Evaluate the client for a therapeutic response to the
Lesson 35: Medication Administration and Dose Calculations
Administering Medications
General Guidelines
Before Administration
Wash your hands.
Assess the prescription and compare new medication
prescriptions with the current list of medications
(reconciliation). If there are questions about or
inconsistencies in the written prescription, the person who
wrote the prescription must be contacted immediately and
the prescription verified.
Ask the client whether he or she has a history of allergies.
Determine the purpose of the medication.
Assess the client for existing medical disorders in which the
prescribed medication is contraindicated (e.g., many
medications are contraindicated in pregnancy and for
breastfeeding clients).
Check the clients age. Absorption, distribution, metabolism,
and excretion of a medication are affected by the clients age
and physiological processes (e.g., the older client and the
neonate are at greater risk for toxicity than is an adult client).
Assess the clients vital signs and significant laboratory results
(e.g., the potassium level in a client who has been prescribed
a loop diuretic).
Assess the clients understanding of the purpose of the
prescribed medication.
Identify and address concerns (e.g., social, cultural, religious)
that the client has with regard to taking the medication.
Use the appropriate resources (e.g., medication formulary,
pharmacist) as necessary when preparing the medication.
Administration
Assess the six rights: right medication, right dose, right client,
right route, right time, and right documentation.
Assess the need for conversion or calculation of a dose when
preparing medication for administration.
Administer the medication within 30 minutes of the
prescribed time.
Avoid administering medications with antacids, which affect
absorption of medication. Also avoid administering
medications with grapefruit juice, which contains an enzyme
that inhibits absorption of many medications.
After Administration
Do not recap needles; discard needles in an appropriate
container, using the safety device provided with the syringe if
one is available.
Dispose of any unused medication in accordance with agency
policy. Never discard medication in a trash container.
Document administration of the medication given
including its name, the dose, the date and time, and your
initials immediately after giving the medication.
Monitor the client for side effects or adverse effects (e.g.,
allergic reaction) to the medication and take action if adverse
effects occur.
medication.
Client Teaching
Teach the client about the medication and how to self-
administer it at home.
Teach the client how to check his or her own temperature,
pulse, and blood pressure; about the side effects and adverse
effects of the medication; and when it is necessary to contact
the health care provider.
Warn the client that he or she should never change a dosage
or abruptly stop taking a medication.
Provide the client with a list of foods, fluids, and any activities
that should be avoided while he or she is taking the
prescribed medication (e.g., alcohol, smoking, activities such
as driving that require alertness).
Teach the client that over-the-counter medications and other
medications such as herbal preparations must be avoided
unless they have been approved by the health care provider.
Explain to the client the need to wear a Medic-Alert bracelet
or carry a Medic-Alert card if he or she is taking medications
such as (but not limited to) anticoagulants, oral
hypoglycemics or insulin, certain cardiac medications,
corticosteroids and glucocorticoids, antimyasthenic
medications, anticonvulsants, and monoamine oxidase
inhibitors.
Instruct the client in the importance of taking the prescribed
dose for the prescribed duration of therapy, and ensure that
the client understands the necessity of compliance.
Stress to the client the need for follow-up with the health
care provider.
Controlled Substances
All controlled substances must be stored in a locked container
requiring a key or computerized access code for entry.
An inventory record of all controlled substances used is
maintained.
If any part of a dose of a controlled substance is discarded, a
second nurse witnesses the disposal and the record is signed
by both nurses. (Agency policies and procedures are always
followed.)
Agency policies and procedures are followed with regard to
the counting of controlled substances at the end of a shift;
any discrepancy in the count is reported immediately.
Administering Oral Medications
Pour tablets or capsules into the medication container's cap,
not your hand. Medications prepared for unit dosage may be
opened at the time of administration in the client's room.
Scored tablets (those marked to facilitate division) may be
divided into halves or quarters.
Enteric-coated tablets and sustained-released capsules must
not be crushed.
To pour medication accurately using a medicine cup, hold the
cup at eye level, then pour to the line designating the desired
measure of medication.
Volumes of less than 5 mL are measured with the use of a
syringe from which the needle has been removed.
 A calibrated dropper is used to give medicine to a child or to
add a small amount of liquid to water or juice.
Do not mix liquid medication with tablets or liquid medication
with other liquid medication in the same container.
Parenteral Medications
Parenteral medications are administered by way of
subcutaneous, intramuscular, or intradermal injection or the
intravenous route.
