Medication Administration

Medication Administration is the Route

     Medication administration focuses on the route used to give a medication. On Medication Management, there is a definition for the word “route,” which includes the following list of ways to administer medications.  

 

 Medications are given by mouth, in the muscle (intramuscularly), in the fat layer (subcutaneously), rectally, through a tube into the stomach, under the tongue, held in the cheek, given as eye drops, nose drops, inhaled, swallowed, injected, given in a vein, into the spinal cord, into joints, as ear drops, skin cream, ointments, emulsions, and even more that don’t come to mind right now. 

 

Routes are Unique

     Each route is a unique method serving a particular purpose and has procedures and processes that make them more or less effective. I provided the information below to bring you the details you need to learn those necessary facts.  The videos at the bottom of the page show you how to administer the medications using the techniques described above. I did not highlight all medication administration techniques; only those used most often or that posed more risk. 

Giving Medicine by Mouth

     Giving medicine by mouth seems simple enough. We’ve all been taking oral medication since we were babies.  What more is there to know now that you’re a caregiver? Maybe nothing new, but it’s best not to assume anything because doing a task for someone else is always a little different than doing it for yourself.

    Giving oral medication to elderly woman      
Let’s go over some important points to keep in mind. Dealing with Confusion
  • If your care-receiver is confused, they may not trust you and not want to take their medicine. Often, your care-receiver will try to trick you by holding the medication under the tongue, inside the cheek, or in the roof of the mouth for hours until you leave, and they can spit it out. If you suspect they are hoarding medication, you might need to use a flashlight and a tongue depressor to check inside their mouth to look for pills. Use a tongue depressor or popsicle stick to move the tongue around and not your hand so you won’t get bitten.
  • If you leave medicine beside the bed for them to take when you go, check later to make sure they took it. You may find it in the trash, under a pillow, or any number of other places.
  • If they are responsible for taking their medication and remembering to do so, using a weekly/daily dispenser is very helpful as a reminder and crosscheck to help them (and you) know if they have taken the dose due at that time.
Choking Risks
  • If choking on pills due to the size is a risk, you can try cutting the tablets in half (you can buy pill cutters) or get an order for the medication to change to a suspension form instead. You can’t cut all the tablets in half. Some are time-released or enteric-coated to break-down in specific sections of the GI tract. Therefore, the integrity of the medication may be compromised if broken. If you are uncertain about cutting it, check with your pharmacist.
  • In addition to cutting tablets in half, you can crush them and mix them with food or beverages that are compatible and liked by the care receiver. Warning, though, sometimes crushing medications makes them very bitter and difficult to tolerate.
Accurate Measurements
  • When measuring a liquid medicine, pour it at eye level and note the dose at the bottom of the liquid bubble formed when the medicine flows. When finished, set the medicine cup on a solid surface to make sure the measurement is accurate.
Don’t Administer Through a Tube
  • If you are giving medicine through a GI tube, you can’t give anything that is enteric coated, or time-released, and all tablets must be crushed well enough not to clog the tube. It’s essential to flush the pipe well afterward.

How Often Do I Need TO Check Tube Placement

     Placement should be confirmed every 4-6 hours. It’s a good idea to know two different methods to check tube placements. If you have doubts about one, the other can serve as a confirmation test.

 

Methods:

     One way is to attach a large syringe to the end of your tube and pull back any contents into the tubing.  If what you pull back looks like formula or clear liquids, then you probably are pulling back stomach contents. 

 

     The second method is to measure the distance from the end of the tube to the stoma.  Is it still the same length as when first inserted? Of course, this method requires that you know the original distance between the stoma and farthest end.

 

     If you don’t feel confident that your tube is in the correct place, do not give the medication or feeding. Call your doctor.

Steps for Giving Medicine Through G or J Tube

  1. Gather supplies
  2. Insert Extension Tubing
  3. Clamp Tubing
  4. Draw up Medication
  5. Unclamp Tubing
  6. Inject Medicine
  7. Clamp Tubing
  8. Draw Up Water for Flush and attach to port
  9. Unclamp Tube
  10. Inject Flush
  11. Clamp Tubing and Disconnect Extension Tube 

Steps to Giving Sublingual Nitroglycerin

  1. Place the tablet or spray the medicine under their tongue.
  2. Do not let them eat or drink anything after taking medicine.
  3. Monitor blood pressure and chest pain while waiting.
  4. If the chest pain has not stopped, you may repeat the dose in five minutes.
  5. Repeat the dose a third time in five minutes if pain continues.
  6. Keep the doctor informed throughout of your family member’s response.

