In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of medication administration in order to:

  • Educate client about medications
  • Educate client on medication self-administration procedures
  • Prepare and administer medications, using rights of medication administration
  • Review pertinent data prior to medication administration (e.g., contraindications, lab results, allergies, potential interactions)
  • Mix medications from two vials when necessary (e.g., insulin)
  • Administer and document medications given by common routes (e.g., oral, topical)
  • Administer and document medications given by parenteral routes (e.g., intravenous, intramuscular, subcutaneous)
  • Participate in medication reconciliation process
  • Titrate dosage of medication based on assessment and ordered parameters (e.g., giving insulin according to blood glucose levels, titrating medication to maintain a specific blood pressure)
  • Dispose of unused medications according to facility/agency policy
  • Evaluate appropriateness and accuracy of medication order for client

Educating the Client About Medications

Clients and significant others should be taught about all aspects of the medications that they are taking. The content of this teaching and education should minimally include:

  • The purpose of the medication
  • The dosage of the medication
  • The side effects of the medication
  • The possible adverse effects of the medication
  • How and where the medication should be safely stored, such as in the refrigerator or in a dark place, for example
  • The importance of and the method for checking the medication's label for the name, dose, and expiration date
  • Special instructions such as shaking the medication, taking the medication with meals or between meals and on an empty stomach, for example
  • When to call the doctor about any side effects
  • The importance of taking the medication as instructed
  • The need to continue the medication unless the doctor discontinues it
  • Information about foods, supplements and other medications, including over the counter medications and preparations, that can interact with the ordered medication
  • The safe disposal of unused and expired medications
  • The importance of keeping medications in a secure place that would not place a curious child or a cognitively impaired adult at risk for taking medications not intended for them
  • The proper and safe disposal of any biohazardous equipment such as used needles that the client uses for insulin and other medications

Educating the Client about the Medications Self-Administration Procedures

The client should be educated about the safe and correct method of self administration of medications. In addition to the education discussed immediately above, some clients may also have to be instructed about special procedures like the proper use of an inhaler, taking insulin, mixing insulins, giving oneself an intramuscular injection or self-administering tube feedings.

All of these procedures are fully discussed below in the sections entitled "Preparing and Administering Medications and Using the Rights of Medication Administration" and "Mixing Medications From Two Vials When Necessary".

Preparing and Administering Medications and Using the Rights of Medication Administration

The "Ten Rights of Medication Administration" are the right, or correct:

  1. Medication
  2. Dose
  3. Time or frequency
  4. Patient
  5. Route
  6. Client education
  7. Documentation
  8. Right to refuse
  9. Assessment and
  10. Evaluation

In addition to the Ten Rights of Medication Administration and identifying the patient using at least two unique identifiers, nurses must also insure medication safety in respect to the storage of medications, the checking for expiration dates, checking for any patient allergies, and checking for any incompatibilities.

Nurses must use at least two (2) unique identifiers, other than room number, prior to all procedures including the administration of medications. Some examples of unique identifiers include the client's first, middle and last name, a unique password or code number assigned to that person upon admission, the client's complete birthday in terms of the month, the day and the year, a photograph, and an encoded bar code containing two (2) or more unique identifiers.

Narcotics must be in a locked and secured in a safe place; other medications must be stored in a place that is secure and one that prevents accidental poisonings among the pediatric population and also among those who are confused and/or cognitively impaired. Additionally, medications that need refrigeration must be refrigerated.

Clients at Risk for Medication Errors and Other Medical Errors

The risk factors associated with medication errors and other medical errors such as wrong patient or wrong site surgery are discussed below:

Developmental disorders: The same concerns and interventions described above for infants and children apply to those with developmental disorders, as specific to the degree of their developmental delay.

Psychiatric disorders: Patients/residents/clients with a psychiatric disorder are at risk for medications as based on their psychiatric mental health disorder and the medications that they may be taking. Some psychotropic medications have sedating effects and the client may be delusional and out of touch with reality.

Infants and children: These young children are at risk for medication errors because they are not able to ask questions about medications and procedures; they may not even be able to state their name. The support and presence of the family is one way to prevent medication errors among this high risk population.

