Safe Administrations of Medications (Draft Chapter)

UNIT 6
Author: Tracy Levett-Jones

Clinical Reviewers: Natalie Govind and David Newby
MEDICATION
ADMINISTRATION
Section 6.1 Introduction
Section 6.2 Oral medication administration
Section 6.3 Topical medication administration
Section 6.4 Parenteral medication administration
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SECTION 6.1
INTRODUCTION
KEY TERMS
adverse effect, 241
chemical name, 240
drug, 240
generic name, 240
medication, 240
medication error, 241
medication history, 246
near miss, 241
prescription, 240
side effect, 241
therapeutic effect, 241
trade name, 240
LEARNING OUTCOMES
On completion of this section you will be able to:
1.
Define the key terms related to medication administration.
2.
Describe the legal and professional aspects of

medication administration.
3.
Discuss the impact of person-centred care and

interprofessional communication on medication safety.
4.
Identify the essential parts of a valid medication order.
5.
Outline the types of medication preparations and routes

of administration.
6.
Outline the key components of a medication history.
7.
List the five rights and three checks for safe

A medication (or drug) is a substance administered for

the diagnosis, cure, treatment, or relief of a symptom or
for prevention of disease. Preparation and administration
of medications are complex processes involving counting,
calculating, measuring, mixing and ensuring that the right
person receives the right medication in the right dose, at the
right time, by the right route, and for the right reason.
In Australia, medications are dispensed on the order of
a doctor, dentist, eligible midwife or nurse practitioner. In
the health care context, the words medication and drug are
often used interchangeably. The written direction for the
preparation and administration of a medication is called a
prescription. Medications have chemical, generic and trade
names. The chemical name describes the constituents of the
drug. The generic name is given by the manufacturer that
first develops the drug and is the name used on prescriptions
and on medication charts. The trade name or brand name
is the name given to it by drug manufacturers. Because one

medication may be manufactured by several companies,
it may have several trade names. For example, N-acetyl-paminophenol is the chemical name for paracetamol (generic
name) which has a number of trade names including
Panadol, Tylenol and Panamax.
LEGAL ASPECTS OF
MEDICATION ADMINISTRATION
The administration of drugs in the Australia is controlled
by law. Nurses need to (a) have a sound understanding of
the laws that govern their scope of practice in relation to
medication administration, and (b) recognise the limits of
their own knowledge and skill.
Under the law nurses are responsible for their own actions
regardless of whether there is a written medication order.
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UNIT 6
STANDARDS FOR PRACTICE

The Nursing and Midwifery Board of Australia
(NMBA) Standards for Practice (2016) specify
that the registered nurse complies with legislation,
regulations, policies, guidelines and other standards or
requirements relevant to the context of practice when
making decisions (NMBA, 2016, p. 3).
This means that if a medical officer writes an incorrect order

(e.g., morphine 100 mg instead of morphine 10 mg), the
nurse who administers the incorrect dosage is responsible
for the error as well as the medical officer. Therefore, nurses
need a sound foundation of pharmacological knowledge, the
skills to access reliable drug resources, and the confidence
to question any order that appears illegible, ambiguous,
unreasonable, or contraindicated by the persons condition.
The right to refuse to administer a medication is sometimes
referred to as one of the Rights of medication administration.
Another legal aspect of medication administration is the use
of controlled substances (listed under Schedule 8 of the Poisons
Standard 2012). In hospitals, controlled substances are kept
in a locked drawer, cupboard, medication cart or computercontrolled dispensing system, and an inventory of their use
is strictly maintained. Hospitals have clear protocols about
the storage, access and use of Schedule 8 medications. These
controlled substances require verification and documentation
of administration by two registered nurses.
MEDICATION SAFETY
Medication errors are the second most common type of
incident reported in Australian hospitals with error rates of over
18% (Johnson, Tran & Young, 2011) and only 421% of people
achieving the optimum therapeutic benefit of medications
(Garfield, Barber, Walley, Willson & Eliasson, 2009). In the
Australian public health system medication adverse events cost
approximately $6 billion dollars per year and inappropriate
use of medicines $380 million (National Health and Hospitals
SECTION 6.1
INTRODUCTION
Reform Commission, 2008). It is likely, however, that the

available figures underestimate the extent of the problem.
CLINICAL SAFETY ALERT

In Australian hospitals, 38% of medication errors
occur at the administration stage, indicating the
critical need for nursing students to develop clinical
skills and knowledge that promote medication safety
(Roughead & Semple, 2009).
The impact of person-centred

care and interprofessional
communication on medication
safety
The safe, timely and effective administration of medicines is
dependent not only on individual responsibilities, but also
effective collaboration between all members of the medication
team (Madegowda et al., 2007). Medication incidents are
often related to a lack of effective communication among
health professionals such as doctors, nurses and pharmacists,
and between health professionals, patients and family
members. Inadequate communication (verbal and written)
is the primary issue in the majority of medication errors,
adverse reactions and near-misses (Britten, 2011).
Miscommunication can result during telephone orders
if unclear or insufficient directions are given (Manias,
2014). Telephone orders should always be followed up by
documentation of the prescription within a defined period,
which is usually 24 hours. Research undertaken with nurses
(n = 1296) about telephone orders showed that only 75%
of nurses always read back the persons name, the name of
the medication, the dose and the route to the prescriber. The
remainder of nurses either sometimes or never perform these
tasks (Cohen & Shastay, 2008).
When taking a telephone order, it is important that the
health professional repeats the persons name, the medication
TABLE 61 Effects of Drugs

Therapeutic effect
The intended effect and the reason the drug is prescribed.
Side effect
An unintended effect of a drug that is usually predictable and may be either harmless or potentially harmful.
Adverse effect
(reaction or event)
A severe side effect that may justify a dose reduction or discontinuation of a drug. An adverse drug
effect is a response to a medication, which is harmful and unintended, and which occurs at normal doses.
Medication error
Any preventable medication event that leads to, or has the potential to lead to, harm to the person.
Near miss
A medication error that was detected and corrected before it reached the person.
Example: the therapeutic effect of morphine sulfate is analgesia.

Example: A side effect of morphine sulfate can be nausea and vomiting.
Example: An adverse effect of morphine sulfate may be respiratory depression.

Example: Administering 30 units of insulin instead of the 3 units ordered.
Example: Amoxicillin is ordered for a person with an allergy to penicillin but identified by the nurse before
for the drug is administered.
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SKILLS IN CLINICAL NURSING
name, which includes spelling the name to avoid an error

due to sound alike medications, the dosage, which includes
pronouncing the amount in single digits (e.g. 15 mg should
be read as one five), route, and frequency, which includes
stating the interval in full rather than using abbreviations
(e.g. three times daily, not TDS).
An individualised and person-centred approach to
medication administration, involving a dialogue between
nurses and patients, promotes patient safety by engaging
the person as a participative member of the medication
team (Bolster & Manias, 2010). There is clear evidence that
a person-centred approach to medication administration
can reduce the number of medication errors. For further
information about the relationship between medication
safety, person-centred care and communication access the
Interprofessional Education for Quality Use of Medicines
modules at <www.ipeforqum.com.au/modules/>.

Medication errors can be caused by
interpersonal and situational factors such as:
Unnecessary interruptions from colleagues during
medication preparation and administration activities.
Miscommunication of orders, misinterpretation of
orders or difficulties in reading orders.
Hierarchies within the health care team that
negatively influence nurses and pharmacists
decisions to seek advice or clarify of orders.
Failure to include the person receiving the medication
as an integral member of the medication team.
Failure to access an interpreter for a person who does
not speak English.
MEDICATION ORDERS
A valid medication order has seven essential parts, these include:
1.
2.
3.
4.
5.
6.
7.
Full name of the person

Date and time the order is written
Name of the drug to be administered
Dosage of the drug
Frequency of administration
Route of administration
Signature of the person writing the order.
In addition, unless it is a standing order, the medication

order should state the number of doses or the number of days
the drug is to be administered. To avoid confusion between
people with the same or similar last names most facilities use the
persons first and last names, and their medical record number
on the medication chart. The day, month, year and often the
time the order was written are also included on the chart. Most
PM
2400
2300
11
1100
12
1200
AM
1300
1
0100
2200
1400
10
0200
1000
2100
0900
2000
0300
0800
0400
0700
7
1900
0600
3 1500
1600
0500
5
1700
1800
FIGURE 61The 24-hour clock

facilities use the 24-hour clock to eliminate confusion between
morning and afternoon times. Time with the 24-hour clock
starts at midnight, which is 0000hours (Figure 61). In Australia
many facilities use the National Inpatient Medication Chart as a
consistent way of recording the ordering and administration of
medication for hospitalized adults (Figure 62).
The generic name (and sometimes the trade name) of
the drug to be administered must be clearly and accurately
written on the chart along with the dosage of the drug, the
amount or the strength of the medication, and the times or
frequency of administration. Because it is not unusual for a
drug to have several possible routes of administration the
route must be clearly specified in the order. For example,
tetracycline 250 mg (amount) four times a day (frequency)
orally (route); or potassium chloride 10% (strength) 5 mL
(amount) three times a day with meals (time and frequency)
orally (route). The medical officer ordering the drug or
the nurse who received the telephone order must sign the
medication chart to ensure the order is legal and valid.
A doctor will provide a written or oral order for a medication
(prescription) often using a number of abbreviations. It is
important that only accepted abbreviations are used in order
to avert the potential for error due to misinterpretation by the
pharmacist or nurse. For example, AZT has been interpreted
as zidovudine or azathioprine and EPO can be interpreted
as evening primrose oil or epoetin-alpha. For these reasons,
it is important that only accepted abbreviations are used
or that medications are written in full when prescribing
and providing directions for use. See Table 62 for a list of
acceptable medication abbreviations.
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FIGURE 62National Inpatient Medication Chart (Continued )
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Source: Australian Commission on Safety and Quality in Health Care (2012). National Inpatient Medication Chart for Adult Patients 2012. Commonwealth of Australia. Reproduced with permission from the Australian Commission
on Safety and Quality in Health Care. Retrieved from www.safetyandquality.gov.au/wp-content/uploads/2012/02/NIMC-acute-PDF-82KB.pdf.
FIGURE 62National Inpatient Medication Chart
UNIT 6
SECTION 6.1
INTRODUCTION
TABLE 62 Acceptable Medication Terms and Abbreviations

INTENTED MEANING
ACCEPTED TERMS OR ABBREVIATIONS
Dose frequency or timing

(in the) morning
Morning, mane
(at) midday
Midday
(at) night
Night, nocte
twice a day
Bd
three times a day
Tds
four times a day
Qid
every 4 hours
every 4 hrs, 4 hourly, 4 hrly
every 6 hours
every 8 hours
once a week
once a week and specify the day in full, e.g. once a week on Tuesdays
three times a week
three times a week and specify the exact days in full, e.g. three times
a week on Mondays, Wednesdays and Saturdays
when required
prn
immediately
stat
before food
before food
after food
after food
with food
with food
epidural
epidural
inhale, inhalation
inhale, inhalation
intra-articular
intra-articular
intramuscular
IM
intrathecal
intrathecal
intranasal
intranasal
intravenous
IV
irrigation
irrigation
left
left
nebulised
NEB
naso-gastric
NG
oral
PO
percutaneous enteral gastrostomy
PEG
per vagina
PV
per rectum
PR
peripherally inserted central catheter
PICC
right
Right
subcutaneous
Subcut
sublingual
Subling
topical
topical
Units of measure and concentation

gram(s)
International unit(s)
International unit(s)
unit(s)
unit(s)
litre(s)
milligram(s)
mg
millilitre(s)
mL
microgram(s)
microgram, microg
percentage
%
(Continued )
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TABLE 62 Acceptable Medication Terms and Abbreviations (Continued)

INTENTED MEANING
ACCEPTED TERMS OR ABBREVIATIONS
millimole
mmol
Dose forms
capsule
cap
cream
cream
ear drops
ear drops
ear ointment
ear ointment
eye drops
eye drops
eye ointment
eye ointment
injection
inj
metered-dose inhaler
metered-dose inhaler, inhaler, MDI
mixture
mixture
ointment
ointment, oint
pessary
pess
powder
powder
suppository
supp
tablet
tablet, tab
patient controlled analgesia
PCA
Source: Australian Commission on Safety and Quality in Health Care (ACSQHC) (2011a). Recommendations for Terminology, Abbreviations and Symbols
Used in the Prescribing and Administration of Medicines. Canberra: Commonwealth Department of Communications, Information Technology and the Arts.
Commonwealth of Australia. Reproduced with permission.
TYPES OF MEDICATION
PREPARATIONS AND ROUTES
OF ADMINISTRATION
Medications are available in a variety of forms and are
administered via a number of routes. See Table 63 for
examples of types of drug preparations. The route of
medication administration is documented on the prescription.
When administering a drug, the nurse should ensure that
the type of medication is appropriate for the route specified.
Examples of routes of administration include:
Topical:
Dermatologic
Ophthalmic
Otic
Nasal
Metered-dose inhalers
Vaginal
Rectal
Oral (including oral, sublingual and buccal)
Parenteral:
Subcutaneous (SCI)
Intramuscular (IMI)
Intravenous (IVI)
TABLE 63 Types of Drug Preparation

TYPE
DESCRIPTION
Aerosol spray or foam
A liquid, powder or foam deposited in a thin layer on the skin by air pressure
Aqueous solution
One or more drugs dissolved in water
Aqueous suspension
One or more drugs finely divided in a liquid such as water
Caplet
A solid form, shaped like a capsule, coated and easily swallowed
Capsule
A gelatinous container to hold a drug in powder, liquid or oil form
Cream
A nongreasy, semisolid preparation used on the skin
Elixir
A sweetened and aromatic solution of alcohol used as a vehicle for medicinal agents
Extract
A concentrated form of a drug made from vegetables or animals
Gel
A clear or translucent semisolid that liquefies when applied to the skin
Liniment
A medication mixed with alcohol, oil or soapy emollient and applied to the skin
Lotion
A medication in a liquid suspension applied to the skin
Lozenge (troche)
A flat, round or oval preparation that dissolves and releases a drug when held in the mouth
Ointment (salve)
A semisolid preparation of one or more drugs used for application to the skin and mucous membrane
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UNIT 6
SECTION 6.1
INTRODUCTION
TABLE6.3 Types of Drug Preparation (Continued )

Paste
A preparation like an ointment, but thicker and stiff, that penetrates the skin less than an ointment
Pill
One or more drugs mixed with a cohesive material, in oval, round or flattened shapes
Powder
A finely ground drug or drugs; some are used internally, others externally
Suppository
One or several drugs mixed with a firm base such as gelatin and shaped for insertion into the body
(e.g. the rectum); the base dissolves gradually at body temperature, releasing the drug
Syrup
An aqueous solution of sugar often used to disguise unpleasant-tasting drugs
Tablet
A powdered drug compressed into a hard small disc; some are readily broken along a scored line; others are
enteric coated to prevent them from dissolving in the stomach
Tincture
An alcoholic or water-and-alcohol solution prepared from drugs derived from plants
Transdermal patch
A semipermeable membrane shaped in the form of a disc or patch that contains a drug to be absorbed through
the skin over a long period of time
Sections 6.26.4 in this unit describe these routes of

medication administration in detail.
Drug calculations
Calculating drug dosages safely and accurately is an important
nursing responsibility in medication administration. Careful and
accurate calculations are essential to the prevention of medication
errors. Sections 6.26.4 include an overview and examples of
drug calculations specific to the different routes described.
Taking a Medication History

Nurses should assess a persons health status and obtain a
medication history prior to administering any medication.
The extent of the assessment depends on the persons condition
and the drug that has been ordered. For example, if a person
has dyspnoea, their respiratory rate and oxygen saturation level
should be assessed before administering any medication that
might affect breathing. It is also important to determine whether
the route of administration is suitable. For example, a person
who is nauseated may not be able to retain a drug taken orally.
Additionally, individuals should be assessed to obtain baseline
data by which to evaluate the effectiveness of the medications
administered. A key nursing responsibility is monitoring the
effectiveness of medications administered. For example, a pain
assessment should be undertaken 30 minutes after administration
of an analgesic medication. Medications should have a therapeutic
effect but side effects are not uncommon and should also be
assessed, documented and reported to the medical officer.
Adverse effects are less common but more serious side effects
and warrant immediate reporting and action. See Table 61.
A more in depth medication history is usually taken
the first time a person presents for care (to a practice nurse
for example) or on admission to an acute care facility. A
medication history includes information about the drugs the
person is taking currently or has taken recently. This includes
prescription drugs; over-the-counter (OTC) drugs such as
analgesics or antacids; traditional medicines; complementary
therapies such as vitamins or herbal medicines; alcohol,
tobacco; and illicit substances such as marijuana. Because
many of these drugs have unknown or unpredictable actions
and side effects they need to be clearly documented. During
the medication history, the nurse should also try to elicit

information about possible drug dependencies. An important
part of the medication history is the persons knowledge of his
or her drug allergies.The nurse should also clarify any previous
drug side effects or adverse reactions. Medication that must be
taken with food or at a specific time should be documented as
well as foods that are incompatible with certain medications;
for example, milk is incompatible with tetracycline.
It is also important for the nurse to identify any problems the
person may have in self-administering a medication. A person
with poor eyesight, for example, may require special labels for
medication containers; and people with rheumatoid arthritis
may not be able to open some medication containers.
It is essential that the medication history includes an
appraisal of how much the person knows about their own
medications, including how medications should be stored
and administered, correct doses, possible side effects and
precautions. The nurse also needs to consider socioeconomic
factors. Two common problems are lack of transportation
to obtain medications and inadequate finances to purchase
medications. An understanding of these factors can help the
nurse to plan care that is individualised and person-centred.
THE PROCESS OF SAFE AND

EFFECTIVE MEDICATION
ADMINISTRATION
When administering any drug, regardless of the route of
administration, the nurse must ensure that they check the
Five Rights of Medication Administration (see Box 61) and
check the medications they are administrating three times
(see Box 62). Following this sequential and logical approach
for all medications administered helps to ensure that
important steps in the process are not overlooked; importantly
this approach helps to prevent medication errors and
promote patient safety. It is important to note that in addition
to the Five Rights nurses should also check that:
Information about the medication has been explained

to the person including the reason for its administration,
what to expect and any related precautions).
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Medication administration is correctly documented

after giving medication and that the students signature
is countersigned by the supervising RN.
When time of administration differs from prescribed
time this is documented along with the reason for
the delay.
Decisions not to administer a medication are
documented and the medical officer notified.
A persons right to refuse a medication is respected and
they are fully informed of the potential consequences
of their refusal. The persons refusal is documented and
their medical officer notified.
A nurses refusal to administer any medication they
believe to be incorrect for the person is documented
and the medical officer notified.
Appropriate patient assessments are undertaken prior
to administration (e.g., apical pulse, blood pressure,
pathology results etc).
Effectiveness of the medication is evaluated (e.g., was the
desired effect achieved or not? Did the person experience
any side effects or adverse reactions?).
BOX 61 The Five Rights of Medication Administration

1. RIGHT MEDICATION
The medication being administered is the medication that

was ordered.
The person receiving the medication is asked to check and

verify the medication (if appropriate).
2. RIGHT DOSE
The dose ordered is appropriate for the patient.
Calculations are correct and verified.
The ordered dose is within the usual dosage range for the
medication.
Dosages outside of the usual dosage range are questioned

and reported to pharmacist or medical officer.
3. RIGHT TIME
The medication is administered at the correct time, no more

than 30 minutes before or after the ordered time.
4. RIGHT ROUTE
The ordered route is appropriate for the medication and the

persons needs/condition.
5. RIGHT PERSON
The persons identification has been verified using arm band,

their first and last name, date of birth and medical record number.

