Section Two: Enteral Medications

Oral Administration
The most common route of administration of medications is through the mouth, or orally. The order is often written, “give PO,” meaning per os or “by mouth.” Advantages of oral preparations are as follows:

• They are easy for the nurse to give and for the patient to swallow.
• Most medications come in this form.
• It is usually not very expensive to make oral preparations.
• If a patient takes too much of an oral medication, the drug can be removed by pumping the patient’s stomach (gastric lavage) or by having the patient vomit.
The major disadvantages of oral preparations are as follows:
• They cannot be given to patients with a lot of nausea, who are vomiting, or who are unconscious.
• Some chemicals are not effective if mixed with gastric secretions.
• The onset of action may vary because the drug may be slowly absorbed in the GI tract.

There are many different forms of oral medications. Each form is desired for a specific reason (for example, to increase absorption, delay absorption, or reduce gastric irritation). The term pill is often used by patients to describe capsules or tablets. Tablets and capsules are very common and are made up of several different chemicals. Tablets may be covered with a special coating that resists the acidic pH of the stomach but will dissolve in the alkaline pH of the intestine.
Safety Alert!

Actions for Which the Nurse Will Be Held Responsible
The nurse has responsibility to make sure patients take the medication given to them. The nurse cannot know if patients take the medicine if the nurse does not see them swallow it. Even when the nurse is busy, medicine should not be left at the bedside for them to take later.

Box 7-1 summarizes the various oral dosage forms and their characteristics.

Box 7-1   Oral Medication Forms
Capsules are gelatin containers that hold powder or liquid medicine. Timed-release or sustained-release capsules contain granules that dissolve at different rates, providing slow and constant release of medications. Capsules are available in a variety of sizes and shapes. They provide an easy way to administer medications that have an unpleasant taste or odor. Capsules must not be opened, crushed, or chewed because irritation and excessive or lessened drug activity may be produced.

Elixirs are liquids made up of drugs dissolved in alcohol and water that may have coloring and flavoring agents added. The alcohol makes the drug more dissolvable than water alone.

Emulsions are solutions that have small droplets of water and medication dispersed in oil, or oil and medication dispersed in water. These preparations help disguise the bitter taste of a drug or increase its solubility.

Lozenges are medicine mixed with a hard sugar base to produce small, hard preparations of various sizes or shapes. Medication is released slowly when the lozenge is sucked.

Suspensions are liquids with solid, insoluble drug particles dispersed throughout. These solid particles tend to settle out in layers, so the medication must be shaken before pouring.

Syrups are liquids with a high sugar content designed to disguise the bitter taste of a drug. These are often used for pediatric patients.

Tablets are dried, powdered drugs compressed into small shapes. These shapes are small enough so that they may be swallowed whole. Tablets usually contain trademarks, designs, or words for product identification and may have a line through the middle so the tablet may be divided equally (this is known as a scored tablet). Tablets may also contain coatings of various types to increase solubility or absorption.

Procedure for Administering Oral Medications
The basic procedure in administration of medication is the same, regardless of type or route of administration. The equipment available and the agency policies may vary because nurses work in many different settings. General principles that underlie all procedures include accuracy, taking responsibility, and asepsis (preventing infection). The legal policies and rules, along with the nursing process and knowledge about the drug, are all part of giving medications. The steps in giving medications by the various routes are generally followed as outlined in the following sections. There are wide differences in the specific process and equipment used in administering medications and institutional procedures may require some changes in the recommended procedure. Procedure 7-1 describes the basic procedure for administering oral medications that may be used when there is no sophisticated equipment available for the process. If there is a bar-coded medication administration system, follow the institutional procedure to check the dosage, confirm that both the correct medication and the correct patient are involved by scanning the bar codes of both, administer the medication, and then make certain that the medication given is noted in the proper section of the electronic medical record. Following these steps each time reduces the chance of medication error. Whether the nurse is pouring the medication itself or just helping remove it from a package, this is a clean procedure and begins with cleanly washed hands.

Procedure 7-1   Administering Oral Medications

Step One: Getting Ready
1. Check the accuracy of the order as written and the time to be given. Clarify any information now known about the patient or the medication, such as allergies.
2. Wash the hands well. This is essential to avoid contaminating the medication. Although it seems an obvious step, it is often neglected by busy nurses.
3. Assemble the medication equipment. Obtain the plastic medication cups, paper souffle cup, glass, water or juice, and straw if needed (A-F). Unlock medication cart, if necessary.