Language barriers: People with language barriers may not understand what you are saying or asking and, you may not know what they are saying or asking you in another language, therefore, the use of interpreters, family or friends, pictures and drawings should be used to overcome a language barrier.

Cognitive impairments: Clients who are confused, disoriented, demented or with delirium are at risk for all types of errors because of the challenges associated with accurate patient identification and the hazards of impaired cognition. Again, patient identification is highly important, and it is also beneficial to communicate with the client in a way that is understandable to them using pictures and drawings and to encourage the participation of the significant other(s) in all aspects of care.

Decreased levels of consciousness: Patients who are not alert, awake and oriented to time, place and person are also at high risk. At times, a family member or friend who is visiting this patient/resident/client can assist with the two unique identifier processes and also serve as a person to question you about questionable medications and to ask questions of you.

Sensory disorders: Assistive devices, such as eyeglasses and hearing aids, must be consistently provided to the sensory impaired person in order to protect their safety. Additionally, the use of large print or Braille reading materials and magnifying glasses may be helpful for the visually impaired; and speaking loudly while facing the patient with an auditory impairment may offer some protection against medication errors.

Routes and Forms of Medications

Medications are manufactured for various routes of administration and in different forms. These forms are:

  • Tablets
  • Capsules (regular and sustained release)
  • Ointments
  • Pastes
  • Creams
  • Oral suspensions
  • Syrups
  • Tinctures
  • Elixirs
  • Ear and eye drops
  • Suppositories
  • IV suspensions and solutions
  • Inhalers

The routes of administration include the following routes:

  • Oral
  • Subcutaneous
  • Intramuscular
  • Intravenous or parenteral
  • Buccal
  • Sublingual
  • Topical
  • Ophthalmic
  • Otic
  • Vaginal
  • Rectal
  • Nasal
  • With a nasogastric or gastrostomy tube
  • Inhalation
  • Intradermal
  • Transdermal
  • Intracardial
  • Intra-articular
  • Intrathecal

The oral route of administration is the preferred route of administration for all clients but the oral route is contraindicated for clients adversely affected with a swallowing disorder or a decreased level of consciousness. Oral medications can, at times, be crushed and put into something like apple sauce, for example, for some clients who have difficulty swallowing pills and tablets, but, time release capsules, enteric coated tablets, effervescent tablets, medications irritating to the stomach, foul tasting medications and sublingual medications should not be crushed. An alternative route for some clients is a liquid form of the medication.

Age Specific Route, Form and Dosage Considerations

  • Infants: Use a syringe, dropper or nipple for oral liquid medications, use the vastus lateralis, rectus femoris and ventrogluteal muscle sites for intramuscular injections and not the deltoid or the gluteus maximus muscles because these muscles have not yet developed in the infant and dosages are based on the infant's weight in kilograms (kg).
  • Toddlers: Liquid oral medications are given with a spoon or a cup, the vastus lateralis, rectus femoris and ventrogluteal sites are used for intramuscular injections, the gluteus maximus muscle can be used after the toddler has been walking for at least a year, flavors can be used to improve the taste of oral medications, and the dosages continue to be based on kilograms of weight.
  • Preschool and school age children: These children are usually able to take capsules and tablets, the gluteus maximus muscle and the deltoid muscle can now be used for intramuscular injections, in addition to the vastus lateralis, rectus femoris and ventrogluteal intramuscular injection sites, and dosages continue to be based on kilograms of weight.
  • Adolescents: Adolescents get adult dosages, routes and forms of medications.
  • The Elderly: Adult dosages may be decreased because the normal physiological changes of the aging process make this age group more susceptible to side effects, adverse drug reactions, and toxicity and over dosages. Renal function is decreased which can impair the elimination and clearance of medications, the liver function can be decreased, absorption in the gastrointestinal tract may be decrease, and the distribution of medications can be decreased because the elderly client may have decreased serum albumin, for example. All of these factors increase the elderly client's risk for side effects, adverse drug reactions, and toxicity and over dosages. For example, the risk of toxicity is increase when the elderly client is taking aminoglycosides, thiazides, a nonsteroidal anti-inflammatory medication, heparin, long acting benzodiazepines, warfarin, isoniazid and many antiarrhythmics.

