Principles of Drug

Administration
Principles of Drug
Administration
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,
 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.
 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
 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.
 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
 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 ORDER:
 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.
 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?
 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.
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
• 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.
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.
 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.
 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.
 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.
“
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.
“
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
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.
 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.
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).
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 swallow.
Medications should be administered one at a
time in the substance.
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
 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.
 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.
MAR #1 – Once Only/ Pre-Operative/
Stat Drugs
MAR #2 – Regular
Drugs
MAR #3 – As needed
Drugs (PRN)
 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
 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.
 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.
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.
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).
“
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
Acceptable
Abbreviations
“
▸ 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
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
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.
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.
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 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;
Drug Administration
 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
 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
 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.
Forms and Routes of Drug Administration
 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 liquida mixture of two liquids
that are not mutually soluble. Suspensions medications.
Emulsions are are liquids in which particles are mixed but
not dissolved.
 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.
 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.
 Forms and Routes of Drug Administration

Instillations
Instillations are liquid medications usually administered as drops,
ointments, or sprays in the following forms:

EYEDROPS EYE OITMENTS EARDROPS NOSE DROPS AND SPRAYS

 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.
Forms and Routes of Drug Administration
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.
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.
Nasogastric and Gastrostomy Tubes
Nasogastric and Gastrostomy Tubes
Parenteral Medications

▸ Methods of parenteral administration include

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

INSULIN SYRINGE
TUBERCULIN SYRINGE
Parenteral Medications

INSULIN SYRINGE
TUBERCULIN SYRINGE
Types of syringe
Prefilled Syringe
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
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.
Intradermal (ID)
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.
 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
Subcutaneous (Subcut, SQ)
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.
 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
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.)
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.
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.
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.
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).
The Z-track injection technique
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.
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
Intravenous (IV)
Technique
Intravenous (IV)
Intravenous Cannula
Infusion Set
Infusion Set
Infusion Set
Infusion Set
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.
Rectal Suppositories
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.
Vaginal Medications
 THANK YOU!
“Develop a passion for learning. If you
do, you will never cease to grow.”
-Anthony D’Angelo, educator