Asking the right questions
Do not ask Are you John Jones? because the
person may answer yes to the wrong name. Instead
ask What is your name?
If a person raises questions about the medication you
give them this should be an alert. Stop! Ask the person
to clarify their concerns about their medications and

double check that the medication order and the person
for whom the medication is prescribed are bothcorrect.
BOX 62 Check Three Times for Safe Medication

Administration
FIRST CHECK
Read the medication chart and remove the medication(s) from

the persons drawer or the medication trolley.
Compare the label of the medication against the medication chart.
Check the expiry date of the medication.
Determine whether you need to do a medication calculation.
SECOND CHECK
While preparing the medication (e.g., pouring, drawing up or

placing in a medication cup), look at the medication label and
compare it with the medication chart.
THIRD CHECK
Recheck the label on the container (e.g., vial, bottle or packet)

against the medication chart before returning to its storage place.
SECTION 6.1
Critical Thinking Questions
1. You have been caring for the same person for six
days. They laugh when you ask their name before
administering their medication and say to you, Do you
really need to ask my name again? It hasnt changed
since the last time you asked! How will you respond?
2. Your patient is ordered ibuprofen but the only medication
in the persons drawer is labelled Nurofen. Can you
explain this discrepancy?
3. You hand the person his medications and he says to you:
The pill I usually take for my blood pressure is not white,
its blue. How would you respond?
4. The medical officer writes an order for Frusemide 400 mg
orally BD. The RN administers 10 tablets of 40 mg each.
After administering the tablets the nurse realises that the
order should have been 40 mg. The nurse is:
a. Not legally responsible for this medication error
because the doctor ordered the wrong dose.
b. Legally responsible because nurses are supposed to
have the knowledge to recognise incorrect medication
orders and the confidence to question orders that
seems unreasonable.
5. A valid medication order has seven essential parts. What
is missing from the following list?
a.
b.
c.
d.
e.
Full name of the patient

Date and time the order is written
Name of the drug to be administered
Dosage of the drug
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SECTION 6.2
ORAL
MEDICATION
ADMINISTRATION
LEARNING OUTCOMES
1.
Define the key terms used in oral medication

administration.
2.
Demonstrate the ability to read and interpret a

medication chart.
3.
Demonstrate accuracy when calculating oral medication

dosages.
4.
Verbalise the steps required to administer oral

medications safely.
5.
Demonstrate critical thinking when administering oral

medications.
6.
Accurately document oral medication administration.
7.
Monitor the effectiveness of oral medications

administered.
Oral medications include tablets, capsules and liquids that

can be swallowed. Oral medication administration is the
most common, least expensive and most convenient route
for most people. The major disadvantages of this route are
irritation of the gastric mucosa, irregular and sometimes
delayed absorption from the gastrointestinal tract.
Rather than being swallowed and absorbed via the
gastrointestinal tract some drugs are absorbed from under
the tongue or from inside the cheek. In sublingual
administration, the drug is placed under the tongue, where
it dissolves and is quickly absorbed into the blood vessels
on the underside of the tongue (Figure 63). Buccal
means pertaining to the cheek. In buccal administration, a
medication (e.g., a tablet) is held in the mouth against the
KEY TERMS
buccal, 249
meniscus, 251
oral, 249
sublingual, 249
mucous membranes of the cheek until the drug dissolves

(Figure 64). The drug may act locally on the mucous
membranes of the mouth or systemically when it is
swallowed in the saliva.
The administration of oral medications may not appear to
be an overly complex procedure. However, safe and effective
oral medication administration requires not just psychomotor
skills but also integration of pharmacological, legal and
professional knowledge, sound critical thinking and clinical
reasoning skills, and well-developed communication skills. In
the clinical scenario below and in the critical thinking questions
that are asked throughout this section the importance of these
multifaceted issues and their application to the clinical skill of
oral medication administration is illustrated.
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1. What would you do if presented with
this situation?
2. What are the legal and professional issues relevant
to this situation?
3. How may Mr Espositos clinical safety be impacted
by the RNs and the nursing students actions?
4. Should Maddie assess Mr Esposito before
administering his medications?
5. Mr Esposito speaks limited English. How might this
impact safe medication administration practices?
FIGURE 63Sublingual administration of a tablet
Calculating dosages for

oral medications
When calculating the number of tablets or amount of liquid
to administer orally there are three main formulas that are
commonly used.
1. For tablets:
Number of tablets required = Strength (or dose) required
Strength in stock
2. For liquids:
Strength (or dose) required
Volume required = Volume of stock solution
Strength in stock
FIGURE 64Buccal administration of a tablet
Examples:
1. A person is prescribed atenol 75 mg orally. The
strength in stock is 50 mg. How many tablets should be

administered?
CLINICAL SCENARIO
Mr Giuseppe Esposito, 81 years, is a person on the
medical ward of Griffith Community Hospital (LevettJones & Newby, 2013). He was admitted two days
ago with gastroenteritis and dehydration. At 0800
hours Madeline (Maddie) OBrien, a nursing student,
was administering Mr Espositos oral medications
(frusemide, digoxin and enalapril). The registered
nurse (RN) supervising Maddie was interrupted by
another nurse who needed assistance with a person in
a nearby bed. The RN said to Maddie, keep going
Ill keep an eye on what you are doing from over
here.
Number of tablets required = Strength (or dose) required

Strength in stock
Number of tablets required = 75 mg = 3 = 11 tablets
50 mg 2
2
2. A person is prescribed erythromycin 750 mg orally. The
strength in stock is 250 mg/5 mL. What volume (in mL)

should be administered?
Strength (or dose) required
Volume required = Volume of stock solution
Strength in stock
Volume required = 750 mg 5 mL
250 mg
Volume required = 15 mL
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UNIT 6
SECTION 6.2
ORAL MEDICATION ADMINISTRATION
Note: Always check that you have used the same unit of
weights in medications calculations, for example all grams,
milligrams or micrograms.
Tablets that are scored (a line marked on the tablet)
may be broken in half or cut (see Figure 65) to obtain the
correct dosage but capsules cannot be divided. For people
who have difficulty swallowing, some medications can
be crushed to a fine powder by using a pill crusher. The
powder is then mixed with a small amount of soft food
(e.g., custard, apple sauce or honey) to improve palatability
and assist with swallowing.
FIGURE 66Pouring a liquid medication

from a bottle
4
Base of
meniscus
3
2
1
FIGURE 65A cutting device can be used to

divide tablets
FIGURE 67The bottom of the curved meniscus

is used to measure the correct dose
Enteric-coated, slow release, sublingual and

buccal medications should not be crushed as
this changes the rate of absorption and can cause
an adverse drug effect. Always check the Australian
Medicines Handbook or a similar drug resource
tocheck whether it is appropriate to crush a
particular tablet.
1. Calculate how many tablets Mr Esposito will be

given based on the following medication orders:
Liquid medications must be carefully measured using a

syringe, dropper or medicine cup.To ensure accurate dosages
the medicine cup should be placed on a flat surface at eye
level and filled to the desired level (see Figure 66). The
bottom of the meniscus (crescent-shaped upper surface of
a column of liquid) should align with the measurements
on the side of the medicine cup and be used to measure the
correct dose (see Figure 67).
frusemide 80 mg orally; strength in stock 40 mg

digoxin 250 mg orally; strength in stock 125 micrograms
enalapril 20 mg orally; strength in stock 10 mg
2. Do you have any concerns about any of these orders? If
so what is the most appropriate nursing action?
STANDARDS FOR PRACTICE

The Nursing and Midwifery Board of Australia
(NMBA) Standards for Practice (2016) specify that
the registered nurse uses the appropriate processes
to identify and report potential and actual risk related
system issues and where practice may be below the
expected standards (NMBA, 2016, p. 5).
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What If
Administering oral medications
Assess: Patient allergies, ability to swallow, and drug action side effects, interactions, and adverse reactions
Perform appropriate assessments specific to the medication as needed
Determine if the above assessment data will influence administration of the medication
Know why the patient is receiving the medication
Check the medication chart
Organize supplies
Perform hand hygiene
Obtain and prepare the medications
Perform the three safety checks to reduce the risk of error
Ensure it is the correct patient, using agency protocol
Help the patient to a sitting position
WHAT IF the medication

needs to be crushed?
THEN determine if it can be crushed

because some medications (e.g.,
enteric coated) cannot be crushed.
Call the pharmacy if unsure. If the
medication can be crushed, do so
and mix with a small amount of soft
food. Label the medication cup.
Take the required assessment measures if not done previously (e.g., apical pulse)
Explain the purpose of the medication

WHAT IF the patient refuses
the medication?
Administer the medications
Document each medication given on the MAR

THEN ask for the reason. The
patient has a right to refuse.
Hold the medication and document
the reason why the patient refused.
If holding could have adverse effects,
notify the medical officer of refusal.
Evaluate the effects of the medication
WHAT IF the patient states

does not know why s/he is
taking the medication?
THEN explain the purpose of the

medication and how it will help.
Use language that the patient can
understand.
WHAT IF the patient begins
having adverse reactions to
the medication?
THEN determine if the symptoms are an

adverse reaction or an allergic reaction.
Inform the Medical officer. Hold future
administration of the medication until
discussing with Medical officer.
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UNIT 6
LIFESPAN CONSIDERATIONS
Knowledge of growth and development is essential
for nurses who administer medications to infants and
children. Nurses must also know the range of safe medication
dosages for infants and children.
Infants
Oral medications can be effectively administered using
syringes, dropper, spoon or medication cups. Never mix
medications into formula or foods that are essential, since the
infant may associate the food with an unpleasant taste and
refuse that food in the future. Place a small amount of liquid
medication along the inside of the babys cheek and wait for
the infant to swallow before giving more to prevent aspiration
or spitting out. When using a spoon, retrieve and refeed
medication that is thrust outward by the infants tongue.
Children
Whenever possible, give children a choice between the
use of a spoon, dropper or syringe.
Dilute the oral medication, if indicated, with a small
amount of water. Oral medications for children are
THE 3PS TABLE
SECTION 6.2
usually prepared in sweetened liquid form to make them

more palatable. Place the young child or toddler on
your lap or a parents lap in a sitting position. Administer
the medication slowly with a measuring spoon, plastic
syringe, or medicine cup. Follow medications with
a drink of water or juice to remove any unpleasant
aftertaste.
Older Adults
The physiological changes associated with ageing
influence medication administration and effectiveness.
Examples include altered memory, less acute vision,
decrease in renal function, less complete and slower
absorption from the gastrointestinal tract, and decreased
liver function. Many of these changes enhance the
possibility of cumulative effects and toxicity. Thus,
older people usually require smaller dosages of drugs,
especially sedatives and other central nervous system
depressants. Because older people are mature adults
capable of reasoning the nurse needs to explain the
reasons for and the effects of the persons medications.
PREPARATION AND PLANNING

ACTION
EXPLANATION AND RATIONALE
Review the medication chart and ensure that there is a

valid order for the drug/s to be administered.
A valid order includes the persons name; the date and time the order was written;
the generic name of the drug to be administered; the dosage of the drug; frequency
and time of administration; route of administration; and signature of the person
who wrote the order. Some medications, for example narcotics and antibiotics,
also require a finish date. The drug order should be legible and correctly spelt.
Note: Nurse initiated drugs and some over-the-counter drugs do not necessarily
require a drug order.
Review the Australian Medicines Handbook or a similar

drug resource if unfamiliar with the medication/s
ordered.
When administering medications nurses must be familiar with the usual dosage,
indications, contraindications, potential side effects, interactions, and adverse
effects of ordered medications.
Ensure the oral route is most appropriate for the person

and for the type of medication prescribed.
Oral medications are contraindicated when a person is vomiting, has gastric

suction, is unconscious, unable to swallow or nil by mouth.
Report and clarify any omissions, inconsistencies,

inaccuracies or incomplete prescription orders to the
supervising RN or MO.
Nurses are legally responsible for their practice. Orders that are not valid, drugs
that are contraindicated, a dose that is too high, previously unreported allergies,
and other concerns should reported in order to prevent potential adverse effects.
Perform hand hygiene.
Oral medication administration is a clean procedure. Hand hygiene is performed

as an infection control precaution.
Gather the correct equipment:

Medicine cup (and syringe if required)
Drinking cup and water
Pill cutter or crusher (if required)
Soft food for crushed medications (when appropriate)
PERFORMING THE PROCEDURE

ACTION
Introduce yourself to the person.
Use full name and designation. This is a professional expectation and helps to
promote a therapeutic relationship.
Demonstrate a person-centred approach to medication

administration.
A person-centred approach enhances patient safety by creating an opportunity

for the person to ask questions and for the nurse to provide education.
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Check whether the person has any drug allergies.
Repeat hand hygiene.
Hand hygiene should be conducted prior to touching the person.
Determine and conduct appropriate assessments and

review related pathology results (if appropriate).
Some drugs require specific assessments. For example, persons taking

antihypertensive medications should have their blood pressure checked and
those taking digitalis medications should have their apical pulse taken.
Some medications have narrow therapeutic levels. For example, digitalis toxicity
can occur if a persons digitalis level is too high.
Unlock the dispensing system and obtain the correct

oral medication.
FIRST CHECK!
Compare the label on the medication container and
packaging against the order on the medication chart to
ensure that the right medication is given.
Use only medications that have clear, legible labels. Notify the RN or pharmacist
if a discrepancy is identified.
Out of date medications will reduce the therapeutic benefit of medications.
Calculate the correct dosage of the medication if required.
Students must ensure that their calculations are checked by their supervising RN.
Check the first five rights of medication administration.
Prevent errors by confirming right drug, right dose, right time, right route and
right person.
Confirm the persons identification by asking them to state their name and date
of birth and checking they are consistent with the persons chart. Confirm that the
medical record number on the medication chart accords with the ID band.
In residential aged care settings photos are often used to confirm a residents ID
rather than ID bands.
Dispense the medication into a medicine cup or

appropriate container using a non-touch technique.
Using a non-touch technique is an infection control measure. Place packaged

unit-dose capsules or tablets directly into the medicine cup. Do not remove the
medication from the package until at the bedside.
If using a stock container, pour the required number of tablets or capsules into
the bottle cap, and then transfer the medication to the disposable cup without
touching the tablets.
When dispensing liquid medications thoroughly mix the medication before
pouring. When giving small amounts of liquids (e.g., less than 5 mL) measure the
medication using a sterile syringe.
SECOND CHECK!
Look at the medication label and compare with the
medication chart.
THIRD CHECK!
Recheck the five rights of drug administration.
Recheck the label on the container against the medication chart.
Assist the person to take the medication.
Help the person into comfortable position to swallow the medication and give
them sufficient water or to swallow the medication. If the person is unable to hold
the pill cup, use the pill cup to introduce the medication into the persons mouth,
giving one tablet or capsule at a time.
Observe the person taking the medication do not leave on a bedside locker.
Sign the medication chart. Supervising RN to countersign.
Most health care facilities and universities require RNs to countersign any
medication administered by students.
Conclude encounter and inform the person of follow up.
This is a professional expectation and helps to maintain a therapeutic relationship.
PRIORITIES POST PROCEDURE

ACTION
Dispose of used equipment appropriately.

Return to the person to monitor effectiveness of the
medication administered.
Depending on the medication administered nurses monitor effectiveness in

different ways. For example, if an analgesic is administered the nurse will return
within 30 minutes to reassess the persons pain. If an antibiotic is administered the
nurse may check the person for side effects such as nausea and vomiting.

