Learning Objectives
By the end of this section, you will be able to:
- Explain medication administration procedures according to route
- Describe the nursing roles and responsibilities of medication administration
Serving as the final checkpoint in the medication process before administration, nurses assume a pivotal role in safeguarding patient safety. As such, the nurse must have demonstrated competency in administering medications via each individual route. Moreover, nurses play pivotal roles in the medication administration process, encompassing assessment, delegation, error reporting, documentation, evaluation, and education. Mastery of these roles and responsibilities is indispensable for nurses to uphold the highest standards of patient care and safety.
Medication Administration Procedures
Medication administration is a critical component of nursing practice that encompasses a variety of routes to deliver therapeutic agents effectively. This section introduces the procedures for administering medications through different routes, including oral, intradermal, subcutaneous, intramuscular, intravenous, as well as ophthalmic (eye), otic (ear), nasal, inhalation, vaginal, and rectal routes. Each route requires specific techniques and considerations to maximize the intended effects of the medication while minimizing potential adverse reactions. Understanding these procedures is essential for nurses to deliver care effectively and to educate patients on their medication regimens.
Oral Medication Administration
Administering medications via the oral route is simple, convenient, and widely accepted, especially in home settings. Medications ordered for oral administration (per os, or PO) are taken by mouth. After swallowing, these medications are typically absorbed in the small intestine. Oral medications generally have a slow onset, taking about thirty to sixty minutes to start working.
When administering oral medications, patient safety is paramount. The nurse must assess for contraindications such as dysphagia (difficulty swallowing), nasogastric (NG) tube with suctioning, nothing by mouth (NPO) status, or the inability to sit upright. If the patient has difficulty swallowing, a tablet (compressed powder or granules) is typically crushed (Figure 11.6) and placed in a substance such as applesauce or pudding for easier swallowing, based on the patient’s prescribed diet. However, it is crucial to verify that a tablet may be crushed by consulting a drug reference or a pharmacist. An enteric-coated tablet (a tablet covered in a substance that delays the medication from dissolving), a capsule (a powder or granules contained in a gelatin shell), and timed-release (slow release of a medication for prolonged action) should never be crushed as this will affect the intended action of the medication. In such cases, the provider must be contacted for a change in the route of administration.
Position the patient in an upright position to decrease the risk of aspiration (Figure 11.7). Patients should remain in this position for thirty minutes after medication administration if possible. If a patient is unable to sit, assist them into a side-lying position. Offer a glass of water or other oral fluid (that is not contraindicated with the medication) to ease swallowing and improve absorption and dissolution of the medication, taking any fluid restrictions into account. Remain with the patient until all medication has been swallowed before documenting to verify the medication has been administered.
Once confirmed that oral medications can be safely administered, the nurse should verify the MAR against the provider’s orders and obtain the medications, confirming the medication rights at each step. After preparing the medications and confirming the rights again, the nurse assists the patient into an upright or side-lying position if necessary, offers a suitable liquid, and ensures all medications are swallowed. The nurse then performs any required post-assessments and documents the patient’s response to the medication.
Life-Stage Context
Administering Oral Medications to Children
Several factors should be kept in mind when administering oral medications to children. Sometimes, children are reluctant to take medications. In these instances, it may be helpful to mix the medication with a soft food (e.g., applesauce) when possible or have the child’s caregiver assist with administering the medication. Medications may need to be prescribed in a liquid or chewable form if the child is unable to swallow medications in a solid form. When administering liquid medications to a child, an oral syringe or medication dropper may be used to provide a precise measurement of the medication. Liquid medications should be squirted between the child’s gum and cheek to avoid aspiration. It is important for the nurse to be patient when administering medications to children and to try to address the child’s and caregiver’s fears.
For medications given sublingually (under the tongue) or buccally (between the cheek and gum), ensure the mouth is moist by offering a drink of water prior to administration, which aids absorption. Instruct the patient to allow the medication to completely dissolve without swallowing or chewing it. Liquid medications should be shaken if they are suspensions and poured with the label in the palm of the hand to prevent blurring from any spills. Measure liquids at eye level to ensure accurate dosing, following specific agency policy and procedure when administering oral medications.
Link to Learning
Watch this video demonstrating how to administer oral medications to patients.
