Engage Fudamentals ATI Medication Administration.pdf

Learning Objectives Discuss nursing actions that support safe medication administration Discuss actions to reduce the risk of medication errors. Compare and contrast the various routes by which medication can be administered. Perform basic dosage calculations....

Learning Objectives Discuss nursing actions that support safe medication administration Discuss actions to reduce the risk of medication errors. Compare and contrast the various routes by which medication can be administered. Perform basic dosage calculations. Discuss the role of the nurse related to educating clients about their medications. Scope of Practice For differences in the scope of practice between RNs and PNs, Engage Fundamentals includes callout boxes focused on PN practice considerations. In addition, PN scope of practice varies by state. For example, some states may allow the PN to contribute directly to a plan of care, while other states limit PN participation to assisting the RN to develop the plan of care. Similarly, most states require the PN to be under the supervision of an RN. As such, PN students should reframe certain discussions in this product to align with their state’s scope of practice. Ultimately, the PN is responsible for functioning within their scope by knowing and abiding by state guidelines for safe practice. Introduction The role of the nurse is essential to safe medication administration. Nurses at the bedside can prevent medication errors from occurring and are the last line of defense to protect the client from errors. A medication error is defined as a preventable occurrence that leads to patient harm while the medication is in control of the health care professional, such as the nurse. To avoid such errors, nurses must competently practice the rights of medication administration, perform medication reconciliation, and understand medication interactions and pharmacokinetics. However, the responsibility for medication safety should not solely rest on the bedside nurse. The organization must also focus on key systematic elements such as the development of interprofessional team policies and procedures for medication administration and quality improvement processes to evaluate the outcomes of medication administration. Other areas for organizational focus involve system-related factors such as utilizing automated medication dispensing units, barcode technology, computerized order entry systems, identification and communication of high-alert medications, smart infusion pumps, and ongoing interprofessional team education on new medications and new technology for medication administration. This lesson focuses on dosage calculation, rights of medication administration, medication preparation and measurement, and the technique to administer medications for each of the prescribed routes (e.g., oral, intramuscular, intravenous, otic). In addition, client education regarding medications, assessments required prior to medication administration, evaluation of medication effectiveness, recognition of adverse reactions and allergic reactions, and important age considerations are reviewed. Dosage-A prescribed quantity of a medication consisting of the dose and the frequency. Pharmacokinetics Pharmacokinetics is the study of the absorption, distribution, metabolism, and excretion (ADME) of medications in the human body. The nurse needs a solid foundation of knowledge of how medications work in the body, their effects on specific organs, their intended actions, and adverse medication reactions. Understanding pharmacokinetics assists the nurse by ensuring safe clinical practice and helps to reduce medication errors. Pharmacokinetics-Study of the absorption, metabolism, distribution, and excretion of drugs in the human body. Absorption Absorption is defined as the movement of a medication from where it was administered (enters the body) to the circulatory system. Absorption is the first step in pharmacokinetics and affects the speed and the intensity of the medication’s action in the body. Several factors affect the rate of absorption: Route of administration: The point where the medication enters the body. Ionization: The pH of the medication and the site of absorption.  Dissolution: The medication must be dissolved before absorption takes place. Blood flow: Medications are absorbed more rapidly where blood flow is high. Lipid solubility: The medication’s formulation can have either high lipid solubility or low lipid solubility. Surface area of the absorptive site: The size of the surface area where the medication will be absorbed. Client-specific factors: Pathophysiological processes, diseases or injury, age, and so on. Ionization-Affects the degree of absorption and the rate at which the drug permeates the cell membranes, which ultimately impacts the distribution of a medication. Dissolution-Medication must be dissolved in solution before absorption takes place. The dissolution of a medication is dependent upon its initial state and route of administration. Dissolution: the process where a gaseous, liquid, or solid phase dissolves in a solvent to form a solution. Each of these factors must be considered as the nurse prepares to administer medications to clients. The medication must be dissolved in solution before absorption takes place. The dissolution of a medication depends on its initial state and route of administration. For example, oral tablets are broken down to smaller molecules before absorption can take place, which may occur over varying time frames. By contrast, orally disintegrating tablets readily dissolve when placed on the tongue, allowing for faster absorption. Liquid forms of a medication will dissolve readily in the stomach, which increases the rate of absorption. orally disintegrating tablets-Drug form that rapidly dissolves on the tongue or oral cavity. Ionization affects the degree of absorption and the rate at which the medication permeates the membranes, which ultimately impacts its distribution within the body. Aspirin in its non-ionized form is easily absorbed in the acidic environment of the stomach. When aspirin enters the small intestines, however, it becomes ionized in the alkaline environment, which slows its absorption rate. The lipid solubility of a medication also affects the rate of absorption. If a medication is highly lipid soluble, it is absorbed more rapidly than a medication that has low lipid solubility. Lipids act as carriers that convey molecules of a medication through the membranes of the blood vessels and into the bloodstream. Recall that absorption is the movement of medication into the circulatory system—which means that blood flow will affect the absorption of a medication as well. The higher the blood flow to the site of administration, the faster a medication will be absorbed. Another actor that affects the rate of absorption is the surface area of the absorptive site. The larger the surface area available, the more rapidly the absorption will occur. Many oral medications have been designed to be absorbed in the small intestine because the small intestine has a larger surface area than the stomach. Many of these medications are also weak bases (ionization) and are better absorbed in the small intestine’s alkaline environment. For enteral medications, most of the absorption occurs in the small intestines, although some medications may be absorbed from the stomach. The route of administration is critical to the absorption rate. Many medications are administered by the oral or enteral route, which provides for a much slower rate of absorption. The mucous membranes of the gastrointestinal (GI) tract delay medication movement. Oral and enteral medications must pass through these GI membranes to reach the circulatory system. Medications administered subcutaneously or intramuscularly have variable rates of absorption that reflects the blood flow to the site of injection. For example, intramuscular injections often have a faster absorption rate than subcutaneous injections due to the large blood vessels found in the muscles. Subcutaneous injections are delivered into the fat layer found immediately under the dermis. The absorption rate with this route of administration may be slower than with an intramuscular injection due to smaller size of blood vessels found in this fat layer. However, both the intramuscular and subcutaneous routes of administration have a faster rate of absorption than either the oral or enteral route. The intravenous route of administration provides the most rapid rate of absorption because the medication is directly injected into the circulatory system through the client’s vein. In consequence, intravenous medications are not affected by the same factors that affect absorption of medications administered through the other routes. Topical medications are applied directly to the area being treated (e.g., skin, eye, ear, nose), as are transdermal patches. In both cases, the medication is absorbed through the mucous membranes or skin in the area of application and moves into the blood through the capillaries in that area. enteral route-Medications administered via the mouth, stomach or intestines. A final factor that affects the absorption rate of a medication is the condition of the body. It is important that the client receives a medication that can be absorbed by their body. For example, if a client is experiencing vomiting or diarrhea due to an alteration in GI motility, absorption of an oral medication may not occur. For oral and enteral medications to be absorbed, the GI tract must be functional. If a client vomits after an oral medication is administered, it raises a concern about how much of the medication dose was absorbed. The decision whether to repeat the dose of medication depends on several factors—the time between administration and the vomiting episode, presence of the medication in the vomitus, the type of medication (e.g., extended release, short-acting), the risks of undertreatment versus toxic effects, and the individual client. Thus, it is important for the nurse to collaborate with the provider to determine if redosing should occur. In addition, pregnant clients have decreased GI motility, which means a medication has more time to be absorbed—and suggests a reduced dose of the oral medication may be appropriate. Dose-The amount of the ordered medication. The nurse recently administered oral medications to a client who notified the assistive personnel (AP) that they just vomited. Which of the following actions should the nurse take first? A Notify the provider and obtain further direction B Inspect the vomitus for any presence of the medication C Document that the client vomited after medication administration D Instruct the AP to provide mouth care to the client Submit Distribution Distribution is the process of medication delivery to the target organ or tissues following absorption into the circulatory system. Distribution is affected by the client’s circulatory status or blood flow, and the medication’s solubility and protein-binding ability. Highly vascular areas such as the heart, brain, liver, and kidneys receive the greatest blood supply, with the bones, skin, and adipose tissue receiving a lesser amount. Lipids are essential to the rate of absorption, as the medication mixes in the bloodstream and crosses membranes. The blood–brain and fetal–placental barriers are protective barriers that prevent substances, including specific medications, from crossing them. Some medications are specifically designed to be more selective in their ability to cross these barriers. Lipid-soluble medications cross these barriers more readily. Thus, health care providers may select an antibiotic that will penetrate the central nervous system or blood–brain