1. Mr Esposito informs Maddie that he has been
taking St Johns Wort (Hypericum perforatum).
In relation to his prescribed medications should Maddie
be concerned about the St Johns Wort?
2. At handover the one of the registered nurses asked if

Mr Espositos dig level had been checked. What does
this mean?
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SECTION 6.3
TOPICAL
MEDICATION
ADMINISTRATION
LEARNING OUTCOMES
1.
Define the key terms used in topical medication

administration.
2.
Verbalise the steps required to administer the following

topical medications safely:
Dermatologic
Ophthalmic
Otic
Nasal
Metered-dose inhalers
Vaginal
Rectal
3.
Demonstrate safe and effective topical medication

administration.
4.
Demonstrate critical thinking when administering topical

medications.
5.
Accurately document topical medication administration.
6.
Monitor the effectiveness of topical medications

administered.
A topical medication is applied locally to the skin or to

the mucous membranes of the eye, ear, nose, lungs, vagina
and rectum. Many drugs are applied topically to produce
a local effect (e.g., an antibiotic cream for a skin infection
or a corticosteroid nasal spray to reduce inflammation
of nasal mucosa from allergies). Some medications
are applied topically for a systemic effect such as slow
absorption of the medication into the general circulation.
KEY TERMS
aerosolisation, 266
atomisation, 266
dermatologic
preparations, 256
metered-dose inhaler
(MDI), 266
nebulisers, 266
ophthalmic, 259
otic, 261
suppositories, 255
transdermal patch, 256
Examples can include the nitroglycerin patch to treat

coronary artery disease or a medication in a suppository
form to treat nausea. Topical skin or dermatological
preparations include ointments, pastes, creams, lotions,
powders, sprays and patches. A suppository is a solid
medication in a roughly conical or cylindrical shape,
which is designed to be inserted into the rectum or vagina
where it dissolves.
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DERMATOLOGIC MEDICATIONS
Dermatologic preparations may be applied to the skin for
a variety of reasons, for example to:
decrease itching (pruritus)

lubricate and soften the skin
cause local vasoconstriction or vasodilation
increase or decrease secretions from the skin
provide a protective coating to the skin
apply an antibiotic or antiseptic to treat or prevent
infection
reduce local inflammation
an entry for medications that will be absorbed into
the systemic circulation
Before applying a dermatologic preparation, thoroughly

clean the area with soap and water and dry it with a patting
motion. Skin encrustations (i.e., crusts or scabs) harbour
microorganisms, and these as well as previously applied
applications can prevent the medication from coming in
contact with the area to be treated. Nurses should wear
gloves when administering skin applications and always use
surgical asepsis when an open wound is present.
Transdermal Medications
A particular type of dermatologic medication delivery
system is the transdermal patch. This system administers
sustained-action medications (e.g., pain relievers,
nitroglycerin, oestrogen and nicotine) via multilayered
films containing the drug and an adhesive layer. The rate

of delivery of the drug is controlled and varies with each
product (e.g., from 12 hours to 1 week). Generally, the
patch is applied to a hairless, clean area of skin that is not
subject to excessive movement, friction (e.g., bra strap or
waistline areas) or wrinkling (i.e., the lower abdomen).
It may be applied on the upper arm, side, lower back or
buttocks (Figure 68). Remove lotion, sunscreen, powder,
or any other product that may impair absorption of the
medication in the patch. Use mild, nonirritating soap and
water to cleanse, if necessary. Patches should not be applied
to areas with cuts, burns or abrasions, or on distal parts of
extremities (e.g., the forearms). Women who use a patch
containing oestrogen or nicotine should not apply the
patch to the breasts, per the manufacturers instructions.
If hair is likely to interfere with patch adhesion or
removal, clipping (not shaving) may be necessary before
application.
CLINICAL ALERT
The nurse should wear gloves when applying a
transdermal patch to avoid getting any of the
medication on his or her skin, which can result in the
nurse receiving the effect of the medication.
Reddening of the skin with or without mild local itching

or burning, as well as allergic contact dermatitis, may
occasionally occur with transdermal patches. Upon removal
BOX 63 General Guidelines for the Administration of Dermatologic Medications

POWDER
Make sure the skin surface is dry. Spread apart any skin folds, and sprinkle the site until the area is covered with a fine thin layer. Cover the
site with a dressing if ordered.
SUSPENSION-BASED LOTION
Shake the container before use to distribute suspended particles. Put a little lotion on a small gauze dressing or pad, and apply the lotion to
the skin by stroking it evenly in the direction of the hair growth.
CREAMS, OINTMENTS, PASTES AND OIL-BASED LOTIONS
Warm and soften the preparation in gloved hands to make it easier to apply and to prevent chilling (if a large area is to be treated). Smear
it evenly over the skin using long strokes that follow the direction of the hair growth. Explain that the skin may feel somewhat greasy after
application. Apply a sterile dressing if ordered by the primary care provider.
AEROSOL SPRAY
Shake the container well to mix the contents. Hold the spray container at the recommended distance from the area (usually about 15 to 30
cm [6 to 12 in.] but check the label). Cover the persons face with a towel if the upper chest or neck is to be sprayed. Spray the medication
over the specified area.
TRANSDERMAL PATCHES
Select a clean, dry area that is free of hair and matches the manufacturers recommendations. Remove the patch from its protective covering,
holding it without touching the adhesive edges, and apply it by pressing firmly with the palm of the hand for about 10 seconds. Advise the person to
avoid using a heating pad over the area to prevent an increase in circulation and the rate of absorption. Remove the patch at the appropriate time,
folding it so that the medicated sticky sides are together. Some patches contain nonvisible metal in their backing. This may cause burning in the
area of the patch. Inform individuals to tell the MRI personnel that they are wearing a transdermal patch (U.S. Food and Drug Administration, 2009).
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UNIT 6
SECTION 6.3
TOPICAL MEDICATION ADMINISTRATION
When transdermal patches are removed, care needs to be

taken as to how and where they are discarded. In the home
environment, if they are simply discarded into a rubbish
bin, pets or children can be exposed to them, causing effects
from any drug remaining on the patch. When removed, they
should be folded with the medication side to the inside, put
into a closed container, and kept out of reach of children
and pets.
Transdermal ointment is another form of transdermal
medication. A common example is nitroglycerin ointment,
which is used to prevent chest pain. The nurse squeezes out
the ordered dose onto a paper dose-measuring applicator
(Figure 69). This paper applicator is placed with the
ointment side down onto a dry, hairless area of skin, similar
to the transdermal patch. Using the paper applicator, lightly
spread the ointment (do not rub) and tape the paper
applicator into place.
FIGURE 68Transdermal patch administration:

A, protective coating removed from patch;
B, patch immediately applied to clean, dry, hairless
skin and labelled with date, time, and initials
Source: From M. Adams, N. Holland & P. Bostwick (2008). Pharmacology for
Nurses: A Pathological Approach (2nd ed.), p. 35. Upper Saddle River, NJ:
Pearson Education, Inc.
of the patch, any slight reddening of the skin usually

disappears within a few hours. All applications should be
changed regularly to prevent local irritation, and each
successive application should be placed on a different site.
All people need to be assessed for allergies to the drug and
to materials in the patch before the patch is applied.
THE 3PS TABLE
FIGURE 69Using premeasured paper to

measure medication dosage
DERMATOLOGIC MEDICATION ADMINISTRATION

ACTION
Review the medication chart and ensure that there is a valid order for
the drug/s to be administered.
Report and clarify any omissions, inconsistencies, inaccuracies or
incomplete prescription orders to the supervising RN or MO.
Nurses are legally responsible for their practice. Orders that

are not valid, drugs that are contraindicated, a dose that is too
high, previously unreported allergies, and other concerns should
reported in order to prevent potential adverse effects.
Review the Australian Medicines Handbook or a similar drug resource if

unfamiliar with the medication/s ordered.
When administering medications nurses must be familiar with the

usual dosage, indications, contraindications, potential side effects,
interactions, and adverse effects of ordered medications.
Dermatological medication administration is a clean procedure.

Hand hygiene is performed as an infection control precaution.

Clean gloves (or sterile for nonintact skin)
Solution to wash area if indicated
Gauze pads for cleaning
Medication (e.g., lotion, cream, ointment, patch)
Application tube (if required)
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ACTION
Use full name and designation. This is a professional expectation and

helps to promote a therapeutic relationship.
Demonstrate a person-centred approach to medication administration

and obtain the persons verbal consent
A person-centred approach enhances patient safety by creating an

opportunity for the person to ask questions and for the nurse to
provide education.
Repeat hand hygiene and dons gloves.
Determine and conduct appropriate patient assessments:

Inspect skin or mucous membranes for lesions, rashes, erythema,
and breakdown. Note size, colour, distribution and configuration
of lesions.
This is a clinical expectation.
Determine the presence of symptoms of skin irritation (e.g.,

pruritus, burning sensation, pain).
Note the presence of excessive body hair that may require
clipping before the application of a topical medication.
If a transdermal patch is to be applied, ask the person if they are
already wearing a patch, and if so, where it is located.
Close curtain or door. Assist the person to a comfortable position,
either sitting or lying. Expose the area to be treated and ensure privacy.
To ensure privacy, comfort and dignity.
Unlock the dispensing system and obtain the correct medication.

FIRST CHECK!
Compare the label on the medication container and packaging
against the order on the medication chart to ensure that the right
medication is given.
Use only medications that have clear, legible labels. Notify the RN or
pharmacist if a discrepancy is identified.
If necessary, calculate the correct dosage of the medication if

required.
Students must ensure that their calculations are checked by their

supervising RN.
SECOND CHECK!
Check the five rights of medication administration.
Prevent errors by confirming right drug, right dose, right time, right
route and right person.
Confirm the persons identification by asking them to state their name
and date of birth and checking they are consistent with the persons
chart. Confirm that the medical record number on the medication
chart accords with the ID band.
This is a safety precaution.
THIRD CHECK!
Apply the medication and dressing as ordered.
Place a small amount of cream or ointment on the gloved hand,
and spread it evenly on the skin.
or
Apply sterile gloves if indicated (i.e., nonintact skin). Pour some
lotion on the gauze, and pat the skin area with it.
Apply a sterile dressing if necessary.
or
Apply a prepackaged transdermal patch.
Write the date and time on the label before application.
or
Squeeze out transdermal ointment onto premeasured medication
administration paper.
Place the applicator paper with ointment side down onto the skin.
Lightly spread the ointment.
Tape the paper applicator into place.
Knowing the date and time ensures safety and communication when
there are multiple caregivers. Writing on the patch could puncture it.
Remove gloves and repeat hand hygiene.
This is an infection control precaution.
Most health care facilities and universities require RNs to countersign

any medication administered by students.
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UNIT 6
SECTION 6.3

Record the type of preparation used, the site to which it was applied,
the time, and the response of the person, including data about the
appearance of the site, discomfort, itching, etc.
For transdermal patches, document both removal and application of
the patch including location.
Conclude encounter, reposition the person comfortably and inform
them of follow up.
This is a professional expectation and helps to maintain a therapeutic

relationship.

ACTION

Return to the person to monitor effectiveness of the medication
administered.
Return at a time by which the preparation should have absorbed to assess

the reaction (e.g., relief of itching, burning, swelling or discomfort).
OPHTHALMIC MEDICATIONS
Ophthalmic medications may be administered by
slowly pouring or dropping liquids or ointments
onto the surface of the eye. Eye drops are packaged in
THE 3PS TABLE
monodrip plastic containers and ointments are usually

supplied in small tubes. All containers must state that the
medication is for ophthalmic use. Sterile preparations and
a sterile technique are used to administer ophthalmic
medications.
ADMINISTERING OPHTHALMIC MEDICATIONS

ACTION



interactions and adverse effects of ordered medications.
Ophthalmic medication administration is a sterile procedure. Hand

hygiene is performed as an infection control precaution.

Clean gloves
Sterile absorbent sponges soaked in sterile normal saline
Medication
Sterile eye dressing (pad) as needed and paper tape to secure it

ACTION
Use full name and designation. This is a professional expectation

and helps to promote a therapeutic relationship.

usually lying.
To ensure privacy, comfort and dignity.

and obtain the persons verbal consent.
A person-centred approach enhances patient safety by creating

an opportunity for the person to ask questions and for the nurse
to provide education.
Determine and conduct appropriate assessments of the person:

Appearance of the eye and surrounding structures for lesions,
exudate, erythema, or swelling.
The location and nature of any discharge, lacrimation and swelling of
the eyelids or of the lacrimal gland.
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Complaints (e.g., itching, burning pain, blurred vision, and photophobia).
Behaviour (e.g., squinting, blinking excessively, frowning, or rubbing
the eyes).
FIRST CHECK!
Use only medications that have clear, legible labels. Notify the RN
or pharmacist if a discrepancy is identified.
Out of date medications will reduce the therapeutic benefit of

medications.
SECOND CHECK!
Confirm which eye is to be treated.
Prevent errors by confirming right drug, right dose, right time,

right route, right person and right eye.
Confirm the persons identification by asking them to state their
name and date of birth and checking they are consistent with the
persons chart. Confirm that the medical record number on the
medication chart accords with the ID band.
Repeat hand hygiene and don gloves.
Clean the eyelid and the eyelashes using sterile cotton balls moistened
with sterile irrigating solution or sterile normal saline.
Wipe from the inner canthus to the outer canthus.
If not removed, material on the eyelid and lashes can be washed

into the eye.
Cleaning towards the outer canthus prevents contamination of the
other eye and the lacrimal duct.
THIRD CHECK!
Apply the medication as ordered.
Draw the correct number of drops into the shaft of the dropper if a
dropper is used.
Instruct the person to look up to the ceiling.
Give the person a dry sterile absorbent sponge.
Expose the lower conjunctival sac by placing the thumb or fingers
of your nondominant hand on the persons cheekbone just below
the eye and gently drawing down the skin on the cheek. If the
tissues are oedematous, handle the tissues carefully to avoid
damaging them.
Holding the medication in the dominant hand, place the hand on the
patients forehead to stabilise the hand.
The person is less likely to blink if looking up. While the person
looks up, the cornea is partially protected by the upper eyelid.
A sponge is needed to press on the nasolacrimal duct after a
liquid instillation to prevent systemic absorption or to wipe excess
ointment from the eyelashes after an ointment is instilled.
Placing the fingers on the cheekbone minimises the possibility of
touching the cornea, avoids putting any pressure on the eyeball
and prevents the person from blinking or squinting.
The person is less likely to blink if a side approach is used. When
instilled into the conjunctival sac, drops will not harm the cornea as
they might if dropped directly on it. The dropper must not touch
the sac or the cornea.
Instilling eye drops

Approach the eye from the side and instil the correct number of drops
onto the outer third of the lower conjunctival sac. Hold the dropper
1 to 2 cm (0.4 to 0.8 in.) above the sac.
Instilling an eye drop into the lower conjunctival sac.

Instilling eye ointment
Discard the first bead of ointment. Holding the tube above the lower
conjunctival sac, squeeze 2 cm (0.8 in.) of ointment from the tube into the
lower conjunctival sac from the inner canthus outward.
The first bead of ointment from a tube is considered to be

contaminated.
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UNIT 6
SECTION 6.3
Instilling an eye ointment into the lower conjunctival sac.

Instruct the person to close the eyelids but not to squeeze them shut.
Closing the eye spreads the medication over the eyeball.

Squeezing can injure the eye and push out the medication.
For liquid medications, press firmly or have the person press firmly on
the nasolacrimal duct for at least 30 seconds.
Pressing on the nasolacrimal duct prevents the medication from

running out of the eye and down the duct, preventing systemic
absorption.
Pressing on the nasolacrimal duct.

Apply an eye pad if needed, and secure it with paper eye tape.
Assess and document the procedure, character and amount of

discharge, appearance of the eye, discomfort, and the persons
response immediately after the instillation.
Most health care facilities and universities require RNs to

countersign any medication administered by students.
Conclude encounter, ensure the persons comfort and inform them of

follow up
This is a professional expectation and helps to maintain a

therapeutic relationship.

ACTION

Return to the person to monitor effectiveness of or reaction to the
OTIC MEDICATIONS
Instillations into the external auditory canal are referred to
as otic instillations.
The position of the external auditory canal varies
with age. In the adult, the external auditory canal is
an S-shaped structure about 2.5 cm long. In the child under
3 years of age, it is directed upward. For this reason, to
administer otic medications to infants and young children
gently pull the pinna down and back. For a child older
than 3 years of age, pull the pinna upward and backward.
Straightening the ear canal of a child younger than 3 years by pulling

the pinna down and back.
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THE 3PS TABLE
ADMINISTERING OTIC MEDICATIONS

ACTION
Review the medication chart and ensure that there is a valid order
for the drug/s to be administered.
Nurses are legally responsible for their practice. Orders that are not
valid, drugs that are contraindicated, a dose that is too high, previously
unreported allergies, and other concerns should reported in order to
prevent potential adverse effects.
Review the Australian Medicines Handbook or a similar drug

resource if unfamiliar with the medication/s ordered.

Otic medication administration is a clean process. However, if the

tympanic membrane is perforated sterile technique is needed. Hand
hygiene is performed as an infection control precaution.

Clean gloves
Cotton-tipped applicator
Correct medication bottle with a dropper
Flexible rubber tip (optional) for the end of the dropper, which
prevents injury from sudden motion, for example, by a person
who is disoriented
Cotton wool
Normal saline

ACTION


usually lying with the ear to be treated uppermost.
To ensure the persons privacy, comfort and dignity.

A person-centred approach enhances patient safety by creating

an opportunity for the person to ask questions and for the nurse to
provide education.

