w1 Pharmacology

PHARMACOLOGY
TERMINOLOGIES
Medication A substance administered for the diagnosis, cure, treatment, or relief of
a symptom or for prevention of disease.
1. Medication and drug are generally used interchangeably. The
term drug also has the connotation of an illicitly obtained
substance such as heroin, cocaine, or amphetamines.
2. One drug can have four kinds of names:
• Generic name
o Assigned by the United States Adopted Names
(USAN) Council and is used throughout the
drug’s lifetime.
• Trade name (or brand name)
o The name given by the drug manufacturer and
identifies it as property of that company.
o Usually short and easy to remember.
• Official name
o The name under which a drug is listed in one of 1
the official publications.
• Chemical name
o The name by which a chemist knows it
o This name describes the constituents of the drug
precisely.
Prescription A written direction for the preparation and administration of a drug.
Pharmacology The study of drugs and their effect on living systems.
Pharmacy • The art of preparing, compounding, and dispensing drugs.
• The place where drugs are prepared and dispensed.
Pharmacist A licensed health professional who prepares, dispenses and advises on
medicinal drugs.
Clinical pharmacist A specialist who often guides the primary care provider in prescribing
drugs.
Pharmacy technician A member of the health team who in some states administers drugs to
clients.
Pharmacologist A scientist that researches new drugs.
Pharmacopoeia • Also spelled as pharmacopeia.
• A book containing a list of products used in medicine, with
descriptions of the product, chemical tests for determining
identity and purity, and formulas and prescriptions.
PHARMACOKINETICS
• Pharmacokinetic refers to what the body does to a drug.
• It is the study of the absorption, distribution,
biotransformation, and excretion of drugs.
PROCESS OF PHARMACOKINETICS (ADME)
1. ABSORPTION
• Absorption is the processes of entry of a drug
into the systemic circulation from the site of its administration.
• Bioavailability
o The rate and extent to which an administered drug reaches the systemic
circulation.
o For example, if 100 mg of a drug is administered orally and 70 mg is
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absorbed unchanged, the bioavailability is 0.7 or 70%.
o Factors influencing bioavailability
▪ First-pass metabolism
• When a drug is
absorbed from the GI
tract, it enters the
portal circulation
before entering the
systemic circulation.
▪ Solubility of the drug
• Aqueous solution mix more readily than those in oily
solution.
• Most drug absorption occurs in small intestine.
• The rate and extent of absorption depend on:
o The environment where the drug is absorbed
o Chemical characteristics of the drug
o The route of administration (which influences bioavailability).
• Factors influencing absorption
o Food
▪ Can delay the dissolution and absorption of some drugs as well as
their passage into the small intestine.
▪ Can also combine with molecules of certain drugs, thereby changing
their molecular structure and subsequently inhibiting or preventing
their absorption.
o Acid in the stomach
▪ Acidity can vary according to the time of day, foods ingested, use of
antacid medications, and the age of the client.
▪ Some drugs do not dissolve or have limited ability to dissolve in the
GI fluids, decreasing their absorption into the bloodstream.
o Blood flow to the absorption site
▪ Nitroglycerin is administered under the tongue where it is absorbed
into the blood vessels that carry it directly to the heart.
• If swallowed, this drug will be absorbed into the bloodstream
and carried to the liver, where it will be destroyed.
▪ Route of choice for rapid action is intravascular administration 3
(e.g., IV)
• It does not involve absorption thus, there is no loss of drug.
Bioavailability = 100%
▪ Intramuscular (IM)route is the next most rapid route due to the
highly vascular nature of muscle tissue.
▪ Absorption from subcutaneous tissue is slower due to pooper blood
supply than muscle tissue.
o Application of heat
▪ Increases blood flow to the area, thus increase rate of absorption of
drug.
▪ Cold slow down absorption of drug.
o Vasoconstrictor
▪ Epinephrine slow down the absorption of other drugs.
o Oil
▪ Some drugs intended to be absorbed slowly are suspended in a low-
solubility medium.
o Route
▪ The absorption of drugs from the rectum into the bloodstream tends
to be unpredictable. Thus, this route is normally used when other
routes are unavailable or when the intended action is localized to the
rectum or sigmoid colon.
2. DISTRIBUTION
• The transportation of a drug from its site of absorption to its site of action.
• When a drug enters the bloodstream, it is carried to the most vascular organs—that
is, liver, kidneys, and brain.
• Body areas with lower blood supply like skin receive the drug later.
3. METABOLISM
• Also called detoxification or biotransformation.
• Biotransformation is the metabolic conversion of drug molecules to more water-
soluble metabolites or less active form that are more readily excreted.
• Most biotransformation takes place in the liver, where many drug-metabolizing
enzymes in the cells detoxify the drugs.
• Metabolites is the product of biotransformation.
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o Two types:
▪ Active metabolite has a pharmacologic action.
▪ Inactive metabolite does not have pharmacologic action.
• Biotransformation may be altered if a person is very young, is older, or has an
unhealthy liver.
• Half-life
o The time interval required for the body’s elimination processes to reduce
the concentration of the drug in the body by one-half.
o Example:
▪ If a drug’s half-life is 8 hours, then the amount of drug in the body
is as follows:
• Initially: 100%
• After 8 hours: 50%
• After 16 hours: 25%
• After 24 hours: 12.5%
• After 32 hours: 6.25%
o Because the purpose of most drug therapy is to maintain a constant drug
level in the body, repeated doses are required to maintain that level.
o Terminology
▪ Onset of action
• The time after administration when the body initially
responds to the drug
▪ Peak plasma level
• The highest plasma level achieved by a single dose when the
elimination rate of the drug equals the absorption rate
▪ Drug half-life (elimination half-life)
• The time required for the elimination process to reduce the
concentration of the drug to one-half what it was at initial
administration
▪ Plateau
• A maintained concentration of a drug in the plasma during a
series of scheduled doses
4. ELIMINATION
• The process by which metabolites and drugs are eliminated from the body.
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• Most drug metabolites are eliminated by the kidneys in the urine.
• Some are excreted in the feces, the breath, perspiration, saliva, and breast milk.
• Older people may require smaller doses of a drug because the drug and its
metabolites may accumulate in the body.
PHARMACODYNAMICS
• The mechanism of drug action and the relationships between drug concentration and
responses in the body.
RECEPTOR
• The drug’s specific target, usually a protein located on the surface of a cell membrane or
within the cell.
• As the drug binds to the receptor, it enhances or inhibits the normal cellular function.
• The binding is usually reversible and the action of the drug terminated once the drug leaves
the receptor.
• When a drug binds to its receptor, the pharmacologic effects are either agonism or
antagonism.
o Agonist
▪ When a drug produces the same type of response as the physiological or
endogenous substance.
▪ For example:
• Epinephrine-like drugs act on the heart to increase the heart rate.
o Antagonist
▪ A drug that inhibits cell function by occupying receptor sites.
▪ It prevents natural body substances or other drugs from activating the
functions of the cell by occupying the receptor sites.
▪ For example:
• Naloxone (Narcan) is an opioid antagonist used as an antidote for
respiratory depression caused by an opioid drug.
o It competes with opioid receptor sites in the brain and
thereby prevents the opioid from binding to its receptors.
o By blocking the effect of the opioid, respiratory depression
is reversed.
FACTORS AFFECTING DRUG THERAPY 6
• Development
o Infants
▪ Immaturity of liver and kidney require decrease dose.
o Older adults
▪ Decrease liver and kidney function lead to accumulation of the drug in the
body.
▪ Decrease circulation and gastric function that lead to decrease medication
absorption.
▪ Many meds (polypharmacy) increases interactions.
o Pregnancy
▪ Some medications may cause abnormal development of embryo
(teratogenic effect).
• Diet
o Nutrients can increase or decrease absorption or action of medication.
• Gender
o Distribution of body fat, body fluid and hormones affect medication action.
• Environment
o Environmental temperature can increase or decrease peripheral vasoconstriction
altering medication action.
o Noise can interfere with effect of sedatives and analgesics.
• Pathology
o Decrease liver or kidney function cause increase medication accumulation.
o Decrease gastric or decrease circulatory function cause decrease medication
absorption.
• Time of administration
o Increase absorption on empty stomach
o With food to decrease gastrointestinal distress
o Circadian and sleep cycles can affect response
• Body weight
o Dose calculated by client’s weight or body surface area
• Genetic and ethnic
o Usual dose may be toxic
o Herbal treatments may interfere with medication therapy
o Asians may need decrease dose of antipsychotic and antianxiety medications due to 7
slower metabolism of these drugs
o African Americans may need to increase dose of antihypertensives
• Psychological issues
o Client’s positive and negative expectations can increase or decrease response.
MEDICATION ADMINISTRATION
TEN RIGHTS OF MEDICATION ADMINISTRATION
1. Right Medication
• Double check the prescription, medication and expiry date on the medicine.
• Does the medication ordered match the medication you are preparing?
• Is the medication appropriate for the client? Appropriateness is determined by
obtaining a complete medical history, an updated medication history, and any
pertinent laboratory studies.
• Knowing the specifics of the ordered medication is also necessary in determining
suitability for the client.
2. Right Client
• Confirm the patient by a minimum of two identifiers
o Their name
o Check the armband
o Compare a photograph on file to the client
3. Right Dose
• Confirm the dosage using a current drug reference
• If unconfirmed, calculate the dosage and double check with another nurse or doctor
4. Right Time
• To achieve a therapeutic blood level, medication must be given at the right time
• The common rule of thumb for most medicines is to give the medicine within 30
minutes of the scheduled time
• Check with the patient when they had their last dosage
5. Right Route
• Ensure the appropriateness of the route ordered and whether the patient can
receive the medication from this route
6. Right Documentation
• Document the administration of the medication as soon as it has been administered 8
7. Right Client Education
• Explain to the client why they receive the medication, what to expect, and if there
are any precautions
8. Right to Refuse
• Adult clients have the right to refuse any medication
• The nurse’s role is to ensure that the client is fully informed of the potential
consequences of refusal and to communicate the client’s refusal to the health care
provider
9. Right Assessment
• Some medications require specific assessments prior to administration (e.g., apical
pulse, blood pressure, lab results)
10. Right Evaluation
• Check if the effect of the medication to the client, if it was a desired effect or no, or
are there any side effects or adverse effect.
CLIENT TEACHING IN MEDICATION ADMINISTRATION
• Assess client attitude, self-administration skills

• Provide clear oral and written instructions, use understandable language
• Include family members
• Evaluate learning, return demonstration
• Inform the client about:
o Generic and trade name, purpose, therapeutic effect
o Dose, route, frequency, and when to take prn medications
o Nontherapeutic effects and what to do if sign and symptoms occur
o What to do if a dose is missed
o Specific implications on how to store, to take with/without food, pre and post-
administration assessments
NEED TO BE DONE BEFORE ADMINISTERING ANY MEDICATION
• Make sure the client is not hypersensitive to the drug being given.
• Make sure your client does not have a known allergy to the medication.
• Get a complete history from your client. Look at all medications the client is taking and 9
make sure there are no adverse drug or food interactions.
• Know why you are giving the drug and what the expected response is.
• Are there any labs or vital signs you need to check prior to administration?
• Document and report any adverse effects and counteract these effects appropriately.
• Find out if the client is pregnant or breast-feeding, as most medications are contraindicated
in these women.
SAFE MEDICATION ADMINISTRATION
• Check client’s record for allergies.

