Check the order on the patient’s medication record against the physician’s order.

Check the label on the medication three times before administering it to a patient to ensure that you’re administering the prescribed medication in the prescribed dose. Check it when you take the container from the shelf or drawer, right before pouring the medication into the medication cup or drawing it into the syringe, and before returning the container to the shelf or drawer. If you’re administering a unitdose medication, check the label for the third time immediately after pouring the medication and again before discarding the wrapper. Don’t open a unit-dose medication until you’re at the patient’s bedside.

Before giving the medication, confirm the patient’s identity by checking two patient identifiers. Then make sure that you have the correct medication.

Explain the procedure to the patient and provide privacy.

Make sure that you have a written order for every medication that’s to be given. If the order is verbal, make sure that the physician signs for it within the time specified by facility policy.

Don’t give medication from a poorly labeled or unlabeled container. Furthermore, don’t attempt to label drugs or reinforce drug labels yourself; a pharmacist must do that.

Never give a medication that someone else has poured or prepared. Never allow your medication cart or tray out of your sight. Never return unwrapped or prepared medications to stock containers. Instead, dispose of them and notify the pharmacy.

If the patient questions you about his medication or the dosage, check his medication record again. If the medication is correct, reassure him that it’s correct. Make sure to tell him about changes in his medication or dosage. Instruct him, as appropriate, about possible adverse reactions and encourage him to report any that he experiences.

To assess the patient’s response to medication, be aware of his condition and what the drug’s desired or expected effect should be. For example, if the patient is receiving an antiarrhythmic but continues to have premature ventricular contractions, tell the physician that the drug isn’t having the desired effect. Monitor the patient’s condition carefully; changes such as weight loss or gain can affect the action of some drugs. Other factors, such as the patient’s age, body build, gender, and emotional state, may also affect his
response to drug therapy. Also, check the results of laboratory tests, which can indicate a therapeutic effect, an adverse effect, or a toxic level.

Because many patients receive more than one drug, it’s important to understand drug interactions. A drug interaction is a change in drug absorption, distribution, metabolism, and excretion that may occur with or shortly after administration of another drug. A desirable interaction is used to help to maintain an effective blood level, or minimize or prevent adverse effects.

Some interactions, however, can have undesirable results, such as weakening a drug’s desired effects or exaggerating its toxic ones. For example, a patient who smokes require larger doses of theophylline than a nonsmoking patient because cigarette smoke activates oxidative enzymes in the liver, increasing drug metabolism.

When you administer a drug, you must be able to recognize and identify adverse effects and toxic and allergic reactions. Some adverse effects are transient and subside as the patient develops a tolerance for the drug; others may require a change in therapy.

A toxic reaction to a drug can be acute, resulting from an excessive dose (an acetaminophen overdose, for instance), or chronic, resulting from progressive accumulation of the drug in the body. It can also result from impaired metabolism or excretion that results in elevated blood levels of a drug.

A drug allergy (hypersensitivity) results from an antigen-antibody reaction in a susceptible patient. Such a reaction can range from mild urticaria to potentially fatal anaphylaxis. Always check for known drug allergies before administering medications. In some instances, sensitivity tests may be performed before the first dose is given. For some patients, genetic testing for the detection of certain alleles can reveal increased risks for hypersensitivity reactions. Be aware that a negative history doesn’t rule out future allergic reactions. Other undesirable effects to watch for when administering drugs include idiosyncratic reactions and dependence.

Documenting all medications given to a patient provides a legal record of drugs the patient received during his stay in the facility. Medication administration involves documenting on a medication administration record (MAR) as well as in the nurse’s notes. After administering a drug, document on the patient’s Kardex or computer files the drug name, dosage, route and time of administration, and your signature and title. In the nurse’s notes, include any assessment data that refer to the patient’s response to the medication and any adverse effects of the medication.

If your facility documents medications digitally, make sure you enter each drug immediately after you give it. This gives all health care team members access to current medication information and is especially important if the system has no hard-copy backup.

