A Nurse Is Preparing To Administer

Administering medication is a critical responsibility for nurses, demanding meticulous attention to detail and a thorough understanding of pharmacology, patient-specific factors, and institutional protocols. The following represents a detailed guide to assist a nurse in preparing to administer medication safely and effectively.

Pre-Administration: Gathering Information and Ensuring Patient Safety

Before even approaching the medication cart, a series of crucial steps must be undertaken. These steps lay the groundwork for safe medication administration and minimize the risk of errors.

1. Verify the Medication Order

• Check the Order's Completeness: Ensure the medication order is complete and legible. A complete order includes:
  • Patient's full name and date of birth
  • Medication name (generic and brand name, if applicable)
  • Dosage
  • Route of administration
  • Frequency and timing of administration
  • Indication for use (why the patient is receiving the medication)
  • Prescriber's signature or electronic signature
• Question Incomplete or Unclear Orders: Never assume anything. If any part of the order is missing, illegible, or unclear, clarify it with the prescriber before administering the medication. This is a non-negotiable aspect of patient safety. Document the clarification process in the patient's medical record.
• Understand the Rationale: Know why the patient is receiving the medication. Understanding the medication's therapeutic effect will help you monitor for its intended effects and potential adverse reactions.

2. Review Patient Information

• Allergies: This is paramount. Confirm the patient's allergy history every time you administer medication. Ask the patient directly about allergies and compare their response to the documented allergy information in the patient's chart. Be especially vigilant about cross-sensitivities (e.g., a patient allergic to penicillin may also be allergic to cephalosporins).
• Medical History: Consider the patient's medical history, especially conditions that might contraindicate the medication or require dosage adjustments. For example, patients with renal impairment may require lower doses of medications that are primarily excreted by the kidneys.
• Current Medications: Obtain a complete list of the patient's current medications, including prescription drugs, over-the-counter medications, herbal supplements, and vitamins. This information is critical to identify potential drug interactions. Use a reliable drug interaction checker (available online and through pharmacy resources) to screen for potential interactions.
• Laboratory Results: Review relevant laboratory results, such as kidney function tests (e.g., creatinine, BUN), liver function tests (e.g., ALT, AST), and electrolyte levels (e.g., potassium, sodium). These results can influence medication selection and dosage.
• Pregnancy/Breastfeeding Status: Determine if the patient is pregnant or breastfeeding, as many medications are contraindicated or require careful consideration in these populations.

3. Understand the Medication

• Pharmacology: Before administering any medication, understand its:
  • Mechanism of action: How does the drug work in the body?
  • Therapeutic effects: What are the expected benefits of the medication?
  • Adverse effects: What are the potential side effects and adverse reactions?
  • Contraindications: What conditions or situations preclude the use of the medication?
  • Drug interactions: What other medications or substances can interact with the medication?
  • Pharmacokinetics: How is the drug absorbed, distributed, metabolized, and excreted?
• Medication Administration Guidelines: Be familiar with specific administration guidelines for each medication, including:
  • Route of administration: Is it given orally, intravenously, intramuscularly, subcutaneously, etc.?
  • Dosage: What is the correct dose for this patient, considering their age, weight, renal function, etc.?
  • Timing: When should the medication be administered (e.g., before meals, at bedtime)?
  • Special considerations: Does the medication need to be diluted, reconstituted, or administered slowly?
• Resources: Utilize reliable resources to obtain information about medications, such as:
  • Pharmacist: Consult with the pharmacist for any questions or concerns about medications.
  • Drug references: Use reputable drug references (e.g., Physician's Desk Reference, Lexicomp) to obtain detailed information about medications.
  • Hospital formulary: Consult the hospital formulary for a list of medications approved for use in the facility.
  • Online databases: Use reputable online databases (e.g., Micromedex, UpToDate) to access up-to-date information about medications.

During Medication Preparation: The Five Rights and Beyond

With the preliminary information gathered, the nurse proceeds to prepare the medication. This stage requires strict adherence to the "Five Rights" of medication administration, with added layers of verification for enhanced safety.