These medications are packaged in ampules, vials, and
premeasured syringes and cartridges.
Types of Syringes
Standard medication doses for adults are to be rounded to
the nearest tenth (0.1) of a milliliter. The standard 3-mL
syringe is calibrated in tenths of a milliliter.
The nurse should not administer more than 3 mL per
intramuscular or subcutaneous injection site; when a volume
greater than 3 mL is required, a 5-mL syringe, calibrated in
fifths, may be used.
1. Tuberculin Syringe
The tuberculin syringe, holding 1 mL, is used to measure small
or critical amounts of medication (e.g., an allergen extract or
vaccine or a child's medication).
It may also be used to inject medication intradermally for
diagnostic testing (e.g., tuberculin testing).
This syringe is calibrated in hundredths (0.01) of a milliliter.
2. Insulin Syringe
The standard U-100 insulin syringe is used to measure U-100
insulin only; it is calibrated for a total of 100 units, or 1 mL.
Insulin should not be measured in any other type of syringe.
When a prescription indicates that regular and NPH insulin
are to be combined, remember RN: Draw up
the regular insulin first, then the NPH insulin.
3. Injectable Medications in Powder Form
Some medications become unstable when stored in solution
and are therefore packaged in powder form.
Powders must be dissolved with sterile diluent,
or reconstituted, before use; usually sterile water or normal
saline solution is used.
Certain steps must be followed when a medication is
reconstituted.
Other Routes of Administration
Eyedrops and Ointments
Drops: Place medication in the lower conjunctival sac and
instruct the client to blink one or two times, then keep the
eyes closed for several minutes.
Ointment: Squeeze a strip about a quarter-inch (0.5 cm) long
(unless otherwise indicated) into the lower conjunctival sac
and instruct the client to gently close his or her eyes and keep
them closed for 2 to 3 minutes (see image).
Eardrops
Instruct the client to lie on the unaffected side or to tilt the
head toward the unaffected side and to remain in this
position for 2 minutes after administration.
Next, pull back the pinna: In an adult client or older child, pull
the pinna up and back; in an infant or child younger than 3
years, pull the pinna down and back.
Transdermal Patch or Ointment
Remove the old patch or ointment and cleanse the skin.
Avoid touching the inside of the patch or the ointment (wear
gloves).
Avoid applying the patch or ointment to skin with hair.
When using ointment, measure out the correct amount on
the appropriate paper applicator (see image) and tape the
paper in place on the skin.
Do not rub the ointment into the client's skin.
Respiratory Inhaler
Instruct the client in how to use the inhaler.
Teach the client to monitor the amount of medication
remaining in the inhaler; many inhaler medication containers
note the number of doses remaining.
Rectal Suppository
To administer a suppository rectally, place the client in
the Sims position.
Lubricate the suppository and insert it, pointed end first,
through the anal sphincter about 4 inches (10 cm) in an
adult, 2 inches (5 cm) in a child (see image).
Instruct the client to remain supine for 5 to 10 minutes.
Vaginal Suppository
To administer a suppository vaginally, first place the client in
the lithotomy position.
Lubricate the suppository and insert it 2 to 3 inches (5 to 7.5
cm), toward the sacrum.
Instruct the client to remain in the supine position for 5 to 10
minutes (offer a perineal pad).
Drug Measurement Systems
The basic drug measurement systems are the metric and
household systems.
Other drug measures include the milliequivalent (mEq) or
mmol/L, used for medications such as potassium, and the
unit, used for medications such as heparin and insulin.
Metric System
1 milligram (mg) = 1000 micrograms (mcg)
1 gram (g) = 1000 mg
1 kilogram (kg) = 1000 g
1 kg = 2.2 pounds (lb)
1 liter (L) = 1000 milliliters (mL)
 Household Systems
1 ounce (oz) = 30 mL
1 quart = 1000 mL or 1 L
1 pint = 16 oz
16 oz = 1 lb
1 tablespoon (T) = 15 mL
1 teaspoon (t) = 5 mL
15 drops (gtt) = 1 mL
Calculating the Correct Dosage
Formula for Calculating a Medication Dose
Although there is more than one way to calculate a
medication dose, in this lesson the basic formula and ratio
and proportion methods are presented. If you have learned a
different method of calculating doses, such as dimensional
analysis, you may continue using that method.
