Administering oral medications

Delegation Considerations
The skill of administering oral medications cannot be delegated to nursing assistive personnel
(NAP).Instruct the NAP about:
 Potential side effects of medications and the need to report their occurrence
 Informing nurse if patient condition worsens (e.g., increased pain, change in behavior).
Equipment
 Automated, computer-controlled drug dispensing system or medication cart
 Disposable medication cups
 Glass of water, juice or preferred liquid and drinking straw
 Device for crushing or splitting tablets (optional)
 Clean gloves (if handling a medication)
 Education administration record (MAR) (electronic or printed)
 Paper towels
ASSESSMENT
1. Check accuracy and completeness of each MAR with health care provider’s medication
order. Check patient’s name, medication name and dosage, and route and time of
administration. Recopy or reprint any part of printed MAR that is difficult to read
Rationale: The order sheet is the most reliable source only legal record of medications that
patient is to receive. Ensures the patient receives correct medications. Illegible MARs are a
source of medication errors
2. Review patient information related to medication action, purpose, normal dose and route,
side effects, time of onset and peak action and nursing implications
Rationale: Allows you to anticipate effects of drug and observe patient’s response
3. Assess for any contraindications to patient receiving oral medication, including being
NPO (nothing by mouth), inability to swallow, nausea or vomiting, bowel suction, and
decreased level of consciousness. Check patient’s swallow, cough, and gag reflexes
Rationale: Alterations in GI function interfere with medications distribution, absorption and
excretion.
Clinical Decision: If there are any contraindications to the patient receiving oral medications or
if in doubt about the patient’s ability to swallow oral medications, temporarily withhold
medication and inform health care provider
4. Assess patient’s medical, medication and diet history and history of allergies. List
patient’s food and drug allergies on each page of the MAR and prominently display it on
 the patient’s medical record per agency policy. When patient has allergy, provide allergy
bracelet.
Rationale: Information reflects patient’s need for and potential responses to medications.
Information also indicates potential food and drug indications.
5. Assess risk for aspiration using a dysphagia screening tool if available
Rationale: Patients with dysphagia are at risk for aspirating oral medications. Early detection of
dysphagia can improve patient outcomes
6. Gather physical examination and laboratory data that influence medication administration
(e.g vital signs, real and liver function, laboratory values).
Rationale: Data sometimes reveal need to hold medication or that medication is contraindicated.
Poor liver and kidney function affects metabolism and excretion of medications
7. Assess patient’s knowledge regarding health and medication use
Rationale: Determines patient’s need for medication education and guidance needed to achieve
drug adherence. Assessment often reveals problems such as medication tolerance, nonadherence,
abuse, addiction or dependence
8. Assess patient’s preferences for fluids. Maintain fluid restriction when applicable.
Determine if medication can be given with preferred fluid.
Rationale: Fluid ease swallowing and facilitate absorption from the GI tract. Some fluids
interfere with absorption of medications.
PLANNING
1. Collect appropriate equipment and MAR
Rationale: Enhances time management and efficiency
2. Plan preparation to avoid interruptions. Do not take phone calls or talk with others.
Follow agency policy.
Rationale: Interruptions contributes to medication errors. Use no-interruption zone when
possible
IMPLEMENTATION
1. Prepare medications
a. Perform hand hygiene
Rationale: reduces transfer of microorganisms
b. If using a medication cart, move it outside patient’s room. Option: Arrange medication
cups in medication preparation area
Rationale: Organization of equipment saves time and reduces error
c. Log into automated dispensing system(ADS) or unit-dose cart or unlock medicine drawer
or cart
Rationale: Medications are safeguarded when locked in cabinet, cart, or computerized m
education dispensing system
d. Prepare medication for one patient at a time. Follow the six rights of medication
administration. Keep all pages of MAR’s for one patient together or look at only one
patient’s medication administration computer screen at a time.
Rationale: Preventing distractions limits preparation errors
e. Select correct medication from stock supply, unit-dose drawer or ADS. Compare name of
medication on label with MAR
Rationale: Reading labels and comparing them with transcribed order reduces error.
This is the first accuracy check.
f. Check expiration date on each medication one at a time. Return outdated drug to
pharmacy
Rationale: Medications used past their expiratory date may lose strength, be inactive or
harm patient.
g. Check or calculate medication dose as necessary .Double check calculation. If needed,
have another nurse verify calculations
Rationale: Double-checking reduces risk of error. Some agencies require nurses to
double-check calculations of certain medications with another nurse
h. If preparing a controlled substance, check record for previous medication count ad
compare current court with supply available
Rationale: Controlled substance laws require nurses to carefully monitor and count
dispensed narcotics
i. Prepare solid forms of oral medications
 To prepare unit-dose tablets, place packaged tablet directly into medicine cup. Do not
remove wrapper
Rationale: Wrapper maintains cleanliness of medications and allows you to identify
medication name and dose at patient’s bed side
 Place all tablets for patient in one medicine cup, except for those requiring
preadministration assessments, keep medications in their wrappers
Rationale: Keeping medications that require preadministration assessments separate