Step Two: Preparing the Medication
1. Read the order on the medication form and obtain the correct medication from the cabinet or cart (G). Medications may come in a cardboard or plastic container, a bottle, or an individually wrapped package.
2. Compare medication order with label on container. First check for the right patient, drug, route, dosage, and time of administration.
3. Open the container and pour the correct number of tablets or capsules into the paper medication cup.
• Do not touch the medication, but pour the medication directly into the bottle lid or the cup.
• Return any extra medication to the container (H).
• To avoid errors, hold the medication cup at eye level when pouring liquids (I).
• If the unit-dose system, Pyxis dispensing machine, or nurse service is used, the medication will come in a labeled package. It is not removed from the wrapping until the nurse is at the patient’s bedside (J).
4. Compare the information on the medication card or the medication administration record (MAR) with the label on the container. This is the second check for accuracy.
5. Close the box or replace the lid on the container, and check the information on it for the third time with the medication card or MAR. Medication lids are always replaced immediately after use.
• Medication that requires special storage (such as refrigeration) is replaced immediately.
6. Put the medication container back on the shelf.
7. Place the cup containing the medication next to the medication card or MAR on the tray.
8. Repeat this process for each medication ordered for the patient. All of the tablets for one patient may be placed in the same medication cup.

Step Three: Administering the Medication
1. Go to the patient’s bedside. Help the patient into an upright position, if possible. Ask the patient his or her full name and birth date while checking the patient’s identification bracelet. The patient’s name may also be on a tag on the bed or door. If possible, scan the bar code of patient’s identification bracelet and each medication to help ensure the correct patient is getting the correct medication. Never give medication without identifying the patient. Confused or critically ill patients may answer to any name.
2. Explain what medicine is being given and answer any of the patient’s questions. Give any special instructions or teach the patient about the medication as needed. Make any special assessments required. If the patient makes any comment about the medication looking different from usual, having just taken the medication, or not having had that medication before, recheck the medication order.
3. Give the patient a glass of water or juice and have the patient place the medication in the back of his mouth, take a sip of water, and swallow. Most medication dissolves better and causes less stomach discomfort when it is taken with adequate liquid.
4. Remain at the bedside until the medication is swallowed. Do not leave medication at the bedside for the patient to take later. The nurse is responsible for making certain the medication is given when ordered. The nurse cannot ensure the patient takes the medicine unless the nurse sees him or her swallow it.

Step Four: Concluding
1. Throw away the medication cup. Wash hands.
2. Update electronic records of the MAR or note on the chart the time that the medication was given and sign your name or initials. Record accurately that the medication was given as ordered. Also record if the drug was refused or omitted and notify the charge nurse or the health care provider if the patient did not take the drug for some reason.
3. Later, check the patient again and note any responses or adverse effects that need to be recorded on the medication card or MAR and reported.

Solid-Form Oral Medications
1. If the medicine does not come in its own unit-dose package, place all tablets or capsules together in a small paper souffle cup so the medicine is not touched.
2. Do not crush tablets or break capsules without checking with the pharmacist. Many medications have special coatings that are essential for proper absorption.
3. Lozenges are to be sucked, not swallowed.
4. If a patient has difficulty swallowing the medication, have him or her take a few sips of water before placing the medication in the back of the mouth, and then follow with more water. Help patients keep their heads forward while swallowing, as they do when they eat. It is generally not helpful to tilt the head backward.
5. If the patient is unable to swallow the medication as ordered, discuss this problem with the person who ordered the medication.

6. Always give the most important tablets, such as heart medications and antibiotics, first. Other medications might even be withheld until the nurse talks with the person ordering the medications if the patient has great difficulty taking them.
Memory Jogger
General Principles That Underlie All Procedures
• Accuracy
• Acceptance of responsibility
• Asepsis—Follow agency procedure if you are to wear gloves during this procedure.

Liquid-Form Oral Medications
1. Liquids or solutions often must be shaken before they are poured. Although this is common sense, always check to make sure the lid is tightly closed before shaking the bottle.
2. Take the lid off the bottle and place the lid upside down (outer surface down) on a flat surface. This protects the inside of the lid from dirt or contamination.
3. When pouring liquids from a bottle into a plastic medication cup, hold the bottle so the label is against the hand. This prevents medicine from running down onto the label so that it cannot be read.

