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1. Nursing responsibilities in medication administration
   1. assessment of the patient prior to administering a medication
   2. having a clear understanding of why a patient is receiving a particular medication
   3. preparing the medication to be administered
   4. performing accurate dosage calculations
   5. administration of the medication
   6. documentation of the medication administered
   7. monitoring of the patient's reaction to the medication administered
   8. evaluating the patient's response to the medication administered
   9. educating the patient regarding his/her medication and medication regimen
2. Medication orders
   1. types of medication orders
      1. standing
         1. may be an ongoing order or may be given for a specific number of doses or days
         2. e.g., Digoxin 0.25 mg PO qd
      2. one-time
         1. given once and usually at a specific time
         2. e.g., Versed 2 mg IM at 0700
      3. prn
         1. given at the patient's request and nurse's judgment concerning need and safety
         2. e.g., Tylenol 650 mg q 4 hr PRN for headache
      4. stat
         1. given once immediately
         2. e.g., Nitroglycerine gr 1/150 SL stat
   2. parts of a medication order
      1. patient's name
      2. date and time the medication order is written
      3. name of the medication to be administered
      4. dosage of the medication to be administered
      5. route by which the medication is to be administered
      6. frequency and duration of administration of the medication
      7. any special instructions for withholding or adjusting the dosage of the medication based on effectiveness or laboratory results
      8. signature of the person writing the medication order
   3. checking a medication order
      1. at the time of contact with the medication bottle or container
      2. before pouring the medication
      3. after pouring the medication
   4. questioning a medication order
      1. any drug order suspected to be in error should be questioned as the nurse is legally responsible for drugs administered
3. Medication supply systems
   1. stock supply system
      1. large quantities of medications are stored on the unit and dispensed to all patients from the same container
      2. advantages
         1. medications are always available
         2. cost efficiency of buying large quantities of medications
      3. disadvantages
         1. drug errors are more prevalent with multiple "pourers"
         2. more risk of abuse by health care workers
         3. less accountability of amount of medication used
         4. inability to track medication usage
   2. unit-dose supply system
      1. medications are packaged and labeled by a pharmacist for a 24 hour period
      2. advantages
         1. saves time for the nurse
         2. no dosage calculation required
         3. patient is billed for specific doses of medications
         4. more accountability
         5. less chance for contamination
      3. disadvantages
         1. potential delay in receiving the medication
         2. medication not immediately replaceable if contaminated
         3. more expensive
4. Medication dosage calculations
   1. systems of measurement
      1. metric
         1. basic facts
            1. developed by the French
            2. uses the meter as the basic unit
            3. is a decimal system with prefixes that designate the various mulitples or divisibles of 10
            4. the most common prefixes in the metric system are as follows:
               1. milli
                  1. equals one one-thousandth (0.001)
               2. centi
                  1. equals one one-hundredth (0.001)
               3. kilo
                  1. equals one thousand (1000)
         2. the basic units of measurement in the metric system are as follows:
            1. meter (m)
               1. the unit of length
               2. rarely used in nursing
            2. gram (g)
               1. the unit of weight
            3. Liter (L)
               1. the unit of volume
         3. the most common metric units used in medication administration are as follows:
            1. length
               1. centimeter (cm)
               2. useful equivalents to know:
                  1. 1 centimeter (cm) = 0.01 m = about 0.4 inch
            2. volume
               1. liter (L), milliliter (mL)
               2. useful equivalents to know:
                  1. 1 liter (L) = 1000 milliliters (mLs) or 1000 cubic centimeters (cc)
                  2. 1 milliliter (mL) = 1 cubic centimeter (cc)
            3. weight
               1. gram (g), microgram (mcg), kilogram (kg)
               2. useful equivalents to know:
                  1. 1,000,000 micrograms (mcg) = 1 gram (g)
                  2. 1000 micrograms (mcg) = 1 milligram (mg)