from others make it easier to withhold medications as necessary.
 If patient has difficulty swallowing and liquid medications are not an option, use pill
crushing device. Clean crushing device before using it. If a pill-crushing device is not
available, place tablet between two medication cups ad grid with a blunt instrument. Mix
ground tablet in small amount of soft food.
Rationale: Large tablets are often difficult to swallow .Ground tablet mixed with
palatable soft food is usually easier to swallow. Clean pill-crushing device ensures that
contamination of medications does not occur.
2. Administer medications
a. Take medication to a patient at a correct time
Rationale: Ensures intended therapeutic effect and complies with professional standards
b. Identify patient using at least 2 identifiers (name and birthday or name and medical
record number) according to agency policy.
Rationale: Ensures correct patient. Complies with the Joint Commission standards and
improves patient safety
c. Compare identifiers with information on patient’s MAR or medical record
Rationale: Final check of medication labels against MAR at patient’s bedside reduces
medication administration errors. This is the third check for accuracy
d. Explain purpose of each medication, its action and possible adverse effects to patient.
Explore concerns expressed by patient and verify orders if concerns about accuracy of
medication orders arise.
Rationale: Patient has the right to be informed; questions often indicate need for
teaching or possible nonadherence to therapy. Allows patient ot express concerns
regarding medications and possibly identifies potential errors in medication orders.
e. Perform necessary preadministration asssessments. Verify allergies with the patient
Rationale: Determines whether specific medications should be withheld at that time
f. Help patient to sitting or Fowlers position. Use side-lying position if sitting is
contraindicated. Have patient stay in the position for 30 minutes after administration.
Rationale: Sitting position prevents aspiration during swallowing
For tablets: Some patients want to hold solid medications in hand or cup before placing in
mouth. Offer water or juice to help patient swallow and give full glass if not
contraindicated.
Rationale: Patient becomes familiar with medications by seeing each drug. Choice of
fluid can improve fluid intake.
g. If patient is unable to hold medications, place medication cup to lips and gently introduce
each drug into mouth, one at atime. Consider using spoon to place pills in mouth. Do not
rush or force medications
Rationale: Administering single tablet or capsule eases swallowing and decreases risk of
aspiration
h. Stay until patient completely takes all medications by their prescribed route. Ask patient
to open mouth if uncertain whether medication was swallowed
Rationale: You are responsible for ensuring that patient receives order dosage. If left
unattended, some patient don not take dose or save medications, causing risk to health
i. For highly acidic medications, offer patient nonfat snack if not contraindicated by his or
her condition.
Rationale: Reduces gastric irritation. The fat content of foods can delay medication
absorption
j. Help patient return to comfortable position
Rationale: Maintains patient’s comfort
k. Dispose of soiled supplies and perform had hygiene.
Rationale: Hand hygiene reduces transmission of microorganisms
l. Replenish stock such as cps and straws, return cart to medication room if used and clean
work area
Rationale: Maintaining clean and organized workspace enhances efficiency of all staff.
EVALUATION
1. Evaluate the patient’s response to medications at a times that correlate with onset, peak,
and duration of the medication
Rationale: Evaluates therapeutic benefit of medication and detects onset of side effects
or allergic reactions
2. Ask patient or family member to identify medication name and explain purpose, action,
dosage schedule and potential side effects of drug
Rationale: Determines level of knowledge gained by patient and family
3. Use teach back to determine patient’s and family’s understanding about oral medications
Rationale: Evaluates what the patient and family are able to explain or demonstrate.
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
1. Patient exhibits adverse effects
 Always notify health care provider and pharmacy when patient exhibits adverse effects
 Withhold further doses and add allergy information to patient’s medical record
2. Patient refuses medications
 Explore reasons why patient does not want medication
 Educate if misunderstandings of medication therapy are apparent
 Do not force patient to take medication: patient have the right to refuse treatment. If
patient continues to refuse medication despite education attempts, record why the drug
was withheld on his or her chart and notify the health care provider
RECORDING AND REPORTING
 Record pertinent information on MAR, included initials or signature, recorded patient
teaching and validation of understanding in nurse’s notes
 Recorded reason for withholding doses in nurses’ notes if necessary
 Report adverse effects/patient response/withheld drugs to nurse in charge or health care
provider
Chest Physiotherapy
Postural Drainage is an airway clearance technique that uses the effect of gravity to clear
secretions from different segments of the lungs. As postural drainage is using the effect of
gravity the affected part of the lungs need to be positioned at a higher point of the body inorder
for the secretions to move. For effective clearance -stay in each position for 10-15 mins
-combined with techniques Postural drainage is combined with techniques like chest wall
vibrations and forced expiration techniques to achieve better efficiency.
Do not perform postural drainage:
 Full stomach (Had a meal less than 1/2 hrs before)
 Gastro-oesophageal reflux or acid reflux
 Nausea -significant increase in breathlessness
  fresh blood in your sputum (haemoptysis)
 recent rib, spine or muscle injury
 wheeze
Purpose

