Forms and Routes in Drug Administration

Oral
Includes all drugs given by mouth. The advantages are ease of administration and a
slow rate of absorption via the stomach and intestinal wall. The disadvantages include
slowness of absorption and destruction of some chemical compounds by gastric juices.
In addition, some medications, such as aspirin, can have a corrosive action on the
stomach lining.

Sublingual
Includes drugs that are held under the tongue and not swallowed. The medication is
absorbed by the blood vessels on the underside of the tongue as the saliva dissolves it.
The rate of absorption is quicker than the oral route. Nitroglycerin to treat angina
pectoris (chest pain) is administered by this route.

Inhalation
Incudes drugs inhaled directly into the nose and mouth. Aerosol sprays are
administered by this route.

Parenteral
An invasive method of administering drugs as it requires the skin to be punctured by a
needle. The needle with syringe attached is introduced either under the skin or into a
muscle, vein, or body cavity.

Intracavitary
Injection into a body cavity such as the peritoneal and chest cavity.
intradermal (ID)
Very shallow injection just under the top layer of skin. Commonly used in skin testing for
allergies and tuberculosis testing.

intramuscular (IM)
Injection directly into the muscle of the buttocks, thigh, or upper arm. Used when there
is a large amount of medication or it is irritating.

Intrathecal
Injection into the meningeal space surrounding the brain and spinal cord.

intravenous (IV)
Injection into the veins. This route may be set up to deliver medication very quickly or to
deliver a continuous drip of medication.

subcutaneous (SC)
Injection into the subcutaneous layer of the skin, usually the upper, outer arm or the
abdomen; for example, insulin injection.
Oral
drugs given by mout

sublingual
drugs that are held under the tongue and not swallowed

inhalation
drugs inhaled directly into the nose and mouth

parenteral
an invasive method of administering drugs as it requires the skin to be punctured by a
needle.

Intracavitary
Injection into a body cavity such as the peritoneal and chest cavity

intradermal (ID)
Very shallow injection just under the top layer of skin. Commonly used in skin testing for
allergies and tuberculosis testing.

intramuscular (IM)
Injection directly into the muscle of the buttocks, thigh, or upper arm.

Intrathecal
Injection into the meningeal space surrounding the brain and spinal cord.

intravenous (IV)
Injection into the veins

subcutaneous (Subc, SubQ)

Injection into the subcutaneous layer of the skin, usually the upper, outer arm or
abdomen

understanding drug labels

Recognize pertinent information on drug labels including:
- Drug form.
- Dosage strength.
- Supply dosage or concentration.
- Total volume of drug container.
- Administration route.
- Expiration date.
Drug order
prescribes how much of a drug the patient is to receive. The nurse must prepare the
order from the drugs on hand. The drug label tell how the available drug is supplied.

Brand and Generic names

proprietary name is the manufacturer's name for a drug. The generic, or established,
non proprietary name. By law, the generic name must be identified on all drug labels.

Generic equivalents
of many brand-name drugs are ordered as 'substitutes.' Nurses need to carefully cross-
check all medications.

Form
'structure and composition of the drug. Solid dosage forms for oral use includes tablets
and capsules. Liquefied, clear solution, suspension aka solid particles in liquid that
separate when held in a container.

Supply Dosage
refers to both dosage strength and form. Solid-form supply dosage is X measured units
per 'tablet.' The liquid-form supply dosage is measured unites per 'milliliter.'

Total volume
full quantity contained in a package, bottle, or vial. 'Tablets and other solid' TOTAL
NUMBER, for liquids its TOTAL FLUID 'VOLUME.'

Administration rotes
site or the method of drugs delivery into the patients: oral, enteral, sublingual, injection,
otic, optic, topical, rectal. Unless specified otherwise, tablets, capsules, and caplets for
oral use.

Directions for mixing or reconstituting

Some drugs are dispensed in powder form the must be reconstituted for use.

Label alerts
warnings on the packaging, special alerts: refrigerate at all time, keep in a dry place,
protect form light, shake well before using.

