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7/25/2019 Safe Administrations of Medications (Draft Chapter)
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Author: Tracy Levett-Jones
Clinical Reviewers: Natalie Govind and David Newby
Section 6.1 Introduction
Section 6.2 Oral medication administration
Section 6.3 Topical medication administration
Section 6.4 Parenteral medication administration
MEDICATIONADMINISTRATION
UNIT 6
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A medication (or drug) is a substance administered for
the diagnosis, cure, treatment, or relief of a symptom or
for prevention of disease. Preparation and administration
of medications are complex processes involving counting,
calculating, measuring, mixing and ensuring that the right
person receives the right medication in the right dose, at the
right time, by the right route, and for the right reason.In Australia, medications are dispensed on the order of
a doctor, dentist, eligible midwife or nurse practitioner. In
the health care context, the words medication and drugare
often used interchangeably. The written direction for the
preparation and administration of a medication is called a
prescription. Medications have chemical, generic and trade
names. The chemical namedescribes the constituents of the
drug. The generic nameis given by the manufacturer that
first develops the drug and is the name used on prescriptions
and on medication charts. Thetrade nameor brand name
is the name given to it by drug manufacturers. Because one
medication may be manufactured by several companies,
it may have several trade names. For example, N-acetyl-p-
aminophenol is the chemical name for paracetamol (generic
name) which has a number of trade names including
Panadol, Tylenol and Panamax.
LEGAL ASPECTS OF
MEDICATION ADMINISTRATION
The administration of drugs in the Australia is controlled
by law. Nurses need to (a) have a sound understanding of
the laws that govern their scope of practice in relation to
medication administration, and (b) recognise the limits of
their own knowledge and skill.
Under the law nurses are responsible for their own actions
regardless of whether there is a written medication order.
LEARNING OUTCOMES
On completion of this section you will be able to:
1. Define the key terms related to medication administration.
2. Describe the legal and professional aspects ofmedication administration.
3. Discuss the impact of person-centred care andinterprofessional communication on medication safety.
4. Identify the essential parts of a valid medication order.
5. Outline the types of medication preparations and routesof administration.
6. Outline the key components of a medication history.
7. List the five rights and three checks for safemedication administration.
INTRODUCTION
SECTION 6.1
KEY TERMS
adverse effect, 241
chemical name, 240
drug, 240
generic name, 240
medication, 240
medication error, 241
medication history, 246
near miss, 241
prescription, 240
side effect, 241
therapeutic effect, 241
trade name, 240
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UNIT 6 SECTION 6.1 INTRODUCTION
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This means that if a medical officer writes an incorrect order
(e.g., morphine 100 mg instead of morphine 10 mg), the
nurse who administers the incorrect dosage is responsible
for the error as well as the medical officer. Therefore, nursesneed a sound foundation of pharmacological knowledge, the
skills to access reliable drug resources, and the confidence
to question any order that appears illegible, ambiguous,
unreasonable, or contraindicated by the persons condition.
The right to refuse to administer a medication is sometimes
referred to as one of the Rights of medication administration.
Another legal aspect of medication administration is the use
of controlled substances (listed under Schedule 8 of the Poisons
Standard 2012). In hospitals, controlled substances are kept
in a locked drawer, cupboard, medication cart or computer-controlled dispensing system, and an inventory of their use
is strictly maintained. Hospitals have clear protocols about
the storage, access and use of Schedule 8 medications. These
controlled substances require verification and documentation
of administration by two registered nurses.
MEDICATION SAFETY
Medication errors are the second most common type of
incident reported in Australian hospitals with error rates of over
18% (Johnson, Tran & Young, 2011) and only 421% of people
achieving the optimum therapeutic benefit of medications
(Garfield, Barber, Walley, Willson & Eliasson, 2009). In the
Australian public health system medication adverse events cost
approximately $6 billion dollars per year and inappropriate
use of medicines $380 million (National Health and Hospitals
Reform Commission, 2008). It is likely, however, that the
available figures underestimate the extent of the problem.STANDARDS FOR PRACTICE
The Nursing and Midwifery Board of Australia
(NMBA) Standards for Practice (2016) specify
that the registered nurse complies with legislation,
regulations, policies, guidelines and other standards or
requirements relevant to the context of practice when
making decisions (NMBA, 2016, p. 3).
TABLE 61 Effects of Drugs
Therapeutic effect The intended effect and the reason the drug is prescribed.Example: the therapeutic effect of morphine sulfate is analgesia.
Side effect An unintended effect of a drug that is usually predictable and may be either harmless or potentially harmful.Example: A side effect of morphine sulfate can be nausea and vomiting.
Adverse effect(reaction or event)
A severe side effect that may justify a dose reduction or discontinuation of a drug. An adverse drugeffect is a response to a medication, which is harmful and unintended, and which occurs at normal doses.Example: An adverse effect of morphine sulfate may be respiratory depression.
Medication error Any preventable medication event that leads to, or has the potential to lead to, harm to the person.Example: Administering 30 units of insulin instead of the 3 units ordered.
Near miss A medication error that was detected and corrected before it reached the person.Example: Amoxicillin is ordered for a person with an allergy to penicillin but identified by the nurse before
for the drug is administered.
CLINICAL SAFETY ALERT
In Australian hospitals, 38% of medication errors
occur at the administration stage, indicating the
critical need for nursing students to develop clinical
skills and knowledge that promote medication safety
(Roughead & Semple, 2009).
The impact of person-centredcare and interprofessionalcommunication on medicationsafetyThe safe, timely and effective administration of medicines is
dependent not only on individual responsibilities, but also
effective collaboration between all members of the medication
team (Madegowda et al., 2007). Medication incidents are
often related to a lack of effective communication among
health professionals such as doctors, nurses and pharmacists,and between health professionals, patients and family
members. Inadequate communication (verbal and written)
is the primary issue in the majority of medication errors,
adverse reactions and near-misses (Britten, 2011).
Miscommunication can result during telephone orders
if unclear or insufficient directions are given (Manias,
2014). Telephone orders should always be followed up by
documentation of the prescription within a defined period,
which is usually 24 hours. Research undertaken with nurses
(n = 1296) about telephone orders showed that only 75%
of nurses alwaysread back the persons name, the name of
the medication, the dose and the route to the prescriber. The
remainder of nurses either sometimes or neverperform these
tasks (Cohen & Shastay, 2008).
When taking a telephone order, it is important that the
health professional repeats the persons name, the medication
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SKILLS IN CLINICAL NURSING
242
name, which includes spelling the name to avoid an error
due to sound alike medications, the dosage, which includes
pronouncing the amount in single digits (e.g. 15 mg shouldbe read as one five), route, and frequency, which includes
stating the interval in full rather than using abbreviations
(e.g. three times daily, not TDS).
An individualised and person-centred approach to
medication administration, involving a dialogue between
nurses and patients, promotes patient safety by engaging
the person as a participative member of the medication
team (Bolster & Manias, 2010). There is clear evidence that
a person-centred approach to medication administration
can reduce the number of medication errors. For furtherinformation about the relationship between medication
safety, person-centred care and communication access the
Interprofessional Education for Quality Use of Medicines
modules at .
facilities use the 24-hour clock to eliminate confusion between
morning and afternoon times. Time with the 24-hour clock
starts at midnight, which is 0000 hours (Figure 61). In Australia
many facilities use the National Inpatient Medication Chart as a
consistent way of recording the ordering and administration of
medication for hospitalized adults (Figure 62).
The generic name (and sometimes the trade name) of
the drug to be administered must be clearly and accurately
written on the chart along with the dosage of the drug, the
amount or the strength of the medication, and the times orfrequency of administration. Because it is not unusual for a
drug to have several possible routes of administration the
route must be clearly specified in the order.For example,
tetracycline 250 mg (amount) four times a day (frequency)
orally (route); or potassium chloride 10% (strength) 5 mL
(amount) three times a day with meals (time and frequency)
orally (route). The medical officer ordering the drug or
the nurse who received the telephone order must sign the
medication chart to ensure the order is legal and valid.
