Administering Oral Medications

• Safe medication administration involves accurate dose calculation, of the correct medication, given to the intended recipient, by the appropriate route, at the right time (the 5 rights).

Calculation of Medications

There are numerous methods for calculating medications. A few examples are listed.

• Desired Dose (mg) × Available Vehicle (mL, tab, etc.)/Available Dose (mg) = Correct Dose (mL, tab)
• Available Vehicle Amount (mL, tab) × Desired Dose (mg)/Available Dose (mg) = Correct Dose (mL, tab)

Special Considerations

• A medication order must include the patient's full name, the date and time the order was written, the name of the medication, the dose, the route, the frequency, and the signature of the person writing the order.
• Medications must be checked for the five rights with each administration: right patient, right medication, right dose, right route, and right time.
• Allergies should be checked prior to each medication administration.
• The timing of the medication can affect the speed with which it is absorbed and acts.
• In general, oral medications are absorbed better on an empty stomach if the patient can tolerate the medication. Many medications cause gastrointestinal distress.
• Circadian rhythm also will affect absorption.
• Check with references or the pharmacy before crushing any medication. Alert the prescriber if a liquid form is needed.
• Do not crush an enteric-coated tablet, as they are not designed to be absorbed immediately.
• Do not crush sustained-release tablets, as the delay in release of the drug will be lost, and more of the drug will be absorbed immediately.
• Some medications, such as liquid iron preparations, will stain the teeth.
• Some medications have special administration instructions, such as the patient must remain upright after administration.
• If a medication falls on the floor, discard it and replace it to prevent contamination.
• If the patient is scheduled for a test or procedure, check with the prescriber regarding medication administration, especially if the patient is ordered to have nothing by mouth.
• Many medications have similar names. If an order is unclear, check with the prescriber before administration.
• Many medications are made by more than one company.
• The nurse needs to know the trade as well as the generic name of the medications being administered.

Pediatric Patient

• Do not refer to medications as candy.
• In administering liquid medications to children, use a calibrated syringe or spoon readily available at drug stores and supermarkets to ensure correct dosing.
• For infants, a syringe or dropper is best.
• Place syringe alongside the tongue to prevent gagging and expulsion of medication.
• To prevent choking, position the infant in a semi-reclining position and administer in small aliquots.
• If using a spoon, collect and re-feed any expelled medication.
• Do not mix medication into a large volume, as the child may not be able to drink the entire amount.
• Play techniques may help elicit the child's cooperation.
• For children taking sweetened medications, especially on a long-term basis, follow medication administration with oral hygiene to assist in decreasing dental caries.

Elderly Patient

• The elderly are often on multiple medications from various physicians.
• Look for possible drug interactions as well as prescriptions for more than one drug from the same class (such as beta-blockers).
• At home, memory aides such as charts, daily-pill dispensers, and calendars can assist in ensuring that medications are taken correctly, especially for those on complex regimens.

Relevant Nursing Diagnoses

• Possible Knowledge Deficit related to safe medication administration

• The correct person will receive the correct medication and the correct dose, by the correct route, at the correct time, without injury or incident

• Order Sheet
• Medication Administration Record (MAR)
• Medication Cart/Automated medication-dispensing system
• Medication to be administered (pills, capsules, liquids)
• Disposable medication cups or syringes as indicated
• Glass of water or other liquid and drinking straw
• Pill-crushing devise, if indicated

