1. Administering Oral, Topical, and Inhalant Medications
Chapter 34
Administering Oral, Topical, and Inhalant Medications
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

2. Chapter 34
Lesson 34.1
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3. Learning Objectives Theory
Describe the legal and professional responsibilities of the LPN/LVN related to medication administration.
Identify the parts of a valid medication order.
Compare and contrast various medication record systems such as the hard copy medication administration record (MAR) and computerized systems.
Discuss medication dispensing and delivery systems.
Analyze the advantages and disadvantages of the unit-dose system and the prescription system.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

4. Learning Objectives Clinical Practice
Demonstrate the accounting for doses of controlled drugs that must be withdrawn from the locked narcotics cabinet or dispensed from an automatic dispensing unit.
Prepare and apply topical medications such as eye ointments, eardrops, nasal medications transdermal patches, and topical ointments.
Review a care plan for a patient who is receiving medication that includes patient-specific data, an identified nursing diagnosis, and interventions that you used.
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5. Nursing Responsibilities in Medication Administration
Be accurate during all steps of medication administration
Follow exactly all procedures related to medication administration
Report any error promptly
Interpret the medication order correctly, then give the correct medication to the patient
Make an assessment of the patient after medication has been administered
Follow the Six Rights of medication administration
Medication errors can occur in several steps during the administration process:
Order interpretation
Patient identification
Administration route
Dosage
Documentation errors
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6. Medication Orders
Nurses must question unclear, incomplete, or ambiguous medication orders
Complete drug orders must contain:
Full name of the patient
Name of the drug and how it is to be given
Dosage to be given and route of administration
Date, time, and signature of the prescribing physician
The Six Rights of drug administration provide a guide for nursing practice.
What are the factors that modify dosage and effects of medications (drugs)? (age, sex, weight, toleration, susceptibility, patient condition, rate of excretion of drug, and cumulative action)
Different systems are available to order medications. However, all of them must have the same information as the one listed above.
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7. Dosages
Dosages may be ordered in the metric system (most often used) or in the apothecary system
Nurses must be able to calculate the dosage in either system
Nurses must be able to convert from one system to the other
Checking conversions with another nurse may prevent medication errors from conversions
Nurses should refer to the metric doses and the apothecary equivalents when converting dosages of medication.
A conversion table of frequently used measurements (weights and liquids) should be posted in the medication preparation area.
The pharmacist should always be consulted when in doubt.
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8. Routes of Oral Medications
PO (per os [by mouth])—solid or liquid medications (oral, sublingual, buccal) or via feeding tube
Patients with difficulty in swallowing may need pills crushed or changed to liquids
Medications that should not be crushed:
Sublingual medications, enteric-coated medications, and sustained-release preparations
Oral medications when crushed are likely to be bitter and poorly tolerated by children and seniors.
When liquid forms of oral medications are not available, the medication may be given with food or juices to mask the taste.
Some medications should not be given with food.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

9. Figure 34-4: Reading the dose prepared at the meniscus of the liquid
More or less medication could be given if this step is not done correctly.
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10. Routes of Topical Medications
Applied in the form of:
Drops (eye or ear)
Ointments, pastes, or lotions
Rectal suppositories
Transdermal medication
Should be applied to a hairless area
Inhalants
Nurses should teach and supervise adult patients in using eyedrops, ointments, pastes or lotions, and suppositories.
Patients may be embarrassed to have a nurse apply these medications.
Self-administered medications for hospital patients should be documented in the patient’s record by the nurse.
Refer to Skill 34-2, Skill 34-3, Steps 34-1, and Steps 34-2.
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11. Question 1
Which medication system is most commonly used in health care agencies?
Stock supply
Individual prescription system
Unit-dose method
Pharmacy profile
Answer: 3
Rationale: The unit-dose system is considered the safest and is most commonly used. It provides one dose at a time. Stock supplies are rarely used today. Individual prescription systems have several days supplied at one time and aren’t as cost-effective as the unit-dose method. A pharmacy profile lists a patient’s allergies and the medications a patient is on, but is not a type of administration system.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12. Question 2
Narcotic orders are good for how long before a physician in a hospital setting must renew them?
24 hours
48 hours
4 days
1 week
Answer: 2
Rationale: Narcotic orders have a 48- to 72-hour limit. The physician must give or write a renewal order to continue the medication.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

13. Chapter 34
Lesson 34.2
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14. Learning Objectives Theory
State four principles to be followed when giving a medication through a feeding tube.
Analyze special considerations when administering oral and topical medications to an elderly patient.
Evaluate your responsibilities in the event of a medication error.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