A doctor will provide a written or oral order for a medication(prescription) often using a number of abbreviations. It is
important that only accepted abbreviations are used in order
to avert the potential for error due to misinterpretation by the
pharmacist or nurse. For example, AZT has been interpreted
as zidovudine or azathioprine and EPO can be interpreted
as evening primrose oil or epoetin-alpha. For these reasons,
it is important that only accepted abbreviations are used
or that medications are written in full when prescribing
and providing directions for use. See Table 62 for a list of
acceptable medication abbreviations.
CLINICAL SAFETY ALERT
Medication errors can be caused by
interpersonal and situational factors such as:
Unnecessary interruptions from colleagues during
medication preparation and administration activities.
Miscommunication of orders, misinterpretation of
orders or difficulties in reading orders.
Hierarchies within the health care team that
negatively influence nurses and pharmacists
decisions to seek advice or clarify of orders.
Failure to include the person receiving the medication
as an integral member of the medication team.
Failure to access an interpreter for a person who doesnot speak English.
FIGURE 61 The 24-hour clock
PM
AM
2400
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300 121
2
3
4
5
6
7
8
9
10
11
0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100
MEDICATION ORDERS
A valid medication order has seven essential parts, these include:
1. Full name of the person
2. Date and time the order is written
3. Name of the drug to be administered
4. Dosage of the drug5. Frequency of administration
6. Route of administration
7. Signature of the person writing the order.
In addition, unless it is a standing order, the medication
order should state the number of doses or the number of days
the drug is to be administered. To avoid confusion between
people with the same or similar last names most facilities use the
persons first and last names, and their medical record number
on the medication chart. The day, month, year and often the
time the order was written are also included on the chart. Most
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FIGURE6
2
NationalInpatientMedicationChart(Con
tinued)
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FIGU
RE6
2
NationalInpatient
MedicationChart
Source:
Aus
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Comm
iss
ionon
Sa
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dQ
ua
lityinHea
lthCare
(2012).NationalInp
atientMedicationChartforAdultPatien
ts2012.
Commonwea
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ithperm
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ion
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-82KB
.pdf.
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UNIT 6 SECTION 6.1 INTRODUCTION
245
TABLE 62 Acceptable Medication Terms and Abbreviations
INTENTED MEANING ACCEPTED TERMS OR ABBREVIATIONS
Dose frequency or timing
(in the) morning Morning, mane
(at) midday Midday
(at) night Night, nocte
twice a day Bd
three times a day Tds
four times a day Qid
every 4 hours every 4 hrs, 4 hourly, 4 hrly
every 6 hours every 6 hrs, 6 hourly, 6 hrly
every 8 hours every 8 hrs, 8 hourly, 8 hrly
once a week once a week andspecify the day in full, e.g. once a week on Tuesdays
three times a week three times a week andspecify the exact days in full, e.g. three timesa week on Mondays, Wednesdays and Saturdays
when required prn
immediately stat
before food before food
after food after food
with food with food
Route of administration
epidural epidural
inhale, inhalation inhale, inhalation
intra-articular intra-articular
intramuscular IM
intrathecal intrathecal
intranasal intranasal
intravenous IV
irrigation irrigation
left left
nebulised NEB
naso-gastric NG
oral PO
percutaneous enteral gastrostomy PEG
per vagina PV
per rectum PR
peripherally inserted central catheter PICC
right Right
subcutaneous Subcut
sublingual Sublingtopical topical
Units of measure and concentation
gram(s) g
International unit(s) International unit(s)
unit(s) unit(s)
litre(s) L
milligram(s) mg
millilitre(s) mL
microgram(s) microgram, microg
percentage %
(Continued )
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TABLE 63 Types of Drug Preparation
TYPE DESCRIPTION
Aerosol spray or foam A liquid, powder or foam deposited in a thin layer on the skin by air pressure
Aqueous solution One or more drugs dissolved in water
Aqueous suspension One or more drugs finely divided in a liquid such as water
Caplet A solid form, shaped like a capsule, coated and easily swallowed
Capsule A gelatinous container to hold a drug in powder, liquid or oil form
Cream A nongreasy, semisolid preparation used on the skin
Elixir A sweetened and aromatic solution of alcohol used as a vehicle for medicinal agents
Extract A concentrated form of a drug made from vegetables or animals
Gel A clear or translucent semisolid that liquefies when applied to the skin
Liniment A medication mixed with a lcohol, oil or soapy emoll ient and appl ied to the sk in
Lotion A medication in a liquid suspension applied to the skin
Lozenge (troche) A flat, round or oval preparation that dissolves and releases a drug when held in the mouthOintment (salve) A semisolid preparation of one or more drugs used for application to the skin and mucous membrane
INTENTED MEANING ACCEPTED TERMS OR ABBREVIATIONS
millimole mmol
Dose forms
capsule cap
cream cream
ear drops ear drops
ear ointment ear ointment
eye drops eye drops
eye ointment eye ointment
injection inj
metered-dose inhaler metered-dose inhaler, inhaler, MDImixture mixture
ointment ointment, oint
pessary pess
powder powder
suppository supp
tablet tablet, tab
patient controlled analgesia PCA
TABLE 62 Acceptable Medication Terms and Abbreviations (Continued)
Source:Australian Commission on Safety and Quality in Health Care (ACSQHC) (2011a). Recommendations for Terminology, Abbreviations and SymbolsUsed in the Prescribing and Administration of Medicines.Canberra: Commonwealth Department of Communications, In formation Technology and the Arts.
Commonwealth of Australia. Reproduced with permission.
TYPES OF MEDICATION
PREPARATIONS AND ROUTES
OF ADMINISTRATION
Medications are available in a variety of forms and are
administered via a number of routes. See Table 63 for
examples of types of drug preparations. The route of
medication administration is documented on the prescription.When administering a drug, the nurse should ensure that
the type of medication is appropriate for the route specified.
Examples of routes of administration include:
Oral (including oral, sublingual and buccal)
Topical:
Dermatologic
Ophthalmic
Otic
Nasal
Metered-dose inhalers
Vaginal
Rectal
Parenteral: Subcutaneous (SCI)
Intramuscular (IMI)
Intravenous (IVI)
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Sections 6.26.4 in this unit describe these routes of
medication administration in detail.
Drug calculationsCalculating drug dosages safely and accurately is an important
nursing responsibility in medication administration. Careful and
accurate calculations are essential to the prevention of medication
errors. Sections 6.26.4 include an overview and examples of
drug calculations specific to the different routes described.
Taking a Medication HistoryNurses should assess a persons health status and obtain a
medication history prior to administering any medication.
The extent of the assessment depends on the persons condition
and the drug that has been ordered. For example, if a person
has dyspnoea, their respiratory rate and oxygen saturation level
should be assessed before administering any medication that
might affect breathing. It is also important to determine whether
the route of administration is suitable. For example, a person
who is nauseated may not be able to retain a drug taken orally.Additionally, individuals should be assessed to obtain baseline
data by which to evaluate the effectiveness of the medications
administered. A key nursing responsibility is monitoring the
effectiveness of medications administered. For example, a pain
assessment should be undertaken 30 minutes after administration
of an analgesic medication. Medications should have a therapeutic
effect but side effects are not uncommon and should also be
assessed, documented and reported to the medical officer.
Adverse effects are less common but more serious side effects
and warrant immediate reporting and action. See Table 61.A more in depth medication history is usually taken
the first time a person presents for care (to a practice nurse
for example) or on admission to an acute care facility. A
medication history includes information about the drugs the
person is taking currently or has taken recently. This includes
prescription drugs; over-the-counter (OTC) drugs such as
analgesics or antacids; traditional medicines; complementary
therapies such as vitamins or herbal medicines; alcohol,
tobacco; and illicit substances such as marijuana. Because
many of these drugs have unknown or unpredictable actionsand side effects they need to be clearly documented. During
the medication history, the nurse should also try to elicit
information about possible drug dependencies. An important
part of the medication history is the persons knowledge of his
or her drug allergies. The nurse should also clarify any previous
drug side effects or adverse reactions. Medication that must be
taken with food or at a specific time should be documented as
well as foods that are incompatible with certain medications;
for example, milk is incompatible with tetracycline.
It is also important for the nurse to identify any problems the
person may have in self-administering a medication. A personwith poor eyesight, for example, may require special labels for
medication containers; and people with rheumatoid arthritis
may not be able to open some medication containers.
