Pharmacological and Parenteral Therapies Study Guide for the NCLEX-RN Exam

Expected Actions and Outcomes

Nurses are expected to know the expected action of, and intended outcomes of, any medications given to patients. Not only should the nurse anticipate these outcomes for their patients, they should also be able to educate and provide guidance to their patients regarding these medications.

Information and Evaluation

Numerous resources are available to help nurses navigate medication education. Most healthcare facilities have a drug formulary that nurses can reference. Pharmacists and pharmacy staff are knowledgeable resources to discuss questions or concerns about medications. Nursing handbooks, the Physician’s Desk Reference (PDR), or reliable Internet resources may also be helpful.

Not only should nurses know where to gather unknown information about medications, they should be aware of all the medications their patients may be taking, acutely or chronically. Recognize that home remedies, herbal supplements, and apothecary are common practices and should be appropriately documented if used by the patient. It is important to understand each patient’s compliance with their prescribed regimen and if they feel the medication is achieving the expected outcome.

Patients should be evaluated for adverse events, side effects, interactions or toxicity from any medication (or combination of medications). It is also good practice to regularly reconcile the patient’s actual use of medications with what is listed in the medical record.

Clinical Decision Making

Clinical decision making is required in all aspects of nursing. Nurses must anticipate the needs of their clients in regard to taking, tolerating, and sustaining medication therapy. Medications are administered in a number of ways. Depending on their administration, nurses should monitor for specific events. The bullets below help identify common expectations with each medication administration type.

Oral (PO)

Formulations—liquid, tablet, capsule, chewable
Identify which medications can be crushed or must be taken whole.
Some medications may be prescribed for sublingual (under the tongue) or buccal (between cheek and gum).
Monitor for choking.

Intradermal (ID)

Formulation—injection
After cleansing the injection side, use a small gauge needle, position the needle flush to near flush (5–15 degree angle) with the surface of the skin, bevel side up. Insert the needle into the skin in the dermal layer, and inject the solution.
Volume <0.5ml
Intradermal administration is most commonly used for sensitivity testing, such as allergy and tuberculosis (TB) testing.
Monitor for injection site reaction.

Subcutaneous (SubQ, SQ)

Formulation—injection
After washing hands, donning gloves, and cleansing the injection site, position the needle at a 45–90 degree angle to the site, squeeze the skin together (to ensure entering the subcutaneous, fatty layer, and not intramuscular layer), insert the needle into the skin bevel up, and inject the medication.
Volume 0.5–1 ml
Common injection sites: upper and outer area of the arm, front and outer sides of the thighs, abdomen (outside of 2 in around the navel), upper and outer area of the buttocks, and outer hip
Subcutaneous medication administration is used for insulin and heparin administration.
Educate clients to rotate their sites if chronically using subcutaneous injection sites to avoid tissue damage.
Monitor for intended effects of the medication (e.g., decreased glucose with insulin administration, therapeutic lab levels, etc.).

Intramuscular (IM)

Formulation—injection
After washing hands, donning gloves, and cleansing the injection site, position the needle at a 90-degree angle to the skin, bevel up, and insert into the intramuscular tissue. Aspirate the syringe to check for blood. If blood appears, withdraw the needle and restart administration. If no blood is present in the needle, inject the medication.
Max volume to be injected into one muscle for adults is 3 mL; children under the age of 2 have a maximum volume of 1 mL.
Common injection sites: deltoid, vastus lateralis, ventrogluteal, gluteus medius, dorsogluteal muscles
For children under 3 years old, the anterolateral thigh muscle (vastus lateralis) is preferred.
Needles of at least 1 inch in length are required to deliver medication intramuscularly.
Medications requiring IM administration: antibiotics and most immunizations
Monitor for effects of medication, anaphylaxis, and injection site changes.

Topical

Formulation—cream, ointment, patch
It can be applied to the skin.
Creams and ointments may be applied to specific areas of concern or on the whole body. Follow the prescription and directions given with the medication.
Monitor for dermatitis, non-improved or worsening of the condition being treated.

Transdermal

Formulation—patch
The option allows slow, continuous administration of medication.
Patches are changed every 24–72 hours.
Wash hands and don gloves. Apply the patch to a clean, dry, hairless, unbroken area of skin. Rotate sites with every patch change to avoid skin irritation.
Common application sites: upper arm, chest, back, flank
Examples of medications that are available as transdermal patches: Fentanyl, Scopolamine, Nitroglycerine, Clonidine, Nicotine, Methylphenidate, Lidocaine
Monitor for dermatitis surrounding the sites.
Ensure proper disposal of patches, especially narcotic patches, to eliminate unintended transmission of medication.