Chemical Name
Not indicated in the drug label

Brand Name
- Manufacture's name for a drug
- Set in large type and boldly visible
- Often followed by registered sign
Generic name
- Established, nonproprietary name
- a.k.a official name
- Appear directly under brand name
- May be inside the parenthesis

Dosage Strength
Weigh or amount of drug provides in a specific unit of measurement

Form
- Structure and composition of drug
- solid form, injectable, suppositories, cream, patches
Supply Dosage
- Dosage per tablet
- Dosage per milliliter

Total Volume
- Full quantity contained in bottle or vial
- Total number of tablets or other solids
- Total fluid volume for liquids

Administration Route
- Refer to the site of the body or method of drug delivery
- oral, enteral, sublingual, injection, otic, optic, topical, rectal, vagina
- Unless specific; tablets, capsule, and caplets are intended for oral use

Label Alert
- Warning may be printed on packaging or added by pharmacy before dispensing
- Look for special storage alerts such as; ref at all times, keep in dry place,replace cap
and close tightly, before storing, protest from light
- Reconstituted suspensions may be dispensed already for use; direction may instruct
the health care professional to "shake well before using" as reminder to remix the
component

Expiration Date
- Check for administration
- Discard or return to pharmacy if expired

What are the SEVEN basic items of data that ALL drug labels provide ?
1. Brand (trade) name, 2. generic name, 3. dosage, 4.form of the drug, 5.expiration
date, 6. lot number, 7. name of the manufacturer

Brand (trade) Name

Is the commercial name given by the pharmaceutical company ( manufacturer of the
drug ). It is printed in large , bold letters.
Generic name
chemical name given to the drug. Printed in small letters, usually under the brand name.

Dosage Strength
drug dose per drug form ( tablet, capsule, liquid ) as stated on the label.

Form of Drug
form of drug relates to dosage strength ( tablet, capsule, liquid)

Expiration date
length of time the drug can be used . Nurse must check expiration date of drug she is
administering.

Lot number
identifies the drug batch in which the medication was produced. Occasionally, a drug is
recalled according to the lot number.

Manufacturer
is the pharmaceutical company that produces the brand name drug.

6 Basic Components of a drug order

(1) date and time the order was written, (2) drug name, (3)drug dosage,(4) route of
administration, (5) frequency of adminstration, (6) physician's or health care
provider's signature.

What happens if any of these Basic Components are missing ?

Means the drug order is incomplete and cannot be carried out. Clarification must be
obtained before the order is carried out.

National Drug Code (NDC)

A unique identifying number that appears on all drug labels
10 Rights in Drug Administration
1) Right patient
1) Check patient's identification bracelet
2) Ask the patient his or her name and birth date
3) Check the name on the patient's medication label

(2) Right drug

1) Check that the drug order is complete and legible
2) Check the drug label three times
3) Check the expiration date
4) Know the drug action

(3) Right dose

1) Calculate the drug dosage
2) Know the recommended dosage range for the drug
3) Recalculate the drug dosage with another nurse if in doubt

4) Right time
1) Administer drug at the specified time(s)
2) Document any delay or omitted drug dose
3) Administer drugs that irritate gastric mucosa with food
4) Administer drugs that cannot be administered with food 1 hour before or 2 hours after
meals
5) Administer antibiotics at even intervals (q6h or q8h)

(5) Right route

1) Know the route for administration of the drug
2) Use aseptic techniques when administering a drug
3) Document the injection site on the MAR/eMAR

(6) Right documentation

1) Place nurse's initials on the MAR sheet or eMAR
2) Document the reason for a patient NOT taking the drug
3) Indicate on the MAR sheet or eMAR whether the drug dose was delayed and the
time is was given

(7) Right to refuse medication

1) Document the time and date the patient refused the drug and the refusal reason
2) Notify the charge nurse and physician that the patient refused the drug
3) Explain the purpose and therapeutic effect of the drug to the patient
4) Record if the refusal could be due to the patient's mental status
(8) Right assessment
1) Assess if the ordered medication is safe to administer
2) Assess the patient's vital signs and determine whether they are safe for the drug
3) Know that opioids can decrease vital signs
4) Assess the effects of the medication(s) being administered
(9) Right education
1) Educate the patient about the purpose(s) for the medication
2) Answer the patient's questions about the medication he or she is receiving
3) Educate the patient about possible side effects of the medication

(10) Right evaluation

1) Evaluate the effects of the medication
2) Record on the MAR or eMAR the effects of the medication(s)
3) Report to the HCP if the medication was ineffective
4) Evaluate whether the medication caused adverse reactions

10 Rights of Medication Administration - Problems

Nurses are primarily involved in the administration of medication across various
settings. Nurses are also involved in both dispensing and preparation of medication.
Research on medical administration errors (MAEs) shows an error rate of 60%, 34
mainly in the form of wrong time, wrong rate, or wrong dose.

