Dr. Anna Thau just opened a new primary care office in the community. She is in the process of hiring office staff, and Dorothy Gaston, CMA (AAMA), is being interviewed for a clinical assisting position. One of Dr. Thau’s chief requirements is that the medical assistants working in the clinical area be familiar with medications and competent in their administration. Her primary concern is the safety of her patients, so she requires that employees perform appropriate safety measures when dispensing and administering oral, topical, and parenteral drugs.

While studying this chapter, think about the following questions:

• What safety guidelines should Dorothy incorporate into her practice each time she receives a drug order from Dr. Thau?

• What information must be included in comprehensive documentation of the administration of medication?

• Are there patient assessment factors that might affect medication administration?

• Why does Dorothy have to understand the details of various drug forms and their administration guidelines?

• What practices mandated by the Occupational Safety and Health Administration (OSHA) must be followed in preparing and administering medications?

• Are there intravenous (IV) principles that Dorothy should understand?

• Does Dorothy need to be aware of the legal implications of drug administration?

Previous medication chapters in this text explained general pharmacologic principles and pharmacology math. In this chapter, you will learn about safety factors in drug administration, documentation guidelines, the forms of medications, and how they are administered. It is important to remember that medications can cause serious harm to a patient. Therefore, the process of dispensing and administering medications must always be treated with great care. Each member of the healthcare team involved in medication administration must be constantly vigilant to prevent errors and to deliver high-quality patient care.

No matter the type of medication administered, the order first must come from the physician. If the physician delegates drug administration to the medical assistant, this must be allowable under state law. Each state has a medical practice act that defines whether a medical assistant can administer drugs under the supervision of a physician. Some states allow medical assistants to administer only certain types of medications; some prohibit medical assistants from giving injections. You should obtain from your local government or medical society information about the scope of practice for medical assistants in your particular state. You should know what the law states and how your duties fit into that law.

Safety in Drug Administration

To ensure patient safety in drug administration, the medical assistant must perform certain procedures every time a medication is ordered. First, it is essential that the medical assistant understand the physician’s order. Safety starts with a clearly written order that can be easily read and understood. Ask the physician for clarification if you have any questions about the medication, dose, strength, or route of administration. Once the order has been clarified, the medical assistant is responsible for looking up the drug in a pharmacology reference, such as the Physicians’ Desk Reference (PDR) (see Chapter 33). A medication should never be given until its purpose, possible side effects, precautions, and recommended dose are known.

After the medical assistant learns about the drug ordered, the medication is dispensed and administered. To safeguard the patient during this process, the medical assistant uses the “seven rights” of proper drug administration. Remember, however, that the patient always has the right to refuse to take a medication. If this occurs, make sure you inform the physician immediately, because he or she may want to follow up with the patient about the importance of the prescribed medication. If a patient refuses to take an ordered medication, be sure to document this refusal in the patient record. The seven rights of drug administration are as follows:

1. The right patient. The easiest way to make sure the medication is being given to the correct individual is to ask the patient his or her name or to address the patient by name before administering the drug.

2. The right drug. This begins with clarification of the physician’s order if needed. Every time a drug is dispensed, the label must be checked three times to confirm the right drug, dose, and strength. You must be competent in reading and understanding the information on the drug label. The drug’s name and strength on the label must exactly match the physician’s written order. Compare the physician’s written order with the medication label when you:

• Take the medication from the storage area

• Dispense the medication from the container

• Replace the container to storage or before discarding the used container

3. The right dose. If the dose ordered does not match the dose available according to the drug label, perform appropriate pharmacology math procedures to determine the accurate dose. Remember to have your calculations checked if you have any doubt about the accuracy of the dose.

4. The right route. Check the physician’s order to clarify the route of administration, whether it is oral, via mucous membrane, or parenteral. Patient assessment includes determining whether this is an appropriate route for that particular patient.

5. The right time. In the ambulatory care setting, most medications are ordered stat. However, it is important to check the physician’s order to clarify the time of administration and to refer to this information when looking up the drug to clarify any questions the patient may have about home administration of the drug.

6. The right technique. A medical assistant must be familiar with the proper techniques for all routes of administration. If you have any doubts about your ability to administer a particular drug, always ask for help.

7. The right documentation. Immediately after administering the drug, document the date and time of administration; the drug’s name, strength, dose, and route of administration; any reactions the patient has to the medication; and the details of patient education about the drug. For parenteral medications, inspect the site of injection before administration for scarring, altered pigmentation, or any other indication of a possible problem with medication absorption. The exact site of administration must be charted. If the patient calls in for a prescription refill, document all pertinent information on the patient’s chart as well. Procedures 35-1 and 35-2 present the safety measures to be followed in preparing and administering a medication and documenting it properly.

