PRINCIPLES OF ADMINISTERING DRUGS
You must know the drug that you are administering, including its uses, actions, common adverse reactions, and any special reactions. You ill probably become familiar with the drugs given most often in your institution. However, many drugs are not given on a daily basis, and new drugs are constantly being developed. Before giving a drug which you are not familiar, seek out information from dependable sources such pharmacist, drugs inserts, and manufacturers’ websites. In addition, know the patient’s drug history, allergies, previous adverse reactions, pertinent laboratory values, and any important changes in his or her condition before administering a drug.
Often prescribers put limitations on when a drug should be given. For example, the prescriber may order that the drug be given only if the patient’s blood pressure is greater or less than a particular value. Similar limitations may be based on heart rate, respiratory rate, or pain level. Be aware of the prescribed limitations and check them before giving the drug. If the patient’s condition or vital signs are outside of the set limits, you must hold the drug and document the reason for your action.
When giving drugs, listen to your patient. Patient comments give clues to adverse reactions such nausea, dizziness, unsteady walking, and ringing in the ears. These comments indicate that the patient may be having an adverse reaction, and you should hold the drug while you notify the prescriber.
 
GETTING READY TO GIVE DRUGS
There are several important guidelines to follow before preparing to give any drug:
·      Always follow the eight “rights”
·      Always check the written order
·      Check the patient’s identification wristband and ask the patient’s name and birthdate
·      Limit interruptions and distractions
·      Wash your hands and wear clean gloves when needed (e.g., parenteral, rectal routes)
·      Keep drugs in their container or wrappers until at the patient’s bedside
·      Avoid touching pills or capsules
·      Never give drugs prepared by someone else
·      Follow sterile technique when handling syringes and needles
·      Remain alert to drug names that sound or look alike. Giving the wrong drug can have serious adverse effects.
Some pills and capsules are prepared for slow absorption. These drugs are often labeled enteric-coated, time release, or slow release. If chewed, crushed , or opened, these drugs may be absorbed too rapidly. This can irritate the gastrointestinal (GI) system or cause symptoms of overdose. If patient cannot take pills or capsules, a liquid form of the drug may be a better option. A prescriber’s order is needed to change the drug form.
           
GIVING ENTERAL DRUGS
A drug given by the enteral route is delivered from the outside of the body to the inside of the body using the GI tract. Enteral drugs enter the body in one of three ways: through the mouth (oral), by feeding tube (e.g., nasogastric tube or percutaneous endoscopic gastrostomy), or through the rectum.
 
ORAL DRUGS
Drugs are most commonly given by mouth or the oral route, also known as the enteral route. Orders for oral drugs are written as “PO”, which means per os or ”by mouth”. Most drugs are available in one or more oral forms: tablets, capsules, and liquids. Oral drugs are easy to give as long as the patient can swallow. A major advantage pf PO drugs is that if a patients receives too much, the drug can be removed by pumping the stomach or causing the patient to vomit. Oral drugs do not work well for patients suffering from nausea and vomiting. Onset of action for this drugs is slow because they must be absorbed through the GI tract.
 
What to do before giving oral drugs
Be sure that the patient can swallow. Sit the patient upright and have a full glass of water ready. Tell him or her what drugs you will be giving and answer any questions asked. Tell the patient if there are any special instructions related to the drug (e.g., getting up slowly from bed after new antihypertensive drugs are given). Ask him or her to place the tablets or capsules in the back of the mouth, take a few sips of water, and swallow the drugs. Unless the patient is on a fluid restriction, have him or her drink the entire glass of water because oral drugs dissolve better and cause less GI discomfort when they are given with enough water. Stay at the bedside until the drugs are swallowed. Do not leave drugs at the patient’s bedside to be taken later. An exception may be made for antacids or nitroglycerine tablets IF there is an order permitting this. You are responsible for documenting that drugs have been taken and must witness that this has occurred.
            If the oral drug is in suspension form, be sure to shake it well. When giving oral liquid drugs, be sure to use a calibrated device to measure the correct dose because household devices such as spoons or cups vary widely in size and their use can result in giving inaccurate doses. Always hold a calibrated medicine cup at eye level to measure the dose.
 
What to do after giving oral drugs
Document that the drug was given. If a drug was refused or not given, document the reason.  Be sure to check the patient later for side effects, adverse effects, and the desired effect. For example, check the patient taking antihypertensive drugs for decreased blood pressure. Document your findings.
 