1. Right Drug.
Check and verify if it's the right name and form. Beware of look-alike and sound-alike
medication names. Misreading medication names that look similar is a common
mistake. These look-alike medication names may also sound alike and can lead to
errors associated with verbal prescriptions. Check out The Joint Commission's list of
look-alike/sound-alike drugs.

2. Right Patient.
Ask the name of the client and check his/her ID band before giving the medication.
Even if you know that patient's name, you still need to ask just to verify.

3. Right Dose.
Check the medication sheet and the doctor's order before medicating. Be aware of the
difference of an adult and a pediatric dose.

4. Right Route.
Check the order if it's PO, IV, SQ, IM, etc..

5. Right Time and Frequency.

Check the order for when it would be given and when was the last time it was given.

6. Right Documentation.
Make sure to right the time and any remarks on the chart correctly.
7. Right History and Assessment.
Secure a copy of the client's history to drug interactions and allergies.

8. Drug approach and Right to Refuse.

Give the client enough autonomy to refuse to the medication after thoroughly explaining
the effects.

9. Right Drug-Drug Interaction and Evaluation.

Review any medications previously given or the diet of the patient that can yield a bad
interaction to the drug to be given. Check also the expiry date of the medication being
given.

buccal
lining of the cheek (usually between the cheek and gums)

sublingual
ventral and surface of the tongue and floor of the mouth

form of oral medication, solid form

tablets
dried powder form of medication that has been compressed into a small disk

capsule
solid dosage form containing medicinal and/or inert substances within a small shell of
gelatin

caplets
are smooth-coated tablet shaped like capsule used as a tempe-resistant alternative to a
capsule, or an easy-to-swollow alternative to regular tablet.

enteric coated tablets

are made to dissolve in the small intestine, to prevent irritation or absorption in the
stomach.
should not be crushed (the coating is protecting the medicine from being dissolved by gastric
juices).

Gel caps
Liquid-filled gelatin capsule which may be broken down and absorbed into the bloodstream in
only a few minutes while it takes 20-30 minutes for a tablets pill.

Time release tablet

Also referred as sustained-release, extended release or controlled release capsules provide a
gradual provide but continuous release of a drug because the granules within the capsule
dissolve at different rates.
Lozenges
Lozenges are solid preparations that are intended to dissolve or disintegrate slowly in the
mouth. They contain one or more medicaments, usually in a flavoured sweetened base.

Effervescent tablets
-dropped into a glass of water before admin
-medication dissolves first in the water (release carbon dioxide) before

Oral medication in liquid form

Elixirs
Liquids made up of drugs dissolved in alcohol and water that may have coloring and
flavoring agents added. The alcohol makes the drug more dissolvable than water alone.

Emulsions
Solutions that have small droplets of water and medication dispersed in oil, or oil and
medicated dispersed in water. These preparations help disguise the bitter taste of a
drug or increase its solubility.

Suspensions
Liquids with solid, insoluble drug particles dispersed throughout. These solid particles
tend to settle out in layers, so the medication must be shaken before pouring.

Syrups
Liquids with a high sugar content designed to disguise the bitter taste of a drug. These
are often used for pediatric patients

Medication Administration Equipment

Souffle cup
Used for solid oral medication (such as capsules or tablets)

Medicine cup
is a plastic measuring cup used to administer liquid oral medication.
-One side shows mL and tsp, and the other size shows ounces.

Dropper
A device used to deliver small quantities of liquid medication.
-Dropper size may vary.
-Medications that need to be administered via a dropper are usually packaged with the
correct size dropper, such as children vitamins.

Teaspoon
Doses of most liquid medication are prescribed in term using the teaspoon as unit of
measure
oral syringe
used to administer liquid meds orally to adults and children with no needle attached

nipple
used for administering medication to infants

2 method of administering IV fluid and drugs

Continuous infusion
-The infusion of IV solution at a constant rate.
-May also be the primary infusion.

Intermittent infusion
-The administration of IV medications at a prescribed interval.
-The IV medication may be delivered via pump or by gravity drip at the appropriate rate.
Upon completion of the delivery of the IV medication, the tubing is disconnected from IV
access and the IV access device is flushed.