Intradermal Medication Administration
Injecting medications into the dermis layer of the skin, just below the epidermis, is known as intradermal (ID) medication administration. This route is commonly used for skin testing, such as tuberculin skin testing (TST), and for administering small volumes of certain medications, such as local anesthetics and allergy tests. Before administering medication intradermally, the nurse must select an appropriate site for injection, typically the inner aspect of the forearm or the upper back, and cleanse the area with an antiseptic solution to minimize the risk of infection. The nurse should also assess the patient’s skin integrity and previous reactions to intradermal injections to ensure safety and efficacy.
When preparing for intradermal medication administration, the nurse should use a small-gauge needle, typically 0.25 to 0.5 in (6.4 to 12.7 mm) and 25 to 27 gauge (diameter of the hole in the needle), to minimize tissue trauma and ensure accurate placement of the medication within the dermis. The needle should be inserted at a 10- to 15-degree angle into the skin, creating a small bleb or wheal (a small, raised, and usually pale bump that forms at the injection site) that indicates proper placement of the medication (Figure 11.8) (Indiana Department of Health, n.d.). The nurse should inject the medication slowly to minimize discomfort and prevent leakage or dispersion of the medication into surrounding tissues. After administering the medication, the nurse should cover the injection site with a sterile gauze pad or adhesive bandage to protect the area and prevent contamination.
Following intradermal medication administration, the nurse should closely monitor the injection site for any signs of adverse reactions, such as redness, swelling, or itching. The nurse should also instruct the patient to avoid scratching or rubbing the injection site to prevent irritation and ensure accurate interpretation of skin test results (Indiana Department of Health, n.d.). Additionally, the nurse should document the medication administration, including the medication name, dose, route, injection site, and any patient responses or adverse reactions.
Link to Learning
Watch this video demonstrating how to administer intradermal medications to a patient.
Subcutaneous Medication Administration
Delivering medications into the fatty tissue layer just beneath the skin is known as subcutaneous (SQ) medication administration. This route is commonly used for medications that require slow and sustained absorption into the bloodstream, such as insulin and certain types of vaccines. Before administering medication via the SQ route, the nurse must assess the patient’s suitability for this method, considering factors such as the thickness of the subcutaneous tissue, the volume of medication to be injected, and the type of medication being administered. Common sites for SQ injections include the abdomen, upper arms, thighs, and buttocks, with the abdomen being the preferred site for most injections due to its large surface area and consistent absorption rates (Figure 11.9).
When preparing for an SQ injection, the nurse must adhere to strict aseptic technique to minimize the risk of infection. This involves washing hands thoroughly, preparing the injection site with an antiseptic solution, and ensuring that all equipment is sterile. Additionally, the nurse should select an appropriate needle length and gauge based on the patient’s age (25G–30G needle that is 3/8 to 5/8 in [9.5 to 15.9 mm] long), body size, and the type of medication being administered (Mannheim, 2023). After preparing the medication, the nurse should pinch the skin at the selected injection site to create a skinfold, which helps facilitate proper needle insertion and medication absorption.
During the injection process, the nurse should use a quick, dart-like motion to insert the needle into the subcutaneous tissue at a 45- to 90-degree angle, depending on the needle length and the patient’s body size. Once the needle is inserted, the medication should be injected slowly and steadily to minimize discomfort and reduce the risk of tissue damage. After administering the medication, the nurse should withdraw the needle swiftly and apply gentle pressure to the injection site to minimize bleeding. Finally, the nurse should dispose of the used needle and syringe in a puncture-proof container and document the medication administration, including the site used and any patient responses or adverse reactions (Mannheim, 2023).
Link to Learning
Watch this video demonstrating how to administer subcutaneous medications to a patient.
Intramuscular Medication Administration
Injecting medications directly into the muscle tissue is known as intramuscular (IM) medication administration. This route is commonly used for medications that require a slow and sustained release into the bloodstream or those that cannot be effectively absorbed through the digestive system. Before administering medication via the IM route, the nurse must assess the patient’s suitability for this method, considering factors such as muscle mass, amount of fatty tissue, and the volume of medication to be injected. Common sites for IM injections include the deltoid muscle in the upper arm, the vastus lateralis muscle in the thigh, and the ventrogluteal or dorsogluteal muscles in the buttocks (Figure 11.10) (Polania & Munakomi, 2023). The choice of injection site depends on factors such as the patient’s age, the volume of medication, and the type of medication being administered.
