Verify the order on the patient's medication record by checking it against the physician's order.
Wash your hands.
Check the label on the medication three times before administering it to make sure you'll be giving the prescribed medication. Check when you take the container from the shelf or drawer, again before you pour the medication into the medication cup, and again before returning the container to the shelf or drawer. If you're administering a unit-dose medication, check the label for the final time at the patient's bedside immediately after pouring the medication and before discarding the wrapper.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your id badge, the patient's id bracelet, and the medication's bar code.
Assess the patient's condition, including level of consciousness and vital signs, as needed. Changes in the patient's condition may warrant withholding medication. For example, you may need to withhold a medication that will slow the patient's heart rate if his apical pulse rate is less than 60 beats/minute.
Give the patient his medication and an appropriate vehicle or liquid, as needed, to aid swallowing, minimize adverse effects, or promote absorption. For example, cyclophosphamide is given with fluids to minimize adverse effects; antitussive cough syrup is given without a fluid to avoid diluting its soothing effect on the throat. If appropriate, crush the medication to facilitate swallowing.
Stay with the patient until he has swallowed the drug. If he seems confused or disoriented, check his mouth to make sure he has swallowed it. Return and reassess the patient's response within 1 hour after giving the medication.
Special considerations
Make sure you have a written order for every medication given. Verbal orders should be signed by the physician within the specified time period. (Hospitals usually require a signature within 24 hours; long-term-care facilities, within 48 hours.)
Notify the physician about any medication withheld, unless instructions to withhold are already written.
Use care in measuring out the prescribed dose of liquid oral medication. (See Measuring liquid medications, page 230.)
Don't give medication from a poorly labeled or unlabeled container. Don't attempt to label or reinforce drug labels yourself. This must be done by a pharmacist.
Never give a medication poured by someone else. Never allow your medication cart or tray out of your sight. This prevents anyone from rearranging the medications or taking one without your knowledge. Never return unwrapped or prepared medications to stock containers. Instead, dispose of them and notify the pharmacy. Keep in mind that the disposal of any opioid drug must be cosigned by another nurse, as mandated by law.
If the patient questions you about his medication or the dosage, check his medication record again. If the medication is correct, reassure him. Make sure you tell him about any changes in his medication or dosage. Instruct him, as appropriate, about possible adverse effects. Ask him to report anything he thinks may be an adverse effect.
To avoid damaging or staining the patient's teeth, administer acid or iron preparations through a straw. An unpleasant-tasting liquid can usually be made more palatable if taken through a straw because the liquid contacts fewer taste buds.
If the patient can't swallow a whole tablet or capsule, ask the pharmacist if the drug is available in liquid form or if it can be administered by another route. If not, ask him if you can crush the tablet or open the capsule and mix it with food. Keep in mind that many enteric-coated or time-release medications and gelatin capsules shouldn't be crushed. Remember to contact the physician for an order to change the administration route when necessary.
PEDIATRIC ALERT Oral medications are relatively easy to give to infants because of their natural sucking instinct and, in infants under 4 months old, their undeveloped sense of taste.
Documentation
Note the drug administered, dose, date and time, and patient's reaction, if any. If the patient refuses a drug, document the refusal and notify the charge nurse and the patient's physician, as needed. Also note if a drug was omitted or withheld for other reasons, such as radiology or laboratory tests, or if, in your judgment, the drug was contraindicated at the ordered time. Sign out all opioids given on the appropriate opioids central record.
NASOGASTRIC TUBES
Besides providing an alternate means of nourishment, a nasogastric (NG) tube or gastrostomy tube allows direct instillation of medication into the GI system of patients who can't ingest the drug orally. Before instillation, the patency and positioning of the tube must be carefully checked because the procedure is contraindicated if the tube is obstructed or improperly positioned; if the patient is vomiting around the tube; or if his bowel sounds are absent.
Oily medications and enteric-coated or sustained-release tablets or capsules are contraindicated for instillation through an NG tube. Oily medications cling to the sides of the tube and resist mixing with the irrigating solution, and crushing enteric-coated or sustained-release tablets to facilitate transport through the tube destroys their intended properties.