barrier to treat bacterial meningitis but must consider the possibility of this medication crossing the fetal–placental barrier when treating a pregnant or nursing client. Metabolism (Biotransformation) Metabolism or biotransformation is the chemical process of converting a medication’s structure. Metabolism can result in amplified medication activity, inactivation of the medication, or increased excretion via the kidneys, and it can toxicity levels of medications. Most medications are metabolized in the liver, although kidneys and sections of the small intestines may also be responsible for some medication metabolism. Medications are transformed by a group of liver enzymes, known as cytochrome P-450, to active and inactive substances to allow for their excretion. Because most medications are metabolized and excreted primarily by the liver and kidneys, clients with kidney and liver disease may have a slower rate of medication clearance. Therefore, it is important for the health care provider to evaluate the client’s renal and hepatic function before ordering medications. The nurse must also check any lab work or current illnesses that may affect the hepatic or renal function as part of the assessment for the right medication administration. Toxicity-An adverse effect in which the body is unable to metabolize or excrete a medication; it can cause irreversible damage to organs. Metabolism may transform a specific medication to another form, resulting in a more active or potent form; for example, codeine is transformed to morphine, resulting in increased pain relief. Prodrugs are inactive chemicals that are activated through metabolism to exert their therapeutic effects. Oral medications pass from the small intestine to the hepatic circulation via the mesenteric and portal veins flowing into the liver, before reaching the systemic circulation. The first-pass effect can result in a lower concentration (bioavailability) of the medication reaching the systemic circulation, if a majority of the medication has already been metabolized into an inactive form before it enters the bloodstream. Prodrugs-Contain inactive chemicals that are activated through metabolism to exert their therapeutic effects. therapeutic effects-The desired effects of a medication. first-pass effect-The passage of oral medications from the small intestine to the hepatic circulation via the mesenteric and portal veins flowing into the liver, before reaching systemic circulation. FIRST-PASS EFFECT Knowledge of medications that undergo precipitous metabolism in the liver is crucial for determining the appropriate route of administration. The health care provider may prescribe these medications to be administered via another route (e.g., parenteral, sublingual, transdermal, or rectal) to achieve the desired effects. Genetic characteristics related to race and/or ethnicity may also influence how rapidly medications are metabolized as a result of a variation in specific genes. Likewise, age plays a role in the rate of metabolism. For example, infants have immature liver function, which reduces their rate of metabolism. In contrast, advancing age reduces the liver’s function and size; blood flow and enzyme production are also slower in the geriatric client. The CYP enzymes found on liver cells play a role in medication metabolism by regulating the rate at which a medication is broken down and the amount of time the medication stays in the body. The nurse must be alert for prolonged effects of medications, possible adverse effects, and higher medication levels. Nutrients can influence medication metabolism by either allowing or preventing enzymes of the cytochrome P-450 (CYP) system to function normally. Excretion Excretion is the process by which a medication is removed from the body. Elimination of the medication from the body requires a joint effort of the body’s metabolism and excretion functions. The kidneys are the primary organ responsible for medication excretion, while the skin, lungs, exocrine glands, liver, mammary glands, and intestines excrete medications to a lesser extent. The rate of medication excretion is affected by kidney, heart, and liver function, which influence the medication’s concentration in the body. Medication levels may remain at higher concentrations prior to the next scheduled dose for clients experiencing liver, kidney, or heart failure. In addition, older adults typically experience at least some degree of kidney dysfunction. In such clients, medication doses may need to be lowered to avoid toxicity or the medication may even need to be discontinued. The nurse must be vigilant in assessing and evaluating these at-risk clients for adverse effects of the medication. Medication toxicity develops when the body is unable to metabolize and excrete a medication. The remaining medication may reach toxic levels and cause deleterious and sometimes irreversible damage to organs. Older adults and those with impaired cardiac, liver, and kidney function are at high risk for developing medication toxicities. Medication Preparations: Therapeutic Actions/Effects Pharmacodynamics is the study of how a medication works, its relationship to medication concentrations, and how the body responds (therapeutic range). Therapeutic drug monitoring (TDM) method used by health care providers to monitor medication concentrations in a client’s blood. TDM is used for those medications that have a narrow therapeutic window, as a means of providing adequate and safe medication administration without causing an adverse medication reaction. It is important for the nurse to ensure that the blood samples for TDM are taken at the appropriate recommended timing, which depends on the specific medication, to ensure accurate medication serum level measurement. Pharmacodynamics-The study of how a drug works, its relationship to drug concentrations, and how the body responds. therapeutic range-A method used by health care providers to monitor drug concentrations to determine therapeutic dose and avoid toxicity. therapeutic drug monitoring (TDM)- Method used by health care providers to monitor drug level concentrations. Peak and trough blood levels will guide the health care provider in maintaining therapeutic medication levels. The peak blood level occurs when the medication is at its highest concentration, but below the toxic level. Peak medication levels occur when absorption is complete. The concentration of a medication is considered to be within the therapeutic range when the medication produces the desired effects. The trough blood level is the lowest level of concentration of a medication that correlates to the rate of elimination. It is measured before administering the next scheduled dose. peak blood level-Highest level of a drug in the bloodstream without being at a toxic level. trough blood level-Lowest concentration of a medication in the systemic circulation. All medications have a half-life, which is the time it takes for the medication to fall to half its strength through excretion. Medications with longer half-lives may be administered only once daily to maintain a therapeutic level. For example, diazepam, a central nervous system depressant, has a half-life of 20 to 50 hours in adults when given orally. The nurse should understand that all medications have different half-lives, as this has important safety implications for clients. half-life-Time it takes for the drug to fall to half its strength through excretion. The half-life of a medication is the length of time it takes for the medication concentration to be reduced by 50%. HALF-LIFE Onset, peak, and duration of a medication are other important considerations when prescribing and administering medications. Onset of action is the time the medication takes to produce a therapeutic effect after its administration. The peak effect occurs when absorption is complete, the medication is distributed throughout the body, and the medication is at its highest concentration. Duration of action comprises the period of time for which the medication maintains its therapeutic effects. Medications that attach themselves to a cell receptor can either activate or inactivate a receptor. Receptors are molecules that are found on the cell membrane or within the cell cytoplasm and are responsible for chemical signaling between and within cells. Activation has the potential to increase or decrease a specific cell function. A medication that activates receptors to initiate a preferred response is known as an agonist, whereas a medication that prevents the activation of a receptor is known as an antagonist. Adverse Drug Reactions Before administering medications, the nurse must assess the client’s status by reviewing any contraindications to receiving the medication, relevant laboratory values, appropriate vital signs, allergies, and potential medication interactions of the medication to be administered. The nurse must inform the health care provider if the nurse has any concerns prior to administering the medication. Nurses need a comprehensive understanding of pharmacology to perform their vital roles in deciding the appropriateness of the medication and practicing safe medication administration. Nurses should have a comprehensive understanding of pharmacology, pathophysiology, therapeutic effects of medications, and evidence-based nursing practice. Adverse drug reactions (ADR) are unintended and nontherapeutic effects, which can range from tolerable to harmful and sometimes to irreversible damage or death. adverse drug reactions (ADR)- Unwanted and non-therapeutic effects of the medication. They can range from mild to severe. The U.S. Food and Drug Administration (FDA) describes a serious adverse drug event (ADE) as a life-threatening medication reaction that requires medical intervention to prevent death, permanent disability, or congenital anomaly, or that causes hospitalization or prolongs a hospitalization. All ADEs must be reported to the FDA so that this agency can work to improve safety outcomes, revise medication labels and warnings, and, when needed, withdraw medications from the market. A black box warning is placed on the labels of medications that may produce lethal and iatrogenic results. Warnings are also included on the packaging of specific medications to inform health care providers and consumers of the potentially dangerous side effects. For example, celecoxib, a COX-2 inhibitor, may cause serious cardiovascular adverse reactions, myocardial infarction, or stroke in clients with a history of cardiovascular disease. The black box warning for celecoxib includes a notice that this medication may cause fatal cardiovascular disease, bleeding, and serious gastrointestinal reactions. Some ADEs may be avoidable through careful assessment and planning. ADEs may range from mild to severe, with some reactions resolving with the discontinuation of the medication. adverse drug event (ADE)- An injury caused from a medical intervention that is linked to a medication. Iatrogenic-An unforeseeable or unintended physical condition, injury, or disorder caused by a treatment or procedure. Allergic Reactions An allergic reaction or hypersensitivity reaction develops when the body perceives a medication as a foreign substance (allergen), which then stimulates an immune response. This reaction produces inflammatory substances, such as histamines and cytokines, in response to tissue injury. An extreme reaction is defined as an allergic reaction. Allergic reactions may range from mild to severe, and produce specific physiologic tissue reactions (e.g., rash, hives, swelling, circulatory collapse and laryngeal edema). The initial treatment for a client experiencing an allergic reaction is to discontinue the medication immediately. allergic reaction-A reaction resulting from a