It is essential that the medication history includes an
appraisal of how much the person knows about their own
medications, including how medications should be stored
and administered, correct doses, possible side effects and
precautions. The nurse also needs to consider socioeconomic
factors. Two common problems are lack of transportation
to obtain medications and inadequate finances to purchasemedications. An understanding of these factors can help the
nurse to plan care that is individualised and person-centred.
THE PROCESS OF SAFE AND
EFFECTIVE MEDICATION
ADMINISTRATION
When administering any drug, regardless of the route of
administration, the nurse must ensure that they check theFive Rights of Medication Administration (see Box 61) and
check the medications they are administrating three times
(see Box 62). Following this sequential and logical approach
for all medications administered helps to ensure that
important steps in the process are not overlooked; importantly
this approach helps to prevent medication errors and
promote patient safety. It is important to note that in addition
to the Five Rights nurses should also check that:
Information about the medication has been explained
to the person including the reason for its administration,what to expect and any related precautions).
Paste A preparation like an ointment, but thicker and sti ff, that penetrates the skin less than an ointment
Pill One or more drugs mixed with a cohesive material, in oval, round or flattened shapes
Powder A finely ground drug or drugs; some are used internally, others externally
Suppository One or several drugs mixed with a firm base such as gelatin and shaped for insertion into the body(e.g. the rectum); the base dissolves gradually at body temperature, releasing the drug
Syrup An aqueous solution of sugar often used to disguise unpleasant-tasting drugs
Tablet A powdered drug compressed into a hard smal l disc; some are readi ly broken along a scored line; others areenteric coated to prevent them from dissolving in the stomach
Tincture An a lcoholic or water-and-alcohol solution prepared f rom drugs derived from plants
Transdermal patch A semipermeable membrane shaped in the form of a disc or patch that contains a drug to be absorbed throughthe skin over a long period of time
TABLE6.3 Types of Drug Preparation (Continued )
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SECTION 6.1Critical Thinking Questions
1. You have been caring for the same person for six
days. They laugh when you ask their name before
administering their medication and say to you, Do you
really need to ask my name again? It hasnt changed
since the last time you asked! How will you respond?
2. Your patient is ordered ibuprofen but the only medication
in the persons drawer is labelled Nurofen. Can you
explain this discrepancy?
3. You hand the person his medications and he says to you:
The pill I usually take for my blood pressure is not white,
its blue. How would you respond?
4. The medical officer writes an order for Frusemide 400 mg
orally BD. The RN administers 10 tablets of 40 mg each.
After administering the tablets the nurse realises that the
order should have been 40 mg. The nurse is:
a. Not legally responsible for this medication error
because the doctor ordered the wrong dose.
b. Legally responsible because nurses are supposed to
have the knowledge to recognise incorrect medication
orders and the confidence to question orders that
seems unreasonable.
5. A valid medication order has seven essential parts. What
is missing from the following list?
a. Full name of the patient
b. Date and time the order is written
c. Name of the drug to be administered
d. Dosage of the druge. Route of administration
BOX 62Check Three Times for Safe MedicationAdministration
FIRST CHECK
Read the medication chart and remove the medication(s) fromthe persons drawer or the medication trolley.
Compare the label of the medication against the medication chart.
Check the expiry date of the medication.
Determine whether you need to do a medication calculation.
SECOND CHECK
While preparing the medication (e.g., pouring, drawing up orplacing in a medication cup), look at the medication label andcompare it with the medication chart.
THIRD CHECK
Recheck the label on the container (e.g., vial, bottle or packet)against the medication chart before returning to its storage place.
Medication administration is correctly documented
after giving medication and that the students signature
is countersigned by the supervising RN.
When time of administration differs from prescribed
time this is documented along with the reason for
the delay.
Decisions not to administer a medication are
documented and the medical officer notified.
A persons right to refuse a medication is respected and
they are fully informed of the potential consequences
of their refusal. The persons refusal is documented and
their medical officer notified.
A nurses refusal to administer any medication theybelieve to be incorrect for the person is documented
and the medical officer notified.
Appropriate patient assessments are undertaken prior
to administration (e.g., apical pulse, blood pressure,
pathology results etc).
Effectiveness of the medication is evaluated (e.g., was the
desired effect achieved or not? Did the person experience
any side effects or adverse reactions?).
BOX 61The Five Rights of Medication Administration
1. RIGHT MEDICATION
The medication being administered is the medication thatwas ordered.
The person receiving the medication is asked to check andverify the medication (if appropriate).
2. RIGHT DOSE
The dose ordered is appropriate for the patient.
Calculations are correct and verified.
The ordered dose is within the usual dosage range for the
medication. Dosages outside of the usual dosage range are questionedand reported to pharmacist or medical officer.
3. RIGHT TIME
The medication is administered at the correct time, no morethan 30 minutes before or after the ordered time.
4. RIGHT ROUTE
The ordered route is appropriate for the medication and thepersons needs/condition.
5. RIGHT PERSON
The persons identification has been verified using arm band,their first and last name, date of birth and medical record number.
to clarify their concerns about their medications and
double check that the medication order and the person
for whom the medication is prescribed are both correct.
CLINICAL SAFETY ALERTAsking the right questions
Do not ask Are you John Jones? because the
person may answer yes to the wrong name. Instead
ask What is your name?
If a person raises questions about the medication you
give them this should be an alert. Stop! Ask the person
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mucous membranes of the cheek until the drug dissolves
(Figure 64). The drug may act locally on the mucous
membranes of the mouth or systemically when it is
swallowed in the saliva.The administration of oral medications may not appear to
be an overly complex procedure. However, safe and effective
oral medication administration requires not just psychomotor
skills but also integration of pharmacological, legal and
professional knowledge, sound critical thinking and clinical
reasoning skills, and well-developed communication skills. In
the clinical scenario below and in the critical thinking questions
that are asked throughout this section the importance of these
multifaceted issues and their application to the clinical skill of
oral medication administration is illustrated.
Oralmedications include tablets, capsules and liquids that
can be swallowed. Oral medication administration is the
most common, least expensive and most convenient route
for most people. The major disadvantages of this route areirritation of the gastric mucosa, irregular and sometimes
delayed absorption from the gastrointestinal tract.
Rather than being swallowed and absorbed via the
gastrointestinal tract some drugs are absorbed from under
the tongue or from inside the cheek. In sublingual
administration, the drug is placed under the tongue, where
it dissolves and is quickly absorbed into the blood vessels
on the underside of the tongue (Figure 63). Buccal
means pertaining to the cheek. In buccal administration, a
medication (e.g., a tablet) is held in the mouth against the
KEY TERMS
buccal, 249
meniscus, 251
oral, 249
sublingual, 249
LEARNING OUTCOMES
On completion of this section you will be able to:
1. Define the key terms used in oral medicationadministration.
2.Demonstrate the ability to read and interpret amedication chart.
3. Demonstrate accuracy when calculating oral medicationdosages.
4. Verbalise the steps required to administer oralmedications safely.
5. Demonstrate critical thinking when administering oralmedications.
6. Accurately document oral medication administration.
7. Monitor the effectiveness of oral medicationsadministered.
ORAL
MEDICATION
ADMINISTRATION
SECTION 6.2
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Calculating dosages fororal medicationsWhen calculating the number of tablets or amount of liquid
to administer orally there are three main formulas that are
commonly used.1. For tablets:
Number of tablets required = Strength (or dose) required
Strength in stock
2. For liquids:
Volume required =
Strength (or dose) required
Volume of stock solution
Strength in stock
Examples:1. A person is prescribed atenol 75 mg orally. The
strength in stock is 50 mg. How many tablets should be
administered?
Number of tablets required = Strength (or dose) requiredStrength in stock
Number of tablets required = 75 mg = 3= 11 tablets50 mg 2 2
2. A person i s prescribed erythromycin 750 mg orally. The
strength in stock is 250 mg/5 mL. What volume (in mL)should be administered?
