PHARMACOLOGY

PREPARED BY: MARIA CHRISTINA SUGUITAN-PAGALILAUAN, RN

PRELIMS COVERAGE
Chapter 1 - Introduction to Chapter 2 – Non – Steroidal
nursing pharmacology Anti – Inflammatory Drugs
(Nsaids)

Lesson 1 Introduction to drugs Lesson 1 Analgesics

Lesson 2 Drugs and the body Lesson 2 Antipyretics
Lesson 3 Toxic effects of drugs
Lesson 4 The nursing process in
drug therapy and patient safety
Lesson 5 Dosage Calculations
Lesson 6 Challenges to effective
drug therapy
Intended Learning Outcomes:

After the designed activities, the students are expected to:

1. Understand terminologies related to pharmacology
2. Identify types, forms and classifications of drugs
3. Discuss nursing responsibilities in drug administration.
4. Demonstrate understanding in the computation of drugs and
intravenous fluid regulation
5. Discuss types of chemotherapeutic agents
6. Discuss the indications, actions, side effects, adverse effects and
nursing considerations in giving chemotherapeutic agents
 CHAPTER 1
INTRODUCTION TO
NURSING
PHARMACOLOGY
I. Introduction to Drugs

Pharmacology is the study drugs which are made up of chemicals

that are introduced into the body to cause biological effects.

Food and Drug Administration (FDA) regulates the testing and

approval of all drugs in this country. To be approved for marketing,
a drug must pass through animal testing, testing on healthy
humans, selected testing on people with the disease being treated,
and then broad testing on people with the disease being treated.
The Food and Drug Administration has established five categories to
indicate the potential for a systemically absorbed drug to cause birth
defects. The key differentiation among the categories rests on the
degree (reliability) of documentation and the risk–benefit ratio.
❖ Category A: Adequate studies in pregnant women have not
demonstrated a risk to the fetus in the first trimester of pregnancy,
and there is no evidence of risk in later trimesters.
❖ Category B: Animal studies have not demonstrated a risk to the
fetus but there are no adequate studies in pregnant women, or
animal studies have shown an adverse effect, but adequate studies
in pregnant women have not demonstrated a risk to the fetus during
the first trimester of pregnancy, and there is no evidence of risk in
later trimesters.
❖ Category C: Animal studies have shown an adverse effect on
the fetus but there are no adequate studies in humans; the
benefits from the use of the drug in pregnant women may be
acceptable despite its potential risks, or there are no animal
reproduction studies and no adequate studies in humans.
❖ Category D: There is evidence of human fetal risk, but the
potential benefits from the use of the drug in pregnant women
may be acceptable despite its potential risks.
❖ Category X: Studies in animals or humans demonstrate fetal
abnormalities or adverse reaction; reports indicate evidence of
fetal risk. The risk of use in a pregnant woman clearly outweighs
any possible benefit.
Regardless of the designated Pregnancy Category or presumed safety, no drug
should be administered during pregnancy unless it is clearly needed. Research
into the development of the human fetus, especially the nervous system, has led
many health care providers to recommend that no drug should be used during
pregnancy because of potential effects on the developing fetus.
Controlled Substances are drugs with abuse potential. The FDA studies
the drugs and determines their abuse potential while the Philippine Drug
Enforcement Agency (PDEA) enforces their control. The prescription,
distribution, storage, and use of these drugs are closely monitored by
the PDEA in an attempt to decrease substance abuse of prescribed
medications.
The controlled drugs are divided into five PDEA schedules based on their
potential for abuse and physical and psychological dependence.
❖ Schedule I (C-I): High abuse potential and no accepted medical use
(heroin, marijuana, LSD)
❖ Schedule II (C-II): High abuse potential with severe dependence
liability (narcotics, amphetamines, and barbiturates)
❖ Schedule III (C-III): Less abuse potential than schedule II
drugs and moderate dependence liability (nonbarbiturate
sedatives, nonamphetamine stimulants, limited amounts of
certain narcotics)
❖ Schedule IV (C-IV): Less abuse potential than schedule III
and limited dependence liability (some sedatives, antianxiety
agents, and nonnarcotic analgesics)
❖ Schedule V (C-V): Limited abuse potential. Primarily small
amounts of narcotics (codeine) used as antitussives or
antidiarrheals. Under federal law, limited quantities of certain
schedule V drugs may be purchased without a prescription
directly from a pharmacist. The purchaser must be at least 18
years of age and must furnish suitable identification. All such
transaction
Generic drugs are chemicals that are produced by companies involved solely in the
manufacturing of drugs. Because they do not have the research, the advertising, or,
sometimes, the quality control departments that the pharmaceutical companies
developing the drugs have, they can produce the generic drugs more cheaply.
Over-the-counter (OTC) drugs are products that are available without prescription for
self-treatment of a variety of complaints. Some of these agents were approved as
prescription drugs but later were found to be very safe and useful for patients without
the need of a prescription.
Although OTC drugs have been found to be safe when taken as directed, nurses should
consider several problems related to OTC drug use:
❖ Taking these drugs could mask the signs and symptoms of underlying disease,
making diagnosis difficult.
❖ Taking these drugs with prescription medications could result in drug interactions
and interfere with drug therapy.
❖ Not taking these drugs as directed could result in serious overdoses.
II. Drugs and the Body