hypersensitivity to an antigen or foreign substance, such as a medication. Anaphylaxis is a severe, life-threatening reaction in which the immune response produces dyspnea, hypotension, and tachycardia. Another potentially fatal medication reaction is Steven-Johnson syndrome (SJS), which develops within 1 to 14 days following dose administration. SJS is manifested by such symptoms as respiratory distress, fever, chills, and a diffuse, fine rash, followed by the development of blisters. Anaphylaxis-An acute allergic reaction to an antigen that may result in life-threatening shock, producing vasodilation, bronchospasm, and laryngeal edema. The nurse’s role related to allergic medication reactions is to check the client’s allergies before administering a medication, manage the client who has a medication reaction, document the incidence of the reaction, and notify the health care provider of the reaction. Urticaria (hives) are a possible manifestation of an allergic reaction. ALLERGIC REACTION: MEDICATION-INDUCED URTICARIA Medication Interactions Drug–drug interactions occur anytime a client is prescribed more than one medication. The effects of drug–drug interactions may include intensifying the effects of one of the medications or decreasing the effects of one of the medications. Keep in mind that the intensification can be to increase either the therapeutic effect or the adverse effects of that medication. Similarly, the decreased effects can involve either the therapeutic effect or the adverse effects. The ultimate result depends on the medications prescribed, their pharmacodynamics, and the effect they have on the pharmacokinetics. Drug–drug interactions are frequently listed in drug reference resources. It is the nurse’s responsibility to use the facility-approved drug reference resources to check for these interactions among certain medications. drug–drug interactions-The effect that two or more drugs that the client is administered have on each other (ex. enhance actions or block actions, increase or decrease ADR etc). Drug–food interactions can also impact rate of absorption (delay or enhance). For instance, iron preparations are better absorbed when given with orange juice or foods containing vitamin C, whereas iron is poorly absorbed when given with dairy products or antacids containing magnesium. Medications taken with food or high-fat meals will have a much slower rate of intestinal absorption. Drug–food interactions can also affect metabolism and excretion, potentially leading to medication toxicity. The nurse should instruct the client when medications should be taken with or without food and with any other restrictions. If medications are ordered or recommended to be taken on an empty stomach the nurse should administer that medication at least 1 hour before or 2 hours after a meal. drug–food interactions-Effects of nutrients on the absorption, distribution, metabolism or excretion of medications. Drug–herbal supplement interactions can result in effects similar to those seen with drug–drug interactions. Therefore, the nurse must assess if the client is currently taking any herbal supplements and teach the client which herbal supplements to avoid based on their medications. INTERACTION WARNINGS IN AN ELECTRONIC MEDICAL RECORD Factors Affecting Medication Actions Many factors may influence the individual response to a given medication, such as developmental changes, age, weight, gender, culture and ethnicity, genetics, nutritional status, and disease states. A cautious approach to medication administration is vital for pregnant and nursing clients. When possible, medication therapy should be postponed during pregnancy. Nevertheless, some preexisting conditions must be treated during pregnancy, such as hypertension, epilepsy, or other chronic diseases. The health care provider considers the effects of any medications given to the pregnant client and growing fetus. Some substances are categorized as teratogenic, meaning they are known to cause fetal defects, pregnancy loss, developmental disabilities, or prematurity. These substances include cocaine, alcohol, angiotensin-converting enzyme (ACE) inhibitors, gentamycin, lithium, nonsteroidal anti-inflammatory drugs (NSAIDs), and tetracycline. The FDA recently changed the labeling of medications in regard to pregnancy and lactation risks, with the intention of providing more information regarding medication use during pregnancy and while breastfeeding. In addition, the new label will include information about the risk of untreated disease during pregnancy, which should prompt a discussion between the health care provider and client about the potential risks and benefits of medication use during pregnancy. The nurse must consult with the prescribing health care provider when administering medications. teratogenicMedications that can cause fetal defects, pregnancy loss, prematurity or developmental disabilities. Client Education and Safety: Pregnant or Nursing Clients The nurse must always check medication information when administering medications to a pregnant or nursing client, as some medications may cross the fetal–placental barriers. Some medications are excreted into breast milk after metabolism. Notably, codeine, morphine, some herbal supplements, and alcohol cross the fetal–placental barrier, which may have detrimental effects on the fetus and newborn. Factors Influencing Medication Effects It is important for the nurse to obtain a current weight for all clients prior to initiating any medications. Medications are often prescribed according to the client’s weight in kilograms—for example, the dose of metronidazole is 15 mg/kg. (See the section “Dosages by Weight” later in this lesson.) Pediatric medications are specifically ordered based on the client’s weight in kilograms. Pediatric dosages are much smaller than adult dosages, as metabolism and excretion are affected by the immaturity of vital organs. Infants and premature neonates are at much higher risk for developing toxicity because they lack metabolizing enzymes. Male and female clients also have differences in fat and muscle distribution, although the resulting changes in dosage based on sex may be minor. Older adults may have difficulty absorbing, metabolizing, and excreting medications because of age-related changes and decline in the functioning of the liver, heart, and kidneys. Older clients tend to have less muscle mass, which is replaced with fat or adipose tissue. Medications are stored in the fatty tissue, resulting in decreased plasma levels and reduced efficacy. Cultural and genetic factors may play a role in the adherence, efficacy, and client’s response to medications. Cultural and spiritual food practices, use of alternative or complementary therapies, and beliefs shaped by ethnicity or cultural background about health and disease may also factor into medication effectiveness. Some clients may prefer to use herbs to treat and prevent illnesses. It is important for the nurse to determine from clients if they are using any herbal compounds. The study of pharmacogenetics is concerned with how particular clients and ethnic groups respond to specific medications. For example, studies have shown that certain genetic phenotypes (e.g., Liddle phenotype) are found in clients with hypertension. Clients with this phenotype do not respond to certain classifications of medications commonly used to treat hypertension. It may be necessary to add diuretics to their medications to control these clients’ blood pressure. A client who is pregnant at 8 weeks gestation reports they are having cold symptoms and trouble sleeping to the nurse. The client asks the nurse if they can take over-the- counter cold medicine. What is the most appropriate response the nurse should make? (Click this card to reveal the answer.) The nurse should explain to the client that although some medications are safe during pregnancy, others can harm the fetus. It is best that the client discusses the situation with the health care provider, who can explain the risks and benefits of the particular medication. Age-Related Considerations When administering pediatric medications, nurses must be familiar with general knowledge of the physiological differences of pediatric clients as compared to adult clients. This information will assist in understanding the differences in dosing of medications and the pharmacokinetics and pharmacodynamics of medication administration in pediatric clients. Pediatric clients have a higher rate of metabolism. They may need medication administered more frequently or in larger doses per kilogram of weight than an adult to maintain therapeutic effects. For example, a 250-mg dose of a medication for a child who weighs 10 kg means the child is receiving 25 mg/kg, whereas a 70-kg adult receiving the same dose is getting only 3.57 mg/kg—and yet both are receiving the recommended dose for their age. In addition, renal excretion in infants is decreased and full renal function is not achieved until 1 year of age. Dosing of medications in pediatric clients does not leave room for error. One strategy to assist in accurate delivery of medication for infants and children is weight dosing for all medications. Accurate weights in kilograms for infants and children are essential. Pediatric clients are at increased risk of ADEs, particularly when they are hospitalized, as many medication dosages are calculated by their weight in kilograms. Medication errors are frequently associated with miscalculations relative to the pediatric client’s weight being recorded in pounds, which would lead to an incorrect amount of medication prescribed. Older adults may have several comorbidities that require them to take multiple medications, making the management of their medications more complex, yet necessary. These clients are more prone to ADEs as a result of natural physiological changes that develop as the body ages. The risk of developing adverse drug reactions (ADRs) and medication interactions increases along with the number of medications being taken. Polypharmacy, defined as the use of five or more medications by a nonhospitalized client, is of greater threat in this age group because physiological changes in the older client affect both pharmacokinetics and pharmacodynamics of the medications. For example, muscle mass decreases while the ratio of body fat to muscle increases with greater age, which alters the distribution of medications and may possibly lead to medication toxicity. Polypharmacy-Multiple medications that one person is taking. Client Rights All clients have the right to expect their health care team and facility to deliver quality care and provide a safe environment. Client safety and quality health care are intertwined—and medication safety is paramount in maintaining optimal client outcomes. Preventable medication errors cause approximately 770,000 injuries or deaths every year in the United States, with a resulting increase in hospital expenses of $1.56 to $5.6 billion per year. For the health care team and facility to assure client rights, there must be processes in place to prevent harm from occurring to clients. One of the major processes to promote safety is the rights of medication administration. Rights of Medication Administration The nurse performs consistent steps during medication administration, commonly known as the rights of medication administration, to ensure safe practices. The components of the rights of medication administration should be verified before medications are dispensed to clients, thereby reducing the possibility of a medication error The Rights of Medication Administration Right client: Verify the client’s identity using two client identifiers. Right medication: Confirm the name and form of the medication is correct. Right