Patients with acute or chronic health problems restore or maintain their health using a variety of strategies. One of these strategies is medication, a substance used in the diagnosis, treatment, cure, relief, or prevention of health problems. No matter where they receive their health care—hospitals, clinics, or home—nurses play an essential role in safe medication preparation, administration, and evaluation of medication effects. When patients cannot administer their own medications at home, family members, friends, or home care personnel are often responsible for medication administration. In all settings, nurses are responsible for evaluating the effects of medications on the patient’s ongoing health status, teaching them about their medications and side effects, ensuring adherence to the medication regimen, and evaluating the patient’s and family caregiver’s ability to self-administer medications.

SCIENTIFIC KNOWLEDGE BASEMedications are frequently used to manage diseases. Because medication administration and evaluation are a critical part of nursing practice, nurses need to have knowledge about the actions and effects of the medications taken by their patients. Administering medications safely requires an understanding of legal aspects of health care, pharmacology, pharmacokinetics, the life sciences, pathophysiology, human anatomy, and mathematics.

Pharmacological ConceptsMedication Names. Some medications have as many as three different names. The chemical name of a medication provides an exact description of its composition and molecular structure. Nurses rarely use chemical names in clinical practice. An example of a chemical name is N-acetyl-para-aminophenol, which is commonly known as Tylenol. The manufacturer who first develops the medication gives the generic or nonproprietary name, with United States Adopted Names (USAN) Council approval. Acetaminophen is an example of a generic name. It is the generic name for Tylenol. The generic name becomes the official name listed in official publications such as the USP. The trade name, brand name, or proprietary name is the name under which a manufacturer markets a medication. The trade name has the symbol (™) at the upper right of the name, indicating that the manufacturer has trademarked the name of the medication (e.g., Panadol,™ Tempra,™ and St. Joseph Aspirin-Free Fever Reducer for Children™).Manufacturers choose trade names that are easy to pronounce, spell, and remember. Many companies produce the same medication, and similarities in trade names are often confusing. Therefore be careful to obtain the exact name and spelling for each medication you administer to your patients. Because similarities in drug names are a common cause of medical errors,

Classification. Medication classification indicates the effect of the medication on a body system, the symptoms the medication relieves, or its desired effect. Usually each class contains more than one medication that is used for the same type of health problem. For example, patients who have asthma often take a variety of medications to control their illness such as beta2-adrenergic agonists. The beta2-adrenergic classification contains at least eight different medications (Lehne, 2010). Some are part of more than one class. For example, aspirin is an analgesic, an antipyretic, and anantiinflammatory medication.

Medication Forms. Medications are available in a variety of forms, or preparations. The form of the medication determines its route of administration. The composition of a medication enhances its absorption and metabolism. Many medications come in several forms such as tablets, capsules, elixirs, and suppositories. When administering a medication, be certain to use the proper form

Forms of MedicationFORM DESCRIPTION

Medication Forms Commonly Prepared for Administration by Oral RouteSolid FormsCaplet Shaped like capsule and coated for ease of swallowingCapsule Medication encased in gelatin shellTablet Powdered medication compressed into hard disk or

cylinder; in addition to primary medication, contains binders (adhesive to allow powder to stick together), disintegrators (to promote tablet dissolution), lubricants (for ease of manufacturing), and fillers (for convenient tablet size)

Enteric-coated tablet Coated tablet that does not dissolve in stomach; coatings dissolve in intestine, where medication is absorbed

Liquid FormsElixir Clear fluid containing water & or alcohol; often

sweetenedExtract Syrup or dried form of pharmacologically active

medication, usually made by evaporating solutionAqueous solution Substance dissolved in water & syrupsAqueous suspension Finely divided drug particles dispersed in liquid medium;

when suspension is left standing, particles settle to bottom of container

Syrup Medication dissolved in a concentrated sugar solutionOther Oral Forms and Terms Associated with Oral PreparationsTroche (lozenge) Flat, round tablets that dissolve in mouth to release

medication; not meant for ingestionAerosol Aqueous medication sprayed and absorbed in mouth and

upper airway; not meant for ingestionSustained release Tablet or capsule that contains small particles of a

medication coated with material that requires a varying amount of time to dissolve

Medication Forms Commonly Prepared for Administration by Topical RouteOintment (salve or cream)

Semisolid, externally applied preparation, usually containing one or more medications

Liniment Usually contains alcohol, oil, or soapy emollient applied to skin

Lotion Liquid suspension that usually protects, cools, or cleanses skin

Paste Thick ointment; absorbed through skin more slowly than ointment; often used for skin protection

Transdermal disk or patch

Medicated disk or patch absorbed through skin slowly over long period of time (e.g., 24 hours, 1 week)

Medication Forms Commonly Prepared for Administration by Parenteral RouteSolution Sterile preparation that contains water with one or more

dissolved compoundsPowder Sterile particles of medication that are dissolved in a

sterile liquid (e.g., water, normal saline) before administration

Medication Forms Commonly Prepared for Instillation Into Body CavitiesIntraocular disk Small, flexible oval (similar to contact lens) consisting of

two soft, outer layers and a middle layer containing medication; slowly releases medication when moistened by ocular fluid

Suppository Solid dosage form mixed with gelatin and shaped in form of pellet for insertion into body cavity (rectum or vagina); melts when it reaches body temperature, releasing medication for absorption

Pharmacokinetics As the Basis of Medication ActionsFor medications to be therapeutic they must be taken into a patient’s body; be absorbed and distributed to cells, tissues, or a specific organ; and alter physiological functions. Pharmacokinetics is the study of how medications enter the body, reach their site of action, metabolize, and exit the body. Use knowledge of pharmacokinetics when timing medication administration, selecting the route of administration, considering the patient’s risk for alterations in medication action, and evaluating the patient’s response.

Absorption. Absorption is the passage of medication molecules into the blood from the site of medication administration.

Factors that influence absorption are the route of administration, ability of the medication to dissolve, blood flow to the site of administration, body surface area (BSA), and lipid solubility of medication.

Route of Administration. Each route of medication administration has a different rate of absorption. When applying medications on the skin, absorption is slow because of the physical makeup of the skin. Medications placed on the mucous membranes and respiratory airways are absorbed quickly because these tissues contain many blood vessels. Because orally administered medications pass through the gastrointestinal (GI) tract, the overall rate of absorption is usually slow. Intravenous (IV) injection produces the most rapid absorption because medications are immediately available when they enter the systemic circulation.

Ability of the Medication to DissolveThe ability of an oral medication to dissolve depends largely on its form or preparation. The body absorbs solutions and suspensions already in a liquid state more readily than tablets or capsules. Acidic medications pass through the gastric mucosa rapidly. Medications that are basic are not absorbed before reaching the small intestine.Blood Flow to the Site of Administration. Medications are absorbed as blood comes in contact with the site of administration. The richer the blood supply to the site of administration, the faster the medication is absorbed.