Procedure 35-1

Administer Medications and Document Patient Care

Safety Measures in Preparing, Administering, and Documenting Medications

GOAL: To safely prepare, administer, and document completion of a medication order.

SCENARIO: Dr. Thau writes the following order: Administer Recombivax 10 mcg IM to Chris MacCarthy.

EQUIPMENT and SUPPLIES

• Written physician’s order, including the drug name, strength, dose, and route of administration

• PDR

• Container of ordered medication

• Correct equipment for dispensing the drug

• Patient’s medical record

Procedural Steps

1. Read the order and clarify any questions with the physician.

2. If you are unfamiliar with the drug, refer to the PDR or the package insert to determine the purpose of the drug, common side effects, typical dose, and any pertinent precautions or contraindications. Recombivax is a hepatitis B immunization. Use the seven rights to prevent errors.

3. Take the written order with you to the medication room and compare the Recombivax label with the physician’s order. Based on the information printed on the medication label, perform calculations needed to match the physician’s order. Confirm the answer with the physician if you have any questions.

4. Dispense the medication in a well-lit, quiet area.
PURPOSE: To prevent distractions and possible errors.

5. Sanitize your hands.

6. Compare the written order with the label on the multidose vial when you remove it from storage. Check the expiration date on the container and, if it was used previously, the date of first use; dispose of the medication if indicated.
PURPOSE: To check the medication the first of three times.

7. Compare the order with the label on the multidose vial just before drawing up the medication into the appropriate syringe unit. Make sure the strength on the label matches the order or that you dispense the correctly calculated dose.
PURPOSE: To check the medication the second of three times.

8. Compare the label and the physician’s order before returning the vial to storage.
PURPOSE: To check the medication the third of three times.

9. Greet and identify Chris by name and inform him you are going to administer a hepatitis B immunization.
PURPOSE: To make sure you have the right patient.

10. Mention the name of the drug and why it is being given and ask the patient whether he is allergic to the medication.
PURPOSE: To educate the patient about drug treatment and to verify that the patient is not allergic to the prescribed medication.

11. If necessary, help the patient into a sitting position.

12. Administer the medication into the left deltoid muscle using correct administration techniques and following OSHA precautions.

13. Conduct patient education on the purpose of the drug, typical side effects, and dosage and storage recommendations if appropriate. Consult the physician to clarify information if needed.
PURPOSE: To ensure compliance with home drug therapy and to monitor for side effects.

14. The patient must remain in the office for 20 to 30 minutes after drug administration as a precaution against untoward effects.

15. If the patient experiences any discomfort after taking a medication, the physician should be notified immediately and the incident documented completely and accurately.

16. Sanitize your hands.

17. Document the administration of the drug, including the date and time; the drug name, dose, strength, and route of administration; any patient side effects; and patient education provided about the drug.

1/12/XX 11:22 AM Administered 10 mcg Recombivax to deltoid. Pt informed this is the first of 3 doses. No side effects noted. Appointment scheduled for patient to return in 1 mo for second dose. — — — — — — — — — — — — D. Gaston, CMA (AAMA) ________________________________________

Procedure 35-2

Document Patient Care and Patient Education

Maintain Medication Records

GOAL: To document completion of medication orders.

SCENARIO: Dr. Thau writes the following orders to control Mrs. Lange’s hypertension:

Lasix 20 mg PO qd

Potassium chloride 20 mEq PO qd to Alice Lange

You review the orders for clarification, complete the three label checks, confirm the identity of the patient, ask the patient about drug allergies, administer the medications as ordered, and answer the patient’s questions about continuation of drug therapy at home. Now, you must document this process in the patient’s medical record.

EQUIPMENT and SUPPLIES

• Written physician’s order, including the name, strength, dose, and route of administration of the medication ordered

• PDR

• Patient’s medical record

Procedural Steps

1. Greet and identify Mrs. Lange by name and inform her that you are going to administer a diuretic and a potassium supplement.
PURPOSE: To make sure you have the right patient.

2. Mention the names of the drugs and why they are being given, and ask Mrs. Lange if she is allergic to the medication.
PURPOSE: To educate the patient about drug treatment and to verify that the patient is not allergic to the prescribed medication. Follow office policy to update the patient’s medical record about any newly reported medication allergies.