Pharmacodynamics is the study of the drug mechanisms that

produce biochemical or physiologic changes in the body. These
changes result from interaction at the cellular level between a drug
and cellular components, such as the complex proteins that make
up the cell membrane, enzymes, or target receptors, represents
drug action. Drugs usually work in one of four ways:

1. To replace or act as substitutes for missing chemicals

2. To increase or stimulate certain cellular activities
3. To depress or slow cellular activities
4. To interfere with the functioning of foreign cells, such as
invading microorganisms or neoplasms
❖ When a drug displays an affinity for a receptor and stimulates it, the drug acts as an
agonist. An agonist binds to the receptor and produces a response.
❖ If a drug has an affinity for a receptor but displays little or no intrinsic activity, it’s
called an antagonist. An antagonist prevents a response from occurring.
❖ Drug potency refers to the relative amount of a drug required to produce a desired
response. Drug potency is also used to compare two drugs. If drug X produces the
same response as drug Y but at a lower dose, then drug X is more potent than drug
Y.
❖ The relationship between a drug’s desired therapeutic effects and its adverse effects
is called the drug’s therapeutic index. It’s also referred to as its margin of safety.
The therapeutic index usually measures the difference between an effective dose for
50% of the patients treated and the minimal dose at which adverse reactions occur.
Drugs with a narrow, or low, therapeutic index have a narrow margin of safety. This
means that there’s a narrow range of safety between an effective dose and a lethal
one. On the other hand, a drug with a high therapeutic index has a wide margin of
safety and poses less risk of toxic effects.
Pharmacokinetics discusses how a drug is absorbed (taken into the body),
distributed (moved into various tissues), metabolized (changed into a form that
can be excreted) and excreted (removed from the body). This branch of
pharmacology is also concerned with a drug’s onset of action, peak
concentration level, and duration of action.
A. Absorption covers a drug’s progress from the time it’s administered, through its passage to
the tissues, until it reaches systemic circulation.
❖ On a cellular level, drugs are absorbed by several means—primarily through active or passive
transport.
❖ If only a few cells separate the active drug from the systemic circulation, absorption will occur
rapidly and the drug will quickly reach therapeutic levels in the body. Typically, absorption
occurs within seconds or minutes when a drug is administered sublingually, I.V., or by
inhalation.
❖ Absorption occurs at a slower rate when drugs are administered by the oral, I.M., or SQ routes
because the complex membrane systems of GI mucosal layers, muscle, and skin delay drug
passage.
❖ Other factors can affect how quickly a drug is absorbed. For example, most absorption of oral
drugs occurs in the small intestine. If a patient has had large sections of the small intestine
surgically removed, drug absorption decreases because of the reduced surface area and the
reduced time that the drug is in the intestine.
❖ High-fat meals and solid foods slow the rate at which contents leave the stomach and enter
the intestines, delaying intestinal absorption of a drug.
❖ Drug formulation (such as tablets, capsules, liquids, sustained-release formulas, inactive
ingredients, and coatings) affects the drug absorption rate and the time needed to reach peak
blood concentration levels.
❖ Combining one drug with another drug, or with food, can cause interactions that increase or
decrease drug absorption, depending on the substances involved.
A. Distribution is the process by which the drug is delivered from the systemic circulation
to body tissues and fluids.
❖ Distribution of an absorbed drug within the body depends on blood flow, solubility and
protein binding.
❖ The drug is quickly distributed to organs with a large supply of blood. These organs
include the heart, liver and kidneys. Distribution to other internal organs, skin, fat, and
muscle is slower.
❖ The ability of a drug to cross a cell membrane depends on whether the drug is water or
lipid (fat) soluble. Lipid-soluble drugs easily cross through cell membranes; water-soluble
drugs can’t. Lipid-soluble drugs can also cross the blood-brain barrier and enter the
brain.
C. Metabolism or biotransformation is the process by which the body changes a drug
from its dosage form to a more water-soluble form that can then be excreted.
❖ The majority of drugs are metabolized by enzymes in the liver; however, metabolism can
also occur in the plasma, kidneys, and membranes of the intestines. Some drugs inhibit
or compete for enzyme metabolism, which can cause the accumulation of drugs when
they’re given together. This accumulation increases the potential for an adverse reaction
or drug toxicity.
❖ Certain diseases can reduce metabolism. These include liver diseases such as cirrhosis as
well as heart failure, which reduces circulation to the liver. Genetics allows some people
to metabolize drugs rapidly and others to metabolize them more slowly.
❖ Developmental changes can also affect drug metabolism. For instance, infants have
immature livers that reduce the rate of metabolism, and elderly patients experience a
decline in liver size, blood flow, and enzyme production that also slows metabolism.
❖ Excretion - refers to the elimination of drugs from the body. Most drugs are excreted by
the kidneys and leave the body through urine. Drugs can also be excreted through the
lungs, exocrine (sweat, salivary, or mammary) glands, skin, and intestinal tract.
Half-life is the time it takes for one-half of the drug to be eliminated by the body.
Factors that affect a drug’s half-life include its rate of absorption, metabolism, and
excretion. Knowing how long a drug remains in the body helps determine how frequently
it should be administered.
Onset, peak, and duration
Onset refers to the time interval from when the drug is administered to when its
therapeutic effect actually begins. Rate of onset varies depending on the route of
administration and other pharmacokinetic properties.
Peak. As the body absorbs more drug, blood concentration levels rise. The peak
concentration level is reached when the absorption rate equals the elimination rate.
Duration is the length of time the drug produces its therapeutic effect.
Pharmacotherapeutics or clinical pharmacology is a branch of pharmacology that deals
with drugs; chemicals that are used in medicine for the treatment, prevention, and
diagnosis of disease in humans. When choosing a drug to treat a particular condition,
health care providers consider not only the drug’s effectiveness but also other factors
such as the type of therapy the patient will receive. The type of therapy a patient
receives depends on the severity, urgency, and prognosis of the patient’s condition
and can include:
1. Acute therapy, if the patient is critically ill and requires acute intensive therapy
2. Empiric therapy, based on practical experience rather than on pure scientific data
3. Maintenance therapy, for patients with chronic conditions that don’t resolve
4. Supplemental or replacement therapy, to replenish or substitute for missing
substances in the body
5. Supportive therapy, which doesn’t treat the cause of the disease but maintains
other threatened body systems until the patient’s condition resolves
6. Palliative therapy, used for end-stage or terminal diseases to make the patient as
comfortable as possible.
❖ Drug tolerance occurs when a patient develops a decreased response to a drug
over time. The patient then requires larger doses to produce the same response.
❖ Tolerance differs from drug dependence, in which a patient displays a physical or
psychological need for the drug. Physical dependence produces withdrawal
symptoms when the drug is stopped, whereas psychological dependence is
based on a desire to continue taking the drug to relieve tension and avoid
discomfort.
❖ Drug interactions can occur between drugs or between drugs and foods. They
can interfere with the results of a laboratory test or produce physical or chemical
incompatibilities. The more drugs a patient receives, the greater the chances that
a drug interaction will occur.
Additive effects can occur when two drugs with similar actions are administered to a
patient. The effects are equivalent to the sum of either drug’s effects if it were
administered alone in higher doses. Giving two drugs together, such as two analgesics
(pain relievers), has several potential advantages: lower doses of each drug,
decreased probability of adverse reactions, and greater pain control than from one
drug given alone (most likely because of different mechanisms of action). There’s a
decreased risk of adverse effects when giving two drugs for the same condition
because the patient is given lower doses of each drug—the higher the dose, the
greater the risk of adverse effects.
Synergistic effect, also called potentiation, occurs when two drugs that produce the
same effect are given together and one drug potentiates (enhances the effect of) the
other drug. This produces greater effects than when each drug is taken alone.
Antagonistic effect occurs when the combined response of two drugs is less than
the response produced by either drug alone
 Sometimes, an absorption-related drug interaction can be avoided by administering the
drugs at least 2 hours apart. When two drugs are given together, they can compete for
protein-binding sites, leading to an increase in the effects of one drug as that drug is
displaced from the protein and becomes a free, unbound drug.