                  3. 1000 milligrams (mg) = 1 gram (g)
                  4. 1000 grams (g) = 1 kilogram (kg) = 2.2 pounds (lb)
         4. converting dosages in the metric system
            1. converting a larger unit into a smaller unit
               1. move the decimal point to the right
               2. the new number is larger than the original
               3. example:
                  1. 0.5 g = ? mg
                     1. move the decimal point three places to the right
                     2. answer = 500 mg
            2. converting a smaller unit into a larger unit
               1. move the decimal point to the left
               2. the new number is smaller than the original
               3. example:
                  1. 900 mg = ? g
                     1. move the decimal point three places to the left
                     2. answer = 0.9 g
      2. apothecary
         1. basic facts
            1. less precise than the metric system
            2. infrequently used
            3. when an apothecary symbol or abbreviation is used, the quantity is written in lowercase Roman numerals and follows the symbol
               1. e.g., 5 gr = gr v
               2. e.g., 8 dr = dr viii
            4. when the quantity one-half is used, it may be indicated by the symbol ss
               1. e.g., 1 1/2 gr = gr iss
               2. e.g., 7 1/2 gr = gr viiss
            5. when a quantity other than one-half is used, it is indicated by common fractions
               1. e.g., gr 1/250
               2. e.g., gr 1/125
         2. the basic units of measurement in the apothecary system are as follows:
            1. grain (gr)
            2. minim (min)
            3. dram (dr)
            4. ounce (oz)
            5. pint (pt)
            6. quart (qt)
         3. the most common apothecary units used in medication administration are as follows:
            1. weight
               1. grain (gr), dram (dr), ounce (oz)
               2. useful equivalents to know:
                  1. 60 grains (gr) = 1 dram (dr)
                  2. 8 drams (dr) = 1 ounce (oz)
            2. volume
               1. minims (min), fluid dram (fl dr), fluid ounce (fl oz), pint (pt), quart (qt), gallon (gal)
               2. useful equivalents to know:
                  1. 60 minims (min) = 1 fluid dram (fl dr)
                  2. 8 fluid drams (fl dr) = 1 fluid ounce (fl oz)
                  3. 16 fluid ounces (fl oz) = 1 pint (pt)
                  4. 2 pints (pt) = 1 quart (qt)
                  5. 4 quarts (qt) = 1 gallon (gal)
      3. household
         1. basic facts
            1. less precise than both the metric or apothecary system
            2. not widely used except in home settings
         2. the basic units of measurement in the household system are as follows:
            1. drop (gtt)
            2. teaspoon (tsp)
            3. tablespoon (tbsp)
            4. glass
         3. the most common household units used in medication administration are as follows:
            1. volume
               1. drop (gtt), teaspoon (tsp), tablespoon (tbsp), glass
               2. useful equivalents to know:
                  1. 1 drop (gtt) = 1 minim (min)
                  2. 1 teaspoon (tsp) = 60 drops (gtt) or 5 milliliters (mL) or 5 cubic centimeters (cc), or 1 dram (dr)
                  3. 1 tablespoon (tbsp) = 3 teaspoons (tsp) or 15 milliliters (mL) or 15 cubic centimeters (cc)
                  4. 1 glass = 240 milliliters or 240 cubic centimeters (cc) or 8 fluid ounces (fl oz)
                  5. 2 glasses = 1 pint (pt)
   2. formulas for computing medication dosages
      1. using ratios to set up a proportion
         1. method:
            1. dosages are on the top line of the proportion
            2. quantities are on the bottom line of the proportion
            3. after the numbers are placed in the proportion, the nurse cross-multiplies to find the desired quantity
         2. formula is:
            1. dose on hand/quantity on hand = dose desired/X (quantity desired)
         3. example:
            1. Ampicillin, 625 mg PO, is ordered. It is supplied as a liquid preparation containing 250 mg in 5 mL. How much does the nurse administer?
               1. formula:
                  1. 250 mg/5 mL = 625 mg/X mL
               2. cross multiply:
                  1. 3125 = 250X
                  2. X = 12.5 mL
      2. using a standard formula
         1. method
            1. the dose desired is on the top line
            2. the dose on hand is on the bottom line
            3. the dose desired is multiplied by the vehicle or drug form
            4. the new dose desired is divided by the dose on hand
         2. formula is:
            1. dose desired/dose on hand x vehicle or drug form
         3. example:
            1. Ampicillin, 625 mg PO, is ordered. It is supplied as a liquid preparation containing 250 mg in 5 mL. How much does the nurse administer?
