Principles of Drug

Administration
 Principles of Drug
Administration

2
 Principles of Drug Administration
“Five-Plus-Five” Rights of
Medication Administration
The nurse following these guidelines will verify the
following: (1) the right patient, (2) the right drug,
(3) the right dose, (4) the right route, (5) the
right time.
The “Plus Five” refers to the five additional rights that
have been recommended: (1) right assessment, (2)
right documentation, (3) the Patient’s right to
education, (4) Right to evaluation and (5) the
patient’s right to refuse.
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 Right Patient
• Ask the patient to state his or her full
name and birth date, and compare these
with the patient’s identification (ID) band
and the medication administration record
(MAR).
• Many facilities have electronic health
records (EHRs) that allow the nurse to
directly scan the bar code from the
patient’s ID band.

4
 Right Patient
Additional nursing implications include the
following:
▸ Most hospitals have color-coded ID bands
that include bands coded for allergy, do not
resuscitate (DNR), fall risk, and restricted
extremity.
▸ Verify the patient’s identification each time
a medication is given.
▸ If the patient is an adult with a cognitive
disorder or a child, verify the patient’s
name with a family member.
▸ Distinguish between two patients with the
same first or last name by placing “name-
alert” stickers as warnings on the medical
5 records.
 Right Drug
The nurse must accurately determine
the right drug before administration.
When working with an EHR, after
scanning the wristband, the patient’s
drug profile appears on the computer
screen. The nurse’s next step is to
scan the medication label, and it will
automatically validate the time, date,
and nurse administering the patient’s
medication.

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 Right Drug
The components of a drug order
are as follows

- Patient name and birth date

- Date the order is written
- Provider signature or name if
an electronic order, T/O, or
V/O
- Signature of licensed staff
who took the T/O or V/O, if
applicable

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 Right Drug
Drug name and strength
• Drug frequency or dose (e.g., once
daily)
• Route of administration
• Duration of administration (e.g., × 7
days, × 3 doses, when applicable)
• Number of patient refills
• Number of pills to be dispensed
• Any special instructions for
withholding or adjusting dosage
based on nursing assessment, drug
effectiveness, or laboratory results
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 DRUG ORDER:

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 Right Drug
- It is the nurse’s responsibility to
administer the drug, as ordered, by the
provider, and if the drug order is
incomplete, the drug should not be
administered. Verification of a
questionable order must be done in a
timely manner.

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 Right Drug
- Medication administration is never
considered just a process of “passing”
drugs.
- Nurses must use critical thinking
skills and assess whether the
medication is correct for the patient’s
diagnosis.
- The nurse must ask critical questions:
Is the dose appropriate? What is the
patient’s expected response?

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 Right Drug
- To avoid drug errors, the drug label
should be read three times:
- (1) when the nurse picks up the drug
and removes it from the automatic
dispensing cabinet (ADC) (2) as the
nurse prepares the drug for
administration, and (3) when the nurse
administers the drug.

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 “
Nursing interventions related to drug orders can
ensure correct administration of medications:
• The nurse should verify the identity of the patient
by comparing the name on the wristband with the
name on the MAR for accuracy.
• Always use two patient identifiers, such as
having patients repeat their name and date of
birth.
• The nurse must become familiar with the
patient’s health history and always perform a head-
to-toe assessment on the patient, including a
complete set of vital signs.
• Always review the patient’s laboratory work
before the administration of drugs.

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 “
• Read the drug order carefully. If the order is unclear,
verify it with the HCP before administering the drug. •
Know the patient’s allergies.
• Know the reason the patient is to receive the
medication.
• Check the drug label by identifying the drug name, the
amount of the drug (tablet or volume), and its suitability
for administration by the intended route. • Check dosage
calculations.

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 “
Know the date the medication was ordered and
ending date. Some agencies have automatic stop
orders that are generally facility specific.
Examples of such orders include controlled drugs that
need to be renewed every 48 hours, antibiotics usually
renewed every 7 to 14 days, and cancellation of all
medications when the patient goes to surgery.

• All orders—including first-dose, one-time, and as-

needed (PRN) medication orders—should be checked
against the original orders.