Body Surface Area. When a medication comes in contact with a large surface area, it is absorbed at a faster rate. This helps explain why the majority of medications are absorbed in the small intestine rather than the stomach.

Lipid Solubility. Because the cell membrane has a lipid layer, highly lipid-soluble medications cross cell membranes easily and are absorbed quickly. Another factor that often affects medication absorption is whether or not food is in the stomach. Some oral medications are absorbed more easily when administered between meals because food changes the structure of a medication and sometimes impairs its absorption. When some medications are administered together, they interfere with one another, which impairs the absorption of both medications. Safe medication administration requires knowledge of factors that alter or impair absorption of prescribed medications. You need an understanding of medication pharmacokinetics, the patient’s health history, the physical examination, and knowledge gained through daily interactions with patients. Use this knowledge to ensure that you administer medications at the correct time for best absorption. When medications

interact with food, know which medications must be administered before or between meals or on an empty stomach. When medications interact with one another, ensure that they are not given at the same time. Consult and collaborate with the patient’s prescribers to ensure that the patient achieves the therapeutic effect of all medications. Before administering any medication, check pharmacology books, drug references, or package inserts or consult with pharmacists to identify medication-medication or medication-food interactions.

Distribution. After a medication is absorbed, it is distributed within the body to tissues and organs and ultimately to its specific site of action. The rate and extent of distribution depend on the physical and chemical properties of the medication and the physiology of the person taking it.

Circulation. Once a medication enters the bloodstream, it is carried throughout the tissues and organs. How fast it reaches the site depends on the vascularity of the various tissues and organs. Conditions that limit blood flow or blood perfusion inhibit the distribution of a medication. For example, patients with heart failure have impaired circulation, which slows medication delivery to the intended site of action. Therefore the efficacy of medications in these patients is often delayed or altered.

Membrane Permeability. Membrane permeability refers to the ability of the medication to pass through tissues and membranes to enter target cells. To be distributed to an organ, a medication has to pass through all of the tissues and biological membranes of the organ. Some membranes serve as barriers to the passage of medications. For example, the blood-brain barrier allows only fatsoluble medications to pass into the brain and cerebral spinal fluid. Therefore central nervous system infections often require treatment with antibiotics injected directly into the subarachnoid space in the spinal cord. Some older patients experience adverse effects (e.g., confusion) as a result of the change in the permeability of the blood-brain barrier, with easier passage of fat-soluble medications. The placental membrane also has a nonselective barrier to medications. Fat-soluble and nonfat-soluble agents often cross the placenta and produce fetal deformities. After birth neonates often experience respiratory depression and withdrawal symptoms when their mothers use or abuse narcotics.

Protein Binding. The degree to which medications bind to serum proteins such as albumin affects their distribution. Most medications partially bind to albumin. Medications bound to albumin cannot exert pharmacological activity. The unbound or “free” medication is its active form. Older adults have a

decrease in albumin, probably caused by a change in liver function. The same is true for patients with liver disease or malnutrition. In both examples patients are at risk for an increase in medication activity, toxicity, or both.

Metabolism. After a medication reaches its site of action, it becomes metabolized into a less active or inactive form that is easier to excrete. Biotransformation occurs under the influence of enzymes that detoxify, break down, and remove biologically active chemicals. Most biotransformation occurs within the liver, although the lungs, kidneys, blood, and intestines also metabolize medications. The liver is especially important because its specialized structure oxidizes and transforms many toxic substances. The liver degrades many harmful chemicals before they become distributed to the tissues. If a decrease in liver function occurs such as with aging or liver disease, a medication is usually eliminated more slowly, resulting in its accumulation. Patients are at risk for medication toxicity if organs that metabolize medications are not functioning correctly. For example, a small sedative dose of a barbiturate sometimes causes a patient with liver disease to lapse into a coma.

Excretion. After medications are metabolized, they exit the body through the kidneys, liver, bowel, lungs, and exocrine glands.The chemical makeup of a medication determines the organ of excretion. Gaseous and volatile compounds such as nitrous oxide and alcohol exit through the lungs. Deep breathing and coughing help patients eliminate anesthetic gases more rapidly after surgery. The exocrine glands excrete lipid-soluble medications. When medications exit through sweat glands, the skin often becomes irritated, requiring you to instruct patients in good hygiene practices. If a medication is excreted through the mammary glands, there is a risk that a nursing infant will ingest the chemicals. Check the safety of any medication used in breastfeeding women.The GI tract is another route for medication excretion. Medications that enter the hepatic circulation are broken down by the liver and excreted into the bile. After chemicals enter the intestines through the biliary tract, the intestines resorb them. Factors that increase peristalsis (e.g., laxatives and enemas) accelerate medication excretion through the feces, whereas factors that slow peristalsis (e.g., inactivity and improper diet) often prolong the effects of a medication.The kidneys are the main organs for medication excretion. Some medications escape extensive metabolism and exit unchanged in the urine. Others undergo biotransformation in the liver before the kidneys excrete them. If renal function declines, a patient is at risk for medication toxicity. When the kidney cannot adequately excrete a medication, it is necessary to reduce the dose. Maintenance of an adequate fluid intake (8 to 9 cups, or

about 2 L of water/day) promotes proper elimination of medications for the average adult.

Types of Medication ActionMedications vary considerably in the way they act and their types of action. Patients do not always respond in the same way to each successive dose of a medication. Sometimes the same medication causes very different responses in different patients. Therefore it is essential to understand all the effects that medications have on patients.

Therapeutic Effects. The therapeutic effect is the expected or predicted physiological response that a medication causes. Each medication has a desired therapeutic effect. For example, nitroglycerin reduces cardiac workload and increases myocardial oxygen supply. Some medications have more than one therapeutic effect. For example, prednisone, a steroid, decreases swelling, inhibits inflammation, reduces allergic responses, and prevents rejection of transplanted organs. Knowing the desired therapeutic effect for each medication allows you to provide patient education and accurately evaluate its desired effect.

Side Effects/Adverse Effects.Every medication has a potential to harm a patient. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic dose. They are either harmless or cause injury. For example, some antihypertensive medications cause impotence in men. If the side effects are serious enough to negate the beneficial effects of the therapeutic action of the medication, the prescriber discontinues the medication. Patients often stop taking medications because of side effects. Adverse effects are unintended, undesirable, and often unpredictable severe responses to medication. Some adverse effects are immediate, whereas others take weeks or months to develop. Early recognition is important. When adverse responses to medications occur, the prescriber discontinues the medication immediately.Health care providers report adverse effects to the FDA using the MedWatch program.

Toxic Effects.Toxic effects develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. Excess amounts of a medication within the body sometimes have lethal effects, depending on its action. For example, toxic levels of morphine, an opioid, cause severe respiratory depression and death. Antidotes are available to treat specific types of medication toxicity. For example, naloxone (Narcan), an opioid antagonist, reverses the effects of Opioid toxicity.