dose: Check medication and dosage against the order in the client’s medical record. Right route: Confirm the route of medication per the provider’s order in the client’s medical record. Right time: Confirm the time medication is to be given and the last time the medication was administered. Right assessment: Confirm the client’s medication allergies, that the medication is appropriate for the client’s condition, and any drug–drug or drug–food interactions that may need addressed. Check lab work or vital signs, per the medication (e.g., a medication to reduce blood pressure should not be administered without checking the client’s blood pressure first). Right documentation: Document the time the medication was administered and any other pertinent information. Right to refuse: The client has the right to refuse the medication. Right education: Provide education to the client addressing the name of the medication, the expected benefits, and the potential adverse medication effects. Right evaluation: Check the client’s medications to determine if an untoward interaction may occur. Monitor the client’s response to the medication. Right Client Medication errors sometimes occur because a medication was given to the wrong client instead of the intended client. The Joint Commission’s National Patient Safety Goals state the importance of identifying the correct client prior to medication administration. Identification needs to include two of the following: Name Date of birth Social Security number Medical record number Telephone number All clients have an identification bracelet (ID). The nurse needs to check and verify the two identifiers with the client’s ID band prior to giving medication. CLIENT IDENTIFICATION BRACELET Each facility will have its own policy stating which identifiers the nurse is to use. It is important for the nurse to review and understand this policy. Clients may be asked to verbalize their identifying information. It is then the nurse’s responsibility to check and verify the information with the client’s ID band. The two identifiers are also compared to the client’s medication administration record (MAR) for confirmation of the correct client. This provides three checks to confirm the client’s identifying information. However, it is not necessary that clients verbalize their name, as this may not be possible with a pediatric client or an adult client who has a cognitive or speech deficit. In such a case, the nurse will still have two acceptable methods of confirmation—that is, the client’s ID band and the MAR. For this reason, it is important for the nurse to ensure that all clients have a readable ID band on them. If the ID band has fallen off or the printed information is smudged, it should be immediately replaced. medication administration record (MAR)- A record of the medications prescribed for the client by the provider. The MAR is used by the nurse to record and confirm medication administration per the prescription. Right Medication Medication errors may also occur because the wrong medication is given to the client. To ensure the right medication is being administered, nurse confirms that the medication to be given is the same as the medication order. Brand names or generic names can have similar spellings or pronunciations. An example is the beta- blockers: Members of this medication category have names ending in “lol,” which gives an indication of how the medication works in the body. Generic-Non-trademarked name of a drug assigned by the Food and Drug Administration. It is essential for nurses to make sure they are administering the right medication, as different medications have very different actions. It is recommended for health care providers to completely write out the generic name and the reason for the ordered medication when prescribing to lessen confusion. In addition to checking that the right medication is being given, the nurse should check the expiration date to avoid giving an expired medication to the client. Right Dose A medication error regarding the right dose is the result of the incorrect dose of medication administered. Medication errors related to right dose may involve administration of an incorrect dose, a miscalculation in the conversion of units, and incorrect medication concentration. Dose-related errors can occur from a displaced decimal point, incorrect math computation, or incorrect conversion in units. For example, an error can occur when converting the client’s weight in pounds to kilograms. Other considerations include checking that the dose is appropriate for the client’s age, body size, and condition. The dosage may need to be adjusted based on the client’s condition and the reason the medication is being given. Right Route of Medication Medications may be given via various routes, and those routes may differ in the time needed for the medication to be absorbed, onset of action, and potential for side effects. It is important for nurses to be knowledgeable about new medications or those less likely to be administered to ensure they can deliver the medications safely in the clinical setting. In addition, nurses are required to have a fundamental knowledge base of the physiological factors that influence medication absorption rates and the time it takes for a medication to take effect. For example, medications that are delivered via the intravenous route have a quicker onset of action than those administered via the oral route. The administration of medication has become increasingly complex over the years as newer medication routes have become available, including delivery through central venous catheters, patient-controlled anesthesia, epidural infusions, and intrathecal administration. Right Time The frequency and timing of the administration of a medication are also important. Each facility should establish its own policy regarding the recommended times of administration. Time of medication administration can affect the therapeutic effects as well as adverse reactions and toxicity of the medication. Medication reference books give the frequencies with which medications should be administered (e.g., every 8 hours, once a day, or every 6 hours). These frequencies are based on the pharmacokinetics and pharmacodynamics of the specific medication. However, the time they are to be administered is also determined by the provider’s prescription. When writing prescriptions, providers should avoid using abbreviations to reduce the risk that the medication order will be misinterpreted. The Joint Commission has approved a short list of abbreviations that may be used for ordering medications. The frequency and route should always be written out to avoid misinterpretation and errors. To confirm the right time, the nurse needs to check the provider’s prescription, the client’s MAR, and the time the last dose was administered. Routine medications are ordered for a specific time or frequency. For example, they may be ordered as daily, twice per day, three times per day, four times per day, at bedtime/hour of sleep, every other day, weekly, or monthly. STAT medication prescriptions prescriptions are given immediately, and usually just one time. “STAT” is derived from the Latin word statim, meaning “immediately.” STAT prescriptions should be administered within 30 minutes of the health care provider placing the order. Such medications are often given during an emergency situation. STAT medication prescriptions-Medications that are required to be given immediately. Urgent, now, or ASAP (as soon as possible) prescriptions should be administered within 30 minutes to 1 hour after the health care provider’s order. Single prescriptions are one- time doses, such as those seen with preoperative medications. PRN (as-needed medications) is a term derived from the Latin phrase pro re nata, meaning given as required for specific symptoms, such as pain, nausea, or fever. Pain medications are usually ordered based on the client’s need for pain relief. PRN-As needed. medications given as required for specific conditions or issues, such as pain, nausea, etc. Time-Critical and Non-Time-Critical Medications Time-critical medications are those that, when administered either 30 minutes before or after the scheduled administration time, can cause harm to the client or result in a substandard pharmacologic effect. They include the following types: time-critical medications-Medications that should be given within either 30 minutes before or after the scheduled administration time.  Medications scheduled to be administered routinely less than 4 hours apart Medications that are required to be given separately from other medications Medications that are administered around mealtimes, such as antidiabetic medications Non-time-critical medications are defined as medications that can be administered between 1 to 2 hours early or late without causing harm or resulting in substandard pharmacologic effects to the client. These medications are prescribed to be administered no more frequently than every 4 hours, including daily, weekly, and monthly medications. non-time-critical medications-Medications that can be administered between 1 to 2 hours before or after the scheduled time without causing harm or resulting in substandard pharmacologic effects to the client. Per Centers for Medicare and Medicaid Services (CMS) regulations, all facilities must have a policies and procedures in place to address the timing of all medications. Nurses must review their facility’s policies and procedures to assure the medications are being given in a timely manner. Right Assessment The nurse assesses the client prior to administering the medication for contraindications, pertinent lab results, vital signs, allergies, and possible medication interactions to determine if the client requires the medication and if it is safe to administer the medicationFor example, if the nurse is administering warfarin, the nurse would check for indications of bleeding (e.g., decrease in hematocrit or blood pressure; guaiac-positive stools, urine, or nasogastric contents) and would monitor prothrombin and international normalized ratio (INR) lab values prior to administering the medication to the client. Right Documentation Each time a medication is given, the nurse should check the client’s MAR before and after its administration. Prior to giving a medication, the nurse should check the MAR to verify the client, as well as the medication route, dose, and time and frequency of administration. It is also important to determine the time the last dose of the medication was administered. The MAR should be checked with the latest provider orders to assure accuracy. After administering the medication, the nurse should immediately document the time and their initials on the client’s MAR per the facility’s policy. If the medication is a PRN medication, the exact time should be entered in the MAR. In addition, the nurse should note in the client’s medical record why the PRN medication was administered and an evaluation of the effectiveness of the PRN medication. For example, if a client is given a PRN medication for headache, the nurse would document the exact time on the MAR and then in client’s chart note that the client reported a throbbing headache identified as a 5 on a 1 to 10 pain scale and acetaminophen was administered. Then, after evaluating the client, the nurse would note in the client’s chart that client reports headache is now a 2 on a 1 to 10 pain scale. The nurse should not document the medication on the MAR until it has actually been given, in case the client refuses the medication. If the medication requires a specific assessment prior to administering the medication, that should be documented on MAR or in client’s chart per facility policy. For example, if the client was to be