Medications (I)

53081 SN 2123

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 Learning Outcomes
• Describe the systems of drug nomenclature and
categorization
• Describe various routes of medication
administration.
• Define pharmacodynamics and pharmacokinetics
• Discuss the factors affecting medication actions.
• Recognize abbreviations commonly used in
medication orders
• Describe the methods of calculation of drug dosage.
• List the steps of administration of medications.
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 Learning Outcomes
• Discuss the objectives and the steps of
administrating:
– oral medication
– topical medication (dermatologic)
– otic instillation
– ophthalmic instillation
– nasal instillation
– vaginal instillation
– rectal suppository
– respiratory inhalation

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 Definition
• Pharmacology:
– the scientific study of the origin, nature,
chemistry, effects, and use of drugs
• Medications:
– A substance administered for the diagnosis, cure,
treatment, mitigation (relief), or prevention of
disease.
– Drug and medication: interchangeable terms
– Prescription and nonprescription medication
(over-the-counter medication [OTC])
– Prescription: written direction for the preparation
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and administration of a drug
 Drug Nomenclature
• Chemical name
– describes its atomic and molecular structure
• Generic name (e.g. propranolol)
– given before a drug becomes official
• Trade name/ brand name (e.g. Inderal)
– named by drug company
– symbol  after the trade name indicates that the
name is registered by and restricted to the drug
manufacturer
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 Categorization of drugs
Classification
– Similar characteristics are classified together,
based on the therapeutic effect
e.g. Inderal
• Pharmacologic category
– beta blocker
• Therapeutic effect
– anti-hypertensive, treat angina
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 Types of drug preparation
Aqueous solution One or more drugs dissolved in water.
Aqueous suspension One or more drugs finely divided in a liquid.

Capsule A gelatinous container to hold a drug in powder, liq., or oil form.

Cream A nongreasy, semisolid preparation used on skin.
Elixir A sweetened & aromatic solution of alcohol used as a vehicle for
medicinal agents.
Gel A clear or translucent semisolid that liquefies when apply to skin.
lotion Liquid suspension apply to skin.
Lozenge Preparation which dissolves & releases drug when held in mouth.
Suppository Drug with a firm base such as gelatin & shaped for insertion into body.
Base dissolved in body temp & release drug.
Syrup Aqueous solution of sugar often used to disguise unpleasant taste.
Tablet Powdered drug compressed into hard disc, may be enteric coated to
prevent from dissolving in stomach.
Transdermal patch Semipermeable membrane shaped in form of disc or patch, absorbed thro’
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skin over a period of time
 Routes of administration of medication
• Oral (PO)
• Sublingual (SL)
• Rectal (PR)
• Vaginal
• Topical (LA) Buccal cavity
• Parenteral
– Intradermal (ID),
– Intramuscular (IM),
– Subcutaneous (SC)
– Intravenous (IV)
• Inhalation (puff) Sublingual

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 Route of Administration

• Oral: most convenient, least expensive, but may be

unpleasant taste & inappropriate if vomiting or
unconscious.
• Sublingual/Buccal: same as for oral but can be faster &
more potent than oral, and if swallowed, may be
inactivated by gastric fluid.
• Rectal: release at slow & steady rate & able to provides a
local therapeutic effect. Dose absorbed is unpredictable
and may be unpleasant in procedure.
• Vaginal: provide local effect, may be messy & soiled
clothing.

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 Route of Administration

• Topical: few side effect but prolonged systemic effect, can

enter body thro’ abrasions & cause systemic effects.
• Subcutaneous: expensive, can administer small volume
only, some drugs are irritating.
• Intramuscular: Drug is rapidly absorbed, can produce
anxiety when injection.
• Intravenous: rapid effect, distribution inhibited by poor
circulation.
• Inhalation: rapid localized relief, can have systemic effect,
limited use (only respiratory system).

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 Pharmacokinetics

• Pharmacokinetics is currently
defined as the study of the time
course of drug absorption,
distribution, metabolism, and
excretion

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 Pharmacokinetics: absorption
• Absorption is the process by which a drug
passes into the bloodstream
• Factors affecting absorption:
– drug form
– route of administration
– food and other drugs
– pH of stomach (diff time, food ingested, age)
– nature of absorbing surface/ membrane
– flow of blood at administrative site
– solubility of drug

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A graphic plot of drug concentration in the blood plasma
following a single dose.