Equipment
Patient's medication record and chart • prescribed medication • towel or linen-saver pad • 50- or 60-ml piston-type catheter-tip syringe • feeding tubing • two 4″ × 4″ gauze pads • stethoscope • gloves • diluent • cup for mixing medication and fluid • spoon • 50 ml of water • rubber band • gastrostomy tube and funnel, if needed • optional: mortar and pestle, clamp.
For maximum control of suction, use a piston syringe instead of a bulb syringe. The liquid for diluting the medication can be juice, water, or a nutritional supplement.
Preparation of equipment
Gather equipment for use at the bedside. Liquids should be at room temperature. Administering cold liquids through an NG tube can cause abdominal cramping. Although this isn't a sterile procedure, make sure the cup, syringe, spoon, and gauze are clean.
Implementation
Verify the order on the patient's medication record by checking it against the physician's order.
Wash your hands and put on gloves.
Check the label on the medication three times before preparing it for administration to make sure you'll be giving the medication correctly.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
If the prescribed medication is in tablet form, crush the tablets to ready them for mixing in a cup with the diluting liquid. Request liquid forms of medications, if available. Bring the medication and equipment to the patient's bedside.
Explain the procedure to the patient; provide privacy.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
Unpin the tube from the patient's gown. To avoid soiling the sheets, fold back the bed linens to the patient's waist and drape his chest with a towel or linen-saver pad.
Elevate the head of the bed so that the patient is in Fowler's position, as tolerated.
After unclamping the tube, take the 50- or 60-ml syringe and create a 10-cc air space in its chamber. Then attach the syringe to the end of the tube.
Auscultate the patient's abdomen about 3″ (7.6 cm) below the sternum with the stethoscope. Then gently insert the 10 cc of air into the tube. When you hear the air bubble entering the stomach, gently draw back on the piston of the syringe. The appearance of gastric contents implies that the tube is patent and in the stomach. (However, only an X-ray can positively confirm the tube's position.) If no gastric contents appear when you draw back on the syringe, the tube may have risen into the esophagus, and you'll have to advance it before proceeding.
If you meet resistance when aspirating for gastric contents, stop the procedure. Resistance may indicate a nonpatent tube or improper tube placement. (Keep in mind that some smaller NG tubes may collapse when aspiration is attempted.) If the tube seems to be in the stomach, resistance probably means that the tube is lying against the stomach wall. To relieve resistance, withdraw the tube slightly or turn the patient.
After you have established that the tube is patent and in the correct position, clamp the tube, detach the syringe, and lay the end of the tube on the 4″ × 4″ gauze pad.
Mix the crushed tablets or liquid medication with the diluent. If the medication is in capsule form, open the capsules and empty their contents into the liquid. Pour liquid medications directly into the diluent. Stir well. (If the medication was in tablet form, make sure the particles are small enough to pass through the eyes at the distal end of the tube.)
Reattach the syringe, without the piston, to the end of the tube and open the clamp.
Deliver the medication slowly and steadily. (See Giving medications through an NG tube.)
If the medication flows smoothly, slowly add more until the entire dose has been given.
If the medication doesn't flow properly, don't force it. If it's too thick, dilute it with water. If you suspect that tube placement is inhibiting the flow, stop the procedure and reevaluate tube placement.
Watch the patient's reaction throughout the instillation. If he shows any sign of discomfort, stop the procedure immediately.
As the last of the medication flows out of the syringe, start to irrigate the tube by adding 30 to 50 ml of water. Irrigation clears medication from the sides of the tube and from the distal end, reducing the risk of clogging.
PEDIATRIC ALERT For a child, irrigate the tube using only 15 to 30 ml of water.
When the water stops flowing, quickly clamp the tube. Detach the syringe and dispose of it.
Fasten the NG tube to the patient's gown.
Remove the towel or linen-saver pad and replace bed linens.
Leave the patient in Fowler's position, or have him lie on his right side with the head of the bed partially elevated. Tell him to maintain this position for at least 30 minutes after the procedure. This position facilitates the downward flow of medication into his stomach and prevents esophageal reflux.
