STORING OF MEDICINES,
SAFETY MEASURES AND NURSES RESPONSIBILITY
IN ADMINISTRATION OF ORAL MEDICINES
STORING OF MEDICINES
Care of Medicine Cabinet and Drugs:
1. To stock the medicines, each ward should be provided with a medicine cabinet.
2. It should be large enough to accommodate all drugs to be stocked in ward.
3. As far as possible, the medicine cabinet should be kept in a separate room adjacent to the nurse’s room.
4. A washing sink with running water should be provided in that room for hand washing facilities.
5. Adequate lighting should be provided within the cabinet to read the labels clearly.
6. There should be separate compartments for different categories of drugs – for mixtures, tablets, powders etc.
7. Drugs used for external use should be kept separate from the drugs used for internal use.
8. The containers should be arranged alphabetically, so that it is easy to find them.
9. Poisonous drugs should be kept in a separate cupboard which must have separate lock and key.
10. A senior nurse should be responsible for the poisonous medicines in the cupboard.
11. A register should be maintained to keep the account of the poisonous drugs.
12. A daily inventory should be taken to prevent theft of narcotics.
13. All the poisonous drugs should be marked ‘poison’ in red ink.
14. No drug should be stored without labels, even for a day. All the containers should have labels written neatly and legibly. The labels should contain the name of the drug, the ingredients, the strength, the dose etc.
15. All medicines containers should be kept closed always. The containers keeping the capsules, alcoholic preparations, volatile drugs etc., should have airtight caps. The tablets and pills tend to disintegrate if exposed to air.
16. The drugs that are unusual in color, odor, and consistency should be returned to the pharmacy and replaced with fresh ones.
17. Check the expiry date of every drug and make use of it before its expiry date is over or send it to the dispensary and get it replaced.
18. The drugs which are destroyed in the room temperature such as vaccines, sera, antibiotics etc., should be kept in the refrigerators.
19. Emergency drugs should be kept in a place where they are readily obtainable for emergency use.
20. When indenting for drugs, indent only the required quantity. The request for new supply of medicines should be signed by the ward sister. All medicines should be checked and signed as they are received from the dispensary.
21. The medicines cabinet should always be kept neat and clean and all equipments should be kept clean and dry after their use.
22. The medicine cabinet should be kept locked and the key should be kept where only doctors and nurses have access to it.
23. The only medicines should be kept in a separate tray or on a piece of waterproof paper to prevent soiling the shelf. Special oil cups or spoons are used which are helpful in keeping the oily odors away from medicine glasses.
SAFETY MEASURES
The ‘Five Rights’ ensures safety in giving drugs:
Right Client:
1. Read the physician’s orders to make sure for whom the medicine is ordered.
2. Read the client’s name on the client’s chart and on the medicine card.
3. Call the client by name and ask him to repeat his name. be very careful if the client is deaf or otherwise does not understand your language.
Right Drug:
1. Read the physician’s orders to study the correct name of the drug. If the order is not clear consult the physician or at least seniors.
2. To make sure the drug is copied correctly on the medicine card, on the nurse’s record etc.
3. Be careful of drugs whose names sound alike.
4. Select the right drugs from the cupboard. Read the label of the medicine container and the name of the medicine in the medicine card thrice.
Before taking the drug from the shelf.
Before measuring it.
When returning the container to the shelf and before removing the hand from the container.
5. Look for the color, odor and consistency of the drug. Unusual characteristics of the drugs should be questioned.
6. Administer medicine only from a clearly labeled container.
7. Avoid conversation or anything that distracts the mind.
8. Be familiar with the trade names. If there is doubt consult the physician or at least seniors or medicine books.
9. Avoid accepting the verbal orders. Verbal orders should be accepted only in emergencies.
10. But it should be written on the chart as early as possible.
11. Always identify the client before giving medication.
12. Make sure that the drug has not been discontinued by the physician.
Right Dose:
1. Read the physician’s orders to know the correct dose.
2. Consider the age and weight of the client. This may help to find an error in the physician’s orders.
3. Know the minimum and maximum dose of the medicine administered. Calculate the fraction of dosage correctly.
4. Measure accurately. Always use a calibrated measure in order to measure accurate doses.
5. Use ounce glasses instead of teaspoons to measure ounces.
6. Have the medicine card or written order in hand before you prepare the drug.
7. Avoid conversation or anything that distracts the mind.
8. Consider how many tablets or capsules are required for the dose.
9. Know the abbreviations and symbols used.
10. Make sure that the medicine glasses are dry before pouring or measuring the medications. Hold the ounce glass at the eye level and place the thumb at the mark up to which the medicine is to be poured. Read the lower meniscus of the fluid level when measuring the fluid medications.
11. Help the client to take all the medicine that is ordered for him.
12. The medicine should be carried to the client without spilling it out of the container.
Right Time:
1. Read the physician’s orders.
2. Know the hospital routines for the intervals.
3. Give at stated intervals for blood levels.
4. Know the abbreviations for the time e.g., B.D., T.D.S. etc.
5. Give the medicine near the time ordered – 15 min before or after the designated time.
6. Give the medicine as ordered in relation to the food intake e.g., before food or after food.
7. Give the medicines according to the action expected e.g., sleeping pills are given at bedtime, the diuretics are given in the morning hours, so that the client will not be disturbed in the night.
Right Method:
1. Read the physician’s orders to determine the route of administration.
2. Dilute the medicine if indicated.
3. Know the method of giving drugs e.g., orally, parenterally, rectally, etc.
4. Know the abbreviations used to designate the route of administration e.g., I.V., I.M., P.O., etc.
5. Identify the client correctly.
6. Stay with the client until he/she has taken the medication.
7. Never leave any medicine with the client.
8. An error in the medication should be reported immediately.
RULES FOR THE ADMINISTRATION OF MEDICATION
While preparing the medicines:
1. Read the physician’s orders before preparing the drug. No medicine should be prepared without the doctor’s written orders. Verbal orders are carried out only in emergency.
2. Check the medicines card against the physician’s orders. Be sure that the medicine is copied correctly on the medicine card and the nurse’s record.
3. Concentrate the mind on the preparation of medicines. Avoid conversations during the preparation of medicines.
4. Calculate the fractions of dosage accurately. If there is doubt, consult the physician or at least seniors.
5. Give the medication only from clearly labeled containers.
6. Read the label of the container and compare it with the medicine care thrice:
Before the medicine container is taken from the shelf.
Before pouring the drug.
Before replacing the container in the shelf.
7. Always use a calibrated measure in order to measure the accurate dose.
8. Make sure that the medicine glasses are clean and dry before the medicine is taken.
9. Shake the fluid medication before pouring it into the ounce glass.
10. Wipe the mouth of the bottle, close it tightly and replace the bottle in the proper place after use.
11. Pour the medicine from the bottle on the side opposite to the label.
12. Hold the once glass at eye level and place the thumb on the mark on the ounce glass to which the medicine is to be poured. Read the lower meniscus of the fluid level in the medicine glass.
13. When taking tablets and capsules do not touch them with hand. Drop the tablets and capsules from the container to its lid and then into the medicine cup to be taken to the bedside.
14. Once the medication is poured out of a bottle, it should not be poured back into the same bottle to prevent contamination of the whole medicine.
15. Do not use the medicines that differ in color, taste, odor and consistency.
16. Prepare the drug just before the time of administration of medicine. Never leave the drug in the medicine tray without proper identification.
Regarding the Administration:
1. Observe the five rights – right client, right medicine, right dose, right time, right method of administration.
2. Observe for the symptoms of over dosage of the drugs before it is administered e.g., a bradycardia observed in the clients getting digoxin tablets.
3. Identify the client correctly – by the bed number, room number, calling the name of the client, asking the client to repeat his name, asking others who know the client.
4. Give the drugs one by one.
5. Stay with the client until he has taken the medication completely.
6. Observe for any contraindications in oral administration of medicine such as nausea, vomiting, unconsciousness, etc., whether the drug can safely be administered through the oral route.