3. Sanitize your hands.

4. Administer the medications orally as ordered, making sure Mrs. Lange swallows the pills without difficulty.

5. Conduct patient education about the purpose of the drugs, typical side effects, and dosage and storage recommendations. Consult the physician to clarify information if needed.
PURPOSE: To ensure compliance with home drug therapy and to monitor for side effects.

6. The patient must remain in the office for 20 to 30 minutes after drug administration as a precaution against untoward effects.

7. If the patient experiences any discomfort after taking a medication, the physician should be notified immediately and the incident documented completely and accurately.

8. Sanitize your hands.

9. Document the administration of the medications, including the date and time; the drug names, dose, strength, and route of administration; any patient side effects; and patient education provided about the drug.

Practice documenting the following orders:

1. Tylenol elixir 120 mg PO to Anthony Baker, 8 years old, for a fever
___________________________________________
___________________________________________

2. Gantrisin Pediatric 500 mg PO to Samantha Carpassi, 3 years old, for a urinary tract infection
___________________________________________
___________________________________________

3. Dilaudid cough syrup 2 mg PO to Roberto Alphonse, 43 years old, for bronchitis
___________________________________________
___________________________________________

4. Diflucan 400 mg PO loading dose to Anastasia Smith, 19 years old, for a vaginal yeast infection
___________________________________________
___________________________________________

4/02/XX 9:30 AM Administered Lasix 20 mg and potassium chloride 20 mEq PO without difficulty. Pt informed of importance of taking medications as prescribed for treatment of hypertension; warned she will have to urinate more frequently. No side effects noted. Appointment scheduled for patient to return in 1 mo for f/u. D. Gaston, CMA (AAMA) ____________________________________________

Additional Safety Steps for Medication Administration

• Prepare medications in a quiet, well-lit area.

• Pay close attention to all the steps involved in dispensing drugs.

• Never substitute a drug or drug strength. Consult the physician for any discrepancy between the medication ordered and the medication available.

• Store medications as ordered on the package, and return containers to the proper storage area immediately after dispensing the dose.

• The person who administers the medication is responsible for any drug errors. Never administer a medication that you have not personally prepared.

• If ordered to prepare a medication for the physician to administer, place the container with the dispensed drug so that the physician can verify the seven rights.

• The physician should write every medication order before the medication is dispensed.

• Routinely check expiration dates when verifying the seven rights. Properly discard expired drugs.

• Discard medications with damaged labels to avoid errors caused by inaccurate reading of label information.

• If a medication is not administered after it is dispensed, discard it rather than returning it to the container.

• Before administering any medication, ask the patient about drug allergies. These can change over time.

• Patients should be observed for untoward effects for 20 to 30 minutes after a medication is administered. Any reactions must be reported to the physician and documented on the patient’s chart.

• Always provide and document patient education about the medication, time of administration, side effects, and so on, when administering a drug.

35-1

Critical Thinking Application

Dr. Thau asks Dorothy what safety precautions she would routinely follow when administering a dose of Plavix. Based on the information you have learned about safe drug administration, what steps should Dorothy follow in dispensing and administering the ordered medication?

Patient Assessment Factors

Although medications are given only under the direct order and supervision of the physician, the medical assistant is part of the assessment and problem-solving process. In medicine, assessment never ends, and it is never the responsibility of just one person. A physician gives the order to administer medication to a patient based on a medical assessment, but you must continue to assess the patient and the patient’s environment as you follow through with that order. The physician depends on the medical assistant to be alert to patient changes or to new information that could mean that the use of a particular drug should be reconsidered. For example, perhaps the patient denied having any allergies to medications, but right before you administer an injection of penicillin, the patient mentions that she developed a rash after the last penicillin shot. You should stop right then and go back to the physician with this new information. It is vital to continuing patient safety that you assess the patient, the drug, and the environment before giving any medication.

Drug therapy should be based on a holistic approach to patient treatment. The patient is more than a particular disease. Many factors may have an impact on the patient’s compliance with drug treatment, as well as the safety and effectiveness of medication therapy. The first step in holistic medication treatment is collecting a complete and accurate history. This includes gathering details about the patient’s health history, current and past use of both prescription and over-the-counter (OTC) drugs, and any negative responses to medications, especially drug allergies. Every time a patient is seen in the office, he or she should be asked about drug allergies. Most medical practices have a specific place on the patient’s chart to document drug allergies (e.g., in red ink in the upper right corner of each documentation sheet), as well as a special label on the front of the patient’s chart that alerts the physician and staff to medication allergies. Electronic health records (EHRs) have a specific area on the chart for updating allergies. It is crucial that the physician have current and accurate information about drug allergies to prevent serious complications and possibly death.