4. Hold the medication cup at eye level to read the proper dose. Often the medication in the cup is not level but is higher on the sides than in the middle. Read the level at the lowest point in the medication cup.
5. Wipe any extra medication from the bottle top and replace the lid quickly to avoid contamination.
6. Do not dilute a liquid medication unless ordered to do so by the physician or nurse practitioner.
7. The medication could also be drawn up from the bottle or medication cup with a syringe or a medicine dropper. These methods are useful in helping the nurse be accurate when a small dose is ordered and are often used when giving medications to infants or small children. The syringe or medicine dropper is placed halfway back in the baby’s mouth, between the cheek and gums, and slowly emptied, giving the baby time to swallow it. The medication in the syringe or medicine dropper could also be emptied into a nipple on which the baby is sucking.
Lifespan Considerations

Older Adults

Administering Medications
Allow extra time when administering medications to older adult patients. These individuals often are slower than others in being ready to take medications, in swallowing medications and water, and in understanding the answers provided to questions about their medications. The same considerations apply to very young patients.

Nasogastric Administration
The nasogastric (NG) tube is another route for enteral medication. Patients who cannot swallow or who are weak or nauseated may be able to take medications through this tube, which leads directly through the nose and into the stomach. The tubing and the clamp allow the nurse to easily give medications over a long period to patients who are unable to take food or medicine by mouth. Some patients find the NG tube so irritating to the nose that the medication must be given another way. In such cases, a percutaneous endoscopic gastrostomy (PEG) tube may be surgically placed directly through the abdomen and into the stomach.

Procedure for Administering Nasogastric, PEG, and Jejunum Tube Medications
The process for giving medications through a tube is similar to that given for oral medications, but with the following precautions:

• Liquid medications may be ordered for patients who have disorders of the esophagus, are in a coma, or cannot swallow. Some tablets may be crushed, mixed with 30 mL of water, and given through the NG tube.
• Because many of the patients getting medications by NG tube are seriously ill or in a coma, it is especially important to be accurate in all phases of giving the medication. The patient may not be able to help by telling the nurse if there are any problems in giving the medicine.
• Follow agency policy about wearing gloves during this procedure.
• Make certain that the NG tube is in the stomach. Aspirate (take out) stomach contents with a syringe, or inject (put in) 5 or 10 mL of air into the tube and listen for a gurgling sound in the abdominal area caused by the air. This may be heard by placing a stethoscope over the stomach. The nurse might also listen for breath sounds, showing that the tubing might be in the lung, by holding the tubing to the ear. Of course, medication must not be given if there is any question about where the NG tube is located. Usually the NG tube is left in place once it is put into the patient.
• The procedure for giving tube medications is very similar to steps 1, 2, and 4 of the procedure for giving oral medications. The major difference is that the medicine must be crushed and then put into the tube rather than having the patient swallow it. Some institutions suggest all medications be crushed, mixed together in one cup, and administered; other institutions wish each medication to be crushed and administered separately. If NG suction is attached to the tubing, disconnect it and clamp the suction tube shut. Clamp the NG tube and attach a bulb syringe. Next, pour the medication into the syringe, unclamp the NG tube, and let the medication run in by gravity. Add water, usually at least 50 mL or according to the institution’s policy, to flush and clean out the tubing when all the medicine has passed through the tube. Reclamp the tube. The tube remains clamped for at least 30 minutes before the suction tube is reattached so that there is time for the medication to be absorbed. This procedure is shown in Figure 7-4.

FIGURE 7-4 Administration of medication by nasogastric tube. Make certain the nasogastric tube is in place by A, aspirating stomach contents; B, listening for gurgling sound in stomach with stethoscope; or C, listening for breath sounds. D, Put the medication into tubing and E, let it run in by gravity. F, After the medication is almost out of the tubing, add water to flush the tubing.

• The process for giving medication through a PEG tube is very similar to that for the NG tube. In addition to the tubing, the PEG has a gastrostomy feeding button (a small, flexible silicone device that has a mushroom-shaped dome at one end and two small wings at the other end) that can be used to close the tube between uses. Irrigate this button with 5 to 10 mL of tap water after food and medication have been given and wiped with a cotton-tipped applicator to help keep the tube open. The PEG tube itself is to be cleaned with 25 to 50 mL of tap water after giving food to prevent it from getting clogged up. Follow institutional policy if it differs from these recommendations.

