Medication Administration

TERMINAL LEARNING OBJECTIVE

A patient care handwash has been performed. Necessary materials and equipment: calibrated medicine cups, disposable medicine cups, tray, medications, medicated pads or patches, application papers, tape, DA Form 3949, and the patient's clinical record.

INTRODUCTION

The preparation and administration of medications are perhaps the most dangerous functions performed by the soldier medic. In addition to administering the correct dosage by the specified route, the soldier medic must observe and interpret the patient's response to the medications as well as recognize medication incompatibilities and reactions. The soldier medic must also be able to recognize unclear or unsafe medication orders and administration practices. This block of instruction will discuss general principles that help you prepare and administer drugs safely.

Terms and Definitions

a. Medication administration requires the soldier medic to be familiar with the terms and definitions of medication administration

b. Drug effects-mechanism of action

(1) Predictable chemical reaction-how the drug works

(2) Changes the physiological activity of the body as the drug bonds chemically at a specific site called a receptor site

(3) Mechanism of actions of drugs include

(a) Drugs that fit the receptor sites well with a good chemical response are called "agonists“

(b) Drugs that attach at a receptor site and become chemically inactive with no drug response is called an "antagonist“

c. Drug actions

(1) Therapeutic effects

(a) Expected positive effect of drug

(b) Single medication may have many therapeutic effects such as aspirin which is an analgesic, reduces inflammation, reduces fever and reduces clot formation

(c) Some drugs have very specific effects such as antihypertensive medications have a therapeutic effect of controlling high blood pressure. Antibiotics treat bacterial infections.

(2) Side effects

(a) Unintended secondary effects

(b) May or may not be harmful to the patient

(d) Patients may stop taking a drug because of unpleasant side effects, i.e. codeine prescribed to control coughing but causes constipation.

(3) Toxic effects

(a) Caused by intake of high doses of medications, ingestion of drugs not intended to be ingested, such as topical medications, or when a drug accumulates in the system due to impaired metabolism or excretion

(b) May be lethal, depending on the action of the drug

(c) Usually seen in accidental poisonings and intentional drug overdoses i.e., intentional ingestion or accidental administration of a large amount of a narcotic may cause severe respiratory depression and death.

(4) Allergic Reactions

(a) Unpredictable response to a drug

(b) May be mild or severe

(c) Mild allergic reactions include hives, rash, pruritus (itching of the skin), rhinitis (stuffy, runny nose) and wheezing.

(d) Severe or anaphylactic reactions are characterized by sudden constriction of the bronchiolar muscles, swelling the throat, severe wheezing and shortness of breath. Without immediate life saving measures, this reaction progresses rapidly and death can occur within minutes.

(e) Always ask patient about allergies to medications. Check unconscious patients for a medical alert bracelet or medal indicating a medication allergy prior to administering medications

(5) Drug tolerance and dependence

(a) Occurs when the patient receives the same drug for long periods of time and requires higher doses to produce the same effect.

(b) For example, patients who take pain medications over a long period of time may develop a tolerance for the drug and require higher doses to achieve the same effect.

(6) Drug interactions

(a) One drug modifies the action of another drug. Drug interactions are common in patients who take many medications

(b) A drug may potentiate or diminish the action of other drugs

(d) Drug interactions may or may not be desirable. For example, combining alcohol with other central nervous system depressants is not desirable. Combining diuretics and vasodilators act together to lower blood pressure in a desirable way.

Routes of Drug Administration

a. Non-parenteral medication administration

(1) Drugs are introduced into the body by different routes, each serving a specific purpose

(2) Oral administration of medications is the most common method

(a) Advantages

1) Convenience

2) Economy

3) The drug need not be absolutely pure or sterile

4) A wide variety of dosage forms are available

(b) Oral medications include tablets, capsules, liquids, and suspensions

1) Inability of some patients to swallow

2) Slow absorption

3) Partial or complete destruction by the digestive system

(d) Other routes associated closely with oral administration

1) Sublingual

a) The drug is placed under the tongue and rapidly absorbed directly into the blood stream

b) Example - Nitroglycerin sublingual tablets

2) Buccal - The drug is placed between the cheek and gum and is quickly absorbed directly into the blood stream

(3) Inhalation

(a) The introduction of medications through the respiratory system in the form of a gas, vapor, or powder

(b) Divided into three major types

1) Vaporization - the drug is changed from a liquid or solid to a gas or vapor by the use of heat, such as steam inhalation

2) Gas inhalation- almost entirely restricted to anesthesia

3) Nebulization - the drug is nebulized into minute droplets by the use of compressed gas or oxygen

(4) Topical ointments

(a) Examples of topical preparations

1) Creams

2) Lotions

3) Shampoos

(b) Topical application serves two purposes

1) Local effect-the drug is intended to relieve itching, burning, or other skin conditions without being absorbed into the bloodstream and

2) Systemic effect-the drug is absorbed through the skin into the bloodstream.

