Chapter 2 –

PRINCIPLES OF
MEDICATION
ADMINISTRATION
 Administration of
medications is a basic
activity in nursing practice
 Nurses must be
knowledgeable about the
specific drugs and their
administration, client
response, drug interactions,
client allergies
 Nurses are accountable for
the safe administration of
medications
 Nurses must know all the
components of a drug order
and questions those orders that
are not complete, unclear,
outside the recommended range
 Nurses are legally liable if they
give a prescribed drug and the
dosage is incorrect or the drug
is contraindicated for the client
Components of a Drug Order:
 Date and time
 Drug name
 Drug dosage
 Route of administration
 Frequency and duration of
administration
 Any special instructions
 Physician or other health care
provider’s signature
THE “FIVE-PLUS-FIVE
RIGHTS” OF DRUG
ADMINISTRATION
The “Five-Plus-Five Rights” of
Drug Administration

• The rights of medication

administration are the foundation
for medication safety
• To provide safe drug administration,
the nurse should practice the
“Rights” of drug
administration
The “Five-Plus-Five Rights” of
Drug Administration
•TRADITIONAL FIVE (5) RIGHTS
• Right Client
• Right Drug
• Right Dose
• Right Time
• Right Route
•Experience indicates that FIVE (5)
Rights are essential to professional
nursing practice
• Right Assessment
• Right Documentation
• Client’s Right to Education
• Right Evaluation
• Client’s Right to Refuse
RIGHT CLIENT

 The nurse is responsible of

accurately identifying the patient
when administering a medication
 Verify client by checking the
identification band
 Distinguish between two clients with
the same last name
RIGHT DRUG

 means that the client receives the

drug that was prescribed
 A telephone order or verbal
order for medication must be
cosigned by the prescribing health
care provider within 24 hours
Components of a Drug Order:
 Date and time
 Drug name
 Drug dosage
 Route of administration
 Frequency and duration of
administration
 Any special instructions
 Physician or other health care provider’s
signature
Four (4) Main Categories of
Drug Orders:
 Standing Order – an ongoing
order or may be given for a specific
number of doses or days
◦ e.g. Digoxin 0.25 mg PO daily
 One-time or Single Order –
given once and usually at a specific
time
◦ e.g. Diazepam 5mg IV before surgery
 PRN Orders – given at the client’s
request and nurse’s judgment
◦ e.g. Tylenol 650mg q3 to 4h PRN for
headache

 STAT Orders – given once,

immediately
◦ e.g. Morphine sulfate 2mg IV STAT
RIGHT DOSE
 isthe dose prescribed for a
particular client
 Nurses must calculate each drug
dose accurately
 Before calculating a drug dose, the
nurse should have a general idea of
the answer based on knowledge of
the basic formula or ratios or
proportions
RIGHT TIME

 is the time at which the prescribed

dose should be administered
 Administer drugs at the specified
times.
 Drugs may be given 30 minutes
before or after the time prescribed
if the administration interval is
>2hours
 Administer drugs that are affected
by foods before meals
 Administer drugs that can irritate
the stomach (gastric mucosa) with
food
 Daily drug dosages are given at
specified times during a day:
bid, tid, qid or q2h, q4h. Q6h. q12h
RIGHT ROUTE

 isnecessary for adequate or

appropriate absorption
 The more common routes are oral,
sublingual (under tongue for venous
absorption), buccal (between gum
and cheek), inhalation (aerosol
sprays), suppository (rectal, vaginal)
& parenteral (ID, SC, IM, IV)
 Assess the client’s ability to swallow
before the administration of oral
medications
 Do not crush or mix medication in
other substances before consultation
with a pharmacist
 Use aseptic technique when
administering drugs. Sterile technique is
required with the parenteral routes
 Stay with the client until oral drugs have
been swallowed
RIGHT ASSESSMENT

 requires that appropriate data be

collected before administration of
the drug
 e.g. taking apical HR before
administration of digitalis
preparations or serum blood sugar
levels before the administration of
insulin
RIGHT DOCUMENTATION

 requires that the nurses immediately

record the appropriate information
about the drug administered
 This includes:
◦ Name of the drug,
◦ Dose,
◦ Route,
◦ Time and date,
◦ Nurse’s initials or signature
RIGHT TO EDUCATION

 requires that clients receive accurate

and thorough information about the
medication and how it relates to
their particular situation including
therapeutic purpose, possible side
effects, dietary restrictions
RIGHT EVALUATION

 requires that the effectiveness of the

medication be determined by the
client’s response to the medication
RIGHT TO REFUSE