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 Pharmacokinetics: distribution
• Distribution: the process by which the drug
becomes available to body fluids and body
tissues
• Influenced by:
– blood flow
– drug’s affinity for lipoid or aqueous tissue
– protein-binding effect

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 Pharmacokinetics: metabolism
• Refers to the body’s ability to change a drug
biologically from its dosage or parent form
to a more water-soluble form
• Liver is the primary site of metabolism
• In liver disease:  drug metabolism rate 
excess drug accumulation  toxicity

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 Pharmacokinetics: excretion
• Route for drug elimination: urine (main), bile,
feces, lungs, saliva, sweat, and breast milk

• With kidney disease   drug excretion 

drug accumulation  adverse reactions
 decreased drug dosage in people with renal
disease or elderly

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Factors affecting medication action
• Developmental factors
• Gender
• Cultural, ethnic, and genetic factors
• Diet
• Environment
• Psychologic factors
• Illness and disease
• Time of administration

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 Effect of drugs
• Therapeutic effect
– The intended or predicted physiological
response that a drug causes
– Examples:
• Palliative
• Curative
• Supportive
• Substitutive
• Chemotherapeutic
• Restorative
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 Effect of drugs
• Side effect = secondary effect
– Unintended, usually predictable
– May be harmless or harmful
• Adverse effect
– More severe side effect
– May justify the discontinuation of a drug

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 Effect of drugs
• Drug toxicity
– results from:
• over dosage
• ingestion of a drug intended for external use
• impaired metabolism or excretion  buildup
of the drug in the blood (cumulative effect)
– toxic effects may occur immediately or not
apparent for weeks or months

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 Effect of drugs
• Drug allergy
– immunologic reaction to a drug
– drug as an antigen  mild or severe allergic reaction
– allergic reaction can occur anytime from a few minutes
to 2 weeks after the administration of drug
– symptoms of mild allergic reactions: skin rash, pruritus,
angioedema, rhinitis, nausea and vomiting, wheezing
and dyspnea, and diarrhea
– severe allergic reaction is called anaphylactic reaction
and it can be fetal

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 Effect of drugs
• Drug tolerance
– Unusually low physiological response
– Requires increases in the dosage to maintain a
given therapeutic effect
• Drug interaction
– One drug alters the effect of one or both drugs

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 Effect of drugs
• Potentiating effect
– Effect of one drugs is increased
by another so that the combined effect is greater
than the sum of the effects of each one alone.
• Inhibiting effect
– Effect of one or both drugs is decreased
• Synergistic effect
– When two (unlike) drugs increase the action of
one or another drug……e.g when two different
groups of antibiotics combined.
 Medication order: Types
• Stat order:
– medication is to be given immediately and only once (e.g.
furosemide [Lasix] 80 mg IV stat) ~ diuretics
• Single order (one-time order):
– medication to be given once at a specified time (e.g. Stadol 4 mg
IM on call to OR) ~ adjunct analgesic
• Standing order:
– carried out until the physician cancels it by another order or until
a prescribed number of days elapse (e.g. Ampicillin 500mg PO
QID x 5 days) ~ steroid
• prn order:
– permit the nurse to give a medication when, in nurse’s judgement,
the client requires it (e.g. Panadol 500mg PO q4h PRN) ~ pain
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 Medication order: Essential parts
• Client’s name
• Date and Time the Order is written
• Name of the drug to be administered
• Dosage of the drug
• Route of administration
• Frequency of administration
• Signature of the person writing the order