1. To perform chest physiotherapy (PT) according to the standard of care.

Assessment

 Assess the client's medical record for orders regarding activity and position restrictions,
tolerance of physiotherapy, and position changes.
 Assess bilateral breath sounds, noting rate and character.
 Assess the time of last oral intake. Avoid initiating therapy until 2 hours after solid food
and 1 hour after liquids.
Equipment

 Stethoscope
 Pillows or folded towels for positioning
 Tilt or postural drainage table (if available) or adjustable hospital bed
 Gloves, face shield, and gown
 Emesis basin
 Facial tissues
 Suction equipment
 Equipment for oral care
 Trash bag
 Optional: sterile specimen container, mechanical ventilator, and supplemental oxygen
Procedure

1. Verify the order.

Rationale: Verification of order prevents potential errors.

2. Confirm the client's ID. Compare the name with the name on the client's ID bracelet
using two client identifiers according to your facility's policy. Do not start the treatment if
the client is not wearing an ID bracelet.

Rationale: Checking identification ensures client safety through concept of correct

procedure for correct client.

3. Provide privacy and explain the procedure to the client.

 Rationale: Explanation protects client's rights and encourages participation in care.

4. Wash your hands, don gloves, a face shield, and a gown, and follow standard precautions.

Rationale: Handwashing and protective equipment reduce transfer of

microorganisms and protect nurse.

5. Auscultate the client's lungs.

Rationale: Auscultation determines baseline respiratory status.