The Five (Plus) Rights of Medication Administration

These rights serve as a cornerstone for preventing medication errors. Adhering to them meticulously is paramount.

• Right Patient: Verify the patient's identity using at least two patient identifiers (e.g., name, date of birth, medical record number). Ask the patient to state their name and date of birth and compare this information to the patient's identification band and the medication administration record (MAR). Never rely solely on the patient's room number or bed number to identify the patient.
• Right Medication: Compare the medication label to the medication order. Check the medication name, strength, and dosage. Be especially careful with medications that have similar names (look-alike, sound-alike medications) to avoid errors.
• Right Dose: Ensure the dose is accurate and appropriate for the patient. Double-check calculations, especially for high-risk medications (e.g., insulin, heparin). Use appropriate measuring devices (e.g., oral syringes, calibrated droppers) to ensure accurate dosing. If uncertain, have another qualified nurse verify the dose.
• Right Route: Verify that the route of administration matches the medication order. Administer the medication only via the prescribed route. If the route is not specified, clarify it with the prescriber.
• Right Time: Administer the medication at the correct time. Consider the frequency of administration, the patient's schedule, and any specific timing requirements (e.g., before meals, at bedtime). Pay close attention to stat, now, and PRN orders.
• Right Documentation: Immediately after administering the medication, document it in the patient's medical record. Include the date, time, medication name, dose, route, and site of administration (if applicable). Document any adverse effects or patient responses to the medication.
• Right Reason: This refers to ensuring that the medication is being given for the appropriate indication. Review the patient's diagnosis and ensure that the medication aligns with the reason it was prescribed.
• Right Response: After administering the medication, monitor the patient for the intended therapeutic effect and any adverse effects. Document the patient's response to the medication.
• Right to Refuse: Patients have the right to refuse medication. If a patient refuses medication, respect their decision. Assess the reason for refusal, provide education about the medication and its benefits, and document the refusal in the patient's medical record. Notify the prescriber of the patient's refusal.

Preparing the Medication

• Hand Hygiene: Wash your hands thoroughly with soap and water or use an alcohol-based hand sanitizer before preparing any medication.
• Clean Work Area: Prepare medications in a clean, well-lit, and uncluttered work area.
• Medication Cart Security: Keep the medication cart locked when unattended.
• Single-Dose Packaging: Use single-dose packaging whenever possible to minimize the risk of contamination and dosage errors.
• Multi-Dose Vials: If using multi-dose vials, wipe the vial stopper with an alcohol swab before each use. Label the vial with the date and time it was opened. Discard the vial after the expiration date or after the recommended storage time.
• Drawing Up Medications: Use proper aseptic technique when drawing up medications from vials or ampules. Use a sterile needle and syringe for each medication. Do not recap needles after use; dispose of them in a sharps container.
• Oral Medications: When pouring liquid medications, use a calibrated measuring device (e.g., oral syringe, medicine cup) to ensure accurate dosing. Avoid pouring medications into unmarked cups or spoons.
• Crushing Medications: Consult with the pharmacist before crushing any medications. Some medications should not be crushed because they are enteric-coated, sustained-release, or have other special formulations. If a medication can be crushed, use a pill crusher and mix the crushed medication with a small amount of food or liquid to facilitate administration.
• Labeling: Label all prepared medications with the medication name, dose, route, patient name, and date/time of preparation.

Double Checks and Verifications

• High-Risk Medications: For high-risk medications (e.g., insulin, heparin, narcotics), have another qualified nurse independently verify the medication order, dosage calculation, and preparation.
• Independent Double Check: The independent double check involves two nurses independently verifying all aspects of the medication administration process, from the medication order to the medication preparation. This process significantly reduces the risk of medication errors.

During Administration: Patient Education and Monitoring

The act of administering the medication is more than just delivering a pill or injection. It involves patient education, careful observation, and documentation.

Patient Education

• Explain the Medication: Tell the patient the name of the medication, the reason they are receiving it, the expected therapeutic effect, and potential side effects. Answer any questions the patient may have.
• Route of Administration: Explain how the medication will be administered.
• Instructions: Provide clear instructions on how to take the medication (e.g., with food, on an empty stomach).
• Side Effects: Educate the patient about potential side effects and what to do if they experience them.
• Importance of Adherence: Emphasize the importance of taking the medication as prescribed.