given digoxin (which can slow the heart rate), the apical pulse should be checked prior to administration, given or held per the provider’s order or facility policy, and documented. Right to Refuse All clients have health care rights that are defined by federal and state laws. These health care rights put clients in charge of their health coverage and care. Specifically, the client bill of rights includes the right to information about insurance health plans, health care providers, and health care institutions; the right to choose a health care provider; the right to emergency services; the right to make choices; the right to be treated with respect; the right to privacy; the right to report problems; and client responsibilities. Health care organizations also usually have a patient bill of rights, which includes the right to informed consent. The nurse is responsible for ensuring that informed consent has been established as indicated by the client’s understanding of all aspects of treatment, to include indications for use of all medications, ADEs, and expected benefits. Although the client has the right to refuse any medication or treatment, the nurse is responsible for investigating the reasons for refusal and attempting to dispel any fears or misconceptions. The nurse should notify the health care provider whenever a client refuses medication and make the appropriate documentation in the client’s medical record. Right Education The nurse educates clients about their medications to ensure the clients understand their medications—a key aspect of safe and effective therapy. Clients need to know why the medication has been prescribed and which side effects they need to report to the nurse or provider. When educating clients, ask them what they already know and correct any misinformation they have provided. Ask them to repeat the actions and side effects of their medications, and explain how the medication will assist in controlling disease processes. If the medication is prescribed for long-term therapy, check whether the client knows how to refill the medication. Right Evaluation After the medication has been administered, the nurse evaluates the effect of the medication to determine whether the medication’s effect matches what is expected. The nurse routinely reviews the client’s medications and, if necessary, continues ongoing observation. The nurse is preparing to administer medications to a client. The pharmacy has delivered the correctly prescribed medications, but they are labeled with another client’s name and medical record number. What action should the nurse take? A Notify the provider of the error B Administer the medications as delivered C Collaborate with the pharmacist D Ask the client what they would prefer Submit All of the rights of medication administration should be addressed prior to giving the client the medication. However, it is also recommended to verify three times during the process of medication administration the following rights: right patient, right medication, right dose, right route of administration, and right time. This three-check procedure should occur at the following times during medication administration. 1. When the medication is obtained by the nurse from the client’s medication drawer or from an automated medication dispensing machine 2. During preparation of the medication 3. At the client’s bedside immediately prior to administration The Medication Prescription A complete medication prescription should contain the following information: client’s name, date/time that the prescription was written, medication name (generic), dosage, route of administration, frequency, indication for use, and provider’s signature. Prescription-A medication order written by the provider that includes the name of drug, amount to be give, the route and frequency of administration. The order needs to have the client s name, the date and time the order was written and the provider s name and title. Prescription Example John Doe 6/22/2020 10:00am Indomethacin 50 mg by mouth every 12 hours for osteoarthritis Dr. Sam Jones The MAR is a record of the medications prescribed for the client by the provider. It is used by the nurse to record and confirm medication administration per the prescription. In health care organizations that use computerized physician order entry (CPOE), the provider enters the medication prescription electronically. The information regarding the medication order then goes to the pharmacy, where the pharmacist reviews the prescribed medication. An electronic version of the MAR appears in the client’s electronic health record (EHR); a paper copy of the MAR is used if the organization is still using paper medical charts. When administering medications to the client, the nurse uses the MAR to comply with the right of administration. The right client is confirmed as the nurse confirms the client’s identity using two identifiers and compares them to the MAR. Right drug, dose, and route are confirmed as the nurse checks the label of the medication against the MAR. This step is carried out three times—when the nurse removes the medication from the drawer, when the nurse pours the medication, and at the bedside. The right assessment is completed before the medication is given by assessing the client physically and reviewing lab work and/or vital signs. The right documentation involves the nurse documenting on the MAR after the medication has been administered. The right to refuse is documented on the MAR as well. The right evaluation is completed after the medication is given, and is charted on the MAR. Review the following provider prescription and then identify the following information as missing or present. (Drag the options to the desired category. If you select the wrong category, the description will automatically move to the correct category.) Prescription reads: Alice Sample 10/12/2020 Tylenol 650 mg every 6 hours for pain Client’s name Date that prescription was written Time that prescription was written Generic name of medication Dose of medication Route of medication administration Frequency of medication administration Indication of use Provider signature Missing Present Factors Contributing to Medication Errors Failure to follow the rights of medication administration (e.g., giving the wrong dose, wrong time, or wrong medication). A late dose or missed dose is considered a medication error. Failure to check for accuracy of the medication prescription. The nurse must collaborate with the pharmacist and the provider in checking for accuracy and appropriateness of medication prescriptions prior to administration. Failure to assess the client for any high-risk variables related to age, disease states, laboratory data, allergies, and prior response to medications.  Giving medications before they can be verified by the pharmacist and other members of the interprofessional team. The pharmacist should review all medications before they are delivered to the nurse for administration. Incomplete or illegible prescriptions with missing components of the medication prescription. Unofficial abbreviations should not be accepted. Working under stressful conditions with numerous interruptions. Medication Reconciliation Medication reconciliation is another important aspect of maintaining and ensuring client safety. Through its Patient Safety Goals and other initiatives, The Joint Commission has emphasized that facilities need to maintain an accurate, up-to-date list of every client’s medications. Medication reconciliation is performed upon admission; whenever the client transitions from one level of care to another, both within the facility (e.g., from the intensive care unit [ICU] to the general medical–surgical unit) or from one health care facility to another (e.g., a client transferred from the hospital to a rehabilitation facility); and when the client is discharged home from a facility. According to The Joint Commission the goal of medication reconciliation is to develop, update, coordinate, and communicate accurate client medication information during transitions of care. The reconciliation process involves reviewing the client’s current medications, comparing them to the newly prescribed medications, and addressing omissions, duplications, interactions, and discrepancies. The nurse considers any potential drug– drug interactions. All types of medications, including over-the-counter (OTC) medications and herbal supplements, should be included in the reconciliation process, as there may be a potential risk for interactions with newly prescribed medications. Having a complete medication list can reduce polypharmacy, which is common among the geriatric population. The interprofessional team, consisting of the pharmacist, provider, nurse, and in some cases, the registered dietitian, is instrumental in the reconciliation process, and their collaboration can result in improved client outcomes. over-the-counter (OTC) medications-Medications that can be purchased without a healthcare providers prescription. Medication reconciliation is a process to maintain an accurate list of client medications and prevent medication errors. BPMH is Best Possible Medication History. MEDICATION RECONCILIATION PROCESS Medication Reconciliation Process Document an accurate and comprehensive list (name, dose, route, frequency, and purpose) of home medications upon admission. Compare the list of home medications to newly prescribed medications during the current hospitalization and reconcile any discrepancies. Update the medication list and repeat the comparison and reconciliation process at any transition of care during the client’s hospitalization, as well as at discharge. Communicate the reconciled medication list to the next care provider. Educate the client and caregivers upon discharge and provide the client with written information about their medication. The FDA (2020) defines a medication error as any avoidable event that could result in an incorrect use or client injury during the time frame in which the medication is the possession of the nurse, client, or health care provider. Most errors occur when the nurse neglects to observe standard procedures and does not follow the rights of medication administration, leading to errors such as wrong time, wrong dose, or failure to give the medication as prescribed. The best strategy for preventing errors associated with medication administration is to acknowledge basic concepts and follow the rights of medication administration. The nurse is both legally and ethically responsible for all steps within the medication administration process, including observation, client education, and documentation. The nurse should never leave medications at the bedside for a client to self-administer, as this practice fails to follow the rights of medication administration and may lead to a medication error or a serious ADE. Technological advances such as automated medication dispensing systems (AMDS) and barcode technology may aid in the reduction of medication errors and support record-keeping of medications on the unit. Research shows that the use of AMDS can lead to a 31% reduction in dispensing medication errors, and barcoding technology can yield a 41% decrease in errors and 51% decrease in potential adverse drug events. AMDS are medication storage machines that control the dispensing of medications, including narcotics. Every nurse has a personal password to access the system. After the nurse enters the client’s name, the name of the medication, the dosage, and the medication route, the system dispenses the medication. The AMDS can also link the medication administration and the nurse who accessed the system to the client’s electronic record. The nurse obtains the client’s medications using an automated medication