Patient assessment does not end with the administration of the drug. Observe patients carefully for drug reactions after the administration of all medications, especially those that are injected. Patients receiving penicillin (a drug with a high incidence of allergic response) or immunotherapy must remain in the office for 20 to 30 minutes after administration in case of an acute anaphylactic reaction. An acute anaphylactic reaction can result in respiratory failure and circulatory collapse within minutes if not reversed with epinephrine. Lesser allergic reactions that may occur include hives, swelling, and itching. The physician may order an antihistamine, such as diphenhydramine (Benadryl), if these reactions occur.

Because patient factors such as age, weight, and height may be used to determine the correct therapeutic dose, accurate recordings of this information should be documented on the chart. As discussed in Chapter 33, chronic conditions, especially liver and kidney disease, may affect the body’s ability to metabolize and excrete medications. Therefore, a complete and accurate medical history is crucial to patient safety.

Besides the patient’s physical state, other holistic factors play a role in successful drug therapy. The patient must understand the drug regimen, may require family support to follow treatment guidelines, and must be able to afford the prescribed medication. Unless these criteria can be met, the patient may be unable to follow through with the treatment protocol. It is important that the medical assistant investigate these issues and offer appropriate community support, if available, to help the patient maintain proper drug therapy.

Approaches to Special Patient Populations

Pregnant and breastfeeding women must be especially careful when taking OTC and prescription drugs, because medications are known to cross the placenta and may affect the developing fetus. A pregnant woman should not take any medication without the knowledge and approval of her physician. As discussed in Chapter 33, the Food and Drug Administration (FDA) identifies five pregnancy risk categories of drugs. The medical assistant should be familiar with the specific drug category before administering any medication to a pregnant woman. Besides passing through the placenta, medications also are transmitted through breast milk. Therefore, similar precautions must be taken when the physician prescribes medications for a lactating mother.

As discussed in Chapter 34, special precautions must be followed in determining the correct dose of medication for children. Pediatric doses are determined primarily by the child’s weight; therefore, it is important to measure and record the child’s weight accurately at each office visit. A child’s body manages drug absorption, distribution, metabolism, and excretion differently from an adult’s body, and the physician considers these factors when prescribing pediatric doses.

Aging people also are more sensitive to the effects of medications, so certain factors must be considered when prescribing and administering drugs to this patient population. The metabolic rate typically slows with the aging process, resulting in increased susceptibility to a buildup of chemicals in the body that may lead to toxic conditions. Part of the normal aging process is loss of subcutaneous fat, which may affect the route of administration of some medications, especially parenteral sites. In addition, many elderly people have accompanying chronic diseases, such as circulatory, liver, or kidney disease, that may affect the distribution, metabolism, and excretion of medications. Geriatric patients frequently take multiple medications prescribed by more than one practitioner, which increases the risk of drug contraindications and interactions.

A holistic approach to aging patients should include a nutritional evaluation, because a poor diet or restricted fluid intake affects drug actions.

Another very real concern for aging patients is the cost of drug therapy. Many patients on fixed incomes may not be able to afford the ordered drug but hesitate to inform the physician of this problem. It may be up to the medical assistant to ask the patient about his or her ability to pay for the ordered medication and to offer available assistance for prescription drugs. This includes offering stocked drug samples with physician approval and/or investigating drug coverage offered by pharmaceutical companies.

Suggestions for Successful Medication Administration to Children

• Explain why the medication is needed and how it will make the child feel.

• Attempt to gain cooperation by getting down on the child’s level and using a soft but firm voice.

• When possible, offer choices of care, such as, “Would you like your medicine in your right or left leg?”

• Divert the child to relieve stressful moments.

• If the child refuses to cooperate, get help as needed to restrain the child so the medication can be given safely.

• Encourage parents to participate as much as possible, and make sure that both parents and the child (if of an appropriate age) understand the prescribed drug therapy.

• Offer a “treat,” such as a sticker, at the end of the visit.

Guidelines for Administration of Medication to Geriatric Patients

• Educate the patient and family about the purpose of the drug; the time, dose, and route of administration; and common side effects. Instructions should be written clearly for home reference.

• If the patient has difficulty swallowing the medication, crush (if allowed) the medication or mix it into applesauce or pudding.