7. Always give the medicine you have prepared yourself.
8. Remove the unpleasant taste of medicines from the mouth by the use of orange syrups, lemon juice or by mouthwash.
9. Do not allow the medicine glass to touch the mouth of the client when the medicine is administered to the client.
10. Always provide a drink of fresh water to the client after giving an oral medicine.
11. Report an error in medication immediately to the charge nurse and the physician.
12. Do not leave the medicine with the client. Prepare a fresh dose of medicine, if the medication is to be given later.
13. The drugs that stimulate appetite should be given before food. The drugs that are irritant to the gastric mucosa should be given only after meals. The drugs given for the local effect in the stomach (e.g., an antacid) should be given after meals to prevent quick absorption of the drug.
14. Never give water after administering the cough syrups. It leaves a soothing effect on the throat and prevent coughing sensation.
15. If the client has a nasogastric tube for feeding purposes, the nurse can powder the medications and dissolve it in a solution and feed the client. The capsules can be opened to mix the powder with the other medications.
16. Enteric coated tablets should never be chewed or broken or crushed for ease of administration, because it has irritating effect on the mucosa of the stomach. Some drugs are destroyed by the action of the gastric juice.
17. The lozenges are to be sucked and not chewed until they are completely dissolved in the mouth.
Regarding the Recording of Drugs:
1. Record each dose of medicine soon after it is administered.
2. Use standard abbreviations in recording the medications.
3. Record only that medicine which you have administered.
4. Record the date, time, name of the drug administered, the dose of the medicine and the strength.
5. Never record a medication, before it is given to the client.
6. Record the effect observed – the local and systemic effects, the side effects, the symptoms of toxicity etc.
7. Record the medications that are vomited by the client, refused by the client and those drugs that are not administered to the client and the reason for not giving the medication.
Nurse’s Responsibility in the Administration of Oral Medications:
Preliminary Assessment:
1. Check the diagnosis and age of the client.
2. Check the purpose of medication.
3. Check the identification of the client – the name, bed no.
4. Check the physician’s orders for the correct name of the drug, dosage and method of administration.
5. Check the nurses record for the time at which the last dose was given.
6. Check the symptoms of over dosage of the drug administered due to the cumulative effect of the drug (e.g. by checking the pulse rate before giving digoxin)
7. Check for any contraindications present in the client for an oral intake of the medicine; such as nausea, vomiting, delirium and unconsciousness, negative attitude of the client to the intake of the medicine.
8. Check the character of the drug – whether it can be taken safely by the oral method (some drugs if taken by the mouth will be destroyed by the action of the gastric and intestinal juices e.g. insulin).
9. Check the form of the drug available and the correct method of administration.
10. Presence of oral and oesophageal lesions.
11. Check the consciousness of the client and the ability to follow instructions.
12. Check the abilities and limitations in swallowing the medications.
13. Check the articles available in the client’s unit.
Preparation of the Medicine Trolly
Articles Required:
A trolly
Purpose: To take different medications and articles to the bedside.
A Tray Containing:
A bowel of clean water.
Purpose: to wash the medicine glass.
Ounce glass, minim glass, teaspoon, dropper etc.
Purpose: To measure the medication.
Drinking water in a glass or feeding cup.
Purpose: to offer to the client after the medicine is given to him.
Mortar and pestle.
Purpose: to crush and powder the tablets if necessary.
Medicine slab and spatula.
Purpose: to divide the powdered drugs into single doses.
Duster or Towel.
Purpose: to wipe the outside of the bottle after pouring the medications.
Kidney tray and paper bag.
Purpose: to discard the wastes.
Plastic measuring cups and soufflé cups.
Purpose: to take the medication to the individual client.
Medicine cards.
Purpose: to write the medication order from the client’s order sheet.
Preparation of the Client:
1. Explain the procedure to the client. Discuss the need for medication.
2. Assist the client to a sitting position, if possible. A lateral position is the next safest and easiest, because a person lying on the back may aspirate the drug and fluids when swallowing. Unless contraindicated, raise the head end with extra pillows to provide a propped up position.