❖ Toxic drug levels can occur when a drug’s metabolism and excretion are inhibited by another
drug.
❖ Drug interactions can also alter laboratory tests and can produce changes seen on a
patient’s electrocardiogram. Interactions between drugs and food can alter the therapeutic
effects of the drug. Food can also alter the rate and amount of drug absorbed from the GI
tract, affecting bioavailability—the amount of a drug dose that’s made available to the
systemic circulation. Dangerous interactions can also occur. For instance, when food that
contains Vitamin K (such as green, leafy vegetables) is eaten by a person taking warfarin,
the drug’s anticoagulation properties are decreased and blood clots may form. Grapefruit
can inhibit the metabolism of certain medications, resulting in toxic blood levels; examples
include fexofenadine, albendazole, and atorvastatin.
❖ A drug’s desired effect is called the expected therapeutic response.
❖ An adverse drug reaction (also called a side effect or adverse effect), on the other
hand, is a harmful, undesirable response. Adverse drug reactions can range from
mild ones that disappear when the drug is discontinued to debilitating diseases that
become chronic. Adverse reactions can appear shortly after starting a new
medication but may become less severe with time. Adverse drug reactions can be
classified as dose-related or patient sensitivity–related.
A drug typically produces not only a major therapeutic effect but also additional,
secondary effects that can be harmful or beneficial. For example, morphine used
for pain control can lead to two undesirable secondary effects: constipation and
respiratory depression. Diphenhydramine used as an antihistamine produces
sedation as a secondary effect and is sometimes used as a sleep aid.
A patient can be hypersusceptible to the pharmacologic actions of a drug. Such a
patient experiences an excessive therapeutic response or secondary effects even
when given the usual therapeutic dose. Hypersusceptibility typically results from
altered pharmacokinetics (absorption, metabolism, and excretion), which leads to
higher-than-expected blood concentration levels. Increased receptor sensitivity also
can increase the patient’s response to therapeutic or adverse effects.
A toxic drug reaction can occur when an excessive dose is taken, either
intentionally or by accident. The result is an exaggerated response to the drug that
can lead to transient changes or more serious reactions, such as respiratory
depression, cardiovascular collapse, and even death. To avoid toxic reactions,
chronically ill or elderly patients often receive lower drug doses.
Some adverse drug reactions, known as iatrogenic effects, can mimic pathologic
disorders. For example, such drugs as antineoplastics, aspirin, corticosteroids, and
indomethacin commonly cause GI irritation and bleeding.
❖ Sensitivity-related reactions result from a patient’s unusual and extreme sensitivity to a
drug. These adverse reactions arise from a unique tissue response rather than from an
exaggerated pharmacologic action. Extreme patient sensitivity can occur as a drug allergy
or an idiosyncratic response.
❖ A drug allergy occurs when a patient’s immune system identifies a drug, a drug
metabolite, or a drug contaminant as a dangerous foreign substance that must be
neutralized or destroyed.
Previous exposure to the drug or to one with similar chemical characteristics sensitizes
the patient’s immune system, and subsequent exposure causes an allergic reaction
(hypersensitivity). The allergic reaction can vary in intensity from an immediate,
life-threatening anaphylactic reaction with circulatory collapse and swelling of the
larynx and bronchioles to a mild reaction with a rash and itching.
Some sensitivity-related adverse reactions don’t result from pharmacologic properties of
a drug or from an allergy but are specific to the individual patient. These are called
idiosyncratic responses and some idiosyncratic responses have a genetic cause.
II. Nursing Process