• Encourage the patient to drink plenty of fluids (at least eight glasses of water per day) while taking the medication.

• Reinforce that the patient should take the medication as prescribed and should not skip or double doses.

• Request that patients bring to every physician visit all of the medications they are currently taking in their labeled containers, including OTCs, so a current medication record can be accurately maintained in the patient record.

• If patients are taking multiple medications, suggest the use of daily or weekly medication dispensers. These can be purchased in drugstores and restocked by family members on a weekly basis. It is safest if all prescriptions are filled at the same pharmacy so the pharmacist can keep track of possible drug interactions or contraindications.

• Encourage patients not to share or “save” medications. All leftover medications should be discarded to avoid use beyond the expiration date.

35-2

Critical Thinking Application

Dr. Thau serves both pediatric and geriatric patients. Summarize key items that Dorothy should consider when administering medications to these specialty patient population groups.

Assessment of the Patient’s Environment

The patient’s surroundings affect the success of medication therapy. The patient may be uncooperative when you attempt to administer a medication (imagine a young child due for immunization updates), or the patient’s family may protest the use of the drug. Administration of certain medications requires the presence of the physician. For example, because of the risk of anaphylactic shock, allergy injections should not be given unless a physician is in the facility. In addition, the environment must be safe for drug administration. Make sure the patient is comfortable and protected from accidental injury. If a patient is to receive an injection, take care to place the patient in a position that best exposes the site and protects the patient from injury in case he or she faints or has a drug reaction. If the patient is to take an oral medication with water, make sure he or she is seated in a position that prevents choking. Because any medication is potentially dangerous to a patient, emergency drugs must be readily available to counteract any adverse effects that might occur immediately after the administration of a medication. Emergency drugs should be in injectable form for rapid effect. Emergency carts typically include adrenergics (e.g., epinephrine), anticholinergics (e.g., atropine), bronchodilators, and histamine blockers. (The pharmaceutical management of emergencies is discussed in Chapter 36.)

The following section presents suggested questions that can be asked to obtain as much information as possible from the patient about medication therapy. Any information gathered should be included in your documentation.

Drug Forms and Administration

As discussed in Chapter 33, the chosen route of drug administration determines the rate and intensity of the drug’s effect. A drug prepared for one route but administered by another route may not have any effect at all and is potentially dangerous. Each route requires different dosage forms.

Solid Oral Dosage Forms

The basic forms for solid oral dosage are tablets, capsules, and lozenges (troches). Figure 35-1 depicts typical caplets, capsules, and tablets. Tablets are compressed powders or granules that, when wet, break apart in the stomach—or in the mouth if they are not swallowed quickly. Tablets may be sugar-coated to taste better, or enteric-coated (e.g., Ecotrin) to protect the stomach mucosa. Buffered tablets are also designed to prevent stomach irritation by combining the drug with a buffering agent that reduces the amount of acidity in the compound. Buffered or enteric-coated tablets should never be crushed or dissolved. Only scored tablets can be cut in half. This is accomplished with a pill cutter (Figure 35-2).

FIGURE 35-1 *Left to right*, Caplets, capsules, and tablets.

Some tablets are coated with a volatile liquid that helps the medication quickly dissolve in the mouth, such as certain antacid tablets and Claritin RediTabs, which are designed to dissolve on the tongue rather than to be swallowed. Caplets are tablets without a coating; they are solid and oblong, similar in shape to capsules.

Capsules are gelatin-coated and dissolve in the stomach, or they may be enteric-coated to protect them from stomach acids. Timed- or sustained-release (SR) capsules or spansules are designed to dissolve at different rates over a period of time to reduce the number of times a patient has to take a medication. These drugs should never be crushed or dissolved, because this negates their timed-release action. Another form of oral medication, the lozenge (or troche), is a flattened disk that is dissolved in the mouth to coat the throat, such as a lozenge for a sore throat.

Liquid Oral Dosage Forms

Many liquid forms of medication are available. They differ mainly in the type of substance used to dissolve the drug: water, oils, or alcohol.

A solution is a mixture of a liquid (usually water) and a powdered drug product (e.g., Amoxicillin solutions for pediatric patients). A solution separates if left standing, so you must shake the container before administering the medication. Liquid forms include the following:

• Syrups: A syrup is a solution of sugar and water, usually containing flavoring and medicinal substances. Cough syrups, such as Robitussin, are the most common.

• Suspensions: Suspensions are insoluble drug substances contained in a liquid. Examples include the following:

• Emulsions: An emulsion is a mixture of oil and water that improves the taste of otherwise distasteful products (e.g., cod liver oil).