Appearance of the pinna of the ear and meatus for signs of
redness and abrasions.
Type and amount of any discharge.
Unlock the dispensing system and obtain the correct

medication.
FIRST CHECK!

medications.
SECOND CHECK!
route, right person and right ear. Confirm the persons identification
by asking them to state their name and date of birth and checking
they are consistent with the persons chart. Confirm that the medical
record number on the medication chart accords with the ID band.
Clean the pinna of the ear and the meatus of the ear canal with
cotton-tipped applicators and cotton balls moistened with sterile
normal saline. Ensure that the applicator does not go into the
ear canal.
This removes any discharge present before the instillation so that it

wont be washed into the ear canal.
This avoids damage to the tympanic membrane or wax becoming
impacted within the canal.
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UNIT 6
SECTION 6.3

THIRD CHECK!
Administer the as ordered.
Warm the medication container in your hand, or place it in warm
water for a short time.
Straighten the auditory canal. Pull the pinna upward and
backward for persons over 3 years of age.
This promotes the persons comfort and pre-vents nerve stimulation

and pain.
The auditory canal is straightened so that the solution can flow the
entire length of the canal.
Normal
position
Straightening the adult ear canal by pulling the pinna upward

and backward.
Instil the correct number of drops along the side of the ear canal.
Pressing on the tragus assists the flow of medication into the ear canal.
Instilling ear drops.

Press gently but firmly a few times on the tragus of the ear
(the cartilaginous projection in front of the exterior meatus
of the ear).
Ask the person to remain in the side-lying position for about
5 minutes.
Insert a small piece of cotton wool loosely at the meatus of the
auditory canal for 15 to 20 minutes.
Do not press it into the canal.
This prevents the drops from escaping and allows the medication to
reach all sides of the canal cavity.
The cotton helps retain the medication when the person is up.
If pressed tightly into the canal, the cotton would interfere with the
action of the drug and the outward movement of normal secretions.
Assess and document the procedure, character and amount

of discharge, appearance of the canal, discomfort the persons
response immediately after the instillation.

Conclude encounter, ensure the persons comfort and inform them

of follow up.

relationship.

ACTION

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NASAL MEDICATIONS
Nasal instillations (nose drops and sprays) are instilled
for their astringent effect (to shrink swollen mucous
membranes), to loosen secretions and facilitate drainage,
or to treat infections of the nasal cavity or sinuses. Nasal
decongestants are the most common nasal instillations.
THE 3PS TABLE
Many of these products are available without a prescription

and people need to be taught to use these medications with
caution as chronic use of nasal decongestants may lead to
a rebound effect and increased nasal congestion. It is not
unusual to swallow a small amount of the nasal medication,
however, if excess decongestant solution is swallowed
systemic effects may develop, especially in children.
ADMINISTERING NASAL MEDICATIONS

ACTION


Nasal medication administration is a clean process. Hand hygiene is

performed as an infection control precaution.

Tissues
Clean gloves

ACTION


and obtain the persons verbal consent
A person-centred approach enhances patient safety by creating an

opportunity for the person to ask questions and for the nurse to provide
education.
Close curtain or door. Assist the person to a comfortable position:

To treat the opening of the eustachian tube, have the person
assume a back-lying position.
To treat the ethmoid and sphenoid sinuses, ask the person to lie in a
backwards position with the head over the edge of the bed or a pillow
under the shoulders so that the head is tipped backward.

Correct positioning allows the drops to flow into the correct sinus.
Nasopharynx
Ethmoid
sinuses
Sphenoid
sinus
Position of the head to instil drops into the ethmoid and

sphenoid sinuses.
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UNIT 6
SECTION 6.3

To treat the maxillary and frontal sinuses, have the person assume
the same back-lying position, with the head turned towards the
side to be treated.
Maxillary
sinuses
Frontal
sinuses
Position of the head to instil drops into the maxillary and frontal
sinuses.
Hand hygiene should be conducted prior to touching the patient.

If nasal secretions are excessive, ask the person to blow the nose
to clear the nasal passages.
Inspect the discharge on the tissues for color, odour and
thickness.
Assess appearance of nasal cavities.
Assess congestion of the mucous membranes and any obstruction
to breathing. Ask the person to hold one nostril closed and blow
out gently through the other nostril. Listen for the sound of any
obstruction to airflow. Repeat for the other nostril.
Assess signs of distress when nares are occluded. Block each
naris and observe for signs of greater distress when the naris is
obstructed.
Facial discomfort with or without palpation. An infected or
congested sinus can cause an aching, full feeling over the area of
the sinus and facial tenderness on palpation.
Assess any crusting, redness, bleeding, or discharge of the
mucous membranes of the nostrils.

FIRST CHECK!

medications.
SECOND CHECK!
route, and right person. Confirm the persons identification by asking
them to state their name and date of birth and checking they are
consistent with the persons chart. Confirm that the medical record
number on the medication chart accords with the ID band.
This is an infection control precaution
THIRD CHECK!
Draw up the required amount of solution into the dropper.
If the solution is directed towards the base of the nasal cavity, it will run
down the eustachian tube.
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Hold the tip of the dropper just above the nostril, and direct the
solution laterally towards the midline of the superior concha of
the ethmoid bone as the person breathes through the mouth. Do
not touch the mucous membrane of the nostril.
Repeat for the other nostril if indicated.
Ask the person to remain in the position for 5 minutes
Touching the mucous membrane with the dropper could damage the
membrane and cause the person to sneeze.
The person remains in the same position to help the solution come in
contact with all of the nasal surface or flow into the desired area.
Assess and document the procedure, the persons condition,

and discomfort experienced by the person and their response
immediately after the instillation.

Conclude encounter, ensure the person is comfortable and inform

them of follow up.

relationship.

ACTION

medication administered
INHALED MEDICATIONS
Nebulisers deliver most medications administered through
the inhaled route. A nebuliser is used to deliver a fine spray
(fog or mist) of medication or moisture to a person.
There are two kinds of nebulisation: atomisation and
aerosolisation. In atomisation, a device called an atomizer
produces droplets for inhalation. In aerosolisation,
the droplets are suspended in a gas, such as oxygen. The
smaller the droplets, the further they can be inhaled into the
respiratory tract. When a medication is intended for the nasal
mucosa, it is inhaled through the nose; when it is intended
for the trachea, bronchi and/or lungs, it is inhaled through
the mouth. A large-volume nebuliser can provide a heated or cool
mist and is generally used for long-term therapy such as that
following a tracheostomy.
A metered-dose inhaler (MDI) (Figure 610) is a
pressurised container of medication that can be used by
a person to release medication through a mouthpiece. The
force with which the air moves through the nebuliser causes
the large particles of medicated solution to break up into
finer particles, forming a mist or fine spray. MDIs can deliver
accurate doses, provide for target action at the needed sites,
and sustain fewer systemic effects than medication delivered
by other routes.
To ensure correct delivery of the prescribed medication
by MDIs, nurses need to instruct the person t how to
use the inhaler correctly. The person needs to compress
the medication canister by hand to release medication

through a mouthpiece. An extender or spacer should
be attached to the mouthpiece to facilitate medication
absorption for better results (see Figure 611). Spacers
are holding chambers into which the medication is fired
and from which the person inhales, so that the dose is
not lost by exhalation. There are also dry powder inhalers
(DPIs) that either have the powder in a reservoir at the
bottom (e.g. Symbicort) or that use a disk with little
blisters containing the powder.
FIGURE 610A Metered-dose inhaler
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UNIT 6
SECTION 6.3
Trent asks you to educate him about the use of his

discharge medications (ventolin inhaler and symbicort
dry powder inhaler).

1. What advice would you give Trent in
regards to the following medications?
FIGURE 611Extender or spacer
CLINICAL ALERT
A persons ability to use an MDI correctly

determines the effectiveness of the medication
delivery. It is important for the nurse to assess whether
the person is able to use the MDI correctly.
CLINICAL SCENARIO
Trent Fulton, 35 years, is being discharged from hospital
today following a two week admission for pneumonia
and acute exacerbation of asthma. The RN caring for
THE 3PS TABLE
2. How would you know if Trent understood the

education provided by you?
Children
Spacers are recommended for children (as well as
adults) as they hold a medication in suspension and
allow the child to take several deep breaths in order to
inhale all the medication.
Learning how to use a spacer can be a frightening
experience for a young child. Use a doll or stuffed animal
to demonstrate its use, and allow the child to play with
the equipment before putting it in place. Having the
child sit in a parents lap during the procedure can help
the child relax and be more cooperative.
ADMINISTERING METERED-DOSE
INHALER MEDICATIONS

ACTION


Metered dose inhaler medication administration is a clean process.

Hand hygiene is performed as an infection control precaution.

Metered-dose inhaler (MDI) with medication canister and spacer
if indicated

ACTION


administration and obtain the persons verbal consent.
A person-centred approach enhances the safety of the person by

creating an opportunity for the person to ask questions and for the
nurse to provide education.
Close curtain or door. Assist the person to a sitting position.

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Lung sounds.
Respiratory rate and depth.
Cough (productive or nonproductive); amount, colour and character
of expectorations.
Presence of dyspnoea.
Vital signs.

FIRST CHECK!

medications.
SECOND CHECK!
THIRD CHECK!
Educate the person about the purpose of the medication and how
the inhaler is to be used (as follows):
Ensure that the canister is rmly and fully inserted into the inhaler.
Remove the cap, holding inhaler upright, shake vigorously for 3
to 5 seconds.
Exhale comfortably (as in a normal full breath) away from the
inhaler.
Hold the inhaler with the canister on top and the mouthpiece at
the bottom.
Slightly tilt chin to ensure open airway.
Place the MDI inhaler mouthpiece in the mouth between the
teeth and close lips to create a seal.
If using a spacer with the metered-dose inhaler:
Shake the MDI for 3 to 5 seconds and insert the mouthpiece into
the spacer.
Place the spacer in the mouth between the teeth and close lips
to create a seal.
Administering the medication
Instruct person to:
Whilst breathing in press down once on the MDI canister and
inhale slowly and deeply.
Remove the inhaler from mouth, close mouth and hold your
breath for a few seconds or as long as possible.
Exhale slowly away from the mouth piece.
Replace cap.
Repeat the inhalation if ordered. Wait 1 to 2 minutes between
inhalations of bronchodilator medications.
If two inhalers are to be used, the bronchodilator medication (which
opens the airways) should be given prior to other medications.
Following use of the inhaler, rinse the mouth with water and spit
it out.
Clean the MDI mouthpiece and spacer if appropriate as indicated
using mild soap and water. Then let it air-dry before reusing.
Store the canister at room temperature.
Unless the persons mouth is closed around the MDI the prescribed
dosage may not be inhaled and the person may not receive the
required therapeutic dose.
This allows the aerosol to reach deeper airways.

Controlled exhalation keeps the small airways open during exhalation.
The first inhalation has a chance to work and the subsequent dose
reaches deeper into the lungs.
Rinsing the mouth removes any remaining medication and prevents

side effects.
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UNIT 6
SECTION 6.3

Assess and document the procedure and the persons condition.

Conclude encounter, ensure the person is comfortable and inform

them of follow up.

relationship.

ACTION

VAGINAL MEDICATIONS
Vaginal medications are inserted as creams, foams or
suppositories to treat infection or to relieve vaginal discomfort
(e.g., itching or pain). Creams and foams are applied by using
THE 3PS TABLE
Note any adverse reactions such as restlessness, palpitations,

nervousness or rash.
a tubular applicator with a plunger. Suppositories are inserted

with the index finger of a gloved hand. Suppositories are
designed to melt at body temperature, so they are generally
stored in the refrigerator to keep them firm.
ADMINISTERING VAGINAL MEDICATIONS

ACTION
Review the medication chart and ensure that there is a valid

order for the drug/s to be administered.
Report and clarify any omissions, inconsistencies, inaccuracies
or incomplete prescription orders to the supervising RN or MO.
Nurses are legally responsible for their practice. Orders that are not valid,
drugs that are contraindicated, a dose that is too high, previously unreported
allergies, and other concerns should reported in order to prevent potential
adverse effects.

When administering medications nurses must be familiar with the usual

dosage, indications, contraindications, potential side effects, interactions,
and adverse effects of ordered medications.
Vaginal medication administration is a clean process. Hand hygiene is


Drape
Correct vaginal suppository or cream
Applicator for vaginal cream
Clean gloves
Lubricant for a suppository
Disposable towel
Clean perineal pad

ACTION
Use full name and designation. This is a professional expectation and helps
to promote a therapeutic relationship.
Close curtain or door.
To ensure privacy for the person.

administration and obtain the persons verbal consent
A person-centred approach enhances the persons safety by creating an

education.
Explain to the woman that a vaginal instillation is normally a painless
procedure, and may bring relief from itching and burning if an infection is
present. Many woman feel embarrassed about this procedure, and some
may prefer to perform the procedure themselves if instruction is provided.
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FIRST CHECK!
against the order on the medication chart to ensure that the
right medication is given.
SECOND CHECK!
Prevent errors by confirming right drug, right dose, right time, right route,
and right person. Confirm the patients identification by asking them to
state their name and date of birth and checking they are consistent with the
persons chart. Confirm that the medical record number on the medication
chart accords with the ID band.

Gloves prevent contamination of the nurses hands from vaginal and perineal
microorganisms.
THIRD CHECK!
Prepare medication
Unwrap the suppository, and put it on the opened wrapper.
or
Fill the applicator with the prescribed cream, or foam
according to the manufacturers instructions.
Ask the woman to pass urine.
If the bladder is empty, the person will have less discomfort during the
treatment, and the possibility of injuring the vaginal lining is decreased.
Assist the woman to a back-lying position with the knees

flexed and the hips rotated laterally.
Drape the woman appropriately so that only the perineal area
is exposed.
To ensure comfort and dignity.
Assess the vaginal orifice for inflammation; amount, character

and odour of vaginal discharge; and for complaints of vaginal
discomfort (e.g., burning or itching).
Clean the perineal area if the woman has not recently showered.
This decreases the chance of moving microorganisms into the vagina.

Suppositories
Lubricate the rounded (smooth) end of the suppository,
which is inserted first.
Lubricate gloved index nger.
Expose the vaginal orice by separating the labia with the
nondominant hand.
Insert the suppository about 8 to 10 cm along the posterior
wall of the vagina, or as far as it will go.
Lubrication facilitates insertion.
The posterior wall of the vagina is about 2.5 cm longer than the anterior
wall because the cervix protrudes into the uppermost portion of the anterior
wall.
Instilling a vaginal suppository.
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UNIT 6
SECTION 6.3

Ask the woman to remain lying in the supine position for
5 to 10 minutes following insertion. The hips may also be
elevated on a pillow.
This position allows the medication to flow into the posterior fornix after it
has melted.
Vaginal creams and foams

Gently insert the applicator about 5 cm.
Using an applicator to instil a vaginal cream.

Slowly push the plunger until the applicator is empty.
Remove the applicator.
Discard the applicator if disposable or clean it according to
the manufacturers directions.
Ask the person to remain lying in the supine position for 5 to
10 minutes following the insertion.
Dry the perineum and if there is excessive drainage apply a
clean perineal pad.
Assess and document the procedure and the persons condition.

Most health care facilities and universities require RNs to countersign any
medication administered by students.
Conclude encounter, ensure the person's comfort and inform

them of follow up.

relationship.

ACTION

Return to the person to monitor effectiveness of or reaction to
the medication administered.
Note any adverse reactions.
RECTAL MEDICATIONS
Insertion of medications into the rectum in the form of

suppositories is convenient and safe method of giving
certain medications. Advantages include the following:
THE 3PS TABLE
It avoids irritation of the upper gastrointestinal tract.

It is advantageous when the medication has an
objectionable taste or odour.
The drug is released at a slow but steady rate.
ADMINISTERING RECTAL MEDICATIONS

ACTION
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Nasal medication administration is a clean process. Hand hygiene is


Correct suppository
Clean glove
Lubricant

ACTION


A person-centred approach enhances the persons safety by creating an

education.
Close curtain or door. Fold back the top bedclothes to expose

only the buttocks.
Assist the person into the left lateral or left Sims position.
The left lateral or Sims position is preferred because it positions

the sigmoid colon downward, which allows gravity to help retain the
suppository.
Determine and conduct appropriate assessments of the person

noting any contraindications to the rectal route such as recent
rectal surgery or rectal pathology, such as bleeding.

FIRST CHECK!

medications.
SECOND CHECK!
THIRD CHECK!
Unwrap the suppository.
Repeat hand hygiene and don a glove on the hand used to insert
the suppository.
Lubricate the smooth, rounded end of the suppository according
to the manufacturers instructions.
Lubricate the gloved index nger.
Ask the person to breathe through the mouth.
Insert the suppository gently into the anus, rounded end rst
according to the manufacturers instructions and along the wall
of the rectum with the gloved index finger. For an adult, insert
the suppository 10 cm after passing the sphincter.
This is an infection control precaution. The glove prevents contamination

of the nurses hand by rectal microorganisms and faeces.
The smooth, rounded end is inserted first. Lubrication prevents anal
friction and tissue damage on insertion.
This usually relaxes the external anal sphincter.
The rounded end facilitates insertion. The suppository needs to be
placed along the wall of the rectum, rather than amid faeces, in order
to be absorbed effectively.
The patient remains in the same position to help the solution come in
contact with all of the nasal surface or flow into the desired area.
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UNIT 6
SECTION 6.3

Rectum
Suppository
Anal-rectal
ridge
This helps minimise any urge to expel the suppository.
Anal sphincter
Inserting a rectal suppository beyond the internal sphincter and

along the rectal wall.
For an infant or child, insert the suppository 5 cm or less after
passing the sphincter.
The suppository should be retained at least 30 to 40 minutes or

according to the manufacturers instructions.
Withdraw the nger and gently press the patients buttocks

together for a few minutes.
Ask the patient to remain at or in the left lateral position for at
least 5 minutes.
Remove glove by turning it inside and repeat hand hygiene.
This is an infection control precaution. Turning the glove inside out

contains the rectal microorganisms and prevents their spread.
Assess and document the procedure include the type of

suppository given/name of the drug, the time it was given, the
amount of time it was retained if it was expelled, the results or
effects, and the response of the person.

Conclude encounter, ensure the persons comfort and inform them

of follow up.

relationship.
Place the call bell within reach of the person.