               1. formula:
                  1. 625 mg/250 mg x 5 ml
               2. multiply 625 by 5
               3. divide the above answer by 250
               4. answer = 12.5 mL
5. The "rights" of medication administration
   1. the five "rights"
      1. right patient
         1. methods for checking a patient's identity
            1. check the name on the patient's name band
            2. ask the patient to state his/her full name
            3. verify the patient's identity with a staff member who knows him/her
      2. right drug
         1. common abbreviations used in a medication order related to the right route
            1. cap
               1. capsule
         1. elix
            1. elixir
         2. supp
            1. suppository
         3. susp
            1. suspension
         4. tinc
            1. tincture
      3. right dose
         1. common abbreviations used in a medication order related to the right dose
            1. cc
               1. cubic centimeter
            2. g
               1. gram
            3. gr
               1. grain
            4. mg
               1. milligram
            5. ml
               1. milliliter
            6. oz
               1. ounce
            7. qs
               1. quantity sufficient
            8. tsp
               1. teaspoon
            9. tbsp
               1. tablespoon
      4. right route
         1. common abbreviations used in a medication order related to the right route
            1. IM
               1. intramuscular
            2. IV
               1. intravenous
            3. IVPB
               1. IV piggyback
            4. KVO
               1. keep vein open
            5. OD
               1. right eye
            6. OS
               1. left eye
            7. OU
               1. both eyes
            8. PO
               1. by mouth
            9. SC
               1. subcutaneous
            10. sl
                1. sublingual
      5. right time
         1. may be given 1/2 hour prior to or after the prescribed time
         2. common abbreviations used in a medication order related to the right time
            1. ac
               1. before meals
            2. ad lib
               1. as desired
            3. bid
               1. twice a day
            4. hs
               1. at bedtime; hour of sleep
            5. pc
               1. after meals
            6. prn
               1. as needed; whenever necessary
            7. q
               1. every
            8. qd
               1. every day
            9. qh
               1. every hour
            10. q2h
                1. every 2 hours
            11. qid
                1. four times a day
            12. qod
                1. every other day
            13. stat
                1. immediately
            14. tid
                1. three times a day
   2. some people add the following five "rights", too
      1. right documentation
         1. e.g., the nurse's name, dose, route, time, date, and initials or signature
      2. right assessment
         1. e.g., patient's apical heart rate prior to administering digitalis, patient's serum blood sugar levels prior to administering insulin
      3. right to education
         1. e.g., educating the patient about the therapeutic purpose of, possible side effects of, any diet restrictions or requirements of, skill of administration of, or laboratory monitoring required by the medication
      4. right evaluation
         1. e.g., was the patient's pain relieved after a pain medication is administered?, did the patient's urine output increase after a diuretic was administered?
      5. right to refuse the medication
         1. patient's can and do refuse to take medications; however, when this happens, the nurse should:
            1. attempt to determine the reason the patient is refusing to take the medication
            2. reinforce the reason that the patient needs to continue to take the medication
            3. institute reasonable measures to facilitate the patient's taking the medication
            4. provide an explanation of the risk to the patient of his/her refusal to take the medication
            5. document the patient's refusal to take the medication
6. Forms and routes for medication administration
   1. enteral
      1. medications administered within the intestines or alimentary canal
      2. types of enteral medication administration
         1. oral
            1. most common, convenient, comfortable, safe route of medication administration
            2. oral medication administration is contraindicated when a patient:
               1. has difficulty swallowing
               2. is unconscious
               3. lacks a gag reflex
               4. is NPO
               5. is vomiting
            3. types of oral medications
               1. solid
                  1. e.g., tablet, capsule, pill
               2. liquid
                  1. e.g., elixir, spirit, suspension, syrup
         2. special techniques when administering oral medications
            1. medications that are enteric-coated or sustained-release capsules should not be chewed or crushed
            2. medications that are scored can be broken in half if a partial quantity is needed
            3. medications that discolor the teeth or damage the enamel should be:
               1. mixed well with water or some other liquid to dilute it
               2. administered through a straw
               3. followed with water after administration through the straw
            4. medications with an objectionable taste can be make more palatable by:
               1. allowing the patient to suck on a piece of ice prior to taking the medication to numb his/her taste buds
               2. refrigerating and administering oily medications at cold, rather than room, temperature
               3. placing the medication in a syringe, placing the syringe well back on the tongue, being careful not to trigger the gag reflex, and administering it slowly through the syringe