dispensing system (AMDS). AN AUTOMATED MEDICATION DISPENSING SYSTEM (AMDS) When using a barcode system, at the time of medication administration, the nurse uses a handheld scanner device to scan the client’s identification wristband and the medication label. If there is a discrepancy between the scanned medication and the client’s bracelet, the system will alert the nurse as to the discrepancy. The medication should not be administered until the reason for the alert is resolved. The nurse scans the prescribed medication and the client to reduce the risk of medication errors. BARCODE SCANNING Three factors reported by nurses as contributing to medication errors are identification, interruption, and correction. Identification components are associated with the nurse’s depth of knowledge regarding the medication and observing the rights of medication administration. Interruption occurs when the nurse is preparing or administering a medication and is interrupted during the process. Interruptions during the medication process impact client safety, quality of care, and workload. Strategies to prevent interruptions include marking the area where medication preparation occurs to prevent people from conversing with a nurse working in the labeled area, limiting excess noises, decreasing the use of cellphones by the nurse, and educating staff not to disturb those preparing medications unless the need is critical in nature. Correction relates to the number of alerts and warnings frequently communicated to nurses on a daily basis and the temptation to ignore an alert that could potentially cause harm to the client. When using an automated dispensing cabinet system, the pharmacist reviews the order before the medication is removed from the system and administered. If the nurse removes the medication before the pharmacist has reviewed the medication for administration, an alert will be generated, requiring the nurse to override the system. Override-The nurse removes a medication from the automatic dispensing system before the pharmacist has reviewed the order. Nurses should not resort to using workarounds when problems arise with the normal process of medication administration. A workaround is the practice of avoiding a policy or procedure in a system. For example, the nurse may be tempted to override the AMDS if a client’s medication wristband falls off or if an error code is displayed after scanning a medication barcode. Taking a shortcut or using a workaround lessens the system’s safety features and leads to errors. The ISMP defines an override as an instance where the nurse removes a medication from the automatic dispensing system before the pharmacist has reviewed the order because the nurse perceives that the client will be harmed if administration of the medication is delayed. Overriding the system creates a risk to the client and should occur only in an emergent situation. Workaround-The practice of avoiding a policy or procedure in a system that is there to protect client safety. High-alert medications are associated with an increased risk of causing considerable client harm when errors in their administration occur. To reduce the risk of harm to clients, safeguards are put into place for such medications. For example, all forms of insulin are regarded as high-alert medications. One strategy that has been instituted as a safety protocol is manual independent double checks, in which two nurses verify the identical information when administering insulin. The information checked by each nurse includes the rights of medication administration—medication order, right dose for client’s age and weight, right time (when the last dose was administered), right dose (right amount of medication drawn up in the syringe or right number/dose of pills), right dose calculation, and right client. Two nurses independently checking the information should result in fewer medication errors. Other high-alert medications include opiates, narcotics, intravenous heparin, and injectable potassium chloride. Safe Medication Administration 1. Medication Administration Medication Errors Medication errors are the most common medical errors, resulting in more than 770,000 injuries or deaths each year in the United States. While nurses are responsible for preventing many medication errors by intervening during the prescribing, transcribing, and dispensing aspects of medication administration, the highest risk of committing a medication error occurs when the nurse actually gives the medication. This increased risk is related to having fewer systems in place to prevent medication errors at the bedside The client could suffer harm—possibly lethal—if an error is not addressed. When it has been determined that a medication error has occurred, the client must be assessed for any change in medical condition.Notify the health care provider as soon as possible to remedy any potentially harmful effects of the error. The organizational protocols will dictate the steps to complete following a medication error, which typically involve notifying the nursing supervisor and completing an incident report once the health care provider has been notified. When completing the incident report, the nurse explains the situation surrounding the error, including what happened, which actions were taken, other people involved, and circumstances that may have played a role in the error. It is important to state only the facts in the incident report, while avoiding any personal opinions or excuses, omitting facts, or trying to place the responsibility on someone else. Although the incident report is considered a legal document, it is not placed or mentioned in the client’s medical record. Following health care facility’s policy, the erroneous medication administered, or scheduled medication omitted, should be documented in the client’s medical record, along with the client assessment, interventions provided, and notification of the health care provider. Strategies for Reducing Medication Administration Errors 1. 1. Identify client by using two types of identifiers (e.g., name, date of birth, Social Security number, medical record number, or telephone number) 2. Use appropriate administration techniques for the prescribed medications. Use aseptic technique when administering parenteral medications. Wear gloves when administering medications per the facility’s policies and procedures. 3. Calculate all doses of medications correctly, with a double-check for complicated calculations, high-risk medications, IV medications, and pediatric dosages. 4. Be alert for sound-alike medications (e.g., dopamine/dobutamine, heparin/Hespan). 5. Clarify any questions or concerns about the medication prescription with the health care provider. The health care provider’s medication prescription must include the medication name, dose, form, route, and time of administration. 6. Never leave any medications at the bedside. Ensure that the client has swallowed the medication. 7. Always have another nurse witness insulin doses and disposal of unused narcotic doses, as required by the facility. 8. Become familiar with the medication prior to administration by consulting a drug reference guide, the health care provider, the pharmacy, or a facility approved application on an electronic device. 9. Educate clients when all new medications are prescribed or when they have questions. 10. Recognize that the client has the right to refuse medications.  11. Observe and assess the client prior to medication administration and following the administration of any PRN or new medications for efficacy and adverse medication effects. 12. Check and confirm client allergies before administration of medications. Certain medication administration processes must be followed regardless of the route of administration. 1. Verify all medication prescriptions and check for allergies. 2. Uphold the rights of medication administration before giving the medications. 3. Perform hand hygiene and, as needed, apply gloves. 4. Use aseptic technique in the preparation and administration of all parenteral medications. 5. Identify the client per the facility’s protocols, using two identifiers. Ensure that the client is wearing an identification band for scanning medications. 6. Validate allergies with the client. 7. Educate the client about all medications to be administered. 8. Position the client appropriately for the route by which the medication will be administered. 9. Prepare all unit dose medications at the bedside. Open unit dose medications after scanning and immediately prior to administration; never prepare medications for future administration. A unit dose medication is a medication that is prepared and packaged by the hospital’s pharmacist or the medication manufacturer in a single unit dose container that is specific to the provider’s prescription for the client. A multi-dose vial is a container that holds more than a single dose of medication and can be used for multiple clients. Multidose medications in syringes, cups, or basins must be labeled when prepared.  10. Never leave medications at the bedside. 11. Document pertinent client information before leaving the bedside (e.g., vital signs, assessment findings, communication with health care provider). 12. Keep medications that require specific assessments (e.g., blood pressure, apical heart rate, or laboratory data) in a separate labeled cup. 13. Assess the client 30 minutes after medication administration for desired effects or adverse effects. 14. Notify the health care provider if any concerns or problems arise in administering medications to the client. unit dose medication-A medication that is prepared and packaged by the hospital’s pharmacists or the drug manufacturer in a single unit dose container that is specific to the provider’s prescription for the client. multi-dose vial-A container of medication that holds more than a single dose of medication and can be used for multiple clients. Routes of Administration There are three major categories of medication administration: enteral, topical, and parenteral. Some medications are formulated to be administered by several routes. For example, acetaminophen can be administered as a pill or liquid (enteral–oral), as a rectal suppository (rectal–topical), or as an intravenous (IV) medication (IV–parenteral). The health care provider will prescribe the route in relation to the client’s needs and condition. For instance, if the client is experiencing vomiting and diarrhea, the health care provider will prescribe acetaminophen to be administered via the parenteral (by injection) route. In emergency situations where the client needs the immediate effects of the prescribed medication, the intravenous route is preferred. The oral route is the most convenient, costs less, and is typically a safer route of medication administration. The selection of the medication route is based on several factors. Medication attributes: Is the medication a solid, liquid, or gas? For example, a medication in gas form is administered via inhalation. Location of desired action: Is the desired effect of the medication local or generalized? For example, local effects can be achieved with the use of topical creams that provide maximal effect while preventing side effects from affecting  other parts of the body. Generalized effects are achieved using oral or injectable medications, such as those used to treat infections inside the body. Digestive juices and first-pass metabolism: Medications that are predominantly digested when given orally are administered by a different route. Speed of desired response in a medical emergency or routine care: Emergent medical conditions usually require intravenous injections so that the medication can reach the desired location quickly. Dosage accuracy: Medications that are