Idiosyncratic Reactions. Medications sometimes cause unpredictable effects such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction different from normal. For example, a child who receives diphenhydramine (Benadryl), an antihistamine, becomes extremely agitated or excited instead of drowsy. It is not always possible to predict if a patient will have an idiosyncratic response to a medication.

Allergic Reactions. Allergic reactions also are unpredictable responses to a medication. Some patients become immunologically sensitized to the initial dose of a medication. With repeated administration the patient develops an allergic response to it, its chemical preservatives, or a metabolite. The medication or chemical acts as an antigen, triggering the release of the antibodies in the body. A patient’s medication allergy symptoms vary, depending on the individual and the medication (Table 31-2). Among the different classes of medications, antibiotics cause a high incidence of allergic reactions. Severe or anaphylactic reactions, which are life threatening, are characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath. Immediate medical attention is required to treat anaphylactic reactions. A patient with a known history of an allergy to a medication needs to avoid exposure to that medication in the future and wear an identification bracelet or medal, which alerts nurses and physicians to the allergy if the patient is unconscious when receiving medical care.

Medication InteractionsWhen one medication modifies the action of another, a medication interaction occurs. Medication interactions are common in individuals taking several medications. Some medications increase or diminish the action of others and may alter the way another medication is absorbed, metabolized, or eliminated from the body. When two medications have a synergistic effect, their combined effect is greater than the effect of the medications when given separately.For example, alcohol is a central nervous system depressant that has a synergistic effect on antihistamines, antidepressants, barbiturates, and narcotic analgesics. Sometimes a medication interaction is desired. Prescribers often combine medications to create an interaction that has a beneficial effect. For example, a patient with high blood pressure takes several medications such as diuretics and vasodilators that act together to control the blood pressure whenone medication is not effective on its own.Timing of Medication Dose Responses

Medications administered intravenously enter the bloodstream and act immediately, whereas medications given in other routes take time to enter the bloodstream and have an effect. The quantity and distribution of a medication in different body compartments change constantly. Medications are ordered at various times, depending on when their response begins, becomes most intense, and ceases. The minimum effective concentration (MEC) is the plasma level of a medication below which the effect of the medication doesnot occur.

Terms Associated withMedication ActionsTERM MEANINGOnset Time it takes after a medication is administered for it to produce

a responsePeak Time it takes for a medication to reach its highest effective

concentrationTrough Minimum blood serum concentration of medication reached just

before the next scheduled doseDuration Time during which the medication is present in concentration

great enough to produce a responsePlateau Blood serum concentration of a medication reached and

maintained after repeated fixed doses

Routes of AdministrationThe route prescribed for administering a medication depends on the properties and desired effect of the medication and the patient’s physical and mental condition. Work with the prescriber in determining the best route for a patient’s medication.Oral Routes. The oral route is the easiest and the most commonly used route. Medications are given by mouth and swallowed with fluid. Oral medications have a slower onset of action and a more prolonged effect than parenteral medications. Patients generally prefer the oral route.Sublingual Administration. Some medications are readily absorbed after being placed under the tongue to dissolve. A medication given by the sublingual route should not be swallowed because the medication does not have the desired effect. Nurses often give nitroglycerin by the sublingual route. Tell the patient not to drink anything until the medication is completelydissolved.

Buccal Administration. Administration of a medication by the buccal route involves placing the solid medication in the mouth against the mucous membranes of the cheek until it dissolves. Teach patients to alternate cheeks with each subsequent dose to

avoid mucosal irritation. Warn patients not to chew or swallow the medication or to take any liquids with it. A buccal medication acts locally on the mucosa or systemically as it is swallowed in a person’s saliva.

Parenteral Routes. Parenteral administration involves injecting a medication into body tissues. The following are the fourmajor sites of injection:1. Intradermal (ID): Injection into the dermis just under the epidermis2. Subcutaneous: Injection into tissues just below the dermis of the skin3. Intramuscular (IM): Injection into a muscle4. Intravenous (IV): Injection into a vein

Some medications are administered into body cavities other than the four types listed here. These additional routes include epidural, intrathecal, intraosseous, intraperitoneal, intrapleural, and intraarterial. Nurses usually are not responsible for the administration of medications through these advanced techniques. Whether or not you actually administer the medication, you remain responsible for monitoring the integrity of the medication delivery system, understanding the therapeutic value of the medication, and evaluating the patient’s response to the therapy.

Epidural. Epidural medications are administered in the epidural space via a catheter, which is placed by a nurse anesthetist or ananesthesiologist. This route is used for the administration of regional analgesia for surgical procedures. Nurses who have advanced education in the epidural route can administer medications by continuous infusion or by a bolus dose.

Intrathecal.Physicians and specially educated nurses administer intrathecal medications through a catheter placed in the subarachnoid space or one of the ventricles of the brain. Intrathecal administration is often associated with long-term medication administration through surgically implanted catheters.

Intraosseous.This method of medication administration involves the infusion of medication directly into the bone marrow. It is most commonly used in infants and toddlers who have poor access to their intravascular space and when an emergency arisesand IV access is impossible.

Intraperitoneal.

Medications administered into the peritoneal cavity are absorbed into the circulation. Chemotherapeutic agents, insulin, and antibiotics are administered in this fashion.

Intrapleural. A syringe and needle or a chest tube is used to administer intrapleural medications directly into the pleural space. Chemotherapeutic agents are the most common medications administered via this method. Physicians also instill medications that help resolve persistent pleural effusion. This is called pleurodesis, which promotes adhesion between the visceral and parietal pleura.

Intraarterial. Intraarterial medications are administered directly into the arteries. Intraarterial infusions are common in patients who have arterial clots. The nurse manages a continuous infusion of clot-dissolving agents and carefully monitors the integrity of the infusion to prevent inadvertent disconnection of the system and subsequent bleeding. Other methods of medication administration that are usually limited to physician administration are intracardiac, an injection of a medication directly into cardiac tissue, and intraarticular, an injection of a medication into a joint.

Topical Administration. Medications applied to the skin and mucous membranes generally have local effects. You apply topical medications to the skin by painting or spreading the medication over an area, applying moist dressings, soaking body parts in a solution, or giving medicated baths. Systemic effects often occur if a patient’s skin is thin or broken down, the medication concentration is high, or contact with the skin is prolonged. A transdermal disk or patch (e.g., nitroglycerin, scopolamine, and estrogens) has systemic effects. The disk secures the medicated ointment to the skin. These topical applications are left in place for as little as 12 hours or as long as 7 days. Nurses administer medications to mucous membranes in a variety of ways, including the following, by: 1. Directly applying a liquid or ointment (e.g., eyedrops, gargling, or swabbing the throat).2. Inserting a medication into a body cavity (e.g., placing a suppository in rectum or vagina or inserting medicated packing into vagina).3. Instilling fluid into a body cavity (e.g., eardrops, nose drops, or bladder and rectal instillation [fluid is retained]).4. Irrigating a body cavity (e.g., flushing eye, ear, vagina, bladder, or rectum with medicated fluid [fluid is not retained]).5. Spraying a medication into a body cavity (e.g., instillation into nose and throat).

