When the medications are stocked in nursing unit, the nurse have responsibility to take care of the medication. Certain guidelines for safe medication storage are as follows.
Store all medications according to the classification in a locked, secure cabinet or container. Place the locked cabinet in bright and ventilative place to check and identify easily, but should be free of direct shine and keep it clean, tidy and dry.
A special nurse in charge carries asset of keys for the cabinet. And the nurse checks the quantities and the qualities of the medications regularly. Replenish the stock medication following the policies of institution and discard the medication with problems.
Placement of medications
Store and place the medications separately according to their different routes of administration (oral, injection, or topical), toxicity or untoxicity and whether to be used for mental diseases or not, with clear indication. Expensive drugs, narcotics and virulent toxicants must be taken charge of by a special nurse who should lock the cabinet and have the key always with her. On every shift, the nurse going off duty counts all medications, especially narcotics and virulent toxicants, with the nurse coming on duty. Both nurses sign the medication record to indicate that the count is correct.
Label the container of medications clearly
Different medications should be labeled with different colorful strips. Blue strip labels oral medications, red strip labels external medications, and black strip labels virulent toxicants. Keep each medication in its original labeled container, and keep the labels and specifications legible. If the labels are soiled or illegible, discontinue using the medications. In addition, label drug name, concentration and dosage.
Check the medications carefully
Check the nature of medications carefully. Discontinue using the medications if they become deposited and cloudy, smell abnormal, change color, get deliquescence or mildewy(发霉的).
Store the medications properly according to their different nature.
Medications which tend to volatilize, deliquesce, or effloresce should be kept in airtight bottles, e.g., ethanol, iodine, sugar-coated tablets.
Medications that will be oxidized if exposed to air and be denatured if exposed to light should be kept in airtight colored bottles. Cover the container with shade paper box if necessary and store it in the shady and cool area, e.g., vitamine C.
Biologic products and antibiotics that will be destroyed and decomposed if exposed heat should be kept in the dry, and shady and cool area (about 20℃) or in refrigerator (about 2～10℃) according to their nature and desire for storage, e.g., an antitoxic serum, vaccine, placental globin, penicillin skin test solution.
Medications should be used designedly according to valid periods in case of invalidation, e.g., antibiotics and insulin.
Store the inflammable and explosive medications in airtight bottle and place in the shady and cool area separately and keep them away from fire and electrical appliances.
Principles of Administering Medications
To provide effective and safe administration, the nurses must strictly comply with the following principles.
Correct Transcription and Communication of Orders
The nurse or a designated unit nurse writes the physician’s complete order on the appropriate medication forms. The transcribed order includes the client’s name, room, and bed number, drug name, dosage, frequency, and route of administration. Each time a drug dosage is prepared the nurse refers to the medication form. When transcribing orders, the nurse should be sure that names, dosages are legible. The nurse rewrites any smudged or illegible transcriptions.
In some institutions a computer print out lists all currently ordered medications with dosage information. Orders are entered directly into the computer, preventing the need for transcription of orders. The same printout may be used to record medications given.
A registered nurse checks all transcribed orders against the original order for accuracy and thoroughness. If an order seems incorrect or inappropriate, the nurse should consult the physician instead of executing the doubtable order blindly or altering it freely. The nurse who gives the wrong medication or an incorrect dose is legally responsible for the error.
Use the Guidelines of Three Checks and Seven Rights to Ensure Safe Drug Administration
Preparing and administering medications require accuracy. To ensure safe medication administration, the nurse uses the guidelines of three checks and seven rights.
Three checks should be implemented when delivering medications. The nurse makes first check before medication preparation for the client that is called as the check before operation. Then the nurse makes a second check, or the double check, just before administering medication to the client that is called as the check during operation. And the nurse makes a third check immediately after medication administration to the client that is the check after operation. What the nurse checks three times are what seven rights refer to.
The seven rights help to ensure accuracy when administering medications. The seven rights include the right name of the client, right bed number of the client, right name of the medication, right concentration, right dose, right route, and right time.
Right client: name and bed number
An important step in administering drugs safely is being sure the drug is given to the right client. It is difficult to remember every client’s name and face. To identify a client correctly, the nurse checks the medicine card or form against the client’s bed card and asks the client to state his or her name. If the bed card becomes smudged or illegible, or is missing, the nurse must acquire a new one for the client. When asking the client’s name and assume that the client’s response indicates that he or she is the right person. Instead, the nurse asks the client to state his or her full name. To avoid making the client feel uneasy, the nurse simply states that the question is routine for giving a drug.
Checking the bed number of the client is to ensure right client again. When two clients have the same name, the nurse can distinguish them by different bed number.
Right drug: name, concentration and dose
When drugs are first ordered, the nurse compares the medications recording form or computer orders with the physician’s written orders. When administering drugs, the nurse compares the label of the drug container with the medication form. The nurse does this three times: (1) before removing the container from the drawer or shelf, (2) as the amount of drug ordered is removed from the container, and (3) before returning the container to storage which are before, during and after dispensing during preparation. If a client questions the medication a nurse prepares, it is important not to ignore these concerns. With unit-dose prepackaged drugs, the nurse checks the label with the medicine form a third time even though there is no permanent container. Unit dose medications may be checked before opening at the client’s bedside.