administered via the intravenous or inhalation route can be adjusted depending on the client response during the treatment. Client condition and adherence: Pediatric and geriatric clients may not adhere to medical advice. Unconscious clients are unable to take medications orally. Common Routes of Medication Administration Route of Advantages Disadvantages Administration Administration Site Oral (PO) By mouth/swallow Safer Slow onset of action Less costly Subject to first-pass effect Convenient (variety May have an unpleasant of forms) taste Painless Not appropriate for Client can self- unconscious clients administer Not appropriate for clients with excessive vomiting and/or diarrhea Sublingual (SL) Beneath the Rapid onset of action Not appropriate for tongue Bypasses first-pass children effects May cause membrane Can be self- irritation administered by the client Rectal (PR) Anus Can be administered Not liked by clients to children, Absorption varies unconscious clients, Rectal mucosa can become or clients who are irritated or swollen unable to swallow Increased concentration is achieved quickly Intravenous (IV) Into the vein Rapid onset Sterilization and aseptic Can be used with technique are essential clients who are High cost unconscious, Invasive technique is noncompliant, or required unable to tolerate oral Can injure nerves, tissues, medications or vessels Buccal Between the cheek Rapid onset of action Can cause irritation to and the gum line open sores in the mouth  Bypasses first-pass Exact site location can be effects difficult Can be self- Decrease in the effect of administered by the the medication if it is client swallowed Client may experience nausea and vomiting if the medication has an undesirable taste Inhalation Local irritation can precipitate Inhaled through Rapid action respiratory secretions or the mouth into the bronchospasms lungs Smaller dose required Medication dosage can be regulated Intramuscular Into the muscle (IM) Faster absorption as Must be administered compared to the oral using aseptic technique route Painful Soluble and Can cause nerve damage suspension substances can be administered Subcutaneous Can be self-administered by Beneath the skin the client Maximum volume delivery (subcut) is 1.5 mL  Slow absorption Transdermal Effects can last for several Medication dosing varies due to Applied to the days client factors skin Otic Can be administered by the Blockage of the ear canal will Outer ear client decrease absorption therefore ear irrigation of ear canal must occur before instilling drops; positioning of ear canal is different for children and adults Opthalmic Can be administered by the Client's contact lens must be Eyes (mucous client removed prior to instilling membrane or medication; bradycardia and conjunctival sac) hypotension can occur with specific opthalmic medications (i.e. beta blockers) Nasal Can be administered by the Permanent swelling of tissue Nostrils client within nose can develop with continued use Enteral Medication Administration Enteral medication administration is used to describe medications that are administered via the GI tract, including the mouth, stomach, and intestines. Enteral medication administration forms include tablets, capsules, and liquids. Sometimes a client is unable to take a medication by mouth and requires an enteral tube, which goes directly into the stomach or small intestine. Oral medications can be given via an enteral feeding tube, although consideration must be given to medication formulation and minimization of tube occlusion. Administering Oral Medications The form of the oral medication being delivered will dictate the type of measuring device required to administer the client’s medication accurately and safely. For example, when administering oral liquid medications, a syringe, dropper, or metered measuring cup is necessary for preparing the medication for administration: When using a syringe to measure the medication, carefully pull up on the plunger until the medication reaches the black line on the top of plunger at the desired measurement marking. Turn the syringe up, and tap gently on the side of the syringe to remove the air bubbles. Remove the air from the syringe by gently  pushing up on the plunger. This procedure may need to be repeated to reach the correct amount of medication ordered. If using a dropper, after placing the dropper into the medication bottle, squeeze the rubber top. Remove the dropper from the bottle and read the amount on the dropper. Carefully squeeze the top of the dropper until the amount lines up with the desired dosage displayed on the dropper. Use only the dropper provided with the medication. as the dropper is typically specific to the prescribed medication. If using a metered measuring cup, place the cup at eye level on a flat surface. Pour the medication until the dose reaches the correct line. APPROVED MEASURING DEVICES FOR LIQUID MEDICATIONS A pill cutter may be necessary to split a medication tablet so that it equals the amount prescribed by the health care provider. Using a pill cutter to split medications ensures that the right dose of medication is administered. For example, the health care provider may have ordered 1 mg of a medication to be administered, but the medication is available only as a 2-mg tablet, requiring the nurse to split the pill in half. The pill must be scored to assure the correct dose will be administered. If the pill is not scored, the nurse should consult with the pharmacist. A nurse should never use the hands or other objects to split pills, as an incorrect dose could be administered. The procedure for splitting a pill is as follows. 1. Perform hand hygiene and collect the necessary supplies (pill cutter, medication, and gloves). 2. Clean the pill cutter (per facility policy and procedure) to prevent cross- contamination of other medications. 3. Put on gloves and place the pill in the pill cutter. 4. Close the pill cutter, which splits the pill in half. 5. Dispose of the unused half of the pill per facility policy. 6. Administer the medication to the client following the rights of medication administration. 7. Clean the pill cutter (Cleveland Clinic, 2022). Oral medications come in different forms. Note the line on the tablet. This tablet is scored and can if necessary by split with a pill cutter along the score line. FORMS OF ORAL MEDICATIONS Oral Medication Administration: Oral, Buccal, Sublingual It is important for the nurse to determine if the tablet or capsule medication should be administered on an empty stomach or with foods. In addition, the nurse should identify whether specific foods may decrease or enhance absorption. Tablets are manufactured by pressing a mixture of substances, including the medication and other ingredients, into a smaller space. Tablets have various shapes, which aid in swallowing of the tablet, and some are scored to make it easier to cut the tablet if needed. Tablets can be in chewable form or have an enteric coating to prevent them from breaking down before they reach the small intestine. Tablets come in various delivery types, including quick release, delayed release, or extended release. Capsules are made of a gelatin that surrounds the medication, a structure that means they have a higher bioavailability than tablets. Therefore, capsules can act more quickly within the body and be more effective because the medication enters the circulation faster. Capsules are less likely than tablets or liquid medication to have an unpleasant taste. However, these formulations usually cannot be split in half or crushed (unlike tablets). The most common types of capsules are soft and hard. Soft capsules contain medication formulated as an easily digested gelatin. Hard capsules consist of two parts that fit together and surround the powder or pellet ingredients. Liquid dosage forms may be easier for some clients who may have difficulty swallowing solid medications. The taste of liquid medications can be unpleasant, however, and may require the addition of a flavoring (cherry or grape) by the pharmacist to make them more palatable for the client. Some basic principles regarding administering an oral medication to a client are listed here. Assess the client’s level of consciousness and ability to swallow. Assist the client to a position that will prevent choking and aspiration, such as elevating the head of the bed to semi-Fowler’s or high-Fowler’s position as the client’s prescribed activity level permits. Offer water or a beverage (per the client’s prescribed diet) of the client’s choice to help the client swallow the medication. Some clients may prefer to take their oral medications mixed in applesauce or pudding. If using a portion of a multidose container, pour liquids into a metered measuring cup and hold the medication label in the palm of the hand. This may prevent the liquid medication from obscuring the label prescription or instructions—that is, necessary information required during medication administration. Remain with the client until the medications are swallowed. Never leave the medications at the client’s bedside. Sublingual medications are placed under the tongue. Instruct the client not to chew or swallow the medication. Remain with the client until the medication has dissolved.  Buccal medications are placed between the cheek and the gum line. Instruct the client not to swallow or chew the medication. Remain with the client until the medication has dissolved. buccal route-Administration of a tablet by placing it in the oral cavity between gum and cheek. Refer to the Skill: Administering Oral Medications. Place sublingual medications under the tongue SUBLINGUAL MEDICATION ADMINISTRATION Enteral Feeding Tube Medication Administration: Nasogastric, Gastrostomy, or Jejunostomy Tubes An enteral feeding tube (EFT) is placed for clients who are unable to absorb nutrition or medications through the GI tract or to deliver nutrition and medications to clients who are unable to take them in through the oral cavity. There are several different types of EFTs, which can be inserted surgically through the abdominal wall, into the stomach (gastrostomy tube [GT]), or into the jejunum (jejunostomy tube [JT]). These are usually placed for long-term use. Other EFTs are inserted through the nose, such as a nasogastric (NG) tube, which is placed into the stomach, or a nasoduodenal (ND) tube, which is placed into the duodenum. These nasally placed tubes are usually used temporarily as a client convalesces or during surgery. A potential complication that may occur with EFTs is clogging of the tube, which may necessitate replacement of the EFT. Clogging is most often due to administration of medications. Several preventive measures should be taken when giving medications via an EFT. Administer medications in liquid form whenever possible to avoid clogging the tube with crushed pills. Some medications are not available in a liquid formula, however; in such a case, a pill must be crushed and dissolved in a liquid (e.g., warm water). Always consult the health care provider and the pharmacist about whether the medication can be crushed and the type and amount of liquid needed to completely dissolve the crushed medication. If the medication can be crushed, be sure to crush it completely. Enteric-coated, capsules, sustained-release, and immediate-release medications should not be crushed or opened, as adverse effects can result when these medication forms are altered. enteric-coated-Medications that are formulated to be dissolved and released in the small intestines for a slower release and can be administered less frequently during the day. sustained-release-Tablets designed to release medication slowly over an extended period. An effective intervention recommended to prevent an EFT from becoming