Dispensing Lecture Reviewer

Prescription Order Writing

Definition: A prescription is a written, verbal, or
electronic order from a prescriber (e.g., physician,
dentist, podiatrist, nurse practitioner) to a pharmacist
for a particular medication for a specific medication at a
certain time.

*MDs must be registered with the DEA to prescribe

those drugs under the control of this act.
*Re-registration is mandatory every three years.
5. New - An original prescription order dispensed for
the first time.
6. Refill - A repeat dispensing of the original
prescription order.

Classification of Medications
Prescription= legend drug or medication
Prescription product label reads:
Caution: Federal Law Prohibits Dispensing without a
Prescription.

Usually, encompasses patients on maintenance therapy,

e.g., digoxin, phenytoin, lovastatin, potassium chloride.

Types of Prescriptions

1. Generic - The nonproprietary name provided by the

United States Adopted Name (USAN) Council
syn. Chemical Name
e.g., amoxicillin, fluoxetine, diazepam, aspirin

Schedule I - No medical use with a high abuse and

dependence potential

Schedule II - A written prescription is required for

this schedule. However, there are no refills
allowable.

Schedule III - Drugs in this schedule have a

moderate abuse and dependence potential
Schedule IV - Drugs in this schedule are considered
to have low abuse and low dependency potential
Schedule V - Drugs in this schedule have the least
amount of abuse potential and an unlikely
dependency

2. Brand Name - The proprietary name or registered

trademark name provided by the pioneer
(innovator) pharmaceutical company who holds the
patent on the drug
e.g., Prozac, Viagra, Xanax

Schedules of Controlled Substances

3. Compounded - Requires the preparation of one or

more active ingredients with one or more
pharmaceutical necessities, e.g., suspending agent,
flavoring agent, to create a finished product.

Nonprescription Medications

For example, an oral compounded prescriptions may be

used to facilitate the administration of a solid dosage
form that is not available in liquid form for patients
unable to swallow a solid dosage form.
e.g., pediatric, geriatric
4. Control Substance - Distribution of certain
medicines with abuse potential is controlled
through the Comprehensive Drug Abuse Prevention
and Control Act of 1970
*This Act is regulated and enforced by the federal Drug
Enforcement Agency (DEA)

Can be purchased at pharmacies and retail outlets

without a prescription (syn. Over-the-counter [OTC]
products)
To date, 99 drugs and/or drug dosage forms have
been switched from prescription to OTC status
(Note Appendix AA)
Besides South Africa, the US is the only country NOT
to have a third class of drugs. That is, available
through the pharmacist.
o FL has a pharmacist only class of
medications
o BTC being considered by FDA

National Coordinating Council for Medication Error

Reporting and Prevention (NCC-MERP) -- Founding
Members
American Association of Retired Persons;
American Health Care Association;
American Hospital Association;
AMA; American Nurses Association;
American Pharmacists Association;
American Society of Health-System Pharmacists;
DA; GPIA; JCAHO;
National Association of Boards of Pharmacy;
National Council of State Boards of Nursing, Inc;
PhRMA; United States Pharmacopeia
NCC-MERP Recommendations to Improve Error-Prone
Aspects of Prescription Writing
All prescriptions must be legible. Prescribers should
move to a direct, computerized, order entry system.
Handwriting examples:

o
o

having safety closures unless the

prescribing physician or the patient
specifically requests otherwise.
Signature Legible in indelible pencil or
pen. Signature selections:
DEA Number If necessary and, usually,
within the heading of the prescription blank
along with the physicians practice
information

Writing Conventions
For compounded prescriptions, when units are not
given, solids are assumed to be in grams (g) and liquids
in milliliters (ml).

Never write a decimal without a zero preceding it,

e.g., 0.15 g Clindamycin HCl. This helps to minimize
an error in translation

Never write a decimal with a zero following it, e.g.,

Propylene Glycol 6.0, Propylene Glycol 6

e.g., Rx Clindamycin HCl

Component Elements of the Prescription

Heading - Physicians name, practice address and

telephone number, DEA number
Date prescription is written
Patient Information - Name, address, age (esp., if
for a pediatric or geriatric patient)
Body of the Prescription
o RX Take Thou. Name of the prescribed
drug or drug product. Also included is the
strength of the medication, the number or
quantity of the prescribed drug in addition
to the dosage form
o Sig Signatura (i.e., Mark Thou).
Directions for use, e.g., one cap every 8 hrs.
o Refills N times or NR. Leaving this
section blank implies that the prescription is
non- refillable
o Generic Authorization Physician
signature on the dispense as written or
may substitute line
o No Child Resistant Packaging
Authorization All legend drugs intended
for oral use must be dispensed by the
pharmacist to the patient in containers

0.15

Propylene Glycol

Lavacol qsad

30

Sig:

Apply to affected area twice daily

*Avoid a tenfold overdose. Place a zero before the

decimal point.
*Avoid potential tenfold overdoses. Never follow drug
doses with a decimal point and zero. (example of 1mg
was read as 10 mg)

Sometimes a vertical line is used for the decimal

point, although, conceivably, it could be
confused as a number one.
______
e.g., Rx Chlorpheniramine
0 l 002
Aspirin
0 l 325
Dispense Caps
#12
Sig: One capsule po four times daily
for allergy and pain
*Avoid using unofficial abbreviations for drugs/drug
product names, e.g., PCN (Penicillin), SMX-TMP
(Sulfamethoxazole-Trimethoprim), TCN (Tetracycline),
KCl (Potassium Chloride), MOM (Milk of Magnesia). If
confused, contact the pharmacist.
2

Prescription Writing Suggestions

Intended to ensure patient safety and minimize

pharmacist intervention on behalf of the prescriber
and the patient.
Keep all prescription blanks in a safe place out of
patient reach. This avoids the temptation and
disappearance of blanks. Further, this procedure
minimizes the number of prescription pads in use.
Use a separate prescription blank for each
prescribed medication.
Ensure that refill directions are included on every
prescription.

