In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of medication administration in order to: Show
Educating the Client About MedicationsClients and significant others should be taught about all aspects of the medications that they are taking. The content of this teaching and education should minimally include:
The client should be educated about the safe and correct method of self administration of medications. In addition to the education discussed immediately above, some clients may also have to be instructed about special procedures like the proper use of an inhaler, taking insulin, mixing insulins, giving oneself an intramuscular injection or self-administering tube feedings. All of these procedures are fully discussed below in the sections entitled "Preparing and Administering Medications and Using the Rights of Medication Administration" and "Mixing Medications From Two Vials When Necessary". Preparing and Administering Medications and Using the Rights of Medication AdministrationThe "Ten Rights of Medication Administration" are the right, or correct:
In addition to the Ten Rights of Medication Administration and identifying the patient using at least two unique identifiers, nurses must also insure medication safety in respect to the storage of medications, the checking for expiration dates, checking for any patient allergies, and checking for any incompatibilities. Nurses must use at least two (2) unique identifiers, other than room number, prior to all procedures including the administration of medications. Some examples of unique identifiers include the client's first, middle and last name, a unique password or code number assigned to that person upon admission, the client's complete birthday in terms of the month, the day and the year, a photograph, and an encoded bar code containing two (2) or more unique identifiers. Narcotics must be in a locked and secured in a safe place; other medications must be stored in a place that is secure and one that prevents accidental poisonings among the pediatric population and also among those who are confused and/or cognitively impaired. Additionally, medications that need refrigeration must be refrigerated. Clients at Risk for Medication Errors and Other Medical ErrorsThe risk factors associated with medication errors and other medical errors such as wrong patient or wrong site surgery are discussed below: Developmental disorders: The same concerns and interventions described above for infants and children apply to those with developmental disorders, as specific to the degree of their developmental delay. Psychiatric disorders: Patients/residents/clients with a psychiatric disorder are at risk for medications as based on their psychiatric mental health disorder and the medications that they may be taking. Some psychotropic medications have sedating effects and the client may be delusional and out of touch with reality. Infants and children: These young children are at risk for medication errors because they are not able to ask questions about medications and procedures; they may not even be able to state their name. The support and presence of the family is one way to prevent medication errors among this high risk population. Language barriers: People with language barriers may not understand what you are saying or asking and, you may not know what they are saying or asking you in another language, therefore, the use of interpreters, family or friends, pictures and drawings should be used to overcome a language barrier. Cognitive impairments: Clients who are confused, disoriented, demented or with delirium are at risk for all types of errors because of the challenges associated with accurate patient identification and the hazards of impaired cognition. Again, patient identification is highly important, and it is also beneficial to communicate with the client in a way that is understandable to them using pictures and drawings and to encourage the participation of the significant other(s) in all aspects of care. Decreased levels of consciousness: Patients who are not alert, awake and oriented to time, place and person are also at high risk. At times, a family member or friend who is visiting this patient/resident/client can assist with the two unique identifier processes and also serve as a person to question you about questionable medications and to ask questions of you. Sensory disorders: Assistive devices, such as eyeglasses and hearing aids, must be consistently provided to the sensory impaired person in order to protect their safety. Additionally, the use of large print or Braille reading materials and magnifying glasses may be helpful for the visually impaired; and speaking loudly while facing the patient with an auditory impairment may offer some protection against medication errors. Routes and Forms of MedicationsMedications are manufactured for various routes of administration and in different forms. These forms are:
The routes of administration include the following routes:
The oral route of administration is the preferred route of administration for all clients but the oral route is contraindicated for clients adversely affected with a swallowing disorder or a decreased level of consciousness. Oral medications can, at times, be crushed and put into something like apple sauce, for example, for some clients who have difficulty swallowing pills and tablets, but, time release capsules, enteric coated tablets, effervescent tablets, medications irritating to the stomach, foul tasting medications and sublingual medications should not be crushed. An alternative route for some clients is a liquid form of the medication. Age Specific Route, Form and Dosage Considerations