Always write legibly. Use only acceptable abbreviations, and use them correctly. When in doubt as to how to abbreviate a term, spell it out. When documenting parenteral medications, be sure to include the injection site and the route used. After administering the first dose, sign your full name, licensure status, and identifying initials in the appropriate place on the MAR.

Patient’s medication record and chart ♦ prescribed medication ♦ sterile tongue blades ♦ gloves ♦ sterile 4″ × 4″ gauze pads ♦ transparent semipermeable dressing ♦ adhesive tape ♦ solvent (such as cottonseed oil) ♦ optional: cotton-tipped applicators, cotton gloves, or terry cloth scuffs

♦ Verify the order on the patient’s medication record by checking it against the physician’s order. Check the patient’s medication record for allergies.

♦ Confirm the patient’s identity using two patient identifiers.

♦ Explain the procedure to the patient because, after discharge, he may have to apply the medication by himself.

♦ Wash your hands to prevent crosscontamination and glove your dominant hand.

♦ Help the patient into a comfortable position and expose the area to be treated. Make sure that the skin or mucous membrane is intact (unless the medication has been ordered to treat a skin lesion). Application of medication to broken or abraded skin may cause unwanted systemic absorption and result in further irritation.

♦ If necessary, clean the skin of debris. You may need to change the glove if it becomes soiled.

♦ To prevent skin irritation from an accumulation of medication, remove residue from previous applications before each new application.

♦ Always wear gloves to prevent your skin from absorbing the medication.

♦ Never apply ointment to the eyelids or ear canal unless ordered. The ointment may congeal and occlude the tear duct or ear canal.

♦ Inspect the treated area frequently for adverse or allergic reactions.

Patient’s medication record and chart ♦ gloves ♦ prescribed medication (patch or ointment) ♦ application strip or measuring paper (for nitroglycerin ointment) ♦ adhesive tape ♦ optional: plastic wrap or semipermeable dressing (for nitroglycerin ointment)

♦ Verify the order on the patient’s medication record by checking it against the physician’s order. Check the patient’s medication record for allergies.

♦ Confirm the patient’s identity using two patient identifiers.

♦ Wash your hands and put on gloves.

♦ Make sure that previously applied medication has been removed.

♦ Locate a new site for application, different from the previous site.

♦ Apply daily transdermal medications at the same time every day to ensure a continuous effect, but alternate the application sites to avoid skin irritation.

♦ Before applying nitroglycerin ointment, obtain the patient’s baseline blood pressure. Obtain another blood pressure reading 5 minutes after applying the ointment. If the blood pressure has dropped significantly and the patient has a headache, notify the physician immediately. If the blood pressure has dropped but the patient has no symptoms, instruct him to lie still until the blood pressure returns to normal.

♦ Before reapplying nitroglycerin ointment, remove the plastic wrap, the application strip, and any ointment
remaining on the skin at the previous site.

♦ When applying a scopolamine patch, instruct the patient not to drive or operate machinery until his response to the drug has been determined.

♦ If the patient is using a clonidine patch, encourage him to check with his physician before using over-the-counter cough preparations. They may counteract the effects of clonidine.

Patient’s medication record and chart ♦ ointment ♦ ruled paper ♦ plastic wrap or transparent semipermeable dressing ♦ adhesive tape ♦ sphygmomanometer ♦ optional: gloves

♦ Verify the order on the patient’s medication record by checking it against the physician’s order. Check the patient’s medication record for allergies.

♦ Confirm the patient’s identity using two patient identifiers.

♦ Take a patient’s baseline blood pressure for comparison with later readings.

♦ Wash your hands. Then put on gloves if you wish to avoid contact with the medication.

♦ Squeeze the prescribed amount of ointment onto the ruled paper, as shown below.

♦ After measuring the correct amount of ointment, tape the paper, with the drug side down, directly to the skin. Some health care facilities require you to use the paper to apply the medication to the patient’s skin, usually on the chest or arm. Spread a thin layer of ointment over a 3″ (7.5-cm) area.

♦ For increased absorption, the physician may request that you cover the site with plastic wrap or transparent semipermeable dressing, as shown below.