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 Right Dose

The right dose refers to

verification by the nurse that the
dose administered is the amount
ordered, and that it is safe for the
patient for whom it is prescribed.
The right dose is based on the
patient’s physical status.
Many medications require the
patient’s weight to determine the
right dose.
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 Right Dose
An important nursing
intervention related to the right
dose includes calculating the
drug dose correctly. If in doubt
about the amount to be
administered, consult with a
nurse peer to validate the
correct amount.

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 Right Time
▸ The right time refers to the time
the prescribed dose is ordered for
administration.
▸ Daily drug dosages are given at
specified intervals, such as twice a
day (bid), three times a day (tid),
four times a day (qid), or every 6
hours (q6h); this is so the plasma
level of the drug is maintained at a
therapeutic level.

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 “ Nursing interventions related to the right
time include the following:
• Administer drugs at the specified times
(refer to agency policy).
• Administer drugs that are affected by
food, such as tetracycline, 1 hour before or
2 hours after meals.
• Give food with drugs that can irritate the
stomach (gastric mucosa)— for example,
potassium and aspirin.

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 “
Adjust the medication schedule to fit the
patient’s lifestyle, activities, tolerances, or
preferences as much as possible.
• Check whether the patient is scheduled for any
diagnostic procedures that contraindicate the
administration of medications, such as
endoscopy or fasting blood tests. Determine
whether the medication should be given

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 “
Check the expiration date. If the date has passed,
discard the medication or return it to the pharmacy,
depending on the policy.
• Administer antibiotics at even intervals (e.g., every 8
hours rather than three times daily) throughout the
24-hour period to maintain therapeutic blood levels.
• Patients who require dialysis usually have blood
pressure medications stopped before dialysis
because dialysis can decrease blood pressure.
However, some doctors order the medications to be
given before dialysis. If any questions arise, check
with the HCP before proceeding. before or after the
test based on the policy.

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 Right Route
▸ The right route is necessary for
adequate or appropriate
absorption.
▸ The right route is ordered by the
HCP and indicates the
mechanism by which the
medication enters the body.

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 “
The more common routes of absorption include
the following: oral (drug in the form of a liquid,
elixir, or suspension); pill (tablet or capsule);
sublingual (under the tongue for venous
absorption); buccal (between the cheek and gum);
feeding tube (enteral); topical (applied to the
skin); inhalation (aerosol sprays); otic (ear);
ophthalmic (eye); nasal (spray instillation);
suppository (rectal or vaginal); and through the
parenteral routes: (1) intradermal, (2)
subcutaneous (subcut), (3) intramuscular (IM), or
(4) intravenous (IV).

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 Nursing interventions related to the right route

“
include the following:
• Assess the patient’s ability to swallow before
administering oral medications; ensure the patient
does not have an order requiring nothing by mouth
(NPO).
Do not crush or mix medications in other
substances without consulting a pharmacist or a
reliable drug reference. Do not mix medications in
an infant’s formula feeding.
If the medication must be mixed with another
substance, explain this to the patient. For example,
elderly patients may use applesauce or yogurt to
mix their medications to make them easier to
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swallow. Medications should be administered one
 When administering many drugs at one time, it

“
is not recommended to mix drugs together. The
correct practice is to administer one pill at a
time.
Instruct the patient that medications must be
swallowed with water. Juice can interfere with
the absorption of certain medications;
Use aseptic technique when administering
drugs. Sterile technique is required with the
parenteral routes
Administer drugs at the appropriate sites for
the route.
• Stay with the patient until oral drugs have
been swallowed
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 Right Assessment
▸ The right assessment requires the
collection of appropriate baseline
data before administration of a
drug.
▸ Examples of assessment data
include taking a complete set of
vital signs and checking lab levels
prior to drug administration.

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 Right Documentation
▸ Both paper and computerized
MAR systems include:
Information about the drug to be
administered, including (1) the
name of the drug, (2) the dose,
(3) the route, (4) the time and
date, and (5) the nurse’s initials
or signature.

