• Tablets and capsules are the most common drug forms; they are convenient and less expensive and do not require additional supplies for administration.

• Oral medications are not given to patients who are vomiting, lack a gag reflex, or who are comatose. Patients who gag may need a brief rest before proceeding with further intake of medications.

• Do not mix medication with a large amount of food or beverage or with contraindicated food. Patients may not be able to eat all of the food and will not get a full dose of medication. Do not mix medication in infant formula.

• Enteric-coated and timed-release capsules must be swallowed whole to maintain a therapeutic drug level. If crushed, the initial excessive drug release poses a risk of toxicity. Because the drug is absorbed prematurely, the drug drops to a subtherapeutic level later in the cycle. To maintain a therapeutic drug level (not toxic and not subtherapeutic), the drug must be swallowed whole so it is released gradually. These medications should never be cut in half or crushed for administration. Follow agency policy for resources available for changing or altering such drugs if patients are unable to swallow them. At times, these medications can be given in liquid or IV form or in a non–extended-release form that may be given in more frequent doses—for example, Roprol XL (metaprolol succinate), which is long-acting, may be changed to Lopressor (metaprolol tartate), which is immediate-release and can be given more frequently.

• Be aware of medications without “extended-release” in the name that should never be cut in half or crushed (e.g., Mucinex tablets, which can be changed to liquid guaifenesin if needed).

• Administer irritating drugs with food to decrease GI discomfort.

• Administer drugs on an empty stomach if food interferes with medication absorption.

• Drugs given sublingually (placed under the tongue) or buccally (placed between the cheek and gum) remain in place until fully absorbed. No food or fluids should be taken while the medication is in place.

• Encourage the use of child-resistant caps. However, if patients have difficulty opening child-resistant caps, they might leave the caps off or not completely tightened, which is a safety hazard. Non–child-resistant caps are available for these patients on request.

• Forms of liquid medication include elixirs, emulsions, and suspensions. Elixirs are sweetened hydroalcoholic liquids used in preparation of oral liquid medications. Emulsions are a mixture of two liquids that are not mutually soluble. Suspensions are liquids in which particles are mixed but not dissolved.

• Read the labels to determine whether dilution or shaking is required. As a general rule, suspensions and emulsions need to be shaken before administration; elixirs do not.

• The meniscus is the slightly concave curved line of a dose of liquid. The bottom of the meniscus should be used to measure the desired dose of medication (Figure 13-2).

• Many liquids require refrigeration once reconstituted.

• Transdermal medication is stored in a patch placed on the skin and absorbed through skin, having a systemic effect. Widespread use of such patches began in the 1980s. Patches for neoplastic drugs, drugs to treat allergic reactions, and insulin are in production or being developed. Transdermal drugs provide more consistent blood levels than oral and injection forms and avoid GI absorption problems associated with oral products. Transdermal patches should be rotated to different sites and not reapplied over the exact same area when changed. Additionally, the area should be thoroughly cleansed before administration of a new transdermal patch. This practice will prevent errors in overdosing the patient.

• Wash hands and wear gloves to administer medicated patches to prevent transfer of medication. Nurses should educate patients to wash hands after applying a patch to avoid transferring medicine to another part of body or to someone else.

• A common question is whether or not to cut the patches in half. A nurse might suggest using patches with a lower dosage rather than cutting patches and guessing the dose the patient will receive. There are two patch designs: (1) If the drug is embedded in a matrix patch and diffuses into the skin (e.g., Climara, Vivelle, Nicotrol, Testoderm), the drug is spread over the entire surface of the patch, which probably may be cut. Patients must be alert for underdosing or overdosing. (2) If the drug is pooled in a reservoir patch and is released via a semipermeable membrane (e.g., Catapres-TTS, Duragesic, Estraderm, Transderm-Nitro, Androderm), the patch should not be cut because too much drug may be released. Advise patients to secure the patch with tape, being careful not to apply it too tightly, which could alter the drug delivery.

• Topical medications are most frequently applied to the skin. They can be applied to the skin in several ways, such as with a glove, tongue blade, or cotton-tipped applicator. Nurses should never apply a topical medication without first protecting their own skin with gloves.

• Use appropriate technique to remove the medication from the container, and apply it to clean, dry skin, when possible. Do not contaminate the medication in a container; instead use gloves or an applicator.

• Gloves and applicators that come in contact with a patient should not be reinserted into the container. Estimate the amount needed and remove it from the container, or use a fresh sterile applicator each time the container is entered.

• Eyedrops (Box 13-1 and Figure 13-3)

• Eye ointment (Box 13-2 and Figure 13-4)

• Eardrops (Box 13-3 and Figure 13-5)

• Nose drops and sprays (Box 13-4 and Figures 13-6 and 13-7)

• Metered-dose inhalers (MDIs) are handheld devices that deliver medication to the lower respiratory tract (Box 13-5). Some MDIs have a counter to indicate the number of inhalations used. For those that do not, the most accurate way to determine this number is for the patient to count and record (e.g., on the box or a calendar) the number of inhalations used; however, this is often not practical. Inhalation counters are now on some inhalation products and are a most welcome addition. Every effort should be made to have the patient know how much medication is in the canister and to anticipate/obtain refills in a timely manner.

• Take special measures when handling the capsules used in some MDIs to prevent the transfer of medication (for example, with Spiriva, if the powder from the punctured capsule gets on the nurse’s hands and transfers to the eyes, it will dilate the pupils).

• Spacers are devices used to enhance the delivery of medications from the MDI. Figure 13-8 illustrates the distribution of medication with and without a spacer. A nebulizer is a device that changes a liquid medication into a fine mist or aerosol that has the ability to reach the lower, smaller airways. Handheld nebulizers deliver a very-fine–sized particle spray of medication.

• When administering drugs via an MDI or nebulizer, the preferred patient position is the semi-Fowler’s or high Fowler’s position.

• Instruct the patient on the correct use and cleaning of MDIs or nebulizers.