♦ After 5 minutes, record the patient’s blood pressure. If it has dropped significantly and he has a headache (as a
result of vasodilation of blood vessels in his head), notify the physician.

♦ If the patient’s blood pressure has dropped but he has no adverse reactions, instruct him to lie still until it returns to normal.

Patient’s medication record and chart ♦ prescribed eye medication ♦ sterile cotton balls ♦ gloves ♦ warm water or normal saline solution ♦ sterile gauze pads ♦ facial tissue ♦ optional: ocular dressing

Make sure that the medication is labeled for ophthalmic use. Then check the expiration date. Remember to date the container after the first use.

Inspect ocular solutions for cloudiness, discoloration, and precipitation, but remember that some eye medications are suspensions and normally appear cloudy. Don’t use a solution that appears abnormal.

♦ Verify the order on the patient’s medication record by checking it against the physician’s order. Check the patient’s medication record for allergies.

♦ Make sure that you know which eye to treat because different medications or doses may be ordered for each eye. Know that “OD” means right eye, “OS” means left eye, and “OU” means both eyes.

♦ Wash your hands and put on gloves.

♦ If the patient has an ocular dressing, remove it by pulling it down and away from his forehead. Avoid contaminating your hands.

♦ To remove exudate or meibomian gland secretions, clean around the eye with sterile cotton balls or sterile gauze pads moistened with warm water or normal saline solution. Have the patient close his eye and then gently wipe the eyelids from the inner to the outer canthus. Use a fresh cotton ball or gauze pad for each stroke.

♦ Have the patient sit or lie in the supine position. Instruct him to tilt his head back and toward his affected eye so that excess medication can flow away from the tear duct, minimizing systemic absorption through the nasal mucosa.

♦ Remove the dropper cap from the medication container and draw the medication into it.

♦ Before instilling eyedrops, instruct the patient to look up and away. This moves the cornea away from the lower lid and minimizes the risk of touching it with the dropper.

♦ When administering an eye medication that may be absorbed systemically, press your thumb on the inner canthus for 1 to 2 minutes after instillation, while the patient closes his eyes.

♦ To maintain the sterility of the drug container, never touch the tip of the dropper or bottle to the eye area. Discard any solution that remains in the dropper before returning it to the bottle. If the dropper or bottle tip becomes contaminated, discard it and use another sterile dropper.

Patient’s medication record and chart ♦ prescribed eye medication ♦ sterile gloves

♦ Verify the order on the patient’s medication record by checking it against the physician’s order. Check the patient’s medication record for allergies.

♦ Confirm the patient’s identity using two patient identifiers.

♦ Make sure that you know which eye to treat because different medications or doses may be ordered for each eye.

♦ If the patient will continue therapy with an eye medication disk after discharge, teach him to insert and remove it himself. Ask him to demonstrate the techniques for you.

♦ Explain that mild reactions are common, but should subside within the first 6 weeks of use. Foreign-body sensation in the eye, mild tearing, redness of the eye or eyelid, increased mucus discharge, and itchiness can occur. Blurred vision, stinging, swelling, and headaches can occur with pilocarpine, specifically. Tell the patient to report persistent or severe signs or symptoms.

Patient’s medication record and chart ♦ prescribed eardrops ♦ light source ♦ facial tissue or cotton-tipped applicator ♦ optional: cotton ball, bowl of warm water

Warm the medication to body temperature in the bowl of warm water or carry it in your pocket for 30 minutes before administration. If necessary, test the temperature by placing a drop on your wrist. (If the medication is too
hot, it may burn the patient’s eardrum.) To avoid injuring the ear canal, check the dropper before use to make sure that it isn’t chipped or cracked.

♦ Verify the order on the patient’s medication record by checking it against the physician’s order. Check the patient’s medication record for allergies.

♦ Wash your hands.

♦ Confirm the patient’s identity using two patient identifiers.

♦ Have the patient lie on the side opposite the affected ear.

♦ Straighten the patient’s ear canal. For an adult, pull the auricle up and back.

For an infant or a child younger than age 3, gently pull the auricle down and back— the ear canal is straighter at this age.