Nurses must, therefore, begin a new medication with the lowest possible dosage and then increase the dosage slowly over time until the therapeutic effect is achieved. The initial dosage may be as low as ½ of the recommended adult dosage.

Reviewing Pertinent Data Prior to Medication Administration

Prior to the administration of medications, the nurse must check and validate the medication order, and also apply their critical thinking skills to the ordered medication and the status and condition of the client in respect to the contraindications, pertinent lab results, pertinent data like vital signs, client allergies, and potential interactions of the medication that is to be given.

A complete medication order must include the client's full name, the date and the time of the order, the name of the medication, the ordered dosage, and the form of the medication, the route of administration, the time or frequency of administration, and the signature of the ordering physician or licensed independent practitioner’s signature.

The four general types of medication orders are stat orders, single orders, standing orders and prn orders. Stat medication orders are administered immediately and only once; single orders are also given only once but not necessarily immediately; a standing order is an order for a medication that will be given at specific times until it is discontinued by a doctor's order or by default when a facility's policy states that all standing orders are automatically discontinued after 7 days unless the physician has reordered the medication. A prn order indicates that the ordered medication is only given when a specified condition, like pain or nausea, is present.

All incomplete, questionable and/or illegible orders must be questioned and validated by the nurse transcribing the order before it is administered to the client. This questioning and validation requires that the registered nurse use, integrate and apply their critical thinking and professional judgment skills. Automated order entry using a computer eliminates some medication order errors including those that result from illegibility of handwriting and ordering a medication with which the client is allergic to, however, nurses should never assume that this is the case. For example, medications that have sound alike names and medications that are similar in terms of their correct spelling can remain at risk even when computerized, automatic order entry is used.

Medication orders are often transcribed by hand onto a medication administration record (MAR) or Medex, when the facility is not using computerized order entry.

The client's allergies are determined, all contraindications for the medication as based on the client's health problems and disease conditions are determined, pertinent diagnostic laboratory results such as checking the client's prothrombin time and partial thromboplastin time prior to the administration of heparin, client data like a blood pressure and a pulse rate prior to the administration of an antihypertensive medication and digoxin, for example, are assessed and any possible interactions with other medications, foods and alternative and over the counter preparations are assessed in order to determine whether or not the medication should be administered. The doctor must be notified whenever the nurse has any concerns or problems with these things.

Mixing Medications From Two Vials When Necessary

Medications can only be mixed together when they are compatible with each other. Many diabetic clients who take two forms of insulin can mix these medications from two vials so that they will only have to use one, rather than two, subcutaneous injection sites. For example, a client who takes NPH insulin in the morning and also takes regular insulin prior to breakfast for the coverage of hyperglycemia can mix the NPH insulin and the regular insulin in the same syringe. The procedure for this mixing insulins is as below.

  1. Prep the top of the longer acting insulin vial with an alcohol swab.
  2. Inject air that is equal to the ordered dosage of the longer acting insulin using the insulin syringe. Do NOT withdraw the longer acting insulin yet.
  3. Prep the top of the shorter acting insulin with an alcohol swab
  4. Inject air that is equal to the ordered dosage of the shorter acting insulin using the same insulin syringe.
  5. Withdraw the ordered dosage of the shorter acting insulin using the same insulin syringe.
  6. And, then lastly, withdraw the ordered dosage of the longer acting insulin using the same insulin syringe.

For example, if the client has an order for 10 units of NPH insulin in the morning and they also need 3 units of regular insulin according to their sliding scale for coverage, the client will draw up both insulins according to the above procedure and then inject 13 units total for the NPH and the regular insulins.

Administering and Documenting Medications Given by a Common Route

The procedures for the administration of medications using different routes are briefly described below. Note that the verification of the order, its appropriateness for the client, client identification using at least two unique identifiers, and explaining the medication and the procedure for it administration is done BEFORE any medication is given to a client.