               4. offering oral hygiene immediately after administering the medication
               5. giving the medication with generous amounts of water or other liquids, if permitted, to dilute the taste
   2. parenteral
      1. medications administered outside the intestines or alimentary canal
      2. equipment needed for parenteral injections
         1. needle
            1. parts of a needle
               1. bevel
               2. lumen
               3. shaft
               4. needle hilt or hub
         2. syringe
            1. parts of a syringe
               1. barrel
               2. plunger
         3. choosing the correct needle and syringe for parenteral injections
            1. route of administration of the medication
               1. e.g., a longer needle is required for an intramuscular injection compared to an intradermal or subcutaneous injection
            2. viscosity of the medication to be administered
               1. e.g., a large-lumen needle is required for viscous medications
            3. quantity of medication to be administered
               1. e.g., a syringe with a greater capacity is required when a large amount of medication is to be administered
            4. patient's body size
               1. e.g., a longer needle is required for obese patients
            5. type of medication to be administered
               1. e.g., a special syringe is required for certain medications (e.g., insulin)
      3. intradermal injection
         1. uses
            1. to administer diagnostic tests, such as a tuberculin test, allergy tests
         2. effect
            1. local
         3. needle placement
            1. just below the epidermis
         4. needle angle
            1. 10 - 15 degrees
         5. injection site(s)
            1. lightly pigmented, thinly keratinized, and hairless skin area on the:
               1. inner surface of the forearm
               2. clavicular area of the upper chest
               3. scapular area of the upper back
         6. injection equipment needed
            1. needle type
               1. 1 mL tuberculin syringe calibrated in tenths and hundredths of a mL
            2. needle length
               1. 1/4 to 1/2 inch
            3. needle gauge
               1. 26 to 27
         7. dosage given
            1. usually 0.5 mL or 0.5 cc or less
         8. basic technique
            1. wash hands
            2. don clean gloves
            3. cleanse area
            4. hold skin taut
            5. insert the needle, bevel up, at a 10 - 15 degree angle
            6. inject the medication slowly to form a wheal (blister or bleb)
            7. do not massage the area and instruct the patient to not massage the area
            8. assess for reaction in 24 - 72 hours
               1. measure the diameter of the local reaction (redness) for allergy test
               2. measure the diameter of induration (not local reaction (redness), for a TB test
      4. subcutaneous injections
         1. uses
            1. to administer non-irritating, water-soluble drugs, such as insulin, heparin, certain immunizations
         2. effect
            1. systemic
         3. needle placement
            1. in the subcutaneous tissue between the epidermis and the muscle
         4. needle angle
            1. 45 - 90 degrees
         5. injection site(s)
            1. outer aspect of the upper arm
            2. abdomen (from below the costal margin to the iliac crests)
            3. anterior aspects of the thigh
            4. upper back
            5. upper ventral or dorsogluteal area of the hips
         6. injection equipment needed
            1. needle type
               1. 1 mL tuberculin syringe calibrated in tenths and hundredths of a mL or cc
               2. insulin syringe calibrated in units
            2. needle length
               1. 5/16 to 1 inch
            3. needle gauge
               1. 25 to 30
         7. dosage given
            1. usually 1 mL or less
         8. basic technique
            1. thin person
               1. was hands
               2. cleanse area
               3. bunch the skin to create a skin fold
               4. insert the needle at a 45 degree angle
               5. release the skin
               6. aspirate, if recommended (except with heparin)
               7. inject the medication
               8. withdraw the needle
               9. gently massage the area (except with heparin)
            2. obese person
               1. wash hands
               2. cleanse the skin
               3. insert the needle at a 90 degree angle
               4. aspirate, if recommended (except with heparin)
               5. inject the medication
               6. withdraw the needle
               7. gently massage the area (except with heparin)
      5. intramuscular injections
         1. uses
            1. to administer irritating drugs, aqueous solutions, or solutions in oil
         2. effect
            1. systemic
         3. needle placement
            1. into the muscle
         4. needle angle
            1. 90 degrees
         5. injection site(s)
            1. ventrogluteal
               1. recommended for
                  1. adults and children over 7 months of age
               2. patient position
                  1. supine, lateral
               3. syringe type
                  1. 3.0 - 5.0 mL
               4. needle length
                  1. 1 1/2 - 2.5 inches
               5. needle gauge
                  1. 20 - 23
               6. dosage given
                  1. usually 5.0 mL or less
               7. method for locating site
                  1. nurse places his/her palm over the patient's greater trochanter with his/her fingers facing the patient's head
                  2. the nurse's index finger is placed on the patient's anterosuperior iliac spine
                  3. the nurse's middle finger extends dorsally palpating the crest of the patient's ileum
                  4. forms a triangle