A. DRUG ORDER
Administering drugs is one of your most critical nursing responsibilities. It’s also the area
with the smallest margin for error. A doctor generates a drug order in one of these
ways:
1. by entering the order into a computer system that transmits it to the pharmacy and
to the nurses’ station
2. by writing the order on the drug order sheet in the patient’s chart
3. by faxing the order to a pharmacy (which saves time by preventing an order from
staying in a patient’s chart or computer until the chart or computer is checked,
although the patient’s confidentiality may be breached by this method).
i. What’s in a drug order?
If a drug order sheet is used, the order sheet is located in the patient’s chart. It must
include all patient information, so it’s usually stamped with the patient’s admission data
plate. When writing the order, the doctor includes:
1. date and time of the order
2. name of the drug, either generic or trade
3. dosage form in metric, apothecaries’, or household measurement
4. abbreviation for the route of administration, such as P.O., I.M., I.V., P.R., or S.L.
5. administration schedule written as times per day or as number of hours between
doses
6. restrictions or specifications related to the order
7. doctor’s signature, or name and code number in a computerized system (one
signature, or name and code number, is sufficient after a group of orders)
8. doctor’s registration number for controlled drugs, if applicable.
i. Following orders
Standard guidelines exist for writing drug orders. Being aware of these guidelines will help
you interpret drug orders:
1. The generic name of a drug is written entirely in lowercase letters.
2. The trade or brand name of a drug begins with a capital letter.
3. Drug names shouldn’t be abbreviated to avoid errors.
4. Information is written down following a standard sequence: drug name first, then
dose, administration route, and lastly time and frequency of administration.
i. A brief look at abbreviating
Standard abbreviations are used to describe drug measurements, dosages, routes and
times of administration, and related terms. The Joint Commission requires every health
care facility to develop a list of approved abbreviations for staff use. However, The Joint
Commission has also developed a “Do not use” list of abbreviations known for causing
medication errors. Remember that abbreviations can be easily misinterpreted, especially if
they’re written carelessly or quickly. If an abbreviation seems unusual or doesn’t make
sense to you, contact the doctor for clarification. Then clearly write the correct term in
your revision and transcription.
Some doctors and health care facilities require pharmacologic orders and medication
administration records to be written and transcribed in military time. For example, an
order might read Lasix 40 mg I.V. b.i.d. at 0900 and 2100 hours. Military time might seem
confusing at first, but it’s actually simple to use. This method of time is based on a
24-hour system. Here’s how it works:
1. To write single-digit times from 1:00 a.m. to 9:59 a.m., put a zero before the times
and remove the colon. For example, 1:00 a.m. is written 0100 hours.
2. To write double-digit times from 10:00 a.m. to 12:59 p.m., just remove the colon.
For example, 11:00 a.m. becomes 1100 hours.
3. The minutes after the hour remain the same. For example, 4:45 a.m. becomes 0445
hours.
4. To write times from 1:00 p.m. to 12 midnight, simply add 1200 to the hour and
remove the colon. For example, 1:00 p.m. becomes 1300 hours (1:00 + 12:00); 3:30
p.m. becomes 1530 hours (3:30 + 12:00); and 12:00 a.m (midnight) becomes 2400
hours (12:00 + 12:00).
5. Study the two clocks below to better understand military time. The clock on the left
represents the hours from 1 a.m. (0100 hours) to noon (1200 hours). The clock on
the right represents the hours from 1 p.m. (1300 hours) to midnight (2400 hours).
Step to it! Learn military time. The time is 5 a.m. or 0500 hours. The time is 9 p.m.
or 2100 hours.
6. To write the minutes between 12:01 a.m. and 12:59 a.m., start
A. Dealing with drug orders