ORAL DRUGS GIVEN BY FEEDING TUBE
Oral drugs may be given by feeding tubes. Patients who are unable to swallow may be given oral drugs by a nasogastric tube. A nasogastric (NG) tube delivers drugs by a tube inserted through the nostrils to the stomach. A percutaneous endoscopic gastronomy (PEG) tube is a feeding tube that is surgical implanted through the abdomen in to the stomach.
 
What to do before giving drugs by NG or PEG tube
As with all oral drugs, check the drug orders, which may be written as PO or by feeding tube. Check your drug book or with the pharmacist before crushing tablets or opening capsules. Wash your hands and place the patient upright. Check to make sure that the tube is located in the stomach by withdrawing (aspirating) stomach contents with a syringe, or you can attach an end-tidal carbon dioxide (CO2) detector to the feeding tube.
            If the patient is receiving a tube feeding, check the amount of tube feeding remaining in the stomach (residual). Some drugs are not well absorbed when food is in the stomach (e.g., phenytoin [Dilantin]), and the tube feeding must be stopped for a period before and after administration. Liquid drugs should be diluted and flushed through the tube. Crushed tablets and the contents of open capsules are first dissolved in water before being given through the tube. To give the drugs, attach a large syringe to the tube, pour the liquid or dissolved drug in to the syringe, and let it run in by gravity.
 
What to do after giving drugs by NG or PEG tube
After giving drugs by this route, flush the tube well to make sure it is clear. Use at least 50 mL of water to prevent the tube from becoming clogged. If the patient’s NG is connected to suction, the tube should be clamped for at least 30 minutes after administering drugs before reattaching it to suction. This allows time for the drugs to be absorbed from the GI system. As with oral drugs, document what has been given and watch the patient for side effects, adverse effects, and the desired effects. Document your findings.
 
 
GIVING RECTAL DRUGS
Patients who are unable to swallow or have severe nausea and vomiting may need to have drugs given by the rectal route (movement of a drug  from outside the body to inside the body through the rectum). These drugs may come as suppositories or in the form of an enema. A suppository  is a small drug plug designed to melt at body temperature when place whiting the rectum or vagina.  With drugs given by this route, absorption is not as dependable or predictable as when drugs are given orally. The patient with diarrhea cannot hold them long enough for absorption to take place. The rate of absorption is also affected by the amount of stool present.
 
What to do before giving rectal drugs
Ask whether  the patient has any health problems such as diarrhea that may make using this route undesirable. Other reasons for not giving  a rectal drug include recent rectal surgery or trauma and a history of vasovagal reactions (slowed heart rate and dilatation of blood vessels, which can lead to fainting, sometimes called syncope).
            Bring the drug, some, lubricant, and a pair of disposable gloves to the bedside. Assist the patient to turn to the side with one leg bent over the other (Sims’ position). The left Sims’ position is best to give rectal suppositories.
            Protect the patient’s privacy by closing doors or drapes and keeping as much of the patient covered as possible. Explain what you will be doing and be sure to include any special instructions such as how long the drug must be held inside the rectum. Put on your gloves. Take the wrapper off the suppository and coat the pointed end with a small amount of water-soluble lubricant. Also apply a small amount of lubricants to the finger that you will be using to insert the drug. Hold the suppository next to the anal sphincter and explain that you are ready to insert the drug. Ask the patient to take a deep breath and bear down a little. With the pointed end first, push the suppository into the rectum about 1 inch.

What to do after giving rectal drugs
Remind the patient to remain on his or her side for about 20 minutes. Clean the patient’s anal area and cover the patient. Remove gloves and wash your hands. Immediately document that the drug was given. Check the patient for any expected or unexpected responses and chart these. For example, if the patient was given a suppository to relieve constipation, be sure to note whether the patient later had a bowel movement.

