Source: Madeline Lassche, MSNEd, RN and Katie Baraki, MSN, RN, College of Nursing, University of Utah, UT
Oral medications are the route most preferred by patients and are one of the most commonly used routes of medication administration by providers. Most oral preparations are taken by mouth, swallowed with fluid, and absorbed via the gastrointestinal tract. Oral medications are available in solid forms (e.g., tablets, capsules, caplets, and enteric-coated tablets) and liquid forms (e.g., syrups, elixirs, spirits, and suspensions). Most oral medications have a slower onset of action and, in the case of liquids and swallowed oral medications, may also have a more prolonged effect. Enteric-coated tablets are covered with material that prevents dissolution and absorption until the tablet reaches the small intestine. Additional oral medication routes (not shown in this video) include sublingual administration, in which the preparation is placed under the tongue to dissolve, and buccal administration, which involves placing the medication in the cheek area between the gums and mucus membranes to dissolve.
When preparing and administering oral tablets and liquid medications, the nurse must consider whether the medication is appropriate given the patient's medical conditions, medication allergies, and current clinical status, and whether previous doses of the medication have been administered. This step represents the Right Assessment. Patients with altered gastrointestinal function (e.g., vomiting and nausea) should not be given oral medications, since they would not be able to retain them. Oral medications are contraindicated in patients who are unconscious, uncooperative, or unable to swallow due to a medical problem. Medication administration also requires the nurse to be knowledgeable about the medication's purpose, adverse effects, and patient preferences. These aspects reflect the Right Education and support the patient’s Right to Refuse. This demonstration will present how to prepare and administer oral medications in both tablet and liquid forms (most common), including the Ten Rights, and will discuss medication documentation.
1. General medication administration considerations (review in the room, with the patient).
Upon first entering the patient's room, wash hands with soap and warm water, and apply vigorous friction for at least 20 seconds. Hand sanitizers may be used if the hands are not visibly soiled, but vigorous friction should also be applied.
At the bedside computer, log into the patient's electronic health record and review the patient's medical history and previous administration times. Verify with the patient any medication allergies and discuss their physical allergic responses and reactions.
At the bedside computer, pull up the Medication Administration Record (MAR).
Review the medications that are due to be administered, and clarify with the patient if they have a preference or concerns prior to acquiring and preparing the medication. Engaging the patient in this discussion aligns with the Right to Refuse and the Right Education.
Some patients may have difficulty swallowing whole tablets or capsules. This may require cutting the tablet into smaller doses or opening the capsule to release the powder or granules. Before splitting a tablet or opening a capsule, you must ensure that it is safe to do so. Enteric-coated medication and extended/sustained-release medications should never be broken.
There are many medications that can be given in liquid form if swallowing partial tablets or granules is still difficult. Consult with a pharmacist to determine liquid preparation availability. Leave the patient's room and wash hands as described above.
The nurse must now maintain a distraction/disruption-free environment while dispensing and administering medications to prevent medication errors. Acquire the oral tablet medication from the medication dispensing device, using the Ten Rights during the first safety check. These include the right patient, right medication, right dose, right time, right route, right documentation, right education, right to refuse, right assessment, and right evaluation.
2. Go to the medication preparation area (this area may be in a secured room or in a secured portion of the nurses' station) and complete the first safety check using the Ten Rights of medication administration.
3. In the medication preparation area, prepare the oral medication according to the MAR, pharmacy instructions, nurse drug guide, patient preference, best practices, and institutional policies/procedures. Pre-packaged oral tablets or capsules that do not require preparation should remain in the original packaging.
Open oral medication packaging and prepare for medication preparation if difficulty swallowing, patient preference, or partial dosing requires it. Partial tablet administration may be required by the oral tablet medication dose or patient preference. Some prescribed doses require splitting a tablet to obtain the desired dose of the medication. Divide a large, scored tablet into two equal pieces by grasping both sides of the tablet and breaking at the scored line. For unscored tablets, place the tablet evenly into a pill cutter and quickly close the device to ensure that the tablet cuts evenly. Dispose of remaining partial doses according to institutional policy if partial dosing is required. If cutting and/or breaking tablets for patients with difficulty swallowing, place all medication pieces into a medication cup.
Oral capsule preparation for patients who are unable to swallow a capsule will require obtaining soft food from the nutrition room. To empty the contents of the oral capsule medication, grasp both ends of the capsule, twist and pull gently, and empty the contents into a medication cup. Be careful not to lose any of the medication. Carefully spoon 2–3 tablespoons of soft food into the medication cup containing the capsule contents. This will facilitate administration and will help to mask the taste of the medication.