After you determine that a drug order contains all the necessary information, you
can begin to interpret it. If any required information is missing or if the doctor’s
handwriting is illegible, check with the doctor and clarify the order before signing
the transcription. Also ask the doctor for clarification if nonstandard abbreviations
are used. When the order is clear, sign it and send a copy to the pharmacy where
the drug will be dispensed according to your facility’s policy.
i. Calibrating the clinical clock

Although the drug order sheet tells you when to give a drug, the actual
administration time depends on three things:
1. your facility’s policy (for drugs that are given a specific number of times per day)
2. the nature of the drug
3. the drug’s onset and duration of action. Be sure to administer drugs within a
half-hour of the times specified on the drug order sheet. After giving a drug, record
the actual time of administration on the medication administration record.
i. Reevaluate, renew, reorder

Health care facilities also have policies for how often drug orders must be
renewed. For example, opioids may need to be reordered every 24, 48, or 72
hours. This requirement allows health care professionals to reevaluate the patient’s
need for the drug and to adjust the dosage or frequency of administration, if
necessary. Remember that I.V. fluids — such as normal saline solution, dextrose
and water, and total parenteral nutrition solutions — are considered drugs. Check
all I.V. fluid orders carefully. Most health care facilities provide guidelines for the
renewal of I.V. fluids as well as for other drugs.
 i. Say it in English!
The following examples illustrate how to read and interpret a wide range of drug
orders.
Drug order Interpretation
Colace 100 mg P.O. b.i.d. p.c. Give 100 mg of Colace by mouth twice per day after
meals.

Vistaril 25 mg I.M. q3h p.r.n. anxiety Give 25 mg of Vistaril intramuscularly every 3 hours as
needed for anxiety.

Increase Duramorph to 6 mg I.V. q8h Increase Duramorph to 6 mg intravenously every 8 hours.

folic acid 1 mg P.O. daily Give 1 mg of folic acid by mouth daily.

Minipress 4 mg P.O. q6h, hold for sys BP less than 120 Give 4 mg of Minipress by mouth every 6 hours; withhold
the drug if the systolic blood pressure falls below 120 mm
Hg.

Nifedipine 30 mg S.L. q4h Give 30 mg of nifedipine sublingually every 4 hours.

Begin aspirin 325 mg P.O. daily Begin giving 325 mg of aspirin by mouth daily.

Persantine 75 mg P.O. t.i.d. Give 75 mg of Persantine by mouth three times per day.

Aspirin grains v P.O. t.i.d. Give 5 grains of aspirin by mouth three times per day.

Vasotec 2.5 mg P.O. daily Give 2.5 mg of Vasotec by mouth daily.

1,000 ml D5 W c_ KCl 20 mEq I.V. at 100 ml/hr Give 1,000 ml of dextrose 5% in water with 20 milliequivalents
of potassium chloride intravenously at a rate of 100 milliliters
per hour.

Discontinue penicillin I.V., start penicillin G 800,000 Discontinue intravenous penicillin; start 800,000 units of
units P.O. q6h penicillin G by mouth every 6 hours.

Diphenhydramine 25–50 mg P.O. at bedtime p.r.n. Give 25 to 50 mg of diphenhydramine by mouth at bedtime as

insomnia needed for insomnia.
A. Handling ambiguous drug orders
All too often, drug orders are unclear because of nonstandard abbreviations, illegible
handwriting, incorrect dosages, or missing information. It helps if handwritten orders
are neat, with drugs spelled correctly.
Rule #1: Bad input equals bad output. Even if the doctor enters drug orders into the
computer system, your interpretation skills are still extremely important. Although
computers solve the problem of illegible handwriting, they can’t correct human error. A
computer will accept the wrong drug, the wrong dose, the wrong route, and the
wrong frequency. Remember, some safeguards are programmed into computer
systems to minimize errors, but it’s still up to you to verify the orders.
Rule #2: Advocate appropriate administration. Your responsibility in interpreting orders includes
making sure that the ordered drug is an appropriate treatment. Your role as patient advocate comes
into play in this situation. To make sure the drug you’re asked to administer is appropriate:
1. Think critically; don’t be timid about asking for clarification and justification.
2. Know the action of each drug you give, the purpose for which it’s given, and its possible adverse
effects.
3. Know your patient. Drugs should be used with caution in very young or very old patients as well
as those who are pregnant or who have known kidney or liver disease, a compromised immune
system, or diabetes.
4. If a drug order seems questionable, use all available resources to check it. For example, ask the
doctor, the pharmacist, and your colleagues and refer to a drug handbook.
5. Always check the 8 “rights” before giving a drug
6. Check and recheck all your drug calculations.
7. Never administer a drug that’s improperly labeled or missing a label or that you personally didn’t
draw from a vial.
8. Never use open or unmarked I.V. solution bags.
Real world problems
The following are examples of poorly written drug orders that need to be clarified by the
doctor who wrote them. See if you can find the errors.