ACTION

suppository.
Administering rectal medications to
infants and children
Obtain assistance to gently hold an infant or young
child to prevent accidental injury due to sudden
movement during the procedure.
For a child under 3 years, the nurse should use the
gloved fifth finger for insertion. After this age, the
index finger can usually be used.
For a child or infant, insert a suppository 5 cm or less.
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SECTION 6.4
PARENTERAL
MEDICATION
ADMINISTRATION
KEY TERMS
ampoule, 277
bevel, 276
burette (piggyback)
infusion, 290
deltoid site, 284
diluent, 277
drawing up needle, 278
gauge, 276
hub, 276
intramuscular (IM)
injections, 282
intravenous push
(bolus), 290
parenteral, 274
piggyback, 290
reconstitution, 277
rectus femoris site, 284
shaft, 276
subcutaneous injection, 278
avastus lateralis site, 283
ventrogluteal site, 282
vial, 277
Z-track technique, 285
LEARNING OUTCOMES
1.
Define the key terms used in parenteral medication

administration.
2.
Describe the types of equipment required for parenteral

a. Syringes
b. Needles
c. Ampoules
d. Vials
3.
Identify sites used for subcutaneous and intramuscular

injections
4.
Describe the various methods used to administer

medications intravenously
5.
Verbalise the steps used in:
6.
Administration of subcutaneous medications

Administration of intramuscular medications
Administration of intravenous medications via a bolus,
burette or infusion
Demonstrate appropriate documentation and reporting

of parenteral medication administration.
Parenteral means administration of a medication using a

route other than topically or via the alimentary or digestive
tract. Nurses give parenteral medications intradermally
(just beneath the dermis or skin), subcutaneously
(in subcutaneous tissue between skin and muscle),
intramuscularly (into a muscle), or intravenously (into
a vein). Because these medications are absorbed more
quickly than oral medications and are irretrievable once

injected, the nurse must prepare and administer them
carefully and accurately. Administering parenteral drugs
requires the same nursing knowledge as for oral and topical
drugs; however, because injections are invasive procedures,
aseptic technique must be used to minimise the risk of
infection.
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UNIT 6
SECTION 6.4
PARENTERAL MEDICATION ADMINISTRATION
EQUIPMENT
To administer parenteral medications, nurses use syringes and
needles to withdraw medication from ampoules and vials.
Syringes
Syringes have three parts: the tip, which connects with
the needle; the barrel, or outside part, on which the scales
are printed; and the plunger, which fits inside the barrel
(Figure 612). When handling a syringe, the nurse may
touch the outside of the barrel and the handle of the
plunger; however, the nurse must avoid letting any unsterile
object contact the tip or inside of the barrel, the shaft of
the plunger, or the shaft or tip of the syringe.
Tip
Barrel
Plunger
FIGURE 614Tips of syringes:

A, Luer-Lok syringe (note threaded tip);
B, non-Luer-Lok (note the smooth graduated tip)
FIGURE 612The three parts of a syringe
2
30
m
There are several kinds of syringes differing in size,

shape, and material (Figure 613). Syringes range in size
from 1 to 60 mL. A nurse typically uses a syringe ranging
from 1 to 3 mL in size for subcutaneous or intramuscular
injections. The choice of syringe depends on many factors,
such as medication, location of injection, and type of tissue.
A
10 20 30 40 50 60 70 80 90 100 units
15 25 35 45 55 65 75 85 95
FIGURE 613Two kinds of syringes: A, 3-mL

syringe marked in tenths (0.1) of millilitres and in
minims; B, insulin syringe marked in 100 units
The tip of a syringe varies and is classified as either

a Luer-Lock or non-Luer-Lock. A Luer-Lock syringe has a
tip that requires the needle to be twisted onto it to avoid
accidental removal of the needle (Figure 614A). A nonLuer-Lock syringe has a smooth graduated tip, and needles
are slipped onto it (Figure 614B).
Most syringes are made of plastic, are individually
packaged for sterility and are disposable. The syringe and
needle may be packaged together or separately.
Injectable medications are frequently supplied in
disposable prefilled syringes ready for use. Because most
prefilled cartridges are overfilled, excess medication must
be ejected before the injection to ensure the right dosage.
Because the needle is fused to the syringe, the nurse cannot
change the gauge or length of the needle. An insulin
syringe (Figure 615) has a scale specially designed for
insulin administration: a 100-unit calibrated scale is
intended for use with U-100 insulin. This corresponds to
the universal 100 units per 1 mL concentration of insulin.
This is the only syringe that should be used to administer
insulin.
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weight, and the type of injection. The length typically

varies from 9 to 50 mm.
3. Gauge (or diameter) of the shaft: The gauge varies from
#18 to #30.The larger the gauge number, the smaller
the diameter of the shaft. Smaller gauges produce
less tissue trauma, but larger gauges are necessary for
viscous medications, such as penicillin.
FIGURE 615An insulin syringe
Bevel
Gauge number
Needles
Needles are made of stainless steel and are disposable.
A needle has three discernible parts: the hub, which
fits onto the syringe; the shaft, which is attached to the
hub; and the bevel, which is the slanted part at the tip of
the needle (Figure 616). Needles used for injections have
three variable characteristics:
1. Slant or length of the bevel: The bevel of the needle
may be short or long. Longer bevels provide the

sharpest needles and cause less discomfort. They are
commonly used for subcutaneous and intramuscular
injections. Short bevels are used for intradermal and
intravenous injections.
2. Length of the shaft: The appropriate needle length is
chosen according to the persons muscle development,
25
Shaft
Hub
FIGURE 616 The parts of a needle

PREVENTING NEEDLESTICK INJURIES
One of the most potentially hazardous procedures that health
professionals face is using and disposing of needles and
sharps. Needlestick injuries present a major risk for infection
with hepatitis B and C virus, human immunodeficiency
virus (HIV), and many other pathogens. Strict precautions
are needed to prevent needlestick injuries (see Box 64).
All needlestick injuries must be reported and document
according to facility policy.
BOX 64 Avoiding Needlestick Injuries
Use appropriate puncture-proof disposal containers to dispose of uncapped needles and sharps (see Figure 617). Never throw sharps in
wastebaskets.
Never bend or break needles before disposal.
Never recap used needles (i.e., ones that have been inserted into people) except under specified circumstances (e.g., when transporting
a syringe to the laboratory for an arterial blood gas or blood culture).
When recapping an unused needle (i.e., one used for drawing up a medication into a syringe prior to administration) use a one-handed
scoop method. This is performed by (a) placing the needle cap and syringe with needle horizontally on a flat surface, (b) inserting the
needle into the cap, using one hand (see Figure 618), and then (c) using your other hand to pick up the cap and tighten it to the needle hub.
FIGURE 617Disposal of a used syringe and

needle in a sharps container
FIGURE 618Recapping a used needle using

the one-handed scoop method
Sian Bradfield. Pearson Australia.
Elena Dorfman. Pearson Education.
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UNIT 6
SECTION 6.4
Ampoules and Vials

Injectable medications can be prepared by withdrawing the
medication from an ampoule or vial into a sterile syringe, by
using prefilled syringes, or by using needleless injection systems.
Ampoules and vials (Figure 619) are frequently used
to package sterile parenteral medications. An ampoule is a
glass container usually designed to hold a single dose of a
drug. It is made of clear glass and has a distinctive shape with
a constricted neck. Ampoules vary in size from 1 to 10 mL
or more. Most ampoules necks have colored marks around
them, indicating where they are prescored for easy opening.
To access the medication in an ampoule, the ampoule
must be broken at its constricted neck. Traditionally, files
have been used to score the ampoule. Today plastic ampoules
openers are available that prevent injury from broken glass.
The device consists of a plastic cap that fits over the top of an
ampoule. The head of the ampoule, when broken, remains
inside the cap and is placed into a sharps container. If an
ampoule opener is not available, the nurse can clean the
ampoules neck with an alcohol swab and, using dry sterile
gauze, snap off the top of the ampoule. Once the ampoule is
broken, the fluid is aspirated into the syringe. Increasingly,
FIGURE 620Plastic vials for IV medications

Source: M.A. Van de Verrede, S. G. Wilson & M. J. Dooley (2008). Intravenous
potassium chloride prescribing and administration practices in Victoria: an
observational study. Med J Aust 189(10), 575577. Copyright 2008 The
Medical Journal of Australia reproduced with permission. Box 1, p. 576.
plastic ampoules are replacing glass one (Figure 620).

When using plastic ampoules syringes can be connected
directly without requiring a needle.
A vial is a small glass bottle with a sealed rubber cap.
Vials come in different sizes, from single to multidose vials.
They usually have a metal or plastic cap that protects the
rubber seal and must be removed to access the medication.
To access the medication in a vial, the vial must be pierced
with a needle. In addition, air must be injected into a vial
before the medication can be withdrawn. Failure to inject air
before withdrawing the medication leaves a vacuum within
the vial that makes withdrawal difficult.
Several drugs (e.g., penicillin) are dispensed as powders in
vials. A liquid called a diluent must be added to a powdered
medication before it can be injected. The technique of adding
a diluent to a powdered drug to prepare it for administration
is called reconstitution. Powdered drugs usually have
printed instructions (enclosed with each packaged vial)
that describe the amount and kind of diluent to be added.
Commonly used diluents are sterile water or sterile normal
saline. Some preparations are supplied in individual-dose
vials; others come in multidose vials. The following are two
examples of the preparation of powdered drugs:
1. Single-dose vial: Instructions for preparing a single-dose
vial state that 1.5 mL of sterile water be added to the

sterile dry powder, providing a single dose of 2 mL.
The volume of the drug powder is 0.5 mL. Therefore,
the 1.5 mL of water plus the 0.5 mL of powder results
in 2 mL of solution. In other instances, the addition of
a solution does not increase the volume. Therefore, it
is important to follow the manufacturers directions.
2. Multidose vial: A dose of 750 mg of a certain drug is
FIGURE 619A, Ampoules; B, vials
ordered. Available is a 10-gram multidose vial. The

directions for preparation read: Add 8.5 mL of sterile
water, and each milliliter will contain 1 g or 1000 mg.
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Glass and rubber particulates have been found in medications

withdrawn from ampoules and vials using a regular needle.
To prevent withdrawing glass and rubber particles drawing
up needles should be used when withdrawing medications
from ampoules and vials. After drawing the medication into
the syringe, the drawing up needle is replaced with the
regular needle for injection. Using a new needle following the
withdrawal of the medication from the vial also minimises
discomfort that can result from minor dulling of the needle
tip from passing through the vial stopper.
Administration of subcutaneous
medications
Among the many kinds of drugs administered subcutaneously
are vaccines, insulin, and heparin. Common sites for
subcutaneous injections are the outer aspect of the upper arms,
the anterior aspect of the thighs and the abdomen. These areas
are convenient and normally have good blood circulation. Only
small doses (0.5to 1 mL) of medication are usually injected via
the subcutaneous route.
The type of syringe used for subcutaneous injections
depends on the medication to be given. Generally a 1- or 2-mL
syringe is used for most subcutaneous injections. However, if
insulin is being administered, an insulin syringe is used; and if
heparin is being administered, a prefilled cartridge may be used.
Needle sizes and lengths are selected based on the persons
body mass, the intended angle of insertion, and the planned site.
Generally a #2526 gauge, 16 mm needle is used for adults of
normal weight, and the needle is inserted at a 45-degree angle;
a 9 mm needle is used at a 90-degree angle. A child may need a
12 mm needle inserted at a 45-degree angle.
One method nurses use to determine length of needle is
to pinch the tissue at the site and select a needle length that
is half the width of the skinfold. To determine the angle of
insertion, a general rule to follow relates to the amount of
tissue that can be pinched or grasped at the site. A 45-degree
angle is used when 2.5 cm of tissue can be grasped at the site;
a 90-degree angle is used when 5 cm of tissue can be grasped.
Subcutaneous injection sites need to be rotated in an orderly
fashion to minimise tissue damage, aid absorption and avoid
discomfort. This is especially important for people who must
receive repeated injections, such as people with type 1 diabetes.
Nurses have traditionally been taught to aspirate by pulling
back on the plunger after inserting the needle and before
CLINICAL SCENARIO
Mr Arthur Barrett, 74 years, was diagnosed with cancer
of the colon and scheduled for a bowel resection
(Levett-Jones, Hoffman, Dempsey & Sinclair, 2013).
As this is major abdominal surgery Mr Barrett was
prescribed enoxaparin sodium (Clexane).

1. Enoxaparin sodium is:
a. used to treat a sodium imbalance
b. used to prevent deep vein thrombosis (DVT)
b. administered via intra muscular injection (IMI)
c. used to treat pulmonary emboli (PE).
2. When preparing to administering Mr Barretts
enoxaparin sodium you note that the dose
prescribed is incorrect. You consider the
implications of the 6th right of medication
administration. This right is often referred to as:
a. the right dose
b. the right person
c. a doctors right to prescribe medications
d. a nurses right to refuse to administer a
medication.
3. For you to administer enoxaparin sodium to
Mr Barrett a valid order is required. This includes
all of the following EXCEPT:
a. the route of administration
b. the dose/strength/amount of the drug to be
administered
c. the trade name of the drug written clearly
and spelt correctly
d. the persons name and medical record number.
4. Including Mr Barrett as an active participant
in his care and talking to about his medications
enhances medication safety because:
a. there is evidence of a relationship between
person-centred care and medication safety
b. asking individuals about their medications
saves time as the nurse wont have to refer to
the Australian Medicines Handbook
c. educated individuals tend to be less demanding
of the nurses time
d. none of the above.
5. When administering enoxaparin sodium which of
the following statements are correct:
a. the injection site should be gently massaged
following injection
b. the injection site should be cleansed with soap
and water
c. the injection sites should be alternated
d. the medication should be injected no further
that 5 cm from the umbilicus.
injecting the medication to determine whether the needle had

entered a blood vessel. However, routine aspiration is no longer
recommended, particularly with insulin administration.
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UNIT 6
THE 3PS TABLE
SECTION 6.4
SUBCUTANEOUS MEDICATION ADMINISTRATION

ACTION
A valid order includes the persons name; the date and time the order
was written; the generic name of the drug to be administered; the
dosage of the drug; frequency and time of administration; route of
administration; and signature of the person who wrote the order. Some
medications also require a finish date. The drug order should be legible
and correctly spelt.


Ensure the SC route is most appropriate for the person and for the
type of medication prescribed.
This is a medication safety precaution.

SC medication administration is a sterile procedure. Hand hygiene is


Medication chart
Vial or ampoules of the correct sterile medication
Syringe, drawing up needle and administration needle
Antiseptic swabs
Clean gloves

ACTION

To ensure privacy for the person.
Demonstrate a person-centred approach to medication administration.
A person-centred approach enhances safety by creating an

provide education.

and review related pathology results (if appropriate).
Check the appearance of the subcutaneous site for lesions, erythema,

swelling, ecchymosis, inflammation and tissue damage from previous
injections. Also check previous injection sites.
Some drugs require specific assessments, for example when
administering insulin the nurses should check the persons blood glucose
level (BGL) and when administering heparin the nurse should check for
bruising.
FIRST CHECK!

medications.

supervising RN.
SECOND CHECK!
Look at the medication label and compare with the medication
chart Check the first five rights of medication administration.
route and right person.
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Confirm the persons identification by asking them to state their name
and date of birth and checking they are consistent with the persons
chart. Confirm that the medical record number on the medication chart
accords with the ID band.
In residential aged care settings photos are often used to confirm a
residents ID rather than ID bands.
THIRD CHECK!
Prepare the medication from the ampoule or vial for drug

withdrawal using a non-touch technique:
Flick the upper stem of the ampoule several times with a
fingernail.
Use a piece of gauze or an unopened alcohol wipe between your
thumb and break off the top by bending it towards you.
Dispose of the top of the ampoule in the sharps container.
Place the ampoule on a flat surface.
Attach the drawing up needle to the syringe.
Remove the cap from the drawing up needle, insert it into the
centre of the ampoule, and withdraw all of the drug.
Hold the ampoule slightly on its side, if necessary, to obtain all of
the medication.
This part of the process may be performed at the persons bedside or

in a medication/treatment room.
This will bring all medication down to the main portion of the ampoule.
The drawing up needle prevents glass particles from being withdrawn

with the medication.
Withdrawing a medication from an ampoule

Remove the drawing up needle and place it in the sharps
container.
Attach the regular needle and discard excess medication into an
acceptable receptacle, depending on ordered amount.
Assist the person into the correct position in which the arm,
leg or abdomen can be relaxed, depending on the site to be
used.
A relaxed position of the site minimises discomfort.
Drape the person with the bedsheet.
To ensure the persons comfort and dignity.
Select the injection site.
Select a site that has not been used frequently and one that is free of
tenderness, hardness, swelling, scarring, itching, burning or localised
inflammation. These conditions could hinder the absorption of the
medication and may also increase the likelihood of injury and discomfort
at the injection site.
Clean the injection site with an antiseptic swab. Start at the centre
of the site and clean in a widening circle to about 5 cm. Allow the
area to dry thoroughly.
The mechanical action of swabbing removes skin secretions, which

contain microorganisms.
This ensures the swab readily accessible when the needle is withdrawn.
Position the swab on the persons skin near to the intended site.
Grasp the syringe in your dominant hand by holding it between
your thumb and fingers. With palm facing to the side or upward
for a 45-degree angle of insertion, or with the palm downward for
a 90-degree angle of insertion, prepare to inject.
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UNIT 6
SECTION 6.4

Using the nondominant hand, pinch or spread the skin at the site,
and insert the needle using the dominant hand and a firm steady
push. If the person has more than 1.3 cm of adipose tissue in the
injection site, administer the injection at a 90-degree angle with
the skin spread.
90
45
Skin
Subcutaneous
tissue
Muscle
Inserting a needle into the subcutaneous tissue using 90

and 45-degree angles.
If the person is thin or lean and lacks adipose tissue, the injection
should be given with the skin pinched and at a 45- to 60-degree
angle.
Administering a subcutaneous injection into pinched tissue.