Oral Route Administration

Give the patient the medication.

Remain with the patient until the medication is swallowed; some clients may pocket and store medications in their cheeks rather than swallow them.

Buccal and Sublingual Route of Administration

Buccal medications are placed between the teeth and the inner aspect of the client's cheek. Sublingual medications are administered under the back of the tongue:

  1. Don gloves.
  2. Place the buccal medication in the buccal pouch and the sublingual medication under the client's tongue.
  3. Instruct the client to not chew or swallow the medication but, instead, to leave the drug in its position until it is completely dissolved.

Topical Route Administration

Some topical medications are only suitable on intact skin and others that contain a medication are used for the treatment of broken skin or a wound.

  1. Open the tube or container.
  2. Place the top upside down on a table top to prevent contamination to the inner aspect of the cap.
  3. Don gloves.
  4. Apply the topical medication onto the ordered area(s) using the gloved hand, a tongue depressor, a cotton tipped applicator or sterile gauze.
  5. Apply the topical medication in long and even strokes following the direction of hair growth when the ordered bodily area has hair.

Transdermal Route Administration

Transdermal medications are absorbed from the surface of the skin. The site should be without hair so it may be necessary to shave the area and these medications are applied on the client’s upper arm or chest. Some transdermal medications are commercially prepared with the ordered dosage and others require the nurse to measure and apply the ordered dosage on a transdermal patch. This procedure is described below.

  1. Remove the old transdermal patch if there is one.
  2. Wash the site with soap and water. Dry the site.
  3. Don gloves.
  4. Measure the ordered dose onto the patch or strip without letting the medication to touch your own skin because this medication can also be absorbed by the nurse's skin.
  5. With the medication against the skin gently move the strip over a 3 inch area to spread it out. Do not rub the medication into the skin.
  6. Secure the site with a plastic wrap or another semipermeable membrane specifically made for this use.
  7. Tape the patch in place if it is not surrounded with an adhesive.
  8. Write the date, time and your initials on the dressing.

Ophthalmic Route Medication Administration

Ophthalmic eye medications are applied using sterile technique which is one of the few routes that require more than medical asepsis or clean technique.

  1. Don gloves.
  2. Position the patient in a sitting position or in a supine position.
  3. Have the patient tilt their head back and toward the eye getting the drops or ointment in order to prevent the medication from entering and collecting in the client's tear duct.
  4. Have the patient look up and away to prevent the tip of the tube or dropper from touching the client's eye. .
  5. Rest your hand against the client's forehead to steady it.
  6. To administer drops, pull down the lower lid and instill the ordered number of drops into the conjunctival space.
  7. To administer an ointment, pull down the lower lid and squeeze the ointment into the conjunctival space from the inner to the outer canthus of the eye without letting the tip of the tube or dropper from touch the client's eye.
  8. Instruct the client to close their eyes, roll their eyes and blink. Blinking will spread the drops and rolling the closed eyes will spread the ointment over the eye.
  9. Clean off any excess drops or ointment gently using a facial tissue from the inner to the outer canthus of the client's eye(s).

Otic Route Administration

  1. Warm the ear drops to body temperature.
  2. Instruct the person to lie on their side so that the ear to receive the medication is upright.
  3. Straighten out the ear canal by pulling the auricle up and back for the adult and down and back for the infant and young child less than 3 years of age.
  4. Administered the ordered number of drops against the side of the inner ear and hold the auricle in place until the medication is no longer visible.
  5. Release the auricle of the ear.
  6. Instruct the client to remain in the side lying position with the treated ear up for at least 10 minutes so that the medication gets a chance to enter the ear.

Inhalation Route Administration

The two different types of inhalers that administer medications via the inhalation route are a metered-dose inhalers and a turbo inhaler.

The procedure for using a metered dose inhaler is:

  1. Shake the bottle and remove the cap.
  2. Instruct the client to exhale as fully as possible.
  3. Have the client then firmly place their lips around the mouthpiece immediately after the strong exhalation.
  4. Press the bottle against the mouthpiece to release the medication while the person is taking in a long, slow inhalation.
  5. Instruct the client to hold their breath for a couple of seconds and then slowly exhale.
  6. Have the client rinse their mouth with water and then spit it out to prevent a fungal infection of the mouth.