Inhalation Route.

The deeper passages of the respiratory tract provide a large surface area for medication absorption. Nurses administer inhaled medications through the nasal and oral passages or endotracheal or tracheostomy tubes. Endotracheal tubes enter the patient’s mouth and end in the trachea, whereas tracheostomy tubes enter the trachea directly through an incision made in the neck. Inhaled medications are readily absorbed and work rapidly because of the rich vascular alveolar capillary network present in the pulmonary tissue. Many inhaled medications have local or systemic effects.

Intraocular Route. Intraocular medication delivery involves inserting a medication similar to a contact lens into the patient’s eye. The eye medication disk has two soft outer layers that have medication enclosed in them. The nurse inserts the disk into the patient’s eye, much like a contact lens, and it can remain there for up to 1 week.

Advantages DisadvantagesOral, Buccal, Sublingual RoutesConvenient and comfortable for patient

Economical

Easy to administer

Often produce local or systemic effects

Rarely cause anxiety for patient.

Oral route is avoided when patient has alterations in gastrointestinal function (e.g., nausea, vomiting), reduced motility (after general anesthesia or bowel inflammation), and surgical resection of gastrointestinal tract.

Oral administration is contraindicated in patients unable to swallow (e.g., patients with neuromuscular disorders, esophageal strictures, mouth lesions).

Oral administration is contraindicated in unconscious or confused patient who is unable or unwilling to swallow or hold medication under tongue.

Oral medications cannot be administered when patients have gastric suction; are contraindicated before some tests or surgery.

Oral medications sometimes irritate lining of gastrointestinal tract, discolor teeth, or have unpleasant taste.

Gastric secretions destroy some medications.

Subcutaneous, Intramuscular (IM), Intravenous (IV), Intradermal (ID) RoutesProvide means of administration when oral medications areContraindicated

More rapid absorption than with topical or oral routes

IV infusion provides medication delivery when patient is critically ill or long-term therapy is necessary; if peripheralperfusion is poor, IV route preferred over injections

Some patients experience pain from repeated needlesticks.

Subcutaneous, IM, and ID routes are avoided in patients with bleeding tendencies.

There is risk of tissue damage.

IM and IV routes have higher absorption rates, thus placing patient at higher risk for reactions.They often cause considerable anxiety in many patients, especially children.

SkinPrimarily provides local effectPainlessLimited side effects

Patients with skin abrasions are at risk for rapid medication absorption and systemic effects.

Medications are absorbed through skin slowly

TransdermalProlonged systemic effects with limited side effects

Medication leaves oily or pasty substance on skin and sometimes soils clothing.

Mucous Membranes*Therapeutic effects provided by local application to involvedsitesAqueous solutions readily absorbed and capable of causingsystemic effectsPotential route of administration when oral medications areContraindicated

Mucous membranes are highly sensitive to some medication concentrations.Patient with ruptured eardrum cannot receive ear irrigations.Insertion of rectal and vaginal medication often causes embarrassment.Rectal suppositories contraindicated if patient has had rectal surgery or if active rectalbleeding is present.

InhalationProvides rapid relief for local respiratory problemsUsed for introduction of general anesthetic gases

Some local agents cause serious systemic effects.

Nurse’s RoleAdministering medications to patients requires knowledge anda set of skills that are unique to a nurse. You first assess thatthe medication ordered is the correct medication. Do not assumethat all medications that are in the patient’s “drawer” or pillboxare to be given to him or her. Assess the patient’s ability to selfadministermedications, determine whether a patient shouldreceive a medication at a given time, administer medicationscorrectly, and closely monitor their effects. Patient and familyeducation about proper medication administration and monitoringis an integral part of your role. Do not delegate any part of themedication administration process to nursing assistive personnel(NAP) and use the nursing process to integrate medication therapyinto care.Medication ErrorsA medication error can cause or lead to inappropriate medicationuse or patient harm. Medication errors include inaccurate prescribing,administering the wrong medication, giving the medicationusing the wrong route or time interval, and administering extradoses or failing to administer a medication. Preventing medicationerrors is essential. The process of administering medications hasmany steps and involves many members of the health care team.Because nurses play an essential role in preparing and administeringmedications, they need to be vigilant in preventing errors(Box 31-4). Advances in technology have helped to decrease theoccurrence of medication errors (Box 31-5).Medication errors are related to practice patterns, health careproduct design, or procedures and systems such as product labeling and distribution. When an error occurs, the patient’s safety andwell-being become the top priority. The nurse first assesses andexamines the patient’s condition and notifies the health care providerof the incident as soon as possible. Once the patient is stable,the nurse reports the incident to the appropriate person in theinstitution (e.g., manager or supervisor). The nurse is responsiblefor preparing a written occurrence or incident report that usuallyneeds to be filed within 24 hours of the error. The report includespatient identification information; the location and time of theincident; an accurate, factual description of what occurred andwhat was done; and the signature of the nurse involved. The occurrencereport is not a permanent part of the medical record and isnot referred to anywhere in the record (see Chapters 23 and 26).This legally protects the nurse and institution. Agencies use occurrencereports to track incident patterns and initiate qualityimprovement programs as needed.

STEPS TO TAKE TO PREVENT MEDICATION ERRORS Prepare medications for one person at a time. Follow the six rights of medication administration. Be sure to read labels at least three times (comparing medication

administration record [MAR] with label) before administering the medication.

Use at least two patient identifiers and review the patient’s allergies whenever administering a medication.

Do not allow any other activity to interrupt administration of medication to a patient (e.g., phone call, pager, discussion with other staff).

• Double-check all calculations and other high-risk medication administration processes (e.g., patient-controlled analgesia) and verify with another nurse.

Do not interpret illegible handwriting; clarify with prescriber. Question unusually large or small doses. Document all medications as soon as they are given. When you have made an error, reflect on what went wrong and ask

how you could have prevented the error. Evaluate the context or situation in which a medication error occurred.

This helps to determine if nurses have the necessary resources for safe medication administration.

Attend in-service programs that focus on the medications commonly administered.

Ensure that you are well rested when caring for patients. Nurses make more errors when they are fatigued.

Involve and educate the patient when administering medications. Address patients’ concerns about medications before administering them (e.g., concerns about their appearance or side effects).

Follow established policies and procedures when using technology to administer medications (e.g., automated medication dispensing systems [AMDSs] and bar-code scanning). Medication errors occur when nurses “work around” the technology (e.g., override alerts without thinking about them).