3. Give a mouthwash, if necessary.
4. If the medication is ill tasting, prepare a drink (e.g. lemon juice) to mask the taste of the medication.
5. Protect the bed clothes and garments with a towel placed under the chin across the chest.
Procedure:
Steps of Procedure:
Wash Hands.
Reason: to prevent cross infection.
Read the physician’s orders and compare it with medicine card. Make sure that all the medicines are copied correctly.
Reason: the physician’s order on the chart is the only legal source; medicine cards are used only for convenience and they may be misplaced or lost.
After reading the medicine card take the appropriate medicine from the shelf. Compare the label with the medicine card. Remember to read the entire label including the expiry date.
Reason: the first safety check to prevent the possibility of pouring the wrong medication. Any medication, with an expiry date over should not be used.
With the medication card in sight, measure the medication. Calculate dose if necessary.
Reason: recheck the medicine bottle with the medication card. The second safety check.
Take the medicine as follows:
Shake the tablets and capsules into lid of the container first and then into the medicine cups. Take the required number. Do not touch with hands.
Reason: shaking the medications into the lid of the container prevents the drugs coming in contact with the hands. It enables us to get the required number of tablets or capsules. Extra tablets, if any can be put back into the container.
Pour liquids from the side of the bottle away from the label. Hold the measuring cup at the eye level and place the thumbnail at the correct measurement mark and pour the medicine with care. Read the lower meniscus of the fluid for accuracy. Do not pour the excess of medicine into the container; discard it into the sink.
Reason: pouring from the side of the bottle prevents spoiling of the label. Placing the thumb on the marking locates the correct dose. To prevent contamination of the drug, never pour medication back into the bottle.
Wipe the mouth of the bottle and close the bottle tightly. Return the containers back into the shelf.
Reason: wiping the bottle keeps the container clean. The containers should be replaced immediately to maintain the order of the medicine cabinet. The third safety check to prevent errors.
Place the card with medication on the tray. No medicine should be kept without medicine card.
Reason: proper identification of each medication assures accurate administration of correct medication to correct client.
Prepare each medication into separate containers. Do not mix medicines.
Reasons: mixing medications in a single container is hazardous. If medications spills, client refuses one or more drugs or if a medication is withheld, it will be an embarrassing situation for the nurse.
Lock the medicine cabinet and take the medicines to the bedside.
Identify the client with the medicine card. Method available for:
Read the name on the door or at the bedside.
Reason: not infalliable. Clients may occupy another bed without prior permission.
Call client by name, in a questioning voice to get a response.
Reason: confused clients may answer to another name.
Ask the client to repeat his name.
Reason: it is one of the correct method.
Verify identification with staff member who knows the client.
Reason: this is also a correct method of identification.
Administer medicines.
Give the water or fluid to moisten the mouth.
Reason: helps in the swallowing of the solid medications.
Give medication one at a time. Stay with the client until he has taken the medication. Check the client’s mouth when indicated to verify that medications are swallowed.
Reason: administering medicines one by one enables the client to swallow them easily. Staying with the client until he has taken the medication ensures the medication is taken.
Provide water to drink after the medicines are administered.
Place the ounce glass in the bowel of water.
Reason: unless the nurse has seen the client swallow the drug. She should not record that the drug was administered. There is a possibility for the client not taking the medicine left with the client or he may save many doses and harm himself by taking them all at a time.
After Care of the Client and Articles:
1. Remove the towel and wipe the face with it.
2. Position the client for good body alignment. Tidy up the bed.
3. Take all articles to the utility room. Wash and dry all articles and replace them in their proper places.
4. Wash hands.
5. Record medications given and omitted on the nurse record. Record the reason for omission. Record any reactions observed after the administration of the medicines.
6. Return to the client to observe any expected and unexpected reactions. Report to the appropriate person immediately any errors, problems, omissions and untoward reactions.
7. Return the medication cards to the storage area.