                  5. the nurse makes the injection in the center of the triangle
               8. advantages
                  1. relatively free of major nerves and vascular branches
                  2. well defined by bony landmarks
                  3. thinner layer of fat than the dorsogluteal site
                  4. sufficient muscle mass for deep IM or Z-track injections
                  5. readily accessible from several patient positions
               9. disadvantages
                  1. should a hypersensitivity reaction occur, tourniquet cannot be applied to delay absorption
                  2. health professional's unfamiliarity with site
            2. vastus lateralis
               1. recommended for
                  1. children younger than 7 months
               2. patient position
                  1. supine, sitting
               3. syringe type
                  1. 3.0 mL
               4. needle length
                  1. 5/8 - 1 inch
               5. needle gauge
                  1. 22 - 25 guage
               6. dosage given
                  1. usually 1.0 mL or less (infants)
                  2. usually 2.0 mL or less (pediatric)
               7. method for locating site
                  1. the nurse divides the patient's thigh into thirds horizontally and vertically
                  2. the nurse makes the injection in the outer middle third of the patient's thigh
               8. advantages
                  1. relatively large muscle mass at birth
                  2. suitable site for infants
                  3. area of sufficient size for several injections
                  4. free of major nerves and vascular branches
               9. disadvantages
                  1. use of a long needle relative to small extremity size may reach sciatic nerve or femoral vascular structures if improper technique is used
            3. deltoid muscle
               1. recommended for
                  1. adults
               2. patient position
                  1. sitting, prone, supine, lateral
               3. syringe type
                  1. 3.0 mL
               4. needle length
                  1. 5/8 - 1 1/2
               5. needle gauge
                  1. 23 - 25
               6. dosage given
                  1. usually 1.0 mL or less
               7. method for locating site
                  1. method one
                     1. the nurse palpates the lower edge of the patient's acromion process and the midpoint on the lateral aspect of the patient's arm that is in line with his/her axilla
                     2. forms a triangle
                     3. the nurse makes the injection in the center of the triangle
                  2. method two
                     1. the nurse places four fingers across the patient's deltoid muscle with his/her first finger on the patient's acromion process
                     2. the nurse makes the injection three finger breadths below the patient's acromion process
               8. advantages
                  1. easily accessible
                  2. general acceptable by patient
                  3. in hypersensitivity reaction, tourniquet may be applied above the injection site
               9. disadvantages
                  1. small muscle mass relative to other sites
                  2. close proximity to nerves and vascular structures
                  3. small margin of safety with any deviation from site
                  4. not suitable for repeated or large-volume injections
            4. dorsogluteal
               1. recommended for
                  1. adults and children greater than 3 years of age
               2. patient position
                  1. prone
               3. syringe type
                  1. 3.0 mL
               4. needle length
                  1. 1.25 - 3
               5. needle gauge
                  1. 18 - 23
               6. dosage given
                  1. usually 3.0 mL or less
               7. method for locating site
                  1. the nurse locates the patient's posterosuperior iliac spine and greater trochanter
                  2. the nurse draws an imaginary line between the above
                  3. the nurse makes the injection lateral and slightly superior to the midpoint of the imaginary line
               8. advantages
                  1. large muscle mass accommodates deep IM or Z-track injections
                  2. injection is not visible to the patient
               9. disadvantages
                  1. boundaries of the upper outer quadrant are arbitrarily selected and may exceed margin of safety
                  2. danger of injury to major nerves and vascular structures if incorrect site or technique
                  3. fat is often very thick and an injection intended for the muscle may be subcutaneous
                  4. if a hypersensitivity reaction occurs, a tourniquet cannot be used
                  5. difficult to maintain asepsis
         6. technique
            1. basic
               1. wash hands
               2. don clean gloves
               3. cleanse the skin
               4. insert the needle at a 90 degree angle
               5. aspirate
               6. inject the medication
               7. withdraw the needle
               8. gently massage the area
            2. z-track (prevents medication from seeping back into the subcutaneous tissue)
               1. wash hands
               2. draw up the medication
               3. replace the first needle with a second needle
               4. don clean gloves
               5. cleanse the skin
               6. pull the skin to the side and hold
               7. insert the needle at a 90 degree angle
               8. holding the skin to the side, inject the medication
               9. withdraw the needle
               10. release the skin
      6. intravenous (future lecture)
         1. action
         2. site
         3. equipment
         4. technique
   3. topical