StandardsStandards are actions that ensure safe nursing practice. Standardsfor medication administration are set by individual health careagencies and the nursing profession. Agency policy usually setslimits on the nurse’s ability to administer medications in certainunits of the acute care setting. Sometimes nurses are limited bycertain medication routes or dosages. Most institutions havenursing procedure manuals that contain policies that define thetypes of medications nurses can and cannot administer. The typesand dosages of medications that nurses deliver often vary from unitto unit within the same facility. For example, phenytoin (Dilantin),

a powerful medication for treating seizures, may be administeredby mouth or IV push. In large dosages phenytoin affects heartrhythm. Therefore some agencies place limits on how much nursescan give to a patient on a nursing unit that does not have the abilityto monitor the patient’s heart rate and rhythm. Not all prescribersare aware of all of the limitations and sometimes prescribe medicationsthat nurses cannot give in a particular health care setting.Recognize these limitations and inform the prescriber accordingly.Take appropriate actions to ensure that patients receive medicationsas prescribed and within the time prescribed in the appropriateenvironment.Professional standards such as Nursing: Scope and Standards ofPractice (American Nurses Association [ANA], 2010) (see Chapters1 and 23) apply to the activity of medication administration. Toprevent medication errors, follow the six rights of medicationadministration consistently every time you administer medications.Many medication errors can be linked, in some way, to aninconsistency in adhering to these six rights:1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentationRight Medication. A medication order is required for everymedication that you administer to a patient. Sometimes prescribers When preparingmedications from bottles or containers, compare the labelof the medication container with the MAR three times: (1) beforeremoving the container from the drawer or shelf, (2) as the amountof medication ordered is removed from the container, and (3) atthe patient’s bedside before administering the medication to thepatient. Never prepare medications from unmarked containers orcontainers with illegible labels (TJC, 2010). With unit-dose prepackagedmedications, check the label with the MAR when takingmedications out of the medication dispensing system. Finally verifyall medications at the patient’s bedside with the patient’s MAR anduse at least two identifiers before giving the patient any medications(TJC, 2011a).Patients who self-administer medications need to keep them intheir original labeled containers, separate from other medications,to avoid confusion. Many hospitals request that all medicationadministration in the hospital setting be completed through nursesrather than letting patients self-administer to ensure that patientsare not receiving double doses. Because the nurse who administersthe medication is responsible for any errors related to it, nurses

administer only the medications they prepare. You cannot delegatepreparation of medication to another person and then administerthe medication to the patient. If a patient questions the medication,do not ignore these concerns. An alert patient or a family caregiverfamiliar with a patient’s medications knows whether a medicationis different from those received before. In most cases the patient’smedication order has changed; however, some patient questionsreveal an error. When this occurs, withhold the medication andrecheck it against the prescriber’s orders. If a patient refuses a medication,discard it rather than returning it to the original container.Unit-dose medications can be saved if they are not opened. If apatient refuses narcotics, follow proper hospital procedure byhaving someone else witness the “wasted” medication.Right Dose. The unit-dose system is designed to minimizeerrors. When preparing a medication from a larger volume orstrength than needed or when the prescriber orders a system ofmeasurement different from that which the pharmacy supplies, thechance of error increases. When performing medication calculationsor conversions, have another qualified nurse check the calculateddoses. After calculating doses, prepare the medication usingstandard measurement devices. Use graduated cups, syringes, andscaled droppers to measure medications accurately. At home havepatients use kitchen measuring spoons rather than household teaspoonsand tablespoons, which vary in volume. Right Patient. Medication errors often occur because onepatient gets a drug intended for another patient. Therefore animportant step in safe medication administration is being sure thatyou give the right medication to the right patient. It is difficult toremember every patient’s name and face. Before administering amedication, use at least two patient identifiers (TJC, 2010). Acceptablepatient identifiers include the patient’s name, an identificationnumber assigned by a health care agency, or a telephone number.Do not use the patient’s room number as an identifier. To identifya patient correctly in an acute care setting, compare the patientidentifiers on the MAR with the patient’s identification braceletwhile at the patient’s bedside. If an identification bracelet becomessmudged or illegible or is missing, obtain a new one. In health caresettings that are not acute care settings, TJC (2008) does not requirethe use of armbands for identification. However, nurses still needto use a system that verifies the patient’s identification with at leasttwo identifiers before administering medications.Patients do not need to state their names and other identifierswhen administering medications. Collect patient identifiers reliablywhen the patient is admitted to a health care setting. Once theidentifiers are assigned to the patient (e.g., putting identifiers onan armband and placing the armband on the patient), the nurse

uses the identifiers to match the patient with the MAR, which liststhe correct medications. Asking patients to state their full namesand identification information provides a third way to verify thatthe nurse is giving medications to the right patient.In addition to using two identifiers, some agencies use a wirelessbar-code scanner to help identify the right patient (Fig. 31-8). Thissystem requires the nurse to scan a personal bar code that is commonlyplaced on the nurse’s name tag first. Then he or she scans abar code on the single-dose medication package. Finally the nursescans the patient’s armband. All this information is then stored ina computer for documentation purposes. This system helps eliminatemedication errors because it provides another step to ensurethat the right patient receives the right medication.Right Route. Always consult the prescriber if an order doesnot designate a route of administration. Likewise, if the specifiedroute is not the recommended route, alert the prescriber immediately.Recent evidence shows that medication errors involving thewrong route are common. For example, enteral and parenteralmedications are at risk for confusion in the pediatric populationbecause liquid medications are frequently given orally. When oralmedications are prepared in parenteral syringes, there is a high riskfor giving an oral medication through the parenteral route (ISMP, Right Time. In addition, you need to know why a medicationis ordered for certain times of the day and whether you are able toalter the time schedule. For example, two medications are ordered,one q8h (every 8 hours) and the other 3 times a day. Both medicationsare scheduled for 3 times within a 24-hour period. The prescriberintends the q8h medication to be given around-the-clockto maintain therapeutic blood levels of the medication. In contrast,the nurse needs to give the 3-times-a-day medication during thewaking hours. Each agency has a recommended time schedule formedications ordered at frequent intervals. You can alter these recommendedtimes if necessary or appropriate.

Right Documentation. Nurses and other health care providersuse accurate documentation to communicate with oneanother. Many medication errors result from inaccurate documentation.Therefore always document medications accurately at thetime of administration and verify any inaccurate documentationbefore giving medications.

Maintaining Patients’ Rights. In accordance with ThePatient Care Partnership (American Hospital Association, 2003)and because of the potential risks related to medication administration,a patient has the following rights:• To be informed of the name, purpose, action, and potential

undesired effects of a medication• To refuse a medication regardless of the consequences• To have qualified nurses or physicians assess a medicationhistory, including allergies and use of herbals• To be properly advised of the experimental nature of medicationtherapy and give written consent for its use• To receive labeled medications safely without discomfort inaccordance with the six rights of medication administration• To receive appropriate supportive therapy in relation tomedication therapy• To not receive unnecessary medications• To be informed if medications are a part of a research studyKnow these rights and handle all inquiries by patients and familiescourteously and professionally. Do not become defensive if apatient refuses medication therapy, recognizing that every personof consenting age has a right to refusal.