When preparing for an IM injection, the nurse must adhere to strict aseptic technique to minimize the risk of infection. This involves washing hands thoroughly, preparing the injection site with an antiseptic solution, and ensuring that all equipment is sterile. Additionally, the nurse should select an appropriate needle length and gauge based on the patient’s age (20G–25G needle that is 5/8–1.5-in [15.9 –38.1 mm] long), muscle mass, and the type of medication being administered. After preparing the medication, the nurse should aspirate the syringe to check for blood return, which helps confirm that the needle is not in a blood vessel before injecting the medication (Polania & Munakomi, 2023).
Life-Stage Context
Administering Intramuscular Medications to Pediatric Patients
When administering intramuscular (IM) medications to pediatric patients, nurses must adapt their approach to ensure safety and minimize discomfort. Selecting the appropriate injection site and needle size is crucial, considering the child’s age, size, and muscle development. For infants and small children, a shorter needle length (e.g., 5/8 in [15.8 mm]) and smaller gauge (e.g., 25G–27G) are typically appropriate to minimize tissue trauma and discomfort. The vastus lateralis muscle in the thigh is often preferred for IM injections in infants and toddlers due to its larger size and well-developed muscle mass, providing adequate absorption and reducing the risk of nerve injury. In older children and adolescents, longer needles (up to 1.5 in [38.1 mm]) and slightly larger gauges may be used, depending on the child’s muscle development and adipose tissue distribution. Nurses should assess the child’s individual characteristics, such as body mass index (BMI) and muscle tone, to determine the most suitable injection technique. By tailoring needle size and injection site selection to the child’s age and anatomical features, nurses can enhance the safety and comfort of IM medication administration in pediatric patients.
During the injection process, the nurse should use a quick, dart-like motion to insert the needle into the muscle tissue at a 90-degree angle (Polania & Munakomi, 2023). Once the needle is inserted, the medication should be injected slowly and steadily to minimize discomfort and reduce the risk of tissue damage. After administering the medication, the nurse should withdraw the needle swiftly and apply gentle pressure to the injection site to minimize bleeding. Finally, the nurse should dispose of the used needle and syringe in a puncture-proof container and document the medication administration, including the site used and any patient responses or adverse reactions.
Link to Learning
Watch this video demonstrating how to administer intramuscular medications to a patient.
Intravenous Medication Administration
Intravenous (IV) medication administration involves delivering medications directly into the bloodstream via a vein. This route allows for rapid absorption and immediate therapeutic effects, making it suitable for medications that require fast onset of action, such as emergency drugs, fluids, and certain antibiotics. Before administering medication intravenously, the nurse must verify the patient’s identity, confirm the medication order against the patient’s medical record, and assess the patient’s vascular access to ensure the availability of suitable veins for infusion. Common sites for IV access include the veins in the arms, hands, and sometimes the feet, depending on the patient’s condition and the type of medication to be administered.
When preparing for IV medication administration, the nurse must follow strict aseptic technique to prevent infection and contamination. This involves washing hands thoroughly, disinfecting the infusion site with an antiseptic solution, and using sterile equipment, including IV catheters (small hollow tube placed in the vein), tubing, and syringes. Additionally, the nurse should select the appropriate size and type of IV catheter based on the patient’s age, vein size, and the viscosity of the medication being administered. The nurse should also assess the compatibility of the medication with the IV solution to avoid potential incompatibilities and adverse reactions.
During the IV medication administration process, the nurse should carefully insert the IV catheter into the vein using aseptic technique and secure it in place to prevent dislodgement. Once the catheter is in place, the nurse should flush the catheter with a saline solution to ensure patency (open and unobstructed line) and confirm proper placement (Figure 11.11). The nurse should administer the medication slowly and continuously, monitoring the patient for any signs of adverse reactions or complications, such as infiltration (occurs when the tip of the catheter slips out of the vein and into the surrounding tissue), extravasation (infiltration of damaging IV medications into the extravascular tissue around the site of infusion), or phlebitis (inflammation of a vein). After completing the medication infusion, the nurse should flush the catheter again to clear any residual medication and maintain catheter patency. Finally, the nurse should document the medication administration, including the medication name, dose, route, infusion site, and any patient responses or adverse reactions.