Volume required =
Strength (or dose) required
Volume of stock solution
Strength in stock
Volume required = 750 mg 5 mL
250 mg
Volume required = 15 mL
FIGURE 64 Buccal administration of a tablet
FIGURE 63 Sublingual administration of a tablet
CLINICAL SCENARIO
Mr Giuseppe Esposito, 81 years, is a person on the
medical ward of Griffith Community Hospital (Levett-
Jones & Newby, 2013). He was admitted two days
ago with gastroenteritis and dehydration. At 0800
hours Madeline (Maddie) OBrien, a nursing student,
was administering Mr Espositos oral medications
(frusemide, digoxin and enalapril). The registered
nurse (RN) supervising Maddie was interrupted by
another nurse who needed assistance with a person in
a nearby bed. The RN said to Maddie, keep going
Ill keep an eye on what you are doing from over
here.
Critical Thinking Questions
1. What would you do if presented withthis situation?
2. What are the legal and professional issues relevant
to this situation?
3. How may Mr Espositos clinical safety be impacted
by the RNs and the nursing students actions?
4. Should Maddie assess Mr Esposito before
administering his medications?
5. Mr Esposito speaks limited English. How might this
impact safe medication administration practices?
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Note: Always check that you have used the same unit of
weights in medications calculations, for example all grams,
milligrams or micrograms.
Tablets that are scored (a line marked on the tablet)
may be broken in half or cut (see Figure 65) to obtain the
correct dosage but capsules cannot be divided. For people
who have difficulty swallowing, some medications can
be crushed to a fine powder by using a pill crusher. The
powder is then mixed with a small amount of soft food
(e.g., custard, apple sauce or honey) to improve palatability
and assist with swallowing.
CLINICAL SAFETY ALERT
Enteric-coated, slow release, sublingual and
buccal medications should not be crushed as
this changes the rate of absorption and can cause
an adverse drug effect. Always check the Australian
Medicines Handbookor a similar drug resource
to check whether it is appropriate to crush a
particular tablet.
FIGURE 66 Pouring a liquid medicationfrom a bottle
Critical Thinking Questions1. Calculate how many tablets Mr Esposito will be
given based on the following medication orders:
frusemide 80 mg orally; strength in stock 40 mg
digoxin 250 mg orally; strength in stock 125 micrograms
enalapril 20 mg orally; strength in stock 10 mg
2. Do you have any concerns about any of these orders? If
so what is the most appropriate nursing action?
FIGURE 65 A cutting device can be used todivide tablets
Liquid medications must be carefully measured using a
syringe, dropper or medicine cup. To ensure accurate dosages
the medicine cup should be placed on a flat surface at eye
level and filled to the desired level (see Figure 66). The
bottom of the meniscus(crescent-shaped upper surface of
a column of liquid) should align with the measurements
on the side of the medicine cup and be used to measure the
correct dose (see Figure 67).
STANDARDS FOR PRACTICE
The Nursing and Midwifery Board of Australia
(NMBA) Standards for Practice (2016) specify that
the registered nurse uses the appropriate processes
to identify and report potential and actual risk related
system issues and where practice may be below the
expected standards (NMBA, 2016, p. 5).
Base of
meniscus
4
3
2
1
FIGURE 67 The bottom of the curved meniscusis used to measure the correct dose
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Assess: Patient allergies, ability to swallow, and drug action side effects, interactions, and adverse reactions
Perform appropriate assessments specific to the medication as needed
Determine if the above assessment data will influence administration of the medication
Know why the patient is receiving the medication
THENdetermine if it can be crushed
because some medications (e.g.,enteric coated) cannot be crushed.Call the pharmacy if unsure. If themedication can be crushed, do soand mix with a small amount of softfood. Label the medication cup.
Help the patient to a sitting position
Administer the medications
Take the required assessment measures if not done previously (e.g., apical pulse)
Check the medication chart
Obtain and prepare the medications
Perform the three safety checks to reduce the risk of error
Ensure it is the correct patient, using agency protocol
Explain the purpose of the medication
Document each medication given on the MAR
Evaluate the effects of the medication
WHAT IF the medication needs to be crushed?
THENask for the reason. The
patient has a right to refuse.
Hold the medication and document
the reason why the patient refused.
If holding could have adverse effects,
notify the medical officer of refusal.
THENexplain the purpose of the
medication and how it will help.
Use language that the patient can
understand.
WHAT IFthe patient states
does not know why s/he istaking the medication?
THENdetermine if the symptoms are an adverse reaction or an allergic reaction. Inform the Medical officer. Hold future administrat ion of the medication until discussing with Medical officer.
WHAT IFthe patient begins
having adverse reactions to
the medication?
Organize supplies
Perform hand hygiene
WHAT IFthe patient refuses the medication?
What If Administering oral medications
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Examples can include the nitroglycerin patch to treat
coronary artery disease or a medication in a suppository
form to treat nausea. Topical skin or dermatological
preparations include ointments, pastes, creams, lotions,
powders, sprays and patches. A suppository is a solid
medication in a roughly conical or cylindrical shape,
which is designed to be inserted into the rectum or vagina
where it dissolves.
A topical medication is applied locally to the skin or to
the mucous membranes of the eye, ear, nose, lungs, vagina
and rectum. Many drugs are applied topically to produce
a local effect (e.g., an antibiotic cream for a skin infection
or a corticosteroid nasal spray to reduce inflammation
of nasal mucosa from allergies). Some medications
are applied topically for a systemic effect such as slow
absorption of the medication into the general circulation.
KEY TERMS
aerosolisation, 266
atomisation, 266
dermatologic
preparations, 256
metered-dose inhaler(MDI), 266
nebulisers, 266
ophthalmic, 259
otic, 261
suppositories, 255
transdermal patch, 256
LEARNING OUTCOMES
On completion of this section you will be able to:
1. Define the key terms used in topical medicationadministration.
2. Verbalise the steps required to administer the followingtopical medications safely:
Dermatologic Ophthalmic Otic Nasal Metered-dose inhalersVaginal
Rectal3. Demonstrate safe and effective topical medication
administration.
4. Demonstrate critical thinking when administering topicalmedications.
5. Accurately document topical medication administration.
6. Monitor the effectiveness of topical medications
administered.
TOPICAL
MEDICATION
ADMINISTRATION
SECTION 6.3
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films containing the drug and an adhesive layer. The rate
of delivery of the drug is controlled and varies with each
product (e.g., from 12 hours to 1 week). Generally, the
patch is applied to a hai rless, clean area of skin that is notsubject to excessive movement, friction (e.g., bra strap or
waistline areas) or wrinkling (i.e., the lower abdomen).
It may be applied on the upper arm, side, lower back or
buttocks (Figure 68). Remove lotion, sunscreen, powder,
or any other product that may impair absorption of the
medication in the patch. Use mild, nonirr itating soap and
water to cleanse, if necessary. Patches should not be applied
to areas with cuts, burns or abrasions, or on distal parts of
extremities (e.g., the forearms). Women who use a patch
containing oestrogen or nicotine should not apply the
patch to the breasts, per the manufacturers instructions.
If hair is likely to interfere with patch adhesion or
removal, clipping (not shaving) may be necessary before
application.
DERMATOLOGIC MEDICATIONS
Dermatologic preparationsmay be applied to the skin for
a variety of reasons, for example to:
decrease itching (pruritus)
lubricate and soften the skin
cause local vasoconstriction or vasodilation
increase or decrease secretions from the skin
provide a protective coating to the skin
apply an antibiotic or antiseptic to treat or prevent
infection
reduce local inflammation
an entry for medications that will be absorbed into
the systemic circulation
Before applying a dermatologic preparation, thoroughly
clean the area with soap and water and dry it with a patting
motion. Skin encrustations (i.e., crusts or scabs) harbour
microorganisms, and these as well as previously applied
applications can prevent the medication from coming in
contact with the area to be treated. Nurses should wear
gloves when administering skin applications and always use
surgical asepsis when an open wound is present.
Transdermal MedicationsA particular type of dermatologic medication delivery
system is the transdermal patch. This system administers
sustained-action medications (e.g., pain relievers,
nitroglycerin, oestrogen and nicotine) via multilayered
BOX 63General Guidelines for the Administration of Dermatologic Medications
POWDER
Make sure the skin surface is dry. Spread apart any skin folds, and sprinkle the site until the area is covered with a fine thinlayer. Cover thesite with a dressing if ordered.