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 Right Education
▸ The right to education requires that
patients receive accurate and
thorough information about the
drugs they are taking and how each
drug relates to their particular
condition.
▸ Patient teaching also includes why
the patient is taking the drug, the
expected result of the drug, possible
side effects of the drug, any dietary
restrictions or requirements, skill of
administration with return
demonstration, and laboratory test
28 result monitoring.
 Right Evaluation
▸ The right evaluation determines the
effectiveness of the drug based on
the patient’s response to the drug.
▸ It is essential that the nurse
evaluate the therapeutic effect of
the medication by assessing the
patient for side effects and adverse
drug reactions.
▸ Evaluation is ongoing and is an
important aspect of patient safety.

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 Right to Refuse
▸ The patient has the right to refuse the
medication, and it is the nurse’s
responsibility to determine the reason
for the refusal, explain to the patient
the risks involved with refusal, and
reinforce the important benefits of
and reasons for taking the medication.
▸ When a medication is refused, the
refusal must be documented
immediately, and follow-up is always
required.

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 Nurses' Rights when administering
Medication
▸ The Nurses’ Six Rights
✓ The right to a complete and clear order
✓ The right to have the correct drug, route, and dose dispensed.
✓ The right to have access to information
✓ The right to have policies to guide safe medication administration.
✓ The right to administer medication safely and to identify problems
in the systems.
✓ The right to stop, think and be vigilant when administering
medication.
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The Joint Commission
National Patient Safety
Goals
 “
▸ Additionally, TJC has taken steps to support
safety and quality care in the workplace. TJC
has developed National Patient Safety Goals,
which focus on problems in health care safety
and how to solve them. These goals are
updated and published annually.

▸ Two important goals that have already become

standards for all TJC accredited organizations
are the “do not use” abbreviations (Table 9.1)
and the list of acceptable abbreviations (Table
9.2).

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 “

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Acceptable Abbreviations
▸ These abbreviations are
frequently used in drug
therapy and must be known
by the nurse, but also check
your facility’s list of medical
abbreviations.
▸ It is now a Joint
Commission standard that
each facility have a list of
acceptable medication
abbreviations.
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 Acceptable Abbreviations

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 “ ▸ Sharps Safety

Needlestick Safety and Prevention Act

(NSPA). The act requires that employers
implement safer medical devices for their
employees, provide a safe and secure
workplace environment with educational
opportunities, and develop written policies
to help prevent sharp injuries--------------
----------------------------------------------

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 Safety Risks with Medication
Administration
Tablet Splitting. In effort to counteract steeply rising drug costs, some
patients are cutting their pills in half. However, this is not recommended by the
FDA. The only time tablet splitting is advisable is when it is specified by the
pharmacist on the label.

•Buying drugs over the Internet. Consumers may find it convenient to order
drugs over the Internet, but precautions must be taken because drugs sold
online may be too old, too strong, or too weak to be effective

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 Counterfeit Drugs

Counterfeit drugs look like the desired drug but may have no active
ingredient, the wrong active ingredient, or the wrong amount of active
ingredient.

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 Dosage Forms: To Crush or Not to Crush
Although some drugs can be crushed, there are many that shouldn’t be
crushed. Always consult with the pharmacist or, when possible, the
HCP before crushing a patient’s drug.
Do not crush any extended- or sustained-release drugs because this
will change the pharmacokinetic phase of the drug.

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41
 High-Alert Medications
High-alert drugs can cause significant harm to the patient. If a high-alert medication is given
in error, it can have a major effect on the patient’s organs; this includes cardiac, respiratory,
vascular, and neurologic systems.
Lists are provided to reduce the risk of errors, but specific strategies can optimize safety
when dealing with high-alert drugs:
1. Simplify the storage, preparation, and administration of high-alert drugs.
2. Write policies concerning safe administration.
3. Improve information and education.
4. Limit access to high-alert medications.
5. Use labels and automated alerts.
6. Use redundancies (automated or independent double-checks).
7. Closely monitor the patient’s response to the medication (possibly the most important
42 step).
 Look-Alike and Sound-Alike Drug
Names
Nurses should be aware that certain drug names sound alike and are
spelled similarly. Examples of drugs involved in medication errors and
recognized as confusing drug names include glipiZIDE with glyBURIDE;
caPTOPRIL with caRVEDILOL;