 client can and do refuse to take a

medication,
 it is the nurse’s responsibility to
determine when possible the reason
for the refusal and to take reasonable
measures to facilitate the client’s
taking the medication and reinforce
the reason for the medication
NURSES’ RIGHTS WHEN
ADMINISTERING
MEDICATIONS
Nurses’ rights when
administering medications
 These rights ensures the nurse of what is needed
to provide safe medication administration
 The nurses’ six rights are
1. The right to a complete and clear order
2. The right to have the correct drug, route and
dose dispensed
3. The right to have access to information
4. The right to have policies to guide safe
medication administration
5. The right to administer the medication safely
6. The right to stop, think and be vigilant when
administering medication
The right to a complete and
clear order
 The drug, dose, route and
frequency be ordered by the
health care provider
 The nurse must question the
health care provider if the order
is not complete or is unclear
The right to have the correct drug,
route and dose dispensed
 Dispensing medications correctly
is the role of the pharmacist
The right to have access to
information
 Includes the right to expect
current and readily accessible
drug information e.g. nursing drug
reference
 Nurses are only to administer
drugs with which they are
knowledgeable
The right to have policies to guide
safe medication administration
 Health care administration’s role
is to provide the structure on
which nurses administer drugs
safely
 Policies guide nursing practice
The right to administer the
medication safely
 Nurses’ right and responsibility
to speak up when they are first
aware of situations that impinge
negatively on safe administration
of medications
 Nurses should be advocate for
safety in the health care settings
The right to stop, think and be
vigilant when administering
medication
 Nurses have the right and
responsibility to stop and think,
consult with other health
profesionals
FORMS & ROUTES FOR DRUG
ADMINSTRATION
FORMS & ROUTES FOR
DRUG ADMINSTRATION
 Forms and routes are used for the administration of
medication including:
◦ Sublingual
◦ Buccal
◦ Oral (tablet, capsules, liquids, suspension, elixirs)
◦ Transdermal
◦ Topical
◦ Instillation (drops and sprays)
◦ Inhalation
◦ Nasogatric and gastrotomoy tubes
◦ Suppossitories
◦ parenteral
Tablets & Capsules
• Tablets and capsules are the most
common drug forms
• Oral medications are not given to
clients who are vomiting, lack of a gag
reflex or who are comatose
• Do not mix medication with a large
amount of food or beverage or with
contraindicated food
Tablets & Capsules
• Enteric-coated capsules must be swallowed
whole to maintain a therapeutic drug level;
“Do not cut or crush!”
• Administer irritating drugs with food to
decrease GI discomfort
• Administer drugs on empty stomach if food
interferes with medication absorption
• Drugs given sublingually or Buccally remain in
place until fully absorbed
Liquids
• Forms of liquid medication
include elixirs, emulsions
and suspensions
• Elixirs are sweetened
hydroalcoholic liquids
• Emulsions are a mixture of
2 liquids that are not fully
soluble
• Suspensions are liquids in
which particles are mixed
but not dissolved
Liquids
• The meniscus is
the slightly concave
curved line of a
dose of liquid.
• The bottom of the
meniscus should be
used to measure
the desired dose of
medication
Transdermal
• Transdermal medication is
stored in a patch laced on the
skin and absorbed through
skin, thereby having systemic
effect
• Transdermal patches should be
rotated to different sites and
not reapplied over the next
exact same area when changed
• The area should be thoroughly
cleaned prior to
administration of a new
transdermal patch
Transdermal
• Wash hands and wear
gloves to administer
medicated patches to
prevent transfer of
medication
Topical
• Applied most frequently to the skin
• can be applied to the skin with glove,
tongue blade or cotton-tipped
applicator
• Use appropriate technique to remove
the medication from the container and
apply it to the clean, dry skin
Instillations
•liquid medications usually
administered as drops,
ointment or sprays in the
following forms:
• Eyedrops
• Eye ointment
• Eardrops
• Nose drops and sprays
Administration of Eye Drops
• Remove any discharge by
gently wiping out from inner
canthus.
• Use separate cloth for each
eye
• Gently draw the skin down
below the affected eye to
expose the conjunctival sac
Administration of Eye Drops
• Administer the prescribed number
of drops into the center of the sac
(not directly on the cornea)
• Gently press on the lacrimal duct
with sterile cotton ball or tissue
for 1-2 min. after instillation to
prevent systemic absorption
• Client should keep eyes closed for
1-2 min. to promote absorption
Administration of Eardrops
• Wash hands
• Medication should be at room
temperature
• Client should sit up with head tilted
slightly toward the unaffected sid
• To Straighten the ear canal:
• CHILD: pull down and back on auricle
• AFTER 3 YEARS OF AGE/ADULT: pull up
and back on auricle
• Instill prescribed number of drops
• Have client maintain position for 2-3 min
Administration of Nose Drops &