Link to Learning
Watch this video demonstrating how to administer intravenous medications to a patient.
Eye Medication Administration
Eye (ophthalmic) medication administration involves the instillation of medications into the eye to treat various ocular conditions such as infections, inflammation, and glaucoma. Before administering eye medications, the nurse should perform hand hygiene and gather the necessary supplies, including the prescribed medication, sterile saline or sterile water, tissues, and gloves if indicated. To prevent errors, it is essential to verify the patient’s identity and confirm the correct medication, dosage, and eye before proceeding with the administration.
To administer an eye drop, liquid medication intended for use in the eye, the nurse should instruct the patient to tilt their head back and look up, or lie down if unable to sit upright. Using one hand, the nurse should gently pull down the lower eyelid to create a pouch for the medication. With the other hand, the nurse should hold the medication dropper or bottle above the eye and instill the prescribed number of drops into the conjunctival sac (Figure 11.12) (Gudgel, 2023). Avoid touching the bottle tip or touching the bottle to the eye or eyelid, to prevent bacterial contamination (Gudgel, 2023). The patient should then close their eyes gently and apply gentle pressure to the inner corner of the eye for one to two minutes to prevent systemic absorption and promote medication absorption.
For eye ointments, which are greasy semisolids that melt into tiny drops with body warmth, the nurse should instruct the patient to tilt their head back and look up, or lie down if unable to sit upright. Using one hand, the nurse should gently pull down the lower eyelid to expose the conjunctival sac. With the other hand, the nurse should apply a thin ribbon of ointment along the inside of the lower eyelid from the inner to the outer corner, ensuring the tube does not touch the eye or eyelashes. The patient should then close their eyes gently and blink several times to distribute the medication evenly across the eye surface. After administration, the nurse should instruct the patient to keep their eyes closed for one to two minutes to minimize eye irritation and systemic absorption. If the patient is receiving eye drops and eye ointments, eye drops should be instilled before applying eye ointment, as the ointment may affect the absorption of the eye drop (Shaw, 2016).
Link to Learning
Watch this video demonstrating how to administer eye medications to a patient.
Ear Medication Administration
Ear (otic) medication administration involves the instillation of medications into the ear canal to treat various ear conditions such as infections, inflammation, and excessive earwax buildup. Before administering ear medications, the nurse should perform hand hygiene and gather the necessary supplies, including the prescribed medication, sterile saline or sterile water, cotton balls or gauze, and gloves if indicated. To prevent errors, it is crucial to verify the patient’s identity and confirm the correct medication, dosage, and ear before proceeding with the administration.
To administer an ear drop, liquid medication applied into the ear canal, the nurse should instruct the patient to lie on their side with the affected ear facing upward. Using one hand, the nurse should gently pull the earlobe upward and backward (downward and backward for a pediatric patient) to straighten the ear canal and create a pathway for the medication (Figure 11.13) (Nemours Kids Health, 2022). With the other hand, the nurse should hold the medication dropper or bottle above the ear and instill the prescribed number of drops into the ear canal, taking care not to touch the ear or ear canal with the dropper. The patient should then remain in the side-lying position for two to three minutes to allow the medication to penetrate the ear canal fully (Cleveland Clinic, 2023).
Link to Learning
Watch this video demonstrating how to administer ear medications to a patient.
Nasal Medication Administration
Nose or nostril (nasal) medication administration involves the delivery of medications into the nasal passages to treat various nasal conditions such as congestion, allergies, and sinus infections. Before administering nasal medications, the nurse should perform hand hygiene and gather the necessary supplies, including the prescribed medication, tissues, and gloves if indicated. To prevent errors, it is essential to verify the patient’s identity and confirm the correct medication, dosage, and route before proceeding with the administration.