clogged is to flush the tube before giving the medication, in between administration of multiple medications at the same time, and immediately following the administration of medications. It is recommended to flush the tubing with 30 to 60 mL of water prior to and after administration of medications and to flush with 15 to 30 mL in between medications. If a medication is given via the enteral route through a feeding tube, the nurse must ensure the medication is compatible with this route. Mixing the medication in the feeding may result in delayed medication absorption, drug–formula interactions, or precipitation of the medication. Adverse events related to tubing misconnections have also been documented. Enteral medications and feedings have been erroneously connected to IV tubing, and IV medications and solutions have been mistakenly connected to EFTs. These medication errors have caused death and severe client injury. Such errors are primarily due to the use of Luer connectors, which permit the nurse to erroneously connect syringes to tubing independent of the type of tubing (IV or enteral). A specially designed enteral connector placed on the end of the EFT and a syringe that will only fit this connector have been developed to prevent the syringe from being connected to any other connector used in the clinical setting. In addition to the engineered connector and syringe, nurses must follow the tubing from the client to the point of origin (feeding pump or IV bag) before connecting or reconnecting any device or infusion (enteral or parenteral). Refer to the Skill: Administering Enteral Medications Topical Medication Administration Topical medications include those applied directly to the skin or mucous membranes of the eyes, nose, respiratory tract, vagina, rectum, and urinary tract. Such medications can be used for local effects (i.e., for treatment of a specific body part) or for a systemic effect, in which the whole body is affected once the medication is absorbed through the skin Transdermal applications allow for the medication to be absorbed slowly, providing prolonged medication release lasting for several days. Transdermal patches are generally applied to the upper torso, chest, upper arms, or back, or behind the ears. The medication released by these patches is absorbed through the skin for systemic distribution for a prescribed amount of time. Examples of types of medication delivered via transdermal patches include opioids, antidepressants, contraceptives, nicotine, and antinausea medications. Transdermal-Delivery of a specially prepared medication designed to be absorbed by the skin. With transdermal medications, the old patch should be removed before a new patch is applied. Nonsterile gloves should be used during the removal and application of the patch to prevent the nurse from absorbing the medication. The new application should be rotated to different sites to avoid irritation. Do not place patch on nonintact or irritated skin. Refer to the Skill: Administering Transdermal Medications. ADMINISTRATION OF A TRANSDERMAL MEDICATION Ophthalmic medications are applied to the mucous membranes of the eyes or conjunctiva. Ophthalmic solutions are instilled into the lower margin of the eyelid (conjunctival sac). Eye drop medications, such as beta-blockers and alpha agonists, can also enter the bloodstream, causing systemic signs and symptoms. Punctal occlusion, also known as nasolacrimal occlusion, is a method used to prevent the medication from entering into the nasolacrimal duct and into the systemic circulation. After the nurse instills the eye drop(s) and the client closes the eye, the nurse places an index finger at the inner corner of the client’s eye, maintaining gentle pressure there for 30 to 60 seconds. Strict aseptic technique must be maintained when administering any medication to the eyes to avoid contamination or infection. Do not instill medication directly on the cornea, as this can cause the client pain, irritate the cornea, and increase the medication’s systemic effects. Refer to the Skill: Administering Ophthalmic Medications. Ophthalmic-Pertaining to the eyes. PUNCTAL OCCLUSION AFTER OPHTHALMIC MEDICATION ADMINISTRATION Otic medications are used for the treatment of local infections and inflammation; they are instilled into the outer ear. When administering otic medications, assure that the medication is at room temperature. Never administer cold solutions into the ear canal, as this may cause the client to become dizzy and cause pain. Prior to instilling the eardrops, pull the pinna up and back gently, which helps to straighten the ear canal and facilitates the movement of the medication through the ear canal. Position the client in a side-lying recumbent position with the affected ear facing up, to prevent the medication from exiting the ear canal. Refer to the Skill: Administering Otic Medications. Otic-Pertaining to the ears. OTIC MEDICATION ADMINISTRATION Nasal medications are drops or sprays instilled within the nostrils, then absorbed through the mucous membranes and into the bloodstream. Medications that can be administered via the nasal route include nicotine (smoking cessation), calcitonin (osteoporosis), sumatriptan (migraines), and corticosteroids (allergies). For these nasal medications to be absorbed, the nostrils must be clean of mucus. Decongestant nasal sprays can be purchased as OTC medications for the treatment for congestion. If the nasal decongestant is used too frequently or for too long, the client can experience rebound congestion. As the client increases the use of the nasal spray, the blood vessels in the nose narrow, causing the inside of the nose to shrink. Once the effects of the nasal spray wear off, the nasal tissue swells. Permanent swelling of the tissue can develop with continued use of the nasal spray. Refer to the Skill: Administering Nasal Medications. Nasal-Medication administered via the nostrils. Intravaginal medications are used to treat infections, administer estrogen during menopause, as hormonal support during in vitro fertilization and for contraception. Forms of medication given by the vaginal route include solution, tablet, cream, gel, suppository, or ring options. With this route of administration, the medication is absorbed through the vaginal wall. The nurse must wear gloves to avoid contact with the client’s secretions. Administration of the medication will be dependent upon the form and purpose. Refer to the Skill: Administering Intravaginal Medications. vaginal route-Delivery of a specially prepared medication designed to be absorbed through the vaginal mucosa. Medications given by the rectal route are supplied in the form of suppositories, although creams and ointments may also be prescribed. Rectal medications can be used for clients who have trouble swallowing, an obstructed bowel, or decreased movement in the intestinal tract, or clients who are unconscious. The medication is absorbed through the lining of the rectal vault. The rectum should be empty of stool before administering the medication, as this increases the medication’s effectiveness. Discuss with the client the need to refrain from passing stool for a minimum of 20 minutes once the suppository has been given to provide enough time for the medication to enter the systemic circulation and have an effect. Suppositories should not be administered to clients who have had recent rectal surgery, who have rectal bleeding, or who are at risk for bleeding (low platelet count). Refer to the Skill: Administering Rectal Medications. rectal route-Administered via the rectum or anus. Inhaled medications take the form of very small droplets that, upon inspiration, pass through the trachea into the lungs. The smaller the droplets, the deeper they will travel into the lungs, which increases the amount of the medication absorbed. Inhaled medications, also known as aerosols, are used to treat respiratory conditions such as asthma, chronic obstructive pulmonary disease, cystic fibrosis, and infectious pulmonary disease. The most common methods of aerosol delivery are metered-dose inhalers (MDIs), dry powder inhalers (DPIs), and nebulizers. These devices expel a preset dose of medication each time they are activated. To effectively use an MDI or DPI, the client must be taught to coordinate inspirations with activation of device and to take a slow deep breath in to achieve distribution of the medication into the lungs and not to the back of their mouth, which may happen if the client inhales too quickly. For clients who are unable to coordinate this activity due to physical, cognitive, or developmental concerns, a spacer should be used to improve medication delivery. A spacer provides a chamber that holds the medication and attaches externally to the inhaler. Refer to the Skill: Administering an MDI. A spacer is used with an MDI to distribute medication more effectively into the lungs. VARIATION OF INHALED MEDICATION (SPACER) Parenteral Medication Administration Medications given by the parenteral route (intradermal, intramuscular, subcutaneous, and IV) are administered by an injection, which means that they bypass the digestive tract. The medication is administered using a needle and syringe or an intravenous catheter, while maintaining aseptic technique. parenteral route-Medication administered by a route that does not involve the gastrointestinal tract. Usually refers to an injection and is administered by a needle such as intravenous or intramuscular. General Information All parenteral medications are given with a syringe and safety needle (IM, intradermal, or subcutaneous injections) or a syringe and needleless system (IV). However, the appropriate type and size of a needle as well as the syringe need to be selected by the nurse as the nurse prepares the medication for administration to the client. Nurses must be aware of the various parts of the syringe and needle that must remain sterile while preparing and administering the medication. The syringe and needle may come packaged as a single unit or separately. PARTS OF A SYRINGE AND NEEDLE To select the correct syringe and safety needle or needleless system, the nurse must use best judgment based on the type of parenteral injection that will be administered (IM or subcutaneous), the location (deltoid or ventrogluteal site), the size or age of the client (pediatric, obese), and the amount and viscosity of the medication. Syringes with safety needles should only be used to administer intramuscular, subcutaneous, or intradermal medications. Some of these needles have a guard that the nurse engages to glide over the needle; in other models, the needle automatically withdraws into the syringe once the injection has been completed. This design is intended to prevent the nurse from having an inadvertent needlestick immediately after the injection. A safety needle can prevent needlestick injuries. SAFETY NEEDLE Syringe Sizes and Types The size of the syringe selected by the nurse is based on the amount of medication to be drawn into the syringe and the desired pressure flow. The barrel of the syringe is labeled with centimeters (cc) or milliliters (mL): 5 cc is the same volume as 5 mL. If a large amount of medication must be administered, the nurse should use a larger syringe. Syringes are designed to have either a Luer connection tip or a non-Luer tip. The tip of the syringe is where the hub of the needle is connected. If the syringe has a Luer connection tip, then the needle hub can be turned and tightened (locked) into place. If the syringe has a non-Luer tip, the needle can only be slipped off and on of the syringe. COMMON SYRINGE SIZES USED FOR PARENTERAL MEDICATION ADMINISTRATION  Note the difference in the tips of the syringes: non-Luer (slip) tip versus Luer-Lock connector tip. Insulin