Premixed liquid oral medications will require gentle shaking of the medication for a few seconds to ensure equal distribution of the medication within the liquid. Obtain an oral syringe and medication cup from the medication drawer in the medication preparation room. Intravenous syringes can easily be mistaken for oral syringes. Always use oral syringes when dispensing oral medications to avoid medication errors.
Calculate the appropriate volume to withdraw given the concentration provided on the liquid medication label. Place the medication cup on a level surface and crouch until you are at eye level with the volume measurement. Pour the medication into the cup until it reaches the correct volume. If the medication requires a precise measurement, an oral syringe should be used to withdraw it from the medication cup. Withdraw slightly more than the prescribed volume, then slowly expel air and excess liquid until the desired volume is reached. Ensure accuracy by aligning the plunger at eye level with the measurement. Dispose of any remaining medication per policy and return multi-dose containers to the dispensing system. Dispose of all packaging in an appropriate waste container.
4.All medications removed from their original packaging must be labeled with the medication name and dose prior to leaving the medication preparation room. This fulfills the Right Documentation.
5. In the preparation area, complete the second safety check using the Ten Rights of medication administration.
6. Gather necessary supplies including a cup of water, straw, non-sterile gloves, oral medication, and medication cups. Take these into the patient's room.
Administration
7. Upon re-entering the patient's room, place the medications on the counter and perform hand hygiene.
8. Complete the third and final medication safety check using the Ten Rights of medication administration. Verify the patient's identity by asking for their name and birthdate and checking against the name band to confirm the Right Patient.
9. Educate the patient about the medication—its name, indication, and action—fulfilling the Right Education. Discuss any potential side effects or adverse effects. Address concerns and ensure the patient's decision is informed. If the patient refuses the medication, ensure they understand the consequences, respecting the Right to Refuse.
10. Administer the oral medication. Confirm the patient can swallow by offering a sip of water. Open pre-packaged medications and place them in a medication cup. Administer according to patient preference and ability.
11. Document the administration in the MAR, including the medication name, dose, route, date, time, and your initials. Include any assessments performed beforehand. This step ensures the Right Documentation, Right Assessment, and supports the Right Evaluation.
12. Remind the patient of possible side effects to report.
13. Exit the patient's room and perform hand hygiene again.
Oral medication administration is one of the most preferred and commonly used routes for patients by providers. Most oral meds are given in a solid or liquid form. Like for any medication administration procedure, a nurse must follow and complete the Ten Rights at the three safety checkpoints. In addition, before administration, the nurse must also know the indication, purpose, and possible side effects of the specific medicine being given to the patient.
This video will illustrate the essential steps on how to prepare and administer solid and liquid forms of oral medications.
Before delving into the administration process, let's take a look at the different types of oral medications commonly encountered in a hospital setting. Solid forms include tablets, capsules, caplets, and enteric-coated tablets. Liquid forms include syrups, elixirs, spirits, and suspensions.
Some forms have unique medication administration qualities. For example, enteric-coated tablets are covered with material that only is absorbed once in the small intestine. These tablets should not be broken or altered in the preparation stages. There are two other oral forms that are less common: sublingual and buccal. In the sublingual form, the patient is given the medication to place under the tongue to dissolve. With buccal, the medication is placed in the cheek areas to dissolve.
Now that you know about the different types, let's review the oral medication preparation procedure. Upon entering the patient's room, wash your hands with soap and warm water for at least 20 seconds, or apply hand sanitizer using vigorous friction. Next, walk to the bedside computer and log into the electronic health record, or EHR. Review the patient's medical history and any recorded allergies to confirm potential adverse reactions. This step corresponds to the Right Assessment.
In the EHR, review the electronic medication administration record, or MAR. On the MAR, find the meds to be administered at that time. Ask the patient if there are preferences for how to prepare the meds. Note that some patients cannot swallow pills, and some may prefer pills crushed. The nurse must know these details before preparing the meds. After confirming with the patient, exit out of the EHR and leave the room, and perform hand hygiene as described previously.
Next, acquire the oral tablet medication from the medication dispensing device using the ten "rights," as described in the first video of this collection. This completes the first of the three safety checks. Now, in the medication preparation area, prepare the medication as indicated in the patient's MAR, pharmacy instructions, nurse drug guide, patient preference, and according to the best practices and institutional policies and procedures. Pre-packaged oral tablets or capsules that do not require preparation will remain in the original packaging.
Open tablet packaging if there is difficulty in swallowing, partial dosing required, or if the patient prefers divided tablets. Some prescribed doses require splitting a tablet to obtain the desired dose of the medication. For splitting, first determine if the tablet is scored-with a visible line where it can be broken in half-or un-scored. Divide large scored tablets into two equal pieces by grasping both sides of the tablet and breaking at the scored line. For un-scored tablets, place the tablet evenly into a pill cutter and quickly close the device to ensure the tablet cuts evenly. If partial dosing is required, dispose of the remaining partial doses according to institutional policy. If cutting and/or breaking tablets for patients with difficulty swallowing, place all medication pieces into a medication cup.