ASSESSMENTDuring the assessment process, thoroughly assess each patient andcritically analyze findings to ensure that you make patient-centeredclinical decisions required for safe nursing care.Through the Patient’s Eyes. Use professional knowledge,skills, and attitudes to provide compassionate and coordinatedcare. This requires you to take the patient’s preferences, values, andneeds into consideration while determining his or her need for andpotential response to medication therapy. Assess patients’ experiencesand encourage them to express their beliefs, feelings, andconcerns about their medications. Putting patients in the center oftheir care helps you to see the situation through their eyes andcontributes to safe medication administration. Begin your assessmentby asking a variety of questions that help you better understandyour patients’ current medication management routine, theability to afford medications, and beliefs and expectations aboutmedications (Box 31-8).History. Before administering medications, obtain or reviewthe patient’s medical history. A patient’s medical history providesindications or contraindications for medication therapy. Disease orillness places patients at risk for adverse medication effects. Forexample, if a patient has a gastric ulcer, medications containingaspirin increase the likelihood of bleeding. Long-term health problems(e.g., diabetes or arthritis) require specific medications. Thisknowledge helps the nurse anticipate the type of medicationsthat a patient requires. A patient’s surgical history indicates use ofmedications. For example, after a thyroidectomy a patient requiresthyroid hormone replacement.Allergies. Inform the other members of the health care team if

the patient has a history of allergies to medications and foods.Many medications have ingredients also found in food sources. Forexample, propofol (Diprivan), which is used for anesthesia andsedation, includes egg lecithin and soybean oil as inactive ingredients.Therefore patients who have an egg or soy allergy should notreceive propofol (Skidmore-Roth, 2011). In some health care settingspatients wear identification bands listing medication andfood allergies. Ensuring that all allergies and the patient’s reactionsare noted on the patient’s admission notes, medication records, and history and physical examination facilitates communication of thisessential information to members of the health care team.Medications. Assess information about each medication thatthe patient takes, including length of time the medication has beentaken, the current dosage, and whether or not the patient experiencesside effects or has had adverse effects from the medication.In addition, review the action, purpose, normal dosage, routes, sideeffects, and nursing implications for administering and monitoringeach medication. Often you need to consult several resources togather necessary information. Pharmacology textbooks and handbooks;electronic medication manuals available on a computer,handheld computer, or AMDS; nursing journals; the Physician’sDesk Reference (PDR); medication package inserts; and pharmacistsare valuable resources. Nurses are responsible for knowing asmuch as possible about each medication given.Diet History. A diet history reveals a patient’s normal eatingpatterns and food preferences. An effective dosage schedule isplanned around them. Teach the patient to avoid foods that interactwith medications. In addition, some medications are moreeffective when taken with meals; teach patients about specificmedications that must be taken with food.Patient’s Perceptual or Coordination Problems. A patient withperceptual fine-motor or coordination limitations has difficultyself-administering medication. For example, a patient who takesinsulin to manage blood glucose and has arthritis has difficultymanipulating a syringe. Assess the patient’s ability to prepare dosesand take medications correctly. If the patient is unable to selfadministermedications, assess if family or friends are available toassist or make a home care referral.Patient’s Current Condition. The ongoing physical ormental status of a patient affects whether a medication is given orhow it is administered. Assess a patient carefully before giving anymedication. For example, check the patient’s blood pressure beforegiving an antihypertensive. A patient who is nauseated is probablyunable to swallow a tablet. Notify the patient’s health care providerif he or she is unable to take a medication. Assessment findingsserve as a baseline in evaluating the effects of medication therapy.

Patient’s Attitude About Medication Use. The patient’sattitude about medications sometimes reveals a level of medicationdependence or drug avoidance. Some patients do not express theirfeelings about taking a particular medication, particularly if dependenceis a problem. Observe the patient’s behavior for evidence ofdependence or avoidance. Also be aware that his or her culturalbeliefs about Western medicine sometimes interfere with medicationcompliance (Box 31-9; see Chapter 9).Patient’s Understanding of and Adherence to MedicationTherapy. The patient’s knowledge and understanding ofmedication therapy influence the willingness or ability to follow amedication regimen. If the patient has a history of poor adherence(e.g., frequently missed doses or failure to fill prescriptions), investigateif he or she can afford prescribed medications and reviewresources available for purchase of medications if indicated. Alsodetermine if the patient understands the purpose of the medication,the importance of regular dosage schedules, proper administrationmethods, and the possible side effects. Without adequateknowledge and motivation, adherence to medication schedules isunlikely.Patient’s Learning Needs. Health-related information is difficultto understand because of the use of technical terminology.Serious errors can occur when patients do not understand informationabout their medications. Assess patients’ health literacyregarding medication administration to determine their need for instruction (Cornett, 2009) (see Chapter 25). Consider patientresponses to assessment questions that you ask about medicationssuch as those listed in Box 31-8. When a patient is unable to answerquestions about medications appropriately, assess him or her forchallenges in health literacy.

COMPONENTS OF MEDICATION ORDERA medication order is incomplete unless it has the following parts:Patient’s full name: The patient’s full name distinguishes the patient fromother persons with the same last name. In the acute care setting patientsare sometimes assigned special identification numbers (e.g., medicalrecord number) to help distinguish patients with the same names. Thisnumber is often included on the order form.Date and time that the order is written: The day, month, year, and timeneed to be included. Designating the time that an order is written helpsclarify when certain orders are to start and stop. If an incident occursinvolving a medication error, it is easier to document what happened whenthis information is available.Medication name: The health care provider orders a medication by itsgeneric or trade name. Correct spelling is essential in preventing confusionwith medications with similar spelling.

Dose: The amount or strength of the medication is included.Route of administration: The health care provider uses acceptedabbreviations for medication routes. Accuracy is important to ensure thatpatients receive medications by the intended route.Time and frequency of administration: The nurse needs to know whattime and how frequently to administer medications. Orders for multipledoses establish a routine schedule for medication administration.Signature of health care provider: The signature makes an order a legalrequest. BOX 31-4 STEPS TO TAKE TO PREVENT

MEDICATION ADMINISTRATIONA sound knowledge base is required for medications to be administeredsafely. Nurses need to be prepared to administer medicationsusing a variety of routes. The following sections explain the stepsinvolved in administering medications using various routes.Oral AdministrationThe easiest and most desirable way to administer medications is bymouth (Skill 31-1 on pp. 612-615). Patients usually are able to

ingest or self-administer oral medications with a minimum ofproblems. Food delays stomach emptying, which may decrease thetherapeutic effects of oral medications. Therefore most oral medicationsreach their therapeutic action best if given 30 minutes to 1hour before meals. In addition, some medications must be takenwith food. Some situations contraindicate the patient’s receivingmedications by mouth (see Table 31-5). Many medications interactwith nutritional and herbal supplements. You need to be knowledgeableabout these interactions to determine the best time to giveoral medications.An important precaution to take when administering any oralpreparation is to protect patients from aspiration. Aspirationoccurs when food, fluid, or medication intended for GI administrationinadvertently enters the respiratory tract. Protect the patientfrom aspiration by assessing his or her ability to swallow. Box 31-14provides techniques that protect patients from aspirating. Properpositioning is essential in preventing aspiration. Position a patientin a seated position at a 90-degree angle when administering oralmedications if not contraindicated by his or her condition. Usuallyhaving the patient slightly flex the head in a chin-down positionreduces aspiration. Use a multidisciplinary approach (e.g., speechtherapist, dietitian, and occupational therapist) with patients whohave difficulty swallowing.