Intravenous (IV)

Formulation—infusion
Medications are required to be administered through a venous access point.
Intravenous lines may be peripheral or central.
Medications that require venous access: injectable antibiotics, continuous sedation drips, IV fluids, injectable steroids, etc.
See more information in the previous section regarding central venous access devices.
Monitor for IV site reactions, phlebitis, infiltration, and device malfunction.

While these are the most common routes for administration of medication, be aware there are still other routes available. Intrathecal (around the spinal cord), rectal, vaginal, ocular (in the eye), otic (in the ear), and inhaled medication routes are available for specific medications. These routes will be further explained in any medical surgical nursing text.

Medication Administration

Proper and appropriate medication administration is one of the most important jobs a nurse will encounter. There are numerous steps to be taken before, during, and after administration of medications. Checking clients’ rights and the rights of medication administration are crucial to ensuring safe delivery of healthcare. Most facilities have protocols nurses are required to follow to assist in minimizing errors of medication administration.

Patient Education

Patients and their caregivers will need to be educated on every aspect of their prescribed medications. This includes education on the name, dosage, intended purpose, potential side effects, potential interactions, and administration.

Some medications require specific storage instructions. Certain medications, such as reconstituted antibiotics, some IM injections, and vaccinations must be refrigerated. Other medications must not be exposed to light. Many medications need to be discarded after specific periods. All medications should be stored out of the reach of children and be protected against unintended use by others.

Instruct clients to take their full dose of medication for the duration instructed by the healthcare provider. This is especially important for antibiotics. Clients should also know the indications for which to call their healthcare provider with questions or concerns.

If the patient is being educated on a self-administered medication (inhaler, injections, etc.), the proper technique should be taught along with how to properly dispose of any unused drug and/or biohazardous materials (e.g., syringes/needles).

Information Review

Prior to administering any medication, you will need to review several bits of essential information:

Review the “rights” of administration

Right client
Right medication
Right dose
Right route
Right time
Right documentation (also known as the sixth right)

Review pertinent patient data

Vital signs
Labs
Current medications
Medication interactions
Diagnosis/diagnoses

Review the patient’s medical history (for contraindications) and listed medication allergies.

Administering Medication

Many aspects are involved in the administration of a medication. First, one must have a working knowledge of pharmacological principles (pharmacokinetics, administration route, distribution, metabolism, and excretion) and understand how these principles apply to patients and their medications.

Understand the proper preparation and administration of each medication, and keep in mind that pediatric and adult routes of administration may differ.

Mixing Medications from Two Vials

At times, it may be necessary to mix two, compatible medicines from different vials prior to injection. Combining insulin NPH and regular insulin is an example of this practice. When drawing up these different insulins, first draw up the clear, regular insulin followed by the cloudy, insulin NPH. Also, remember that prior to drawing up each medication, both vials will need to be cleansed with alcohol and the vials injected with the same amount of air as the dose without touching either medication with the needle.

Documentation

Documentation is known as the ‘sixth right’ of medication administration. Nurses are responsible for documenting the patient’s choices regarding medication administration. This includes route, whether the medication was omitted, held, or refused, interactions, effects, and any other observations.

Medication Reconciliation

A large number of medical errors occur due to poor or incomplete communication regarding a patient’s medications. A medication reconciliation is a process that can be used to prevent medical errors. It is particularly useful for newly admitted patients and those being transferred elsewhere or discharged. Here is the process:

Make a list of the patient’s current medications and a list of newly prescribed medications.
Critically compare the two and note discrepancies or inconsistencies.
Report the findings to the appropriate healthcare provider and document the nursing actions.

Remember that all over-the-counter medications, herbal or dietary supplements, blood or blood products, vaccinations, contrast or other diagnostic agents, and radioactive medications should be included on both of the lists.

Titration

A titration is an adjustment in the dosage of a given medication based upon certain parameters or criteria. These will usually be defined in the healthcare provider’s order for the medication. The two most common types of medications used in this way are insulin and certain blood pressure medications.

Handling and Disposal

Each facility or agency will have its own specific guidelines as to the handling and disposal of unused medication. They will also have specific guidelines on the handling of specific medications such as narcotics and chemotherapy. Patients will need education on the process of taking and managing medications at home. Nurses should indicate which patients need specific supplies such as needles, syringes, sharps containers, and information regarding community disposal sites/narcotic collection days.

Evaluation

Always verify the medication order for accuracy. Ensure that all aspects are correct and that the order is valid and signed by the prescriber. The nurse will be held responsible if medications are administered in an incorrect order, an incorrect dose, or on the incorrect patient.