3) Example - Nitroglycerin paste

(5) Suppositories

(a) Rectal is preferred to the oral route when patient is

1) Nauseated or vomiting

2) Unconscious, uncooperative, or mentally incapable

(b) Vaginal suppositories, creams, or tablets are examples of vaginal preparations that are inserted into the vagina to produce a local effect

b. Parenteral medications are those introduced by injection

(1) All drugs used by this route must be

(a) Pure

(b) Sterile

(d) Liquid state

(2) Several types of parenteral administration

(a) Subcutaneous

1) The agent is injected just below the skin's cutaneous layers

2) Example - Insulin

(b) Intradermal

1) The drug is injected within the dermis

2) Example - Purified Protein Derivative (PPD)

1) The drug is injected into the muscle

2) Example - Procaine penicillin G

(d) Intravenous

1) The drug is introduced directly into the vein

2) Example - Intravenous fluids/antibiotics

(e) Intrathecal/intraspinal - The drug is introduced into the subarachnoid space of the spinal column.

Bulk and Unit Dose Medications

a. Bulk drugs

(1) Commonly called floor stock or clinic stock

(2) Description - large quantity of drug from which individual medication dose is removed

(3) Storage guidelines

(a) Once individual dosage is removed, it can NEVER be returned to bulk container

(b) Individual dosage drawn from bulk drug container will be disposed of IAW local SOP

b. Unit dose

(1) Description - single dose of a drug in a tablet, capsule, liquid, or injectable form that is prepackaged by the pharmaceutical company or pharmacy

(2) Storage guidelines

(a) Normally found in medication cart

(b) If still in original wrapper/unused condition, can be returned to medication cart/storage

c. Internal and topical (external) medications must be stored separately to prevent accidental use of the inappropriate medication. Example - injectable, ointments, and tablets are stored on separate shelves

d. Specific medications kept in secured (limited access) area

(1) All narcotics

(2) All medications with abuse potential, e.g., diazepam (Valium)

(3) All pre-filled hypodermic needles and syringes

Guidelines and Principles

a. General guidelines

(1) Check the physician's/PA orders

(2) Wash hands prior to touching any medication

(3) Five patient rights

(a) Right patient - verify patient's identity by comparing the patient's medical record, provider's orders, and the medical bracelet (hospital) or ask patient to state full name

(b) Right medication - compare provider's orders, medication sheet, and medication label

(c) Right dose - ensure amount of medication ordered by the provider is measured correctly (i.e., graduated medicine cup, syringe, number of tablets, number of milligrams, etc.)

(d) Right time - administer medications at the prescribed time as per provider's orders

(e) Right route - administer medication via the route specified in the provider's order (i.e., PO, IM, IV, etc.)

(4) Check medical records, allergy bands, medic-alert tags and ask patient for medication allergies

b. Principles of Medication Administration

(1) Only administer medication that you have prepared or received from the pharmacy as unit dose

(2) Be familiar with all potential medication effects, both therapeutic and non-therapeutic. This information can be found in the

(a) Manufacturer's medication insert that accompanies prepackaged medications

(b) Local SOP

CAUTION: If there is any doubt about administering a medication, check with supervisor, nurse, physician, PA, or pharmacist.

(3) Administration route and time will be followed IAW provider's orders

WARNING: NEVER alter medication dosage ordered by physician/PA!

(4) If in doubt about medication dose, time, administration route, or if a medication is missing, check with supervisor, nurse, physician, PA or pharmacist

(a) MD/PA's order and medication label DO NOT match exactly

(b) Illegible medication label; return to pharmacy or follow local SOP

(5) Check all medications label 3 times to ensure that the correct medication is being prepared for administration

(a) When removing the medication or container from the storage area

(b) When preparing the medication dose

(6) Check the expiration date of the medication

(7) Handle only one medication at a time

(8) While administering medication, do not perform other duties (i.e., obtain vital signs, dressing changes)

(9) Prepare the prescribed dose of medication

(a) Tablet or capsules - transfer the prescribed dose of tablets or capsules to the medicine cup or if unit dose- open the package and give directly to the patient

(b) Liquids - pour the prescribed dose of liquid medication into the medicine cup. Small amounts of liquid medication should be drawn up in a syringe

1) Pour the required amount of water or juice into a paper cup

2) Reconstitute the medication at the patient's bedside

WARNING: Never directly touch oral medications. Some medications can be absorbed through the skin, also the medication will become contaminated.

3) The medic may assist the patient in taking the medication if the patient is physically unable

WARNING: DO NOT administer oral medications to patients with a decreased level of consciousness. Check with supervisor for instructions.

CAUTION: Positive patient ID required prior to administering medication.