6. Position the client as ordered. In generalized disease, drainage usually begins with the
lower lobes, continues with the middle lobes, and ends with the upper lobes. In localized
disease, drainage begins with the affected lobes and then proceeds to the other lobes to
avoid spreading the disease to uninvolved areas (Fig. 1).

Rationale: Gloves and equipment protect you from secretions.

Position 1 is for secretion at the front and top of both lungs

-sit up in bed
Position 2 is for secretion at the back and top of both lungs
-sit up in bed, lean forward onto 2 pillows
Position 3 is for secretion at the front upper portion of both lungs
-lie facing up with a pillow under your knees for comfort
Position 4 is for secretion at the upper back portion of right lung
-lie on left side with knees bent. Place 1 pillow under the chest, rotate body slightly forward
Position 5 is for the secretion at the upper back portion of left lung
Lie on the right side with knees bent Place 1 pillow under the chest, rotate body slightly forward,
Elevate head of bed
Position 6 is for secretion at the middle right lung
-lie on the left side with knees bent, place 1 pillow behind the back, rotate body slightly
backwards, elevate the foot of bed 15 degrees
Position 7 is for secretion at the middle left lung
-lie on the right side with knees bent, place 1 pillow behind the back, rotate body slightly
backwards, elevate the foot of bed 15 degrees
Position 8 is for secretion at the front lower portion of both lungs
-lie facing up with a pillow under the knees for comfort, elevate the foot of bed 20 degrees
Position 9 is for secretion at the back portion of both lungs
-lie facing down with 1 pillow under abdomen
Position 10 is for secretion at the lower back portion of both lungs
-lie facing down, elevate the foot of bed 20 degrees
Position 11 is for the lower back portion of the right lung
-lie on the left side with knees bent, place a pillow under chest, rotate body slightly forward,
elevate the foot of bed 20 degrees
Position 12 is for the lower back portion of the left lung
-lie on the right side with knees bent, place a pillow under the chest, rotate the body slightly
forward
Instruct the client to remain in each position for 10 to 15 minutes. During this time, perform
percussion and vibration, as ordered.

Rationale: Percussion and vibration loosen secretions in target areas.

a. To perform percussion, instruct the client to breathe slowly and deeply, using the
diaphragm, to promote relaxation. Hold your hands in a cupped shape, with fingers flexed
and thumbs pressed tightly against your index fingers. Percuss each segment for 1 to 2
minutes by alternating your hands against the client in a rhythmic manner. Listen for a
hollow sound on percussion to verify correct performance of the technique (Fig. 2).
b. To perform vibration, ask the client to inhale deeply and then exhale slowly through
pursed lips. During exhalation, firmly press your fingers and the palms of your hands
against the chest wall. Tense the muscles of your arms and shoulders in an isometric
contraction to send fine vibrations through the chest wall. Vibrate during five exhalations
over each chest segment

Forced Expiratory Techniques

Technique 1- Huffing
Huffing involves taking a breath in and actively exhaling with your mouth and throat open. It is
as if you are misting up a mirror. Perform 2 or 3 times before coughing
Technique 2 - Coughing
Coughing is key in clearing secretions in airways. It involves taking a breath in and forcefully
exhaling with your mouth and throat open
Chest Wall Vibrations involve the application of fine oscillatory movements combined with
chest wall compressions. Initiated at the end of inspiration and applied throughout expiration.
The chest wall vibrations move secretions towards the larger airways for removal. You may put a
layer of towel over the chest wall area for comfort

Technique 1
With one hand over the other place hand firmly on the chest wall over the part of the lung that
needs to be drained. Press the top and bottom hands into each other, instruct the patient to
breathe in and breathe out. As patient breathes out tense the muscles of your arms and shoulders
and apply a light vibration pressure in an inward and downward direction. Instruct the patient to
cough or huff forcefully, if the patient feels that secretions are in his throat.
Technique 2
Place your hands side by side firmly on the chest wall over the part of the lungs that needs to be
drained.