What?
K 40 mEq I.V. daily — It’s unclear
what drug is being ordered. Is it vitamin K or potassium chloride (KCl)? If it’s KCl,
remember that this electrolyte must be diluted in a large volume of I.V. fluid before
administration.
How?
Digoxin 0.25 mg daily — The administration route is missing. Digoxin may be given
orally as a pill or elixir or may be given I.V.
When?
Nifedipine 10 mg P.O. — The frequency of administration is missing. Nifedipine can
be given in a single dose for hypertension, or it can be given on another schedule as
a maintenance drug. In the latter case, it’s usually given orally
A. A look at administration records
Maintaining accurate medication administration records is a vital nursing responsibility,
both for legal reasons and for patient safety. The liability risk of the health care provider
may increase if medication administration isn’t properly documented. Missing or inaccurate
documentation can lead to drug errors that may jeopardize your patient’s health.
Record-keeping systems
Two main types of medication administration record systems are used today: the
medication administration record (MAR) and computer charting.
1. The MAR is an 8 1⁄2 by 11 form that goes into the patient’s chart. It also may be kept
in the medication room on the medication cart in a three-ring binder or may be
attached to the patient’s chart or clipboard while the patient is hospitalized. On
discharge, the MAR is placed in the patient’s chart with the other MARs already used for
that patient.
2. Another system, computer charting, is being used increasingly by more health care
facilities. Information is entered into a computer that automatically generates a list of
administration times for all scheduled medications. Computer systems cut the risk of drug
errors caused by illegible handwriting.

No matter what type of medication charting system your facility uses, you must still record
certain standard information. Standardization allows medication administration records to
be used as legal documents if it ever becomes necessary to prove that a drug
E. Documentation
In general, documentation reflects the tasks, assessments, and procedures nurses perform.
Documenting on the administration record indicates that you’ve carried out the doctor’s order.
i. Recording patient information
If your facility uses a computerized system, you don’t need to transcribe patient
information onto the administration record. It’s already there because the admissions
office enters the patient information into the system, and the pharmacy adds
information, such as the patient’s height, weight, and allergies. In some systems,
however, nurses may also enter this information. If you use an MAR, stamp the form
with the patient’s admission data plate. If this isn’t available, copy the information
from the patient’s identification bracelet. Record the patient’s full name, hospital
identification number, unit number, bed assignment, and allergies, even those that
aren’t drug related. If the patient doesn’t have any known allergies, write “NKA.” If
the name of his insurance carrier is written on his identification bracelet, record this,
too. Transcribe the information exactly as it appears on the bracelet.
 ii. Recording drug information
Next, transcribe from the doctor’s order complete information about every drug
the patient is taking. Include dates and drug names, dosages, strengths, dosage
forms, administration routes, and administration times.
1. You must always record these dates on the administration record: the date the
prescription was written; the date the drug should begin, if this is different from the
original order date; and the date the drug should be discontinued. At some facilities,
the time and date the drug should begin are recorded together. This serves as a
reference for the time to discontinue a drug when a limited period is indicated. Many
facilities also have a standard length of time a drug may be given before it’s
automatically discontinued.
2. Record the drug’s full generic name. If the doctor ordered the drug using a proprietary
(trade or brand) name, record this name as well. Don’t use abbreviations, chemical
symbols, research names, or special facility names. Doing so can cause medication
errors or delay therapy.
3. When recording drug strength, be sure to write the amount of the drug to be
administered.
4. Also record the drug dosage form that the doctor ordered. Then decide whether
the form is appropriate, considering the patient’s special needs. For example, if
sustained-action theophylline tablets are ordered for a patient with a nasogastric
tube, he won’t be able to take the tablets orally. You’ll have to crush them before
administering them through the tube. However, crushing sustained-action tablets
destroys the drug’s integrity and alters its therapeutic action. So, you’ll need to
contact the doctor and discuss an alternative drug dosage form.
5. Recording the route of administration is especially critical for drugs that may be
given by two different routes. For example, acetaminophen can be given orally or
rectally. Other drugs can be given by only one correct route; for example, NPH
insulin may be given subcutaneously but not I.V.
6. The doctor’s order should include an administration schedule, such as t.i.d. or q6h.
Transcribe the schedule onto the administration record; then convert it into actual
times based on your facility’s policy and the drug’s availability, characteristics, onset,
and duration of action. For example, t.i.d. may mean 9 a.m., 1 p.m., and 5 p.m. in one
facility and 10 a.m., 2 p.m., and 6 p.m. in another. Similarly, b.i.d. may be 10 a.m. and
6 p.m. or 10 a.m. and 10 p.m.
7. Remember that time notations are based on a 24-hour clock, unless otherwise
specified. This means that the hour appearing first on a 24-hour clock should appear
first in the time notation. In other words, if an administration schedule is 2-10-2-10,
the first 2 represents 2 a.m., or 0200 hours; the first 10 represents 10 a.m., or 1000
hours; the second 2 is 2 p.m., or 1400 hours; and the second 10 is 10 p.m., or 2200
hours.
8. Some facilities have separate administration records or specially designated areas of the
regular administration record for transcribing single orders or special drug orders. Special
orders include drugs given p.r.n., largevolume parenteral drugs, and dermatologic and
ophthalmic medications dispensed in bottles or tubes. Other facilities put single orders or
special drugs on the regular administration record. If this is the case where you work, be
careful to distinguish these drugs from those that are regularly scheduled. All facilities have
special forms for recording controlled substances.