The procedure for using a turbo inhaler is:

  1. Slide the sleeve away from the mouthpiece.
  2. Turn the mouthpiece counter-clockwise to open it.
  3. Place the colored part of the medication into the stem of the mouthpiece.
  4. Rescrew the inhaler.
  5. Slide the sleeve all the way down to puncture the capsule.
  6. Instruct the client to fully exhale and then to deeply inhale and hold their breath for several seconds.
  7. Repeat inhalations until all of the medication has been used.
  8. The patient can then gargle and rinse their mouth.

Nasogastric Tube Route Bolus Administration Using Gravity

  1. Position the patient in a Fowler’s position and up at least at a 30 degree angle.
  2. Insure proper tube placement by aspirating the residual and checking the pH of the aspirate or by auscultating the epigastric area with the stethoscope to hear air sounds when about 30 mLs of air are injected into the feeding tube. A pH > 6 indicates that the tube is improperly placed in the respiratory tract rather than the gastrointestinal tract.
  3. Prepare the medication(s) to be administered.
  4. Insert the syringe without the piston into the end of the nasogastric tube.
  5. Pour the medications into the syringe and allow them to flow with gravity.
  6. Follow the administration with about 30 to 50 ml of water for an adult and 15 to 30 ml for children to clear the tube and to maintain its patency.
  7. Leave the person in a Fowler’s position for at least 30 minutes after instillation. If the person cannot remain in a Fowler’s position, place the patient on the right side with the head elevated.

Vaginal Route Administration

  1. Assist the client into the lithotomy position.
  2. Drape the patient exposing only the perineum.
  3. Remove the suppository from the wrapper and lubricate it with a water soluble jelly.
  4. Don gloves.
  5. Spread the labia and insert the suppository about 3 to 4 inches into the vagina.
  6. If an applicator was used, wash it or discard it if the applicator is for a single use.

Rectal Route Suppository Administration

  1. Position the patient on their left side in the Sim’s position.
  2. Drape the patient exposing only the buttocks.
  3. Remove the suppository from the wrapper and lubricate it with a water soluble jelly.
  4. Don gloves.
  5. Lift the person’s upper buttock with the nondominant hand and insert the suppository with the tapered end first into the rectum for about 3 inches beyond the rectal sphincter while the patient is taking deep breaths to relax the sphincter.
  6. Instruct the person to lie still so the suppository can be retained. If the person has the urge to defecate, place a gauze pad over the rectum and gently press the area until the urge to defecate passes.

Rectal Ointment Administration

  1. Drape the patient exposing only the buttocks.
  2. Don gloves.
  3. Place the ointment on a gauze pad and apply to the rectum.

Subcutaneous Route Injections

Subcutaneous injections can be given in the abdomen, upper arms and the front of the thighs. Subcutaneous injections are used for the administration of insulin, heparin and other medications. The sites for these injections should be rotated.

  1. Select the site.
  2. Don gloves.
  3. Clean the injection site with an alcohol swab in an outward circular pattern of about 2 inches around the selected site.
  4. Gently pinch the site so a 1 inch fat fold appears.
  5. Position the needle with the bevel up and insert at a 45 degree angle unless you CANNOT pinch an inch or more. In this case, use a 90 degree angle with the exception of heparin. Heparin is always injected at a 90 degree angle.
  6. Release the skin pinch.
  7. Pull the plunger back to check for blood. If blood appears withdraw the needle and start again.
  8. Slowly inject the medication.
  9. Withdraw the needle and cover the site with an alcohol swab.
  10. Gently massage the site, except if you are injecting heparin.
  11. Discard the needle and syringe in the proper container.

Intramuscular Route Administration

The sites for intramuscular medications are the gluteus maximus, the deltoid muscle, the vastus lateralis, the rectus femoris muscle, and the ventrogluteal muscle. The gluteus maximus muscle and the deltoid muscle are NOT used for infants or young children who are less than 3 years of age.