When the needle is inserted, move your nondominant hand to the
barrel of the syringe and the dominant hand to the end of the plunger.
Inject the medication by holding the syringe steady and depressing
the plunger with a slow, even pressure.
The needle should be embedded within the skin for 5 seconds
after complete depression of the plunger.
Remove the needle.
Remove the needle smoothly, pulling along the line of insertion
while depressing the skin with your nondominant hand.
Holding the syringe steady and injecting the medication at an even

pressure minimises discomfort.
This ensures complete delivery of the dose.
Depressing the skin places countertraction on it and minimises the

persons discomfort.
Discard the uncapped needle and attached syringe into the

proper receptacle.
Do not recap the needle before disposal as this increases the risk of
needlestick injuries.
If bleeding occurs, apply pressure to the site with dry sterile gauze
until it stops.
Bleeding rarely occurs after subcutaneous injection.


relationship.

ACTION
Proper disposal protects the nurse and others from injury and
contamination.
This is an infection control procedure.

administered and report deviations from normal to the persons
doctor.
Depending on the medication administered nurses monitor effectiveness

in different ways.
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BOX 65 Precautions When Administering Heparin

The subcutaneous administration of heparin requires special precautions because of the drug's anticoagulant properties:
Select a site on the abdomen at least 5 cm inches away from the umbilicus and above the level of the iliac crests. Avoid injecting into
bruises, scars or areas of tenderness.
Do not aspirate when administering heparin subcutaneously as this can damage the surrounding tissue and cause bleeding and bruising.
Do not massage the site after the injection as this causes bleeding and hastens drug absorption.
Alternate injections sites regularly.
Note: Enoxaparin sodium, a low molecular weight heparin, comes in prefilled syringes with a small air bubble. Do not expel the air bubble
unless the dose needs to be adjusted.
Intramuscular medication
administration
Injections into muscle tissue, or intramuscular (IM)
injections, are absorbed more quickly than subcutaneous
injections because of the greater blood supply to the body
muscles. Muscles can also take a larger volume of fluid without
discomfort than subcutaneous tissues, although the amount
varies among individuals. An adult with well-developed
muscles can usually tolerate up to 3 mL of medication in the
gluteus medius and gluteus maximus muscles (Figure 621).
A maximum volume of 1 to 2 mL is usually recommended
for adults with less developed muscles. In the deltoid muscle,
volumes of 0.5 to 1 mL are recommended.
Iliac crest
Anterior superior
iliac spine
Gluteus medius
Gluteus minimus
(underlying medius)
For example, a smaller needle such as a #23 to #25-gauge

needle 25 mm long is commonly used for the deltoid muscle.
More viscous solutions require a larger gauge (e.g., #20
gauge). People who are very obese may require a needle
longer than 38 mm inches (e.g., 50 mm), and people who are
emaciated may require a shorter needle (e.g., 25 mm). Needle
length must be long enough to penetrate the subcutaneous
fat layer and be injected directly into the muscle.
A major consideration in the administration of IM
injections is the selection of a safe site located away from
large blood vessels, nerves, and bone. Contraindications for
using a specific site include tissue injury and the presence of
nodules, lumps, abscesses, tenderness, or other pathology.
Ventrogluteal Site
The ventrogluteal site is in the gluteus medius muscle,
which lies over the gluteus minimus (see Figure 622). The
ventrogluteal site is the preferred site for IM injections in people
older than 7 months (Zimmerman, 2010) because the area:
Gluteus maximus
Greater trochanter
of femur
FIGURE 621Lateral view of the right buttock

showing the three gluteal muscles used for
intramuscular injections
Usually a 25-mL syringe is needed for intramuscular
injections. The size of syringe used depends on the amount
of medication being administered. The IM needle used is
usually 25 mm and #2125 gauge. Several factors indicate
the size and length of the needle to be used:
The muscle
The type of solution
The amount of adipose tissue covering the muscle

The age of the person
Contains no large nerves or blood vessels.

Provides the greatest thickness of gluteal muscle
consisting of both the gluteus medius and gluteus
minimus.
Contains consistently less fat than the buttock area,
thus eliminating the need to determine the depth of
subcutaneous fat.
The persons position for a ventrogluteal injection can

be a back, prone, or side-lying position. The side-lying
position, however, helps locate the ventrogluteal site more
easily. Positioning the person on their side with the knee bent
and raised slightly towards the chest allows the trochanter
to protrude, which helps to locate the ventrogluteal site. To
establish the exact site, the nurse places the heel of the hand
on the persons greater trochanter, with the fingers pointing
towards the persons head. The right hand is used for the left
hip, and the left hand for the right hip. With the index finger
on the persons anterior superior iliac spine, the nurse stretches
the middle finger dorsally (towards the buttocks), palpating
the crest of the ilium and then pressing below it. The triangle
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UNIT 6
Anterior superior
iliac spine
Injection site
SECTION 6.4
Greater trochanter
of femur
Deep
femoral
artery
Iliac crest
Sciatic
nerve
Rectus
femoris
Vastus
lateralis
Femoral
artery
and vein
FIGURE 622Landmarks for the ventrogluteal

site for an intramuscular injection
Courtesy of Custom Medical Stock Photo, Inc.
FIGURE 624The vastus lateralis muscle of an infants

upper thigh, used for intramuscular injections
(Figures 625 and 626).The person can assume a back-lying

or a sitting position for an injection into this site. The vastus
lateralis site is considered a good option for administering an
IM injection when the person is obese.
FIGURE 623Administering an intramuscular

injection into the ventrogluteal site
Greater trochanter
of femur
Photographer: Jenny Thomas.
formed by the index finger, the third finger, and the crest of the
ilium is the correct injection site (Figures 622 and 623).
Vastus lateralis
(middle third)
Vastus Lateralis Site

The vastus lateralis muscle is usually thick and well
developed in both adults and children. The vastus lateralis
site is recommended as the site of choice for IM injections
for infants 1 year and younger. Because there are no major
blood vessels or nerves in the area, it is desirable for infants
whose gluteal muscles are poorly developed. It is situated on
the anterior lateral aspect of the infants thigh (Figure 624).
The middle third of the muscle is the correct injection site.
In the adult, the landmark is established by dividing the area
between the greater trochanter of the femur and the lateral
femoral condyle into thirds and selecting the middle third
Lateral femoral
condyle
FIGURE 625Landmarks for the vastus lateralis site

of an adults right thigh, used for an intramuscular
injection
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Posterior
superior
iliac spine
Injection
site
Greater
trochanter
Sciatic
nerve
FIGURE 627Landmarks for the dorsogluteal site

for an intramuscular injection
FIGURE 626A, Determining landmarks;

B, administering an intramuscular injection into
the vastus lateralis site
Contraindications for using the

dorsogluteal site for IM injections
The dorsogluteal site has been commonly used for IM
injections. However, this site is close to the sciatic nerve
and the superior gluteal nerve and artery. As a result,
complications (e.g., numbness, pain, paralysis) can occur if
medications are injected near the sciatic nerve. Additionally,
the dorsogluteal muscle has the lowest drug absorption rate
and because there tends to be more subcutaneous tissue at
the dorsogluteal site, medications may be injected into the
subcutaneous tissue instead of the muscle. Because of this,
the ventrogluteal site is the preferred site for IM injection.
It is important for nurses to know all potential sites
for IM injections in order to make the best decision
for the safety of the person. If a nurse decides to use the
dorsogluteal site because other, safer sites are unavailable,
it is imperative that the nurse palpate the correct landmarks
and choose the injection site carefully to avoid striking
the sciatic nerve, major blood vessels, or bone. The nurse
palpates the posterior superior iliac spine, then draws an
imaginary line to the greater trochanter of the femur. This

line is lateral to and parallel to the sciatic nerve. The injection
site is lateral and superior to this line (Figure 627).
Palpating the ilium and the trochanter is important; visual
calculations alone can result in an injection that is placed
too low and injures other structures. The person needs to
assume a prone position with the toes pointed inward or a
side-lying position with the upper knee flexed and in front
of the lower leg. These positions promote muscle relaxation
and therefore minimize discomfort from the injection.
Rectus Femoris Site

The rectus femoris muscle, which belongs to the quadriceps
muscle group, is used only occasionally for IM injections. The
rectus femoris site is situated on the anterior aspect of the
thigh (Figure 628). Its chief advantage is that people who
administer their own injections can reach this site easily.
Its main disadvantage is that an injection here may cause
considerable discomfort for some people.
Deltoid Site
The deltoid muscle is found on the lateral aspect of the upper
arm. It is infrequesntly used for IM injections because it is a
relatively small muscle and is very close to the radial nerve
and radial artery. The deltoid site is sometimes considered
for use in adults because of rapid absorption from the deltoid
area, but no more than 1 mL of solution can be administered.
This site is recommended for the administration of hepatitis B
vaccine in adults.
The upper landmark for the deltoid site is located by
the nurse placing four fingers across the deltoid muscle
with the first finger on the acromion process. The top of
the axilla is the line that marks the lower border landmark
(Figure 629). A triangle within these boundaries indicates
the deltoid muscle about 5 cm below the acromion process
(Figures 630 and 631).
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UNIT 6
SECTION 6.4
Anterior superior
iliac spine
Clavicle
Acromion process
Deltoid muscle
Scapula
Rectus femoris
Axilla
Vastus lateralis
Humerus
Deep brachial
artery
Radial nerve
Patella
FIGURE 630Landmarks for the deltoid muscle

of the upper arm, used for intramuscular
injections
FIGURE 628Landmarks for the rectus femoris

muscle of the upper right thigh, used for
intramuscular injections
Clavicle
Acromion process
Deltoid muscle
Scapula
Axilla
FIGURE 631Administering an intramuscular

injection into the deltoid site
Humerus
Deep brachial
artery
Radial nerve
FIGURE 629A method of establishing

the deltoid muscle site for an intramuscular
injection
THE Z-TRACK TECHNIQUE FOR

IM INJECTIONS
The Z-track technique is recommended for all IM
injections. This method his less painful than the traditional
injection technique and decreases leakage of irritating and
discoloring medications into the subcutaneous tissue.
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THE 3PS TABLE
INTRAMUSCULAR MEDICATION ADMINISTRATION

ACTION
A valid order includes the persons name; the date and time the
order was written; the generic name of the drug to be administered;
the dosage of the drug; frequency and time of administration;
route of administration; and signature of the person who wrote
the order. Some medications also require a finish date. The drug
order should be legible and correctly spelt.


Ensure the IM route is most appropriate for the person and for the type
of medication prescribed.


high, previously unreported allergies and other concerns should
IMI medication administration is a sterile procedure. Hand hygiene

is performed as an infection control precaution.

Medication chart
Syringe, drawing up needle and administration needle Antiseptic swabs.
Clean gloves.

ACTION

To ensure the persons privacy.
A person-centred approach enhances safety by creating an

provide education.
Determine and conduct appropriate assessments and review related

pathology results (if appropriate).
Check the tissue integrity of the site and whether the selected muscle is
appropriate for the amount of medication to be injected.
An average adults deltoid muscle can usually absorb 0.51.0 mL

of medication. The gluteus medius muscle can absorb 14 mL,
although 4 mL may be contraindicated because it can be very
painful.
FIRST CHECK!
Compare the label on the medication container and packaging against
the order on the medication chart to ensure that the right medication
is given.

medications.

supervising RN.
SECOND CHECK!
Look at the medication label and compare with the medication chart

right route and right person.
In residential aged care settings photos are often used to confirm
a residents ID rather than ID bands.

THIRD CHECK!
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UNIT 6
SECTION 6.4

Prepare the medication from the ampoule or vial for drug withdrawal
using a non-touch technique:
This part of the process may be performed at the persons bedside

or in a medication/treatment room.
Flick the upper stem of the ampoule several times with a fingernail.
Use a piece of gauze or an unopened alcohol wipe between your thumb
and break off the top by bending it towards you to ensure.
Dispose of the top of the ampoule in the sharps container.
Place the ampoule on a flat surface.
Attach the drawing up needle to the syringe.
Remove the cap from the drawing up needle, insert it into the centre of
the ampoule, and withdraw all of the drug.
Hold the ampoule slightly on its side, if necessary, to obtain all of the
medication.
Remove the drawing up needle and place it in the sharps container.
Attach the regular needle, invert the syringe upright, expel air and
discard excess medication into an acceptable receptacle, depending
on ordered amount.
This will bring all medication down to the main portion of the
ampoule.
Assist the person into a supine, lateral, prone or sitting position,

depending on the chosen site. If the target muscle is the gluteus medius
(ventrogluteal site), assist the person into a supine position with knees
flexed; or into the lateral position with the upper leg flexed.
Appropriate positioning promotes relaxation of the target muscle.
Drape the person with the bedsheet.
To ensure the persons comfort and dignity.
Select the correct injection site.
Select a site free of skin lesions, tenderness, swelling, hardness or

localised inflammation and one that has not been used frequently.
Clean the injection site with an antiseptic swab. Start at the centre of
the site and clean in a widening circle to about 5 cm. Allow the area to
dry thoroughly.
Position the swab on the persons skin near to the intended site.
This prevents entry of bacteria into the injection site.
Remove and discard the needle cover. Inject the medication using a
Z-track technique:
Use the ulnar side of the nondominant hand to pull the skin
approximately 2.5 cm to the side. When the skin returns to its
normal position after the needle is withdrawn and a seal is formed over
the intramuscular site.
Pulling the skin and subcutaneous tissue makes it firmer and

facilitates needle insertion.
This prevents seepage of the medication into the subcutaneous
tissues and subsequent discomfort.
The drawing up needle prevents glass particles from being

withdrawn with the medication.
The outside of a new needle is free of medication, will not irritate

subcutaneous tissues as it passes into the muscle.
This ensures the swab readily accessible when the needle is

withdrawn.
Skin
Subcutaneous
tissue
Muscle
Medication
A
Inserting an intramuscular needle at a 90-degree angle using the Z-track method: A, skin pulled
to the side; B, skin released.
Note: If the person is emaciated or an infant, the muscle may be pinched.
Holding the syringe between the thumb and forefinger (as if holding a
pencil), pierce the skin quickly and smoothly at a 90-degree angle
and insert the needle into the muscle.
Rationale: Using a quick motion lessens the persons discomfort.

Holding the syringe like a pen or pencil reduces accidental
depression of the plunger and inadvertent administration of the
medication while the needle is being inserted.
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Holding the syringe between the thumb and forefinger.

Note that the nurse is using the Z-track technique.
Hold the barrel of the syringe steady with your nondominant hand and
aspirate by pulling back on the plunger with your dominant hand.
Aspirate for 5 to 10 seconds. If blood appears in the syringe, withdraw
the needle, discard the syringe, and prepare a new injection.
If the needle is in a small blood vessel, it takes time for the blood
to appear.
In addition to pulling the skin to the side, the nondominant hand is

holding the barrel of the syringe to avoid it from moving while the
dominant hand aspirates by pulling back on the plunger.
Note: Aspiration is a controversial procedure so check local policy
guidelines.
If blood does not appear, inject the medication steadily and slowly
(approximately 10 seconds per milliliter) while holding the syringe
steady.
Injecting medication slowly promotes comfort and allows time for

tissue to expand and begin absorption of the medication. Holding
the syringe steady minimises discomfort.
After injection, wait 10 seconds.
Waiting permits the medication to disperse into the muscle tissue,

thus decreasing the persons discomfort.
Withdraw the needle smoothly, at the same angle of insertion then

release the skin.
This minimises tissue injury.
Discard the uncapped needle and attached syringe into the proper
receptacle.
Do not recap the needle before disposal as this increases the risk
of needlestick injuries.
Apply gentle pressure at the site with dry sterile gauze.
Use of an alcohol swab may cause pain or a burning sensation.
Do not massage the site.
Massaging the site may cause the leakage of medication from the
site and result in irritation.

Conclude encounter and inform person of follow up.
This is a professional expectation and helps to maintain a

therapeutic relationship.