SUSPENSION-BASED LOTION
Shake the container before use to distribute suspended particles. Put a little lotion on a small gauze dressing or pad, and apply the lotion tothe skin by stroking it evenly in the direction of the hair growth.
CREAMS, OINTMENTS, PASTES AND OIL-BASED LOTIONS
Warm and soften the preparation in gloved hands to make it easier to apply and to prevent chilling (if a large area is to be treated). Smearit evenly over the skin using long strokes that follow the direction of the hair growth. Explain that the skin may feel somewhat greasy after
application. Apply a sterile dressing if ordered by the primary care provider.AEROSOL SPRAY
Shake the container well to mix the contents. Hold the spray container at the recommended distance from the area (usually about 15 to 30cm [6 to 12 in.] but check the label). Cover the persons face with a towel if the upper chest or neck is to be sprayed. Spray the medicationover the specified area.
TRANSDERMAL PATCHES
Select a clean, dry area that is free of hair and matches the manufacturers recommendations. Remove the patch from its protective covering,holding it without touching the adhesive edges, and apply it by pressing firmly with the palm of the hand for about 10 seconds. Advise the person toavoid using a heating pad over the area to prevent an increase in circulation and the rate of absorption. Remove the patch at the appropriate time,folding it so that the medicated sticky sides are together. Some patches contain nonvisible metal in their backing. This may cause burning in thearea of the patch. Inform individuals to tell the MRI personnel that they are wearing a transdermal patch (U.S. Food and Drug Administration, 2009).
CLINICAL ALERTThe nurse should wear gloves when applying a
transdermal patch to avoid getting any of the
medication on his or her skin, which can result in the
nurse receiving the effect of the medication.
Reddening of the skin with or without mild local itching
or burning, as well as allergic contact dermatitis, may
occasionally occur with transdermal patches. Upon removal
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of the patch, any slight reddening of the skin usually
disappears within a few hours. All applications should be
changed regularly to prevent local irritation, and each
successive application should be placed on a different site.
All people need to be assessed for allergies to the drug and
to materials in the patch before the patch is applied.
When transdermal patches are removed, care needs to be
taken as to how and where they are discarded. In the home
environment, if they are simply discarded into a rubbish
bin, pets or children can be exposed to them, causing effectsfrom any drug remaining on the patch. When removed, they
should be folded with the medication side to the inside, put
into a closed container, and kept out of reach of children
and pets.
Transdermal ointment is another form of transdermal
medication. A common example is nitroglycerin ointment,
which is used to prevent chest pain. The nurse squeezes out
the ordered dose onto a paper dose-measuring applicator
(Figure 69). This paper applicator is placed with the
ointment side down onto a dry, hairless area of skin, similar
to the transdermal patch. Using the paper applicator, lightly
spread the ointment (do not rub) and tape the paper
applicator into place.
FIGURE 69 Using premeasured paper tomeasure medication dosage
DERMATOLOGIC MEDICATION ADMINISTRATIONTHE 3PS TABLEPREPARATION AND PLANNING
ACTION EXPLANATION AND RATIONALE
Review the medication chart and ensure that there is a valid order forthe drug/s to be administered.
Report and clarify any omissions, inconsistencies, inaccuracies orincomplete prescription orders to the supervising RN or MO.
Nurses are legally responsible for their practice. Orders thatare not valid, drugs that are contraindicated, a dose that is toohigh, previously unreported allergies, and other concerns shouldreported in order to prevent potential adverse effects.
Review the Australian Medicines Handbookor a similar drug resource ifunfamiliar with the medication/s ordered.
When administering medications nurses must be familiar with theusual dosage, indications, contraindications, potential side effects,interactions, and adverse effects of ordered medications.
Perform hand hygiene. Dermatological medication administration is a clean procedure.Hand hygiene is performed as an infection control precaution.
Gather the correct equipment:
Clean gloves (or sterile for nonintact skin)
Solution to wash area if indicated
Gauze pads for cleaning
Medication (e.g., lotion, cream, ointment, patch)
Application tube (if required)
FIGURE 68 Transdermal patch administration:A, protective coating removed from patch;B,patch immediately applied to clean, dry, hairless
skin and labelled with date, time, and initialsSource:From M. Adams, N. Holland & P. Bostwick (2008). Pharmacology forNurses: A Pathological Approach(2nd ed.), p. 35. Upper Saddle River, NJ:Pearson Education, Inc.
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PERFORMING THE PROCEDURE
ACTION EXPLANATION AND RATIONALE
Introduce yourself to the person. Use full name and designation. This is a professional expectation andhelps to promote a therapeutic relationship.
Demonstrate a person-centred approach to medication administrationand obtain the persons verbal consent
A person-centred approach enhances patient safety by creating anopportunity for the person to ask questions and for the nurse toprovide education.
Repeat hand hygiene and dons gloves. Hand hygiene should be conducted prior to touching the person.
Determine and conduct appropriate patient assessments:
Inspect skin or mucous membranes for lesions, rashes, erythema,and breakdown. Note size, colour, distribution and configurationof lesions.
Determine the presence of symptoms of skin irritation (e.g.,
pruritus, burning sensation, pain). Note the presence of excessive body hair that may require
clipping before the application of a topical medication.
If a transdermal patch is to be applied, ask the person if they arealready wearing a patch, and if so, where it is located.
This is a clinical expectation.
Close curtain or door. Assist the person to a comfortable position,either sitting or lying. Expose the area to be treated and ensure privacy.
To ensure privacy, comfort and dignity.
Unlock the dispensing system and obtain the correct medication.
FIRST CHECK!
Compare the label on the medication container and packagingagainst the order on the medication chart to ensure that the right
medication is given.
Use only medications that have clear, legible labels. Notify the RN orpharmacist if a discrepancy is identified.
Check the expiry date of the medication. Out of date medications will reduce the therapeutic benefit of medications.
If necessary, calculate the correct dosage of the medication ifrequired.
Students must ensure that their calculations are checked by theirsupervising RN.
SECOND CHECK!
Check the five rights of medication administration.
Prevent errors by confirming right drug, right dose, right time, rightroute and right person.
Confirm the persons identification by asking them to state their nameand date of birth and checking they are consistent with the personschart. Confirm that the medical record number on the medicationchart accords with the ID band.
Check whether the person has any drug allergies. This is a safety precaution.
THIRD CHECK!
Recheck the label on the container against the medication chart.
Apply the medication and dressing as ordered.
Place a small amount of cream or ointment on the gloved hand,and spread it evenly on the skin.
or
Apply sterile gloves if indicated (i.e., nonintact skin). Pour somelotion on the gauze, and pat the skin area with it.
Apply a sterile dressing if necessary.
or
Apply a prepackaged transdermal patch. Write the date and time on the label beforeapplication.
or
Squeeze out transdermal ointment onto premeasured medicationadministration paper.
Place the applicator paper with ointment side down onto the skin.
Lightly spread the ointment.
Tape the paper applicator into place.
Knowing the date and time ensures safety and communication whenthere are multiple caregivers. Writing on the patch could puncture it.
Remove gloves and repeat hand hygiene. This is an infection control precaution.
Sign the medication chart. Supervising RN to countersign. Most health care facilities and universities require RNs to countersignany medication administered by students.
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PERFORMING THE PROCEDURE
Record the type of preparation used, the site to which it was applied,the time, and the response of the person, including data about theappearance of the site, discomfort, itching, etc.
For transdermal patches, document both removal and application ofthe patch including location.
Conclude encounter, reposition the person comfortably and informthem of follow up.
This is a professional expectation and helps to maintain a therapeuticrelationship.
PRIORITIES POST PROCEDURE
ACTION EXPLANATION AND RATIONALE
Dispose of used equipment appropriately.
Repeat hand hygiene.
Return to the person to monitor effectiveness of the medicationadministered.
Return at a time by which the preparation should have absorbed to assessthe reaction (e.g., relief of itching, burning, swelling or discomfort).
OPHTHALMIC MEDICATIONS
Ophthalmic medications may be administered by
slowly pouring or dropping liquids or ointments
onto the surface of the eye. Eye drops are packaged in
monodrip plastic containers and ointments are usually
supplied in small tubes. All containers must state that the
medication is for ophthalmic use. Sterile preparations and
a sterile technique are used to administer ophthalmic
medications.