Nurses must, therefore, begin a new medication with the lowest possible dosage and then increase the dosage slowly over time until the therapeutic effect is achieved. The initial dosage may be as low as ½ of the recommended adult dosage. Reviewing Pertinent Data Prior to Medication AdministrationPrior to the administration of medications, the nurse must check and validate the medication order, and also apply their critical thinking skills to the ordered medication and the status and condition of the client in respect to the contraindications, pertinent lab results, pertinent data like vital signs, client allergies, and potential interactions of the medication that is to be given. A complete medication order must include the client's full name, the date and the time of the order, the name of the medication, the ordered dosage, and the form of the medication, the route of administration, the time or frequency of administration, and the signature of the ordering physician or licensed independent practitioner's signature. The four general types of medication orders are stat orders, single orders, standing orders and prn orders. Stat medication orders are administered immediately and only once; single orders are also given only once but not necessarily immediately; a standing order is an order for a medication that will be given at specific times until it is discontinued by a doctor's order or by default when a facility's policy states that all standing orders are automatically discontinued after 7 days unless the physician has reordered the medication. A prn order indicates that the ordered medication is only given when a specified condition, like pain or nausea, is present. All incomplete, questionable and/or illegible orders must be questioned and validated by the nurse transcribing the order before it is administered to the client. This questioning and validation requires that the registered nurse use, integrate and apply their critical thinking and professional judgment skills. Automated order entry using a computer eliminates some medication order errors including those that result from illegibility of handwriting and ordering a medication with which the client is allergic to, however, nurses should never assume that this is the case. For example, medications that have sound alike names and medications that are similar in terms of their correct spelling can remain at risk even when computerized, automatic order entry is used. Medication orders are often transcribed by hand onto a medication administration record (MAR) or Medex, when the facility is not using computerized order entry. The client's allergies are determined, all contraindications for the medication as based on the client's health problems and disease conditions are determined, pertinent diagnostic laboratory results such as checking the client's prothrombin time and partial thromboplastin time prior to the administration of heparin, client data like a blood pressure and a pulse rate prior to the administration of an antihypertensive medication and digoxin, for example, are assessed and any possible interactions with other medications, foods and alternative and over the counter preparations are assessed in order to determine whether or not the medication should be administered. The doctor must be notified whenever the nurse has any concerns or problems with these things. Mixing Medications From Two Vials When NecessaryMedications can only be mixed together when they are compatible with each other. Many diabetic clients who take two forms of insulin can mix these medications from two vials so that they will only have to use one, rather than two, subcutaneous injection sites. For example, a client who takes NPH insulin in the morning and also takes regular insulin prior to breakfast for the coverage of hyperglycemia can mix the NPH insulin and the regular insulin in the same syringe. The procedure for this mixing insulins is as below.
For example, if the client has an order for 10 units of NPH insulin in the morning and they also need 3 units of regular insulin according to their sliding scale for coverage, the client will draw up both insulins according to the above procedure and then inject 13 units total for the NPH and the regular insulins. Administering and Documenting Medications Given by a Common RouteThe procedures for the administration of medications using different routes are briefly described below. Note that the verification of the order, its appropriateness for the client, client identification using at least two unique identifiers, and explaining the medication and the procedure for it administration is done BEFORE any medication is given to a client. Oral Route AdministrationGive the patient the medication. Remain with the patient until the medication is swallowed; some clients may pocket and store medications in their cheeks rather than swallow them. Buccal and Sublingual Route of AdministrationBuccal medications are placed between the teeth and the inner aspect of the client's cheek. Sublingual medications are administered under the back of the tongue:
Topical Route AdministrationSome topical medications are only suitable on intact skin and others that contain a medication are used for the treatment of broken skin or a wound.
Transdermal Route AdministrationTransdermal medications are absorbed from the surface of the skin. The site should be without hair so it may be necessary to shave the area and these medications are applied on the client's upper arm or chest. Some transdermal medications are commercially prepared with the ordered dosage and others require the nurse to measure and apply the ordered dosage on a transdermal patch. This procedure is described below.
Ophthalmic Route Medication AdministrationOphthalmic eye medications are applied using sterile technique which is one of the few routes that require more than medical asepsis or clean technique.
Otic Route Administration
Inhalation Route AdministrationThe two different types of inhalers that administer medications via the inhalation route are a metered-dose inhalers and a turbo inhaler. The procedure for using a metered dose inhaler is:
The procedure for using a turbo inhaler is:
Nasogastric Tube Route Bolus Administration Using Gravity
Vaginal Route Administration
Rectal Route Suppository Administration
Rectal Ointment Administration
Subcutaneous Route InjectionsSubcutaneous injections can be given in the abdomen, upper arms and the front of the thighs. Subcutaneous injections are used for the administration of insulin, heparin and other medications. The sites for these injections should be rotated.
Intramuscular Route AdministrationThe sites for intramuscular medications are the gluteus maximus, the deltoid muscle, the vastus lateralis, the rectus femoris muscle, and the ventrogluteal muscle. The gluteus maximus muscle and the deltoid muscle are NOT used for infants or young children who are less than 3 years of age.
Z Track Intramuscular InjectionsZ tract injections are a special type of an intramuscular injection that is used for iron administration, for example, to avoid any staining of the skin as the result of the medication. This route is also advantageous to insure that the injected medication is completely injected into the muscle and not into the subcutaneous tissue.