Oral capsule preparation for patients who are unable to swallow a capsule will require obtaining a soft food, like puree or pudding, from the nutrition room. To empty the contents of the oral capsule medication, grasp both ends of the capsule, twist and pull gently, and empty the contents into a medication cup. Be careful not to lose any of the contained medications.
For premixed liquid oral medications, gently shake the medication for a few seconds to ensure equal distribution of the medication within the liquid. Next, calculate the appropriate volume to withdraw given the concentration provided on the liquid medication label. If the MAR indicates a dose of 200 mg and the concentration provided is 32 mg/mL, then you need to withdraw 6.25 mL from the container. To do that, place a medication cup on a level surface and crouch until you are at eye level with the volume measurement. Then pour the premixed liquid medication into the medication cup until it reaches the correct volume. Liquid poured while standing and looking down at the medication cup will cause an insufficient volume to be dispensed and a medication error.
If the medication indicates a precise measurement, such as liquid digoxin, then obtain an oral syringe from the medication drawer. Always use an oral syringe to withdraw oral medication, as an intravenous syringe can easily be mistaken for intravenous use, and may lead to medication errors. If withdrawing from a multi-dose container, place a medication cup on a level surface and pour a volume greater than needed for the prescribed dose. Pouring out the volume to be used before withdrawing keeps the multi-dose container clean, if not using a sterile oral syringe.
If using a sterile oral syringe, you may draw directly from the container. Always withdraw slightly greater than the prescribed volume. Then turn the tip of the syringe up and move it to eye level. Now slowly push the plunger until all air is dispensed and the top of the plunger seal reaches the desired volume. If a single-dose container is used, the nurse may withdraw directly from the container and dispose of the remaining volume according to institutional policy. Dispose of all medication packaging in the trash receptacle.
Next, using tape or a pre-printed medication label, write the medication name and dosage amount on the label, and place it on the syringe. Note that all medications that have been removed from the original packaging must be labeled prior to leaving the medication preparation room.
In the medication preparation area, complete the second safety check using the “ten rights" of medication administration. After the second safety check, gather the needed supplies, including a cup of water, a straw, non-sterile gloves, oral medication, and medication cups, and walk to the patient's room.
Upon first entering the patient's room, set the medications down on the counter and perform hand hygiene as described before, with vigorous friction for at least 20 seconds. In the patient's room, complete the third and final medication safety check, adhering to the ten "rights" of medication administration. Verify the patient is wearing the correct name band by asking them to state their name and birthdate. Compare this information with what is provided on the name band to confirm the Right Patient.
At this point, provide the patient teaching regarding the oral medication. Tell the patient the medication name, indication, and action. Review any side effects associated with the medication. Discuss any concerns that the patient might have regarding the medication. Should the patient refuse the medication, ensure that they are aware of the potential physiological or psychological impact of their refusal on their health and recovery.
At this point, provide the patient teaching regarding the oral medication. Tell the patient the medication name, indication, and action. Review any side effects associated with the medication. Discuss any concerns that the patient might have regarding the medication. Should the patient refuse the medication, ensure that their right to refuse is respected and that they are aware of the possible physiological or psychological consequences.
Before giving the medication, ask the patient to take a small sip of water to ensure they are able to swallow without difficulty. Now, open any packaged medications, place them in a medicine cup, and give them to the patient according to his or her preferences and abilities.
After administration, document the following in the patient's MAR: the dose of the medication, route of administration, date, and exact time administered, with your initials. Any assessments required before administration, such as vital signs or lab values, should also be included in the documentation. Observe the patient for any expected therapeutic effect or adverse reactions, which fulfill the Right Evaluation. Leave the patient's room, and upon exiting, remember to perform hand hygiene as described previously.
"Because dosage variations in the institutional pharmacy may be limited, it is important for the nurse to verify the correct medication dose is obtained from the medication dispensing device and prepare the medication according to the dose indicated in the patient's medication administration record."
"A common oral liquid medication error would be to pour a liquid medication without it being at eye level or on a level surface. In both cases, this would result in an administration dosing error, with under-dosing resulting in potentially as harmful effects as over-dosing, depending on the medication administered and the desired effects."
You've just watched JoVE's video on verification and administration of oral medication, including tablets, capsules, and liquid preparation. You should now understand the different forms of oral medications, how to prepare the medications for administration, and the safe practices of medication administration using the ten "rights." As always, thanks for watching!
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