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 Drug Administration

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45
 Forms and Routes of Drug Administration

- Tablets and Capsules

Tablets and capsules are the most common drug forms; they are convenient and
less expensive and do not require additional supplies for administration

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 Forms and Routes of Drug Administration

Tablets and capsules

- Enteric-coated and timed-release capsules must be swallowed whole

to maintain a therapeutic drug level, so the drug is released gradually.
- If crushed, the initial excessive drug release poses a risk of toxicity
such that it could lead to a potentially fatal overdose.
- Crushing can increase the rate of absorption, and it can cause
oropharyngeal irritation. These medications should never be cut in half
or crushed for administration.
- Advise the patient or family member to notify the health care provider
(HCP) or pharmacist if the patient is having difficulty swallowing the
47 medication.
 Forms and Routes of Drug Administration

- Drugs given via sublingual (under the tongue) or buccal (between the
cheek and gum) routes remain in place until fully absorbed, therefore
no food or fluid should be taken while the medication is in place.

- • If patients have difficulty opening child-resistant caps, have them

request non– child-resistant caps from the pharmacist.

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 Forms and Routes of Drug Administration

- Liquids
Forms of liquid medication include elixirs, emulsions, and suspensions.
Elixirs are sweetened, hydro-alcoholic liquids used in the preparation of
oral liquid medications. Emulsions are a mixture of two liquids that are
not mutually soluble. Suspensions are liquids in which particles are
mixed but not dissolved.

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 Forms and Routes of Drug Administration

Transdermal
Transdermal medication is stored in a patch placed on the skin and is absorbed through
the skin to produce a systemic effect. To prevent skin breakdown, transdermal patches
should be rotated to different sites and should not be reapplied over the exact same area
every time.

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 Forms and Routes of Drug Administration

Topical medications
▹ are most frequently applied to the skin by painting or spreading the
medication over an area and applying a moist dressing or leaving the area
exposed to air.
▹ Such medications can be applied to the skin in several ways, such as with a
glove, tongue blade, or cotton-tipped applicator.
▹ Nurses should never apply a topical medication without first protecting their
own skin with gloves.

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 Forms and Routes of Drug Administration

Instillations
Instillations are liquid medications usually administered as drops, ointments, or
sprays in the following forms:
• Eyedrops
• Eye ointments
• Eardrops
• Nose drops and sprays

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53
54
55
56
 Forms and Routes of Drug Administration

Inhalations
Metered-dose inhalers (MDIs) are handheld devices used to deliver a
number of commonly prescribed asthma and bronchitis drugs to the
lower respiratory tract via inhalation.

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 Nasogastric and Gastrostomy Tubes

- Before administering drugs, always check for proper tube placement of any
feeding tube that enters the mouth, nose, or abdomen, and always assess
the gastric residual. Return any aspirated gastric fluid to the stomach.
- Place patient in a high Fowler position or elevate the head of bed at least 30
degrees to avoid aspiration.

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 Nasogastric and Gastrostomy Tubes

▹ Remove the plunger from the syringe and attach it to the feeding tube, pour
liquefied medication into syringe, release the clamp , and allow the
medication to flow in properly by gravity.
▹ Ensure proper identification of each drug up until the time of
administration. Do this by administering one drug at a time. Flush with 10 to
15 mL of water between each administration to maintain patency of the
tubing.
▹ When finished with drug administration, flush tubing with 30 mL of water
or whichever amount is recommended by the agency’s policy. Always
record the amount of water used with the administration of drugs on the
patient’s input sheet.
▹ Clamp the tube and remove the syringe.
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 Parenteral Medications

▸ Methods of parenteral administration include

Intradermal, Subcutaneous, Intramuscular, Ζ-track
technique, and Intravenous administration.

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 Parenteral Medications
▸ Safety is a special concern with parenteral drugs, which are
administered via injection.
▸ Manufacturers have responded with safety features to help
decrease or eliminate needlestick injuries and possible transfer of
blood-borne diseases such as hepatitis and human
immunodeficiency virus.