      1. medications administered to the skin, cornea, or mucous membranes of the eye, mouth, oropharynx, nose, rectum, or vagina
      2. types of topical medication administration
         1. transdermal
            1. administration of a medication through the skin where it is absorbed
            2. basic technique
               1. transdermal patch
                  1. wash hands
                  2. don clean gloves
                  3. remove old patch and dispose
                  4. assess skin area where old patch was removed for irritation
                  5. apply new patch at the same time of day
                  6. write the date and time on the new patch
         2. buccal
            1. administration of a medication by placing it against the mucous membrane of the cheek where it dissolves and is absorbed
            2. basic technique
               1. place the medication against the patient's right or left cheek
               2. instruct the patient not to swallow the medication
               3. instruct the patient to let the medication remain in place until it is fully dissolved and absorbed
               4. instruct the patient to not eat any food or drink any fluids while the medication is in place
         3. sublinqual
            1. administration of a medication by placing it under the tongue where it dissolves and is absorbed
            2. basic technique
               1. place the medication under the patient's tongue
               2. instruct the patient not to swallow the medication
               3. instruct the patient to let the medication remain in place until it is fully dissolved and absorbed
               4. instruct the patient to not eat any food or drink any fluids while the medication is in place
         4. installations
            1. administration of a medication into a body cavity or orifice such as the eye, ear, nose, rectum, or vagina
            2. types of installations
               1. optic
                  1. medications administered into the lower conjunctival sac of the eye(s)
                  2. basic technique
                     1. optic drops
                        1. wash hands
                        2. don clean gloves
                        3. clean the patient's affected eye with sterile cotton balls moistened with sterile normal saline by wiping from the inner to outer canthus
                        4. position the patient
                           1. if the patient is sitting up, instruct him/her to tilt his/her head back and look up toward the ceiling
                           2. if the patient is lying down, place his/her head over a pillow and look up toward the ceiling
                        5. evert the medication bottle so that the tip of the bottle faces down about 1/2 - 3/4 inches above the patient's affected eye being careful not to touch the eyelid, eyelashes, or eyeball with the tip of the bottle
                        6. gently draw the skin down below the patient's affected eye to expose the lower conjunctival sac
                        7. gently instill the correct number of drops onto the outer third of the lower conjunctival sac of the patient's affected eye
                        8. gently apply pressure over the inner canthus of the patient's affected eye to prevent the drops from flowing into the tear duct
                     2. optic ointment
                        1. wash hands
                        2. don clean gloves
                        3. clean the patient's affected eye with sterile cotton balls moistened with sterile normal saline by wiping from the inner to outer canthus
                        4. position the patient
                           1. if the patient is sitting up, instruct him/her to tilt his/her head back and look up toward the ceiling
                           2. if the patient is lying down, place his/her head over a pillow and look up toward the ceiling
                        5. evert the tube so that the tip of the tube faces down about 1/2 - 3/4 inches above the patient's affected eye being careful not to touch the eyelid, eyelashes, or eyeball with the tip of the tube
                        6. gently draw the skin down below the patient's affected eye to expose the lower conjunctival sac
                        7. gently squeeze about a 1/2 inch strip of ointment from the tube along the exposed lower conjunctival sac
                        8. instruct the patient to close his/her eyes for 2 - 3 minutes
                        9. instruct the patient to move his/her affected eye underneath his/her closed eyelid to spread the ointment under the eyelid and over the surface of the eyeball
                        10. instruct the patient that he/she can expect blurred vision for a short time
               2. otic
                  1. medications administered into the auditory canal
                  2. basic technique
                     1. wash hands
                     2. don clean gloves
                     3. warm the medication bottle to room temperature
                     4. if necessary, clean the patient's affected ear with sterile cotton balls moistened with sterile normal saline
                     5. position the patient
                        1. if the patient is sitting up, instruct him/her to tilt his/her head to the side with his/her affected ear facing up toward the ceiling
                        2. if the patient is lying down, instruct the patient to turn onto his/her side with his/her affected ear facing up toward the ceiling
                     6. draw up the correct amount of solution into the dropper
                     7. straighten the auditory canal of the patient's affected ear
                        1. pull the pinna up and back (if adult)
                        2. pull the pinna down and back (if an infant or child under 3)
                     8. hold the dropper so that the tip faces down about 1/2 - 3/4 inches above the auditory canal of the patient's affected ear