• Confirm written order; repeat back and have a witness for verbal or phone orders
• Question overdose or subtherapeutic dose
• Question medication duplication or extended use
• Question medication order without indication for use
• Investigate compatibilities and interactions
• Calculate medication dosage accurately; have another practitioner double check calculation.
• Follow client administration rights, and triple check procedures.
• Do not rush client, ensure client has ingested oral medications.
• Record medication administered.
• Document reasons for non-administered medication.
• Evaluate client’s response (therapeutic, nontherapeutic).
• Notify the doctor of concerns or if client vomits within 10min after ingestion.
• Do not borrow medications from another client.
• Give only medications personally prepared.
• Do not leave medications at bedside.
• Double lock-controlled medications; have waste witnessed.
• Use filtered needle when drawing medications from ampule.
• Crush medications to facilitate ingestion; do not crush enteric or time-release drugs; mix
with smallest volume (applesauce).
• Never document before medication is administered.
• Document and report all medication errors.
OVER THE COUNTER MEDICATIONS
• Over-the-counter medications (OTC) are medications that can be obtained without a 10

prescription, allowing clients to self-treat their ailments without seeking health care advice.
o Be sure to review the use of OTCs during the client’s health history.
o Teach your client these medications can be harmful if not taken correctly.
o Your client should also be able to recognize contraindications and possible adverse
reactions.
o Some of the more common types of OTC medications are antacids (Tums, Maalox)
and acid-controlling drugs (Tagamet, Pepcid); antifungal agents (Lotrimin,
Monistat); antihistamines and decongestants (Benadryl, Claritin, Robitussin);
acetaminophen (Tylenol); aspirin (Bayer, Ecotrin); and ibuprofen (Advil, Motrin).
ALTERNATIVE OR COMPLEMENTARY THERAPIES
• Alternative or complementary therapies are nontraditional therapeutic methods such as

herbal medicines, chiropractics, acupuncture, and reflexology.
• Herbal remedies need to be considered when obtaining a medication history from your
client. They are available over-the-counter and used for a variety of ailments. As with any
drug, herbal products can have drug or food interactions when taken with certain
medications.
• Clients should be aware that even though herbs are natural substances, they can still be
harmful and manufacturers of these products are not required to provide proof of
effectiveness or safety.
DEVELOPMENTAL CONSIDERATION IN ADMINISTERING MEDICATION
• Infant and children

o Oral medications
▪ Prepared in sweetened liquid form to make them more palatable.
▪ Nursing care
• Do not use necessary foods such as milk or orange juice to mask the
taste of medications, because the child may develop unpleasant
associations and refuse that food in the future.
o Injections
▪ Nursing care
• The nurse needs to acknowledge that the child will feel some pain;
denying this fact only deepens the child’s distrust.
• Older adults 11
o Physiological changes that influence medication administration and effectiveness
▪ Altered memory
▪ Decreased visual acuity
▪ Decrease in renal function, resulting in slower elimination of drugs and
higher drug concentrations in the bloodstream for longer periods.
▪ Less complete and slower absorption from the GI tract.
▪ Increased proportion of fat to lean body mass, which facilitates retention of
fat-soluble drugs and increases potential for toxicity.
▪ Impaired circulation delays the action of medications given intramuscularly
or subcutaneously.
▪ Decreased liver function, which hinders biotransformation of drugs.
▪ Decreased organ sensitivity, which means that the response to the same
drug concentration in the vicinity of the target organ is less in older people
than in the young.
▪ Altered quality of organ responsiveness, resulting in adverse effects before
therapeutic effects are achieved.
▪ Decrease in manual dexterity due to arthritis and/or decrease in flexibility
o Due to these changes, the possibility of cumulative effects and toxicity increases.
o Reaction of older people in sedatives are unpredictable and often bizarre; that is
why they require smaller dosages of drugs.
o Nursing care
▪ The nurse should stay with client until they have swallowed the medications.
Some older people do not swallow or spitting out tablets or capsules after
the nurse leaves the room.
▪ Nurse should instruct the client when to take the drugs, what effects to
expect, and when to consult a primary care provider.
▪ The nurse needs to develop simple, realistic plans for clients to follow at
home.
▪ Older clients sometimes forget that they already took the medication, thus,
the nurse should advise the client to use a special container or glass strictly
for medications.
ROUTES TO ADMINISTER MEDICATION

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ORAL ROUTE
• The drug is swallowed.

• Oral medications are absorbed in the small intestine and circulate through the liver.
• Toxicities and overdose by the oral route may be overcome with antidotes, such as
activated charcoal.
• Nursing care
o Increase head of bed to ensure safe swallowing
o Pace intake to decrease aspiration
o If difficulty swallowing:
▪ Crush and mix with food (contraindicated for extended release and enteric
coated medications) or obtain liquid form if available.
▪ Obtain order for alternate route
ADVANTAGE DISADVANTAGE
Most convenient Inappropriate for clients with nausea or
vomiting
Usually least expensive Drug may have unpleasant taste or odor
Safe, does not break skin barrier Inappropriate when GI tract has reduced
motility
Administration usually does not cause stress Inappropriate if client cannot swallow or is
unconscious
Some new oral medications are designed to Cannot be used before certain diagnostic tests
rapidly dissolve on the tongue, allowing for or surgical procedures
faster absorption and action Drug may discolor teeth, harm tooth enamel
Drug may irritate gastric mucosa
Drug can be aspirated by seriously ill clients
SUBLINGUAL ROUTE
• Placement under the tongue allows a drug to diffuse into

the capillary network and to enter the systemic circulations directly.
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• The medication should not be swallowed.
• Nursing care
o Instruct the client to keep liquid/tablet under tongue.
o Warn not to chew/swallow tablet or sleep until it is absorbed.
More potent than oral route because drug If swallowed, drug may be inactivated by
directly enters the blood and bypasses the liver gastric juice
Usually least expensive Drug must remain under tongue until
dissolved and absorbed.
Safe, does not break skin barrier May cause stinging or irritation of the mucous
membranes
Administration usually does not cause stress Drug is rapidly absorbed into the bloodstream
Drug can be administered for local effect
Most convenient
BUCCAL ROUTE
• Tablet held between cheek and gum until dissolved

• The drug may act locally on the mucous membranes of the
mouth or systemically when it is swallowed in the saliva.
• Local effect absorbed within mins
• Nursing care
o Alternate cheeks to avoid mucosal irritation
o Warn not to chew or swallow tablet or sleep until dissolved to decrease risk of
aspiration
More potent than oral route because drug If swallowed, drug may be inactivated by
directly enters the blood and bypasses the liver gastric juice
Usually least expensive Drug must remain under tongue until
dissolved and absorbed.
Safe, does not break skin barrier May cause stinging or irritation of the mucous
membranes
Administration usually does not cause stress Drug is rapidly absorbed into the bloodstream 14
Drug can be administered for local effect

Most convenient
Some oral medications are rapidly dissolved on
the tongue for faster absorption and action
PARENTERAL ROUTE
• This route introduces drugs directly across the body’s barrier defenses into the systemic
circulation.
• Used for drugs that are poorly absorbed from the GI tract and for agents that are unstable
in GI tract.
• Used also for treatment of unconscious clients and under circumstances that require a rapid
onset of action.
• These routes have the highest bioavailability and not subject to first-pass metabolism or
harsh GI environment.
• Parenteral administration provides the most control over the actual dose of drug delivered
to the body.
• Four major parenteral routes
o Intravenous (IV) route
▪ Solution injected into intravascular
compartment via a vein.
▪ Drugs administered are irreversible.
▪ This route may cause pain, fear, local tissue damage and infections.
▪ Immediate onset
▪ Most common parenteral route.
▪ It permits a rapid effect and maximum degree of control over the circulating
levels of the drug.
▪ When injected as a bolus, the full amount of a drug is delivered to the
systemic circulation almost immediately.
▪ The same dose is also may be administered as an IV infusion during a longer
time, resulting in a decrease in the peak plasma concentration and an
increase in the time the drug is present in the circulation. 15
▪ IV injection is advantageous for administering chemicals that may cause
irritation when administered via other routes because the substance is
rapidly diluted by the blood.
Rapid effect Limited to highly soluble drugs
Valuable in emergency situations Drug distribution inhibited by poor circulation
Ideal for high molecular weight proteins and Most substances must be slowly injected
peptide drugs
Ideal if dosed in large volumes Unsuitable for oily substances
Suitable for irritating substances and complex Injected medication cannot be recalled by
mixtures strategies such as by binding to activated
charcoal.
May introduce bacteria and other infective
particles through contamination at the site of
injection.
May also precipitate blood constituents,
induce hemolysis, or cause other adverse
reaction by the too rapid delivery of high
concentrations of drug to the plasma and
tissues.
o Intramuscular (IM) route

▪ Solution injected into muscle
▪ Onset 3-5min
▪ Volume 1-3mL
▪ Drugs administered IM can be aqueous solutions, which are absorbed
rapidly or in specialized depot preparation which are absorbed slowly.
▪ Depot preparation often consist of a suspension of the drug in a nonaqueous
vehicle. As the vehicle diffuses out of the muscle, the drug precipitates at
the site of injection, drug then dissolved slowly providing sustained dose
over an extended period of time.
▪ Nursing care 16
• Use standard precautions

• Use sterile technique
• Position client to access injection site
• Rotate sites; landmark sites
Can administer larger volume than Can produce anxiety
subcutaneous
Drug is rapidly absorbed Breaks skin barrier, more tissue damage than
subcutaneous
Suitable if drug volume is moderate Affects certain lab tests (creatine kinase)
Suitable for oily vehicles and certain irritating Can cause intramuscular hemorrhage
substances
Used when oral route is contraindicated; more Requires adequate peripheral circulation
rapidly absorbed than oral, topical, or
subcutaneous
o Subcutaneous (SC) route
▪ Injected in tissue just below skin
▪ Onset 3-20min
▪ Volume less than or equal to 1mL
▪ Like IM injection, it requires absorption
via simple diffusion and is somewhat slower
than the IV route.
▪ SC injection minimizes the risk of hemolysis or thrombosis associated with
IV injection and may provide constant, slow and sustained effect.
▪ This route should not be used with drugs that cause tissue irritation because
severe pain and necrosis may occur.
▪ Nursing care
• Use sterile technique
• Rotate injection sites
• Landmark sites
ADVANTAGE DISADVANTAGE 17
Absorption is slower (an advantage for insulin Must involve sterile technique because breaks
and heparin administration) skin barrier
Faster than oral More expensive than oral
Can administer only small volume
Some drugs can irritate tissues and cause pain
Can produce anxiety
Breaks skin barrier
o Intradermal (ID) route

▪ Solution injected into dermis just under epidermis
▪ Slow absorption
▪ Volume 0.1-0.3mL
▪ Used for allergy testing
▪ Nursing care
• Assess for allergic/anaphylactic reaction when used for allergy
testing
Absorption is slow (this is an advantage in Amount of drug administered must be small
testing for allergies) Breaks skin barrier
INHALATION ROUTE
• Medications are dispersed through aerosolized solution or powder that penetrates airways
rapidly promoting absorption
• May be oral or nasal inhalation
• Provide rapid delivery of drug across the large surface of area of the mucus membranes of
the respiratory tract and pulmonary epithelium, producing an effect as rapidly as IV
injection.
• Used for drugs that are gases and those that can be dispersed in an aerosol.
• This route is effective and convenient for clients with respiratory complaints because the
drug is delivered directly to the site of action, thereby minimizing systemic side effects.
• Types
▪ Metered-dose inhaler (MDI)
▪ The MDI is a small, portable
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self-contained drug device combination
that dispenses multiple doses by a metered
value.
▪ Dry powdered inhaler (DPI)

▪ Dose in chamber is aerosolized when inhaled
o Nonpressurized aerosol (nebulizer) (NPA)

▪ An aerosol generator that converts liquid drug solutions
or suspensions into aerosol and is powered by
compressed air, oxygen, a compressor, or an electrically
powered device.
Ideal for gases Client may have difficulty regulating dose
Effective for clients with respiratory problems Most addictive route (drug can enter the brain
quickly)
Localized effect to target lungs: lower doses Drug intended for localized effect can have
used compared to that with oral or parenteral systemic effect
administration.
Fewer systemic side effects Of use only for the respiratory system
Dose can be titrated Some clients may have difficulty using inhalers
TOPICAL ROUTE
• Used when a local effect of the drug is desired.

• Topical applications include
o Dermatologic preparations: applied to the skin
o Instillations and irrigations: applied into body cavities or orifices, such as the
urinary bladder, eyes, ears, nose, rectum, or vagina
ADVANTAGE DISADVANTAGE 19
Few side effects Drug can enter body through abrasions and
cause systemic effects
Leaves residue on the skin that may soil clothes
TRANSDERMAL (PERCUTANEOUS) ROUTE
• Via skin
• Prolonged systemic effect
• Achieves systemic effects by application of drugs to the skin, usually via transdermal patch.
• The rate of absorption can vary markedly, depending
on physical characteristics of the skin
at the site of application as well as the lipid
solubility of the drug.
• This route most often used for the sustained
delivery of drugs.
• For example, nitroglycerin, an antianginal drug.
Prolonged systemic effect Rate of delivery may be variable
Few side effects Some clients are allergic to patches, which can
Avoids GI absorption problems cause irritation
Onset of drug action faster than oral
Convenient and painless
RECTAL ROUTE
• Suppository or solution inserted into anus

• 50 percent of the drainage of rectal region
bypasses the portal circulation, the biotransformation
of drugs by the liver is minimized with rectal
administration.
• Slow absorption
• Local or systemic effect
• Commonly used to administer antiemetic agents.
• Contraindication 20
o For clients with rectal surgery or rectal bleeding
• Nursing care
o Use standard precautions
o Position client in lateral or Sim’s position for insertion
Can be used when drug has objectionable taste May be perceived as unpleasant by the client
or odor
Provides a local therapeutic effect Dose absorbed is unpredictable
Drug released at slow, steady rate Limited use
Bypasses destruction by stomach acid Drugs may irritate the rectal mucosa
Ideal if drug causes vomiting
TYPES OF DRUG PREPARATIONS
TYPES OF DRUG PREPARATIONS
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 non-greasy, 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 or jelly A clear or translucent semisolid that liquefies when applied to the
skin
Liniment A medication mixed with alcohol, oil, or soapy emollient and
applied to the skin
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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 mouth
Ointment (salve, unction) A semisolid preparation of one or more drugs used for
application to the skin and mucous membrane
Paste A preparation like an ointment, but thicker and stiff, 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 small disk; some are
readily broken along a scored line; others are enteric coated to
prevent them from dissolving in the stomach
Tincture An alcoholic or water-and-alcohol solution prepared from drugs
derived from plants
Transdermal patch A semipermeable membrane shaped in the form of a disk or
patch that contains a drug to be absorbed through the skin over
a long period of time
THERAPEUTIC ACTIONS OF DRUGS