ADMINISTERING OPHTHALMIC MEDICATIONSTHE 3PS TABLEPREPARATION AND PLANNING
ACTION EXPLANATION AND RATIONALE
Review the medication chart and ensure that there is a valid order forthe drug/s to be administered.
Report and clarify any omissions, inconsistencies, inaccuracies orincomplete prescription orders to the supervising RN or MO.
Nurses are legally responsible for their practice. Orders thatare not valid, drugs that are contraindicated, a dose that is toohigh, previously unreported allergies, and other concerns shouldreported in order to prevent potential adverse effects.
Review the Australian Medicines Handbook or a similar drug resource ifunfamiliar with the medication/s ordered.
When administering medications nurses must be familiar with theusual dosage, indications, contraindications, potential side effects,interactions and adverse effects of ordered medications.
Perform hand hygiene. Ophthalmic medication administration is a sterile procedure. Handhygiene is performed as an infection control precaution.
Gather the correct equipment:
Clean gloves
Sterile absorbent sponges soaked in sterile normal saline
Medication
Sterile eye dressing (pad) as needed and paper tape to secure it
PERFORMING THE PROCEDURE
ACTION EXPLANATION AND RATIONALE
Introduce yourself to the person. Use full name and designation. This is a professional expectationand helps to promote a therapeutic relationship.
Close curtain or door. Assist the person to a comfortable position,usually lying.
To ensure privacy, comfort and dignity.
Demonstrate a person-centred approach to medication administrationand obtain the persons verbal consent.
A person-centred approach enhances patient safety by creatingan opportunity for the person to ask questions and for the nurseto provide education.
Repeat hand hygiene. Hand hygiene should be conducted prior to touching the person.
Determine and conduct appropriate assessments of the person:
Appearance of the eye and surrounding structures for lesions,exudate, erythema, or swelling.
The location and nature of any discharge, lacrimation and swelling ofthe eyelids or of the lacrimal gland.
This is a clinical expectation.
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PERFORMING THE PROCEDURE
Complaints (e.g., itching, burning pain, blurred vision, and photophobia).
Behaviour (e.g., squinting, blinking excessively, frowning, or rubbingthe eyes).
Unlock the dispensing system and obtain the correct medication.
FIRST CHECK!
Compare the label on the medication container and packagingagainst the order on the medication chart to ensure that the rightmedication is given.
Use only medications that have clear, legible labels. Notify the RNor pharmacist if a discrepancy is identified.
Check the expiry date of the medication. Out of date medications will reduce the therapeutic benefit ofmedications.
SECOND CHECK!
Check the five rights of medication administration.
Confirm which eye is to be treated.
Prevent errors by confirming right drug, right dose, right time,right route, right person and right eye.
Confirm the persons identification by asking them to state theirname and date of birth and checking they are consistent with thepersons chart. Confirm that the medical record number on themedication chart accords with the ID band.
Check whether the person has any drug allergies. This is a safety precaution.
Repeat hand hygiene and don gloves. This is an infection control precaution.
Clean the eyelid and the eyelashes using sterile cotton balls moistenedwith sterile irrigating solution or sterile normal saline.
Wipe from the inner canthus to the outer canthus.
If not removed, material on the eyelid and lashes can be washedinto the eye.
Cleaning towards the outer canthus prevents contamination of theother eye and the lacrimal duct.
THIRD CHECK!
Recheck the label on the container against the medication chart.
Apply the medication as ordered.
Draw the correct number of drops into the shaft of the dropper if adropper is used.
Instruct the person to look up to the ceiling.
Give the person a dry sterile absorbent sponge.
Expose the lower conjunctival sac by placing the thumb or fingersof your nondominant hand on the persons cheekbone just belowthe eye and gently drawing down the skin on the cheek. If thetissues are oedematous, handle the tissues carefully to avoiddamaging them.
Holding the medication in the dominant hand, place the hand on thepatients forehead to stabilise the hand.
The person is less likely to blink if looking up. While the personlooks up, the cornea is partially protected by the upper eyelid.
A sponge is needed to press on the nasolacrimal duct after aliquid instillation to prevent systemic absorption or to wipe excessointment from the eyelashes after an ointment is instilled.
Placing the fingers on the cheekbone minimises the possibility oftouching the cornea, avoids putting any pressure on the eyeballand prevents the person from blinking or squinting.
The person is less likely to blink if a side approach is used. Wheninstilled into the conjunctival sac, drops will not harm the cornea asthey might if dropped directly on it. The dropper must not touchthe sac or the cornea.
Instilling eye drops
Approach the eye from the side and instil the correct number of dropsonto the outer third of the lower conjunctival sac. Hold the dropper1 to 2 cm (0.4 to 0.8 in.) above the sac.
Instilling an eye drop into the lower conjunctival sac.
Instilling eye ointment
Discard the first bead of ointment. Holding the tube above the lowerconjunctival sac, squeeze 2 cm (0.8 in.) of ointment from the tube into the
lower conjunctival sac from the inner canthus outward.
The first bead of ointment from a tube is considered to becontaminated.
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PRIORITIES POST PROCEDURE
ACTION EXPLANATION AND RATIONALEDispose of used equipment appropriately.
Repeat hand hygiene.
Return to the person to monitor effectiveness of or reaction to themedication administered.
OTIC MEDICATIONS
Instillationsinto the external auditory canal are referred to
as oticinstillations.
LIFESPAN CONSIDERATIONS
The position of the external auditory canal varies
with age. In the adult, the external auditory canal is
an S-shaped structure about 2.5 cm long. In the child under
3 years of age, it is directed upward. For this reason, to
administer otic medications to infants and young children
gently pull the pinna down and back. For a child older
than 3 years of age, pull the pinna upward and backward. Straightening the ear canal of a child younger than 3 years by pulling
the pinna down and back.
PERFORMING THE PROCEDURE
Instilling an eye ointment into the lower conjunctival sac.
Instruct the person to close the eyelids but not to squeeze them shut. Closing the eye spreads the medication over the eyeball.Squeezing can injure the eye and push out the medication.
For liquid medications, press firmly or have the person press firmly on
the nasolacrimal duct for at least 30 seconds.
Pressing on the nasolacrimal duct.
Pressing on the nasolacrimal duct prevents the medication from
running out of the eye and down the duct, preventing systemicabsorption.
Apply an eye pad if needed, and secure it with paper eye tape.
Remove gloves and repeat hand hygiene. This is aninfection control precaution.
Assess and document the procedure, character and amount ofdischarge, appearance of the eye, discomfort, and the personsresponse immediately after the instillation.
Sign the medication chart. Supervising RN to countersign. Most health care facilities and universities require RNs tocountersign any medication administered by students.
Conclude encounter, ensure the persons comfort and inform them offollow up
This is a professional expectation and helps to maintain atherapeutic relationship.
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PERFORMING THE PROCEDUREACTION EXPLANATION AND RATIONALE
Introduce yourself to the person. Use full name and designation. This is a professional expectation andhelps to promote a therapeutic relationship.
Close curtain or door. Assist the person to a comfortable position,usually lying with the ear to be treated uppermost.
To ensure the persons privacy, comfort and dignity.
Demonstrate a person-centred approach to medication administrationand obtain the persons verbal consent.
A person-centred approach enhances patient safety by creatingan opportunity for the person to ask questions and for the nurse toprovide education.
Repeat hand hygiene. Hand hygiene should be conducted prior to touching the person.
Determine and conduct appropriate assessments of the person: Appearance of the pinna of the ear and meatus for signs ofredness and abrasions.
Type and amount of any discharge.
This is a clinical expectation.
Unlock the dispensing system and obtain the correctmedication.
FIRST CHECK!
Compare the label on the medication container and packagingagainst the order on the medication chart to ensure that the rightmedication is given.
Use only medications that have clear, legible labels. Notify the RN orpharmacist if a discrepancy is identified.
Check the expiry date of the medication. Out o f date medications w ill r educe the therapeutic benefit o fmedications.
SECOND CHECK!
Check the five rights of medication administration.