An alert client will know whether a drug is different from those received before. In most cases the client’s drug order has been changed; however, the client’s questions might reveal an error. The nurse should withhold the drug until the preparation can be rechecked against the physician’s orders.
Clients who self-administer drugs should keep them in their original labeled containers, separate from other drugs, to avoid confusion.
The nurse never prepares medications from unmarked containers or containers with illegible labels. If a client refuses a drug, the nurse should discard it rather than return it to the original container. Unit-dose packaged drugs can be saved if they are unopened.
Sometimes, one medication has various forms with different concentration. Nurses should par attention to the concentration of the medication administered. Excessively higher concentration or lower concentration will influence the client health. When a medication must be prepared from a high concentration, the nurse should ensure the process of calculation and implementation correct to make the accurate concentration. When calculating the concentration of medication and diluting the medication, the nurse should have another qualified nurse check the results.
The unit-dose system is designed to minimize errors. When a medication must be prepared from a larger volume or concentration if required or the physician prescribes a medication with a measurement system different from that of the medication supplied, the chance of error increases. When calculating or converting the dosage of the medication, the nurse should have another qualified nurse check the results. After calculation, the nurse prepares the medication using standard measurement devices. Graduated cups, syringes, and scaled droppers can be used to measure medications accurately. Some dosages are based on the client’s weight or body surface area. Always verify calculations of divided or individualized doses with another nurse. Always check heparin, insulin, and digitalis doses with another nurse.
If a physician’s order does not designate a route of administration, the nurse consults the physician. Likewise, if the specified route is not the recommended route, the nurse should alert the physician immediately. When the nurse administers injections, precautions are necessary to ensure that the drugs are given correctly. It is also important to prepare injections only from preparations designed for parenteral use. The injection of a liquid designed for oral use can produce local complications, such as a sterile abscess, or fatal systemic effects. Drug companies label parenteral drugs for “injectable use only”.
The nurse must know why a drug is ordered for certain times of the day and whether the time schedule can be altered. For example, two drugs are ordered, one q8h (every 8 hours) and the other t.i.d. (3 times a day). Both medications are to be given 3 times within a 24-hour period. The physician intends the q8h medication to be given around the lock to maintain therapeutic blood levels of the drug. In contrast, the t.i.d. medication is given during the waking hours. Each institution has a recommended time schedule for medications ordered at frequent intervals.
The physician often gives specific instructions about when to administer a medication. A preoperative medication to be given on call means that the nurse is to administer the drug when the operating room notifies the nursing division. A drug ordered pc (after meals) is to be given within half an hour after a meal when the client has a full stomach. A stat medication is to be given immediately. Absorption of oral drugs is affected by stomach contents as well as the ingestion of other drugs. Note before-meal and between-meal formulations.
Drugs that must act at certain times are given priority. For example, insulin should be given at a precise interval before a meal. All routinely ordered medications should be given within 30 minutes of the times ordered (30 minutes before or after the prescribed time).
Some drugs require the nurse’s clinical judgment in determining the proper time for administration. A prn sleeping medication should be administered when the client is prepared for bed or at a time appropriate for maximum benefit. A nurse also uses judgment when administering prn analgesics. For example, the nurse may need to obtain a stat order from the physician if the client requires a drug before the prn interval has elapsed.
Administer medication safely and accurately
Nurses should understand the right time, the skill when administering medications. The prepared drug should be delivered to the patients and taken timely in case of being contaminated or the invalidation. Explain and demonstrate method for the client so that he can cooperate with us. Instruct the client to administer drugs correctly. Inquire the client’s history of allergies and perform the allergy test as ordered before administering medications that can arouse allergies. Only when the outcome is negative, the medication can be used.
Observe the client’s response to the medication after administration
After administration, observe the therapeutic effect and side effect and record them. After the digitalis is administered, the nurse should inspect the rate and rhythm of the heart closely. If the heart rate is lower than 60 times per second or arrhythmia occurs, which means toxic effects, inform the physicist and discontinue this drug.
Routes of Administration
The route prescribed for administering a drug depends on the drug’s properties and desired effect and on the client’s physical and mental condition. A nurse collaborates with the physician in determining the best route for a client’s physical and mental condition in determining the best route for a client’s medication, as in the following hypothetical situations:
The client, Mr. Li, has progressively worsened physically. His temperature is 39.2℃. He complains of nausea and is unable to tolerate oral fluids. The nurse checks Mr. Li’s order, which reads,” Aspirin 600mg orally for temperature above 38.5 ℃.” On the basis of the assessment, the nurse believes that Mr. Li will not be able to tolerate an oral does of aspirin. By consulting the physician, the nurse acquires an order for a rectal suppository instead.