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 Intradermal (ID)
Action
• Local effect
• Administered for skin testing (e.g., tuberculin screening, allergy
testing, and testing for other drug sensitivities; some immunotherapy
for cancer).
Sites
• Locations are chosen so an inflammatory reaction can be observed.
Preferred areas are lightly pigmented, free of lesions, and hairless
such as the ventral midforearm, clavicular area of the chest, or
scapular area of the back
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 Intradermal (ID)
Action
• Local effect
• Administered for skin testing (e.g., tuberculin screening, allergy
testing, and testing for other drug sensitivities; some immunotherapy
for cancer).
Sites
• Locations are chosen so an inflammatory reaction can be observed.
Preferred areas are lightly pigmented, free of lesions, and hairless
such as the ventral midforearm, clavicular area of the chest, or
scapular area of the back
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 Intradermal (ID)
Equipment
▸ Needle: 25 to 27 gauge, ¼ to ½ inch long, tuberculin syringe
Syringe: 1 mL calibrated in increments of (0.01) hundredth mL
represented on syringe as 0.1 mL to 1 mL.
▸ Syringe holds up to 1 mL of solution; however, tuberculin skin tests
require injection of a small amount of solution (usually 0.01 to 0.1
mL) to ensure formation of bleb.

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 Intradermal (ID)

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66
 Subcutaneous (subcut)
Action
▸ • Systemic effect
▸ • Sustained effect; absorbed mainly through capillaries; usually slower
in onset than with the intramuscular (IM) route.
Sites
▸ • Locations for subcutaneous injections are chosen for adequate fat-
pad size. Areas such as the upper outer aspect of the arms, the
abdomen, at least 2 inches from the umbilicus, and the anterior thighs
are important subcutaneous sites.

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 Subcutaneous (Subcut, SQ)
Equipment
▸ Needle: 25 to 27 gauge; ⅜ to ⅝ inch long
▸ The length of the needle and the angle of the needle insertion are based on the
amount of subcutaneous tissue present. The shorter, ⅜-inch needle should be
inserted at a 90-degree angle, and the longer, ⅝-inch needle is inserted at a 45-
degree angle (see Fig. 10.13).
▸ Syringe: 1 to 3 mL (injection of solution is usually 0.5 to 1 mL)
▸ Insulin syringe measured in units for use with insulin only

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 Subcutaneous (Subcut, SQ)

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70
 Intramuscular (IM)
Action
• Systemic effect
• Usually a more rapid effect of drug than with a subcut route
• Used for solutions that are more viscous and irritating for adults, children,
and infants
• IM injections are associated with many risks, so the nurse should use
accurate, careful technique when administering an IM injection and should
check the agency’s policy.

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 Intramuscular (IM)
Sites
•Locations are chosen for adequate muscle size and minimal major nerves and
blood vessels in the area. Other considerations include the volume of drug
administered, needle size, angle of injection, patient position, site location, and
advantages and disadvantages of the site. Underweight patients should be
evaluated for sites with adequate muscle.

Equipment
• Needle: 18 to 25 gauge; ⅝ to 1½ inches long. Patient’s weight, age, and the
amount of adipose tissue influence needle length
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 Intramuscular (IM)
Technique
▸ Perform hand hygiene and apply gloves.
▸ Same as for subcut injection with two exceptions: Flatten the skin area
using the thumb and index finger and inject between them, and insert the
needle at a 90-degree angle into the muscle.
▸ Syringe: 1 to 3 mL (usually no more than 1 to 1.5 mL of solution is
injected), although this varies based on the intended site, the age of the
patient, and the developed muscle site. (Check the agency’s policy.)

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 Preferred Intramuscular Injection Sites

VENTROGLUTEAL

• Located near the gluteus medius, a deep muscle,

and away from major nerves, this site is well suited
for Z-track injections.
• Volume of drug is 1 to 1.5 mL, administered with an
18- to 25-gauge, 1½-inch needle. The gauge and
length of the needle depends on the medication to
be administered and the size of the patient. Slightly
angle the needle toward the iliac crest.
• The ventrogluteal is the preferred site for most
injections given to adults and all children, including
infants of any age.