Is it refillable or not?
if refillable, indicate the number of times or the
duration of time that refills are authorized. It will save
the prescriber time and interruptions in the long run.
Legally, aside from refill limitations associated with
controlled substances, a prescription refill for a
conventional, non-controlled medication has a one year
expiration time.

Attempt to make the prescription order alteration

proof.
Use indelible pencil or ink and for controlled
substances write the number and spell it out.
Otherwise, for example, a XII can be forged to
read XXX. Use the same pen or indelible pencil
for the entire prescription. If a mistake is made,
e.g., number of tablets, cross out the mistake,
write/print error above it, and then initial it.
Avoid writing a prescription for a large quantity of
drug unless it is absolutely determined that such a
quantity is necessary.

For an anticipated chronic medication, it is better to

start with a lower number at first in the event that the
patient cannot tolerate it because of side effects. Think
also of the economic considerations. Insurance plans
will limit the amount to one to three months at most.

When an institutional prescription blank is used,

the prescriber should clearly print his/her name,
address, DEA registration number on the blank.

Prescription writing for controlled

substances

Again, this is intended to ensure patient safety and

minimize pharmacist intervention on behalf of the
prescriber and the patient.
Use a separate prescription blank for each
substance prescribed.

Maintain only a minimum stock of controlled

substances in the medical bag, and it should be taken by
the physician while away from the automobile. Keeping
the medical bag locked in the automobile trunk is not
always an effective deterrent.

During the drug history, if a patient concedes that

he/she has received a controlled substance
prescription from another physician, consult that
physician or the hospital records, and/or examine
the patient to decide if a controlled substance
should be prescribed.
Do not allow the patient to dictate the controlled
substance, if any, to be prescribed. The patient may
be doctor shopping.
Maintain an accurate record of controlled
substance products dispensed as required by the
Controlled Substances Act.
A prescription order blank should only be used for
writing the prescription.
Do not use it to write a note and/or information for
the patient. An unscrupulous drug dealer or abuser
could erase the information easily and use the blank
to forge a prescription drug.
The prescriber should use the pharmacist as a
valuable resource when needed. Also, assist the
pharmacist when he/she inquires to verify
information about a prescription order. A
corresponding responsibility/liability rests with the
pharmacist who dispenses the prescription order.
Telephone the nearest DEA field office to secure
and/or furnish information. The call is held in
strictest confidence.

Unlabeled (syn Off-Label) Use (Indication)

Serendipitous observations (e.g., decreased

migraine headache attacks while maintained on blockers for cardiovascular therapy; sildenafil
citrate clinically evaluated for lowering blood
pressure demonstrating use for erectile
dysfunction) and therapeutic interventions of
physicians have led to medicines being prescribed
for unlabeled use for which the drug has not been
approved by the FDA.
The off-label use is supposed to be based upon a
rational scientific theory, expert medical opinion, or
evidence based on sound clinical trial(s).

Single Patient Compassionate Use

A FDA-requested mechanism for a physician to use

a drug in a single patient, usually in a desperate
situation when there is no response to other
therapies or in which there is no approved or
recognized treatment available.

Approval for a compassionate use may be sought in

the following situations when a(n):

*Commonly used for depression, cancer, HIV/AIDS,

dermatological disorders, and migraine.
*Common in the pediatric populationdanger AEs.
*In 2001, ~73% off label prescriptions were not
supported by scientific evidence.

The FDA makes clear that it neither has, nor desires,

the authority to compel physicians to adhere to
only official labeled indications. Simply,
experience has demonstrated that the official
indications lag behind scientific knowledge and
the scientific/medical literature.
A Supplemental New Drug Application (NDA) may
be filed by the drug manufacturer when approval is
sought for an additional indication for a drug
already approved for another indication. It has
been estimated that 40% of all prescriptions are
written for indications for which a Supplemental
NDA has not been filed. While this process is less
demanding, drug manufacturers do not want to
invest the time, energy, and $$ to do so.
Consequently, this has resulted in 75 to 90% offlabel prescribing for infants and children. The
caveat is less than desirable dosing and warnings
for the pediatric patient with increased incidence of
adverse effects.

IND is in effect, but the drug is still in the

early stages of testing.

IND is in effect, but the intent of the drug

use is not for the purpose described in the
IND.

drug has an IND, but it is not marketed.

drug has had previous FDA approval but has

been withdrawn from the market because
of questions regarding its safety.

drug is being investigated or marketed

outside of the US, but no IND is in effect
within the US.

Often, the FDA will permit the proposed use under

a commercial sponsors IND or under a new IND
filed by the physician in behalf of an identified
patient.