  1. Select the appropriate intramuscular injection site using bony landmarks.
  2. Position the client as indicated.
  3. Don gloves.
  4. Clean the injection site with an alcohol swab in an outward circular pattern of about 2 inches around the selected site.
  5. Position the needle with the bevel up and insert at a 90 degree angle.
  6. Pull the plunger back to check for blood. If blood appears withdraw the needle and start again.
  7. Slowly inject the medication.
  8. Withdraw the needle and cover the site with an alcohol swab.
  9. Gently massage the site.
  10. Discard the needle and syringe in the proper container.

Z Track Intramuscular Injections

Z tract injections are a special type of an intramuscular injection that is used for iron administration, for example, to avoid any staining of the skin as the result of the medication. This route is also advantageous to insure that the injected medication is completely injected into the muscle and not into the subcutaneous tissue.

  1. Select the appropriate intramuscular injection site using bony landmarks.
  2. Position the client as indicated.
  3. Don gloves.
  4. Pull the skin over the selected site to the side.
  5. Inject the medication into the selected muscle.
  6. Release the skin.
  7. Do NOT massage the site if a dark solution like iron was administered.

Intravenous Route Bolus Administration (IV Push)

The procedure for IV push without an existing IV line is as follows:

  1. Select the largest vein suitable for the medication.
  2. Don gloves.
  3. Apply a tourniquet, locate the vein, prep the skin and insert the needle at a 30 degree angle with the bevel up.
  4. Lower the angle when you are in the vein.
  5. Check for blood backflow.
  6. Remove the tourniquet and slowly inject the medication at the ordered or recommended rate.
  7. Withdraw the needle, cover the site with a gauze pad and pressure for 3 minutes.
  8. Place a bandage over the site.

The procedure for an IV push bolus with an existing IV line is as follows:

  1. Make sure that the medication is compatible with the IV solution and any additives.
  2. Don gloves.
  3. Close the flow clamp on the IV tubing or pinch the tubing just above the injection port.
  4. Prep the injection port with alcohol.
  5. Inject the medication slowly over several minutes.
  6. Open the flow clamp and readjust the flow rate to the ordered rate.

Intravenous Piggy Back or Secondary Line Administration

This procedure is as follows:

  1. Make sure that the medication is compatible with the IV solution and any additives.
  2. Hang the secondary IV set (piggy back).
  3. Clean the injection port on the primary intravenous line with alcohol.
  4. Insert the secondary set needle or needless system into the injection port of the primary IV tubing.
  5. Lower the primary IV using an extension hook to run only the piggy back medication. This allows the higher piggy back to run until it is finished, after which the primary intravenous will automatically run at the established rate. If you want to run the primary intravenous solution at the same time as the piggy back, keep the primary and the secondary containers at the same height.
  6. Remove the secondary set when the medication is completely administered.

More information about intravenous fluid and medication administration and how to start an intravenous line was discussed in the section entitled "Educating the Client on the Reason For and Care of a Venous Access Device" of this NCLEX-RN review guide.

Documenting Medications Given Using All Routes

Nurses are legally and ethically responsible and accountable for accurate and complete medication administration, observation, and documentation.

Some health care facilities use double locked cabinets to secure controlled substances and others use more sophisticated bar coded entry systems to access controlled substances. When the older model double locked narcotics cabinet is used, the contents are counted and checked by the nurse at the beginning of the shift; this count is then compared to the documented count that was done by the nurse from the prior shift. If there are any discrepancies, these are immediately addressed, explored and corrected if it was a simple oversight or mathematical error. When the narcotics count cannot be corrected, a report must be filed according to the facility's policies and procedures. At times illegal drug diversion may be the reason for inconsistent narcotics counts.

When a bar coded entry system for narcotics and controlled substances are used, each nurse can access these medications because the nurse's identification is automatically processed and the controlled substances are also automatically processed and recorded. When this automated system is not used, the "narcotic keys" are retained by one nurse and, if another nurse has to administer a controlled substances, this nurse will enter the narcotics cabinet with the nurse who is holding the keys.