Intravenous Route Bolus Administration (IV Push)The procedure for IV push without an existing IV line is as follows:
The procedure for an IV push bolus with an existing IV line is as follows:
Intravenous Piggy Back or Secondary Line AdministrationThis procedure is as follows:
More information about intravenous fluid and medication administration and how to start an intravenous line was discussed in the section entitled "Educating the Client on the Reason For and Care of a Venous Access Device" of this NCLEX-RN review guide. Documenting Medications Given Using All RoutesNurses are legally and ethically responsible and accountable for accurate and complete medication administration, observation, and documentation. Some health care facilities use double locked cabinets to secure controlled substances and others use more sophisticated bar coded entry systems to access controlled substances. When the older model double locked narcotics cabinet is used, the contents are counted and checked by the nurse at the beginning of the shift; this count is then compared to the documented count that was done by the nurse from the prior shift. If there are any discrepancies, these are immediately addressed, explored and corrected if it was a simple oversight or mathematical error. When the narcotics count cannot be corrected, a report must be filed according to the facility's policies and procedures. At times illegal drug diversion may be the reason for inconsistent narcotics counts. When a bar coded entry system for narcotics and controlled substances are used, each nurse can access these medications because the nurse's identification is automatically processed and the controlled substances are also automatically processed and recorded. When this automated system is not used, the "narcotic keys" are retained by one nurse and, if another nurse has to administer a controlled substances, this nurse will enter the narcotics cabinet with the nurse who is holding the keys. All controlled substances are documented on the narcotics record as soon as they are removed, and all controlled substances, like all other medications, are documented on the client's medication record as soon as they are administered. If a controlled substance is wasted for any reason, either in its entirety or only partially, this waste must be witnessed or documented by the wasting nurse and another nurse. Both nurses document this wasting. All medications that are given, omitted, held or refused by the patient must be documented in the patient's medication record in addition to other data like vital signs, apical rate, PT and/or PTT as indicated by the actions of the medication and/or the doctor's order. Additional professional responsibilities, in terms of medication administration, include the observation and assessment of the patient prior to the administration of a medication and the observation and evaluation of the patient's responses to the medication including the therapeutic effects, any side effects and adverse drug reactions to the medication. Participating in the Medication Reconciliation ProcessAccording to the Institute of Medicine's Preventing Medication Errors report, more 40% of medication errors are the result of a lack of communication related to the client's medications; these errors can be prevented by performing the medication reconciliation process for all clients, particularly those clients who are newly admitted, transferred or discharged to another facility or health care setting. All medications including all prescription medications, vitamins, over the counter medications, herbal remedies, nutritional and dietary supplements, vaccinations, blood derivatives, diagnostic and contrast agents, and radioactive medications are included in the compilation of the list which contains all current medications and treatments. The procedure for this medication reconciliation process are:
Titrating the Dosage of a Medication Based on the Assessment and Ordered ParametersTitration is defined as adjusting the dosage of a medication according to some ordered and specified parameters or criteria. The most commonly occurring example of a titrated medication is insulin coverage with regular insulin that is based on the client's blood glucose levels. For example, the client's order for regular insulin before a meal may specify that the client take 2 units of regular insulin for blood glucose levels from 200 to 260. Some intravenous medications are also titrated. For example, an intravenous antihypertensive drug like Hyperstat will be titrated and adjusted according to the client's blood pressure. Disposing of Unused Medications According to the Facility/Agency PolicyAgencies vary in terms of how they dispose of unused medications after the client has been discharged and/or no longer in need of a specific medication. Refer to your facility's policies and procedures relating to the disposal of unused medications. Clients in the home environment must also be instructed about the proper and safe disposal of unused and expired medications in order to prevent use by others and to protect the environment. The U.S. Drug Enforcement Administration (DEA) periodically hosts National Prescription Drug Take-Back days for the disposal of prescription drugs, some local law enforcement departments may have a local take back program, and some local health care agencies and pharmacies may also take back unwanted medication. When these resources are not available in the community, the home care client should be instructed to contract their local solid waste department to find out how these medications should be discarded. If a controlled substance is wasted, this waste must be witnessed by and documented by the wasting nurse and another nurse. Controlled substances and narcotics are immediately documented on the narcotic record when they are taken from their secure and double locked cabinet. This documentation is NOT done after the medication is administered. Narcotics and controlled substances are then documented in the patient's medication record as soon as they are administered. During the change of shift, two nurses perform a complete count of all narcotics and controlled substances. If a discrepancy occurs, it is immediately reported for further investigation. Evaluating the Appropriateness and Accuracy of Medication Orders for the ClientAll medication orders are evaluated by the nurse in terms of their accuracy and appropriateness of the order. Some of the things that are considered and evaluated include:
The doctor must be notified whenever the nurse has any concerns or problems with these things. RELATED CONTENT: SEE - Pharmacological & Parenteral Therapies Practice Test Questions Latest posts by Alene Burke, RN, MSN (see all) |