MEDICATION ORDER
Medication order
What prescribed drugs are generally referred to

How can medication orders be given?

written order, telephone, and verbal are acceptable for some agencies.

Nursing students are prohibited from?

taking phone and verbal medication orders.

What are four common medication orders?

stat, single, standing, and prn.

What is a stat order?

indicates the medication is to be given immediately and only once.

What is a single order?

one time order; medication is to be given once at a specified time.

What is a standing order?

may or may not have a termination date. 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. In some
agencies, they are automatically canceled after a specified number of days and must be
reordered.
What is a prn order?
as needed order, permits the nurse to give medication when, in the nurses judgment,
the client requires it. The nurse must use good judgment about when the medication is
needed and when it can be safely administered.

Unless the order is a standing order it should?

state the number of doses or the number of days the drug is to be administered.

What does the signature of the ordering pcp on the order form mean?
makes the drug order a legal request.

When an order is not signed?

has no validity and the ordering physician or nurse practitioner needs to be notified.

PARTS OF A MEDICATION ORDER

Clients full name
Using clients full name helps prevent confusion of one client with another, preventing
administer wrong medication to wrong patient.

Date and time order was written

The date and time of the order include the month, day, year and the time the order was
written.

Name of medication
The med. may be ordered by the generic or brand name. To avoid confusion with
another medication, the name of the medication should be written clearly and spelled
correctly

Dosage of medication
The amount and strength of the medication should be clearly written to avoid confusion.
Dosage indicates the amount or weight provided in the form.

Route of administration
The route of the administration is a very important part of a medication order, because
medications can be administered by several routes.

Time and frequency of administration

Standard abbreviations should be used to indicate the times a medication is to be given

Signature of the person writting the order

For a medication order to be legal, it must be signed by the health care provider.
Signature must be included and it be legible.
COMMON ABBREVIATIONS USED
IN A MEDICAL ORDER
OD (qd) – once a day; daily
• BID – twice a day; two times a day
• TID – thrice a day; three times a day
• QID – four times a day
• HS – at bedtime
• ODHS – once at bedtime
• ANST – after negative skin test
• ac – before meals
• pc – after meals
• PRN – as needed
• STAT - immediately
• PO – per orem; orally
• IM – intramuscular
• SC (subq) – subcutaneous
• ID – intradermal
• IV – intravenous
ROUND THE CLOCK ORDERS
• q1h
• q4h
• q8h
• q12h

Route:
IM - intramuscular
IV - intravenous
IVPB - intravenous piggyback
SC (subcut) - subcutaneous
SL - sublingual
ID - intradermal
PO - orally
PR - per rectum
Frequency:
a.c. - before meals
p.c. - after meals
p.r.n. - when necessary
Stat - immediately, at once
b.i.d. - twice a day
t.i.d. - three times a day
q.i.d. - four times a day
hs - at bedtime
METHODS OF CALCULATING MEDICATION
DOSAGES
20 to 60 years
When prescribing for an adult, the age range is generally considered "adult" is:

The abbreviation for grains is:

Gr

One microgram is equal to _____ milligram(s)

0.001

Insulin-dependent diabetes is termed:

Type I

Which insulin has the most rapid onset?

Humalog

One of the most accurate methods for calculating dosage for infants and children up to
12 years of age uses

Body Surface Area (BSA)

Guidelines for the administration of medications include:
Always check the expiration date on a medication that is to be given

Disadvantages to oral medication are:

Irritation of the stomach and discoloration of the teeth

Injections should be avoided in which areas?

Burns, inflamed areas, and previous injection sites

Rapid response to a medication can be expected with which method of administration?

Intravenous and intramuscular

PEDIATRIC DOSAGE CALCULATIONS

Pediatric Dosage Calculation
Dosage calculation in _______ are based on age, body surface area (BSA), and body
weight. BSA and body weight are the methods most frequently used to calculate
______. The formulas are: Clark's rule, Fried's rule, and Body surface area (BSA) rule
Clark's rule
weight of child/150 lb. x adult dose= child's dose

Fried's rule
age in months/150 x average adult dose = child dose

Body surface area (BSA) rule

body surface area of child (square meters)/1,7 x adult dose = child dose

Katie has just turned 3 years old and weighs 30 ponds. her mother wants to know
how much cough syrup to give Katie. The directions have worn off the bottle and
she can only make out the dosage for adults- 2 teaspoons every four hours. How
much should Katie receive
Clark's rules:
30/150 x 10 ml = Katie's dose
1/5 x 10 ml = 2 ml
Fried's rule 36/150 x 10 ml = Katie's dose
0.24 x 10 ml = 2.4 ml