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 Common Abbreviations
• Regular Medication Times • DOSES
QD = OD = Once a day = q. 24 hrs gm = gram
08.00 (or 20.00) mg = milligram (1/1000 gram)
BID = BD = Twice a day = q.12 hrs mcg = microgram (
08.00 and 20.00 (iron = 09.00 & 1/1,000,000 gram)
18.00)
cc = cubic centimeter
TID = TDS = 3 times a day
ml = milliliter
08.00 14.00 22.00
tsp = teaspoonful
QID = QDS = 4 times a day
Tbsp = tablespoonful
08.00 12.00 18.00 22.00 – 1 tbsp (tablespoon) = around 15
mL
q h = every hour
– 1 tsp (teaspoon) = around 5 mL
ac = before meals gtt = drop
pc = after meals
Stat = immediately
oz = ounce 28
 Common Abbreviations
• PRN = as needed • amp.- ampule
• q. = every or each • aq.- aqueous
• TKVO / TKO = to • Cap.- capsule
keep vein open, slow
iv drip • liq.- liquid
• NKDA = no known • oint – ointment
drug allergies • pil – pill
• D/C = discontinued or • syr – syrup
discharged
• supp. – suppository
• NPO = Nil Per Oral =
nothing by mouth • tab - tablet
• PO = Per Oral = by
mouth
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 Common Abbreviations
• PO = by mouth
• PR = per rectum
• opth. = pertaining to the
eye
• OD = right eye
• OS = left eye
• OU = both eyes (BE)
• otic = pertaining to the
ear
• AD = right ear
• AS = left ear
• AU = both ears
• SL = sublingual
• SC = subcutaneous
• PER G.T.= through
gastrostomy tube
• IM/IMI = intramuscular
injection
• IV/IVI = intravenous
• buc = inside the cheek
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 Dosage calculations exercise
• Amount to administer (x) =

Desired dose x Quantity at hand

Dose at hand

• Questions:
– medication order:
Erythromycin suspension 250 mg PO
– pharmacy delivers bottle with label stating
“5 ml contains 125 mg of erythromycin” 31
 Code of Professional Conduct & Code of
Ethics for Nurses in Hong Kong

• Provide Safe & Competent Nursing Care

– The nurse is responsible and accountable for
individual nursing judgments and actions
– The nurse uses judgment in relation to
individual knowledge, qualifications, &
competence when accepting or delegating
duties or responsibilities
 Nursing responsibilities
• Ensure patient safety
• Maximizing therapeutic effect

By* Applying nursing process

* Knowing the drug
* Administering the drugs accurately
* Providing appropriate patient teaching
* Following legal regulations
 Know the drugs
• “Never administer a drug without knowing
it”
• Indications
• Normal dosage
• Therapeutic effects
• Adverse effects
• Potential interactions

* Be familiar with it's pharmacokinetics such as how a

drug is absorbed, distributed, metabolized, and excreted.
 Legal Concerns
• Protecting yourself from liability
• Obtain a legal order
– Medication Administration Record (MAR)
– Components:
• Patient’s particular allergic history
• Date of prescription
• Signature
• Drug name
• Route
• Dosage
• Frequency of administration
• Time schedule
• Follow agency policies
 Medication order: Nurse’s role
• Nurse should always question the physician about any order
that is ambiguous, unusual, or contraindicated by the client’s
condition (legal liability by the licensed)
• When the nurse suspects a physician’s order as inappropriate,
actions are required:
– contact the physician for clarification
– document when the physician is informed, what was conveyed
to physician and the physician’s responses
– if physician cannot be reached, document all attempts to
contact him and the reason for withholding the medication
– if someone has given the medication that you have any doubt,
document the client’s condition before and after the medication
– if an incident is indicated, clearly document factual information

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 Assessment
• Medical history
• History of allergies
• Drug data
• Diet history
• Client’s current condition
• Client’s perceptual or coordination problems
• Client’s attitude about the use of drugs
• Client’s knowledge and understanding of
drug therapy
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Process of administrating medications

• Identify the client

• Inform the client
• Administer the drug
• Provide adjunctive interventions as
indicated
• Record the drug administered
• Evaluate the client’s response to the drug

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 Administering medications:
3 Checks and 5 Rights
• 3 Checks
– After taking the medication out from the cupboard/ drawer,
Check the label of the container against MAR .
– Before (or after) pouring the medication into the medication
cup
– Before returning the medication to the cupboard/ drawer.
• 5 Rights
– right Client - right Drug -right Dosage
– right Time - right Route
– (Expiry date, condition of packing)

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Medication Cart

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 Administering Oral Medications
Compare the medication label to the MAR A cutting device can
be used to divide tablets

Pouring a liquid medication from a bottle

The bottom of the meniscus

is the measuring guide 41
Practice Guidelines: Administrating Medications.