GIVING PARENTERAL DRUGS
Drugs given by the parenteral route are injected through the skin. They may be injected intradermally, subcutaneously, intramuscularly, or intravenously. There are four primary reasons for giving drugs parenterally. The patient may:
·      Be unable to take oral drugs.
·      Need a drug that acts rapidly.
·      Need a constant blood level of a drug.
·      Need drugs such as insulin, which are not made in an oral form.
Standard precautions from the Centers for Disease Control and Prevention (CDC) recommend wearing gloves whenever you are exposed to blood or other body fluids, mucous membranes, or any area of broken skin.
            Giving parenteral drugs requires that you use needles and syringes safely. Do not recap needles, and always dispose of needles and syringes in labeled containers. “Sharps” containers are located in every patient room. Many hospitals use needleless systems, retractable needled, or needles with plastic guards that slip over the needle to protect against needlesticks.
            The Needlestick Safety and Prevention Act was signed into law in November 2000. In 2001, the Occupational Safety and health Administration (OSHA) developed guidelines to help prevent needlesticks. OSHA advises that prevention of needlesticks is best and recommends that health care employers select safer needle devices. Needlesticks injuries should be tracked using a Sharp Injury Log. The purpose of this log is to identify problem areas. In addition, OSHA recommends that employers have a written Exposure Care Plan that is updated on an annual basis.


GIVING INTRADERMAL DRUGS
A drug administered by the intradermal route is administered by an injection between the layers of the skin. The most common site for intradermal injections is the inner part of the forearm. The primary uses of intradermal injections are for:
·      Allergy testing
·      Local anesthetics
·      Tuberculosis (TB) testing
The TB test is done with purified protein derivative. A small amount of drug is injected into the space between the epidermis and the dermis layers of the skin. This results in a bump (bleb) that looks like an insect bite. The volume of drug injected is small (0.01-0.1 mL), and the needle used is short and small (3/8 inch, 25 gauge).
 
 
What to do before giving intradermal drugs
Put on gloves. Cleanse the injection site in a circular motion, beginning from the center and moving outward. Insert the needle at a 10- to 15-degree angle with the bevel facing up. Do not pull back (aspirate) on the plunger of the syringe. Inject the drug so a little bump forms and remove the needle. Do not massage the area. If the little bump does not form, the drug has probably been injected too deeply into the subcutaneous tissue, and test results will not be accurate. When this happens, discard the used equipment and use a different site with a new sterile needle and syringe for the intradermal injection.
 
What to do after giving intradermal drugs
Document the drug administration immediately. Check the patient for allergic or sensitivity reactions to the injection. These reactions may take several hours to days. Making a circle around the injection site with a pen may help to accurately check the site. Document any reactions and notify the prescriber. TB tests must be checked and read 2 to 3 days (48 to 72 hours) after the injection.
 
GIVING SUBCUTANEOUS DRUGS
A drug given by the subcutaneous route is injected into tissues between the skin and muscle. Although several drugs are given by this route, two drugs commonly given subcutaneous are insulin and heparin. Subcutaneous drugs are absorb more slowly than intramuscular drugs. Typically these injections are from 0.5 to 1 mL. When a larger volume of drug is ordered, give the injection in two different sites with different syringes and needles. Small, short needles are used (3/8 inch, 25 to 27 gauge). Sites for subcutaneous injections include the upper arms, the abdomen, and the upper back. Some sources also recommend use of the anterolateral thigh. Rotate the sites for the injections to avoid damage to the patient’s tissue.
 
What to do before giving subcutaneous drugs
Insert the needle at a 45-degree angle for most patients. If the patient is obese, you may need to use a 90-degree angle. If the patient is thin, you may need  an angle that is less than 45 degrees. Before giving any subcutaneous injection, do not aspirate (pull back on the plunger of the syringe). Inject the drug and remove the needle.
 
What to do after giving subcutaneous drugs
Apply pressure to prevent bleeding. If a patient has a bleeding disorder  or is receiving anticoagulation therapy, you may need to apply pressure longer until the bleeding has stopped. Document giving the drug immediately, including the site used for injection. Check the patient for side effects, adverse effects, and expected effects. Document your findings.
 
GIVING INTRAMUSCULAR DRUGS
A drug given by the intramuscular (IM) route  is given by injection deep into a muscle. Because of the rich blood supply in the muscles, IM drugs are absorbed much faster than subcutaneous drugs. IM injections can also be much larger than subcutaneous injections (1 to 3mL). Injections into an adult’s arm should should not be more than 2 mL.  Infants and children usually do not receive more than 1 mL. If an injection order is for more than 3 mL, divide the dose and give two injections. Injections of more than 3 mL are not as well absorbed.
            Needled for these injections are longer (1 to 1.5 inches) and larger (20 to 22 gauge). Sites for IM injections include the upper arm deltoid muscle, the high vastus laterals muscles, and the ventrogluteal muscle in the hip. The dorsogluteal site is not favored because of the presence of nerves and major blood vessels. This site is avoided in obese patients because research has shown that injections do not reach the muscle. Be sure to rotate injection sites when multiple IM injections are prescribed.
 