Dosage Calculations Based on Body Weight

Drug dosages are sometimes administered on a body weigh basis, for example in
mg/kg. This may require conversion of pounds to kilograms (1kg = 2.2 lbs.). The
dose/kg is then multiplied by the number of kilograms

There is a drug order for the antibiotic amikacin 7.5mg/kg administered

intravenously (IV) for a patient weighing 110 pounds. Amikacin is available as 100
mg/2-ml vial. How much milligrams of drug are required and in what volume?
- Convert pounds to kilograms
110 lbs. divided by 2.2 lb./kg = 50 kg
- Determine how many mg of drug are required
7.5 mg/kg x 50 = 375 mg
- Determine how many ml of stock solution contains 375 mg, using proportion equation
method.
1000 mg:2 ml = 375 mg:X ml
100X = (375)2 or 750
X = 750/100 = 7.5 ml of vial solution
Therefore, 7.5 divided by 2 = 3.75 or 3 3/4 vials

If the patient in the previous problem was an infant weighing 20 lbs. with a body
surface area of 0.44 square meter. What would be the dose based on BSA rule?
BSA rule: BSA (square meters)/1.7 x adult dose
0.44/1.7 x 375 = 0.258 x 375 = 96.75 mg or 97 mg
Since vials contain 100mg/2ml, calculate volume
100/2ml = 97 mg/ Xml
100X = 2(97) or 194
X = 1.94 ml of vial solution
Monitoring IV infusion Rates
Hospitalized patients often receive drug administration by slow IV infusion. Drugs are
added to various sterile IV solutions such as sodium chloride injection. United States
Pharmacopeia (USP), or dextrose 5% injection, USP. Drug concentrations and solutions
are prepared by the hospital pharmacy. . The IV drugs must be prepared under aseptic
conditions, drugs and solutions mixed must be chemically compatible, and infusion
solution must be adjusted to a specific pH value
The drug solution is administered according to a specific infusion rate, in drops per
minute. Usually there are 12-15 drops/ml of solution, but this number can vary with the
viscosity of different solutions.

Formula for adjusting IV infusion rate:

ml of IV solution x number of drops/ml divided by hours of administration x 60 drops =
drops per minute

1 teaspoon
5 mL/cc

1 tablespoon
15 mL/cc

1 ounce
30 mL/ cc

16 oz
1 pound (body weight)

pounds to kilogram
pounds/2.2

convert :20 pounds 5 ounces to kilogram

1st: need to convert 5 ounces to a fraction of a pound 5 divided by 16=0.31
2nd: 20.31 pounds divided by 2.2=9.23 kg
Note: medication would be calculated based on 9.23 kilograms
DO NOT ROUND TO 9.2

Pediatric specific Calculations

Mg / Kg dosing based on Weight (Kg)
Safe dosing ranges
IV pediatric infusion rates
IV administration of meds via IV pump or Syringe pump.
24 hour fluid calculation

if a child weight 84 lbs, what is the weight in Kg?

84 lb = X Kg
84 divided by 2.2 = 39.18 kg
if a child weights 6 lbs 6 ounces what is the weight in Kg?
6 ounces/ 16 ounces= .375----->>.37
6.37 pounds divided by 2.2=2.89 Kg

Type of medication errors

Prescribing error
Incorrect drug selection (based on indications, contraindications, known allergies,
existing drug therapy, and other factors), dose, dosage form, quantity, route,
concentration, rate of administration, or instructions for use of a drug product ordered or
authorized by physician (or other legitimate prescriber); illegible prescriptions or
medication orders that lead to errors that reach the patient

Omission error
The failure to administer an ordered dose to a patient before the next scheduled dose, if
any

Wrong time error

Administration of medication outside a predefined time interval from its scheduled
administration time (this interval should be established by each individual health care
facility)

Unauthorized drug error

Administration to the patient of medication not authorized by a legitimate prescriber for
the patient

Improper or wrong dose error

Administration to the patient of a dose that is greater than or less than the amount
ordered by the prescriber or administration of duplicate doses to the patient (i.e., one or
more dosage units in addition to those that were ordered)

wrong dosage-form error

Administration to the patient of a drug product in a different dosage form than ordered
by the prescriber