9. Remember that every time you transcribe orders onto the administration record, you
must sign it. First initial the record after transcribing from the doctor’s order sheet. Many
facilities also require the nurse to perform a chart check and initial the doctor’s order sheet
on a line after the last order. This indicates that all orders have been transcribed correctly
onto the administration record. If someone other than the nurse transcribes the order, a
nurse must co-sign the order sheet and the administration record.
10. Immediately after giving a drug, document the time of administration to prevent you from
mistakenly giving the drug again. For scheduled drugs, you’ll usually initial the appropriate time
slot for the date that the drug is administered. Scheduled drugs are considered on time if
they’re given within a half-hour of the ordered time. For unscheduled drugs, such assingle
doses and p.r.n. drugs, record the exact time of administration in the appropriate slot. If the
dose you administer varies in any way from the strength or amount ordered, note this in a
special area on the administration record or, if there isn’t an administration record, in the
progress notes. For example, you would document whether the patient refused to take a drug,
consumed only part of a drug, or vomited shortly after taking a drug.
11. Document detours If you administer a drug by a different route from that which the doctor
originally ordered, indicate that change, along with the reason and authorization for the
change. Also document if a special administration technique, such as a Z-track I.M. injection,
was used.
12. When administering a drug by a parenteral route, record the injection site to facilitate site
rotation. Most administration forms include a numbered list of recognized sites, allowing you to
record the site by its number. However, if necessary, describe anatomical landmarks used to
locate the specific site.
13. If you don’t give a drug on time or if you miss a dose, document the reason on
either the administration record or the patient’s progress notes. Facility policy may
require you to initial and circle the particular time missed on the administration record to
draw attention to it.
14. You need to sign the administration record after giving a drug. Put your initials in
the appropriate space on the form. Make sure that they’re legible and always sign them
the same way. If another nurse on your unit has the same initials or name, use your
middle initial to avoid confusion. In addition, write your full name, title, and initials in
the signature section of the administration record. This information must appear on
every record you initial when administering drugs.
iii. Real world problems

Here are some examples of administration record problems you may

encounter in the real world.
1. Your patient receives oral potassium chloride supplements. You’re due to give a
dose but the patient was made NPO for a test, so you withheld the dose. How do
you record this? In most facilities still using written charts, you record a withheld
dose by placing your initials in the appropriate time slot on the MAR, and then
circling them. You can dictate the reason you withheld the dose (in this case, the
patient was made NPO) in the progress notes.
2. Your patient needs a dose of morphine sulfate, a controlled substance. You only
need 2 mg of the 4-mg prefilled syringe available. On the record, how do you
indicate that the extra morphine was appropriately discarded? First, ask another
nurse to watch as you appropriately discard the extra medication. Then, have her
sign the controlled inventory record (or follow your facility’s policy) to verify this
process.
HERE’S A QUICK REVIEW OF IMPORTANT POINTS ABOUT DRUG ORDERS.
1. Reading and transcribing drug orders
✔ Make sure the drug order includes all of the following information drug name,
dose, administration route, time and frequency of administration.
2. Using military time
✔ To write single-digit times from 1:00 a.m. to 12:59 p.m., put a zero before the
time and remove the colon. (Example: 4:00 a.m. is 0400 hours)
✔ To write double-digit times from 1:00 a.m. to 12:59 p.m., just remove the colon.
(Example: 12:00 p.m. [noon] is 1200 hours)
✔ To write times from 1:00 p.m. to 12 a.m. (midnight), add 1200 to the hour and
remove the colon. (Example: 9:00 p.m. is 2100 hours)
✔ Minutes after the hour remain the same. (Example: 10:36 p.m. is 2236 hours)
3. Administering drugs
✔ Give within 30 minutes of the specified time.
✔ Record the actual administration time.
✔ If the drug is discontinued, make sure the doctor writes a new order.
✔ With each order, ensure that the appropriate drug is being administered.
KEEP THESE IMPORTANT POINTS ABOUT ADMINISTRATION RECORDS IN MIND.
1. Drug administration record systems
✔ MAR – Uses a form to record medication administration
✔ Computer charting – Medication administration information entered into a computer
– Automatic, computer-generated list of scheduled medications and their administration
times – Used increasingly over other systems
2. Documenting drug administration
✔ Write legibly in blue or black ink.
✔ Record allergy information if it isn’t already documented, using “NKA” if no allergies are
known.
✔ Transcribe from the doctor’s order complete information about each drug (dates and drug
names, dosages, strengths, dosage forms, administration routes, and administration
times).
✔ If parenteral, record the injection site.
✔ Immediately document the times of all administrations.
✔ If unscheduled, record the exact time the drug was given.
✔ If given late or not at all, document the reason.
✔ Always sign any documentation on the administration record.