What to do before given intramuscular drugs
Held the patient into a comfortable position that is appropriate for the site you plan to use. Select the injection site by identifying the correct anatomic landmarks. Wash your hands and be sure to wear gloves. Cleanse the injection site. Using a 90-degree angle, insert the needle firmly into the muscle. Aspiration is not recommended for IM injection of vaccines or immunizations. For drugs as such penicillin, aspiration may be indicated. When indicated, aspirate the syringe (pull back on the plunger) to make sure that the needle is not in the vein. If needle is in a vein, blood will appear in the syringe. Remove the needle and discard the drug if this happens. Get anew dose of the drug and a sterile needle and syringe and give the injection in another site. Once you have determined that the needle is not in a blood vessel, inject the drug an d remove the needle.
            Use the Z-track method of IM injection for drugs that are irritating and subcutaneous tissue or that may permanently stain the tissues. After drawing the drug into the syringe, draw in 0.1 to 0.2 mL of air. The air follows the drug into the muscle and stops it from oozing through the path of the needle. After you select and cleanse the site, pull the tissue laterally and hold it. Insert the needle into the muscle; inject the drug and release the tissue as you remove the needle. Releasing the tissue allows the skin to slide over the injection and seal the drug in the muscle.
 
What to do after giving intramuscular drugs
Apply pressure after removing the needle to prevent bleeding. When charting the drug administration, be sure to include the injection site. Check the patient for adverse effects, side effects, and expected effects of the drug. Document your findings.
 
GIVING INTRAVENOUS DRUGS
A drug given by the intravenous (IV) route is injected directly into the vein. This route is selected when a drug need to enter the bloodstream rapidly or when large doses of the drug must be given. The rate of absorption and action are rapid with this route. Emergency drugs may be given by a needle and syringe directly into a vein; however, most IV drugs are given slowly through a needle or catheter that has been inserted into a vein. The needle or catheter is attach to IV tubing with an injection port. IV drugs maybe pushed slowly over 1 or more minutes, push rapidly over a few seconds, or given slowly by IV piggyback. They may be given through an IV line or a saline lock.
 
 
 
What to do before giving intravenous drugs
Check the IV site to make sure that it is patent. Document the condition of the IV site. If the drug has been added to IV fluid, be sure to remove all air from the tubing. (This is called priming the IV tubing.) If the drug is to be administered in a continuous IV infusion or IV piggyback, it should be place on an infusion pump to control the rate.
            In most cases, registered nurses (RNs) would give IV push and IV piggyback drugs. Be sure to check the scope of practice or laws of your state. In some states, license practical nurses or license vocational nurses may administer IV drugs with additional training.
 
 
What to do after given intravenous drugs
Document that the drug has been given, including the site and flow rate. Continue to check the IV site for signs of these conditions:
·      Infection
·      Escape of fluid from the vein into tissue (extravasation)
·      Collection of fluid in the tissues (infiltration)
If fluid escapes or collects in the tissues, the IV catheter must be discontinue and replace in a different vein. As with administration of any drug, check the patient for side effects, adverse effects, or expected effects of the drug. Document these effects.
 
GIVING PRECUTANEOUS DRUGS
A drug given by the percutaneous route is applied to and absorbed through the skin and mucous membrane. Absorption of these drugs affected by several factors:
·      Size of area covered by the drug
·      Concentration or strength of the drug
·      Time the drug remain in contact with the skin or mucous membranes
·      Condition of the skin (breakdown, thickness, hydration, nutrition, and skin tone)
 
 
GIVING TOPICAL OR TRANSDERMAL DRUGS
A drug giving by the topical route is applied directly to the skin for local effects. Topical drugs include creams, lotions, and ointments. They soften or lubricated the skin. Some are used to treat superficial infections of the skin. Topical drugs are applied in a thin, even layer over the affected are of skin.
            A drug given by the transdermal route is apply to the skin, but it is absorbed and enters the blood stream. The transdermal route allows the patient to maintain a steady blood level of the drug. For this reason, toxicity and adverse effects can usually be avoided. Examples of transdermal drugs are:
·      Nitroglycerine to treat cardiac problems
·      Scopolamine to treat dizziness and nausea
·      Birth control
·      Nicotine patches for smoking cessation
·      Long-term pain drugs
They are applied as patches or ointments. Drug patches have a semipermeable membrane and an adhesive that attaches to the skin. Common sites of application include the chest, flank, back, and upper arms.
 