• Check MAR against order sheet, including checking for patient allergies and order-expiry dates. Notify prescriber/supervisor of discrepancies and correct as necessary.
• Promotes safety, prevents errors, and prevents patient injury and unnecessary allergic reactions.
• Wash hands.
• Reduces transfer of infections.
• Assemble equipment.
• Improves efficiency.
• Obtain appropriate medications. Pour correct amount. Begin at the top of the MAR. Check each against bottle label and MAR when pulled from the shelf or machine, as it is poured, and as bottle is replaced or drawer closed. Calculations should be made using standard formulas according to institutional policy when required.
• To ensure no medications are missed and the correct medication and dose are poured.
• For tablets or capsules: pour into cap of bottle then into medication cup without touching the tablets/capsules.
• To prevent contamination.
• Unit dose: leave in packages until at the bedside.
• Keeps the medication clean and facilitates identification at the bedside
• Breaking tablets: Only scored tablets should be broken. Use a cutting device as needed. The rest of the unused tablet should be discarded according to agency policy.
• To ensure correct amount is given and that safety is maintained.
• Crushing tablets: Place tablet between two medicine cups then crush with pill crusher until a fine powder. Mix at bedside with small amount soft food or liquid.
• Fine powders mix better. To assist patients who have difficulty swallowing whole pills.
• Pouring liquids: Gently mix liquid by inverting bottle a few times.
• Many liquids settle while on the shelf.
• Set the cap upside down on the counter.
• To avoid contamination.
• Pour liquid away from label.
• To prevent destruction of label.
• Pour liquid medication into cup set on a firm surface, and read at the lowest level of the meniscus.
• Ensures the most accurate dose.
• Wipe bottle before replacing cap.
• To keep cap from sticking.
• Controlled substances: The dose must be signed out on the narcotics sheet with the patient's name, medication, dose, date, time, and your name as the administering nurse. For those with automated dispensing machines, this is done automatically when the medication is removed.
• To comply with federal regulations.
• Obtain assessment data.
• To determine whether any medications need to be withheld for safety
• Take medication to bedside with liquid for swallowing.
• In preparation for administration.
• Assist the patient into a semi-Fowler's position.
• To decrease risk for aspiration.
• Don gloves if exposure to saliva is possible.
• Protects nurse from infection.
• Recheck patient's identity using armband and bar code, and asking patient's name. Explain procedure and medications.
• To ensure correct medication is being given to the correct patient. To enlist cooperation.
• If patient questions any medication, hold the medication and recheck order.
• To ensure safety. Unfamiliar medications may signal a previously unidentified discrepancy.
• If a medication has a bad taste, sucking on ice before taking the medication, giving it in a small amount of juice, or following it with a small amount of juice is permitted.
• Facilitate compliance by decreasing the bad taste.
• Open unit dose packets and place one at a time into a medication cup.
• Give tablet or capsule medications to patient. Ask patient to take one medication at a time and drink plenty of water.
• To ensure medication is swallowed and not lodged in throat or esophagus.
• Liquid medications should be taken after capsules and tablets are taken. Ask the patient to finish the liquid medication. Follow with a small amount of water.
• Some liquids should not be further diluted.
• Stay with the patient until all medications are taken. Check patient's mouth if there is any question that the medication has been swallowed.
• Ensures all of the medications are taken and not retained in mouth or cheek.
• Reposition patient, lift side rails if lowered, and place call light within reach.
  Instruct patient to call nurse for any deleterious side effects or symptoms of allergic reaction.
• Facilitates comfort. Ensures safety.
• Discard trash and remove any medications not ingested.
• Maintain safe environment.
• If patient refused medication or wishes to take it later, do not leave at bedside.
• Maintain a safe environment.
• Remove medication and restore to shelf or machine only if in unopened unit-dose packet.
• Allows nurse to administer later.
• All open pills and open unit-dose packets must be discarded according to facility policy. Witness is needed for controlled substances.
• To comply with federal regulations.
• Wash hands
• Prevent spread of infection.
• Document administration.
• Serves as legal record of medication administration, and prevents inadvertent double dosing.
• Check patient 30 to 60 minutes later.
• To detect effectiveness of medication and/or any adverse or side effects.

Evaluation and Follow-Up Activities

• Many medications have side effects; the patient should be carefully assessed for side effects and adverse reactions

Key Points for Reporting and Recording

• Routine medications are documented on the MAR.
• The record should be clearly labeled with the person's name. It should include the medication name, dose, route, frequency, and the time medication was administered.
• Any assessment data pertinent to the medication should be easily accessible, such as blood pressure measurement and heart rate for certain cardiovascular agents.
• For controlled substances, the dose must be signed out on the narcotics sheet with the patient's name, medication, dose, date, time, and name of the administering nurse to comply with federal regulations.
• In automated dispensing machines, this is done automatically when the medication is removed.
• If the patient refuses a medication, document which medication is being refused and the reason and that the medication was withheld.
• Also document the notification of the prescriber.
• For medications administered on an as-needed basis (PRN), the assessment data pertinent to the medication, the reason the medication was given, the effects of the medication (Did it help?), and any teaching done should be recorded in the patient care record.
• Side effects from medications should be documented in the patient record.
• In shift report, it is assumed that all routine medications were given on time unless otherwise specified.
• Any problems, such as with swallowing, gastric distress, refused medications, or any changes in the routine should be reported.
• Any PRN medications, including results, should be reported.