• Nurses who administer medications are responsible

for their own actions. Question any order that is
illegible or considered incorrect.
• Be knowledgeable about the medications you
administer.
• Follow DDA guidelines.
• Use only medications that are clearly labeled.
• Do not use syrup or liquid medication which has
changed in texture/colour.
• Calculate drug doses correctly. Ask for double
checking if in doubt.
• Administer only medications personally prepared. 42
 Practice Guidelines: Administrating
Medications (cont’d)
• 3 checks & 5 rights.
• Do not leave medications at bedside.
• If client vomit after administration, report.
• Certain drugs required checking by two nurses:
insulin, anti-coagulant, certain IV preparations.
• When a medication is omitted for any reason,
document together with that reason.
• When medication error is made, report it
immediately.
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 Dangerous Drug Ordinance (brief)
• According to the ordinance, only authorized personnel have
the right to possess DD. (eg registered medical practitioner,
registered dentist, chief pharmacist, registered pharmacist);
• Only authorized person has the right to prescribe DD. (No
trainee is allowed for prescribing DD)
• A record of order or prescription should be entered in a book
kept solely for the purpose.
• Every DD should be kept in a locked receptacle which can be
open only by someone who has the right (under this ordinance)
of possession of DD.
• All DD which are in the possession of any person, by virtue of
this ordinance, should be examined at least once in every
month by the person appointed by the medical officer in
charge of the hospital: checking the prescription, the quantity
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(balance of stock kept).
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 Dangerous Drug Handling
In addition to the above,
• Should have two qualified persons each time when
checking out from the locked storage.
• The administration of DD should be closely
monitored.
• Any lost, contamination or other incidence related
to the usage & storage of DD should be reported
immediately.
• The stock of DD should be kept minimal, any
unnecessary items should be returned to hospital
pharmacy as soon as possible
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 IPMOE in HA
(Inpatient Medication Order Entry)

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Before IPMOE

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 IPMOE Procedure
1. Login;
2. Select Drug Admin by Ward/by patient;
3. Select corresponding patient to administer due (with “Y”) and PRN drug in the
list;
4. Check patient’s identification, allergy status, patient’s condition before AOM;
5. Select medication to be administered from drawer;
6. Manual checking of drug packing against prescription shown on screen (5
Rights);
7. System checking by scanning 2D barcode label on drug packing;
8. Then prepare the right dose;
9. Manual checking the drug again before putting back drug package back to
drawer;
10. Repeat 5 to 9 for another drug;
11. Click “Proceed”, and a pop-up message indicating patient’s details will show on
screen & the display of scanner;
12. Bedside: verbal & visual checking ID, followed by 2D barcode scanning on
bracelet;
13. “Patient match” will be shown on scanner if correct, then press “M1/M2” for
confirmation…….. List on the system will be updated 52
1. One-click ordering
2. Improved administration safety by barcoding.
3. Better labelling of IV.
4. Allow explicit discontinuation of drug.
5. Ultimately: Right patient, Right drug, Right route, Right time, & Right dose.
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 Oral medication
• Objective:
– To provide a medication that has
systemic effects and/ or local effect on
the gastrointestinal tract