Topical Medication ApplicationsTopical medications are medications that are applied locally, mostoften to intact skin. They come in many forms (see Table 31-1).They are also applied to mucous membranes.Skin Applications. Because many locally applied medicationssuch as lotions, pastes, and ointments create systemic and localeffects, apply these medications using gloves and applicators. Usesterile technique if the patient has an open wound. Skin encrustationand dead tissues harbor microorganisms and block contact ofmedications with the tissues to be treated. Before applying medications,clean the skin thoroughly by washing the area gently withsoap and water, soaking an involved site, or locally debriding tissue.Apply each type of medication according to directions to ensureproper penetration and absorption. When applying ointments orpastes, spread the medication evenly over the involved surface andcover the area well without applying an overly thick layer. Prescriberssometimes order a gauze dressing to be applied over the medicationto prevent soiling clothes and wiping away the medication.Lightly spread lotions and creams onto the surface of the skin;rubbing often causes irritation. Apply a liniment by rubbing itgently but firmly into the skin. Dust a powder lightly to cover theaffected area with a thin layer.

Some topical medications are applied in the form of a transdermalpatch that remains in place for an extended amount of time(e.g., 12 hours or 7 days). Before applying a new patch, remove theold one. Medication remains on the patch even after its recommendedduration of use. Nurses and patients have inadvertentlyleft old transdermal patches in place, resulting in the patient receivingan overdose of the medication. For example, patients who usefentanyl transdermal patches for pain management can experiencerespiratory depression, coma, and death when the patches are notremoved. Many patches are clear, which makes them difficult tosee. Therefore carefully assess the patient’s skin and be sure toremove the existing patch before applying a new patch. Followthese guidelines to ensure safe administration of transdermal ortopical medications (ISMP, 2007b):• Document the location on the patient’s body where themedication was placed on the MAR.• When applying a transdermal patch, ask the patient if he orshe has an existing patch.• When taking a medication history or reconciling medications,specifically ask the patient if he or she takes any medicationsin the forms of patches, topical creams, or any routeother than the oral route.• If the dressing or patch is difficult to see (e.g., clear), applya noticeable label to the patch.• Document removal of the patch or medication on the MAR.Nasal Instillation. Patients with nasal sinus alterations sometimesreceive medications by spray, drops, or tampons (Box 31-16).The most commonly administered form of nasal instillation isdecongestant spray or drops, used to relieve symptoms of sinuscongestion and colds. Caution patients to avoid abuse of medicationsbecause overuse leads to a rebound effect in which the nasalcongestion worsens. When excess decongestant solution is swallowed,serious systemic effects also develop, especially in children.Saline drops are safer than nasal preparations that contain sympathomimetics(e.g., Afrin or Neo-Synephrine) as a decongestant forchildren.It is easier to have the patient self-administer sprays because heor she is able to control the spray and inhale as it enters the nasalpassages. For patients who use nasal sprays repeatedly, check thenares for irritation. Nasal drops are effective in treating sinus infections.Position patients to permit the medication to reach theaffected sinus. Severe nosebleeds are usually treated with packingor nasal tampons, which are treated with epinephrine, to reduceblood flow. Usually a physician or advanced practice clinicianplaces nasal tampons.

Eye Instillation. Common medications used by patients areeyedrops and ointments, including OTC preparations such as artificialtears and vasoconstrictors (e.g., Visine and Murine). Manypatients, especially older adults, receive prescribed ophthalmicmedications for eye conditions such as glaucoma or after cataractextraction. Age-related problems, including poor vision, handtremors, and difficulty grasping or manipulating containers, affectthe older adult’s ability to self-administer eye medications. Instructpatients and family members about the proper techniques foradministering them (Skill 31-2 on pp. 616-619). Determine thepatient’s and family’s ability to self-administer through a returndemonstration of the procedure. Showing patients each step of theprocedure for instilling eyedrops can improve adherence. Followthese principles when administering eye medications:• Avoid instilling any form of eye medications directly ontothe cornea. The cornea of the eye has many pain fibers andthus is very sensitive to anything applied to it.• Avoid touching the eyelids or other eye structures with eyedroppersor ointment tubes. The risk of transmitting infectionfrom one eye to the other is high.• Use eye medication only for the patient’s affected eye.• Never allow a patient to use another patient’s eye medications.Intraocular Administration. The nurse administers some medicationsintraocularly (see Skill 31-2). Medications delivered thisway resemble a contact lens. Place the medication into the conjunctivalsac where it remains in place for up to 1 week. Medicationssuch as pilocarpine are administered this way. Patients requireteaching about monitoring for adverse reactions to the disk. Theyalso need to know how to insert and remove the disk.Ear Instillation. Internal ear structures are very sensitive totemperature extremes. Instill eardrops at room temperature toprevent vertigo, dizziness, or nausea. Although the structures ofthe outer ear are not sterile, sterile solutions are used in case theeardrum is ruptured. The entrance of nonsterile solutions intomiddle ear structures can result in infection. If a patient has eardrainage, be sure that the eardrum has not ruptured. Never occludeor block the ear canal with the dropper or irrigating syringe.Forcing medication into an occluded ear canal creates pressure thatinjures the eardrum. Box 31-17 provides guidelines for administeringeardrops.Vaginal Instillation. Vaginal medications are available as suppositories,foam, jellies, or creams. Solid, oval-shaped suppositories come individually packaged in foil wrappers and are sometimesstored in the refrigerator to prevent them from melting. After asuppository is inserted into the vaginal cavity, body temperaturecauses it to melt and be distributed and absorbed. Foam, jellies,

and creams are administered with an applicator inserter (Box31-18). Give a suppository with a gloved hand in accordancewith standard precautions (see Chapter 28). Patients often preferadministering their own vaginal medications and need privacy.Because vaginal medications are often given to treat infection, dischargeis usually foul smelling. Follow aseptic technique and offerthe patient frequent opportunities to maintain perineal hygiene(see Chapter 39).Rectal Instillation. Rectal suppositories are thinner and morebullet-shaped than vaginal suppositories. The rounded end preventsanal trauma during insertion. Rectal suppositories containmedications that exert local effects such as promoting defecationor systemic effects such as reducing nausea. Rectal suppositoriesare often stored in the refrigerator until administered. Sometimesit is necessary to clear the rectum with a small cleansing enemabefore inserting a suppository.

