

• Enteral (GI Tract):
  • Oral (most common and safest)
  • Sublingual and buccal (absorbed under the tongue or cheek)
  • Feeding tube (NG, PEG, or J-tube): crush medications if allowed and flush with water
• Topical:
  • Includes transdermal patches, creams, ointments, eye drops, ear drops, and rectal/vaginal suppositories
• Parenteral (Injection):
  • Intradermal (ID): 15° angle into the skin (e.g., TB test)
  • Subcutaneous (SC): 45° or 90° angle into fat (e.g., insulin)
  • Intramuscular (IM): 90° angle into muscle (e.g., vaccines)
  • Intravenous (IV): Directly into the bloodstream – fastest effect

Dosage Calculations

• The Metric system is standard (mg, mL, kg)
• Convert units (1 tsp = 5 mL, 1 tbsp = 15 mL, 1 kg = 2.2 lbs)
• For example, a prescription for 10 mL of liquid cephalexin is 2 teaspoons (because 1 tsp = 5 mL
• Use dimensional analysis for multi-step conversions and calculations

Client Education About Medications

• Rights of Clients: Right to refuse, the right to informed consent, and the right to education

Teaching Must Include

1. Name and purpose of the medication.
2. How to take it (with food, timing, or vital sign checks).
3. Possible side effects and when to call the provider.
4. Don't stop suddenly without medical advice.
5. What to do if a dose is missed.
6. Importance of completing the full course (especially antibiotics).

Techniques

• Use the teach-back method where the client repeats instructions in their own words
• Be sure to use simple language and demonstrations and return demos (e.g.,insulin injections)
• Provide written medication lists, including OTC and herbal medications

Special Considerations

• Pediatric Clients: Use weight in kilograms, not pounds
• Immature kidneys and liver = higher risk of toxicity
• Geriatric Clients: Risk of polypharmacy (5+ medications). Altered metabolism and elimination requires dose adjustments
• Teratogenic Risk: Some medications may harm the fetus. Avoid if possible during pregnancy

Medication Reconciliation

• Ensures a complete and accurate medication list across all settings through a review of prescribed medications, OTC and supplements, and duplicate therapies or omissions
• Conduct at admission, transfer, and discharge

High-Alert Medications

• These require extra safety protocols
• Double-check insulin, heparin, IV potassium chloride, and narcotics
• Two nurses must verify the right client, dose, drug, the right route, and time

Actions to Take for a STAT Medication

• STAT orders are emergencies to give the medication right away
• Example: A client has chest pain, and the doctor orders morphine STAT → You stop your current task, get the morphine, verify the 6 rights, and give it within 15 minutes
• Document time given and client response and notify the provider
• STAT is immediate use for urgent clients that have pain or life-saving meds

Administering Medications to a Client Without an ID Bracelet

• Medication cannot be given legally or safely without confirming identity
• Pause medication pass, call the charge nurse, and replace the ID band immediately before administering medications
• This prevents giving the wrong drug to the wrong patient, which is a major safety risk

Factors That Affect Medication Absorption

• How quickly medications work depends on route, meaning IV is fastest and oral takes longer
• Food has a role, since some medications must be taken on an empty stomach (like levothyroxine)
• Body conditions, like slow GI movement, poor circulation, or stomach pH can slow absorption
• Giving oral iron with milk slows absorption and to give with vitamin C juice instead
• Medication depends on the route (oral, IV, etc.), stomach contents, and how the body processes drugs

Client at Greatest Risk for Medication Toxicity

• This client includes older adults (slower liver/kidneys), people with kidney or liver failure, and clients on multiple medications
• Signs of toxicity: Confusion, vomiting, slow breathing, and tremors
• Monitor lab values (like creatinine or liver enzymes), adjust doses, and report symptoms.
• Some clients can't break down medications well, like older adults or those with liver/kidney problems and they're more likely to have a toxic buildup

Priority Action After Allergic Reaction

• Stop the medication immediately, stay with the client, check the airway, breathing, and vitals, call the provider, and prepare to give epinephrine or antihistamines
• Watch for hives, difficulty breathing, swelling, or wheezing (signs of anaphylaxis)

Preventing Medication Errors

• Do not give medications if the client is in the Bathroom
• Wait until the client comes out, then check the 6 rights, verify the patient's ID, and watch them take it.
• Never leave medications unattended or on a tray/table
• The above method confirms the medication was actually taken and not lost, wasted, or mixed up