ACTION
contamination.

administered and report deviations from normal to the persons doctor.
Depending on the medication administered nurses monitor

effectiveness in different ways.
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UNIT 6
What If
SECTION 6.4
Administering an intramuscular injection using

S-Track technique
WHAT IF the patient is obese?
THEN use the ventrogluteal site

and use a longer needle.
WHAT IF the patient has

decreased muscle mass?
Assess: Patient's age, weight, tissue integrity
Inform the patient

Follow the three checks for administering the medication
Organise the equipment
THEN use the ventrogluteal site

and use a shorter needle.
If possible, change the needle

on the syringe

Prepare the medication
Prepare the patient: Verify identity and assist to appropriate position
Select and locate the site

Apply clean gloves
Cleanse the site
Remove the cover from the needle
WHAT IF the patient has
decreased muscle mass?
Using the ulnar side of the nondominant hand, pull

the skin to the side
WHAT IF the patient is

obese?
THEN with the nondominant

hand, stretch the skin over
the injection site to displace
the underlying subcutaneous
tissue.
Hold the syringe between thumb and forefinger,

pierce the skin quickly and smoothly at a 90-degree angle
THEN consider pinching the

muscle instead of pulling the skin
to the side.
Hold the barrel of the syringe steady with the

nondominant hand and aspirate with the dominant hand
Inject the medication steadily and slowly while
holding the syringe steady
Wait 10 seconds to permit the medication to disperse into the muscle tissue
WHAT IF blood appears in

the syringe on aspiration?
THEN - withdraw needle,

- dispose of medication
and syringe/needle
- prepare new medication
Withdraw the needle at the same angle of insertion

Activate the needle safety device and discard the syringe into the sharps container
Remove gloves. Perform hand hygiene
Document
Assess the effectiveness of the medication
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Infants and children
The vastus lateralis site is recommended as the
site of choice for IM injections for infants. There are
no major blood vessels or nerves in this area, and it is
the infants largest muscle mass. It is situated on the
anterior lateral aspect of the thigh.
Use needles that will place medication in the main
muscle mass; infants and children usually require smaller,
shorter needles (#22 to #25 gauge, 16 to 25 mm long)
for IM injections.
The vastus lateralis is recommended as the site of
choice for toddlers and children.
For the older child and adolescent, the recommended
sites are the same as for the adult: ventrogluteal or
deltoid. Ask which arm they would like the injection in.
Before administering any medications to an existing

IV infusion or port, the nurse must first check for signs of
phlebitis, thrombophlebitis, infection, inflammation, or
infiltration including redness, warmth, pallor, discomfort or
oedema at the IV site or along the vein (see Figure 632).
Baseline observation of vital signs should also be attended to
determine whether there are any systemic signs of infection.
The 5 rights rights should be checked as well as verifying
compatibility of the drug and the IV fluid that is running.
For example, the drug phenytoin (Dilantin) is incompatible
with glucose and will form a precipitate if injected into an
IV line with glucose/dextrose infusing. If any doubt about
incompatibility remains after consulting the IV drug guide,
the clinical pharmacist should be consulted for advice.
Older Adults
Older people may have decreased muscle mass or
muscle atrophy. A shorter needle may be needed.
Assessment of appropriate injection site is critical.
Absorption of medication may occur more quickly than
expected.
INTRAVENOUS MEDICATION
ADMINISTRATION
Because IV medications enter the persons bloodstream
directly by way of a vein, they are indicated when a rapid
effect is required. The IV route is also appropriate when
medications are too irritating to tissues to be given by other
routes. Examples of methods used to administer medications
intravenously include:
IV push (bolus) directly into the systemic circulation

over a few minutes
Intermittent IV infusion (via burette or piggyback)
diluting the medication in a small amount of IV solution
and administering over 3060 minutes (usually)
Via an IV infusion diluting the medication in the IV
bag and administering over hours
For each of these methods, the person will require an

existing IV line or an IV port. In Unit 11, IV fluid infusions
are discussed; in this section we focus on IV medication
administration only.

Sixty-one per cent of most serious adverse
drug events in hospitals are IV-drug/fluid related
(Husch et al., 2005)
FIGURE 632Superficial phlebitis in the lower arm

Science Photo Library
With IV medication administration it is very important

to observe individuals closely for signs of adverse reactions.
Because the drug enters the bloodstream directly and acts
immediately, there is no way it can be withdrawn or its action
terminated. Therefore, nurses must take special care to avoid
any errors in the preparation of the drug and the calculation
of the dosage. Most hospitals have strict procedures and
policies about who may administer IV medications and most
require two registered nurses to check all IV medications
prior to administration.
Administering intravenous
medications via IV push (bolus)
An IV push or bolus is the intravenous administration of
medication directly into the systemic circulation. It is used
when a medication cannot be diluted or in an emergency
situation. A bolus IV injection is introduced into an IV line
through an injection port close to the patient. Medications
administered in this way may be irritating to the lining
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UNIT 6
of the blood vessels and it is therefore imperative that the

nurse identify the correct fluid and correct concentration
for diluting the prescribed medication (if ordered), and the
correct rate of administration. Also check that the medication
is compatible with the fluid that in the IV line. Most IV bolus
medications are delivered slowly, between 1 and 5 minutes,
however the nurse should check the intravenous drug guide
and manufacturers product guide for directions.
SECTION 6.4
Medication port
Air filter
Administration spike
Note: In some organisations a heparin or normal saline

flush may be used before and after administration of an
IV medication to prevent occlusion of the cannula so local
policies and guidelines should be checked.

The IV bolus route is the most hazardous of
all medication routes because the entire dose
is administered directly into the person over a short
period of time and the effects are immediate.
medications via a burette or a
piggy-back
An intermittent infusion is a method of administering a
medication mixed in a small amount of IV solution, such
as 50 or 100 mL (Figure 633) via a burette (Figure 634)
or a piggyback (Figure 635). The drug is administered at
regular intervals, such as every 8 hours, with the drug
being infused over a short period of time such as 30 to
60 minutes.
FIGURE 634An IV infusion set with a volumetric

burette
A burette is a volume control device that is either an integral

part of an IV line or is attached separately to an existing IV
line immediately after the IV bag). The medication is diluted
in a precise amount of the IV fluid in the burette. Giving an
IV medication via a burette is beneficial when the undiluted
medication would normally be irritating to the vein.
When using a piggy-back bag for intermittent IV
medication administration, a second IV set connects the
second bag to the primary IV line at the upper port using
threaded-lock or lever-lock cannulae. Most IV tubing has a
one-way valve a short distance from the IV bag to prevent
fluid from flowing up into the container rather than down
the tubing to the person. It is important to ensure that the
piggy-back line is connected below this valve.
medications via an IV infusion
FIGURE 633Medication in a labelled infusion bag
IV Medications can be diluted in volumes of 250, 500,

or 1,000 mL in a IV bag/container according the medical
orders. Fluids such as IV normal saline or Hartmanns
are frequently used, depending on compatibility with
IV medication to be administered. Medications such as
potassium chloride may be added to the IV bag by the nurse
or alternatively the pharmacist may add the medication to
the IV bag.
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CLINICAL SCENARIO
Mr Arthur Barrett (Levett-Jones, Hoffman, Dempsey &
Sinclair, 2013) was prescribed four IV medications.
For each medication specify the action, the correct
type of IV injection procedure to be followed, and any
related practice points in terms of contraindications
and compatibility with IV fluids etc.

Clamp
IV medications ordered:
1. Frusemide 40mg
2. Amoxicillin 500mg
Piggyback set
Primary set
Piggyback or
primary port
with backcheck
valve
Clamp
Secondary port
FIGURE 635Secondary intravenous lines using

a piggyback system
THE 3PS TABLE
3. Potassium Chloride 2g
4. Gentamycin 80 mg

Analysis of incident data and published literature
allows has identified six groups of medicines that
are considered as high risk. The acronym A PINCH is
a useful way of remembering these group of medicines:
A
P
I
N
S
C
H
anti-infective agents
potassium
insulin
narcotics
sedative agents
chemotherapy drugs
Heparin (and other anticoagulants).
www.cec.health.nsw.gov.au/programs/high-riskmedicines#publications1
INTRAVENOUS MEDICATION ADMINISTRATION

BOLUS, BURETTE OR VIA AN INFUSION

ACTION
A valid order includes the persons name; the date and time the
order was written; the generic name of the drug to be administered;
the dosage of the drug; frequency and time of administration; route
of administration; and signature of the person who wrote the order.
Some medications also require a finish date. The drug order should
be legible and correctly spelt.


Ensure the IV route is most appropriate for the person and for the type
of medication prescribed.
Determine whether the medication should be given by bolus injection

or via a burette (or piggy-back).
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UNIT 6
SECTION 6.4


IV medication administration is a sterile procedure. Hand hygiene

is performed as an infection control precaution.

Medication chart
Antiseptic swabs
Clean gloves
Correct medication
Dilutent (if medication is in powdered form)
Sterile syringe of appropriate size
Sterile drawing up needle if not using a needleless system
Burette or piggy-back bag (if required)
IV additive label (for burette)
Sterile normal saline if there is a need to ush the cannula before or
after the IV medication
Sharps container (if required for glass ampoules, vials or needles)

ACTION
Introduce yourself to the person

To ensure the persons privacy.
A person-centred approach enhances the patients safety by

creating an opportunity for the person to ask questions and for
the nurse to provide education.
Determine and conduct appropriate assessments.
Inspect and palpate the IV insertion site for signs of infection,

infiltration or a dislocated catheter.
Inspect the surrounding skin for redness, pallor, or swelling.
Palpate the surrounding tissues for coldness, tenderness, and
the presence of oedema, which could indicate leakage of the IV
fluid into the tissues.
Take vital signs for baseline data
FIRST CHECK!
NOTE: In most facilities two RNs are required to check IV medications
Compare the label on the medication container and packaging against
the order on the medication chart to ensure that the right medication
is given.
Check the compatibility of the medication(s) and IV fluid.

medications.

For bolus injections ensure the correct rate of injection is known.

supervising RN.
SECOND CHECK!
Look at the medication label and compare with the medication chart

right route and right person.
In residential aged care settings photos are often used to confirm
a residents ID rather than ID bands.
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THIRD CHECK!
Prepare the medication according to the manufacturers directions

and withdraw into the syringe using a non-touch technique and a
drawing up needle (depending on hospital policy).
ADMINISTERING A BOLUS IV MEDICATION
Identify the injection port closest to the person
Clean the port with an antiseptic swab.
Stop the IV ow by closing the clamp or pinching the tubing above
the injection port.
Injecting an IV bolus medication with tubing pinched

If an IV port rather than an IV infusion line is to be accessed a 1 mL
IV flush of normal saline may be ordered prior to and following the
Inject the medication at the correct rate.
Withdraw the syringe.
Release the clamp or tubing
Resume IV ow at correct rate as ordered (or ush with of 1 mL of
normal saline if ordered)
Use a watch to time injection because a too rapid injection could

be dangerous.
ADMINISTERING AN IV MEDICATION VIA A BURETTE or

PIGGYBACK INFUSION
Fill the burette with the required amount of uid to dilute the
medication usually 50100 mL.
Clean the injection port with an antiseptic swab
Clamp the inow line from the IV bag using the roller or slide clamp
Open the air vent
Insert the needle connected to the syringe into the medication port
of the burette
Inject the medication into the burette and gently rotate and until well
mixed.
Open the roller clap below the burette drip chamber to resume the IV
at the correct flow rate
Complete the details on the additive label and attach to the
burette ensuring that the measurement lines on the burette are
not obscured.
Sufficient volume is necessary to dilute the medication adequately.

This reduces the risk of introducing microorganisms into the
container when the needle is inserted.
This prevents the medication from being further diluted by the
fluid in the bag.
This documents that medication has been added to the solution.

The label should be easy to read when the bag is hanging.
ADMINISTERING AN IV MEDICATION VIA AN IV INFUSION

Clean the injection port of the IV bag with an antiseptic swab
Insert the needle connected to the syringe directly into the medication
port of the bag.
This reduces the risk of introducing microorganisms into the

container when the needle is inserted.
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UNIT 6
SECTION 6.4
Inserting an IV medication through the injection port of an IV bag

Ensure the amount of uid in the bag is appropriate for the medication
to be diluted
Inject the medication into the bag and gently rotate and until well mixed.
Ensure the IV ow rate is correct
Complete the details on the additive label and attach to the bag
ensuring that the measurement lines on the bag are not obscured.
This documents that medication has been added to the solution.

The label should be easy to read when the bag is hanging.


relationship.
PRIORITIES POSR PROCEDURE

ACTION
contamination.
Return to the person to reassess the IV site and the IV infusion.
Depending on the medication administered nurses must also

monitor effectiveness in different ways.
FURTHER READING
Parker, B., Kucia, A., Fedoruk, M., Laws,

T.& Phillips, C. (2015). Medications. In
A. Berman, S. Snyder, T. Levett-Jones,
T. Dwyer, M. Hales, N. Harvey . . . S. Stanley
(Eds.), Kozier & Erbs fundamentals of nursing
(3rd ed.) (pp. 900975). Sydney: Pearson
WEBLINKS
Interprofessional Education for Quality use

of Medicines modules at: www.ipeforqum.
com.au/modules/
Review the Asthma Australia inhaler

technique videos at the following link:
http://www.asthmaaustralia.org.au/
Inhaler-technique-videos.aspx
NPS Medicinewise Learning Medication

Safety Module: httwww.nps.org.au/
health-professionals/cpd/activities/onlinecourses/medication-safety-training
Australian Government Department of

Health Quality Use of Medicines (QUM)
NPS Medicinewise Learning National

Inpatient Medication Chart Training
Module: http://learn.nps.org.au/mod/
http://learn.nps.org.au/mod/page/view.
php?id54279
page/view.php?id54278
http://www.health.gov.au/internet/main/
publishing.nsf/Content/nmp-quality.htm
NPS Medicinewise Learning Quality use of

medicines for health professional students
Module:
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REFERENCES
Adams, M., Holland, N., & Bostwick, P.

(2008). Pharmacology for Nurses:
A Pathological Approach (2nd ed.). Upper
Saddle River, NJ: Pearson Education, Inc.
Britten, N. (2011). Qualitative research

on health communication: What can it
contribute? Patient Education and Counseling,
82(3), 384388.
Australian Commission on Safety and

Quality in Health Care (ACSQHC)
(2011). Recommendations for Terminology,
Abbreviations and Symbols Used in the
Prescribing and Administration of Medicines.
Canberra: Commonwealth Department
of Communications, Information
Technology and the Arts.
Cohen, H., & Shastay, A. D. (2008). Getting

to the route of medication errors. Nursing,
38(12), 3947.
Australian Commission on Safety and

Quality in Health Care (2012). National
Inpatient Medication Chart for Adult Patients
2012. NIMC (acute). Retrieved from
www.safetyandquality.gov.au/wpcontent/uploads/2012/02/NIMCacute-PDF-82KB.pdf.
Australian Medicines Handbook (online). (2016
January). Adelaide: Australian Medicines
Handbook Pty Ltd. Retrieved from:
http://amhonline.amh.net.au/
Berman, A., & Snyder, S. (2012). Skills in
Clinical Nursing (7th ed.). Upper Saddle
River, NJ: Pearson Education.
Berman, A., & Snyder, S. (2016). Skills in
Clinical Nursing (8th ed.). Upper Saddle
River, NJ: Pearson Education.
Bolster, D., & Manias E. (2010). Personcentred interactions between nurses and
patients during medication activities
in an acute hospital setting: qualitative
observation and interview study.
International Journal of Nursing Studies, 47(2),
15465
Garfield, S., Barber, N., Walley, P., Willson, A., &

Eliasson, L. (2009). Quality of medication
use in primary care mapping the
problem, working to a solution: a
systematic review of the literature. BMC
Medicine, 7(1), 50.
Husch, M., Sullivan, C., Rooney, D.,
Barnard, C., Fotis, M., Clarke, J., &
Noskin, G. (2005). Insights from the
sharp end of intravenous medication
errors: implications for infusion pump
technology. Quality and Safety in Health Care,
14(2), 8086.
conversaations for patient safety. T. Levett-Jones

(Ed.). Sydney: Pearson
Nursing and Midwifery Board of
Australia (NMBA) (2016). Registered
Nurse Standards for Practice (2016),
Canberra: Author. Retrieved from
www.nursingmidwiferyboard.gov.au/
News/2016-02-01-revised-standards.
aspx.
Roughead, E., & Semple, S. (2009).
Medication safety in acute care in
Australia: where are we now? Part 1:
A review of the extent and causes of
medication problems 20022008.
Australia and New Zealand Health Policy, 6, 18.
US Food and Drug Administration (2009).
Food Code 2009. Retrieved from www.
fda.gov/Food/GuidanceRegulation/
RetailFoodProtection/FoodCode/
ucm2019396.htm.
Johnson, M., Tran, D., & Young, H. (2011).

Developing risk management behaviours
for nurses through medication
incident analysis. International Journal of
Nursing Practice, 17(6), 548-555. doi:
10.1111/j.1440-172X.2011.01977.x
Westbrook, J., Woods, A., Rob, M.,

Dunsmuir, W., & Day, R. (2010).
Association of interruptions with
an increased risk and severity of
medication administration errors.
Archives of Internal Medicine, 170, 683690.
Levett-Jones, T., & Newby, D. (2013).

Caring for a person experiencing and
adverse drug event. T Levett-Jones (Ed.)
Clinical Reasoning: Learning to think like a nurse,
Frenchs Forrest: Pearson.
Van de Verrede, M.A,, Wilson S.G., &

Dooley M.J. (2008). Intravenous
potassium chloride prescribing and
administration practices in Victoria:
an observational study. Med J Australia,
189(10), 575577.
Madegowda, B., Hill, P. D., & Anderson, M.