Rectal Administration
When a patient has severe nausea or vomiting, medication may need to be put into the rectum, thus avoiding the mouth and stomach. Unlike an enema, when medication is given rectally, the medication is left to be absorbed and not expelled. Accurate dosage through rectal administration is somewhat more difficult and harder to predict than are the small, accurate doses used in oral medications. This is true for a variety of reasons:
• Some required medications do not come in suppository or enema form.
• Sometimes the patient has diarrhea and cannot hold the medication.
• Sometimes other rectal problems may make using this route a problem.
• If the patient has a lot of fecal material, the medication may not be well absorbed.
• Medications are not absorbed from the rectal mucosa at a standard or predictable rate.
The procedure for administering rectal medications is described in Procedure 7-2. Note that steps 1, 2, and 4 again are similar to those for administering oral medications.

Procedure 7-2   Administering Rectal Medications

Step One: Getting Ready
1. Check the medication order on the Kardex or electronic medication report sheet. Check the accuracy of the order as written and the time to be given. Clarify any information known about the patient or the medication.
2. Wash hands. This is essential to avoid contaminating the medication.
3. Assemble all the necessary equipment. In addition to the medication order or card, get the medication tray, souffle or medication cups, medication cart, lubricant, and rubber gloves.

Step Two: Preparing the Medication
1. Read the medication order on the medication card or MAR and get the correct medication from the cabinet, refrigerator, or cart. Medication may come in a bottle, in a plastic container, or as a suppository wrapped in foil and kept in the refrigerator.
2. Compare the medication card or MAR with the label on the container. First check for the right patient, drug, route, dosage, and time of administration.
3. Obtain the proper amount of liquid, disposable medicated enema, or suppository. Suppositories must be firm or they cannot be properly inserted. If the suppository has melted, it may be hardened by being put in a small container of ice for a few minutes. If the unit-dose system or nurse service is used, the medication comes in a labeled package. It is not removed from the wrapping until the nurse is at the patient’s bedside.
4. Compare the information on the medication card or MAR with the label on the container. This is the second check for accuracy.
5. Replace the medication container and check the information on it for the third time with the medication card or MAR. Medication such as suppositories requiring special storage (refrigeration) are to be replaced immediately.
6. Place the cup containing the medication next to the medication card or MAR on the tray. Suppositories require insertion immediately, before they melt.

Step Three: Administering the Medication
1. Go to the patient’s bedside. Help the patient turn over on his or her side with one leg bent over the other in a Sims’ position. Protect the patient’s modesty as much as possible by closing the drapes and draping the patient. Ask the patient his or her name while at the same time checking the patient’s identification bracelet and bed tag. Never give medication without identifying the patient.
2. Explain what medicine is being given and answer any of the patient’s questions. Give any special instructions, such as holding the medicine inside and not letting it come out, and teach the patient about the medication as needed. Make any special assessments required.
3. Put on gloves. If the nurse is giving a suppository, remove the suppository from the foil packet and place a small amount of water-soluble lubricant on the tip of the suppository and on the inserting finger. Tell the patient the procedure is ready to begin. Hold the suppository at the anal sphincter for a few seconds, and tell the patient to take a deep breath and to bear down slightly. This will relax the sphincter so the suppository may be pushed into the rectum about 1 inch (A-D). Use the fourth finger (which is smaller) for children. The patient should remain on his or her side for approximately 20 minutes. With children, it may be necessary to hold their buttocks together to prevent them from releasing the suppository.
If the medication is being given by disposable enema, the procedure is the same, except that the lubricated tip is inserted into the rectum and the 50 to 150 mL of medication is slowly squeezed from the disposable container (E-G).

Step Four: Concluding
1. Dispose of the foil packet or plastic containers and the gloves. Clean the medication tray or cart.
2. Leave patients with tissues to wipe themselves if needed and a way to wash their hands.
3. Wash hands.
4. Note on the medication card or MAR the time that the medication was given and sign your name or initials. Record accurately that the medication was given as ordered.
5. Check the patient again later and note any response or adverse effects that must be recorded on the medication card or MAR and reported. Medicated enemas may be given for severe asthma, to relieve constipation, or to instill steroids used to treat bowel disorders. The nurse must always look for and report any response to the medicated enema.

Memory Jogger
Safe Medication Administration Equation

Legal

regulations
+

Nursing

process
+

Knowledge

about

pharmacology
+

Following

standard

procedures
=
Safe

medication

administration