There are seven parts to this section:
1 Principles of medicine administration
2 Routes of medicine administration
3 Immunisation
4 Anaphylaxis
5 Syringe driver pumps
6 Patient-controlled analgesic devices
7 Patient compliance devices
Learning outcomes
By the end of this section, you should know how to:
▪ support and prepare the patient for this practice
▪ collect and prepare the equipment
▪ carry out the administration of medicines safely and accurately
▪ educate the patient on follow-up care.
Background knowledge required
A review of:
▪ the pharmacology of the medicine to be administered (Downie et al 2003, McGavock 2005)
▪ the metric system of volume and weight used in the dose calculation of a medication (Lapham & Agar 2003, Downie et al 2006)
▪Medicines Act (1968) as amended
▪ the Misuse of Drugs Act (1971 reprinted 1985), including all its amendments
▪ the ‘Guidelines for the administration of medicines’ (Nursing and Midwifery Council 2004b)
▪ the Medicinal Products: Prescription by Nurses Act (1992)
▪ the document ‘Immunisation against infectious disease’ (Department of Health 1996)
▪ ‘Guidelines for records and record keeping’ (Nursing and Midwifery Council 2005)
▪ health authority policy regarding the patient’s medicine prescription and recording documents, the administration of drugs, the disposal of equipment and the management of anaphylactic shock.
Indications and rationale for the administration of medicines
Professional issues to consider prior to procedure
The role of the nurse involved in drug administration is multi-faceted, therefore prior to commencing any procedure it is important to be aware of the following issues:
1. The nurse in charge of the ward, department, and unit or treatment room at any time of the day or night is responsible for maintaining the safe and correct storage of all medicines, these storage requirements being enforced by law through the Medicines Act (1968) and the Misuse of Drugs Act (1971). Medicines kept in patients’ own homes are their responsibility, but the community nurse has an important role in educating patients on all aspects of their regimen. The manufacturer’s recommendations for the storage environment and expiry date should be adhered to or the composition of the medicine may be altered. Vaccines, in particular, need to be stored under very stringent conditions (recommendations being provided by both the manufacturer and the health authority).
2. A nurse can administer a medicine only on the written instruction of an authorised prescriber (Nursing and Midwifery Council 2004b). Changes to regulations in May 2006 enabled nurses who are trained as independent prescribers to prescribe any licensed medicine within their level of experience and competence. District nurses and health visitors will continue to be entitled to prescribe from a limited formulary known as the ‘Nurse Prescribers’ Formulary for Community Practitioners’, which can be accessed in the British National Formulary (BNF; British Medical Association 2006). The Nursing and Midwifery Council (NMC) Standards for Nurse/Midwifery Prescribing (2006) and health authority policy should be followed with respect to this practice.
3. The medicine prescription should be written in black indelible ink, giving the date, the patient’s full name and age, the name (preferably generic title) of the medication, the dosage to be given and the time of administration. The whole prescription should be legible (Nursing and Midwifery Council, 2004b and Nursing and Midwifery Council, 2005).
4. The nurse is responsible for the correct administration and documentation of a prescribed medication. Recording the administration may be performed only once the nurse is satisfied that the patient has received the prescribed medication.
5. A student nurse should be supervised by a member of staff who is registered with the NMC while administering medicines.
6. Should any error occur during administration, this must be reported using local policy so that the appropriate action can be implemented (Nursing and Midwifery Council, 2004b and Nursing and Midwifery Council, 2005).
7. The nurse should be familiar with the use, action, and common side-effects and therapeutic dose of the medicine being administered. This will help in the education of patients and assists in identifying any adverse reaction that may develop. When an adverse effect is not life threatening, it may be necessary for the patient to adjust to a change in his or her activity of living. The nurse, therefore, has a role as an educator and facilitator during the adjustment. It is important to observe the effectiveness of a medicine, for example following the administration of an anti-emetic or analgesic. Any sign of the development of a side-effect, of non-effectiveness or of dependence should be reported to the medical practitioner or prescriber.
Reference books available to healthcare professionals include: the British National Formulary (British Medical Association 2006) the Monthly Index of Medical Specialities (http://www.mims) and the Data Sheet Compendium (ABPI 2000). The ward pharmacist or on-call pharmacist is another invaluable resource.