Before using a nasal medication for the first time, the nasal spray bottle must be primed. This preparatory step entails expelling a few test sprays to eliminate any air from the nozzle or tubing of the bottle, thereby confirming the initial dose administered to the patient contains the accurate amount of medication as intended by the healthcare provider. To administer nasal medications, the nurse should instruct the patient to blow their nose gently to clear the nasal passages. The patient should then sit upright or tilt their head back slightly. Using one hand, the nurse should support the back of the patient’s head, while with the other hand, they should hold the medication bottle or nasal spray device. The nurse should insert the nozzle of the bottle or spray device into one nostril, aiming slightly outward toward the ear, and gently press the bottle or spray device to administer the prescribed number of sprays or drops (Figure 11.14). The patient should inhale gently through the nose while the medication is being administered to ensure proper distribution throughout the nasal passages. The process should then be repeated for the other nostril if indicated. The patient should be instructed to avoid blowing their nose or tilting their head forward for five to ten minutes to prevent the medication from leaking out of the nostrils (Cleveland Clinic, 2022).
Link to Learning
Watch this video demonstrating how to administer nasal medications to a patient.
Inhalation Medication Administration
Inhalation medication administration involves delivering medications directly into the respiratory system through inhalation. This method is commonly used to treat respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), and respiratory infections. Before administering inhaled medications, the nurse should perform hand hygiene and gather the necessary supplies, including the prescribed medication, inhalation device (such as a metered-dose inhaler or nebulizer), and a spacer (a clear tube that fits between the inhaler and the mouthpiece, allowing the medication to move into the spacer for the patient to inhale more slowly and with control) if indicated. To prevent errors, it is crucial to verify the patient’s identity and confirm the correct medication, dosage, and route.
For inhalers (pocket-sized devices that deliver medications into the lungs without the use of electricity) and metered-dose inhalers (MDIs) (devices that use electricity to create an aerosolized mist of medication that is inhaled into the lungs), the nurse should instruct the patient to shake the inhaler well before each use and remove the cap. The patient should then exhale fully to empty the lungs, place the mouthpiece of the inhaler between their lips, and create a tight seal with their lips around the mouthpiece. While breathing in slowly and deeply, the patient should simultaneously press down on the inhaler to release the medication and continue to inhale until their lungs are full. After inhaling the medication, the patient should hold their breath for ten seconds to allow the medication to deposit in the lungs before exhaling slowly. If multiple doses are prescribed, the patient should wait the specified amount of time between doses as directed (National Heart, Lung, and Blood Institute, 2021a).
Link to Learning
Watch this video demonstrating how to administer metered-dose inhaler medications to a patient.
Small electric or battery-powered machines that deliver a fine mist of liquid medications, or nebulizers, are another common method for delivering inhaled medications and are particularly useful for patients who have difficulty using MDIs or require higher doses of medication. To administer medication via nebulizer, the nurse should assemble the nebulizer according to the manufacturer’s instructions and add the prescribed amount of medication to the nebulizer chamber. The patient should then sit upright or in a comfortable position and insert the mouthpiece of the nebulizer into their mouth or use a mask if indicated. The nebulizer should be turned on, and the patient should inhale the medication mist produced by the nebulizer until all the medication is gone, which typically takes about five to ten minutes. After administration, the nebulizer should be cleaned and disinfected according to the manufacturer’s instructions to prevent contamination and ensure optimal functioning for future use (National Heart, Lung, and Blood Institute, 2021b).
Link to Learning
Watch this video demonstrating how to administer nebulized medications to a patient.
Vaginal Medication Administration
The insertion of medication into the vaginal canal, known as vaginal medication administration, treats various gynecological conditions such as vaginal infections and hormonal imbalances. It is also used to prepare for certain medical procedures. Before administering vaginal medications, the nurse should ensure privacy for the patient and explain the procedure to alleviate any concerns or anxieties. Hand hygiene should be performed, and appropriate supplies, including the prescribed medication, gloves, lubricant (if needed), and applicator (if provided), should be gathered.
To administer vaginal medications, the patient should be instructed to assume a comfortable position, such as lying on their back with knees bent, standing with one foot elevated on a stool, or a left lateral lying position. The nurse should don gloves and prepare the medication according to the provider’s orders and manufacturer’s instructions. If an applicator is provided, the medication should be drawn into the applicator barrel. If no applicator is provided, the medication may be applied directly from the container or with the nurse’s gloved fingers.