• Gels and magmas: Gels and magmas consist of minerals suspended in water. Minerals settle; therefore, products containing minerals must be shaken before use. Milk of magnesia is an example.

A drug substance can be mixed with alcohol to enhance the drug’s properties. Examples include the following:

• Fluid extracts: Fluid extracts are combinations of alcohol and vegetable products that are more potent than tinctures. For example, belladonna fluid extract has a higher percentage of the powdered belladonna leaf than tincture of belladonna.

• Tinctures: A tincture is an alcoholic preparation of a soluble drug or chemical substance, usually from plant sources. Examples include tincture of benzoin and tincture of iodine, which are applied externally.

• Extracts: Extracts are very concentrated combinations of vegetable products and alcohol or ether that are evaporated until a syrupy liquid, a solid mass, or powder is formed. Extracts are many times stronger than the crude drug.

• Elixirs: An elixir is an aromatic, alcoholic, sweetened preparation. Elixir of phenobarbital is one example; others include the alcoholic cough medicines terpin hydrate with codeine and plain elixir of codeine. Elixirs differ from tinctures in that they are sweetened. They should be used with caution in patients with diabetes or a history of alcohol abuse. Some pediatric medications retain the name elixir, although they no longer contain alcohol.

35-3

Critical Thinking Application

Dorothy is ordered to administer a loading dose of cephalexin to a 17-year-old patient with acute bronchitis. The physician’s order reads, “Administer cephalexin 500 mg cap PO stat.” The patient is sent home with a prescription for Keflex, 250 mg cap q6h times 7 days. Document the details that should be included in Dorothy’s note.

__________________________________________

Oral Administration

If the drug is not intended to coat the oral cavity or throat, oral medications should be taken with enough water to transport the drug to the stomach. Make sure the patient is able to swallow the medication. It may be helpful to place the medication on the back part of the tongue. Liquid medications are ideal for children. Solid drugs should not be administered to children until they reach the age at which they can safely swallow a solid drug form without the danger that they will aspirate the drug. Oral syringes are the best way to give liquid medications to children because there is less likelihood the medication will be spilled (Figure 35-3). Liquid medications, especially those that stain the teeth, can be taken through a straw. If the patient has been vomiting or is nauseated, an alternative route of administration may be necessary. Always remain with the patient until all of the medication has been swallowed. Procedure 35-3 outlines how to dispense and administer oral medications.

Procedure 35-3

Administer Oral Medications

ORDER: Administer hydrochlorothiazide (HydroDiuril) 100 mg PO tab stat for hypertension.

GOAL: To safely dispense, administer to a patient, and document the administration of an oral medication.

EQUIPMENT and SUPPLIES

• Container of ordered medication

• Calibrated medication cup

• Written physician’s order, including the drug name, strength, dose, and route

• Water if appropriate

• Patient’s medical record

Procedural Steps

1. Read the order and clarify any questions with the physician.

2. If you are unfamiliar with HydroDiuril, refer to the PDR or the package insert to determine the purpose of the drug, common side effects, typical dose, and any pertinent precautions or contraindications. Be prepared to answer any questions the patient may have about the medication. Use the seven rights to prevent errors.

3. Perform calculations needed to match the physician’s order. Confirm the answer with the physician if you have any questions.

4. Dispense the medication in a well-lit, quiet area.
PURPOSE: To prevent distractions and possible errors.

5. Sanitize your hands.

6. Compare the order with the label on the container of medicine when you remove it from storage. Check the expiration date on the container and dispose of the medication if it has expired.
PURPOSE: To compare the medication label and the physician’s order the first of three times.

7. Compare the order with the label on the container of medicine just before dispensing the ordered dose. Make sure the strength on the label matches the order or that you dispense the correctly calculated dose.
PURPOSE: To compare the medication label and the physician’s order the second of three times.

Dispensing Solid Oral Medications (Hydrodiuril Tablet)

8. Gently tap the prescribed dose into the lid of the medication container. Do not touch the inside of the lid or the medication (Figure 1).

PURPOSE: Touching the medication or the inside of the container contaminates the drug.

9. Empty the medication in the container lid into a medicine cup.

Dispensing Liquid Oral Preparations (Hydrodiuril Solution)

10. Mix medication well if required.

11. When liquid medications are poured, the label should be held in the palm of the hand.
PURPOSE: To protect the label from medication spills. The medication must be discarded if staff members are unable to read the drug label clearly.