Outline of the procedure
The administration of medicine encompasses many different procedures depending on the needs of the patient. The NMC (2004b) lays great emphasis on issues of accountability for any nurse undertaking this practice. It is important that the following guidelines are used in conjunction with health authority policy as there may be policy or procedural differences, such as the grade and number of nurses required to undertake these practices (Crown 1999).
Equipment1. Means of identifying the patient
2. Patient’s medicine prescription and recording documents
3. Trolley, tray or a suitable work surface for equipment
4. Medication to be administered
5. Equipment for use during medicine administration, e.g.
— oral administration: medicine glass or spoon, glass of water
— injection: appropriately sized sterile needles and syringe, disposable gloves, alcohol-impregnated cleansing swab, cotton wool, adhesive plaster
6. Sharps box
7. Receptacle for soiled material
8. Equipment/medication for the treatment of anaphylactic shock (as per health authority policy).
1. PRINCIPLES OF MEDICINE ADMINISTRATION
Guidelines and rationale for this nursing practice
All forms of medicine administration
▪ discuss the procedure with the patient, asking whether he or she has any known allergy to this drug or other drugs or substances such as eggs, which are used as a carrier substance in some medications, and obtain consent (this may not always be possible, for example when the patient is unconscious) to inform the patient about the procedure, discuss any concerns or queries, identify any known allergies and ensure that the patient is aware of his or her rights as a patient
▪ wash the hands to reduce the risk of cross-infection
▪ observe the patient throughout this procedure to identify any potential reactions to the medicine
▪ identify the medicine to be administered on the prescription document. The prescription should be complete and legible to ensure that all details about the medicine can be clearly identified on the prescription documentation
▪ check that the medicine has not already been administered to ensure that only one dose of the medicine is given
▪ select the appropriate medicine against the prescription documentation to ensure that the correct medicine is administered
▪ check the medicine’s name, dosage, timing and expiry date. If the medication has been dispensed to a specific patient, check that his or her name is on the container to ensure that all the relevant details are listed on the medicine container
▪ remove the prescribed dosage from the container to ensure that the correct amount of medicine is removed from the container
▪ check the prescription and dosage against the medicine container to ensure that the medicine details match
▪ identify the patient to whom the medicine is to be administered. In an institution, this will normally be achieved by checking the details on the patient’s identification bracelet. In a community setting, verbal verification should be obtained from either the patient or the carer to ensure that the medicine is administered to the correct patient
▪ administer the medicine by the route prescribed
▪ ensure that the patient is comfortable following the administration of the medicine to identify any reaction to the medication or to the chosen route of delivery
▪ follow local policy regarding the time that a nurse must remain with a patient following the administration of certain medicines. This is particularly relevant when the medicine is being administered in the patient’s own home or in a treatment room to ensure prompt recognition and treatment of any reaction to the drug (see ‘Anaphylaxis’, p. 24)
▪ record the medication details on the patient documentation, monitor any after-effects and report abnormal findings immediately to ensure that there is a permanent record of the medicine administration and that any side-effects are reported to medical staff
▪ dispose of contaminated equipment according to health authority policy to prevent the transmission of infection or the poisoning of other persons/to allow for checking if the patient has an adverse reactionue
▪ if the patient has difficulty swallowing an oral preparation, the nurse may request that the medicine be supplied in another form. The pharmacist should be consulted before any tablet is crushed or halved (as this may affect the composition or absorption of the medicine). Pills, capsules and cachets should be supplied in the dosage stated on the prescription sheet
▪ in undertaking this practice, nurses are accountable for their actions, the quality of care delivered and record-keeping according to the Code of Professional Conduct (Nursing and Midwifery Council 2004a), Guidelines for Administration of Medicines (Nursing and Midwifery Council 2004b) and Guidelines for Records and Record Keeping (Nursing and Midwifery Council 2005).
Controlled medicines
Institutional setting
The administration of a controlled medicine within an institutional setting must involve two nurses, or a nurse and another approved professional such as a medical practitioner or operating department practitioner. One nurse must be a registered nurse practitioner and may, according to local policy, need to be employed within that healthcare setting. A controlled drug register is kept on each ward or department, giving details of the stock and administration of controlled drugs.