Next, the nurse should gently insert the applicator or fingers containing the medication into the vaginal canal, aiming toward the small of the patient’s back (Figure 11.15). The depth of insertion may vary depending on the specific medication and provider’s instructions. Once the medication is deposited into the vagina, the applicator should be slowly withdrawn, or the nurse’s fingers should be gently removed. Patients should be advised to remain lying down for a few minutes after administration to allow the medication to distribute evenly within the vaginal canal (Carter, 2024).
After administering the medication, the nurse should dispose of any used supplies appropriately and provide the patient with any necessary postadministration instructions. These instructions may include avoiding sexual intercourse or vaginal douching for a specified period, as well as any potential side effects or adverse reactions to monitor for.
Link to Learning
Watch this video demonstrating how to administer vaginal medications to a patient.
Rectal Medication Administration
The insertion of medication into the rectum for local or systemic effects is known as rectal medication administration. This route is commonly used when the oral route is not feasible due to patient conditions such as vomiting, unconsciousness, or inability to swallow. Before administering rectal medications, the nurse should ensure the patient’s privacy and explain the procedure to alleviate any concerns. Hand hygiene should be performed, and appropriate supplies, including the prescribed medication, gloves, lubricant (if needed), and applicator (if provided), should be gathered.
To administer rectal medications, the patient should be instructed to assume a comfortable position, typically lying on their left side with the right knee bent. The nurse should don gloves and prepare the medication according to the provider’s orders and manufacturer’s instructions. If an applicator is provided, the medication should be drawn into the applicator barrel. If no applicator is provided, the medication may be applied directly from the container or with the nurse’s gloved fingers.
Next, the nurse should gently insert the applicator or fingers containing the medication into the rectum, aiming toward the patient’s umbilicus (Figure 11.16). The depth of insertion may vary depending on the specific medication and provider’s instructions. Once the medication is deposited into the rectum, the applicator should be slowly withdrawn, or the nurse’s fingers should be gently removed. Patients should be advised to remain lying down for a few minutes after administration to allow the medication to be absorbed (Wilson, 2023).
After administering the medication, the nurse should dispose of any used supplies appropriately and provide the patient with any necessary postadministration instructions. These instructions may include avoiding defecation for a specified period to allow the medication to be absorbed, as well as any potential side effects or adverse reactions to monitor for.
Link to Learning
Watch this video demonstrating how to administer rectal medications to a patient.
Nursing Roles and Responsibilities of Medication Administration
Nurses play a pivotal role in the safe and effective administration of medications, encompassing a broad range of responsibilities that ensure optimal patient outcomes. These duties include thorough assessment, careful delegation of tasks, accurate documentation, evaluation of medication efficacy, education of patients and their families, and diligent reporting of any errors. By integrating these key responsibilities into their practice, nurses uphold high standards of care and patient safety in medication administration.
Assessment
When administering medications, one of the pivotal responsibilities of the nurse is comprehensive patient assessment. This assessment occurs before, during, and after medication administration. Prior to administering medications, nurses assess various aspects of the patient’s condition, such as their ability to swallow, current dietary restrictions such as NPO status, and vital signs if deemed necessary. For instance, cardiac medications may require evaluation of heart rate and blood pressure to ensure patient safety. Similarly, reviewing laboratory results is crucial; administering potassium to a patient with elevated levels may lead to further complications. Additionally, before giving PRN medications, assessments of pain levels or sleep patterns are imperative, with the nurse’s clinical judgment dictating whether administration is appropriate.
During medication administration, nurses conduct ongoing patient safety assessments. This includes verifying patient identity, checking for allergies, reviewing the medication “rights,” and ensuring the patient can safely swallow medications. Any signs of difficulty swallowing, such as coughing or choking, warrant halting administration until further assessment can be made to ensure patient safety.
Following medication administration, nurses continue to assess the patient’s response to the medications. This entails monitoring tolerance, evaluating whether the intended response occurred, reassessing indications for PRN medications, and vigilantly observing for adverse reactions. These postadministration assessments inform clinical decision-making, guiding the nurse on potential changes to the patient’s care plan. For example, persistent pain despite pain medication administration may necessitate alternative interventions or medication adjustments. Adverse reactions may prompt discontinuation of the medication and the need for new orders.