THERAPEUTIC ACTIONS OF DRUGS
Palliative Relieves the symptoms of a disease but does not affect the disease
itself.
• Example
o Morphine sulfate, aspirin for pain
Curative Cures a disease or condition.
• Example 22
o Penicillin for infection
Supportive Supports body function until other treatments or the body’s
response can take over.
• Example
o Norepinephrine bitartrate for low blood pressure;
aspirin for high body temperature
Substitutive Replaces body fluids or substances.
• Example
o Thyroxine for hypothyroidism, insulin for
diabetes mellitus
Chemotherapeutic Destroys malignant cells.
• Example
o Busulfan for leukemia
Restorative Returns the body to health.
• Example
o Vitamin, mineral supplements
EFFECTS OF MEDICATIONS
EFFECTS OF MEDICATIONS
Adverse effect Severe side effect or toxicity
Allergic reaction Immunological reaction
Anaphylactic reaction Hypersensitive, life-threatening reaction
Cumulative effect Excessive level of medication in the body when intake is higher
than metabolism or excretion
Drug abuse Inappropriate intake of a medication
Drug dependence Psychological/physiological need to take a medication
Drug habituation Mild form of psychological dependence
Drug interaction When 1 medication alters the effect of 1 or more medications
Drug tolerance Requiring increase dose to achieve therapeutic effect
Drug toxicity Dangerous effect secondary to excessive dose
Idiosyncratic effect Unexpected or unique response
Inhibiting effect 1 medication decreases effect of another medication
Potentiating/ 1 medication adds to, prolongs, or increase action of another
synergistic effect
medication
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Side effect Predictable nontherapeutic effect that is tolerable
Therapeutic/ Reason medication was prescribed
desired effect
MEDICATION ORDERS
TYPES OF MEDICATION ORDERS
• Stat order
o The medication is to be given immediately and only once.
• Single order
o Also known as one-time order is for medication to be given once at a specified time.
• Standing order
o May or may not have a termination date.
o May be carried out indefinitely until an order is written to cancel it, or it may be
carried out for a specified number of days
• PRN order
o Also known as ‘as-needed order’, permits the nurse to give a medication when, in
the nurse’s judgment, the client requires it.
SEVEN ESSENTIAL PARTS OF MEDICATION ORDER
1. Client’s full name

2. Date and time the order is written
3. Name of the drug to be administered
4. Dosage of the drug
5. Frequency of administration
6. Route of administration
7. Signature of the person writing the order
DRUG MEASUREMENT SYSTEMS
METRIC SYSTEM
ABBREVIATIONS EQUIVALENTS
meter: m 1 mcg = 0.000001 g
liter: L 1 mg = 1000 mcg or 0.001 g
milliliter: mL 1 g = 1000 mg
kilogram: kg 1 kg = 1000 g
gram: g 1 kg = 2.2 lb
milligram: mg 1 mL = 0.001 L 24
microgram: mcg
APOTHECARY AND HOUSEHOLD SYSTEMS

ABBREVIATIONS EQUIVALENTS
Apothecary (Weight) 1 gr = 60 or 65 mg
• grain: gr 5 gr = 300 or 325 mg
• ounce: oz 15 gr = 1000 mg or 1 g
Household (Volume) 1 =150 gr = 0.4 mg
• drops: gtt 1 fl oz = 30 mL
• teaspoon: t or tsp 1 T = 15 mL or 3 tsp
• tablespoon: T or tbs 1 t or tsp = 5 mL
• fluid ounce: fl oz 1 C = 8 fl oz
• cup: C 1 qt = 946 mL or 0.946 L
• pint: pt 1 qt = 2 pt or 32 fl oz
• quart: qt 1 pt = 16 fl oz
Household (Weight) 16 oz = 1 lb
• pound: lb 2.2 lb = 1 kg
CALCULATING DOSAGES
BASIC FORMULA
The basic formula for calculating drug dosages is commonly used and easy to remember:
D = Desired dose (i.e., dose ordered by primary care provider)
H = Stock on hand (i.e., dose on label of bottle, vial, ampule)
Q = Quantity (form in which the drug comes, such as tablet or liquid).
Formula = DxQ
H
• Examples
1. Order: Erythromycin 500 mg
On hand: 250 mg in 5 mL
D = 500 mg H = 250 mg Q = 5 mL 25
500 mg x 5 mL = 2,500 = 10 mL
250 mg 250
2. Order: Keflex 750 mg

On hand: Keflex 250 mg capsules
D = 750 mg H = 250 mg Q = 1 tablet
750 mg x 1 tablet = 750 = 3 tablets

250 mg 250
3. Order: Lanoxin 0.25 mg

On hand: Lanoxin 0.125 mg tablets
D = 0.25 mg H = 0.125 mg Q = 1 tablet
0.25 mg x 1 tablet = 0.25 = 2 tablets

0.125 mg 0.125
4. Order: dofetilide 0.5 mg

On hand: 125 mcg capsules
D = 0.5 mg H = 125 mcg Q = 1 capsule
1000 mcg = 1 mg
125 mcg x 1 mg = 0.125 mg/capsule

1 capsule 1000 mcg
0.5 mg x 1 capsule = 4 capsule

0.125 mg
5. Order: Tylenol gr xv (15)

On hand: Tylenol 325 mg tablets
60 mg = 1 gr
325 mg x 1 gr = 5.42 gr/tablet

1 tablet 60 mg
15 gr x tablet = 2.76 tablet or 3 tablets

5.42 gr
26
CALCULATION OF MEDICATION IN CHILDREN

• Body weight
o Children’s dosages are not always standard. Body weight significantly affects
dosage; therefore, dosages are calculated.
o Steps
1. Convert pounds to kilograms.
2. Determine the drug dose per body weight by multiplying drug dose × body
weight × frequency.
3. Choose a method of drug calculation to determine the amount of
medication to administer.
o Examples
1. Order: Keflex, 20 mg/kg/day in three divided doses. The client weighs 20
pounds.
On hand: Keflex oral suspension 125 mg per 5 mL
2.2 pounds = 1 kg
20 pounds x 1 kg = 9 kg
2.2 pounds
20 mg x 9 kg = 180 mg/day
1 kg
180 mg = 60 mg/dose (desired dose)

3 doses
60 mg x 5 mL = 2.4 mL per dose

125 mg
INTRAVENOUS FLOW RATES

• Monitor IV flow rate frequently even if the IV solution is being administered through
an electronic infusion device (follow agency policy regarding frequency).
• If an IV is running behind schedule, collaborate with the physician to determine the
client’s ability to tolerate an increased flow rate, particularly for clients with cardiac,
27
pulmonary, renal, or neurological conditions.
• The nurse should never increase the rate (speed up) of an IV infusion to catch up if
the infusion is running behind schedule.
• Whenever a prescribed IV rate is increased, the nurse should assess the client for
increased heart rate, increased respirations, and increased lung congestion, which
could indicate fluid overload.
• Intravenously administered fluids are prescribed most frequently based on milliliters
per hour to be administered.
• The volume per hour prescribed is administered by setting the flow rate, which is
counted in drops per minute.
• Most flow rate calculations involve changing milliliters per hour into drops per minute.
• Intravenous tubing
o Intravenous tubing sets are calibrated in drops per milliliter; this calibration is
needed for calculating flow rates.
o A standard or macrodrip set is used for routine adult IV administrations;
depending on the manufacturer and type of tubing, the set will require 10, 15,
or 20 gtt to equal 1 mL.
o A minidrip or microdrip set is used when more exact measurements are needed,
such as in intensive care units and pediatric units.
o In a minidrip or microdrip set, 60 gtt is usually equal to 1 mL.
o The calibration, in drops per milliliter, is written on the IV tubing package.
FLOW RATE
Total volume x drop factor = Drops per minute

Time in minutes
INFUSION RATE
Total volume to infuse = Infusion time

Milliliters per hour being infused
NUMBER OF MILLILITERS PER HOUR
Total volume in milliliters = Number of milliliters per hour 28

Number of hours
• Example:
• FLOW RATE
o Ancef 1gm in 100 mL normal saline to be infused over 30 minutes. You have
macrodrip tubing with a drop factor of 10 gtts/mL. How many drops per min
to be infuse?
100 mL x 10 gtts = 33.3 or 33 gtts/min
30 min
• INFUSION RATE
o There are 250 mL of D5W infusing at 33 gtt/min on IV tubing calibrated at 10
gtt/mL. Calculate the infusion time.
250 mL / (33 gtts/min x 60 min) = 250/ (1,980)
10 gtts/mL 10
250/198 = 1.26 hours
0.26 x 60 = 16 min
1 hour and 16 min infusion time
• NUMBER OF MILLILITERS PER HOUR

o 500 mL normal saline to infuse over 12 hours with a microdrip set. How many
mL per hour to be infuse?
500 mL = 41.6 or 42 mL/hour

12 hours
ADMINISTERING ORAL MEDICATION

• Purpose:
o To provide a medication that has systemic effects or local effects on the GI tract or 29
both
ADMINISTERING ORAL MEDICATION

Procedure Score
1 Assessment
• Allergies to medication(s)
• Client’s ability to swallow the medication
• Presence of vomiting or diarrhea that would interfere with the ability
to absorb the medication
• Specific drug action, side effects, interactions, and adverse reactions
• Client’s knowledge of and learning needs about the medication
2 Know the reason why the client is receiving the medication, the drug
classification, contraindications, usual dosage range, side effects, and
nursing considerations
3 • Check for the drug name, dosage, frequency, route of
administration, and expiration date for administering the medication
• Report any discrepancies to the charge nurse
4 Determine whether the client can swallow, is NPO, is nauseated or
vomiting, has gastric suction, or has diminished or absent bowel sounds
5 Hand wash
Check the medication to be given to the client.
Use only medications that have clear, legible labels to ensure accuracy.
6 Calculate the medication dosage accurately
7 Prepare the correct amount of medication for the required dose
8 Tablets or capsules
• Break only scored tablets if necessary, to obtain the correct dosage.
• If the client has difficulty swallowing, check if the medication can be
crushed (there are drugs that cannot be crushed)
9 Liquid medication
• Thoroughly mix the medication before pouring
• Discard any medication that has changed color or turned cloudy
• Place the medication cup on a flat surface at eye level and fill it to
the desired level. This method ensures accuracy of measurement.
• Before capping the bottle, wipe the lip with a paper towel to prevent
the cap from sticking. 30
• When giving small amounts of liquids

(e.g., less than 5 mL), prepare the medication in a sterile syringe
without the needle or in a specially designed oral syringe
10 Oral narcotics
• Check the narcotic record for the previous drug count and compare
it with the supply available
• Remove the next available tablet and drop it in the medicine cup.
• After removing a tablet, record the necessary information on the
appropriate narcotic control record and sign it.
11 Recheck the label on the container before returning the bottle, box, or
envelope to its storage place.
12 Avoid leaving prepared medications unattended. To prevent prevents
potential mishandling errors.
13 Lock the medication cart before entering the client’s room. Medication carts
are not to be left open when unattended.
14 Check the room number of the client to ensure that the nurse is entering the
correct client room.
15 Provide for client privacy
16 Prepare the client
• Introduce self and verify the client’s identity to ensure the right
client receives the medication.
• Assist the client to a sitting position to facilitate swallowing and
prevent aspiration
• Take the required assessment measures before giving the
medications
o Take the apical pulse rate before administering digitalis.
o Take blood pressure before giving antihypertensive drugs.
o Take the respiratory rate prior to administering narcotics
because narcotics depresses the respiratory center.
• Consult the primary care provider before administering the
medication if findings are above or below the predetermined
parameters.
17 Explain the purpose of the medication by using words that easily understand 31
by the client. This can facilitate acceptance of and compliance with the
therapy.
18 Administer the medication at the correct time.
19 • Give the client sufficient water or preferred juice to swallow the
medication. Before using juice, check for any food and medication
incompatibilities to facilitate absorption from the GI tract.
• Liquid medications other than antacids or cough preparations may
be diluted with 15 mL of water to facilitate absorption.
20 If the client is unable to hold the pill cup, use the pill cup to introduce the
medication into the client’s mouth, and give only one tablet or capsule at a
time to ease swallowing.
21 If an older child or adult has difficulty swallowing, ask the client to place the
medication on the back of the tongue before taking the water to stimulate
swallowing reflex.
22 If the medication has an objectionable taste, ask the client to suck a few ice
chips beforehand, or give the medication with juice, applesauce, or pudding
if there are no contraindications. The cold of the ice chips will desensitize
the taste buds, and juices, applesauce, or pudding may mask the taste of the
medication.
23 If the client says that the medication you are about to give is different from
what the client has been receiving, do not give the medication without first
checking the original order. Unfamiliar medications may signal a possible
error.
24 • Stay with the client until all medications have been swallowed before
the drug administration can be recorded.
• The nurse may need to check the client’s mouth to ensure that the
medication was swallowed and not hidden inside the cheek.
25 • Document each medication given, dosage, time, any complaints or
assessments of the client, and your signature.
• If medication was refused or omitted, record this fact on the
appropriate record; document the reason.
26 Discard used disposable supplies. 32
27 Replenish stock like medication cups.