1. After postural drainage, percussion, or vibration, instruct the client to cough to remove
loosened secretions. First, tell the client to inhale deeply through the nose and then exhale
in three short huffs. Then, have the client inhale deeply again and cough through a
slightly open mouth. Three consecutive coughs are highly effective. An effective cough
sounds deep, low, and hollow; an ineffective one sounds high pitched.

Rationale: Coughing removes secretions that have accumulated in trachea.

2. Have the client perform coughing exercises for about 1 minute and then rest for 2
minutes. Gradually progress to a 10-minute exercise period four times daily. Try to
schedule the last session just before bedtime.

Rationale: Scheduling chest physiotherapy before bed will help maximize client's

oxygenation while sleeping.

3. If the client's cough is ineffective, suction the client.

Rationale: Suction removes secretions that have accumulated in trachea.

4. Monitor the client's response to the treatment. Be alert for significant color changes,
particularly if the client becomes dusky.

Rationale: A dusky color may indicate poor oxygenation.

5. Dispose of secretions appropriately.

 6. Provide oral hygiene.

Rationale: Secretions may have a foul taste or a stale odor.

7. Auscultate the client's lungs.

Rationale: Auscultation evaluates effectiveness of therapy.

8. Record the date and time of chest PT; which chest segments were percussed or vibrated;
the color, amount, odor, and viscosity of any secretions produced and the presence of any
blood; any complications and nursing actions taken; and the client's tolerance of
treatment.

Special Considerations

 For optimal effectiveness and safety, modify chest PT according to the client's condition.
For example, initiate or increase the flow of supplemental oxygen, if indicated. If the
client tires quickly during therapy, shorten the sessions because fatigue leads to shallow
respirations and increased hypoxia.
 Maintain adequate hydration in the client receiving chest PT to prevent mucus
dehydration and promote easier mobilization of secretions. Avoid performing postural
drainage immediately before or within 1½ hours after meals to avoid nausea, vomiting,
and aspiration of food or vomitus.
 Because chest percussion can induce bronchospasm, any adjunct treatment (for example,
intermittent positive-pressure breathing, aerosol, or nebulizer therapy) should precede
chest PT.
 Refrain from percussing over the spine, liver, kidneys, or spleen to avoid injury to the
spine or internal organs. Avoid performing percussion on bare skin or the female client's
breasts. Percuss over soft clothing (but not over buttons, snaps, or zippers) or place a thin
towel over the chest wall. Remember to remove jewelry that might scratch or bruise the
client.
 Teach coughing and deep-breathing exercises preoperatively so that the client can
practice them when pain-free and better able to concentrate.
 Postoperatively, splint the client's incision using your hands or, if possible, teach the
client to splint it to minimize pain during coughing.
Complications

 During postural drainage in head-down positions, pressure on the diaphragm by

abdominal contents can impair respiratory excursion and lead to hypoxia or orthostatic
hypotension. The head-down position also may lead to increased intracranial pressure,
which precludes the use of chest PT in a client with acute neurologic impairment.
  Vigorous percussion or vibration can cause rib fracture, especially in the client with
osteoporosis. In an emphysematous client with blebs, coughing could lead to
pneumothorax.

Administer Nasal Medications

Nasal medications are instilled for the treatment of allergies, nasal congestion, and sinus
infections. The nose is not a sterile cavity, but medical asepsis must be observed because of its
connection to the sinuses. Prior to administering nasal medications ask the patient to gently blow
their nose.

Following administration, burning may be felt. At this point blowing the nose is discouraged, as
the medication has not had time to absorb. Depending on the purpose of the nasal medication,
different positioning may help facilitate delivery of the medication to the correct sinus area.

Safety considerations:

 Have the patient gently blow their nose prior.