Prevent errors by confirming right drug, right dos e, right time, rightroute, right person and right ear. Confirm the persons identificationby asking them to state their name and date of birth and checkingthey are consistent with the persons chart. Confirm that the medicalrecord number on the medication chart accords with the ID band.
Check whether the person has any drug allergies. This is a safety precaution.
Repeat hand hygiene and don gloves. This is an infection control precaution.
Clean the pinna of the ear and the meatus of the ear canal withcotton-tipped applicators and cotton balls moistened with sterilenormal saline. Ensure that the applicator does not go into theear canal.
This removes any discharge present before the instillation so that itwont be washed into the ear canal.
This avoids damage to the tympanic membrane or wax becomingimpacted within the canal.
ADMINISTERING OTIC MEDICATIONSTHE 3PS TABLEPREPARATION AND PLANNING
ACTION EXPLANATION AND RATIONALE
Review the medication chart and ensure that there is a valid orderfor the drug/s to be administered.
Report and clarify any omissions, inconsistencies, inaccuracies orincomplete prescription orders to the supervising RN or MO.
Nurses are legally responsible for their practice. Orders that are notvalid, drugs that are contraindicated, a dose that is too high, previouslyunreported allergies, and other concerns should reported in order toprevent potential adverse effects.
Review the Australian Medicines Handbook or a similar drugresource if unfamiliar with the medication/s ordered.
When administering medications nurses must be familiar with theusual dosage, indications, contraindications, potential side effects,interactions, and adverse effects of ordered medications.
Perform hand hygiene. Otic medication administration is a clean process. However, if thetympanic membrane is perforated sterile technique is needed. Hand
hygiene is performed as an infection control precaution.Gather the correct equipment:
Clean gloves
Cotton-tipped applicator
Correct medication bottle with a dropper
Flexible rubber tip (optional) for the end of the dropper, whichprevents injury from sudden motion, for example, by a personwho is disoriented
Cotton wool
Normal saline
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PERFORMING THE PROCEDURE
THIRD CHECK!
Recheck the label on the container against the medication chart.Administer the as ordered.
Warm the medication container in your hand, or place it in warmwater for a short time.
Straighten the auditory canal. Pull the pinna upward andbackward for persons over 3 years of age.
Straightening the adult ear canal by pulling the pinna upwardand backward.
Instil the correct number of drops along the side of the ear canal.
Instilling ear drops.
Press gently but firmly a few times on the tragus of the ear
(the cartilaginous projection in front of the exterior meatusof the ear).
Ask the person to remain in the side-lying position for about5 minutes.
Insert a small piece of cotton wool loosely at the meatus of theauditory canal for 15 to 20 minutes.
Do not press it into the canal.
This promotes the persons comfort and pre-vents nerve stimulationand pain.
The auditory canal is straightened so that the solution can flow theentire length of the canal.
Pressing on the tragus assists the flow of medication into the ear canal.
This prevents the drops from escaping and allows the medication to
reach all sides of the canal cavity.
The cotton helps retain the medication when the person is up.
If pressed tightly into the canal, the cotton would interfere with theaction of the drug and the outward movement of normal secretions.
Remove gloves and repeat hand hygiene. This is an infection control precaution.
Assess and document the procedure, character and amountof discharge, appearance of the canal, discomfort the personsresponse immediately after the instillation.
Sign the medication chart. Supervising RN to countersign. Most health care facilities and universities require RNs to countersignany medication administered by students.
Conclude encounter, ensure the persons comfort and inform themof follow up.
This is a professional expectation and helps to maintain a therapeuticrelationship.
PRIORITIES POST PROCEDURE
ACTION EXPLANATION AND RATIONALE
Dispose of used equipment appropriately.
Repeat hand hygiene.
Return to the person to monitor effectiveness of or reaction to the
medication administered.
Normalposition
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ADMINISTERING NASAL MEDICATIONSTHE 3PS TABLEPREPARATION AND PLANNING
ACTION EXPLANATION AND RATIONALE
Review the medication chart and ensure that there is a valid orderfor the drug/s to be administered.
Report and clarify any omissions, inconsistencies, inaccuracies orincomplete prescription orders to the supervising RN or MO.
Nurses are legally responsible for their practice. Orders that are notvalid, drugs that are contraindicated, a dose that is too high, previouslyunreported allergies, and other concerns should reported in order toprevent potential adverse effects.
Review the Australian Medicines Handbook or a similar drugresource if unfamiliar with the medication/s ordered.
When administering medications nurses must be familiar with theusual dosage, indications, contraindications, potential side effects,interactions, and adverse effects of ordered medications.
Perform hand hygiene. Nasal medication administration is a clean process. Hand hygiene isperformed as an infection control precaution.
Gather the correct equipment:
Tissues
Clean gloves
Correct medication bottle with a dropper
PERFORMING THE PROCEDURE
ACTION EXPLANATION AND RATIONALE
Introduce yourself to the person. Use full name and designation. This is a professional expectation andhelps to promote a therapeutic relationship.
Demonstrate a person-centred approach to medication administrationand obtain the persons verbal consent
A person-centred approach enhances patient safety by creating anopportunity for the person to ask questions and for the nurse to provideeducation.
Close curtain or door. Assist the person to a comfortable position:
To treat the opening of the eustachian tube, have the personassume a back-lying position.
To treat the ethmoid and sphenoid sinuses, ask the person to lie in abackwards position with the head over the edge of the bed or a pillowunder the shoulders so that the head is tipped backward.
Position of the head to instil drops into the ethmoid andsphenoid sinuses.
To ensure the persons privacy, comfort and dignity.
Correct positioning allows the drops to flow into the correct sinus.
Ethmoid
sinuses
Sphenoid
sinus
Nasopharynx
NASAL MEDICATIONS
Nasal instillations (nose drops and sprays) are instilled
for their astringent effect (to shrink swollen mucousmembranes), to loosen secretions and facilitate drainage,
or to treat infections of the nasal cavity or sinuses. Nasal
decongestants are the most common nasal instillations.
Many of these products are available without a prescription
and people need to be taught to use these medications with
caution as chronic use of nasal decongestants may lead to
a rebound effect and increased nasal congestion. It is notunusual to swallow a small amount of the nasal medication,
however, if excess decongestant solution is swallowed
systemic effects may develop, especially in children.
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PERFORMING THE PROCEDURE
To treat the maxillary and frontal sinuses, have the person assumethe same back-lying position, with the head turned towards theside to be treated.
Position of the head to instil drops into the maxillary and frontalsinuses.
Repeat hand hygiene. Hand hygiene should be conducted prior to touching the patient.
Determine and conduct appropriate assessments of the person:
If nasal secretions are excessive, ask the person to blow the noseto clear the nasal passages.
Inspect the discharge on the t issues for color, odour andthickness.
Assess appearance of nasal cavities.
Assess congestion of the mucous membranes and any obstructionto breathing. Ask the person to hold one nostril closed and blowout gently through the other nostril. Listen for the sound of anyobstruction to airflow. Repeat for the other nostril.
Assess signs of distress when nares are occluded. Block eachnaris and observe for signs of greater distress when the naris isobstructed.
Facial discomfort with or without palpation. An infected orcongested sinus can cause an aching, full feeling over the area ofthe sinus and facial tenderness on palpation.
Assess any crusting, redness, bleeding, or discharge of themucous membranes of the nostrils.
This is a clinical expectation.
Unlock the dispensing system and obtain the correct medication.
FIRST CHECK!
Compare the label on the medication container and packagingagainst the order on the medication chart to ensure that the rightmedication is given.
Use only medications that have clear, legible labels. Notify the RN orpharmacist if a discrepancy is identified.
Check the expiry date of the medication. Out o f date medications w ill r educe the therapeutic benefit o fmedications.
SECOND CHECK!
Check the five rights of medication administration.
Prevent errors by confirming right drug, right dose, right time, right
route, and right person. Confirm the persons identification by askingthem to state their name and date of birth and checking they areconsistent with the persons chart. Confirm that the medical recordnumber on the medication chart accords with the ID band.
Check whether the person has any drug allergies. This is a safety precaution.
Repeat hand hygiene and don gloves. This is an infection control precaution
THIRD CHECK!