(2007). Medication errors in a rural
hospital. MEDSURG Nursing, 16, 175180.
Manias, E. (2014). Communicating to
promote medication safety. Critical
Zimmerman, P. G. (2010). Revisiting

IM injections. American Journal of Nursing,
110(2), 6061. doi:10.1097/01.
NAJ.0000368058.72729.c6
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UNIT 6
SECTION 6.4
UNIT 6 CLINICAL SKILLS APPRAISAL FORMS

Section 6.2 Clinical Skills Appraisal Form
U Unsatisfactory, D Developing, S Satisfactory, NA Not applicable
PREPARATION AND PLANNING FOR THE PROCEDURE
Reviews the medication chart and ensures that there is a valid order for the drug/s to be
administered
Reviews the Australian Medicines Handbook or a similar drug resource if unfamiliar with the
medication/s ordered
Ensures the oral route is most appropriate for the person and for the type of medication prescribed
Reports and clarifies any omissions, inconsistencies, inaccuracies or incomplete prescription
orders to the supervising RN or MO
Performs hand hygiene
Gathers the correct equipment:
Medicine cup (and syringe if required)
Drinking cup and water
Pill cutter or crusher (if required)
Soft food for crushed medications (when appropriate)
Introduces self to the person
Demonstrates a person-centred approach to medication administration
Checks whether the person has any drug allergies
Repeats hand hygiene
Conducts appropriate assessments of the person and reviews related pathology results
(if appropriate)
Unlocks the dispensing system and obtains the correct oral medication.
FIRST CHECK: Compares the label on the medication container or package against the order
on the medication chart to ensure that the right medication is given
Checks the expiry date of the medication
Calculates the correct dosage of the medication
Checks the first five rights of drug administration
SECOND CHECK: Compares the medication label with the medication chart
Dispenses the medication into a medicine cup or appropriate container using a non-touch technique
THIRD CHECK: Rechecks the label on the container against the medication chart and
Rechecks the five rights of drug administration
Assists the person to take the medication
Student and supervising RN complete and sign the medication chart correctly
Concludes encounter and informs the person of follow up
Disposes of or returns used equipment
Returns to the person to monitor effectiveness of the medication administered
Student:
Assessor name and signature:
Comments:
NA
Date:
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DERMATOLOGIC MEDICATION ADMINISTRATION
administered
Clean gloves (or sterile for nonintact skin)
Solution to wash area if indicated
Gauze pads for cleaning
Medication (e.g., lotion, cream, ointment, patch)
Application tube (if required)
Demonstrates a person-centred approach to medication administration and obtains the
persons verbal consent
Repeats hand hygiene and dons gloves
Conducts appropriate assessments of the person:
Inspects skin or mucous membranes for lesions, rashes, erythema, and breakdown. Notes
size, color, distribution, and configuration of lesions.
Determines the presence of symptoms of skin irritation (e.g., pruritus, burning sensation, pain).
Notes the presence of excessive body hair that may require clipping before the application
of a topical medication.
If a transdermal patch is to be applied, asks the person if they are already wearing a patch,
and if so, where it is located.
Closes curtain or door. Assists the person to a comfortable position, either sitting or lying.
Exposes the area to be treated and ensures the persons privacy.
If necessary, calculates the correct dosage of the medication
SECOND CHECK: Checks the five rights of drug administration
THIRD CHECK: Rechecks the label on the container against the medication chart
Applies the medication as ordered
Removes gloves and repeats hand hygiene
Student and supervising RN completes and signs the medication chart correctly
Concludes encounter, reposition the person and informs them of follow up
Student:
Comments:
NA
Date:
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UNIT 6
SECTION 6.4

OPTHALMIC MEDICATION ADMINISTRATION
NA
administered

Clean gloves
Sterile absorbent sponges soaked in sterile normal saline
Medication
Sterile eye dressing (pad) as needed and paper tape to secure it

Introduces self to the patient
Closes curtain or door. Assists the person to a comfortable position, usually lying.
Demonstrates a person-centred approach to medication administration obtains the persons
verbal consent
Appearance of the eye and surrounding structures for lesions, exudate, erythema, or
swelling.
The location and nature of any discharge, lacrimation, and swelling of the eyelids or of
the lacrimal gland.
The persons complaints (e.g., itching, burning pain, blurred vision, and photophobia).
The persons behaviour (e.g., squinting, blinking excessively, frowning, or rubbing the
eyes).
Checks the expiry date of the medication.
Confirms which eye is to be treated.
Repeats hand hygiene and changes gloves
Cleans the eyelid and the eyelashes using sterile cotton balls moistened with sterile irrigating
solution or sterile normal saline.
Wipes from the inner canthus to the outer canthus.
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Applies the medication as ordered.
Draws the correct number of drops into the shaft of the dropper if a dropper is used
Instructs the person to look up to the ceiling.
Gives the person a dry sterile absorbent sponge.
Exposes the lower conjunctival sac by placing the thumb or fingers of nondominant hand
on the persons cheekbone just below the eye and gently drawing down the skin on the
cheek.
Holding the medication in the dominant hand, places the hand on the persons forehead
to stabilize the hand.
Instilling eye drops
Approaches the eye from the side and instills the correct number of drops onto the outer
third of the lower conjunctival sac. Holds the dropper 1 to 2 cm (0.4 to 0.8 in.) above
the sac.
Instilling eye ointment
Discards the first bead of ointment. Holding the tube above the lower conjunctival sac,
squeezes 2 cm (0.8 in.) of ointment from the tube into the lower conjunctival sac from
the inner canthus outward.
Instructs the person to close the eyelids but not to squeeze them shut.
For liquid medications, presses firmly or has the patient press firmly on the nasolacrimal duct
for at least 30 seconds.
Applies an eye pad if needed, and secure it with paper eye tape
Assesses and documents the procedure, character andamount of discharge, appearance of the
eye,discomfort, and the persons response immediately after the instillation.
Concludes encounter, ensures the persons comfort and informs them of follow up
Student:
Comments:
Date:
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UNIT 6
SECTION 6.4

OTIC MEDICATION ADMINISTRATION
NA
administered
Clean gloves
Cotton-tipped applicator
Flexible rubber tip (optional) for the end of the dropper, which prevents injury from
sudden motion, for example, by a person who is disoriented
Cotton wool
Normal saline
Closes curtain or door. Assists the person to a comfortable position, usually lying with ear to
be treated uppermost.
Appearance of the pinna of the ear and meatus for signs of redness and abrasions.
Type and amount of any discharge
Confirms which ear is to be treated.
Repeats hand hygiene and changes gloves
Cleans the pinna of the ear and the meatus of the ear canal with cotton-tipped applicators and
cotton balls moistened with sterile normal saline. Ensures that the applicator does not go into
the ear canal.
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Warm the medication container in your hand, or place it in warm water for a short time.
Straighten the auditory canal. Pull the pinna upward and backward for persons over
3 years of age. Instil the correct number of drops along the side of the ear canal
Press gently but firmly a few times on the tragus of the ear (the cartilaginous projection
in front of the exterior meatus of the ear).
Ask the person to remain in the side-lying position for about 5 minutes.
Insert a small piece of cotton wool loosely at the meatus of the auditory canal for 15 to
20 minutes.
Do not press it into the canal
Assess and document the procedure, character andamount of discharge, appearance of the
canal,discomfort the persons response immediately after the instillation
Student:
Comments:
Date:
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UNIT 6
SECTION 6.4

NASAL MEDICATION ADMINISTRATION
administered
Tissues
Clean gloves
Closes curtain or door. Assists the person to a comfortable and correct position depending
upon the sinus to be treated.
Conducts appropriate assessments of the person
Draw up the required amount of solution into the dropper
Hold the tip of the dropper just above the nostril, and direct the solution laterally towards
the midline of the superior concha of the ethmoid bone as the person breathes through
the mouth. Do not touch the mucous membrane of the nostril.
Repeat for the other nostril if indicated.
Ask the person to remain in the position for 5 minutes
Remove gloves and repeat hand hygiene
Assess and document the procedure, the persons condition, and discomfort experienced by
the patient and their response immediately after the instillation
Student:
Comments:
NA
Date:
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METERED-DOSE INHALER MEDICATION ADMINISTRATION
NA
administered
Metered-dose nebuliser with medication canister and spacer if indicated
Closes curtain or door. Assists the person to a sitting position
Educates the person about the purpose of the medication and instructs person about how
the inhaler is to be used:
Ensure that the canister is firmly and fully inserted into the inhaler.
Remove the cap, holding inhaler upright, shake vigorously for 3 to 5 seconds.
Exhale comfortably (as in a normal full breath) away from the inhaler.
Hold the inhaler with the canister on top and the mouthpiece at the bottom.
Slightly tilt chin to ensure open airway
Place the MDI inhaler mouthpiece in the mouth between the teeth and close lips to create
a seal
If using a spacer with the metered-dose inhaler:
Shake the MDI for 3 to 5seconds and insert the mouthpiece into the spacer.
Place the spacer in the mouth between the teeth and close lips to create a seal
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UNIT 6
SECTION 6.4

Instructs person to:
Whilst breathing in press down once on the MDI canister and inhale slowly and deeply
Remove the inhaler from mouth, close mouth and hold your breath for a few seconds or
as long as possible.
Exhale slowly away from the mouth piece
Replace cap.
Repeat the inhalation if ordered. Wait 1 to 2 minutes between inhalations of
bronchodilator medications.
If two inhalers are to be used, the bronchodilator medication (which opens the airways)
should be given prior to other medications.
Assesses and documents the procedure and the persons condition

Student:
Comments:
Date:
305
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VAGINAL MEDICATION ADMINISTRATION
NA
administered
Drape
Correct vaginal suppository or cream
Applicator for vaginal cream
Clean gloves
Lubricant for a suppository
Disposable towel
Clean perineal pad
Closes curtain or door
Prepares medication:
Unwraps the suppository, and puts it on the opened wrapper.
or
Fills the applicator with the prescribed cream, or foam according to the manufacturers
instructions
Asks the woman to pass urine
Assists the woman to a back-lying position with the knees flexed and the hips rotated laterally
Drapes the woman appropriately so that only the perineal area is exposed
Assesses the vaginal orifice for inflammation; amount, character, and odour of vaginal discharge;
and for complaints of vaginal discomfort
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UNIT 6
SECTION 6.4

Cleans the perineal area if required
Suppositories:
Lubricates the rounded (smooth) end of the suppository, which is inserted first
Lubricates gloved index finger.
Exposes the vaginal orifice by separating the labia with the nondominant hand.
Inserts the suppository about 8 to 10 cm along the posterior wall of the vagina
Asks the woman to remain lying in the supine position for 5 to 10minutes following
insertion.
Vaginal creams and foams
Gently inserts the applicator about 5 cm.
Slowly pushes the plunger until the applicator is empty
Removes the applicator
Discards the applicator if disposable or cleans it according to the manufacturers directions.
Ask the person to remain lying in the supine position for 5 to 10 minutes following the
insertion.
Dries the perineum and if there is excessive drainage applies a clean perineal pad
Removes gloves a repeats hand hygiene
Assesses and documents the procedure and the persons condition
Student:
Comments:
Date:
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RECTAL MEDICATION ADMINISTRATION
Reviews the medication chart and ensures that there is a valid order for the drug/s to be administered
Correct suppository
Clean glove
Lubricant
Demonstrates a person-centred approach to medication administration and obtains the persons
verbal consent
Closes curtain or door. Folds back the top bedclothes to expose only the buttocks.
Assists the person into the left lateral or left Sims position
U D
NA
FIRST CHECK: Compares the label on the medication container or package against the order on
the medication chart to ensure that the right medication is given
Repeats hand hygiene and dons a glove on the hand used to insert the suppository
Lubricates the smooth, rounded end of the suppository according to the manufacturers instructions
Lubricates the gloved index finger.
Asks the person to breathe through the mouth
Inserts the suppository gently into the anus, rounded end first according to the
manufacturers instructions and along the wall of the rectum with the gloved index finger.
For an adult, inserts the suppository 10 cm after passing the sphincter. For an infant or child,
inserts the suppository 5 cm or less after passing the sphincter.
Withdraws the finger and gently presses the persons buttocks together for a few minutes
Ask the person to remain flat or in the left lateral position for at least 5 minutes
Removes glove by turning it inside and repeats hand hygiene
Assesses and documents the procedure includes the type of suppository given/name of the
drug, the time it was given, the amount of time it was retained if it was expelled, the results or
effects, and the response of the person
Concludes encounter, ensures the persons comfort and informs them of follow up. Places the
call bell within reach of the person
Disposes of used equipment
Student:
Comments:
Date:
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SUBCUTANEOUS MEDICATION ADMINISTRATION
Reviews the medication chart and ensures that there is a valid order for the drug to be administered
Ensures the subcutaneous route is most appropriate for the person and for the type of
medication prescribed
Medication chart
Syringe, drawing up needle and administration
Antiseptic swabs
Clean gloves
Conducts appropriate assessments of the person and reviews related pathology results (if appropriate)
FIRST CHECK: Compares the label on the medication container or package against the order on
the medication chart to ensure that the right medication is given
SECOND CHECK: Compares the medication label with the medication chart. Checks the first
five rights of drug administration
THIRD CHECK: Rechecks the label on the container against the medication chart and rechecks
the five rights of drug administration
Withdraws the medication from the ampoules or vial using a non-touch technique and a
drawing up needle
Attaches regular needle and discards excess medication according to local policy
Assists the person into the correct position while maintaining their privacy
Selects an appropriate injection site
Cleans the injection site with an antiseptic swab
Inserts the needle and injects the medication appropriately
Discards the uncapped needle and attached syringe into the proper receptacle; does NOT recap
the needle
Concludes encounter and informs person of follow up
Student:
Comments:
NA
Date:
309
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INTRAMUSCULAR MEDICATION ADMINISTRATION
Reviews the medication chart and ensures that there is a valid order for the drug to be administered
Ensures the IMI route is most appropriate for the person and for the type of medication prescribed
Medication chart
Syringe, drawing up needle and administration needle
Antiseptic swabs
Clean gloves
Conducts appropriate assessments of the person and reviews related pathology results (if appropriate)
Withdraws the medication from the ampoules or vial using a non-touch technique and a
drawing up needle
Attaches regular needle and discards excess medication according to local policy
Assists the person into the correct position while maintaining their privacy
Selects an appropriate injection site
Inserts the needle and injects the medication appropriately
Removes the needle smoothly
Discards the uncapped needle and attached syringe into the proper receptacle; does NOT
recap the needle
Student:
Comments:
NA
Date:
310
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UNIT 6
SECTION 6.4

INTRAVENOUS MEDICATION ADMINISTRATION
NA
Reviews the medication chart and ensures that there is a valid order for the drug to be
administered
Ensures the IV route (bolus, burette or infusion) is most appropriate for the person and for
the type of medication prescribed
Determines whether the medication should be given by bolus injection, burette
(or piggy-back), or via an IV infusion
Medication chart
Antiseptic swabs
Clean gloves
Correct medication
Dilutent (if medication is in powdered form)
Sterile syringe of appropriate size
Sterile drawing up needle if not using a needleless system
Burette or piggy-back bag (if required)
IV additive label (for burette)
Sterile normal saline if there is a need to flush the cannula before or after the IV medication
on the medication chart to ensure that the right medication is given.
ENSURES TWO RNS ARE PRESENT TO CHECK THE MEDICATION
For bolus injections ensures the correct rate of injection is known
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Prepares the medication according to the manufacturers directions and withdraws into the
syringe using a non-touch technique and a drawing up needle (depending on hospital policy)
ADMINISTERING A BOLUS IV MEDICATION
Selects the injection port closest to the person
Stops the IV flow by closing the clamp or pinching the tubing above the injection port
Injects the medication at the correct rate
Withdraws the syringe
Resumes IV flow as ordered
ADMINISTERING AN IV MEDICATION VIA A BURETTE OR PIGGYBACK INFUSION
Fills the burette with the required amount of fluid to dilute the medication
Clamps the inflow line from the IV bag using the roller or slide clamp
Opens the air vent
Inserts the needle connected to the syringe into the medication port of the burette
Injects the medication into the burette and gently rotates and until well mixed
Opens the roller clap below the burette drip chamber to resume the IV at the correct flow rate
Completes the details on the additive label and attaches to the burette
ADMINISTERING AN IV MEDICATION VIA AN IV INFUSION
Cleans the injection port of the IV bag with an antiseptic swab
Inserts the needle connected to the syringe directly into the medication port of the bag
Ensures the amount of fluid in the bag is appropriate for the medication to be diluted
Injects the medication into the bag and gently rotates and until well mixed
Ensures the IV flow rate is correct
Completes the details on the additive label and attaches to the bag
Returns to the person to reassess the IV site and the IV infusion
Student:
Comments:
Date:
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Safe Administrations of Medications (Draft Chapter)

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UNIT 6

Author: Tracy Levett-Jones

Define the key terms related to medication administration.

Describe the legal and professional aspects of

Discuss the impact of person-centred care and

Identify the essential parts of a valid medication order.

Outline the types of medication preparations and routes

Outline the key components of a medication history.

List the five rights and three checks for safe

A medication (or drug) is a substance administered for

is the name given to it by drug manufacturers. Because one

STANDARDS FOR PRACTICE

This means that if a medical officer writes an incorrect order

Reform Commission, 2008). It is likely, however, that the

CLINICAL SAFETY ALERT

The impact of person-centred

TABLE 61 Effects of Drugs

The intended effect and the reason the drug is prescribed.

Example: the therapeutic effect of morphine sulfate is analgesia.

Example: An adverse effect of morphine sulfate may be respiratory depression.

SKILLS IN CLINICAL NURSING

name, which includes spelling the name to avoid an error

CLINICAL SAFETY ALERT

Full name of the person

In addition, unless it is a standing order, the medication

FIGURE 61The 24-hour clock

FIGURE 62National Inpatient Medication Chart (Continued )

FIGURE 62National Inpatient Medication Chart

TABLE 62 Acceptable Medication Terms and Abbreviations

ACCEPTED TERMS OR ABBREVIATIONS

Dose frequency or timing

three times a day

four times a day

every 4 hrs, 4 hourly, 4 hrly

every 6 hrs, 6 hourly, 6 hrly

every 8 hrs, 8 hourly, 8 hrly

three times a week

percutaneous enteral gastrostomy

peripherally inserted central catheter

Units of measure and concentation

SKILLS IN CLINICAL NURSING

TABLE 62 Acceptable Medication Terms and Abbreviations (Continued)

ACCEPTED TERMS OR ABBREVIATIONS

metered-dose inhaler, inhaler, MDI

patient controlled analgesia

Oral (including oral, sublingual and buccal)

TABLE 63 Types of Drug Preparation

Aerosol spray or foam

One or more drugs dissolved in water

One or more drugs finely divided in a liquid such as water

A solid form, shaped like a capsule, coated and easily swallowed

A gelatinous container to hold a drug in powder, liquid or oil form

A nongreasy, semisolid preparation used on the skin

A concentrated form of a drug made from vegetables or animals

A clear or translucent semisolid that liquefies when applied to the skin

A medication in a liquid suspension applied to the skin

TABLE6.3 Types of Drug Preparation (Continued )

An aqueous solution of sugar often used to disguise unpleasant-tasting drugs

An alcoholic or water-and-alcohol solution prepared from drugs derived from plants

Sections 6.26.4 in this unit describe these routes of

Taking a Medication History

the medication history, the nurse should also try to elicit

THE PROCESS OF SAFE AND

Information about the medication has been explained