APPENDIX A

APPENDIX AA

CONVERSION FACTOR
Writing Conventions (contd)
Liquid household measures
Milliliter = ml
1 teaspoonful = 5 ml
1 tablespoonful = 15 ml
2 tablespoonfuls = 30 ml (approximately one
ounce)
8 fluid ounces ~ 240 ml
One pint = 16 fluid ounces = 473 ml
One quart = 32 fluid ounces = 946 ml
One gallon = 4 quarts = 8 pints = 3750 ml
gtts = drops (e.g., oral, ophthalmic, ear, topical)
Writing Conventions (contd)
Solid weights
mcg

microgram

mg

milligram

gram

gr
=
reserved
medications).

grain (old apothecary system

for older, traditional

Note for these one grain is equal to 60 mg.

Otherwise, one grain = 64.8 mg.
e.g., nitroglycerin, 1/150 gr, 1/200 gr, 1/400 gr;
phenobarbital, gr., gr.,1 gr.;
thyroid gr, gr, 1 gr.

APPENDIX C

REPUBLIC ACT NO. 6675

SEC. 3. DEFINITION OF TERMS
An act to promote, require and ensure the
production of an adequate supply, distribution,
use and acceptance of drugs and medicines
identified by their generic names.

Approved September 13, 1988

Identification of drugs and medicines by

their scientifically and internationally
recognized AI or by their official generic
name as determined by BFAD

Generics Act of 1988

Active Ingredient

SEC. 2 - STATEMENT OF POLICY

Chemical component responsible for the

claimed therapeutic effect of the
pharmaceutical product

SEC. 1 - TITLE

Promote, encourage and require the use

of generic terminology

Generic Name or Generic Terminology

Importation
Manufacture
Distribution
Marketing, advertising and promotion
Prescription and dispensing
Ensure adequate supply of drugs with
generic names at the lowest possible
cost
Endeavor to make them available for
free to indigent patients
Encourage the extensive use of drugs
with generic names
Emphasize scientific basis for use of
drugs
Promote drug safety by minimizing
duplication in medications and/or use of
drugs with potentially adverse drug
interactions

Chemical Name
Description of the chemical structure of
the drug or medicine
Complete identification of a compound
Drug Product
Finished product form that contains the
active ingredients
Generally but not necessarily in
association with inactive ingredients
Drug Establishment
Any organization or company involved in
the manufacture, importation, repacking
and/or distribution of drugs/medicines
Drug Outlets
Drugstores, pharmacies, and any other
business establishments which sell drugs
or medicines
10

Essential Drugs List or National Drug

Formulary
List of drugs prepared and periodically
updated by the DOH
Based on the health conditions obtaining
in the Philippines
Core List and Complementary List
Core List
Drugs that meets the health care needs
of the majority of the population
Complementary Drugs
List of alternative drugs used when there
is no response to the core essential drug
or when there is a hypersensitivity
reaction
Brand Name

SEC. 5. POSTING AND PUBLICATION

DOH
Shall publish annually in at least 2
newspapers of general circulation in the
Philippines
Generic names and the corresponding
brand names of all drugs and medicines
available in the Philippines
SEC. 8. REQUIRED PRODUCTION
Subject to the rules and regulations
promulgated by the Secretary of Health
Every drug manufacturing company
operating in the Philippines shall be
required to produce, distribute and
make available to the general public the
medicine it produces in the form of
generic drugs

Proprietary name given by the

manufacturer to distinguish its product
from those of competitors
Generic Drugs
Not covered by patent protection and
which are labeled solely by their INN or
Generic Name

11

REPUBLIC ACT 9502

Universally Accessible Cheaper and
Quality Medicines Act of 2008
AN ACT PROVIDING FOR CHEAPER AND
QUALITY MEDICINES, AMENDING FOR
THE PURPOSE REPUBLIC ACT NO. 8293
OR THE INTELLECTUAL PROPERTY CODE,
REPUBLIC ACT NO. 6675 OR THE
GENERICS ACT OF 1988, AND REPUBLIC
ACT NO. 5921 OR THE PHARMACY LAW,
AND FOR OTHER PURPOSES

Short Title. This Act shall be known as

the Universally Accessible Cheaper and
Quality Medicines Act of 2008
Definition of Terms
(a) Compulsory License
is a license issued by the Director
General of the Intellectual Property
Office to exploit a patented invention
without the permission of the patent
holder, either by manufacture or
through parallel importation;
(b) Drug outlet
refers to drugstores, pharmacies, and
any other business establishments which
sell drugs and medicines;
(c) Drugs and medicines

intended for use in the treatment,

prevention or diagnosis of disease in
humans or animals, including but not
limited to:
(1) any article recognized in the official
United States Pharmacopoeia-National
Formulary (USP-NF), official
Homeopathic Pharmacopoeia of the
United States, Philippine Pharmacopoeia,
Philippine National Drug Formulary,
British Pharmacopoeia, European
Pharmacopoeia, Japanese
Pharmacopoeia, Indian Pharmacopoeia,
any national compendium or any
supplement to any of them;
(2) any article intended for use in the
diagnosis, cure, mitigation, treatment, or
prevention of disease in humans or
animals;
(3) any article other than food intended
to affect the structure or any function of
the human body or animals;
(4) any article intended for use as a
component of any articles specified in
clauses (1), (2), and (3) not including
devices or their components, parts,
or accessories; and
(5) herbal and/or traditional drugs which
are articles of plant or animal origin used
in folk medicine which are:

refers to any chemical compound or

biological substance, other than food,
12

(i) recognized in the Philippine National

Drug Formulary;
(ii) intended for use in the treatment or
cure or mitigation of disease symptoms,
injury or body defects in humans;
(iii) other than food, intended to affect
the structure or any function of the
human body;
(iv) in finished or ready-to-use dosage
form; and
(v) intended for use as a component of
any of the articles
specified in
clauses (i), (ii), (iii), and (iv);
(d) Essential drugs list or national drug
formulary
refers to a list of drugs prepared and
periodically updated by the Department
of Health on the basis of health
conditions obtaining in the Philippines as
well as on internationally accepted
criteria;
(e)Importer
refers to any establishment that imports
raw materials, active ingredients and
finished products for its own use or for
distribution to other drug
establishments or outlets;
(f) Manufacture
includes any process or part of a process
for making, altering, finishing, packing,

labeling, breaking or otherwise treating

or adapting any drug with a view to its
sale and distribution, but does not
include the compounding or dispensing
of any drug in the ordinary course of
retail business;
(g) Manufacturer
refers to any establishment engaged in
the operations involved in the
production of a drug with the end view
of storage, distribution, or sale of the
product
(h) Multisource pharmaceutical
products
refers to pharmaceutically equivalent or
pharmaceutically alternative products
that may or may not be therapeutically
equivalent. Multisource pharmaceutical
products that are therapeutically
equivalent are interchangeable;
(i) Retailer
refers to a licensed establishment
carrying on the retail business of sale of
drugs and medicines to customers;
(j) Trader
refers to any licensed establishment
which is a registered owner of a drug
product that procures the materials and
packaging components, and provides the
production monographs, quality control
standards and procedures, but
13

subcontracts the manufacture of such

products to a licensed manufacturer;
(k) TRIPS Agreement
or Agreement on Trade-Related Aspects
of Intellectual Property Rights
refers to the international agreement
administered by the WTO that sets down
minimum standards for many forms of
intellectual property regulation; and
(l) Wholesaler
refers to a licensed establishment or
drug outlet who acts as merchant,
broker or agent, who sells or distributes
for resale or wholesale drugs and
medicines.
SEC. 17. DRUGS AND MEDICINES PRICE
REGULATION AUTHORITY OF THE
PRESIDENT OF THE PHILIPPINES.
President have the power to impose
maximum retail prices over any or all
drugs and medicines as enumerated in
Section 23, upon recommendation of
the Secretary of the Department of
Health.
SEC. 18. DRUGS AND MEDICINES PRICE
MONITORING AND REGULATION
AUTHORITY OF THE SECRETARY OF THE
DEPARTMENT OF HEALTH.

SEC 6. Who shall use Generic Terminology

As amended:
(e) There shall be appear prominently on
the label of a generic drug the following
statement: THIS PRODUCT HAS THE SAME
THERAPEUTIC EFFICACY AS ANY OTHER
GENERIC PRODUCT OF THE SAME NAME,
SIGNED: BFAD.
SEC 8. Required Production:
Subject to the rules and regulations
promulgated by the Secretary of Health,
every drug manufacturing company
operating in the Philippines shall be
required to produce, distribute and
make widely available to the general
public an unbranded generic counterpart
of their branded product
SEC. 43. Sale of medicines,
pharmaceuticals, drugs and devices
No medicine, pharmaceutical, or drug,
EXCEPT FOR THOSE WHICH ARE NONPRESCRIPTION OR OVER-THE-COUNTER,
of whatever nature and kind or device
shall be compounded, dispensed, sold or
resold, or otherwise be made available
to the consuming public except through
a prescription drugstore or hospital
pharmacy, duly established in
accordance with the provisions of this
Act.

14

 non-prescription or over-the-counter
drugs may be sold in their original
packages, bottles, containers or in small
quantities, not in their original
containers to the consuming public
through supermarkets, convenience
stores and other retail establishments.
Pharmaceutical, drug or biological
manufacturing establishments,
importers and wholesalers of drugs,
medicines, or biological products
o SHALL NOT SELL THEIR PRODUCTS
FOR RE-SALE EXCEPT ONLY TO
RETAIL DRUG OUTLETS, HOSPITAL
PHARMACIES OR TO OTHER DRUG
WHOLESALERS UNDER THE
SUPERVISION OF A REGISTERED
PHARMACIST, AND
SUPERMARKETS, CONVENIENCE
STORES, OTHER RETAIL
ESTABLISHMENTS FOR OVER-THECOUNTER DRUGS, DULY LICENSED
BY THE BUREAU OF FOOD AND
DRUGS.