3.Recording controlled-substance administration

✔ Include date and time dose is removed from locked storage area.
✔ Include amount of drug remaining in locked storage area.
✔ Record the patient’s full name.
✔ Document the doctor’s full name.
✔ Enter the drug dose given.
✔ Include your full signature (if a form is used; the nurse’s password serves as a
signature if a computer is used).
✔ If any part of the drug was discarded, obtain the signature of another nurse who
verified the amount discarded (or have her enter her password as verification if using
a computer).
A. Dosage Calculations
Doing the necessary mathematical calculations to determine what should be given is
the responsibility of the prescriber who orders the drug, the pharmacist who
dispenses the drug, and the nurse who administers the drug. This allows the
necessary checks on the dose being given before the patient actually receives the
drug.
A. Comparing Basic Units of Measure by Measuring Systems

System Solid measure Liquid measure

Metric gram (g): liter (L):

The metric system is the most 1 milligram (mg) = 0.001 g 1 1 milliliter (mL) = 0.001 L
widely used system of measure.
It is based on the decimal microgram (mcg) = 0.000001 g 1 mL = 1 cubic centimeter = 1 cc
system, so all units are
determined as multiples of 10. 1 kilogram (kg) = 1,000 g
This system is used worldwide
and makes the sharing of
knowledge and research
information easier. The metric
system uses the gram as the
basic unit of solid measure and
the liter as the basic unit of
liquid measure
Apothecary grain (gr): minim (min):

The apothecary system is a 60 gr = 1 dram (dr) 60 min = 1 fluidram (fl dr)

very old system of
measurement that was 8 dr = 1 ounce (oz) 8 fl dr = 1 fluid ounce (fl oz)
specifically developed for
use by apothecaries or
pharmacists. The
apothecary system uses the
minim as the basic unit of
liquid measure and the
grain as the basic unit of
solid measure. This system
is much harder to use than
the metric system and is
rarely seen in most clinical
settings.
Household pound (lb): pint (pt):

The household 1 lb = 16 ounces (oz) 2 pt = 1 quart (qt)

system is the
measuring system 4 qt = 1 gallon (gal)
that is found in
recipe books. This 16 oz = 1 pt = 2 cups
system uses the (c)
teaspoon as the
basic unit of fluid 32 tablespoons (tbsp) =
measure and the 1 pt
pound as the basic
unit of solid measure 3 teaspoons (tsp) = 1
tbsp

60 drops (gtt) = 1 tsp

B. Commonly Accepted Conversions Between Systems of Measurement

Solid measure

1 kg 2.2 lb

454 g 1.0 lb

1 g – 1,000 mg 15 gr

60 mg 1 gr
Liquid measure

1 L – 1,000 ml About 1 qt

240 ml 8 fl oz 1 cup

30 ml 1 fl oz 2 tbsp

15 – 16 ml 4 fl dr 1 tbsp – 3 tsp

8 ml 2 fl dr 2 tsp

4 – 5 ml 1 fl dr 1 tsp – 60 gtt

1 ml 15 – 16 min

0.06ml 1 min
Liquid measure

1 L – 1,000 ml About 1 qt

240 ml 8 fl oz 1 cup

30 ml 1 fl oz 2 tbsp

15 – 16 ml 4 fl dr 1 tbsp – 3 tsp

8 ml 2 fl dr 2 tsp

4 – 5 ml 1 fl dr 1 tsp – 60 gtt

1 ml 15 – 16 min

0.06ml 1 min
C. Conversion Between Systems

simplest way to convert measurements from one system to another is to set up a ratio and
proportion equation. The ratio containing two known equivalent amounts is placed on one
side of an equation, and the ratio containing the amount you wish to convert and its
unknown equivalent is placed on the other side.

D. Calculating dose

1. Oral drugs

Frequently, tablets or capsules for oral administration are not available in the exact dose
that has been ordered. In these situations, the nurse who is administering the drug must
calculate the number of tablets or capsules to give for the ordered dose.
2. Parenteral Drugs

All drugs administered parenterally must be administered in liquid form. The person
administering the drug needs to calculate the volume of the liquid that must be given
to administer the prescribed dose. The same formula can be used for this
determination that was used for determining the dose of an oral liquid drug:
3. Intravenous Solutions

Intravenous (IV) solutions are used to deliver a prescribed amount of fluid,

electrolytes, vitamins, nutrients, or drugs directly into the bloodstream. Although
most institutions now use electronically monitored delivery systems, it is still
important to be able to determine the amount of an IV solution that should be
given, using standard calculations. Use the following ratio to determine how many
drops of fluid to administer per minute:
4. Pediatric Considerations

For most drugs, children require doses different from those given to adults. The “standard”
drug dose that is listed on package inserts and in many references refers to the dose that
has been found to be most effective in the adult male. An adult’s body handles drugs
differently and may respond to drugs differently than children.
THE R’S OF SAFE DRUG ADMINISTRATION

Right patient.
Right drug.
Right storage.
Right route.
Right dose.
Right preparation.
Right time.
Right recording.
1. Vistaril 25 mg IM q 3h prn for anxiety – (1st
1pm)
2. Aspirin 325 mg PO bid – (1st – 9pm)
3. Persatine 75 mg PO tid (1st – 7pm)
4. Diphenhydramine 50 mg PO @ bedtime (8pm)
5. Tramadol 10 mg IV qid for pain (1st-2pm)