Sprays
• Wash hands and wear gloves
• Advise the patient to blow the nose
• Have the client tilt head back for drops
to reach frontal sinus and tilt head to
affected side to reach ethmoid sinus
• Administer the prescribed number of
drops or sprays
• Have the client keep head tilted
backward for 5 minutes after
instillation
Correct Use of Metered Dose
Inhaler
• Insert the medication canister into the
plastic holder
• Shake the inhaler well before using.
Remove cap from mouthpiece
• Breath out through the mouth. Open
mouth wide and hold the mouthpiece 1 to
2 inches from the mouth; do not put the
mouthpiece in mouth unless using a
spacer
• With open mouth, take slow, deep breath
through mouth and at the same time push
the top of the medication canister down
Correct Use of Metered Dose
Inhaler
•Hold breath for 10 seconds;
exhale slowly through pursed
lips
•If a second dose is required,
wait for 1-2 minutes
•Teach patient to rinse the
mouth after to prevent
irritation and secondary
infection to oral mucosa
especially when using a steroid
drug
Nasogastric and Gastrostomy
Tubes
 Check for proper tube placement before
administering medications. Replace any
aspirated gastric fluid.
 Pour drug into syringe without plunger or
bulb, release clamp, and allow medication
to flow in properly, usually by gravity.
 Flush tubing with 50 mL of water, or the
prescribed amount. (Refer to agency
policy for exact amount.)
 Clamp tube and remove syringe.
Nasogastric and Gastrostomy
Tubes
SUPPOSITORIES
1. Rectal Suppositories
• Can be given rectally for local and
systemic absoption
• Suppositories tend to soften at room
temperature and therefore need to
be refrigerated
• Use a glove for insertion
• Instruct the client to lie on left side
and breath through the mouth to
relax the anal sphincter
SUPPOSITORIES
1. Rectal Suppositories
• Apply a small amount of water-
soluble lubricant to the tip and gently
insert the suppository beyond the
internal sphincter
• Have the client remain lying on the
side for 20 min after instillation
2. Vaginal Suppositories
• Generally inserted into the vagina
with an applicator
• Wear gloves
• The client should be in the
lithotomy position
• Remain lying for a period of time
to allow for absorption
• After the insertion of the
medication, provide the client
with a sanitary pad
Parenteral
 Safety is a special concern with
parenteral medication
 Administered via injection to bypass
the first pass effect of the liver
 Types of parenteral routes include:
◦ Intradermal
◦ Subcutaneous
◦ Intramuscular
◦ intravenous
Intradermal
• Local effect
• Syringe: 1 ml calibrated in 0.01 ml
increments (usually 0.01 to 0.1 ml
injected)
• Sites: location to observe
inflammatory reaction such as ventral
mid-forearm
• Used for observation of an
inflammatory (allergic) reaction to
foreign proteins e.g. tuberculin testing,
testing for drug sensitivities
Intradermal
• Insert the needle bevel up, at a 10-
15 degree angle
• Inject medication slowly to form a
wheal (bleb)
• Do not massage the area
• Assess for allergic reaction in 24 to
72 hours (measure the diameter of
local reaction) after tuberculin
testing
Subcutaneous
• Systemic effect
• Usually slower in onset than with IM
route
• Syringe: 1-3 ml (Usually 0.5 to 1.5 ml
injected)
• Sites: abdomen, upper hips, upper back,
lateral upper arms and lateral thighs
• Sites should be rotated with
subcutaneous injections i.e. Insulin &
Heparin
Subcutaneous
• Insert the needle at an angle
appropriate to body size: 45 to 90
degrees
• Aspirate except heparin & Insulin
• Gently massage the area unless
contraindicated, as with heparin &
Insulin
• Inject medication slowly
• Apply gentle pressure to the injection
site to prevent bleeding into the tissue
Intramuscular
• Systemic effect
• Syringe: 1-3 ml (usually 0.5 to 1.5
ml injected)
• Usually more rapid effect of drug
than with SQ
• Sites: Ventrogluteal, Dorsogluteal,
Deltoid and Vastus Lateralis
(pediatrics)
Intramuscular
• Volume of drug administration:
• Ventrolgluteal 1-3 ml
• Dorsogluteal 1-3 ml
• Deltoid muscle 0.5 to 1.0 ml
• Vastus lateralis <0.5 ml in
infants (max = 1 ml), adult 2.0
ml
• Flatten the skin area using the
thumb and index finger and inject
between them
• Insert the needle at 90 degree angle
 Deltoid Site for IM injection
Vastus Lateralis site
Z-Track Injection technique
• Prevents the medication from leaking back
into the subcutaneous tissue
• Used for medications that cause visible
permanent skin discolorations (e.g. iron
dextran)
• Gluteal site is preferred
• STEPS:
1. pull the skin to one side and hold
2. insert needle
3. Hold skin to side
4. inject medication
Z-track technique
Intravenous
• Systemic effect
• More rapid than the IM or
subcutaneous routes
• Site: cephalic vein of the arm, dorsal
vein of hand for direct IV
• Equipment – needle
• Adults: 20-21 gauge
• Infants: 24 gauge
• Children: 22 gauge
Direct IV
• Procedure:
1. Wash hands and wear gloves
2. Apply tourniquet
3. Cleanse area using aseptic technique
4. Insert the needle into the vein until
blood returns
5. Remove the tourniquet
6. Stabilize the needle
7. Inject medication slowly
8. Dress site
IV injection through
Y-port IV system
Direct IV Injection