You may be asked to deliver medications through a gastrostomy tube. (See Giving medications through a gastrostomy tube.)
If medication is prescribed for a patient with a gastrostomy feeding button, ask the physician to order the liquid form of the drug if possible. If not, you may give a tablet or capsule dissolved in 30 to 50 ml of warm water (15 to 30 ml for children). To administer medication this way, use the same procedure as for feeding the patient through the button. (See “Gastrostomy feeding button care,” page 577.) Then draw up the dissolved medication into a syringe and inject it into the feeding tube.
Withdraw the medication syringe, and flush the tube with 50 ml of warm water.
PEDIATRIC ALERT Flush the tube with 30 ml of water for a child.
Then replace the safety plug, and keep the patient upright at a 30-degree angle for 30 minutes after giving the medication.
GIVING MEDICATIONS THROUGH AN NG TUBE
Holding the nasogastric (NG) tube at a level somewhat above the patient's nose, pour up to 30 ml of diluted medication into the syringe barrel. To prevent air from entering the patient's stomach, hold the tube at a slight angle and add more medication before the syringe empties. If necessary, raise the tube slightly higher to increase the flow rate.
After you've delivered the whole dose, position the patient on her right side, head slightly elevated, to minimize esophageal reflux.
Special considerations
To prevent instillation of too much fluid (for an adult, more than 400 ml of liquid at one time), don't schedule the drug instillation with the patient's regular tube feeding, if possible.
If you must schedule a tube feeding and medication instillation simultaneously, give the medication first to ensure that the patient receives the prescribed drug therapy even if he can't tolerate an entire feeding. Remember to avoid giving foods that interact adversely with the drug. Tube feedings of Osmolite or Isocal must be held 2 hours before and 2 hours after phenytoin administration.
If the patient receives continuous tube feedings, stop the feeding and check the quantity of residual stomach contents. If it's more than 50% of the previous hour's intake, withhold the medication and feeding and notify the physician. An excessive amount of residual contents may indicate intestinal obstruction or paralytic ileus.
If the NG tube is attached to suction, be sure to turn off the suction for 20 to 30 minutes after administering medication.
If possible, teach the patient who requires long-term treatment to instill his medication himself through the NG tube. Have him observe the procedure several times before trying it himself.
Remain with the patient when he performs the procedure for the first few times so that you can provide assistance and answer any questions. Encourage him and correct any errors in technique, as necessary.
Documentation
Record the instillation of medication, date and time of instillation, dose, and patient's tolerance of the procedure. On his intake and output sheet, note the amount of fluid instilled.
BUCCAL, SUBLINGUAL, AND TRANSLINGUAL DRUGS
Certain drugs are given buccally, sublingually, or translingually to prevent their destruction or transformation in the stomach or small intestine. These drugs act quickly because the oral mucosa's thin epithelium and abundant vasculature allow direct absorption into the bloodstream.
Drugs given buccally include nitroglycerin and methyltestosterone; drugs given sublingually include ergotamine tartrate, isosorbide dinitrate, and nitroglycerin. Translingual drugs, which are sprayed onto the tongue, include nitrate preparations for patients with chronic angina.
Equipment
Patient's medication record and chart • prescribed medication • medication cup.
Implementation
Verify the order on the patient's medication record by checking it against the physician's order on his chart.
Wash your hands with warm water and soap. Explain the procedure to the patient if he's never taken a drug buccally, sublingually, or translingually before.
Check the label on the medication before administering it to make sure you'll be giving the prescribed medication. Verify the expiration date of all medications, especially nitroglycerin.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Buccal and sublingual administration
For buccal administration, place the tablet in the buccal pouch, between the cheek and gum. For sublingual administration, place the tablet under the patient's tongue. (See Placing drugs in the oral mucosa, page 234.)
Instruct the patient to keep the medication in place until it dissolves completely to ensure absorption.
Caution him against chewing the tablet or touching it with his tongue to prevent accidental swallowing.
Tell him not to smoke before the drug has dissolved because nicotine's vasoconstrictive effects slow absorption.
Translingual administration
To administer a translingual drug, tell the patient to hold the medication canister vertically, with the valve head at the top and the spray orifice as close to his mouth as possible.