Errors

• Common causes are look-alike or sound-alike medications (e.g., hydralazine vs. hydroxyzine), and poor communication or illegible handwriting or verbal orders
• Prevent errors by following checklists, double-checking labels, and clarifying unclear orders
• Common causes of errors include rushing and not double-checking, without confirming identity

Reduce Medication Errors

• Use 2 identifiers (name and DOB), scan barcodes, check allergies, and know the medications
• Best practices include using 2 identifiers, scanning barcodes, one patient at a time, and maintain a quiet zone during the medication pass

Errors on the Team

• Encourage reporting near-misses so the team can learn and prevent future errors
• Barcodes, double-checking medications, and avoiding distractions can keep clients safe from harm

Medication Reconciliation

• Match the client's home medications with the hospital's list at admission, transfer, and discharge
• Ask what the client takes at home (include OTC + herbal) and report any changes or duplicates
• Comparison of the client's old medications with their new ones during admission, transfer, or discharge prevents duplicate or missing medications

Priorities When Preparing Insulin

• Check blood glucose, verify correct insulin type (e.g., regular vs. NPH), double-check dose with another nurse, and administer at the correct time before meals
• Mixing up short-acting and long-acting insulin is a common medication error and to always label syringes if mixed
• Insulin is a high-risk drug to always check blood sugar, double-check the dose and type, and often have another nurse verify

Routes of Medication Administration

• Choose the least invasive and safest method first: Oral > Sublingual > Rectal > IM > IV
• If a client can swallow, oral is best and to use injectins only if oral routes cannot be used

Giving Medications to a Preschooler

• Use fun words for medications and offer small choices to help them feel in control
• Never say "shot" or "it won't hurt" if it will, offer praise and give liquid form with a syringe or medicine cup
• Need gentle explanations, choice and praise is required to build trust and cooperation

Enteral Tube Medications

• Check placement (pH, x-ray if new), stop feeding before medications, crush medications separately (if allowed) & dissolve in water, and flush before, between, and after with 15–30 mL water
• Don't mix medications together, and use liquid medications when available
• Check placement, crush only approved medications, and flush with water before, between, and after to avoid clogs

Nitroglycerin Patch Teaching

• Apply to hairless, clean skin and rotate sites while removing the old patch before the new one and avoiding cuts to the patch
• Keep away from heat and it must be applied to clean, dry skin
• May cause headaches or dizziness so sit down after applying. Rotate sites, remove old patches, and don't touch the sticky side

Dosage Calculations

• Determine the dose using the formula: (Desired dose ÷ Dose on hand) × Volume = mL to give, especially important for kids
• Use weight-based dosing (e.g., mg/kg)
• Amikacin is weight-based and to multiply mg/kg by client weight in kg to get the correct dose

Calculating Clindamycin

• Use concentration on label (e.g., 150 mg/mL)
• The label concentration is used to find how many mL to draw. Example: 300 mg ordered ÷ 150 mg/mL = 2 mL

Twice Daily Phenytoin

• BID = twice a day where Total daily dose = 200 mg is to give 100 mg in the morning and 100 mg at night
• Split the total dose evenly between the morning and night

Measurement Systems conversions

• 1 g = 1,000 mg
• 1 mg = 1,000 mcg
• 1 tsp = 5 mL
• 1 tbsp = 15 mL
• 1 oz = 30 mL

Systems Important Points

• The metric system is used in hospitals
• You should know how to convert between mg, mcg, g, tsp, tbsp, and mL
• Use metric more often in healthcare

Client Education About Medications

• You must explain: name, purpose, how to take, actions, and side effects. Ask them to repeat back what they understand and use simple terms, check their understanding, and include family when possible
• The teaching and knowledge can be assessed with"Can you show me how you'll take this at home?" to check if your teaching was clear

Antibiotics reminders

• Remind clients to finish all doses even if feeling better, don't share with others, report allergic reactions, and watch for side effects like diarrhea or rash
• Teach to finish the full course, report side effects, and never share antibiotics
• For teaching: use simple words, visuals, and include family if possible and to always repeat and ask for questions

Medication Guidance

• You must give written and verbal instructions, involve caregivers, and answer all questions before they go home

Nitroglycerin Patch Teaching

• Use 1 patch a day and apply to chest/upper arm, while rotating sites
• Remove the patch at bedtime if ordered to prevent tolerance and store in safe, cool place
• Tell clients to apply patches to clean skin, remove old ones, and to avoid placing them near heat sources