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 Preferred Intramuscular Injection Sites

DORSOGLUTEAL
• Do not use this site for IM injections.
Studies have demonstrated that the
exact location of the sciatic nerve varies
from person to person, and if a needle
hits the sciatic nerve, the client can
experience an adverse outcome,
including permanent or partial paralysis
of the involved leg.

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 Preferred Intramuscular Injection Sites

DELTOID
• This muscle is easy to find, but it is not well
developed in many adults.
• The volume of drug administered is 0.5 to 1 mL,
with a 23- to 25-gauge, ⅝- to 1½-inch needle. Place
the needle at a 90-degree angle to the skin or
slightly toward the acromion.
• There is risk for injury because of the nerves and
arteries that lie within the upper arm along the
humerus.
• Use this site for small medication volumes or when
other sites are inaccessible.
• This site is not used in infants or children due to
underdeveloped muscles.

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 Preferred Intramuscular Injection Sites

VASTUS LATERALIS
• The vastus lateralis is a good site for multiple
injections. It is frequently used in infants (less
than 12 months) receiving immunizations and
is often used in older children and toddlers
receiving immunizations.
• If a long needle is used, insert it with caution
to avoid sciatic nerve or femoral structures.
The volume of drug administered is 0.5 mL in
infants (maximum [max] 1 mL), 1 mL in
pediatric patients, and 1 to 1.5 mL in adults
(max 2 mL).

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 The Z-track injection technique

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 Intravenous (IV)
Action
• Systemic effect
• More rapid than IM or subcutaneous routes

Sites
Accessible peripheral veins are preferred (e.g., cephalic or cubital vein of arm,
dorsal vein of hand.
When possible, ask the patient about his or her preference, and avoid needless
body restriction. In newborns, the veins of the feet, lower legs, and head may also
be used after other sites have been exhausted.
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 Intravenous (IV)
Equipment
• Needle
• Adults: 20 to 21 gauge, 1 to 1½ inches
• Infants: 24 gauge, 1 inch
• Children: 22 gauge, 1 inch
• Larger bore for viscous drugs and whole blood and a large volume for rapid
infusion
• Electronic IV delivery device, an infusion controller, or pump
• May use a mixture of lidocaine/prilocaine anesthetic if appropriate

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 Intravenous (IV)
Technique

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 Intravenous (IV)

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 Rectal Suppositories

▸ Medications administered as suppositories or enemas

can be given rectally for local and systemic absorption.
The numerous small capillaries in the rectal area
promote medication absorption.

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 Rectal Suppositories

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 Vaginal Medications

▸ Vaginal drugs are available as suppositories, foams,

jellies, or creams.
▸ Advise patients to remain lying for a time sufficient to
allow medication absorption; times vary depending on
the medication. After insertion, provide the patient with
a sanitary pad. If the patient is able, she may want to
insert vaginal drugs herself.

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 Vaginal Medications

86
 Developmental Needs of a
Pediatric Patient
▸ Anticipate patients’ developmental needs. Examples of needs
associated with administration of medications

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 Developmental Needs of a
Pediatric Patient
▸ Stranger anxiety (infant): Act to instill a sense of safety and
security in the infant.

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 Developmental Needs of a
Pediatric Patient
▸ Hospitalization, illness, or injury is viewed as punishment (3–
6 years of age): Allow control when
▸ appropriate; obtain the child’s view of the situation;
encourage activities, positive relationships, and
▸ expression of feelings in an acceptable manner. Include family
or support person, if appropriate.

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 Developmental Needs of a
Pediatric Patient
▸ Fear of the procedure (3–6 years of age): Explain procedures
carefully; use less intrusive routes, such
▸ as the oral route, whenever possible; allow children to give
“play” injections to a doll or stuffed
▸ animal.

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91
 THANK YOU!
“Develop a passion for learning. If you do, you will
never cease to grow.”
-Anthony D’Angelo, educator

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