Delegation
When delegating medication administration to assistive personnel (if permitted in the state of practice), the nurse must ensure the five rights of delegation: right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. In determining the right task, it is important for the nurse to ensure the assistive personnel has received the appropriate training and has been deemed competent in the skill. In determining the right circumstance, the nurse should consider the patient’s circumstances before delegating the task. Instances in which the results are unpredictable, risks are involved, or medication administration challenges are predicted should not be delegated to the assistive personnel. The right person involves delegating the right task to the right person. It is important for the nurse to be aware of which assistive personnel have been credentialed to administer medications and correctly identify the patient to receive the medication. In ensuring the right directions and communication, the nurse should provide clear instructions regarding the task that needs to be completed, when it should be completed, as well as any additional expectations associated with the task. The right supervision and evaluation require the nurse to provide appropriate monitoring, evaluation, intervention, and feedback.
Documentation
Upon completion of administering medications, the nurse is responsible for documenting the medication administration as well as any required postadministration assessments. This step is the one in which the medication administration “rights” of right documentation and right response are verified. To ensure accurate documentation, guidelines have been developed to ensure that only approved abbreviations are used, documentation is timely, and there is adequate evaluation of the patient’s response to the medication.
Accuracy of Documentation
Thorough and accurate documentation is critical for clinical decision-making and the delivery of high-quality care. The patient’s medical record serves as a communication tool for the interdisciplinary team and is crucial for ensuring continuity of care. Not only does accurate documentation inform the care team of the patient’s current situation and allow for treatment decisions to be made, but it also provides legal evidence that may be used in the court of law. Therefore, accurate documentation is needed to provide the very best care and to mitigate risks.
Approved Abbreviations
When documenting medication administrations, it is essential to use only approved abbreviations to avoid potential errors. Agencies should implement standardized abbreviations to ensure consistency and reduce confusion. The ISMP’s National Medication Errors Reporting Program highlights numerous error-prone abbreviations linked to medication errors, which should be avoided. TJC’s Do Not Use List must be incorporated into organizational policies. For instance, abbreviations for magnesium sulfate (MgSO4) and morphine sulfate (MSO4) should never be used due to the high risk of significant patient harm. Medication names should typically be spelled out in full to prevent confusion, such as avoiding HCT for hydrocortisone and HCTZ for hydrochlorothiazide.
Link to Learning
View The Joint Commission’s Do Not Use List fact sheet.
Dosages should avoid fractions and Roman numerals, as they can be misinterpreted, and proper spacing between drug names, doses, and units of measurement should be maintained to prevent errors. For example, write "Metoprolol 25 mg" with adequate spacing to avoid it being read as "Metoprolol 125 mg." Use commas for numbers greater than one thousand, and use standard measurement units such as mL for milliliters and mcg for micrograms. Routes of administration should be written out in full, though some agencies may allow abbreviations such as PO for oral and IM for intramuscular. Additionally, documenting the administration site for injections is crucial to avoid confusion.
When expressing medication frequency, writing the frequency in full (e.g., daily, at bedtime) is safest, although abbreviations such as Q for every may be used with caution. For instance, QD can denote daily, but spelling out daily is recommended. Symbols are generally not recommended in medication documentation; instead, spell out terms such as more than and less than rather than using > and <. Similarly, use words such as increase and decrease instead of directional arrows, and avoid symbols such as @, &, and +, which can be misinterpreted. Using clear and standardized documentation practices is crucial to ensuring safe medication administration.
Link to Learning
View the ICMP’s list of error-prone abbreviations.
Timing of Documentation
Medications should be documented immediately after administration to reduce potential errors and ensure accuracy. This practice minimizes the risk of duplicate administration and can alert clinicians to any changes in the patient’s condition. Documenting medication administration prior to actually administering the medication can lead to errors if the patient’s condition changes. For instance, a nurse may document an IV medication before administration, only to discover the IV has infiltrated. Similarly, documenting oral medications before administration may be problematic if the patient cannot safely swallow, or if the patient refuses the medication when it is offered. There is also a risk that the nurse might document the administration of the medication but then forget to actually administer it.
Evaluation
After administering medications, it is crucial for the nurse to ensure the medication achieved the intended outcome as part of the nursing process. For instance, the nurse should check if the patient’s blood pressure decreased after administering blood pressure medication or if a fever reduced after giving a fever reducer. If the medication does not produce the expected outcome, the nurse should report this to the provider and document the response in the patient’s chart.