28 • Return to the client when the medication is expected to take effect
(usually 30 minutes) to evaluate the effects of the medication on the
client.
• Observe for desired effect
• Note any adverse effects or side effects (e.g., nausea, vomiting, skin
rash, or change in vital signs).
• Report significant deviations from normal to the primary care
provider.
NASOGASTRIC AND GASTROSTOMY MEDICATIONS
• If the client have a nasogastric tube or a gastrostomy tube in place this can be use as an
alternative route for administering medication.
• A nasogastric (NG) tube is inserted from nasopharynx to stomach
o For feeding
o To remove gastric secretions
• A gastrostomy tube is surgically placed directly into the client’s

stomach
o To provide another route for administering medications
and nutrition
GUIDELINES IN ADMINISTERING MEDICATIONS BY NASOGASTRIC OR GASTROSTOMY TUBE
1. Always check with the pharmacist to see if the client’s medications come in a liquid form.
33
These are less likely to cause tube obstruction.
2. If there is no liquid form, check if the drug can be crushed. Enteric-coated, sustained-action,
buccal, and sublingual medications should never be crushed.
3. Liquid medication must be further diluted with sterile water to smoothly flow to the tube.
4. Crush a tablet into a fine powder and dissolve in at least 30 mL of warm sterile water
because cold liquids may cause client discomfort.
5. Do not use tap water it often contains chemical contaminants that might interact with the
drug. Use sterile water instead.
6. Open hard gelatin capsules and mix the powder with sterile water.
7. Do not administer whole or undissolved medications, it will clog the tube.
8. Assess tube placement prior to administration of medications.
9. Before giving the medication, aspirate all the stomach contents and measure the residual
volume.
10. Administer the medication
o Remove the plunger from the syringe and connect the syringe to a pinched or
kinked tube. Pinching or kinking the tube prevents excess air from entering the
stomach and causing distention.
o For adult, put 15 to 30 mL (for children 5 to 10 mL) of sterile water into the syringe
barrel to flush the tube before administering the first medication. Raise or lower
the barrel of the syringe to adjust the flow as needed. Pinch or clamp the tubing
before all the water is instilled to avoid excess air entering the stomach.
o Pour liquid or dissolved medication into the syringe barrel and allow to flow by
gravity into the enteral tube.
o If you are giving several medications, administer each one separately and flush with
at least 15 to 30 mL (5 mL for children) of tap water between each medication.
o Once done, flush with another 15 to 30 mL (5 to 10 mL for children) of warm water
to clear the tube.
11. If the tube is connected to suction, disconnect the suction and keep the tube clamped for
20 to 30 minutes after giving the medication to enhance absorption.
PARENTERAL MEDICATIONS
• Nurses give parenteral medications intradermally (ID), subcutaneously, intramuscularly
(IM), or intravenously (IV). 34
• Aseptic technique must be used to minimize the risk of infection.
• Syringe
o Parts
▪ Tip
• Connects with the needle
▪ Barrel
• Outside part where the scales are printed
▪ Plunger
• Fits inside the barrel
o The nurse should avoid letting any unsterile object touch the tip or inside of the
barrel, the shaft of the plunger, or the shaft or tip of the syringe.
o Kinds of syringe
▪ Hypodermic syringe
• Comes in 3- and 5-mL sizes
▪ Insulin syringe
• The scale is specially designed for insulin.
• A 100-unit calibrated scale intended
for use with U-100 insulin.
• The only syringe that should be used to
administer insulin.
• Have a nonremovable needle.
• Insulin pen
o An insulin injector device that looks like a pen and contains
an insulin cartridge.
o The client attaches a new
needle for each injection,
dials in a dose, inserts the
needle, and presses the
injection button to deliver the insulin.
▪ Tuberculin syringe
• Originally designed to administer tuberculin solution
35
• A narrow syringe calibrated in tenths
and hundredths of a milliliter (up
to 1 mL) on one scale and in
sixteenths of a minim (up to 1 minim) on the other scale.
• Useful in administering other drugs, particularly when small or
precise measurement is indicated.
o Factors in choosing syringe
▪ Medication
▪ Location of injection
▪ Type of tissue
• Needles
o Made of stainless steel
o A dull or damaged needle should never be used.
o Parts of needle
▪ Hub
• Fits onto the syringe
▪ Cannula, or shaft
• Attached to the hub
▪ Bevel
• The slanted part at the tip of the needle
o Three variables of needles used in injections
▪ Slant or length of the bevel
• Longer bevels
o Provide the sharpest needles and cause less discomfort.
o Commonly used for subcutaneous and intramuscular
injections.
• Short bevels
o Used for intradermal and IV injections because a long bevel
can become occluded if it rests against the side of a blood
vessel.
▪ Length of the shaft
• Varies from 1/2 to 2 inches
• Appropriate needle length is chosen according to the client’s muscle
development, the client’s weight, and the type of injection.
▪ Gauge (or diameter) of the shaft
36
• The gauge varies from #18 to #30.
• The larger the gauge number, the smaller the diameter of the shaft.
• Smaller gauges produce less tissue trauma.
• Larger gauges are necessary for viscous medications, such as
penicillin
AVOIDING PUNCTURE INJURIES
AVOIDING PUNCTURE INJURIES

1 Use appropriate puncture-proof disposal containers to dispose of
uncapped needles and sharps.
2 Sharps include the following:

• Needles
• Surgical blades
• Lancets
• Razors
• Broken glass
• Broken capillary pipettes
• Exposed dental wires
• Reusable items (e.g., large-bore needles, hooks, rasps, drill points)
• ANY SHARP INSTRUMENT!
3 Never bend or break needles before disposal
4 Never recap used needles except under specified circumstances (when transporting a
syringe to the laboratory for an arterial blood gas or blood culture)
5 When recapping a needle
• Use a safety mechanical device that firmly grips
the needle cap and holds it in place until it is ready to recap
• Use a one-handed “scoop” method
o Placing the needle cap and syringe with needle
horizontally on a flat surface
o Insert the needle into the cap, using one hand
o Using your other hand to pick up the cap and tighten
it to the needle hub.
o Be careful not to contaminate the needle. If the
needle becomes contaminated, replace the needle with 37
a new one.
PREPARING INJECTABLE MEDICATIONS
• Prepared by withdrawing the medication from an ampule or vial into a sterile syringe, using
prefilled syringes, or by using needleless injection systems.
• Ampules
o A glass container usually designed to hold a single dose of a drug.
o Made of clear glass and has a distinctive shape with a constricted neck.
o Vary in size from 1 to 10 mL or more.
o Most ampule necks have colored marks around them for easy opening.
o The ampule must be broken at its constricted neck
o Opening ampules
▪ Plastic ampule openers are available that prevent injury from broken glass.
▪ If an ampule opener is not available
• The nurse can clean the ampule neck with an alcohol swab and,
using dry sterile gauze, snap off the top of the ampule.
• Once the ampule is broken, the fluid is aspirated into a syringe using
a filter needle or filter straw. Both prevent aspiration of any glass
particles.
• Vials
o A small glass bottle with a sealed rubber cap.
o Vials come in different sizes, from single-use vials to multiple-dose vials.
o Vial must be pierced with a needle to access the medication
o Air must be injected into a vial before the
medication can be withdrawn because there is a
vacuum within the vial that makes withdrawal
difficult.
o Powder in vials have their own diluents
however, commonly used diluents are sterile water or sterile normal saline. 38
o Make sure to follow the instructions in diluting powder in vials.
PREPARING MEDICATIONS FROM AMPULE
PREPARING MEDICATIONS FROM AMPULE

Procedure Score
1 Assessment
• Client allergies to medication
• Client’s knowledge about the medication
• Intended route of parenteral medication to determine appropriate
size of syringe and needle for the client
• Ordered medication for clarity and expiration date
2 Check the label on the ampule carefully
• Read the label on the medication
o When it is taken from the medication cart
o Before withdrawing the medication
o After withdrawing the medication.
3 Organize the equipment
4 Wash hands
5 Prepare the medication ampule for drug withdrawal
• Flick the upper stem of the ampule several times with a fingernail
to bring all medication down to the main portion of the ampule.
• Use an ampule opener or place a piece of sterile gauze or alcohol
wipe between your thumb and the ampule neck or around the
ampule neck.
• Break off the top by bending it toward you to ensure the ampule is
broken away from yourself and away from others. Sterile gauze
protects the fingers from the broken glass, and any glass fragments
will spray away from the nurse.
• Dispose of the top of the ampule in the sharp container.
6 Withdraw the medication
• Place the ampule on a flat surface.
• Attach the needle to the syringe.
• Remove the cap from the needle and insert the needle into the
center of the ampule. Do not touch the rim of the ampule with the 39
needle tip or shaft. Rationale: This will keep the needle sterile.
• Withdraw the amount of drug required for the dosage.
• With a single-dose ampule, hold the ampule slightly on its side, if
necessary, to obtain more than the ordered amount of medication.
7 Remove the needle from the ampule.
Recap the needle using the scoop method to maintain its sterility. If
necessary, tap the syringe barrel to dislodge any air bubbles present in the
syringe.
If giving an injection replace the needle with a regular needle, tighten the
cap at the hub of the needle, and push solution into the needle to eject air
before injecting the client.
PREPARING MEDICATIONS FROM VIALS
PREPARING MEDICATIONS FROM VIALS

Procedure Score
1 Assessment
• Client allergies to medication
• Client’s knowledge about the medication
• Ordered medication for clarity and expiration date
4 Wash hands
5 • Mix the solution by rotating the vial between the palms of the hands, 40
not by shaking. Some vials contain aqueous suspensions, which
settle when they stand. Shaking is contraindicated because it may
cause the mixture to foam.
• Remove the protective cap, or clean the rubber cap of a previously
opened vial with an antiseptic wipe by rubbing in a circular motion
to reduces the number of microorganisms.
6 Withdraw the medication
• Attach a needle to the syringe, make sure it is firmly attached.
• Remove the cap from the needle.
• Draw up into the syringe the amount of air equal to the volume of
the medication to be withdrawn.
• Carefully insert the needle into the upright vial through the center
of the rubber cap, maintaining the sterility of the needle.
• Inject the air into the vial, keep the bevel of the needle above the
surface of the medication. The air will allow the medication to be
drawn out easily because negative pressure will not be created inside
the vial. The bevel is kept above the medication to avoid creating
bubbles in the medication.
• Withdraw the prescribed amount of medication.
• Hold the syringe and vial at eye level to determine that the correct
dosage of drug is drawn into the syringe. Eject air remaining at the
top of the syringe into the vial.
• Remove the needle from the vial.
• Recap the needle using the scoop method to maintain its sterility. If
necessary, tap the syringe barrel to dislodge any air bubbles present
in the syringe.
7 If giving an injection replace the needle with a regular needle, tighten the
cap at the hub of the needle, and push solution into the needle to eject air
before injecting the client.
MIXING MEDICATIONS USING ONE SYRINGE
MIXING MEDICATIONS USING ONE SYRINGE

Procedure Score
41
1 Assessment
• Client allergies to medications
• Client’s knowledge about the medications
• Ordered medications for clarity and expiration date
• Determine that the two medications are compatible
• Ensure that the total volume of the injection is appropriate for the
injection site.
4 Hand wash
5 Prepare the medication ampule or vial for drug withdrawal.
• Inspect the appearance of the medication for clarity. Preparations
that have changed in appearance should be discarded.
• For ampule
o Flick the upper stem of the ampule several times with a
fingernail to bring all medication down to the main portion
of the ampule.
o Use an ampule opener or place a piece of sterile gauze or
alcohol wipe between your thumb and the ampule neck or
around the ampule neck.
o Break off the top by bending it toward you to ensure the
ampule is broken away from yourself and away from others.
Sterile gauze protects the fingers from the broken glass, and
any glass fragments will spray away from the nurse.
o Dispose of the top of the ampule in the sharp container.
• For insulin
o Thoroughly mix the solution in each vial prior to
administration. 42
o Rotate the vials between the palms of the hands. Mixing
ensures an adequate concentration and accurate dose.
Shaking insulin vials can make the medication frothy,
making precise measurement difficult.
• Clean the tops of the vials with antiseptic swabs.
6 Withdraw medications
7 Mixing medication from two vials
• Take the syringe and draw up a volume of air equal to the volume
of medications to be withdrawn from both vials A and B.
• Inject a volume of air equal to the volume of medication to be
withdrawn into vial A.
• Withdraw the needle from vial A and inject the remaining air into
vial B.
• Withdraw the required amount of medication from vial B. The same
needle is used to inject air into and withdraw medication from the
second vial. It must not be contaminated with the medication in vial
A.
• Using a newly attached sterile needle, withdraw the required
amount of medication from vial A.
• With this method, neither vial is contaminated by microorganisms
or by medication from the other vial. Be careful to withdraw only
the ordered amount and to not create air bubbles because an excess
amount cannot be returned to the vial.
Mixing medications from one vial and one ampule
• First prepare and withdraw the medication from the vial because
ampules do not require the addition of air prior to withdrawal of the
drug.
• Then withdraw the required amount of medication from the
ampule.
Mixing insulin
Withdraw first the clear insulin before cloudy. (Regular insulin is clear and
NPH is cloudy due to the proteins in the insulin) to minimizes the
possibility of the regular insulin becoming contaminated with the additional
protein in the NPH.
• Mixing 10 units of regular insulin and 30 units of neutral protamine
43
Hagedorn (NPH) insulin, which contains protamine.
o Inject 30 units of air into the NPH vial and withdraw the
needle. (The needle should not touch the insulin)
o Inject 10 units of air into the regular insulin vial and
immediately withdraw 10 units of regular insulin.
o Reinsert the needle into the NPH insulin vial and withdraw
30 units of NPH insulin.
o Be careful to withdraw only the ordered amount and to not
create air bubbles. If excess medication has been drawn up,
discard the syringe and begin the procedure over again.
o The syringe now contains two medications, and an excess
amount cannot be returned to the vial because the syringe
contains regular insulin, which, if returned to the NPH vial,
would dilute the NPH with regular insulin.
INTRADERMAL INJECTIONS
• Administration of a drug into the dermal layer of the skin

just beneath the epidermis.
• Frequently used for allergy testing and tuberculosis
(TB) screening.
• Common sites
o Inner lower arm
o Upper chest
o Back beneath the scapulae
• The left arm is commonly used for TB screening and the right arm is used for all other tests.
ADMINISTERING AN INTRADERMAL INJECTION FOR SKIN TESTS
• Purpose
o To provide a medication that the client requires for allergy testing and TB
screening
ADMINISTERING AN INTRADERMAL INJECTION FOR SKIN TESTS