All controlled substances are documented on the narcotics record as soon as they are removed, and all controlled substances, like all other medications, are documented on the client’s medication record as soon as they are administered. If a controlled substance is wasted for any reason, either in its entirety or only partially, this waste must be witnessed or documented by the wasting nurse and another nurse. Both nurses document this wasting.

All medications that are given, omitted, held or refused by the patient must be documented in the patient’s medication record in addition to other data like vital signs, apical rate, PT and/or PTT as indicated by the actions of the medication and/or the doctor's order.

Additional professional responsibilities, in terms of medication administration, include the observation and assessment of the patient prior to the administration of a medication and the observation and evaluation of the patient’s responses to the medication including the therapeutic effects, any side effects and adverse drug reactions to the medication.

Participating in the Medication Reconciliation Process

According to the Institute of Medicine's Preventing Medication Errors report, more 40% of medication errors are the result of a lack of communication related to the client's medications; these errors can be prevented by performing the medication reconciliation process for all clients, particularly those clients who are newly admitted, transferred or discharged to another facility or health care setting.

All medications including all prescription medications, vitamins, over the counter medications, herbal remedies, nutritional and dietary supplements, vaccinations, blood derivatives, diagnostic and contrast agents, and radioactive medications are included in the compilation of the list which contains all current medications and treatments.

The procedure for this medication reconciliation process are:

  1. Compile a list of current medications
  2. Compile a list of newly prescribed medications
  3. Compare the two lists and make note of any discrepancies and inconsistencies
  4. Employ critical thinking and professional judgments during the comparisons of the two lists
  5. Communicate and document the new list of medications to the appropriate healthcare providers

Titrating the Dosage of a Medication Based on the Assessment and Ordered Parameters

Titration is defined as adjusting the dosage of a medication according to some ordered and specified parameters or criteria. The most commonly occurring example of a titrated medication is insulin coverage with regular insulin that is based on the client's blood glucose levels. For example, the client's order for regular insulin before a meal may specify that the client take 2 units of regular insulin for blood glucose levels from 200 to 260.

Some intravenous medications are also titrated. For example, an intravenous antihypertensive drug like Hyperstat will be titrated and adjusted according to the client's blood pressure.

Disposing of Unused Medications According to the Facility/Agency Policy

Agencies vary in terms of how they dispose of unused medications after the client has been discharged and/or no longer in need of a specific medication. Refer to your facility's policies and procedures relating to the disposal of unused medications.

Clients in the home environment must also be instructed about the proper and safe disposal of unused and expired medications in order to prevent use by others and to protect the environment. The U.S. Drug Enforcement Administration (DEA) periodically hosts National Prescription Drug Take-Back days for the disposal of prescription drugs, some local law enforcement departments may have a local take back program, and some local health care agencies and pharmacies may also take back unwanted medication. When these resources are not available in the community, the home care client should be instructed to contract their local solid waste department to find out how these medications should be discarded.

If a controlled substance is wasted, this waste must be witnessed by and documented by the wasting nurse and another nurse.

Controlled substances and narcotics are immediately documented on the narcotic record when they are taken from their secure and double locked cabinet. This documentation is NOT done after the medication is administered. Narcotics and controlled substances are then documented in the patient’s medication record as soon as they are administered. During the change of shift, two nurses perform a complete count of all narcotics and controlled substances. If a discrepancy occurs, it is immediately reported for further investigation.

Evaluating the Appropriateness and Accuracy of Medication Orders for the Client

All medication orders are evaluated by the nurse in terms of their accuracy and appropriateness of the order. Some of the things that are considered and evaluated include:

  • The completeness of the medication order
  • The accuracy of the medication order
  • The appropriateness of the medication order
  • Client allergies
  • The client's health condition
  • The client's pertinent laboratory findings
  • Other client data like vital signs, for example

The doctor must be notified whenever the nurse has any concerns or problems with these things.


SEE – Pharmacological & Parenteral Therapies Practice Test Questions

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