▪ as for ‘All forms of medicine administration’ up to the guideline ‘check that the medicine has not already been administered’
▪ remove the appropriate medicine from the controlled drug store, check the stock number with the number detailed in the register, along with the other nurse, to ensure that the number of drugs in the container matches the number recorded in the register
▪ check the date of the prescription to ensure that the medicine is administered on the correct date
▪ check the time of administration to ensure that the medicine is given at the correct time
▪ check the method of administration to ensure the correct route of administration
▪ remove the appropriate dose from the stock of controlled medicine, checking the name and dosage with the second nurse. Check and record the stock number of the remaining controlled medicine to ensure that the correct dose is withdrawn from the container and the remaining balance recorded
▪ enter into the controlled medicine record sheet the appropriate details to ensure a permanent record of the administration details (date, time, patient’s name, drug dosage and initials of staff)
▪ continue as for ‘All forms of medicine administration’.
Community setting
The administration of a controlled medicine within the patient’s own home may be carried out by the patient or carer (this being the normal practice for medicines in tablet or liquid form). When medicines are given by injection, as a suppository or via a syringe driver, this is normally carried out by the community nurse(s). The number and grade of staff depend on health authority policy.
Controlled medicines belong to the patient and remain within his or her home. Advice should be given to the patient/carer on the safe storage of these medicines. A controlled medicine record sheet giving details of any medicine administered by the nurse and a balance of stock should be placed in the patient’s house, along with a special prescription sheet for controlled medicines (completed and signed by the general practitioner or hospital consultant in charge of the patient’s care). A guide to good practice in the management of controlled drugs in primary care (England) is available at the National Prescribing Centre (2006), available at http://www.npc.co.uk/index.htm.
▪ as for ‘All forms of medicine administration’ up to the guideline ‘check that the medicine has not already been administered’
▪ check the stock number of medicines against the number detailed in the controlled drug record sheet to ensure the number of medicines in the container matches the number recorded in the drug record
▪ check the date of the prescription to ensure that the medicine is administered on the correct date
▪ check the time of administration to ensure that the drug is given at the correct time
▪ check the method of administration to ensure the correct route of administration
▪ remove the appropriate dose from the stock of controlled medicines, checking the name and dosage. Check and record the stock number of the remaining controlled medicines to ensure that the correct dose is withdrawn from the container and the remaining balance recorded
▪ enter into the controlled drug record sheet the appropriate details to ensure a permanent record of the administration details (date, time, medicine dosage and signature of staff)
▪ continue as for ‘All forms of medicine administration’.
2. ROUTES OF MEDICINE ADMINISTRATION
Oral preparation
▪ as for ‘All forms of medicine administration’ up to the guideline that begins ‘remove the prescribed dosage’
▪ remove the required number of tablets, pills or cachets from the medicine container without contaminating the preparation. Place into the medicine glass or medicine spoon to ensure that the correct drug dosage is dispensed
or
▪ shake the liquid medicine preparation well. Pour into the appropriate container at eye level and on a solid flat surface, pouring away from label, to preserve label to allow future recognition of contents. Wipe bottle (to prevent contamination). If the medicine is a powder that needs to be mixed with water, the instructions on the container should be followed to ensure that the medicine moves efficiently down the oesophagus into the stomach
or
▪ draw up into a syringe to ensure accurate drug dose measurement
▪ check the medicine prescription and dosage against the container to ensure that the correct medicine and dosage has been dispensed
▪ identify the patient according to local policy to ensure that the medicine is administered to the correct person
▪ administer the medicine and offer the patient water (if allowed) to aid the swallowing of an oral preparation
▪ continue as for ‘All forms of medicine administration’.
Equipment1. Appropriately sized needles (21G, 23G and 25G) and syringes
2. Alcohol-impregnated swab
3. Drug ampoule or vial
4. Ampoule breaker
5. Diluent if required
6. File
7. Disposable gloves
8. Gauze swab
9. Sterile adhesive plaster (if required).
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