Administration Techniques

• Oral Medications: Assist the patient with taking oral medications. Ensure the patient is sitting upright and able to swallow. Provide water or juice to help the patient swallow the medication.
• Subcutaneous and Intramuscular Injections: Use proper injection techniques when administering subcutaneous and intramuscular injections. Select appropriate injection sites, use the correct needle size and length, and aspirate before injecting to ensure the needle is not in a blood vessel.
• Intravenous Medications: Administer intravenous medications according to established protocols. Monitor the patient for signs of infiltration, phlebitis, or other adverse reactions.
• Topical Medications: Apply topical medications according to the manufacturer's instructions. Wear gloves to prevent absorption of the medication.

Monitoring and Observation

• Monitor for Adverse Effects: Observe the patient for any signs of adverse effects or allergic reactions after administering the medication.
• Assess Therapeutic Effect: Monitor the patient for the intended therapeutic effect of the medication.
• Document Patient Response: Document the patient's response to the medication in the medical record.

Post-Administration: Documentation and Evaluation

The final, but equally important, step involves accurate documentation and evaluation of the medication's effect.

Documentation

• Medication Administration Record (MAR): Document the medication administration immediately after giving the medication. Include the date, time, medication name, dose, route, site of administration (if applicable), and your initials.
• PRN Medications: Document the reason for administering PRN medications and the patient's response.
• Adverse Effects: Document any adverse effects or allergic reactions.
• Refusal of Medication: Document any refusal of medication and the reason for refusal.
• Patient Education: Document the patient education provided.

Evaluation

• Evaluate Therapeutic Effect: Evaluate the patient's response to the medication and document the findings.
• Monitor for Side Effects: Continue to monitor the patient for side effects and adverse reactions.
• Communicate with Prescriber: Communicate any concerns or significant findings to the prescriber.

Special Considerations

• Pediatric Patients: Medication administration in pediatric patients requires special considerations, including weight-based dosing, age-appropriate administration techniques, and careful monitoring for adverse effects.
• Geriatric Patients: Geriatric patients are more susceptible to adverse effects from medications due to age-related changes in pharmacokinetics and pharmacodynamics. Start with low doses and titrate slowly, and monitor closely for adverse effects.
• Patients with Renal or Hepatic Impairment: Patients with renal or hepatic impairment may require dosage adjustments to prevent drug accumulation and toxicity.
• Cultural Considerations: Be aware of cultural factors that may influence a patient's medication beliefs and practices.

Technology and Medication Safety

Technology plays an increasingly important role in medication safety.

• Electronic Health Records (EHRs): EHRs can help to prevent medication errors by providing access to patient information, medication orders, and drug interaction checkers.
• Barcoding: Barcode medication administration (BCMA) systems use barcodes to verify the right patient, right medication, right dose, right route, and right time.
• Smart Pumps: Smart pumps are intravenous infusion pumps that have built-in safety features, such as dose limits and alerts for potential drug interactions.
• Automated Dispensing Cabinets: Automated dispensing cabinets (ADCs) are computerized medication storage devices that improve medication security and reduce the risk of dispensing errors.

Continuous Quality Improvement

Medication safety is an ongoing process that requires continuous quality improvement.

• Medication Error Reporting: Report all medication errors, near misses, and adverse drug events through the facility's reporting system.
• Root Cause Analysis: Conduct root cause analysis to identify the underlying causes of medication errors.
• Implement Corrective Actions: Implement corrective actions to prevent future medication errors.
• Education and Training: Provide ongoing education and training to nurses on medication safety best practices.

Conclusion

Administering medication safely and effectively is a complex and multifaceted process that requires knowledge, skill, and attention to detail. By following these guidelines, nurses can minimize the risk of medication errors and ensure the best possible outcomes for their patients. Continuous learning, vigilance, and a commitment to patient safety are essential for all nurses involved in medication administration. Remember, every medication administration is an opportunity to improve patient safety and provide excellent care.