(10) Patient Identification

(a) Patient identification (Hospital)

1) Be sure the patient has received and wears an identification band

2) Check the information on the band to see that it is correct

3) Check the tag on the bed or wall and door, and make sure the patient is properly identified

4) Ask the patient to state his/her name

5) Check patient ID band for medication allergies and other pertinent information

6) In a hospital environment, have patients return to their bedside to receive medication

(b) Patient identification (Clinic)

1) Have patient state name

2) Ask patient if he/she has any allergies to medications

Dosage

a. Systems of drug measurement (definitions)

(1) Metric system

(a) Decimal system, each basic unit of measure is organized into units of 10

(b) Basic units of measure are the meter (length), the liter (volume), and the gram (weight)

1) Gram = g or GM

2) Liter = l or L

(d) Small letters are abbreviations for subdivisions of major units

1) Milligram = mg

2) Milliliter = ml

(2) Household measurements

(a) Familiar to most people

(b) Used when more accurate systems of measure are unnecessary

(c) Basic units of measure include drops, teaspoons, tablespoons, cups, and glass for volume; and ounces and pounds for weight

b. Dosage

(1) A dose is the amount of medication to be administered

(2) Dosology is the study of dosage and the criteria that influence it

(3) United States Pharmacopeia and National Formulary (USP-NF) states the doses given are the average therapeutic doses or "usual adult doses"

(4) The following terms are used in connection with doses

(a) Therapeutic dose

1) Amount needed to produce the desired therapeutic effect

2) Also referred to as "usual adult dose"

3) Calculated on an average adult about 24 years old, weighing approximately 150 pounds

(b) Dosage range

1) The range between the MINIMUM amount of drug and the MAXIMUM amount of drug required to produce the desired effect

2) Many drugs, such as antibiotics, require large initial doses that are later tapered to smaller amounts

3) MINIMUM dose, the least amount of drug required to produce a therapeutic effect

4) MAXIMUM dose, the largest amount of drug that can be given without reaching the toxic effect

5) TOXIC dose, the least amount of drug that will produce symptoms of poisoning

6) Minimum lethal dose - The least amount of drug than can produce death

c. Factors affecting dosage

(1) Many factors that affect the dose, method of administration, and frequency of the dose

(2) Although a physician prescribes the amount to be given, you need to know how and why these quantities are determined

(3) Two primary factors that determine or influence the dose are age and weight

(4) Age is the most common factor that influences the amount of drug to be given

(a) An infant would require much less than an adult

(b) Elderly patients may require more or less than the average dose, depending upon the action of the drug and the condition of the patient

(5) Weight has a more direct bearing on the dose than any other factor, especially in the calculation of pediatric doses

(6) Other factors that influence dosage are

(a) Genetic make-up - The genetic structure of the individual may cause peculiar reactions to medications in some patients

(b) Habitual use - Some patients must take medications chronically, causing their bodies to build up tolerance to the drug. This tolerance may require larger doses than their initial doses to obtain the same therapeutic effect.

(c) Time of administration - Therapeutic effect may be altered depending upon time of administration. Example - Before or after meals.

(d) Mode of administration - This has a definite impact on the dose. Example - Injections

Principles of Patient Observation and Medication Documentation

a. Patient observation

(1) Remain with patient until medication is swallowed completely, injected, or applied topically

(2) If patient refuses medication

(a) Remove medication from the patient's room

(b) Report the patient refusal to the nurse/supervisor

(d) If refused a second time, record the omission per SOP and document the reason for the omission in the nursing notes. Report patient refusal to direct supervisor.

CAUTION: DO NOT leave medications in the patient's possession without a specific physician's order to do so.

(3) Observe for medication effects and/or side effects

(a) Medical history

1) Before administering medications, review the patient’s medical history for possible indications or contraindications for medication therapy

2) Disease or illness may place patient at risk for adverse medication effects

3) Long-term health problems or surgical history may require medications

(b) History of allergies

1) Allergic to medication

2) Food allergies should be documented

3) If patient is allergic to shellfish, they may be sensitive to any product containing iodine such as Betadine or dyes used in radiological testing

1) Length of time drug has been taken

2) Current dosage schedule

3) Any ill effects experienced

4) Drug data - action, purpose, normal dosage, routes, side effects and nursing implications for administration and monitoring

(4) If the patient has an adverse reaction. (Rash, itching, and nausea/vomiting/diarrhea are common examples of adverse reactions.)

WARNING: Anaphylaxis is the most severe form of adverse reaction to a medication.

(a) Stop dosage immediately

(b) Assess patient's airway, breathing, circulation

b. Medical documentation

(1) Record administration of medication IAW SOP. Minimum information needed is

(a) Name of medication given

(b) Dosage of medication

(d) Route of administration

(e) Patient's reaction (effects/side effects)

(f) Name of person who administered medication

(2) Record the omission of a medication on the appropriate medical forms whenever a scheduled medication is not administered IAW local SOP

Medication Errors

a. Any event that causes the patient to receive inappropriate drug therapy (medications) or failing to receive appropriate drug therapy (medications)

b. Can be made by anyone involved in the prescribing (MD/PA), transcribing of the order, preparing and dispensing (pharmacist, RN, 91W) or administering the medication (RN, LPN, 91W)

c. Strict adherence to the five "rights“ of medication administration helps to prevent errors

d. Errors should be acknowledged as soon as they are discovered or known to have happened and reported immediately to the appropriate people for patient follow-up

e. Professional and ethical obligations to your patients mandate that you report all medication errors

SUMMARY

Medication administration is a significant 91W responsibility that requires adherence to the safety principles discussed in this block of instruction. Every patient has a unique response to the drugs they are given so these principles should be followed every time you are required to administer a medication.