15

ROUTES OF DRUG
ADMINISTRATION
Factors Influencing the Route of Administration
A route of administration is a way of getting a
drug onto or into the body
Drugs come in many different forms:
o designed by pharmaceutical scientists
for administration or application
Many factors determine the choice of route of
administration
Ease of Administration
Prescribers assess characteristics to determine
route of administration
o some patients are unable swallow
o very young or older adult patients might
have difficulty swallowing
avoid solid, oral dose forms in
favor of liquid dose forms or
nonoral routes of administration
o oral route of administration is
inadvisable for a patient experiencing
nausea and vomiting
Site of Action
Choice of route of administration is influenced
by desired site of action
The term local use refers to site-specific
applications of drugs
The term systemic use refers to the application
of a drug to the site of action by absorption into
the blood and subsequent transportation
throughout the body
o even drugs meant for systemic
administration are usually targeted to a
specific site of action

Onset of Action
Onset rate varies with route of administration:
Oral medications for systemic use must proceed
through a series of steps before they exert their
therapeutic effect (desired pharmaceutical action
on the body)
Liquid solutions or suspensions work faster
than oral tablets or capsules
o medication is more readily available for
absorption
Tablets placed under tongue or between cheek
and gums work quickly
o medication bypasses stomach and liver,
goes directly into bloodstream
Drugs injected/infused directly into
bloodstream are carried immediately
throughout the body
Topical medications work quickly
o localized therapeutic effects, especially
those
applied to the skin
inhaled into the lungs
instilled into the eye
Duration of Action
The duration of action is the length of time a
drug gives the desired response or is at the
therapeutic level
Controlled- /extended-release tablet may last
for 12 to 24 hours compared with 4 to 6 hours
for same drug in immediate-release
formulation
Transdermal patches deliver small amounts of a
drug steadily over many hours or even days
Sustained-duration effect can be achieved by
means of intravenous (IV) infusion
Injections into the muscle and skin last longer
than injections directly into the bloodstream

16

Quantity of Drug
Sometimes route of administration is chosen
because of the amount of a drug
o a tablet containing a lot of filler (diluent)
might be preferred for a drug containing a
very small amount of active ingredient
IV infusion is an excellent method for systemic
delivery of large quantities of material
o rapidly diluted in the bloodstream
IV injections and infusions can deliver a higher
dose of medication to the target site
o important in serious illnesses
METABOLISM BY THE LIVER OR EXCRETION BY THE
KIDNEY
Liver metabolism breaks down active drug to
inactive metabolites for elimination and to
prevent drug accumulation
The first-pass effect is the extent to which a
drug is metabolized by the liver before reaching
systemic circulation
o influences activity of several drugs
o such drugs have to be given in large oral
doses or by another route of administration
to bypass or overcome metabolism by the
liver
Age-related or disease-related changes in liver
or kidney function can cause:
o drug accumulation
o toxicity
Older patients are often prescribed lower doses
of medication
If patients are on multiple potent prescription
drugs, there is a risk of a drug-drug interaction
o drug accumulation
o toxic blood levels increases
TOXICITY
Toxicology is the study of toxic effects of drugs
or other substances on the body
Physicians must weigh therapeutic benefit
against the risk of toxicity

Some drugs have a narrow therapeutic-toxic

index called the therapeutic window
o very little difference exists in the
therapeutic versus toxic blood level
o laboratory drug levels are ordered if the
physician suspects toxicity
Toxicity of a drug may affect route of
administration
ORAL ROUTES OF ADMINISTRATION
Oral refers to two methods of administration:
o applying topically to the mouth
o swallowing for absorption along the
gastrointestinal (GI) tract into systemic
circulation
o po (from the Latin per os) is the
abbreviation used to indicate oral route of
medication administration
ORAL DOSE FORMS
Common dose forms for oral administration
o tablets
o capsules
o liquids
o solutions
o suspensions
o syrups
o elixirs
Sublingual administration is where the dose
form is placed under the tongue
rapidly absorbed by sublingual
mucosa
Buccal administration is where the dose form
is placed between gums and inner lining of the
cheek (buccal pouch)
absorbed by buccal mucosa
Dose forms for sublingual and buccal
administration:
tablets
lozenges
gum

17

Capsules are preferred over tablets for patients

with difficulty swallowing
Water preferred over beverages
to aid in swallowing
Some dose forms are designed to
be sprinkled on food when
swallowing a solid is difficult
Liquid doses are swallowed more easily and are
suitable for:
o patients with swallowing difficulties
o small children

ADVANTAGES AND DISADVANTAGES OF THE ORAL

ROUTE
Ease and safety of administration
Active ingredient is generally contained in
powders or granules which dissolve in GI tract
Sublingual (and buccal) administration has a
rapid onset (less than 5 minutes)
Delayed onset
o dose form must disintegrate before
absorption
Destruction or dilution of drug by
o GI fluids
o food or drink in stomach or intestines
Not indicated in patients who
o have nausea or vomiting
o are comatose, sedated, or otherwise unable
to swallow
Unpleasant taste of some liquid dose forms
o must be masked by flavorings to promote
compliance
Sublingual (and buccal) administration has a
short duration of action
o less than 30 to 60 minutes
o not appropriate for routine delivery of
medication
Buccal route may have
o medicinal taste
o local mouth irritation

DISPENSING ORAL MEDICATIONS

Patients should be told:
Not to crush tablets or open capsules intended
to be swallowed whole
o e.g., sustained-release, long-acting, and
enteric-coated drugs
What foods to take (and not take) the
medication with
What behaviors to avoid while taking the
medication
The dispensed drug package may include
colorful auxiliary labels to remind the patient
what to do (or not do) while taking a
medication