15. Learning Objectives Clinical Practice
Give oral and topical medications using the Six Rights.
Teach a patient to use a metered-dose inhaler.
Instill a vaginal and a rectal suppository safely and effectively.
Document medication administration and your patient’s response to the therapy.
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16. Administering Meds via Feeding Tube
If patient unable to swallow meds
Meds in liquid form best
Tablets can be used if place in liquids
Do not mix meds with formula or tube feeding
Open capsules
Crush tablets if allowed
Aspirate liquid from capsule
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17. Routes of Eye and Ear Medications
Ophthalmic (eye) medications may be in the form of drops, ointment, or eye disk
The word ophthalmic must be clearly visible on container
Otic (ear) medications are usually administrated as drops or irrigation
Ensure that patients who have an allergy are wearing their allergy alert armband next to their ID bracelet.
Checking the bracelet alone is no substitute for asking patients about allergies before giving medications.
Don’t record blanket notes “See Allergy List.” Each allergy should be listed individually in the notes as well as in the history.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

18. Figure 34-5: Straightening the ear canal for otic drops
When the ear canal is straightened, medication can be delivered more effectively.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

19. Routes of Nasal Medications
Come in atomizers or dropper bottles
Have patient block one nostril and inhale through nose as atomizer is squeezed
Drops should be administered with patient lying on the back with neck hyperextended while medication is dropped into the nostrils
Inhalants and nasal medications may have a systemic and local effect.
Drugs used for systemic effect are in the form of fine mist or gas and may be administered under pressure to have an immediate effect on the large surface of the lungs.
Local effect—may be in the form of medicated steam and fumes.
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20. Figure 34-6: Instilling nose drops (Proetz’s position)
Instilling nose drops and nasal sprays can be ineffective if not done correctly.
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21. Routes of Inhalation Medications
May be administered through a nebulizer, spray, or atomizer to penetrate the lungs
Metered-dose inhaler: prescribed amount of medication is administered in each spray; it is held in front of the mouth and medication is inhaled as the inhaler is triggered
May require a spacer for effective use
Moist or steam inhalations are used chiefly for the following purposes:
To relieve inflammation of the mucous membrane in acute colds and sinusitis.
To relieve inflammation of the larynx.
To soften thick, tenacious mucus and relieve coughing from many causes.
To warm and moisten the air when following operation such as a tracheotomy.
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22. Figure 34-8: Using a metered-dose inhaler
Discuss why metered-dosed inhalers are important.
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23. Routes of Vaginal Medications
Used to:
Cleanse the vagina for surgery
Reduce bacterial growth
Remove odors and discharge
Apply heat or cold to inflamed tissues
Absorb medication into local mucosa
Discuss three ways of administering vaginal medications and the therapeutic advantages or disadvantages of each.
Discuss the prevalence of vaginal abscesses in elderly patients.
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24. Figure 34-9: Inserting vaginal medications
Insert the medication into the vagina making sure to prevent the medication from slipping or draining out.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

25. Routes of Rectal Medications
Dispensed in the form of suppositories; used to:
Prevent vomiting
Soothe hemorrhoids
Prevent bladder spasms
Promote bowel evacuation
Reduce fever
Medications are absorbed by the mucous membranes of the rectum, vagina, urethra, and bladder.
Rectal medications are useful alternatives for patients who cannot take oral medications.
Be sensitive to the patient’s or family member’s difficulty with administering rectal medications.
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26. Figure 34-10: Inserting a rectal suppository
Ensure the suppository is touching the wall of the rectum in order for the drug to be effective.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