Instruct him to spray the dose onto his tongue by pressing the button firmly.
Remind the patient using a translingual aerosol form that he shouldn't inhale the spray but should release it under his tongue. Also tell him to wait 10 seconds or so before swallowing.
Special considerations
Don't give liquids to a patient who is receiving buccal medication because some buccal tablets can take up to 1 hour to be absorbed. Tell the patient not to rinse his mouth until the tablet has been absorbed.
Tell the angina patient to wet the nitroglycerin tablet with saliva and to keep it under his tongue until it has been fully absorbed.
PLACING DRUGS IN THE ORAL MUCOSA
Buccal and sublingual administration routes allow some drugs, such as nitroglycerin and methyltestosterone, to enter the bloodstream rapidly without being degraded in the GI tract. To give a drug buccally, insert it between the patient's cheek and teeth (as shown below). Ask him to close his mouth and hold the tablet against his cheek until the tablet is absorbed.
To give a drug sublingually, place it under the patient's tongue (as shown below), and ask him to leave it there until it's dissolved.
Complications
Some buccal medications may irritate the mucosa. Alternate sides of the mouth for repeat doses to prevent continuous irritation of the same site. Sublingual medications—such as nitroglycerin—may cause a tingling sensation under the tongue. If the patient finds this annoying, try placing the drug in the buccal pouch instead.
Documentation
Record the medication administered, dose, date and time, and patient's reaction, if any.
RECTAL SUPPOSITORIES AND OINTMENTS
A rectal suppository is a small, solid, medicated mass, usually cone-shaped, with a cocoa butter or glycerin base. It may be inserted to stimulate peristalsis and defecation or to relieve pain, vomiting, and local irritation. Rectal suppositories commonly contain drugs that reduce fever, induce relaxation, interact poorly with digestive enzymes, or have a taste too offensive for oral use. Rectal suppositories melt at body temperature and are absorbed slowly.
Because insertion of a rectal suppository may stimulate the vagus nerve, this procedure is contraindicated in patients with potential cardiac arrhythmias. It may have to be avoided in patients with recent rectal or prostate surgery because of the risk of local trauma or discomfort during insertion.
An ointment is a semisolid medication used to produce local effects. It may be applied externally to the anus or internally to the rectum. Rectal ointments commonly contain drugs that reduce inflammation or relieve pain and itching.
Equipment
Rectal suppository or tube of ointment and applicator • patient's medication record and chart • gloves • water-soluble lubricant • 4″ × 4″ gauze pads • optional: bedpan.
Preparation of equipment
Store rectal suppositories in the refrigerator until needed to prevent softening and, possibly, decreased effectiveness of the medication. A softened suppository is also difficult to handle and insert. To harden it again, hold the suppository (in its wrapper) under cold running water.
Implementation
Verify the order on the patient's medication record by checking it against the physician's order.
Make sure the label on the medication package agrees with the medication order. Read the label again before you open the wrapper and again as you remove the medication. Check the expiration date.
Wash your hands with warm water and soap.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Explain the procedure and the purpose of the medication to the patient.
Provide privacy.
Inserting a rectal suppository
Place the patient on his left side in Sims' position. Drape him with the bedcovers to expose only the buttocks.
Put on gloves. Remove the suppository from its wrapper, and lubricate it with water-soluble lubricant.
Lift the patient's upper buttock with your nondominant hand to expose the anus.
Instruct the patient to take several deep breaths through his mouth to help relax the anal sphincters and reduce anxiety or discomfort during insertion.
Using the index finger of your dominant hand, insert the suppository—tapered end first—about 3″ (7.6 cm), until you feel it pass the internal anal sphincter. Try to direct the tapered end toward the side of the rectum so that it contacts the membranes. (See How to administer a rectal suppository or ointment.)
Ensure the patient's comfort. Encourage him to lie quietly and, if applicable, to retain the suppository for the appropriate length of time. A suppository administered to relieve constipation should be retained as long as possible (at least 20 minutes) to be effective. Press on the anus with a gauze pad if necessary until the urge to defecate passes.
Remove and discard your gloves.
Applying rectal ointment