The timing for evaluating the medication’s effect depends on its onset. Typically, oral medications should be assessed within thirty minutes to one hour, whereas IV medications should be evaluated much sooner, usually within five to fifteen minutes, depending on the medication. Nurses should follow their agency’s policies for evaluation time frames.
In addition to the intended response, the nurse should document any adverse reactions, including allergic responses. For example, if a rash develops thirty minutes after administering a new medication, the nurse should document this reaction in the MAR and write a progress note detailing the response, including that the provider was notified and any additional orders received. PRN medications must also be evaluated, with clear documentation of the indication for the medication and reassessment according to its onset. For instance, pain assessments should be conducted thirty minutes to one hour after administering oral pain medications and within ten to fifteen minutes after administering IV pain medications.
Education
Educating patients about their medications is crucial for ensuring they understand the purpose, dosage, and potential side effects of their prescribed drugs. Nurses should explain how and when to take the medication, any dietary or activity restrictions, and the importance of adhering to the prescribed regimen.
Nurses should also explain what patients can expect with medication administration. This includes potential immediate effects, how long it might take for the medication to start working, and any common side effects they should watch for. Nurses should inform patients about signs of adverse reactions that would require contacting their healthcare provider. It is also important to teach patients how to administer their medications safely and effectively, demonstrating the proper techniques for the administration route.
Educating patients empowers them to take an active role in their own health care, promotes adherence to treatment plans, and enhances overall health outcomes. Nurses should also assess the patient’s understanding and readiness to learn, tailoring their educational approach to meet individual needs and ensuring that the patient or caregiver can correctly follow the medication regimen independently. Providing written materials or resources can help reinforce this information.
Patient Conversations
Educating a Patient on Nasal Sprays
Nurse: Good morning, Mrs. Yang. I see here that your provider has prescribed a nasal spray for your congestion. Have you used one before?
Patient: Yes, I’ve used nasal sprays in the past, but it has been a while.
Nurse: No problem, I’ll walk you through it. Nasal sprays are liquid medications that you spray into your nostrils to help clear congestion and reduce inflammation in your nasal passages.
Patient: How many times should I spray it?
Nurse: Your prescription indicates that you should administer one spray in each nostril once a day. It’s important not to exceed this dosage unless instructed otherwise by your provider.
Patient: Got it. How do I use it?
Nurse: Before using the nasal spray for the first time, you’ll need to prime the bottle. To do this, you’ll pump the spray bottle a few times until you see a fine mist. Once it’s primed, tilt your head slightly forward, insert the nozzle into one nostril, and point it toward the back of your head, away from the center of your nose. As you spray, inhale gently and then repeat the process for the other nostril.
Patient: Should I blow my nose before or after using the spray?
Nurse: It’s best to blow your nose gently before using the spray to clear any excess mucus. Afterward, try to avoid blowing your nose for a few minutes to allow the medication to be absorbed properly.
Patient: Okay, that makes sense. Thank you for your help.
Nurse: You’re welcome, Mrs. Yang. If you have any other questions or concerns, don’t hesitate to ask.
Reporting Errors
Nurses are legally responsible for ensuring safe and accurate administration of medications and may be held liable for medication errors. When a medication error occurs, the nurse’s first responsibility is to ensure the patient’s safety by immediately monitoring the patient for any adverse effects and providing necessary interventions. Following this, the nurse must notify the appropriate healthcare team members, including the nurse manager (and/or charge nurse) and the prescribing provider, to ensure timely corrective measures are taken. Documentation of the error is also essential, often in the form of an incident report. This report should detail the nature of the error, the patient’s response, and any actions taken. The aim of reporting is not to assign blame but to identify and address potential system-wide issues, contributing to a culture of safety within the healthcare environment. By reporting medication errors, nurses play a vital role in preventing future errors, enhancing patient safety, and fostering continuous quality improvement in healthcare settings.
The nurse is also legally responsible for delegated tasks. Some states may allow the nurse to delegate medication administration to unlicensed assistive personnel (UAP) (Carder & O’Keeffe, 2016). In these instances, the nurse is responsible for supervising the UAP throughout the medication administration process. Although some tasks may be delegated to the UAP, the nurse remains responsible for the assessment, planning, teaching, evaluation, and nursing judgment associated with the administration of medications.