Patients need instruction on proper storage of

nitroglycerin
Sublingual nitroglycerin tablets should be
stored in their original container (brown glass
bottle)
o lid screwed on tightly to prevent
sunlight and air from causing potency
loss
o pillboxes are not recommended
18

o refill nitroglycerin with a fresh bottle

every 6 months
ADMINISTERING ORAL MEDICATIONS
Patients with difficulty in swallowing solids
should place the dose on the back of the
tongue and tilt the head forward
Liquid medication doses must
be accurately measured
o in a medication cup
o medication measuring spoon
Common household utensils are
not accurate
o an oral syringe or measuring dropper
may be used for infants or small
children
Buccally administered nicotine gum
o proper administration allows the gum to
release nicotine slowly and decrease
cravings

Proper administration technique:

o Chew the gum slowly and stop chewing
when you notice a tingling sensation in
the mouth.
o Park the gum between the cheek and
gum, and leave it there until the taste or
tingling sensation is almost gone.
o Resume slowly chewing a few more
times until the taste or sensation
returns.
o Park the gum again in a different place
in the mouth.
o Continue this chewing and parking
process until the taste or tingle no
longer returns when the gum is chewed
(usually 30 minutes).

Proper administration technique for buccally

administered lozenges:
o Allow lozenge to dissolve slowly over a
30-minute period without chewing or
swallowing.
o A tingling sensation (from the release of
nicotine) is expected.
Topical Routes of Administration
Topical administration is the application of a
drug directly to the surface of the skin
Includes administration of drugs to any mucous
membrane
o eye
o vagina
o nose
o urethra
o ears
o colon
o lungs
Topical Dose Forms
Dose forms for topical administration include:
Skin:
o Creams
o Ointments
o Lotions
o Gels
o transdermal patches
o disks
Vagina:
o tablets
o creams
o ointments
Urethra:
o inserts
o suppositories
Rectum:
o creams
o ointments
o solutions
o foams
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Eye or ear:
o solutions
o suspensions
o ointments
Nose and lungs:
o sprays and powders
Transdermal administration:
o delivers drug to bloodstream via absorption
through the skin via a patch or disk
Skin presents a barrier to ready absorption
o absorption occurs slowly
o therapeutic effects last for 24 hours up to 1
week
Chemicals in the patch or disc force drug
o across membranes of the skin
o into layer where absorption into
bloodstream occurs
Ocular administration is the application of a
drug to the eye
Conjunctival administration is the application of
a drug to the conjunctival mucosa or lining of
the inside of the eyelid
Nasal administration is the application of a drug
into the passages of the nose
Otic administration is the application of a drug
to the ear canal

ADVANTAGES AND DISADVANTAGES OF THE

TOPICAL ROUTE

Rectal dosage forms:

Suppository
o solid dose form formulated to melt in
the rectum at body temperature and
release the active drug
Creams, ointments, and foams
o used for local effects
Rectal solutions, or enemas used for
o cleansing the bowel
o laxative or cathartic action
o drug administration in colon disease

Local therapeutic effects

Not well absorbed into the deeper layers of the
skin or mucous membrane
o lower risk of side effects
Transdermal route offers steady level of drug in
the system
o sprays for inhalation through the nose
may be for local or systemic effects
The intrarespiratory route of administration is
the application of drug through inhalation into
the lungs, typically through the mouth
o lungs are designed for exchange of
gases from tissues into bloodstream
o usual dose form is an aerosol
o environmental friendly propellants
now required to replace
chlorofluorocarbons (CFCs)
A metered-dose inhaler (MDI) is a common
device used to administer a drug in the form of
compressed gas through inhalation into the
lungs
A diskus is a newer dosage form to administer
drug to lungs as micronized powder
Advantages and Disadvantages of the Topical
Route
The vaginal route of administration is
application of drug via cream or insertion of
tablet into the vagina
Common dose forms include:
o Emulsion foams
o Inserts
o Ointments
o Sponges
o Solutions
o Suppositories
o Tablets

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The vaginal route is preferred for:

o cleansing
o contraception
o treatment of infections
Major disadvantages:
o Inconvenience
o messiness
The urethral route of administration is
application of drug by insertion into the urethra
Common dose forms include:
o solutions
o suppositories
Urethral delivery may be used to treat
o incontinence
o impotence in men
Disadvantages
o inconvenience
o localized pain
Rectal administration is a preferred method
when:
An oral drug might be destroyed or diluted by
acidic fluids in the stomach
An oral drug might be too readily metabolized
by the liver and eliminated from the body
The patient is unconscious and needs
medication
Nausea and vomiting or severe acute illness in
the GI tract make patient unable to take oral
drugs
Rectal administration disadvantages:
inconvenience
erratic and irregular drug absorption
Dispensing and Administering Topical Medications
It is important for the patient to understand
appropriate use and administration of topical
drugs at the time of dispensing
Improper technique or overuse of topical drugs
can
increase the risk of side effects

alter drug efficacy

Ointments, Creams, Lotions and Gels
Dose forms should be applied as directed
o generally applied to the skin
o lotions, creams, and gels are worked
into the skin
o ointments are skin protectants and do
not work into the skin but stay on the
surface
When using nitroglycerin ointment the patient or
caregiver should wear gloves
to avoid absorbing excessive amounts of drug,
which could cause a headache
When using topical corticosteroids:
Apply sparingly to affected areas for short
periods of time
Affected area should not be covered up with a
bandage unless directed by the physician
occlusive dressings can significantly increase
drug absorption and risk of side effects
Overuse of potent topical corticosteroids can
lead to serious systemic side effects
Transdermal Patches
Site of administration must be rotated and
relatively hair free
Should not be placed over a large area of scar
tissue
Some are replaced every day, others maintain
their effect for 3 to 7 days
Some patients should remove nitroglycerin
patch at bedtime to prevent development of
drug tolerance where the body requires higher
doses of drug to produce the same therapeutic
effect.
Some testosterone patches are applied to the
skin of the scrotum