Administering Medications by InhalationMedications administered with handheld inhalers are dispersedthrough an aerosol spray, mist, or powder that penetrates lungairways. The alveolar-capillary network absorbs medicationsrapidly.Pressurized metered-dose inhalers (pMDIs), breath-actuatedmetered dose inhalers (BAIs), and dry powder inhalers (DPIs)deliver medications that produce local effects such as bronchodilation.Some medications create serious systemic side effects. pMDIsuse a chemical propellant to push the medication out of the inhalerand require the patient to apply approximately 5 to 10 pounds ofpressure to the top of the canister to administer the medication.Children or older adults with chronic respiratory diseases often usepMDIs. These two populations have diminished hand strength.Therefore it is essential to assess if patients in these groups haveenough strength to use the pMDI.

Administering Medications by IrrigationsSome medications irrigate or wash out a body cavity and are deliveredthrough a stream of solution. Irrigations most commonly usesterile water, saline, or antiseptic solutions on the eye, ear, throat,vagina, and urinary tract. Use aseptic technique if there is a breakin the skin or mucosa. Use clean technique when the cavity to beirrigated is not sterile, as in the case of the ear canal or vagina.Irrigations cleanse an area, instill a medication, or apply hot or coldto injured tissue (see Chapter 48).Parenteral Administration of MedicationsParenteral administration of medications is the administration ofmedications by injection into body tissues. When medications are

administered this way, it is an invasive procedure that is performedusing aseptic techniques (Box 31-20). After a needle pierces theskin, there is risk of infection. Each type of injection requirescertain skills to ensure that the medication reaches the proper location.The effects of a parenterally administered medication developrapidly, depending on the rate of medication absorption. The nurseclosely observes the patient’s response.Equipment. A variety of syringes and needles are available,each designed to deliver a certain volume of a medication to aspecific type of tissue. Use nursing judgment when determining thesyringe or needle that will be most effective.Syringes. Syringes consist of a cylindrical barrel with a tipdesigned to fit the hub of a hypodermic needle and a close-fittingplunger. In general syringes are classified as being Luer-Lok ornon–Luer-Lok. This nomenclature is based on the design of the tipof the syringe. Luer-Lok syringes have needles that are twisted ontothe tip and lock themselves in place (Fig. 31-10, A and B). Thisdesign prevents the inadvertent removal of the needle. Non–Luer-Lok syringes (Fig. 31-10, C and D) have needles that slip onto thetip. Syringes have safety devices to prevent needlestick injury.Syringes come in a number of sizes, from 0.5 to 60 mL. It isunusual to use a syringe larger than 5 mL for an injection. A 1- to3-mL syringe is usually adequate for a subcutaneous or IM injection.A larger volume creates discomfort. Use larger syringes toadminister certain IV medications and irrigate wounds or drainagetubes. Syringes often come prepackaged with a needle attached.However, you sometimes change a needle based on the route ofadministration and size of the patient.a minim and hundredths of a milliliter and has a capacity of1 mL. Use a tuberculin syringe to prepare small amounts of medications(e.g., intradermal or subcutaneous injections). A tuberculinsyringe is also useful when preparing small, precise doses forinfants or young children.Insulin syringes (Fig. 31-10, D) are available in sizes that hold0.3 to 1 mL and are calibrated in units. Most insulin syringes areU-100s, designed to be used with U-100 strength insulin. Eachmilliliter of U-100 insulin contains 100 units of insulin.Fill a syringe by pulling the plunger outward while the needletip remains immersed in the prepared solution. Only touch theoutside of the syringe barrel and the handle of the plunger tomaintain sterility. Avoid letting any unsterile object touch the tipor inside of the barrel, the hub, the shaft of the plunger, or theneedle (Fig. 31-11).Needles. Some needles come packaged in individual sheaths toallow flexibility in choosing the right needle for a patient, whereasothers are preattached to standard-size syringes. Most needles are

made of stainless steel, and all are disposable. A needle has three parts: the hub, which fits onto the tip of a syringe; the shaft, whichconnects to the hub; and the bevel, or slanted tip.

Administering InjectionsEach injection route differs based on the type of tissues the medicationenters. The characteristics of the tissues influence the rate ofmedication absorption and thus the onset of medication action.Before injecting a medication, know the volume of the medicationto administer, the characteristics and viscosity of the medication,and the location of anatomical structures underlying injection sites(Skill 31-5 on pp. 626-631).If a nurse does not administer injections correctly, negativepatient outcomes result. Failure to select an injection site in relationto anatomical landmarks results in nerve or bone damage duringneedle insertion. Inability to maintain stability of the needle andsyringe unit can result in pain and tissue damage. If you fail toaspirate the syringe before injecting an IM medication, the medicationmay accidentally be injected directly into an artery or vein.Injecting too large a volume of medication for the site selectedcauses extreme pain and results in local tissue damage.Many patients, particularly children, fear injections. Patientswith serious or chronic illness often are given several injectionsdaily. Minimize the patient’s discomfort in the following ways:• Use a sharp-beveled needle in the smallest suitable lengthand gauge.• Position the patient as comfortably as possible to reducemuscular tension.• Select the proper injection site, using anatomicallandmarks.• Apply a vapocoolant spray (e.g., Fluori-Methane sprayor ethyl chloride) or topical anesthetic (e.g., EMLA cream)to the injection site before giving the medication whenpossible.• Divert the patient’s attention from the injection throughconversation using open-ended questioning.• Insert the needle quickly and smoothly to minimize tissuepulling.• Hold the syringe steady while the needle remains in tissues.• Inject the medication slowly and steadily.Subcutaneous Injections. Subcutaneous injections involveplacing medications into the loose connective tissue under thedermis (see Skill 31-5). Because subcutaneous tissue is not as richlysupplied with blood as the muscles, medication absorption issomewhat slower than with IM injections. However, medicationsare absorbed completely if the patient’s circulatory status is normal.

Because subcutaneous tissue contains pain receptors, the patientoften experiences slight discomfort.The best subcutaneous injection sites include the outer posterioraspect of the upper arms, the abdomen from below the costalmargins to the iliac crests, and the anterior aspects of the thighs(Fig. 31-17). The site most frequently recommended for heparininjections is the abdomen (Fig. 31-18). Alternative subcutaneoussites for other medications include the scapular areas of the upperback and the upper ventral or dorsal gluteal areas. The injectionsite chosen needs to be free of skin lesions, bony prominences, andlarge underlying muscles or nerves.