                     9. gently instill the correct number of drops from the dropper alongside the the side of the auditory canal of the patient's affected ear
                     10. gently press on the tragus of the patient's affected ear a few times
                     11. if ordered, loosely insert a cotton ball into the patient's affected ear to prevent the medication from leaking out
                     12. instruct the patient to remain in a sitting or side-lying position with his/her ear facing up toward the ceiling for 5 minutes
               3. nasal
                  1. medications administered into the nasal cavity
                  2. basic technique
                     1. wash hands
                     2. don clean gloves
                     3. provide the patient with paper tissues and instruct him/her to blow his/her nose prior to instilling the nose drops
                     4. position the patient
                        1. if the patient is sitting up, instruct him/her to tilt his/her head back with his/her nose facing up toward the ceiling
                        2. if the patient is lying down, place a pillow under his/her shoulders and allow his/her head to fall over the edge of the pillows his/her nose is facing up toward the ceiling
                     5. draw up the correct amount of solution into the dropper
                     6. hold the tip the patient's affected naris
                     7. evert the dropper so that the tip of the dropper faces down
                     8. place the tip of the dropper just inside the patient's affected naris
                     9. gently instill the correct number of drops from the dropper into the patient's affected naris
                     10. instruct the patient to remain in a sitting position with his/her nose facing up toward the ceiling or a lying position with a pillow under his/her shoulders, allowing his/her head to fall over the edge of the pillow, with his/her nose facing up toward the ceiling for 5 minutes
               4. inhalation
                  1. administration of medications into the lungs
                  2. basic technique
                     1. metered-dose inhaler without spacer
                        1. remove the mouthpiece cover from the inhaler
                        2. shake the inhaler well
                        3. instruct the patient to take a deep breath and exhale
                        4. instruct the patient to open his/her mouth wide
                        5. instruct the patient to hold the inhaler 1 - 2 inches from his/her open mouth
                        6. instruct the patient to inhale slowly and deeply through his/her mouth
                        7. instruct the patient to press down on the medication canister while continuing to inhale through his/her mouth
                        8. instruct the patient to hold his/her breath for 5 - 10 seconds or as long as possible
                        9. instruct the patient to wait 1 - 5 minutes before administering a second dose
                     2. metered-dose inhaler with spacer
                        1. remove the mouthpiece cover from the inhaler
                        2. shake the inhaler well
                        3. attach spacer to mouthpiece of inhaler
                        4. instruct the patient to take a deep breath and exhale
                        5. instruct the patient to grasp the mouthpiece of the spacer securely with his/her teeth and lips
                        6. instruct the patient to inhale slowly and deeply through his/her mouth
                        7. instruct the patient to press down on the medication canister while continuing to inhale through his/her mouth
                        8. instruct the patient to hold his/her breath for 5 - 10 seconds or as long as possible
                        9. instruct the patient to wait 1 - 5 minutes before administering a second dose
               5. suppositories
                  1. rectal
                     1. installations through the anus and into the rectum
                     2. basic technique
                        1. wash hands
                        2. don clean gloves
                        3. position patient on his/her left side
                        4. remove foil around suppository
                        5. lubricate suppository (if desired)
                        6. instruct the patient to breathe through his/her mouth to relax the internal and external anal spinchters
                        7. separate the patient's buttocks
                        8. gently insert the uppository, rounded end first, beyond the internal anal spinchter
                        9. if stool is present, do not embed the suppository in the sool, but place it between the stool and rectal mucosa
                        10. instruct the patient to remain on his/her left side
                            1. 5 minutes (if non-laxative)
                            2. 35 - 45 minutes (if laxative)
                  2. vaginal
                     1. administration of medication through the introitus and into the vagina
                     2. basic technique
                        1. wash hands
                        2. don clean gloves
                        3. position patient in a lithotomy position
                        4. remove foil around suppository
                        5. lubricate suppository (if desired)
                        6. spread the patient's labia with your fingers
                        7. clean the patient's vaginal orifice with cotton balls and warm water using a single stroke moving from the above the orifice down toward the sacrum
                        8. gently insert the suppository, rounded end first, through the introitus well into the vagina for its full length
                        9. instruct the patient to remain in a supine position for 5 - 10 minutes
                        10. provide the patient with a perineal pad to collect drainage

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