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OPHTHALMIC MEDICATIONS
Must be at room temperature or body
temperature before application
Should be stored according to package
information
o reduces bacterial growth
o ensures stability
Considered sterile products
o only preparations with preservatives
can be repeatedly used
Before application, patient should wash hands
o prevents contamination of application
site
Tube or dropper should not touch the
application site
o medication may become contaminated
Only sterile ophthalmic solutions or
suspensions should be used in the eye
o not preparations intended for other
uses (e.g., otic)
Some products are unit of use
o to be used for one administration only
and then discarded
Previously applied medications should be
cleaned away
o also any drainage from the eye
Intended location is the conjunctiva
Poorly administered eye drops could result in
loss of medication through the tear duct
Poorly placed ointments may be distributed
over the eyelids and lashes
Patients head should be tilted back
After administration, the patient should place a
finger in the corner of the eye, next to the nose
to close the lacrimal gently
o prevents loss of medication through
tear duct
Patient should also keep the eyes closed for 1or
2 minutes after application

When multiple drops of more than one

medication are to be administered, the patient
should wait 5 minutes between different
medications
o the first drop may be washed away
If an ointment and a drop are used together,
the drop is used first
o wait 10 minutes before applying the
ointment
Ointments are generally applied at night
o drug form of choice when extended
contact with the medication is desired
o remind patient that some temporary
blurring of vision may occur after
application
OTIC MEDICATIONS
Must be at room temperature or body
temperature
o heated drops may cause rupturing of
the eardrum
o cold drops can cause vertigo and
discomfort
Old medication should be removed along with
any drainage before applying fresh medication
Alcohol causes pain and burning sensation
o should not be used if the patient has a
ruptured tympanic membrane
(eardrum)
Tilt head to side with ear facing up
o 2 to 5 minutes
Cotton swabs placed in the ear after
administration of drops will prevent excess
medication from dripping out of the ear
o swabs will not reduce drug absorption

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NASAL MEDICATIONS
Applied by:
o drops (instillation)
o sprays
o aerosol (spray under pressure)
o Used for:
o relief of nasal congestion or allergy
symptoms
o administration of flu vaccine
Patient should:
o tilt head back
o insert dropper or spray or aerosol tip
into the nostril pointed toward the eyes
o apply prescribed number of drops or
sprays in each nostril
Breathing should be through mouth to avoid
sniffing medication into the sinuses
Important not to overuse nasal decongestants
o follow label instructions carefully
INHALED MEDICATIONS
Metered-dose inhalers (MDI) provide
medication with compressed gas
o deliver specific measured dose with
each activation
Some devices use a powder or nonaerosolized
spray for inhalation instead of compressed gas
Nebulizers create a mist when a stream of air
flows over a liquid
o commonly utilized for young children or
elderly patients with asthma or lung
disease
Proper administration of aerosolized medications:
Shake canister well
Prime by pressing down and activating a
practice dose.
Insert canister into a mouthpiece or spacer to
reduce the amount of drug deposited on the
back of the throat.
Breathe out and hold spacer between lips
making a seal.

Activate MDI and take a deep slow inhalation.

Hold breath briefly and slowly exhale through
the nose.

VAGINAL MEDICATIONS
Indicated for
o bacterial or fungal infection
o hormone replacement therapy
o The patient is instructed to use the
medication for the prescribed period to
ensure effective treatment
Application should follow a specific technique:
Begin with an empty bladder and washed
hands.
Open the container and place dose in
applicator.
Lubricate applicator with water-soluble
lubricant if not pre-lubricated.
Lie down, spread the legs, open the labia with
one hand, and insert the applicator about two
inches into the vagina with the other hand.
Release labia; use free hand to push applicator
plunger.
Withdraw the applicator and wash the hands.
RECTAL MEDICATIONS
Suppository
o remove suppository from its package
o insert small tapered end first with index
finger for the full length of the finger
o may need to be lubricated with a watersoluble gel to ease insertion
Enemas
o rectal injection of a solution
Parenteral Routes of Administration
Parenteral administration is injection or
infusion by means of a needle or catheter
inserted into the body
Parenteral forms deserve special attention
o Complexity
o widespread use
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o potential for therapeutic benefit and

danger
The term parenteral comes from Greek words
para, meaning outside enteron, meaning the
intestine
This route of administration bypasses the
alimentary canal
Parenteral preparations must be sterile
o free of microorganisms
To ensure sterility, parenterals are prepared using
aseptic techniques
special clothing (gowns, masks, hair net, gloves)
laminar flow hoods placed in special rooms
IV route
o directly into a vein
Prepared in hospitals and home healthcare
pharmacies
o antibiotics
o chemotherapy
o nutrition
o critical care medications
Intramuscular (IM) injections
o into a muscle
Subcutaneous injections
o under the skin
Intradermal (ID) injections
o into the skin
Disposable syringes and needles are used to
administer drugs by injection
Different sizes are available depending on the
type of mediation and injection needed