Procedure Score 44
1 Assessment
• Appearance of injection site
• Specific drug action and expected response
• Client’s knowledge of drug action and response
2 Check the label on the medication carefully
4 Hand wash
5 Prepare the medication from the vial or ampule for drug withdrawal.
6 • Prior to performing the procedure, introduce self and verify the
client’s identity to ensures that the right client receives the
medication.
• Explain to the client that the medication will produce a small wheal,
sometimes called a bleb. The client will feel a slight prick as the
needle enters the skin.
8 Select a site
• Avoid using sites that are tender, inflamed, or swollen and those that
have lesions
9 • Apply gloves
• Cleanse the skin at the site using a firm circular motion starting at
the center and widening the circle outward. Allow the area to dry
thoroughly.
10 Prepare the syringe for the injection.
• Remove the needle cap while waiting for the antiseptic to dry.
• Expel any air bubbles from the syringe.
11 • Grasp the syringe in your dominant hand
• Close to the hub, holding it between thumb and forefinger.
• Hold the needle almost parallel to the skin surface, with the bevel of
the needle up. The possibility of the medication entering the
subcutaneous tissue increases when using an angle greater than
15°. 45
12 • With the nondominant hand, pull the skin at the site until it is taut.
Taut skin allows for easier entry of the needle and less discomfort
for the client.
• Insert the tip of the needle far enough to place the bevel through
the epidermis into the dermis. The outline of the bevel should be
visible under the skin surface.
• Stabilize the syringe and needle.
• Inject the medication carefully and slowly
so that it produces a small wheal on the
skin to verify that the medication entered the
dermis
• Withdraw the needle quickly at the same angle at which it was
inserted.
• Discard the uncapped needle and attached syringe into designated
receptacles.
13 Do not massage the area. Massage can disperse the medication into the
tissue or out through the needle insertion site.
14 Remove and discard gloves
15 Wash hands
16 Circle the injection site with ink to observe for redness or induration
(hardening)
17 Record the testing material given, the time, dosage, route, site, and nursing
assessments.
18 Evaluate the condition of the site in 24 or 48 hours, depending on the test.
Measure the area of redness and induration in millimeters at the largest
diameter and document findings.
SUBCUTANEOUS INJECTIONS
• Drugs administered subcutaneously are vaccines, insulin, and

heparin.
• Common sites
o Outer aspect of the upper arms 46
o Anterior aspect of the thighs
o Abdomen
o Areas of the upper back
o Upper ventrogluteal
o Dorsogluteal areas
• Only small doses (0.5 to 1 mL) of medication are usually
injected via the subcutaneous route.
• To determine the angle of insertion, a general rule to follow relates to the amount of tissue
that can be pinched or grasped at the site.
• Subcutaneous injection sites need to be rotated in an orderly fashion to minimize tissue
damage, aid absorption, and avoid discomfort.
• Insulin
o Absorbed most quickly when injected into the abdomen and then into the arms,
and most slowly when injected into the thighs and buttocks.
o Rotate the injection sites weekly to prevent lipoatrophy and lipohypertrophy.
• According to the American Diabetes Association routine aspiration is no longer
recommended with insulin administration.
• Crawford and Johnson (2012), there is no need to aspirate for blood when administering
vaccines, immunizations, heparin, and insulin.
• After inserting the needle make sure to pull back first the plunger to make sure whether
the needle had entered a blood vessel. If there is no blood upon pull back it is safe to inject
the medication.
ADMINISTERING SUBCUTANEOUS INJECTION
• Purpose
o To provide a medication the client requires
o To allow slower absorption of a medication compared with either the intramuscular
or intravenous route.
ADMINISTERING SUBCUTANEOUS INJECTION

Procedure Score
1 Assessment
• Allergies to medication 47
• Appearance of injection site
• Ability of client to cooperate during the injection
• Previous injection sites used
2 Check the label on the medication carefully make sure that the correct
medication is being prepared.
4 Hand wash
7 • Introduce self to the client and verify the client’s identity to ensures
that the right client receives the medication.
• Assist the client to a position depending on the site to be used. A
relaxed position of the site minimizes discomfort.
• Obtain assistance in holding an uncooperative client to prevents
injury due to sudden movement after needle insertion.
8 Explain the purpose of the medication to facilitate acceptance of and
compliance with the therapy.
9 Select a site
have lesions
• Select a site that has not been used frequently. These conditions
could hinder the absorption of the medication and may also increase
injury and discomfort at the injection site.
10 • Apply clean gloves
• Clean the skin using a firm circular motion starting at the center
and widening the circle outward. Allow the area to dry thoroughly.
• Place and hold the swab between the third and fourth fingers of the
nondominant hand, or position the swab on the client’s skin above
the intended site to keep the swab readily accessible when the 48
needle is withdrawn.
11 Prepare the syringe for the injection.
• Remove the needle cap while waiting for the antiseptic to dry.
• Dispose of the needle cap.
12 • Grasp the syringe in your dominant hand by holding it between your
thumb and fingers. With palm facing to the side or upward for a
45° angle insertion, or with the palm downward for a 90°angle
insertion.
• Using the nondominant hand, pinch or spread the skin at the site,
and insert the needle using the dominant hand and a firm steady
push.
• If the client has more than 1/2 inch of
adipose tissue in the injection site, it
would be safe to administer the injection
at a 90° angle with the skin spread. If the
client is thin or lean and lacks adipose
tissue, the subcutaneous injection should be given with the skin
pinched and at a 45°to 60° angle.
• When the needle is inserted, move your nondominant hand to the
end of the plunger, inject the medication by holding the syringe
steady and depressing the plunger with a slow, even pressure to
minimizes discomfort for the client.
13 Remove the needle smoothly
• If bleeding occurs, apply pressure to the site with dry sterile gauze
until it stops.
14 Discard the uncapped needle and attached syringe into designated
receptacles to protect the nurse and others from injury and contamination.
15 Remove and discard gloves
16 Wash hands
17 Document the medication given, dosage, time, route, and any assessments.
18 Assess the effectiveness of the medication at the time it is expected to act
and document it.
19 • Conduct appropriate follow-up such as desired effect, adverse effect
and side effects. 49
• Relate to previous findings if available.

• Report deviations from normal to the primary care provider.
ADMINISTERING HEPARIN INJECTION
• It requires special precautions because of its anticoagulant properties.

• Procedure
o Select a site on the abdomen at least 2 inches away from the umbilicus and above
the level of the iliac crests.
o Avoid injecting into bruises, scars, masses, or areas of tenderness.
o Use a 3/8-inch, #25- or #26-gauge needle or smaller, and insert it at a 90° angle.
If a client is very lean or wasted, use a needle longer than 3/8 inch and insert it at a
45° angle. The arms or thighs may be used as alternate sites.
o Do not aspirate when giving heparin by subcutaneous injection as it can possibly
damage the surrounding tissue and cause bleeding as well as ecchymoses (bruises).
o Do not massage the site after the injection to prevent bleeding and ecchymoses and
hasten drug absorption.
o Alternate the sites of subsequent injections.
ADMINISTERING ENOXAPARIN (LOVENOX)
• Lovenox is a low molecular weight heparin that is used to prevent deep venous thrombosis
(DVT).
• Procedure
o Choose an area on the abdomen at least 2 inches from the umbilicus and above the
level of the iliac crests.
o Lovenox syringes come prefilled. Check that the syringe is for the correct dosage.
Every syringe comes with a small air bubble. Do not expel the air bubble unless you
have to adjust the dose.
o Pinch an inch of the cleansed area on the abdomen to make a fold in the skin. Insert
the full length of the needle at a 90° angle into the fold of the skin.
o Press the plunger with your thumb until the syringe is empty.
o Pull the needle straight out at the same angle that it was inserted and release the
skinfold. 50
o Point the needle down and away from yourself and others and push down on the
plunger to activate the safety shield.
INTRAMUSCULAR INJECTIONS
• Injections into muscle tissue.

• Absorbed more quickly than subcutaneous injections because of greater blood supply to
the body muscles.
• Can also take a larger volume of fluid without discomfort than subcutaneous tissues can.
o It depends on muscle tissue size and condition and the site used.
• An adult can usually safely tolerate up to 3 mL of medication in the gluteus medius and
gluteus maximus muscles.
• In deltoid muscle, volumes of 0.5 to 1 mL are recommended.
• About 1 to 2 mL is recommended for adults with less developed muscles.
• Usually a 3- to 5-mL syringe is needed.
• The standard prepackaged intramuscular needle is 1 1/2 inches and #21 or #22 gauge.
• Factors indicate the size and length of the needle
o The muscle
o The type of solution
o The amount of adipose tissue covering the muscle
o The age of the client
• Intramuscular injection site
o Ventrogluteal site
▪ The preferred site for intramuscular injections due to:
• Contains no large nerves or blood
vessels
• Greatest thickness of gluteal muscle
• Is sealed off by bone
• Less fat than the buttock area,
thus, eliminating the need to determine the depth of subcutaneous
fat.
▪ Safest site for clients older than 7 months due to thickness of gluteal muscle
and free of penetrating nerves.
▪ To establish the exact site: 51
• The nurse places the heel of the hand on the client’s greater
trochanter, with the fingers pointing toward the client’s head. The
right hand is used for the left hip, and the left hand for the right hip.
• With the index finger on the client’s anterior superior iliac spine, the
nurse stretches the middle finger dorsally (toward the buttocks),
palpating the crest of the ilium and then pressing below it.
• The triangle formed by the index finger, the third finger, and the
crest of the ilium is the injection site.
o Vastus lateralis site
▪ The vastus lateralis muscle usually thick and well
developed in both adults and children.
▪ Recommended site for infants and young children
because it is the largest muscle mass
▪ Recommended for infants because there are no
major blood vessels or nerves in the area.
• Gluteal muscle in infants are poorly
developed.
▪ It is situated on the anterior lateral aspect of the infant’s thigh.
o Dorsogluteal site (avoid using this site)
▪ The dorsogluteal site was primarily used for intramuscular injections. this
site is close to the sciatic nerve and the
superior gluteal nerve and artery.
• If the nurse injected a medication
near or into the sciatic nerve,
complications such as numbness,
pain and paralysis will occur.
▪ More subcutaneous tissue at the dorsogluteal site.
• If the nurse injected the medication in subcutaneous tissue, it could
affect the intended therapeutic effect.
o Rectus femoris site
▪ Belongs to the quadriceps muscle group.
▪ Located on the anterior aspect of the thigh.
▪ Advantage 52
• Clients who administer their own
injections can reach this site easily.
▪ Disadvantage
• An injection here may cause discomfort
for some people.
o Deltoid site
▪ Lateral aspect of the upper arm.
▪ Not often used because it is a small muscle and
is very close to the radial nerve and radial artery.
▪ Sometimes used in adults because of rapid
absorption from the deltoid area, but no more
than 1 mL of solution can be administered.
▪ Recommended for the administration of hepatitis B vaccine in adults.
▪ Location:
• Place four fingers across the deltoid muscle with the first finger on
the acromion process.
• A triangle within these boundaries indicates the deltoid muscle
about 5 cm (2 in.) below the acromion process
INTRAMUSCULAR INJECTION
• Should use z-tract technique

