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Medication, if properly prescribed and administered, can be a wonderful, lifesaving thing. As for medication that’s been through a human-error wringer? Now that’s an entirely different story.
Providing medication for patients is such a basic and vital part of nursing, and yet so many nurses, especially those fresh out of the classroom, are uncomfortable with all the “must-know” knowledge and the level of personal responsibility that comes with it. That’s why a quick medications refresher course is never without its advantages, and to keep you on your game, Kati Kleber (aka Nurse EyeRoll) has compiled a quick and dirty guide for you to eyeball.
Now, onward to a calmer, more confident state of mind:
One of the major things you learn in nursing school is how to give medications. I’d like to explain some basic things because when I was in school, no one told me this stuff…it was just assumed we knew all of this. So here are some basic yet essential things to know about giving medications to patients.
When I was in nursing school, I had to buy a medication reference book. It was outdated before I even graduated. That’s why I’m quite the proponent of online resources for drugs. On Twitter I asked people what their favorite free online resources for medications were, and the three resources recommended were Epocrates, drugs.com and the Medscape app. My favorite resource for medications is Micromedex through the electronic medical record (EMR) that we have at my hospital. I use that every single shift.
Why these meds?
One of the most important things to know is why your patient is taking these specific medications. So take a look at their diagnoses and their medical history to identify why they might be on them.
Also, if you’re looking up medications and can’t figure out why the heck a medication was prescribed, never fear! Sometimes patients take things for an off-label use. So don’t forget to take a peek at off-label uses for the medication before you freak out.
Typically nursing students have to look up the meds that their patient is on the night before their shift. Therefore, you’re looking things up without physically seeing them. Quick tip: If it’s something weird that you’ve never heard of or it mentions percentages of fluid…it’s probably some sort of intravenous (IV) medication.
There are a few different ways you can give meds. These are the most common…there are a few others that I won’t go into now because we’re talking basics.
1. PO, or orally. Easy enough, right?
2. IV push, meaning you have a syringe of the medication and you push it directly into their vein. If you’re not sure how quickly you can push something, look at your medication reference guide. Most meds are to be pushed around one to two minutes, but always check! Sometimes you need to reconstitute with some normal saline, but most IV push meds are ones that you draw up from the vial and administer without diluting/reconstituting with saline.
3. IV infusion, meaning it’s going through their IV and typically set up on an IV pump to deliver the appropriate amount at the appropriate rate. So, if the order says to infuse normal saline at 75 ml/hr, you’re going to grab a liter bag (1,000 ml) of saline, prime your tubing and hook it up to your pump. You will program your IV pump to administer 75 ml every hour, then flush your patient’s IV with a syringe of normal saline, attach it to your patient’s IV and press start.
4. IV piggyback (IVPB), meaning you hook it up at the port before the IV pump on your maintenance fluid (or a dedicated medication line). You set the appropriate rate for the medication to infuse (so 100 ml/hr, 200 ml/hr, etc.), and once it has infused all of that medication, the pump automatically flips back to the mainline fluid to flush it through to make sure all of the medication was administered. (I explain more soon!)
5. Transdermal. A patch on their skin. Pretty straightforward.
6. Sublingual, meaning under the tongue. Again, nothing too bad!
7. PR, or rectally. Um. Yeah. I probably don’t need to explain that one, right?
8. IM injection. As a floor or ICU nurse, you don’t give these too often. They are usually immunizations, but there are a few others you may give. Typically given in the arm or—gasp!—the tush. I’d look this up prior to giving one to ensure you’re doing this correctly, referencing appropriate landmarks and using the correct technique. I’ve probably given less than five in the last year, honestly.
9. Subcutaneous injection. This is very common. The most common med given this way is insulin! So, so much insulin. Another common one is subcutaneous heparin (for DVT prophylaxis). You’ll give so many insulin injections, you’ll lose track after the first two weeks. It’s a smaller needle and you pinch some skin in various approved areas and inject. It’s very simple, but can be intimidating at first. Again, take a peek at your clinical handbook prior to doing this!
When you’re giving IV medications, it’s important to ensure everything is compatible. What does this mean?
When IV fluid is running, it is running through a primary line. So their primary IV fluids (normal saline, half normal saline, D5, D10, normal saline with potassium added, etc.) are the main fluids running. When you need to hang an IV antibiotic, you typically “piggyback” (hence the term “IV piggyback”) this onto your primary fluids, provided they are compatible. The antibiotic is then considered a secondary line. It is connected to the primary tubing. You set the pump to run your antibiotic at the prescribed rate and then it will (typically) automatically switch back over to your maintenance fluids.
For example, if my patient has normal saline with 20 mEq of potassium chloride running at 75 ml/hr and I have a dose of Ancef due, I need to check to see if my normal saline with potassium chloride is compatible with Ancef. If it is not compatible, then I need to start another IV, or if they have a PICC line (peripherally inserted central catheter), midline catheter or CVC (central venous catheter), I have to use a different port.
However, please make sure to follow your hospital’s policy because some require people have a dedicated line just for antibiotics (typically called a “med line”), rather than piggybacking it to a maintenance line.
To crush or not to crush
Many patients cannot swallow whole pills. This is typically due to impaired swallowing. I don’t mean to brag, but I am a fantastic applesauce mixologist and can get even the grumpiest patients to take their meds. However, before you crush medications, you must know if they can be crushed! If it is an extended-release med, chemo or capsule…don’t crush it!
There are also some meds that for whatever reason cannot be crushed. Depending on the medication administration process at your hospital, your EMR may tell you when you can and cannot crush your med. However, you must be diligent before crushing and double check before doing so.
There are so many medications for nurses to learn, but don’t lose hope! No one expects you to know all of the medications ever made, their dosages, interactions, trade and generic names, etc.
You’re just building the medication foundation right now—and you’re not just building a house, you’re building a skyscraper.
When you get out of school and start your first job, you will get very used to the medications you give day in and day out. You will learn them inside and out. If you’re a cardiac nurse, you will know amiodarone, Lopressor, Cardizem and epinephrine. If you’re an L&D nurse, you’ll know Pitocin and magnesium. If you’re a neuro nurse, you’ll be rocking 3 percent saline, mannitol and Keppra. Once you know what you need to focus on, I promise it will get much easier.
As always, follow your rights to medication administration!
Are you a newbie nurse? What questions do you have?
Are you a seasoned nurse? What guidance, advice and wisdom can you offer to those just starting out giving meds that’s not in their textbooks?