27. Routes of Transdermal Medications
Supplied as paste or patch
Should be applied to clean, hairless area and left in place
Typical drugs available
Nitroglycerin, scopolamine, estrogen, fentanyl
Patches are designed to gradually release medications for 5 to 7 days.
They should be placed on inactive parts of the body (for example, abdomen, hip, upper thigh); avoid limbs.
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28. Regularly Scheduled Medication Orders
Maintain desired level of medication in the bloodstream, often given several times a day
Physician’s order will specify how often the medication is to be given
Three times a day (tid), every 4 hours (q4hr), etc.
Policies designate time of day corresponding to the frequency ordered by the physician.
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29. PRN Medication Orders
Some PRN medication orders specify when or how often the medication can be given
hs PRN, meaning “hour of sleep as needed”
q4hr PRN, meaning “as often as every 4 hours as needed”
Medications taken “as needed” are given in response to a patient’s request or when the need is indicated.
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30. Stat and Single-Dose Medication Orders
May consist of more than one drug or may involve spacing drops or tablets over a short period
Stat orders indicate that the order has top priority and medication must be administered without delay
When are stat orders most commonly administered?
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31. Renewal Orders
Many hospitals have medication policies limiting the time for which certain types of medication orders are valid
Opiate analgesics generally have a 48- or 72-hour limit
Sedatives and antibiotics may have a 5- or 7-day limit
A 30-day limit may be imposed by some agencies on all medications
At the end of the specified period, the order is no longer considered valid, and no additional doses of the drug may be given.
What should be done if you think the medication will need to be continued after the time limit has been reached?
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32. Stop or Discontinue Orders
Medications given to patient until the specified number of doses have been administered or until the order has expired or has been canceled
All medication orders automatically canceled whenever a patient undergoes surgery or general anesthesia
Usually change in medication is ordered by the physician
New orders must be rewritten after surgery, even for routine medications
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33. Medication Administration Record (MAR)
Used to record a patient’s medications
Nurses record the doses of drugs administered each day
Referred to when giving regularly scheduled and PRN medications
Usually found in the patient’s electronic record, but may be in binders or in a special Kardex kept in the medication area
More facilities are going to computerized medication documentation.
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34. Medication Cards
Rarely used now, but may be encountered in small long-term care facilities or rehabilitation centers
For each patient, one card is made for each medication ordered
The card is used:
When the dose is prepared
At the bedside to help identify what is being given
To chart after the medication is given
Information on the card includes patient’s name, room number, physician’s name, name of drug, dose, route, and time of administration, the date the order was written, and the initials of the person making the card.
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35. Medication Administration and Technology
Improve medication administration safety
Computerized physician order entry systems (CPOE)
Prescriber directly enters the medication order in the computer; this decreases potential for transcription errors
Bar code scanners
Scan the medication package and the patient ID bands
Personal digital assistants
Download and upload specific patient information to a PDA that is connected to the larger hospital information system
What other features may be included in the CPOE?
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36. Unit-Dose System Provides premeasured, prepackaged, prelabeled dose
Safest because dose prescribed is dose dispensed
May be dispensed from mobile cart, or the fixed medication preparation center
Benefits
Pharmacy supplies the exact dose of medication ordered
Saves time for the nurse
Patient is charged only for medications used
Allows keeping a minimum amount of drugs on the nursing units
Almost all oral medications, liquids, suppositories, and lotions are now available in unit doses and in prefilled cartridges or syringes for injection.
Where are the medication records usually kept?
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37. Figure 34-2: Unit-dose medications
Discuss how a unit dose is different than the type of method with which drugs are dispensed from the local pharmacy.
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38. Prescription System
Prescription is written for each drug ordered and is filled by the pharmacist, who provides individual containers holding doses for several days
In the long-term care facility, a week’s or month’s supply of each medication is often provided in a bubble pack
The prescription system is similar to the unit-dose system, except that a sufficient number of doses for several days is supplied.
What are the advantages of the prescription system?
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39. Preparation of Oral Controlled Substances from a Dispenser
A controlled dispensing system is used for distributing opiate analgesics and hypnotics
Legally controlled substances must be under lock and key
Automated controlled substance dispensing machines are often used in the clinical setting to monitor and control narcotic use
When not in a dispensing machine, drugs are supplied in a controlled dispenser or a commercially prepared package
What are the advantages of automated controlled substance dispensing machines?
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40. Figure 34-3: Nurse obtaining medication from automated dispensing unit
Illustrate how to obtain medications from an automated dispensing unit.
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41. Medication Errors All medication errors must be reported
An incident or occurrence form is filled out for the medication error
After notifying the physician, orders are carried out to safeguard the patient
The goal is to prevent harm to the patient from the error and to prevent similar errors from happening again
In the United States, an estimated 1.5 million patients are harmed each year by medication errors (Metules, 2007) in spite of all the safeguards.
Who should fill out the incident report when a medication error has occurred?
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42. Question 3
Paige is getting ready to administer eardrops to a 2-year-old girl. When administering eardrops, it is important to remember to:
pull the earlobe downward to straighten the canal.
pull the earlobe upward to straighten the canal.
pull the earlobe toward the back of the head to straighten the canal.
None of the above
Answer: 1
Rationale: Ear medication is mostly administered in children. For a child younger than the age of 3, pull the earlobe downward to straighten the canal; in an adult, pull the top of the pinna out and upward.
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43. Question 4
Allison is getting ready to administer her patient’s medication through a feeding tube. Which types of medications cannot be crushed or administered through a feeding tube?
Buccal, sublingual, and liquid
Liquid, sublingual, and enteric-coated
Sublingual, enteric-coated, or sustained-release
Liquid, sustained-release, and suppository
Answer: 3
Rationale: Medications that should not be crushed and administered through a feeding tube are sublingual, enteric-coated, and sustained-release medications. Sublingual medications are to be placed under the tongue and absorbed by vessels in the oral mucosa. Enteric-coated medications have a special coating that does not dissolve until the medication reaches the intestine. Crushing it would allow it to be absorbed before reaching the intestines. Sustained-release medications should not be crushed because the proper desired sustained effect of the medication would be compromised.
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44. Question 5
Allison’s patient is going to surgery. What will happen to her patient’s medication orders?
They will go with the patient at all times throughout the surgery.
New orders will probably be added after surgery.
All orders are canceled and new orders must be rewritten after surgery.
All orders are canceled and new orders must be rewritten after surgery except routine medications.
Answer: 3
Rationale: All medication orders are automatically canceled whenever a patient undergoes surgery or anesthesia. New orders must be rewritten after surgery, even for routine medications.
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