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 Sublingual medication

• Put under the tongue

• Allowed to dissolve
completely
• Leave as last drug to
administer
• Wear glove
 Buccal administration
• Between cheek and gum
• Allowed to dissolve
• Leave as the last drug to
administer
• Wear glove
 Administering medications by
Nasogastric or Gastrostomy tube
• Check with pharmacist to see if the medications come in liquid
form.
• Check if tablets can be crushed.
• Crush into fine powder & dissolve into at least 30 ml of warm
water. (cool liquid may cause client discomfort).
• Carefully check before a capsule is open (consult pharmacist if
needed).
• Assess placement before administration.
• Flush tube before & after procedure.
• If multiple medications are required, administer each one
separately & flush with water in between each medication.
• If tube is connected to suction or bed side bag, disconnect & keep
the tube clamped for 20 to 30 minutes before re-connect to 57
system.
 Topical medication
• Topical medications are those that are applied locally
to the skin or to mucous membranes in areas such as
the eye, external ear canal, nose, vagina, and rectum
• Objective of skin application:
– to decrease itching
– to lubricate and soften the skin
– to cause local vasoconstriction or vasodilation
– to increase or decreases secretions from the skin
– to provide a protective coating to the skin
– to apply an antibiotic or antiseptic to treat or prevent
infection
– to reduce inflammation
– to administer sustained-action transdermal medications 58
 Administering topical
medication on skin
• Lotions, ointments, creams
• Absorbed through the skin
• Methods
– For Skin Patches
• Remove old patch and cleanse the area
• Apply the new patch over a clean, dry
area of the body that is free of hair
– For Skin Ointment
• Use gloves or applicator to prevent
nurse’s exposure
• Spread the medication over a clean
gauze/ gloved hand
• A thin, even layer is usually adequate
• Apply light circular motion to assist
absorption according to manufacturer
guide
• Avoid touching the medicated area
 Otic instillations (Ear drops)
• Objective:
– to soften the earwax so
that it can be readily
removed at a later time
– to provide local therapy
to reduce inflammation
and/ or destroy
infective organisms in
the external ear canal
– to relieve pain
Straightening the ear canal of a
• Medical asepsis is used child by pulling the pinna down
and back 60
 Otic instillations (Ear drops)
• Review medication order for number of drops and ear to be
medicated.
• Warm medication bottle to room temperature. That is, hold bottle
in hands to warm contents.
• Wash hands and wear glove if necessary.
• Identify client by checking armband.
• Instruct client to lie on side or to sit with head tilted so that
affected ear is facing up.
• For proper placement of ear drops in an adult, pull pinna of ear up
and out. In a child, pull pinna down and back.
• Hold dropper 1 cm above ear canal, and instil prescribed number
of drops.
• Gently massage pre-auricular area.
• Instruct client to remain on side for up to 10 minutes to prevent
loss of medication.
• Replace dropper. Never rinse ear dropper..
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Ophthalmic instillation (Eye drops)
• Objective:
– to provide an eye
medication the client
requires to treat an infection
or for other reasons
• Sterile preparations and
sterile technique are
indicated

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 Ophthalmic instillation
• Review medication order for number of drops and eye to be medicated (O.D.
= right eye, O.S. = left eye, O.U. = both eyes).
• Wash hands, and put on gloves if necessary.
• Identify client.
• Instruct client to lie supine or to sit with head slightly tilted back and to look
up.
• Clean eye with normal saline soaked cotton wool ball.
• Pull lower lid down gently to expose the conjunctiva sac, creating a pocket.
• Hold eyedropper 1-2 cm above the conjunctiva sac (pocket).
• Place hand holding dropper on the client's cheek or forehead to stabilize as
needed.
• Drop prescribed number of drops into the center of the pocket (conjunctival
sac). Avoid touching eye or conjunctiva sac with tip of eyedropper.
• Instruct client to close eye gently.
• Apply gentle pressure with finger to the lacrimal duct at the inner canthus for
1 - 2 min. This is to avoid overflow drainage into nose and throat, thus
minimizing risk of absorption into the systemic circulation.
• With tissue, remove excess medication around eye.
• Replace dropper. Never rinse eyedropper.
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 Nasal instillations
• Objective:
– to decrease nasal congestion and improve nasal
breathing
– to treat infections, inflammations, or allergies of the
nasal cavity or facial sinuses

Position of the head to instill Position of the head to instill

drops into the ethmoid and drops into the maxillary and
sphenoid sinuses frontal sinuses. 64
 Vaginal instillations
• Objective:
– to treat and prevent infection
– to remove an offensive or irritating discharge
– to reduce inflammation
– to relieved vaginal discomfort
• Medical aseptic technique is used