YouTube Video Resources

How to Split A Pill in Half    

This video presents information on how to split a medicine into equal parts. Some medicines are scored in advance by the manufacturer to make breaking them easy; others are not. Some you can use a pill-splitter to break. Not all pills can be cut in half safely. If you are not sure that you have an exact amount, consult with a pharmacist regarding how to determine the dosage you may give or throw it away and start over. You don’t want to provide an amount that might cause harm.

Crushing Medications for a Tube Feeding or to give Orally 

 Feeding tubes serve as reliable alternatives when patients are unable to take food or medicines by mouth. However, many medications are too large to pass through the lumen of a tube without becoming stuck.  Therefore, they must be crushed and mixed with something that can transport them through the NG tube to the stomach. This video demonstrates the procedure for grinding medication and then mixing them for delivery. Time-released drugs are delivered too quickly through NG tubes to work correctly. Also, if you crush pills with enteric coatings, they lose their protection and irritate the stomach lining.  In both cases, ask for alternate forms of the medicines rather than put them through an NG tube.

Do Not Crush Medication Mnemonic 

 

The nurse who produced the video developed a mnemonic to remember when not to crush pills.  The mnemonic is, “Seniors  Erroneously Crush Enteric-Coated Laxatives.” The mnemonic goes as follows:  Seniors (Sustained Released), Erroneously (Extended Released), Crush (Controlled Released), Enteric-Coated (Enteric-Coasted), Laxatives (Long-Acting). I think it’s kind of complicated to remember but if it helps you, I think that’s great.  All you really need to know anyway is which ones you can’t crush for your family member.  Usually, it’s just the ones that are timed released or enteric-coated.  Ask your pharmacist for assistance if you have questions. 

How to Take Eye Drops

 

Putting drops in the eye properly without missing the target or wasting medicine is difficult for many people. This video shows the proper way to take drops and gives two simple methods for people who can’t bring themselves to put anything into their own eyes. Also included are important tips on the timing of eye drops and how to reduce stinging.

Giving a Nebulizer Treatment

Nebulizers deliver medications that help you to breathe.  A nebulizer is a motor that pumps air through a tube and comes up through the medicine so that a mist is formed. The mist is breathed in through a mouthpiece, mask, or tee adapter.  Following each treatment, clean the supplies with soap and water to prevent the spread of infection. The video provides additional information regarding infection control and troubleshooting equipment issues. 

How to Apply and Remove a Transdermal Patch

A popular treatment for pain management is the use of a Fentanyl patch. Since Fentanyl is a narcotic, you must be careful to monitor its use.  It can cause a lot of heavy sedation and drops in blood pressure and breathing. This video reviews the impact and cautions associated with Fentanyl use. Caution must be applied whenever you work with transdermal patches (i.e., patches impregnated with medication). The reason you take precautions is that the drug affects whoever touches it the same way.  Therefore, you must be particularly careful when placing it on the patient. Even when removing it, you need to carefully remove it using gloves. 

YouTube Video Resources

Giving Medicines through a G-Tube or J-Tube

Children’s Hospital of Wisconsin’s Gastroenterology, Liver and Nutrition Program staff show and discuss how to give medicines through a G-tube.

Important Reminders:

  1. If you are giving more than one medication at a time, use about 10 ml of water between each medicine to flush the line clear to help prevent clotting.
  2. Always finish up with a flush to clear the line to prevent help prevent clotting
  3. If you are having difficulty getting the medication to flow with gravity, you may try milking the tubing gently with your fingers by squeezing the tube downward gently.

How Often Do I need to Check Tube Placement?

Guidelines on how to check placement on a nasogastric tube prior to starting a tube feeding

Withdrawing Medications from an Ampule

Medications occasionally come in ampules. Open the ampule by snapping it in half after wiping the neck with alcohol and wrapping it in gauze.  Withdrawn the medicine from the ampule using a filter needle to prevent any shards of glass from cutting anyone. 

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Steps to Opening an Ampule

  1. Inspect the bottle for any cracks, chips, or breaks
  2. Clean the neck of the bottle with alcohol
  3. Wrap gauze around the neck and break off the top of the ampule
  4. Attach the filter straw to the syringe
  5. Draw up the medication

How to Read a Syringe

This video explains how to read measurements on the side of syringes to accurately give the correct medication dose. The pictures clearly show where the measures should occur and the variety of marking designs used among different syringes.

How to Give a Subcutaneous Injection Using a Prefilled Syringe

Many medications now come pre-filled.  All you need to do is remove them from the refrigerator and attach a needle before giving them. 