Recheck the label on the container against the medication chart.
Administer the as ordered.
Draw up the required amount of solution into the dropper. If the solution is directed towards the base of the nasal cavity, it will rundown the eustachian tube.
Maxillary
sinuses
Frontal
sinuses
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the medication canister by hand to release medication
through a mouthpiece. An extender or spacer should
be attached to the mouthpiece to facilitate medication
absorption for better results (see Figure 611). Spacers
are holding chambers into which the medication is fired
and from which the person inhales, so that the dose is
not lost by exhalation. There are also dry powder inhalers
(DPIs) that either have the powder in a reservoir at the
bottom (e.g. Symbicort) or that use a disk with little
blisters containing the powder.
PERFORMING THE PROCEDURE
Hold the tip of the dropper just above the nostril, and direct thesolution laterally towards the midline of the superior concha ofthe ethmoid bone as the person breathes through the mouth. Donot touch the mucous membrane of the nostril.
Repeat for the other nostril if indicated.
Ask the person to remain in the position for 5 minutes
Touching the mucous membrane with the dropper could damage themembrane and cause the person to sneeze.
The person remains in the same position to help the solution come incontact with all of the nasal surface or flow into the desired area.
Remove gloves and repeat hand hygiene. This is an infection control precaution.
Assess and document the procedure, the persons condition,and discomfort experienced by the person and their responseimmediately after the instillation.
Sign the medication chart. Supervising RN to countersign. Most health care facilities and universities require RNs to countersignany medication administered by students.
Conclude encounter, ensure the person is comfortable and informthem of follow up.
This is a professional expectation and helps to maintain a therapeuticrelationship.
PRIORITIES POST PROCEDURE
ACTION EXPLANATION AND RATIONALE
Dispose of used equipment appropriately.
Repeat hand hygiene.
Return to the person to monitor effectiveness of or reaction to themedication administered
INHALED MEDICATIONS
Nebulisersdeliver most medications administered through
the inhaled route. A nebuliser is used to deliver a fine spray
(fog or mist) of medication or moisture to a person.
There are two kinds of nebulisation: atomisation and
aerosolisation. In atomisation, a device called an atomizer
produces droplets for inhalation. In aerosolisation,
the droplets are suspended in a gas, such as oxygen. The
smaller the droplets, the further they can be inhaled into the
respiratory tract. When a medication is intended for the nasal
mucosa, it is inhaled through the nose; when it is intended
for the trachea, bronchi and/or lungs, it is inhaled through
the mouth. A large-volume nebulisercan provide a heated or cool
mist and is generally used for long-term therapy such as that
following a tracheostomy.
A metered-dose inhaler (MDI) (Figure 610) is a
pressurised container of medication that can be used bya person to release medication through a mouthpiece. The
force with which the air moves through the nebuliser causes
the large particles of medicated solution to break up into
finer particles, forming a mist or fine spray. MDIs can deliver
accurate doses, provide for target action at the needed sites,
and sustain fewer systemic effects than medication delivered
by other routes.
To ensure correct delivery of the prescr ibed medication
by MDIs, nurses need to instruct the person t how to
use the inhaler correctly. The person needs to compress
FIGURE 610 A Metered-dose inhaler
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FIGURE 611 Extender or spacer
CLINICAL ALERT
A persons ability to use an MDI correctly
determines the effectiveness of the medication
delivery. It is important for the nurse to assess whether
the person is able to use the MDI correctly.
LIFESPAN CONSIDERATIONS
Children Spacers are recommended for children (as well as
adults) as they hold a medication in suspension and
allow the child to take several deep breaths in order to
inhale all the medication.
Learning how to use a spacer can be a frightening
experience for a young child. Use a doll or stuffed animalto demonstrate its use, and allow the child to play with
the equipment before putting it in place. Having the
child sit in a parents lap during the procedure can help
the child relax and be more cooperative.
ADMINISTERING METERED-DOSEINHALER MEDICATIONS
THE 3PS TABLE
PREPARATION AND PLANNING
ACTION EXPLANATION AND RATIONALE
Review the medication chart and ensure that there is a valid orderfor the drug/s to be administered.
Report and clarify any omissions, inconsistencies, inaccuracies orincomplete prescription orders to the supervising RN or MO.
Nurses are legally responsible for their practice. Orders that are notvalid, drugs that are contraindicated, a dose that is too high, previouslyunreported allergies, and other concerns should reported in order toprevent potential adverse effects.
Review the Australian Medicines Handbook or a similar drugresource if unfamiliar with the medication/s ordered.
When administering medications nurses must be familiar with theusual dosage, indications, contraindications, potential side effects,interactions, and adverse effects of ordered medications.
Perform hand hygiene. Metered dose inhaler medication administration is a clean process.
Hand hygiene is performed as an infection control precaution.Gather the correct equipment:
Metered-dose inhaler (MDI) with medication canister and spacerif indicated
PERFORMING THE PROCEDURE
ACTION EXPLANATION AND RATIONALE
Introduce yourself to the person. Use full name and designation. This is a professional expectation andhelps to promote a therapeutic relationship.
Demonstrate a person-centred approach to medicationadministration and obtain the persons verbal consent.
A person-centred approach enhances the safety of the person bycreating an opportunity for the person to ask questions and for the
nurse to provide education.Close curtain or door. Assist the person to a sitting position. To ensure the persons privacy, comfort and dignity.
CLINICAL SCENARIOTrent Fulton, 35 years, is being discharged from hospital
today following a two week admission for pneumonia
and acute exacerbation of asthma. The RN caring for
Trent asks you to educate him about the use of his
discharge medications (ventolin inhaler and symbicort
dry powder inhaler).
Critical Thinking Questions
1. What advice would you give Trent in
regards to the following medications?
2. How would you know if Trent understood the
education provided by you?
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PERFORMING THE PROCEDURE
Repeat hand hygiene. Hand hygiene should be conducted prior to touching the person.
Determine and conduct appropriate assessments of the person:
Lung sounds.
Respiratory rate and depth.
Cough (productive or nonproductive); amount, colour and characterof expectorations.
Presence of dyspnoea.
Vital signs.
This is a clinical expectation.
Unlock the dispensing system and obtain the correct medication.
FIRST CHECK!
Compare the label on the medication container and packagingagainst the order on the medication chart to ensure that the rightmedication is given.
Use only medications that have clear, legible labels. Notify the RN orpharmacist if a discrepancy is identified.
Check the expiry date of the medication. Out o f date medications w ill r educe the therapeutic benefit o fmedications.
SECOND CHECK!
Check the five rights of medication administration.
Prevent errors by confirming right drug, right dose, right time, rightroute, and right person. Confirm the persons identification by askingthem to state their name and date of birth and checking they areconsistent with the persons chart. Confirm that the medical recordnumber on the medication chart accords with the ID band.
Check whether the person has any drug allergies. This is a safety precaution.
Repeat hand hygiene. This is an infection control precaution.
THIRD CHECK!
Recheck the label on the container against the medication chart.
Educate the person about the purpose of the medication and howthe inhaler is to be used (as follows):
Ensure that the canister is firmly and fully inserted into the inhaler.
Remove the cap, holding inhaler upright, shake vigorously for 3to 5 seconds.
Exhale comfortably (as in a normal full breath) away from theinhaler.
Hold the inhaler with the canister on top and the mouthpiece atthe bottom.
Slightly tilt chin to ensure open airway.
Place the MDI inhaler mouthpiece in the mouth between theteeth and close lips to create a seal.
If using a spacer with the metered-dose inhaler:
Shake the MDI for 3 to 5 seconds and insert the mouthpiece intothe spacer.
Place the spacer in the mouth between the teeth and close lipsto create a seal.
Unless the persons mouth is closed around the MDI the prescribed
dosage may not be inhaled and the person may not receive therequired therapeutic dose.
Administering the medication
Instruct person to:
Whilst breathing in press down onceon the MDI canister andinhale slowly and deeply.
Remove the inhaler from mouth, close mouth and hold yourbreath for a few seconds or as long as possible.
Exhale slowly away from the mouth piece. Replace cap.
Repeat the inhalation if ordered. Wait 1 to 2 minutes betweeninhalations of broncho
Recommended