Using an applicator to
Instilling a vaginal suppository instill a vaginal cream 65
Vaginal Administration
 Administering vaginal instillation
 Assist patient in dorsal recumbent position or supine lying
with legs abducted
 For suppository: remove outer wrapper on suppository and
lubricate with a water-soluble lubricant
 For application of vaginal cream: lubricate the applicator with
a water –soluble lubricant
 Gently separate labial folds in the front-to-back direction
with non-dominant hand
 Instruct the patient to take slow breaths and deep exhale
during insertion
 For suppository: gently insert the suppository along posterior
wall of vaginal canal (about 10 cm) with gloved index finger
of the dominant hand
 For vaginal cream: gently insert applicator approximately 5-
7.5 cm. Then push plunger to deposit medication into vagina
 Remain flat lying or on side for at least 10 minutes
 Rectal instillations
• Objective:
– to provide a local medicinal
effect (e.g. laxative
suppository to soften feces
and stimulate defecation)
– to provide a systemic
medicinal effect
– to provide an alternate route
when the oral route is
contraindicated or the client Inserting a rectal suppository
is vomiting beyond the internal sphincter
and along the rectal wall.
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 Rectal instillations
• Review medication orders, and check for drug allergies.
• Wash hands and glove.
• Identify client by checking armband.
• Position client in a left lateral side-lying position (Sim's).
• Remove suppository from wrapper.
• Moisten rounded end of suppository and dominate forefinger
(gloved) with water-soluble lubricant.
• Instruct client to take slow breaths and deeply exhale during
insertion of suppository. This will relax anal sphincter.
• Gently insert lubricated end of suppository into anus, past the
rectal sphincter, and into anal canal. (Adult: insert 10 cm
[beyond the internal sphincter]; Child or infant: 5 cm)
• Instruct client to lie flat or on side to prevent expulsion of
suppository.
• Instruct client to retain suppository for at least 30 min to allow
absorption to occur, unless the suppository is administered to
stimulate defecation. 69
 Respiratory inhalation
• Objective:
– to relieve dyspnea
– to assist the removal
of accumulated lung
secretions
– to prevent the
accumulation of
secretions in clients
at risk

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 Respiratory inhalation
• Ensure canister is firmly & fully inserted
into inhaler.
• Remove mouthpiece cap, hold inhaler
upright after shaking.
• Exhale completely & comfortably (normal
full breath).
• Put the inhaler into mouth with lips tightly
close around mouthpiece.
• Press down once on the canister & inhale
slowly and deeply. Inhaler without
• Hold breath for 10 sec., then remove spacer
inhaler from mouth.
• Exhale slowly thro’ a pursed lips
(controlled exhalation keeps small
airways open). 71
 Respiratory inhalation
• Repeat inhalation if ordered.
Wait 20 to 30 sec. between
inhalations.
• Rinse mouth after inhalation to
reduce irritation & risk of
infection.
• Clean the mouthpiece after use. Inhaler with spacer
• Store at room temp.

**(If two inhalers are to be used,

the bronchodilator medications
should be given 10 minutes prior
to other corticosteroid
medications )** 72
 Common Medication Errors & Remediation strategies
1. Omission*
2. Unauthorized drug*
3. Wrong drug*
4. Wrong route*
5. Wrong rate*
6. Wrong dosage form
7. Wrong preparation of a
dose*
8. Wrong time*
9. Incorrect administration
technique
10. Wrong patient*
*Can be avoided by guideline
Three Checks Five Rights!!
1. Check Rx regularly for new or
stat order
2. Consult references for drugs
with similar names
3. Check Rx & label carefully
4. Master knowledge &skill
5. Use infusion pump
6&7 Check calculation with other
RN; any query for abnormal
dosage?
8. Check last admin test and the
frequency ordered
9. Seek advice whenever in
doubt; master the skill
10. Check patient identification
right before giving medication73
 References
Kozier, B., Erb, G., Berman, A., & Snyder, S. (2008). Fundamentals of
nursing: Concepts, process, and practice. (8th ed.). New Jersey:
Prentice Hall.

Moore, K. L., Dalley, A. F. (1999). Clinically oriented anatomy. (4th ed.).

Philadelphia: Lippincott Williams & Wilkins.

Potter, P. A., & Perry, A. G. (1997). Fundamentals of nursing: Concepts,

process, and practice. (4th ed.). St. Louis: Mosby.

Taylor, C., Lillis, C., & LeMone, P. (2001). Fundamentals of nursing:

The art & science of nursing care. (4th ed.). Philadelphia: Lippincott.

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