What to do before giving topical or transdermal drugs
Wash your hands and put on gloves. Clean the area of skin where the drug will be applied. Apply topical drugs in a smooth, thin layer, and cover the area. When administering transdermal drugs, remove old patches or doses of the drug. Be sure to remove all traces of the drug from the previous dosage site, and rotate sites to avoid skin irritation or breakdown.
            Do not shave skin before applying topical or transdermal drugs. Shaving may cause skin irritation and change the absorption of the drug.
 
What to do after giving topical or transdermal drugs
Document that the drug has been given, including the site where it was applied. Be sure to write the date, time, and your initials on the new patch. Check the patient for adverse effects or expected effects and document these. For example, headache and dizziness related to decreased blood pressure or common side effects of nitroglycerine ointment.
 
GIVING DRUGS THROUGH THE MUCOUS MEMBRANE
Drugs may be absorb through the mucous membranes. The following are examples of drug forms used for the different mucous membranes found in the body:
·      Buccal or sublingual drugs are used in the mouth.
·      Drops and ointments are applied to the eyes, nose, or ears.
·      Inhalation drugs are drawn into the lungs.
·      Suppositories and creams are used in the vagina.
Drugs are usually well absorb through these areas; however, the blood supply to mucous membranes varies. When you administer a drug through  mucous membranes, be sure to use a sterile procedure before placing eye drops or ointments and a clean procedure before giving drugs into ears, nose, mouth, or vagina.
 
 
What to do before giving drugs through the mucous membranes
Always check the order and the patient’s identity. Wash your hands and wear gloves. Follow the eight “rights”
 
Buccal and sublingual drugs
Drugs given by the buccal route, such as lozenges, are placed between the cheek and the molar teeth of the upper jaw. A drug given by the sublingual route, such as nitroglycerine, is placed under the tongue. The blood supply is very good in the mouth; therefore these drugs dissolve and are absorb quickly. The patient should not eat or drink until the drug is completely dissolved. Teach the patient not to swallow or chew while the drug is in the mouth because these drugs are not effective if absorb through the GI tract.
 
 
Ear drops
Ear drops are drugs  given to treat local infection or inflammation and should be kept at room temperature. Help the patient to lie on one side with the affected ear up. For children younger than 3 years, pull the ear lobe (pinna) down and back.  For older children and adults, pill the ear lobe up and out. This straightens the ear canal. Do not let the ear dropper touch the ear.  Have the patient stay in the same position for at least 5 minutes so the drug can coat the inner ear canal. Sometimes a cotton ball is ordered to be placed in the ear canal. Repeat this procedure for the other ear when both ears are affected. 
 
Nose drops
Nose drops or sprays are most often used to treat congestion or infection. To give nose drops, draw the drops into a dropper. Ask the patient to gently blow his or her nose and then lie down with the head hanging over the edge of the bed. Hold the dropper over the nostril and give the  ordered number of nose drops. Do not let the dropper touch the nose. Repeat for the second nostril if needed.
            To give nasal spray, position the patient sitting up with one nostril blocked by a finger.  Place the tip of the spray in the other nostril. Ask the patient to take a deep breath. During the deep breath, squeeze a puff of spray into the nostril. Wipe the spray bottle tip if it is to be used with both nostrils. Nasal sprays are absorb quickly from the nasal mucosa. Do not use the same spray container for any other patient. 
 
Inhalers
Drugs may be inhaled through the respiratory tract. Different types of devices are used for delivery of inhaled drugs. 
 
Vaginal drugs
Vaginal drugs are given to treat irritation or infection. Types of vaginal drugs include creams, jellies, tablets, foams, or suppositories. These drugs should be kept at room temperature. Ask the patient to empty her bladder then lie down. Be sure to put on gloves after washing your hands. Suppositories are lubricated and given in the same way as rectal suppositories.  Creams, jellies, tablets, and foams are given with a special applicator that is place in the vagina as far as possible. The plunger of the applicator is pushed to give the drug. Be sure to have the patient lie down for 10 to 15 minutes after receiving these drugs.
 
What to do after giving drugs through the mucous membrane
Always document that the drugs have been given, including the route. Check the patient for any expected or unexpected actions of the drug that you have given. Document these effects. 
 
 

https://www.nursingcenter.com/ncblog/may-2016/medication-safety-go-beyond-the-basics