o It is less painful technique, and it
decreases leakage of irritating
medications into the subcutaneous
tissue.
• Aspirating for blood before administering the injection to prevent accidently injecting the
medication into a blood vessel.
o Pulling the syringe plunger back for 5 to 10 seconds to create negative pressure in
the tissue and look for blood return.
ADMINISTERING AN INTRAMUSCULAR INJECTION
• Purpose
o To provide a medication the client requires.
53
ADMINISTERING INTRAMUSCULAR INJECTION
Procedure Score
1 Assessment
• Allergies to medication
• Tissue integrity of selected site
• Client’s age and weight to determine site and needle size
• Ability of client to cooperate during the injection
2 Check the label on the medication carefully to make sure that the correct
medication is being prepared
• Confirm that the dose is correct.
4 Hand wash
• Whenever feasible, change the needle on the syringe before the
injection to prevent not irritation of subcutaneous tissues as it
passes into the muscle.
7 • Prior to performing the procedure, introduce self and verify the
client’s identity to ensures that the right client receives the
medication.
• Assist the client to a position depending on the site to be used to
promote relaxation of the muscle and minimizes discomfort.
• Obtain assistance in holding an uncooperative client to prevents
injury due to sudden movement after needle insertion.
8 Explain the purpose of the medication to facilitate acceptance of and
compliance with the therapy.
9 Select a site
have lesions 54
• Select a site that has not been used frequently to reduce the
discomfort of intramuscular injections.
• Locate the exact site for the injection.
10 Wear clean gloves.
11 Clean the site with an antiseptic swab in circular motion, start at the center
and move outward.
Transfer and hold the swab between the third and fourth fingers of your
nondominant or position the swab on the client’s skin above the intended
site.
Allow skin to dry prior to injecting medication to reduce the discomfort of
the injection.
12 Remove the needle cover and discard without contaminating the needle.
13 Use the ulnar side of the nondominant hand to pull the skin approximately
2.5 cm to the side to make it firmer and facilitates needle insertion.
14 • Holding the syringe between the thumb and forefinger pierce the
skin quickly and smoothly at a 90° angle to lessen client’s
discomfort. Insert the needle into the muscle.
• Hold the barrel of the syringe steady with your nondominant hand
and aspirate by pulling back on the plunger with your dominant
hand.
• If blood appears in the syringe, withdraw the needle, discard the
syringe, and prepare a new injection.
• If blood does not appear, inject the medication steadily and slowly
while holding the syringe steady to promote comfort and allow time
for tissue to expand and begin absorption of the medication
15 After injection, wait 10 seconds
• Withdraw the needle smoothly at the same angle of insertion to
minimize tissue injury.
• Release the skin.
• Apply gentle pressure at the site with a dry sponge.
o It is not necessary to massage the area at the site of injection
to prevent leakage of medication from the site and result in
irritation.
• If bleeding occurs, apply pressure with a dry sterile gauze until it 55
stops.
16 Discard the uncapped needle and attached syringe into the proper
receptacle.
17 Remove and discard gloves, wash hands.
18 • Document the time of administration, drug name, dose, route, and
the client’s reactions.
• Assess the effectiveness of the medication at the time it is expected
to act.
19 Follow-up:
• Desired effect (e.g., relief of pain or vomiting)
• Adverse reactions or side effects
• Local skin or tissue reactions at injection site (e.g., redness,
swelling, pain, or other evidence of tissue damage).
• Relate to previous findings, if available.
• Report significant deviation from normal to the primary care
provider.
INTRAMUSCULAR INJECTION CONSIDERATIONS
• Infants
o The vastus lateralis site is recommended for intramuscular injections for infants.
There are no major blood vessels or nerves in this area, and it is the infant’s largest
muscle mass.
o Obtain assistance to immobilize an infant or young child.
▪ The parent may hold the child to prevent accidental injury during the
procedure.
• Children
o Use needles that will place medication in the main muscle mass.
o The vastus lateralis is recommended as the site of choice for toddlers and children.
o For the older child and adolescent, the recommended sites are ventrogluteal or
deltoid. Ask which arm they would like the injection in.
• Older adults
o Older clients may have a decreased muscle mass or muscle atrophy. A shorter
needle may be needed.
o Absorption of medication may occur more quickly than expected.
56
INTRAVENOUS MEDICATIONS
• Appropriate when a rapid effect of medication is required.

• Appropriate when medications are too irritating to tissue to be given by other routes.
• Administering medications through IV
o Large-volume infusion of intravenous fluid
o Intermittent intravenous infusion (piggyback or tandem setups)
o Volume-controlled infusion (often used for children)
o Intravenous push (IVP) or bolus
o Intermittent injection ports (device).
• Nursing intervention
o Nurses should observe clients closely for signs of adverse reactions. The drug enters
the bloodstream directly and acts immediately and there is no way it can be
withdrawn or its action terminated.
o Avoid any error in preparing the drug and the calculation of dosage.
o If the drug is potent, an antidote to the drug should be available.
o Assess the vital signs before, during, and after infusion of the drug.
o Use standard precautions
o Use sterile technique
o IV push, intermittent, continuous titrated drips
o Change tubing every 24-72hr and site 3-7 days as per agency policy
o Clients must be carefully monitored for unfavorable drug reactions, and the rate of
infusion must be carefully controlled.
o Before adding any medications to an existing intravenous infusion, check for the
“rights” and check compatibility of the drug and the existing intravenous fluid.
o For example
▪ Phenytoin (Dilantin) is incompatible with glucose and will form a
precipitate if injected through a port in an intravenous line with glucose/
dextrose infusing.
LARGE VOLUME INFUSIONS

• Mixing a medication into a large-volume IV container is the safest and easiest way to
administer a drug intravenously.
• The drugs are diluted in volumes of 250, 500, or 1,000 mL of compatible fluids.
57
• IV normal saline or Ringer’s lactate are frequently used.
• Commonly added drugs are potassium chloride and vitamins.
• Main danger of infusing a large volume of fluid is circulatory overload (hypervolemia).
ADDING MEDICATIONS TO INTRAVENOUS FLUID CONTAINERS
• Purpose
o To provide and maintain a constant level of a medication in the blood
o To administer well-diluted medications at a continuous and slow rate
ADDING MEDICATIONS TO INTRAVENOUS FLUID CONTAINERS

Procedure Score
1 Assessment
• Inspect and palpate the IV insertion site for signs of infection,
infiltration, or a dislocated catheter.
• Inspect the surrounding skin for redness, pallor, or swelling.
• Palpate the surrounding tissues for coldness and the presence of
edema, which could indicate leakage of the IV fluid into the tissues.
• Take vital signs for baseline data for medication that is particularly
potent.
• Determine if the client has allergies to the medication(s).
• Check the compatibility of the medication(s) and IV fluid.
2 • Check the label on the medication to make sure that the correct
o Read the label on the medication
▪ When it is taken from the medication cart
▪ Before withdrawing the medication
▪ After withdrawing the medication.
• Confirm dosage and route is correct.
• Verify which infusion solution is to be used with the medication.
• Confirm the compatibility of the drug and solutions to be mixed with
the pharmacist.
4 Wash hands
5 Prepare the medication ampule or vial for drug withdrawal
6 Add the medication
• To new IV container 58
o Locate the injection port.

o Clean the port with the antiseptic or alcohol swab to reduce
the risk of introducing microorganisms into the container
when the
needle is inserted.
o Remove the needle cap from the syringe
o Insert the needle through the center of the
injection port.
o Inject the medication into the bag.
o Activate the needle safety device.
o Gently rotating the bag or bottle to mix the
medication and solution.
o Complete the IV additive label with name and dose of
medication, date, time, and nurse’s initials.
o Attach it on the bag or bottle. This documents that
medication has been added to the solution. The label should
be easy to read when the bag is hanging.
o Clamp the IV tubing to prevents rapid infusion of the
solution.
o Regulate infusion rate as ordered.
• To an existing infusion
o Determine that the IV solution in the container is sufficient
for adding the medication to dilute the medication
adequately.
o Confirm the desired dilution of the medication
o Close the infusion clamp to prevents the medication from
infusing directly into the client as it is injected into the bag
or bottle.
o Wipe the medication port with the alcohol or disinfectant
swab to reduces the risk of introducing microorganisms into
the container when the needle is inserted.
o Remove the needle cover from the medication syringe.
o While supporting and stabilizing the bag with your thumb
and forefinger, carefully insert the syringe needle through the
port and inject the medication to avoid punctures. 59
o Remove the bag from the pole and gently rotate the bag to
mix the medication and solution.
o Rehang the container and regulate the flow rate.
o Complete the medication label and apply to the IV container.
7 Dispose of the equipment and supplies to prevent inadvertent injury to
others and the spread of microorganisms.
8 Document the medication(s) on the appropriate form in the client’s record.
9 Conduct appropriate follow-up
• Desired effect of medication
• Adverse reactions
• Side effects
• Change in vital signs.
10 Reassess the status of IV site and patency of IV infusion
11 Relate to previous findings, if available.
Report significant deviations from normal to the primary care provider.
INTERMITTENT INTRAVENOUS INFUSIONS
• A method of administering a medication mixed in a small amount of IV solution, such as

50 or 100 mL.
• The drug is administered at regular intervals, such as every 4 hours, with the drug being
infused for a short period of time such as 30 to 60 minutes.
• Two commonly used additive or secondary IV setups are the
tandem and the piggyback.
• Tandem setup
o A second container is attached to the line of the first container
at the lower, secondary port. This permits medications to be
administered intermittently or simultaneously with the
primary solution.
• Piggyback alignment
o A second set connects the second container to the tubing of the primary container
at the upper port.
o Used solely for intermittent drug administration. 60
• Syringe pump or mini-infuser

o The medication is mixed in a syringe that is connected to the
primary IV line via a mini-infuser.
VOLUME CONTROL INFUSIONS
• Small fluid containers (100 to 150 mL in size) attached below the primary infusion
container so that the medication is administered through the
client’s IV line.
• Volume-control sets are frequently used to infuse
solutions into children and older clients when the volume
administered is critical and must be carefully monitored.
• Nursing care
o Withdraw the required dose of the medication into a syringe.
o Ensure that there is sufficient fluid in the volume-control fluid
chamber to dilute the medication.
o Close the inflow to the fluid chamber by adjusting the upper roller or slide clamp
above the fluid chamber; also ensure that the clamp on the air vent of the chamber
is open.
o Clean the medication port on the volume-control fluid chamber with an antiseptic
swab.
61
o Inject the medication into the port of the partially filled volume- control set.
o Gently rotate the fluid chamber until the fluid is well mixed.
o Open the line’s upper clamp, and regulate the flow by adjusting the lower roller or
slide clamp below the fluid chamber.
o Attach a medication label to the volume-control fluid chamber.
o Document relevant data, and monitor the client and the infusion.
INTRAVENOUS PUSH
• Intravenous push (IVP) or bolus is the intravenous administration of an undiluted drug

directly into the systemic circulation.
• Used when a medication cannot be diluted or in an emergency.
• An IV bolus can be introduced directly into a vein by venipuncture or into an existing IV
line through an injection port or through an IV lock.
• The administered medication takes effect immediately.
• Two disadvantages
o Any error in administration cannot be corrected after the drug has entered the
client
o The drug may be irritating to the lining of the blood vessels.
• Nursing care:
o Before administering a bolus, the nurse should look up the maximum concentration
recommended for the particular drug and the rate of administration to achieve rapid
serum concentrations.
o Never administer a medication IVP into an IV line that is infusing blood, blood
products, or parenteral nutrition.
o Check the compatibility of the IV solution and what to do if it is incompatible with
the IVP medication.
o Check if the IVP medication needs to be diluted before administration.
ADMINISTERING INTRAVENOUS MEDICATIONS USING IV PUSH
• Purpose
o To achieve immediate and maximum effects of a medication
ADMINISTERING INTRAVENOUS MEDICATIONS USING IV PUSH

Procedure Score
1 Assessment 62
• Inspect and palpate the IV insertion site for signs of infection,
infiltration, or a dislocated catheter.
• Inspect the surrounding skin for redness, pallor, or swelling.
• Palpate the surrounding tissues for coldness and the presence of
edema, which could indicate leakage of the IV fluid into the tissues.
• Take vital signs for baseline data if the medication being administered
is particularly potent.
• Determine if the client has allergies to the medication(s).
• Check the compatibility of the medication(s) and IV fluid.
• Determine specific drug action, side effects, normal dosage,
recommended administration time, and peak action time.
• Check patency of IV
2 • Check the label on the medication to make sure that the correct
o Read the label on the medication
▪ When it is taken from the medication cart
▪ Before withdrawing the medication
▪ After withdrawing the medication.
• Calculate the medication dosage accurately.
• Confirm dosage and route is correct.
4 Prepare the medication
• Existing line
o Prepare the medication according to the manufacturer’s
direction.
• IV lock
o Flushing with saline:
▪ Prepare two syringes, each with 1 mL of sterile normal
saline.
o Flushing with heparin and saline:
▪ Prepare one syringe with 1 mL of heparin flush
solution (if indicated by agency policy).
▪ Prepare two syringes with 1 mL each of sterile, normal
saline.
▪ Draw up the medication into a syringe 63
5 Put a small-gauge needle on the syringe if using a needle system.
6 Wash hands and apply clean gloves to reduce transmission of microorganisms
and reduces nurse’s hands contacting the client’s blood.
7 Provide for client privacy.
• Introduce self to the client and verify the client’s identity to ensure
that the right client receives the right medication
• If not previously assessed, take the appropriate assessment measures
necessary for the medication. If findings are above or below the
predetermined parameters, consult the primary care provider before
administering the medication.
8 Explain the purpose of the medication, the effects of the medication to
facilitate acceptance of and compliance with the therapy.
9 Administer the medication by IV push.
• IV lock with needle
o Clean the injection port with the antiseptic swab to prevent
microorganisms from entering the circulatory system during
the needle insertion.
o Insert the needle of the syringe containing normal saline
through the injection port of an IV lock and aspirate for blood
to confirms that the catheter or needle is in the vein
o Flush the lock by injecting 1 mL of saline slowly to remove
blood and heparin (if present) from the needle and the lock.
o Observe the area above the IV catheter for puffiness or
swelling. This indicates infiltration into tissue, which would
require removal of the IV catheter.
o Remove the needle and syringe. Activate the needle safety
device.
o Clean the lock’s diaphragm with an antiseptic swab to
prevents the transfer of microorganisms.
o Insert the needle of the syringe containing the prepared
medication through the center of the injection port.
o Inject the medication slowly at the recommended rate of
infusion because injecting the drug too rapidly can have a
serious untoward reaction.
o Observe the client closely for adverse reactions. 64
o Remove the needle and syringe when all medication is
administered.
o Clean the injection port of the lock.
o Attach the second saline syringe, and inject 1 mL of saline to
flush the medication through the catheter and prepares the
lock for heparin if this medication is used.
o Heparin is incompatible with many medications.
o If heparin is to be used, insert the heparin syringe and inject
the heparin slowly into the lock.
• Existing line
o Identify the injection port closest to the client. An injection
port must be used because it is self-sealing.
o Clean the port with an antiseptic swab.
o Stop the IV flow by closing the clamp or pinching the tubing
above the injection port.
o Connect the syringe to the IV system.
o Insert the needle of the syringe that contains the medication
through the center of the port to prevent damage to the IV line
and to the diaphragm of the port.
o Inject the medication at the ordered rate because a too rapid
injection could be dangerous.
o Release the clamp or tubing.
o After injecting the medication, withdraw the needle and
activate the needle safety device.
10 Dispose of equipment according to agency practice reduce needlestick
injuries and spread of microorganisms.
11 Remove and discard gloves. Wash hands.
12 Observe the client closely for adverse reactions.
13 Determine agency practice about recommended times for changing the IV
lock.
14 Document
• Record the date, time, drug, dose, and route; client response; and
assessments of infusion or heparin lock site.
15 • Follow-up such as desired effect of medication any adverse reactions 65
or side effects, or change in vital signs.