  1. Before giving an injection, plan to take the medication out of the refrigerator about 30 minutes before giving it, if you don’t want the person to feel the needle.
  2. On the other hand, cold medicine can sometimes act as a numbing agent in some situations.
    • If you have a shot that is causing pain, you might try leaving it in the frig until the last minute. 
  3. You can use milk cartons as needle disposal units. Used needles cannot be tossed into regular trash because they have body fluids (blood) on them.  Therefore, place all used syringes into hazardous waste containers.  Obtain Hazardous Waste containers at area pharmacies.  Follow the instructions in your area to be sure you know what to do.

Intramuscular (IM) Injection Sites

 

The appropriate place for intramuscular injection for those under two years of age is the vastus lateralis muscle (the thigh muscle). The preferred area for persons three years of age and older is the deltoid muscle over the triceps area of the upper arm. Giving injections in the buttocks is no longer recommended. Using the upper thigh is still an option in adults the same as in children and you may use the upper, outer hip area. Safe injection practices minimize the risk of injuries, infections, and non-infectious adverse events for both patients and providers.

YouTube Video Resources

IM Injections in the Deltoid Muscle using Z Track Technique

Z track technique is now the recommended technique for all IM injections.  A z-track means that you pull the skin to the side and then inject at a 90-degree angle.  When you release the skin’s surface, the track creates a type of zig-zag.

When you give a Z track injection, push the medication in slowly about (10 sec/ml) at a time and then wait another 10 seconds before withdrawing the needle.  This delay allows the absorption of the medicine into the muscle so that it won’t irritate the subcutaneous tissue when withdrawing the needle. Do not massage the muscle or aspirate to check for potential vein access per the recommendation of the Center for Disease Control.

How to Give an IM Injection in the Buttocks

IM (intramuscular) injection site (dorsogluteal muscle). Hip injection technique administration of the dorsogluteal muscle, also known as a butt muscle or hip muscle for injection. Update 2018: Due to recent research, the CDC NO longer recommends the dorsogluteal site as a potential site for intramuscular injection for nurses. WHY? The site is very close to essential structures such as the sciatic nerve and blood vessels. Also, a  large amount of fatty tissue resides at this site, increasing the risk of a subcutaneous type of injection rather than an intramuscular injection. Therefore, avoid this IM injection site. 

How to Give an IM Injection in the Ventrogluteal (buttock) Muscle

A video tutorial on how to give an intramuscular injection in the ventrogluteal butt muscle. (closer to the hip).  Produced in 2014.  In 2017 the CDC announced new guidelines stating not to aspiration before giving an injection.

The reason:  

  1. Aspiration caused more pain
  1. The research did not support a need to check for blood when using the correct size needle because the needle did not insert deep enough to reach a blood vessel.
  2. The only exception to the new guideline occurred if the medication administered was highly toxic and likely to cause harm if it accidentally accessed a blood vessel.

Administration of Buccal Midazolam for Seizure Control via the Cheek

Midazolam is a medication used to stop seizures and only if ordered by your doctor. If you have an order to use this medication, remember to stay in contact with the physician if the need arises to use it. 
Steps to Use Midazolam

  • Open the medication
  • Turn your family member on their side if you can or at least turn their head to the side
  • Allow the medicine to drip into the inside of their mouth between the cheek and teeth one drip/second.  Do not squeeze the medication into the mouth.
  • Monitor breathing continuously and open the airway further if breathing becomes shallow.
  • A seizure may continue for a while after the medicine goes in. Notify the doctor if one dose does not stop the seizure. 
Sublingual Nitroglycerin

 

  1. Place the tablet or spray the medicine under their tongue.
  2. Do not let them eat or drink anything after taking medicine.
  3. Monitor blood pressure and chest pain while waiting.
  4. If the chest pain has not stopped, you may repeat the dose in five minutes.
  5. Repeat the dose a third time in five minutes if pain continues.
  6. Keep the doctor informed throughout of your family member’s response.

Fear of Needles: Nursing Tips for Patients with Needle Phobia

As a caregiver, you may need to give injections to someone who has a phobia of needles. Needle phobia (called belonephobia, aichmophobia, or trypanophobia) can come in different levels of intensity.  This video provides some pointers in helping you approach someone who has a fear of needles.  Most of it probably would not apply to you in the home environment, but the part about distraction is relevant.

Distraction is always an excellent tool to use whenever there is a need to perform a task that is unpleasant or difficult for either of you. If you can engage your family member in talking about something pleasant that takes you to a “happy place,” it helps make the situation go smoother.