12. Place the medicine cup on a flat surface and, at eye level, pour the medication to the prescribed dose mark on the medicine cup (Figure 2).

PURPOSE: At eye level, the base of the meniscus is where the prescribed dose should be measured.

For Both Solid and Liquid Oral Medications

13. Recap the container and compare the label with the physician’s order before replacing the container in storage.
PURPOSE: To compare the medication label and the physician’s order the third of three times.

14. Transport the medication to the patient.

15. Greet and identify the patient by name.
PURPOSE: To make sure you have the right patient.

16. Mention the name of the drug and why it is being given and ask the patient whether she or he has any allergies to the medication.
PURPOSE: To educate the patient about drug treatment and to verify that the patient is not allergic to the prescribed medication.

17. If necessary, help the patient into a sitting position.

18. Administer tablets, capsules, or caplets with water. If the patient is receiving liquid medication, offer water after the medication has been taken if appropriate. Make sure the patient swallows the entire dose.

19. Provide patient education about the purpose of the drug, typical side effects, and dosage and storage recommendations. Consult the physician to clarify information if needed.
PURPOSE: To ensure compliance with home drug therapy and to monitor for side effects.

20. The patient must remain in the office for 20 to 30 minutes after drug administration as a precaution against untoward effects.

21. If the patient experiences any discomfort after taking a medication, the physician should be notified immediately and the incident documented completely and accurately.

22. Sanitize your hands.

23. Document the administration of the drug, including the date and time; the drug name, dose, strength, and route of administration; any patient side effects; and patient education provided about the drug.

6/8/XX 9:45 AM HydroDiuril 100 mg tab administered PO per physician order. Pt ed conducted; pt had no questions. Dorothy Gaston, CMA (AAMA) ______________________________________

Mucous Membrane Forms

Some mucous membranes are selected for their ability to absorb medication for a systemic effect. The most commonly used areas are the gums, the cheeks (buccal), under the tongue (sublingual), the rectum, and the respiratory mucosa (inhalation). Nasal, ophthalmic, rectal, and vaginal preparations may also be applied to these mucous membranes for their localized effects. Inhalation drugs are discussed in Chapter 46.

Rectal Administration

The rectal mucosa allows rapid absorption of a drug, even though the surface of the rectum is small. Drugs are absorbed directly into the bloodstream without being altered, as they would be by the digestive processes, and without irritating the patient’s gastric mucosa. Rectal medications are useful if the patient is nauseated, vomiting, or unconscious. For example, Tylenol or Compazine suppositories may be prescribed for a child who has fever, nausea, and vomiting. Manufacturers supply rectal medications in the form of gelatin- or cocoa butter–based suppositories, which melt in the warmth of the rectum and release the medication (Figure 35-4). Suppositories may also be used to soften the stool or to stimulate evacuation of the bowel; enemas are used to cleanse and evacuate the bowel.

FIGURE 35-4 Sample rectal suppositories.

The best time to administer a rectal drug intended for a systemic effect is after a bowel movement or enema. The patient should be cautioned to remain lying down for 20 to 30 minutes to prevent accidental evacuation of the drug. Of course, suppositories intended to treat constipation are administered to bring about bowel evacuation. The patient should be instructed to remove the outer wrapping and insert the suppository approximately 2 inches above the rectal sphincter muscles; a little mineral oil or vegetable oil may be used as a lubricant. If suppositories are individually wrapped in foil, make sure the patient knows that the foil is the wrapper and is not part of the treatment. Suppositories are typically stored in the refrigerator to keep them firm.

Vaginal Administration

Vaginal suppositories, tablets, creams, and fluid solutions are used to treat local infections. Irrigating solutions (douches) may be used as anti-infective treatments. Creams and foams are available as local contraceptives. Vaginal instillation is most effective if the patient remains lying down after administration to prevent leakage; many preparations, therefore, are intended to be used at bedtime. The patient may need to wear a pad to absorb drainage. Solid suppositories and tablets may be lubricated or moistened with water and inserted by hand or with an applicator. Creams are instilled with applicators. Prepackaged, disposable irrigation kits are available for douching.

When instructing patients, confirm that the patient can differentiate the urinary meatus from the vaginal orifice and the rectum. Mistakes could result in vaginal infections or in damage to or infection of the urinary tract. A simple drawing and explanation may be required.