• Reassess status of IV lock site and patency of IV infusion, if running.
• Relate to previous findings, if available.
provider.
• Inspect appearance of medication and check expiration date.
TOPICAL MEDICATIONS
• Applied locally to the skin or to mucous membranes in areas such as the eye, external ear
canal, nose, vagina, and rectum.
TRANSDERMAL PATCH
• Nursing care
o Assessed for allergies to the drug and to materials in the patch before the patch is
applied.
o Applied to a hairless, clean area of skin that is not subject to excessive movement
or wrinkling (example is trunk or lower abdomen)
o Patches should not be applied to areas with cuts, burns, or abrasions, or on distal
parts of extremities
o Patch containing estrogen or nicotine should not apply the patch to the breasts.
o The 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.
o Use site indicated by manufacturer (chest, upper arms, anterior thighs); rotate sites
o Upon removal, any slight reddening of the skin usually disappears within a few
hours.
o All applications should be changed regularly to prevent local irritation.
o Successive application should be placed on a different site.
o The transdermal patch should be dated, timed, and initialed by the nurse before it
is applied to the client.
o Duplication of patches may cause adverse reactions. Remove the old patch and
66
clean the skin thoroughly before applying a new one.
o 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. Because if it is
not properly discarded, it may cause effects from any drug remaining on the patch.
OPHTHALMIC MEDICATION
• Medications may be administered to the eye using irrigations or instillations.

o Eye irrigation is administered to wash out the conjunctival sac to remove secretions
or foreign bodies or to remove chemicals that may injure the eye.
o Ophthalmic medications are instilled in the form of liquids or ointments
ADMINISTERING OPHTHALMIC INSTILLATIONS
• Purpose
o To provide an eye medication the client requires to treat an infection or for other
reasons
ADMINISTERING OPHTHALMIC INSTILLATIONS
Procedure Score
1 Assessment
• Appearance of eye and surrounding structures for lesions, exudate,
erythema, or swelling
• The location and nature of any discharge, lacrimation, and swelling
of the eyelids or of the lacrimal gland
• Client complaints (e.g., itching, burning pain, blurred vision, and
photophobia)
• Client behavior (e.g., squinting, blinking excessively, frowning, or
rubbing the eyes).
2 • Check medication: drug name, dose, and strength.
• Confirm the prescribed frequency of the instillation and which eye is
to be treated
• Check client allergy
• Know the reason why the client is receiving the medication, the drug
classification, contraindications, usual dose range, side effects, and
nursing considerations for administering and evaluating the 67
intended outcomes of the medication.
3 Compare the label on the medication tube or bottle with the medication
record and check the expiration date
4 Introduce self to the client
Verify the client’s identity to ensure that the right client receives the right
medication
Explain to the client what you are going to do, why it is necessary, and how
he or she can participate.
5 Wash hands
6 Provide privacy
7 Assist the client to a comfortable position
8 Apply clean gloves
Use sterile cotton balls moistened with sterile irrigating solution or sterile
normal saline, and wipe from the inner canthus to the outer canthus to
prevents contamination of the other eye and the lacrimal duct.
9 Check the ophthalmic preparation for the name, strength, and number of
drops if a liquid is used to prevent a medication error.
10 Dropper
• Draw the correct number of drops into the shaft of the dropper
Ointment
• Discard the first bead because it is considered to be contaminated.
11 • Instruct the client to look up to the ceiling because the person is less
likely to blink if looking up.
• Give the client a dry sterile absorbent sponge to press on the
nasolacrimal duct after a liquid instillation to prevent systemic
absorption or to wipe excess ointment from the eyelashes after an
ointment is instilled.
• Expose the lower conjunctival sac by placing the thumb or fingers of
your nondominant hand on the client’s cheekbone just below the eye
and gently drawing down the skin on the cheek to minimizes the
possibility of touching the cornea, avoids putting any pressure on the
eyeball, and prevents the person from blinking or squinting.
• Holding the medication in the dominant hand, place hand on client’s
forehead to stabilize hand
• Approach the eye from the side and instill the
68
correct number of drops onto the outer third
of the lower conjunctival sac. Hold the dropper
1 to 2 cm above the sac because the client is less likely to blink if a
side approach is used. When instilled into the conjunctival sac, drops
will not harm the cornea as they might if dropped directly on it. The
dropper must not touch the sac or the cornea.
• Holding the tube above the lower conjunctival sac, squeeze ointment
from the tube into the lower conjunctival sac from the inner canthus
outward.
• Instruct the client 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.
12 For liquid medications, press firmly or have the client press firmly on the
nasolacrimal duct for at least 30 seconds. Pressing on the nasolacrimal duct
prevents the medication from running out of the eye and down the duct,
preventing systemic absorption.
13 Irrigation
• Place absorbent pads under the head, neck, and shoulders.
• Place an emesis basin next to the eye to catch drainage.
• Expose the lower conjunctival sac. Or, to irrigate in stages:
o First hold the lower lid down, then hold the upper lid up.
o Exert pressure on the bony prominences of the cheekbone
and beneath the eyebrow when holding the eyelids to
prevents reflex blinking. Exerting pressure on the bony
prominences minimizes the possibility of pressing the eyeball
and causing discomfort.
o Fill and hold the eye irrigator about 2.5 cm above the eye. At
this height, the pressure of the solution will not damage the
eye tissue, and the irrigator will not touch the eye.
• Irrigate the eye, directing the solution onto the lower conjunctival
sac and from the inner canthus to the outer canthus to prevent
possible injury to the cornea and prevents fluid and contaminants
from flowing down the nasolacrimal duct.
• Irrigate until the solution leaving the eye is clear or until all the 69
solution has been used.
• Instruct the client to close and move the eye periodically to help
move secretions from the upper to the lower conjunctival sac.
14 Clean and dry the eyelids as needed. Wipe the eyelids gently from the inner
to the outer canthus to collect excess medication.
15 Remove and discard gloves. Wash hands.
16 Apply an eye pad if needed, and secure it with paper eye tape.
17 Assess the client’s response immediately after the instillation or irrigation
and again after the medication should have acted.
18 Document all relevant assessments and interventions.
• Name of the drug or irrigating solution
• The strength
• The number of drops if a liquid medication
• The time
• The response of the client
19 Evaluation
• Perform follow-up based on findings of the effectiveness of the
administration or outcomes that deviated from expected or normal
for the client.
• Relate findings to previous data if available
provider.
ADMINISTERING OPHTHALMIC MEDICATIONS FOR INFANTS AND CHILDREN
• Explain the technique to the parents of an infant or child.

• For a young child or infant, obtain assistance to immobilize the arms and head. The parent
may hold the infant or young child to prevents accidental injury during medication
administration.
• For a young child, use a doll to demonstrate the procedure to facilitates cooperation and
decreases anxiety.
• Drops may be tolerated better by children than ointment since they are less likely to cause
blurred vision.
70
• An IV bag and tubing may be used to deliver irrigating fluid to the eye.
OTIC MEDICATIONS
• Instillations or irrigations of the external auditory canal are carried out for cleaning
purposes.
• Applications of heat and antiseptic solutions are also prescribed.
• Irrigations performed in a hospital require aseptic technique so that microorganisms will
not be introduced into the ear.
• Sterile technique is used if the eardrum is perforated.
• The position of the external auditory canal varies with age.
o Child under 3 years of age, it is directed upward.
o In the adult, the external auditory canal is an S-shaped structure about 2.5 cm long.
ADMINISTERING OTIC INSTILLATIONS
• Purpose
o To soften earwax so that it can be readily removed at a later time
o To provide local therapy to reduce inflammation, destroy infective organisms in the
external ear canal, or both
o To relieve pain
ADMINISTERING OTIC INSTILLATIONS

Procedure Score
1 Assessment
• Appearance of the pinna of the ear and meatus for signs of redness
and abrasions
• Type and amount of any discharge.
2 Check the drug name, strength, number of drops, and prescribed frequency.
3 Check client allergy status
classification, contraindications, usual dose range, side effects, and nursing
considerations for administering and evaluating the intended outcomes of the
medication.
5 Compare the label on the medication container with the medication record
and check the expiration date
6 Explain to the client what you are going to do, why it is necessary, and how
71
he or she can participate.
7 Wash hands.
8 Provide for client privacy.
9 Prior to performing the procedure, introduce self and verify the client’s
identity using agency protocol to ensures that the right client receives the
right medication.
Assist the client to a comfortable position for eardrop administration, lying
with the ear being treated uppermost.
10 • Apply gloves if infection is suspected.
• Use cotton-tipped applicators and solution to wipe the pinna and
auditory meatus to remove any discharge present before the
instillation so that it will not be washed into the ear canal.
• Ensure that applicator does not go into the ear canal to avoid damage
to tympanic membrane or wax becoming impacted within the canal.
11 Administer the ear medication.
• Warm the medication container in your hand, or place it in warm
water for a short time to promote client comfort and prevents nerve
stimulation and pain.
• Partially fill the ear dropper with medication.
• Straighten the auditory canal.
o Pull the pinna upward and backward for clients over 3 years
of age. The auditory canal is straightened so that the solution
can flow the entire length of the canal.
• Instill the correct number of drops along the side of the ear canal.
• Press gently but firmly a few times on the tragus of the ear to assists
the flow of medication into the ear canal.
• Ask the client to remain in the side-lying position for about 5 minutes
to prevents the drops from escaping and allows the medication to
reach all sides of the canal cavity.
• Insert a small piece of cotton fluff loosely at the meatus of the auditory
canal for 15 to 20 minutes. Do not press it into the canal, the cotton
helps retain the medication when the client is up. If pressed tightly
into the canal, the cotton would interfere with the action of the drug
and the outward movement of normal secretions.
12 Ear irrigation 72
• Explain that the client may experience a feeling of fullness, warmth,
and, occasionally, discomfort when the fluid comes in contact with the
tympanic membrane.
• Assist the client to a sitting or lying position with head tilted toward
the affected ear for the solution flow from the ear canal to a basin.
• Place the moisture-resistant towel around the client’s shoulder under
the ear to be irrigated, and place the basin under the ear to be
irrigated.
• Fill the syringe with solution.
or
• Hang up the irrigating container, and
run solution through the tubing and the
nozzle to remove air from the tubing
and nozzle.
• Straighten the ear canal.
• Insert the tip of the syringe into the auditory meatus, and direct the
solution gently upward against the top of the canal. The solution will
flow around the entire canal and out at the bottom. The solution is
instilled gently because strong pressure from the fluid can cause
discomfort and damage the tympanic membrane.
• Continue instilling the fluid until all the solution is used or until the
canal is cleaned.
• Take care not to block the outward flow of the solution with the
syringe.
• Assist the client to a side-lying position on the affected side to help
drain the excess fluid by gravity.
• Place a cotton fluff in the auditory meatus to absorb the excess fluid.
13 Remove and discard gloves. Wash hands
14 Assess the client’s response and the character and amount of discharge,
appearance of the canal, discomfort, and so on, immediately after the
instillation and again when the medication is expected to act. Inspect the
cotton ball for any drainage.
15 • Document all nursing assessments and interventions relative to the
procedure.
• Name of the drug or irrigating solution 73
• The strength
• The number of drops if a liquid medication
• The time
• The response of the client
16 • Follow-up on findings of the effectiveness of the administration or
outcomes that deviated from expected or normal for the client.
• Relate findings to previous data if available.
• provider.
NASAL MEDICATIONS
• Nasal instillations usually instilled for their astringent effect to loosen secretions and
facilitate drainage, or to treat infections of the nasal cavity or sinuses.
• Nasal decongestants are the most common nasal instillations.
• Chronic use of nasal decongestants may lead to a rebound effect (an increase in nasal
congestion)
• If excess decongestant solution is swallowed, serious systemic effects may also develop,
especially in children.
• Saline drops are safer as a decongestant for children.
• Clients should blow their noses prior to administration of nasal sprays unless
contraindicated.
• The head tilted back, the client holds the tip of the container just inside the nares and
inhales as the spray enters the nasal passages.
• Clients who use nasal sprays repeatedly, the nares need to be assessed for irritation.
• In children, nasal sprays are given with the head in an upright position to prevent excess
spray from being swallowed.
• Nursing care
o To treat the ethmoid and sphenoid sinuses:
▪ Instruct the client to lie back with the head over
the edge of the bed or a pillow under the shoulders
so that the head is tipped backward.
o To treat the maxillary and frontal sinuses: 74
▪ Instruct the client to assume the same back-lying position, with the head
turned toward the side to be treated.
▪ Advise the client to:
• Breathe through the mouth to prevent
aspiration of medication into the trachea and
bronchi.
• Remain in a back lying position for at least
1 minute so that the solution will come into contact with the entire
nasal surface
• Avoid blowing the nose for several minutes.
VAGINAL MEDICATIONS
• Vaginal medications, or instillations, are inserted as creams, jellies, foams, or suppositories