 Many nasal medications require shaking to disperse medication in liquid.
 If specific sinuses are targeted for the medication, position accordingly:
 Posterior pharynx—position the head backward
 Ethmoid / sphenoid sinuses—with patient supine place pillow under shoulders and tilt
head back
 Frontal / maxillary sinuses—place head back and turned toward the side intended to
receive the medication
 Avoid blowing nose immediately after to allow medication an opportunity to absorb.

STEPS

1. Perform hand hygiene prior to medication preparation. Check MAR to guide you to which
medications you are preparing. Follow agency policy to ensure MARs are accurate and verified
appropriately.
Rationale: A MAR that is checked by more than one healthcare professional provides a very
reliable record for administering medications. Agencies may vary in relation to MAR
verification
2. a. As you are removing medications from the dispensing system, perform the SEVEN rights
three times with each individual medication:
 The right patient
 The right medication (drug)
 The right dose
 The right route
 The right time
 The right reason
  The right documentation
Rationale: The right patient: Check that you have the correct patient using two patient
identifiers (e.g., name and date of birth).
The right medication (drug): Check that you have the correct medication and that it is
appropriate for the patient in the current context.
The right dose: Check that the dose makes sense for the age, size, and condition of the patient.
Different dosages may be indicated for different conditions.
The right route: Check that the route is appropriate for the patient’s current condition.
The right time: Adhere to the prescribed dose and schedule.
The right reason: Check that the patient is receiving the medication for the appropriate reason.
The right documentation: Always verify any unclear or inaccurate documentation prior to
administering medications.

b. The label on the medication must be checked for name, dose, and route, and compared with
the MAR at three different times:
 When the medication is taken out of the drawer.
 When the medication is being poured.
 When the medication is being put away or at bedside.
Rationale: These checks are done before administering the medication to your patient. If taking
drug to bedside (e.g., nose drops), do a third check at the bedside.
3. Before instilling nasal medication, ask the patient to gently blow their nose.
Rationale: Nose blowing clears the nose prior to medication instillation.
4. Donne clean, non-sterile gloves
Rationale: Using gloves protects the nurse from potential contact with patient body fluids and
medications.

Steps for using a pump bottle

1. Gently blow your nose to clear it of mucus before using the medicine.
2. Remove the cap. Shake the bottle. The first time you use the pump spray each day, you
may have to “prime” it. Do this by squirting it a few times into the air until a fine mist comes
out.
3. Put your head down and then pull your nostril out with one finger so the left nostril is
going to spray with the right hand while pulling the nostril out with the left finger.
4. Hold the pump bottle with your thumb at the bottom and your index and middle fingers
on top.
5. Insert the canister tip in your nose, aiming the tip toward the back of your head. Pull your
nostril out with one finger so the left nostril is going to spray with the right hand while pulling
the nostril out with the left finger.
6. Squeeze the pump then sniff a little bit so it doesn’t drip out and to keep the medication
up in the nose. The proper angle is up and slightly out so it’s almost towards the corner of the
eye. Repeat these steps for the other nostril. If you’re using more than one spray in each nostril,
follow all these steps again.
 Note: Some people use the right hand to spray both sides of the nose so if you’re right handed
the angles are perfect for spraying to your left side. It’s not perfect to spray in the right side. It is
because you will end up spraying right onto the wall of septum that divides the left and right side
of nose and if the spray collects there, it tends to cause an irritation and bleeding.

7. Try not to sneeze or blow your nose just after using the spray. Do not spray it and snort it
because it will go immediately on your throat and you will taste it and it’s not going to
be effective.

5. Remove gloves and assist patient to a comfortable and safe position.

Rationale: This ensures patient safety and comfort.
6. Perform hand hygiene.
Rationale: Hand hygiene prevents the spread of microorganisms.
7. Document as per agency policy. Include date, time, dose, route; which naris the medication was
instilled into (or whether it was both nares); and patient’s response to procedure.
Rationale: Timely and accurate documentation helps to ensure patient safety.