Advantages and Disadvantages of the Parenteral

Route

The IV route is the fastest method for delivering

systemic drugs
o preferred administration in an
emergency situation
It can provide fluids, electrolytes, and nutrition
o patients who cannot take food or have
serious problems with the GI tract
It provides higher concentration of drug to
bloodstream or tissues
o advantageous in serious bacterial
infection
V infusion provides a continuous amount of
needed medication
o without fluctuation in blood levels of
other routes
infusion rate can be adjusted
o to provide more or less medication as
the situation dictates
Traumatic injury from the insertion of needle
Potential for introducing:
o toxic agents
o microbes
o pyrogens
Impossible to retrieve if adverse reaction
occurs
o injected directly into the body
Intramuscular (IM) and subcutaneous routes of
administration are convenient ways to deliver
medications
Compared with the IV route:
o onset of response of the medication is
slower
o duration of action is much longer
Practical for use outside the hospital
Used for drugs which are not active orally

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For intramuscular (IM) and subcutaneous

routes of administration, the injection site
needs to be prepped
o using alcohol wipe
Correct syringe, needle, and technique must be
used
Rotation of injection sites with long-term use
o prevents scarring and other skin
changes
o can influence drug absorption
The intradermal (ID) route of administration is
used for diagnostic and allergy skin testing
o patient may experience a severe local
reaction if allergic or has prior exposure
to a testing antigen

DISPENSING AND ADMINISTERING PARENTERAL

MEDICATIONS
Most parenteral preparations are made up of
ingredients in a sterile-water medium
o the body is primarily an aqueous (watercontaining) vehicle
Parenteral preparations are usually:
o solutions
o suspensions
IV injections and infusions are introduced
directly into the bloodstream
o must be free of air bubbles and
particulate matter
o introduction of air or particles might
cause embolism, blockage in a vessel, or
severe painful reaction at the injection
site
INTRAVENOUS INJECTIONS OR INFUSIONS

Fast-acting route because the drug goes

directly into the bloodstream
o often used in the emergency
department and in critical care areas
Commonly used
o for fluid and electrolyte replacement

o to provide necessary nutrition to the

patient who is critically ill
Intravenous (IV) injections are administered at
a 15- to 20-degree angle
INTRAMUSCULAR INJECTIONS

Care must be taken with deep IM injections to

avoid hitting a vein, artery, or nerve
In adults, IM injections are given into upper,
outer portion of the gluteus maximus
o large muscle on either side of the
buttocks
For children and some adults, IM injections are
given into the deltoid muscles of the shoulders
Typical needle is 22- to 25-gauge - to 1-inch
needle
Intramuscular (IM) injections are administered
at a 90-degree angle
o volume limited to less than 3 mL
Intramuscular Injections
Used to administer
o antibiotics
o vitamins
o iron
o vaccines
Absorption of drug by IM route is unpredictable
o not recommended for patients who are
unconscious or in a shocklike state

INTRADERMAL INJECTIONS

Given into capillary-rich layer just below

epidermis for
o local anesthesia
o diagnostic tests
o immunizations
Examples of ID injections include
skin test for tuberculosis (TB) or fungal
infections
o typical site is the upper forearm, below
the area where IV injections are given
allergy skin testing
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o small amounts of various allergens are

administered to detect allergies
o usually on the back
SUBCUTANEOUS INJECTIONS
Administer medications below the skin into the
subcutaneous fat
o outside of the upper arm
o top of the thigh
o lower portion of each side of the
abdomen
o not into grossly adipose, hardened,
inflamed, or swollen tissue
Often have a longer onset of action and a
longer duration of action
o compared with IM or IV injection
Insulin is given using 28- to 30-gauge short
needles
o in special syringe that measures in units
Insulin is administered following a plan for site
rotation
o to avoid or minimize local skin reactions
Absorption may vary depending on
o site of administration
o activity level of the patient
Keep insulin refrigerated
Check expiration dates frequently
o opened vials should be discarded after
one month
A vial of insulin is agitated and warmed by
rolling between the hands and should never be
shaken
The rubber stopper should be wiped with an
alcohol wipe
When administering insulin, air is injected into
vial
o equal to the amount of insulin to be
withdrawn
Air is gently pushed from syringe with the
plunger

Patient should plan meals, exercise, and insulin

administration
o to gain the best advantage of the
medication
o avoid chances of creating hypoglycemia
Medications administered by this route include:
o epinephrine (or adrenaline)
for emergency asthmatic attacks
or allergic reactions
o heparin or low molecularweight
heparins
to prevent blood clots
o sumatriptan or Imitrex
for migraines
o many vaccines
Normally given with the syringe held at a 45degree angle
o in lean older patients with less tissue
and obese patients with more tissue,
the syringe should be held at more of a
90-degree angle
Correct length of needle is determined by a skin
pinch in the injection area
o proper length is one half the thickness
of the pinch
Given at a 45-degree angle
o 25- or 26-gauge needle, 3/8 to 5/8 inch
length
No more then 1.5 mL should be injected into
the site
o to avoid pressure on sensory nerves
causing pain and discomfort

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