to treat infection or to relieve vaginal discomfort.
• Medical aseptic technique is usually used.
• Vaginal creams, jellies, and foams are applied by using a tubular applicator with a plunger.
• Suppositories
o Suppositories are inserted with the index finger of a gloved hand.
o Suppositories are designed to melt at body temperature, so they are generally stored
in the refrigerator to keep them firm for insertion.
• Vaginal irrigation
o A vaginal irrigation (douche) is the washing of the vagina by a liquid at a low
pressure.
o Vaginal irrigations are used to:
▪ Prevent infection by applying an antimicrobial solution that discourages the
growth of microorganisms
▪ Remove an offensive or irritating discharge
▪ Reduce inflammation or prevent hemorrhage by the application of heat or
cold.
ADMINISTERING VAGINAL INSTALLATION
• Purposes
o To treat or prevent infection
75
o To reduce inflammation
o To relieve vaginal discomfort
ADMINISTERING VAGINAL INSTALLATION

Procedure Score
1 Assess
• The vaginal orifice for inflammation; amount, character, and odor of
vaginal discharge
• For complaints of vaginal discomfort (e.g., burning or itching).
2 Check medication
• Drug name, strength, and prescribed frequency.
3 Check client allergy status
classification, contraindications, usual dose range, side effects, and nursing
considerations for administering and evaluating the intended outcomes of
the medication.
5 Compare the label on the medication container with the medication record
and check the expiration date.
6 Calculate the medication dosage.
7 • Explain to the client what you are going to do, why it is necessary,
and how she can participate.
• Explain to the client that a vaginal instillation is normally a painless
procedure.
8 Wash hands
9 Provide client privacy
10 • Introduce self and verify the client’s identity to ensure that the right
client receives the right medication.
• Ask the client to void for less discomfort during the treatment, and
the
• possibility of injuring the vaginal lining is decreased.
• Assist the client to a back-lying position with the knees flexed and
the hips rotated laterally.
• Drape the client appropriately so that only the perineal area is
exposed.
11 • Unwrap the suppository, and place it on the opened wrapper or fill
the applicator with the prescribed cream, jelly, or foam. 76
• Directions are provided with the manufacturer’s applicator.

• Apply gloves to prevent contamination of the nurse’s hands from
vaginal and perineal microorganisms.
• Inspect the vaginal orifice, note any odor of discharge from the
vagina, and ask about any vaginal discomfort.
• Provide perineal care to remove microorganisms to decreases the
chance of moving microorganisms into the vagina.
12 Administer the vaginal suppository, cream, foam, jelly, or irrigation.
• Suppository
o Lubricate the rounded end of the suppository, which is
inserted first to facilitate insertion.
o Lubricate your gloved index finger.
o Expose the vaginal orifice by
separating the labia with your
nondominant hand.
o Insert the suppository about 3 to 4
inches along the posterior wall of
the vagina, or as far as it will go.
The posterior wall of the vagina is about 1 inch longer than
the anterior wall because the cervix protrudes into the
uppermost portion of the anterior wall.
o Ask the client to remain lying in the supine position for 5 to
10 minutes following insertion. The hips may also be elevated
on a pillow to allows the medication to flow into the posterior
fornix after it has melted.
• Vaginal cream, jelly or foam
o Gently insert the applicator about
2 inches.
o Slowly push the plunger until the
applicator is empty.
o Remove the applicator and place
it on the towel to prevent the spread of microorganisms.
o Discard the applicator if disposable or clean it according to
the manufacturer’s directions.
o Ask the client to remain lying in the supine position for 5 to10 77
minutes following the insertion.
• Irrigation
o Place the client on a bedpan.
o Clamp the tubing. Hold the irrigating container about 12
inches above the vagina. At this height, the pressure of the
solution should not be great enough to injure the vaginal
lining.
o Run fluid through the tubing and nozzle into the bedpan to
remove air and to moisten the nozzle.
o Insert the nozzle carefully into the vagina. Direct the nozzle
toward the sacrum, following the direction of the vagina.
o Insert the nozzle about 3 to 4 inches, start the flow, and rotate
the nozzle several times to irrigate all parts of the vagina.
o Use all of the irrigating solution, permitting it to flow out
freely into the bedpan.
o Remove the nozzle from the vagina.
o Assist the client to a sitting position on the bedpan to help
drain the remaining fluid by gravity.
13 Ensure client comfort.
• Dry the perineum with tissues as required.
• Apply a clean perineal pad if there is excessive drainage.
14 Remove and discard gloves, wash hands
15 Document all nursing assessments and interventions relative to the skill.
Include the name of the drug or irrigating solution, the strength, the time,
and the response of the client.
16 • Perform follow-up based on findings of the effectiveness of the
administration or outcomes that deviated from expected or normal
for the client. Relate findings to previous data if available.
provider.
RECTAL MEDICATIONS
• Insertion of medications into the rectum in the form of suppositories.

• Advantages: 78
o It avoids irritation of the upper GI tract in clients who have nausea or vomiting.
o It is advantageous when the medication has an objectionable taste or odor.
o The drug is released at a slow but steady rate.
o Rectal suppositories are thought to provide higher bloodstream levels of medication
because the venous blood from the lower rectum is not transported through the
liver.
o Procedure:
▪ Assist the client to a left lateral or left Sims’ position, with the upper leg
flexed.
▪ Fold back the top bedclothes to expose the buttocks.
▪ Put a glove on the hand used to insert the
suppository.
▪ Unwrap the suppository and lubricate the
smooth rounded end. The rounded end is
usually inserted first and lubricant reduces
irritation of the mucosa.
▪ Lubricate the gloved index finger.
▪ Encourage the client to relax by breathing through the mouth this also
relaxes the external anal sphincter.
▪ Insert the suppository gently into the anal
canal, rounded end first along the rectal wall using the gloved index finger.
▪ For an adult, insert the suppository beyond the internal sphincter about 4
inches
▪ Avoid embedding the suppository in feces in order for the suppository to be
absorbed effectively.
▪ Press the client’s buttocks together for a few minutes.
▪ Ask the client to remain in the left lateral or supine position for at least 5
minutes to help retain the suppository. The suppository should be retained
for varying lengths of time according to the manufacturer’s instructions.
ADMINISTERING RECTAL MEDICATION IN INFANT AND CHILDREN
• Obtain assistance to immobilize an infant or young child to prevent accidental injury due 79
to sudden movement during the procedure.
• For a child under 3 years of age, the nurse should use the gloved fifth finger for insertion.
• After 3 years of age, the index finger can usually be used.
• For a child or infant, insert a suppository 2 inches or less.
INHALED MEDICATIONS
• Nebulizers
o Nebulizers deliver most medications administered through the inhaled route.
o Used to deliver a fine spray (fog or mist) of medication or moisture to a client.
o Two kinds of nebulization:
▪ Atomization
• A device called an atomizer produces rather
large droplets for inhalation.
▪ Aerosolization
• The droplets are suspended in a gas, such as oxygen.
o The smaller the droplets, the further they can be inhaled into the respiratory tract.
o When a medication is intended for the nasal mucosa, it is inhaled through the nose.
o When a medication is intended for the trachea, bronchi, and/or lungs, it is inhaled
through the mouth.
• Metered-dose inhaler (MDI)
o A handheld nebulizer.
o A pressurized container of medication that can be used by the client to release the
medication through a mouthpiece.
o Client teaching:
▪ Ensure that the canister is firmly and fully inserted into the inhaler.
▪ Remove the mouthpiece cap. Holding the
inhaler upright, shake the inhaler
vigorously for 3 to 5 seconds to mix the
medication evenly.
▪ Exhale comfortably
▪ Hold the canister upside down
• Hold the MDI 1 to 2 inches from the open mouth.
• Or put the mouthpiece far enough into the mouth with its opening 80
toward the throat such that the lips can tightly close around the
mouthpiece.
▪ Press down once on the MDI canister (which releases the dose) and inhale
slowly (for 3 to 5 seconds) and deeply through the mouth.
▪ Hold your breath for 10 seconds or as long as possible to allow the aerosol
to reach deeper airways.
▪ Remove the inhaler from or away from the mouth.
▪ Exhale slowly through pursed lips because controlled exhalation keeps the
small airways open during exhalation.
▪ Repeat the inhalation if ordered. Wait 20 to 30 seconds between inhalations
of bronchodilator medications. The first inhalation has a chance to work and
the subsequent dose reaches deeper into the lungs.
▪ Following use of the inhaler, rinse mouth with tap water to remove any
remaining medication and reduce irritation and of infection.
▪ Clean the MDI mouthpiece after each use. Use mild soap and water, rinse
it, and let it air dry before replacing it on the device.
▪ Store the canister at room temperature.
▪ Avoid extremes of temperature.
▪ Report adverse reactions such as restlessness, palpitations, nervousness, or
rash to the primary care provider.
▪ Many MDIs contain steroids for an anti-inflammatory effect. Prolonged use
increases the risk of fungal infections in the mouth, indicating a need for
attentive mouth care.
81

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PHARMACOLOGY

PROCESS OF PHARMACOKINETICS (ADME)

FACTORS AFFECTING DRUG THERAPY 6

• Assess client attitude, self-administration skills

NEED TO BE DONE BEFORE ADMINISTERING ANY MEDICATION

SAFE MEDICATION ADMINISTRATION

• Check client’s record for allergies.

OVER THE COUNTER MEDICATIONS

• Over-the-counter medications (OTC) are medications that can be obtained without a 10

ALTERNATIVE OR COMPLEMENTARY THERAPIES

• Alternative or complementary therapies are nontraditional therapeutic methods such as

DEVELOPMENTAL CONSIDERATION IN ADMINISTERING MEDICATION

• Infant and children

ROUTES TO ADMINISTER MEDICATION

• The drug is swallowed.

• Placement under the tongue allows a drug to diffuse into

• Tablet held between cheek and gum until dissolved

Drug can be administered for local effect

o Intramuscular (IM) route

• Use standard precautions

o Intradermal (ID) route

▪ Dry powdered inhaler (DPI)

o Nonpressurized aerosol (nebulizer) (NPA)

• Used when a local effect of the drug is desired.

TRANSDERMAL (PERCUTANEOUS) ROUTE

• Suppository or solution inserted into anus

THERAPEUTIC ACTIONS OF DRUGS

1. Client’s full name

DRUG MEASUREMENT SYSTEMS

APOTHECARY AND HOUSEHOLD SYSTEMS

D = Desired dose (i.e., dose ordered by primary care provider)

H = Stock on hand (i.e., dose on label of bottle, vial, ampule)

Q = Quantity (form in which the drug comes, such as tablet or liquid).

2. Order: Keflex 750 mg

750 mg x 1 tablet = 750 = 3 tablets

3. Order: Lanoxin 0.25 mg

0.25 mg x 1 tablet = 0.25 = 2 tablets

4. Order: dofetilide 0.5 mg

125 mcg x 1 mg = 0.125 mg/capsule

0.5 mg x 1 capsule = 4 capsule

5. Order: Tylenol gr xv (15)

325 mg x 1 gr = 5.42 gr/tablet

15 gr x tablet = 2.76 tablet or 3 tablets

CALCULATION OF MEDICATION IN CHILDREN

180 mg = 60 mg/dose (desired dose)

60 mg x 5 mL = 2.4 mL per dose

INTRAVENOUS FLOW RATES

Total volume x drop factor = Drops per minute

Total volume to infuse = Infusion time

NUMBER OF MILLILITERS PER HOUR

Total volume in milliliters = Number of milliliters per hour 28

250/198 = 1.26 hours

1 hour and 16 min infusion time

• NUMBER OF MILLILITERS PER HOUR

500 mL = 41.6 or 42 mL/hour

ADMINISTERING ORAL MEDICATION

ADMINISTERING ORAL MEDICATION

• When giving small amounts of liquids

27 Replenish stock like medication cups.

• A gastrostomy tube is surgically placed directly into the client’s

GUIDELINES IN ADMINISTERING MEDICATIONS BY NASOGASTRIC OR GASTROSTOMY TUBE

AVOIDING PUNCTURE INJURIES

AVOIDING PUNCTURE INJURIES