Oral Administration

Mouth and throat agents come in the form of sprays, swabs, sublingual tablets, and buccal tablets. The mouth and throat membranes may be treated locally with antiseptics for oral hygiene and local infection, with anesthetics for pain relief, and with astringents that form a protective film over the mucous membranes. The patient may have to gargle, or the area may be painted or sprayed. To paint or spray the throat, first look for the area of inflammation to be treated. Otherwise, the part needing treatment may be missed entirely. Avoid touching the posterior pharynx (back of the throat); this causes gagging and possibly vomiting.

Sublingual (SL) tablets are placed under the tongue, where they are rapidly absorbed into the bloodstream by the rich supply of capillaries. Sublingual absorption is systemic and bypasses the acids in the stomach. Nitroglycerin, used for treating the chest pains of angina pectoris, may be administered sublingually. Patients should not chew or swallow sublingual medications. The patient should be instructed not to smoke, eat, or drink immediately before administration of these drugs. Buccal tablets are placed between the cheek and the upper molars and are quickly absorbed by the oral capillaries.

Nasal Administration

Nose drops and nasal sprays may be used for localized effect, but, like the inhalation drugs, they can spill over into the bloodstream. Some nasal preparations, such as decongestants, can cause an increased heart rate, elevated blood pressure, or central nervous system stimulation. Nasal medications are commonly used for blocked nasal passages (decongestants) and nosebleeds (hemostatics). Instillation of nasal medications is covered in Chapter 37. Nasal decongestant sprays are often misused by patients. Be sure to teach the patient not to exceed the amount or frequency ordered by the physician. If too much is used, these drugs can dry the mucosa and make congestion worse. Nasal inhalants can also be used for their systemic effect, such as the corticosteroid Flonase, which may be prescribed as part of asthmatic treatment.

Topical Forms

Topical drugs are prescribed for both local and systemic effects. Skin medication forms include lotions, liniments, ointments, and transdermal patches. The medical assistant should wear gloves when applying any topical treatment, to prevent self-administration of the drug.

Lotions

Often used to control itching, lotions are applied by dabbing with a soft cloth, a cotton ball, or a tongue blade. Calamine is an example. Some lotions are used to relieve inflammation and pain in muscles and joints. After the lotion has been applied, the area may be covered with a thick cloth to retain heat. However, the therapeutic value of these preparations is controversial. The effects of musculoskeletal lotions are limited to the skin surface where the medication is applied.

Liniments

Liniments (emulsions) have a higher portion of oil than lotions, and volatile active ingredients may be added. Liniments are often used to protect dried, cracked, or fissured skin.

Ointments

Ointments, such as bacitracin, are semisolid medications containing bases such as petrolatum and lanolin. An ointment should be removed from a jar or tube with a tongue blade to prevent contamination of the remaining medication.

Transdermal Patches

Certain medications can be absorbed slowly through the skin to create a constant, time-released systemic effect (Figure 35-5). The nitroglycerin patch is particularly useful for patients with frequent attacks of angina. Hormone patches, such as estrogen and testosterone, also can be absorbed slowly through the skin. With dermal patches, drugs can be administered in a time-released manner for as long as 7 days. The date and time the patch was applied should be written on the patch and documented in the patient’s record.

Patient Teaching Recommendations for Transdermal Patches

• The patient may shower with the patch in place.

• Rotate sites to prevent skin irritation. Follow package insert directions on where to apply the patch, avoiding scars and areas with a great deal of body hair.

• If the patch is to remain on for 24 hours for an extended number of days, apply a new patch at the same time every day and keep the old patch on for 30 minutes after applying the new patch to maintain therapeutic blood levels of the medication.

• Dispose of used patches appropriately, out of the reach of children or pets, because the old patch may still contain medication.

Parenteral Medication Forms

Injectable medications must be sterile and in liquid form. These medications may be supplied in an ampule, a single-dose vial, or a multidose vial (Figure 35-6). The drug usually is in a solution that is minimally irritating to human tissues (e.g., physiologic saline solution, sterile water) and may contain a preservative or a small amount of antibiotic to prevent bacterial growth in the vial. All injectable medications are dated. Before use, check the expiration date and examine the solution for possible deterioration. If the medication is discolored or if any sediment has formed at the bottom of the vial, the vial should be discarded. A parenteral medication is administered with a sterile syringe and needle. Occupational Safety and Health Administration (OSHA) guidelines must be followed when any sharp is used, including all types of needles, because every needle used on a patient is contaminated with blood and body fluids. The medical assistant must wear disposable gloves when administering parenteral injections, must immediately dispose of the needle and syringe unit into a sharps container after use, and must never recap used needles.