When calculating a dose of an oral medication, check your
calculation and then question the prescription if the
calculation calls for more than three tablets.
When calculating a dose of a parenteral medication, check
your calculation and then question the prescription if the
amount to be given is larger than normal or seems excessive.
Be sure that all measures are in the same system and that all
units are in the same size, converting when necessary;
carefully consider the reasonable amount of the medication
that should be administered.
If rounding is necessary, perform the rounding after you have
completed the calculation.
Administering Medication to an Infant or Child
Oral Medications
Oral pediatric medications are generally presented in liquid or
suspension form because most young clients are not yet able
to swallow tablets.
A solution may be measured with the use of an oral syringe; if
an oral syringe is not available, a hypodermic syringe without
the needle may be used. When the volume of an oral liquid is
extremely small, it is measured with the use of another
calibrated measuring device (see image).
Medications in suspension settle to the bottom of the bottle
between uses, so thorough mixing is required before the
medication is poured; the medication must be administered
immediately after measurement.
Oral medications are administered with the child sitting
upright to prevent aspiration if the child cries or resists.
Never pinch an infant or child's nostrils shut when
administering medication.
Never place medication in a baby's bottle.
Draw the required dose of an unpleasant-tasting medication
into a small syringe and place the syringe in the side and
toward the back of the infant's mouth; administer the
medication slowly, allowing the infant to swallow.
To disguise an unpleasant taste, mix liquid medications with
less than an ounce of fluid.
After administering a tablet or capsule, check the child's
mouth to ensure that it has been swallowed.
Some tablets may be crushed and given in small amounts of
pured food if swallowing is a problem. (Remember,
however, that enteric-coated tablets, timed-release tablets,
and capsules may not be crushed.)
Subcutaneous and Intramuscular Medications
Insulin and immunizations are the medications most often
given by way of the subcutaneous route.
Any site with sufficient subcutaneous tissue (e.g., the lateral
aspect of the upper arm, the abdomen, the anterior thigh)
may be used for a subcutaneous injection.
The safe use of all injection sites is based on normal muscle
development and the size of the child; the preferred muscle
site for an intramuscular injection in an infant is the vastus
lateralis.
Generally, no more than 0.5 (infant) to 2.0 mL (child) is
injected per site, and the site of injection is rotated if
frequent injections are necessary.
The usual needle length and gauge for pediatric clients ranges
from 0.5 to 1 inch (1.25 to 2.5 cm) and from 22 to 25 gauge.
Needle length can also be estimated by grasping the muscle
for injection between the thumb and forefinger; half of the
resulting distance represents the needle length.
Pediatric dosages are calculated to the nearest hundredth;
the dose is measured with the use of a tuberculin syringe;
always follow agency guidelines.
Calculation of Body Surface Area
Not all children are the same size at the same age; therefore
the nomogram chart (see image) is used to determine the
body surface area (BSA) of a child, which serves as a basis for
dosing.
Procedure
Look at the nomogram chart (see image), noting that height is
on the left side of the chart and weight is on the right.
Place a ruler on the chart.
Line up the left side of the ruler on the height and the right
side of the ruler on the weight; the BSA is found at the point
where the straight edge of the ruler intersects with the
surface area column.
The estimated surface area is expressed in square meters
(abbreviated as m2). For example, the BSA of a child whose
height is 58 inches and weight is 12 kg is 0.66 m2.
Example: The average adult dose of a medication is 250 mg
and the child has a BSA of 0.41 m2.
 Priority Points to Remember!

Assess the medication prescription; if any questions arise or

inconsistencies are noted in the written prescription, the
person who wrote the prescription must be contacted
immediately and the prescription verified.
Assess the six rights: right medication, right dose, right client,
right route, right time, and right documentation.
Document the administration of every medication
including the name of the medication, the dose, the date and
time when the medicine was administered, and your initials
immediately after giving the medication.
All controlled substances must be stored in a locked container
requiring a key or computerized access code for entry.
If any part of a dose of a controlled substance is discarded, a
second nurse must witness the disposal, after which the
record is signed by both nurses (agency policy and procedures
are always followed).
Enteric-coated tablets and sustained-released capsules
should not be craushed.
Insulin should be measured only in an insulin syringe.
Never place medication in a baby's bottle.
Selection of injection sites in pediatric clients is based on
normal muscle development and the size of the child; the
preferred site for intramuscular injection in infants is the
vastus lateralis.