This document discusses medication orders, types of medication orders, essential parts of a medication order, communicating orders, calculating dosages, administering medications, and medication reconciliation. It provides details on physician and nurse practitioner ordering abilities, verbal/telephone orders, stat, single, standing, and PRN orders. It also outlines the 7 essential parts of orders, 2 methods for individualizing dosages, systems for dispensing medications, and the 5 rights of administration.

1. PHARMACOLOGY (NCM 106)
Basics in Medication
Mr. JHONEE F. BALMEO

2. Medication Orders
 A physician usually determines the client’s medication
needs and orders medications, although in some settings
nurse practitioners and physician assistants now order
some drugs.
 State law dictates whether the nurse practitioner and
physician assistant have prescriptive ability and the class
of drug for which they may prescribe.
Also, each health agency will have its own policies*

3. Medication Orders
 Usually the order is written, although telephone and
verbal orders are acceptable in a number of agencies.
 Nursing students need to know the agency policies about
medication orders.
 In some hospitals, for example, only licensed nurses are
permitted to accept telephone and verbal orders.

4. Types of Medication Orders
 Four common medication orders are the stat order, the single
order, the standing order, and the prn order.
1. A stat order indicates that the medication is to be given
immediately and only once (e.g., morphine sulfate 10 milligrams
IV stat).

5. Types of Medication Orders
 2. The single order or one-time order is for medication to be
given once at a specified time (e.g., Seconal 100 milligrams at
bedtime before surgery).
 3. The standing order may or may not have a termination
date.

6. Types of Medication Orders
 A standing order may be carried out indefinitely (e.g.,
multiple vitamins daily) until an order is written to cancel
it, or it may be carried out for a specified number of days
(e.g., KCl twice daily 2 days).
 In some agencies, standing orders are automatically
canceled after a specified number of days and must be
reordered.

7. Types of Medication Orders
 4. A prn order, or as-needed order, permits the nurse to
give a medication when, in the nurse’s judgment, the
client requires it (e.g., Insulin 5u prn). The nurse must use
good judgment about when the medication is needed and
when it can be safely administered.

8. Essential Parts of a Medication Order
 The drug order has seven essential parts.
 In addition, unless it is a standing order it should state the
number of doses or the number of days the drug is to be
administered.

9. Essential Parts of a Medication Order
 1. The client’s full name, that is, the first and last names and
middle initials or names, should always be used to avoid
confusion between two clients who have the same last name.
 In some agencies, the client’s identification number and
primary care provider’s name are placed on the order as
further identification.

10. Essential Parts of a Medication Order
 2. In addition to the day, the month, and the year the order was
written, some agencies also require that the time of day be
written.
 Many health agencies use the 24-hour clock, which eliminates
confusion between morning and afternoon times. Time with the
24-hour clock starts at midnight, which is 0000hours

11. Essential Parts of a Medication Order
 3. The name of the drug to be administered must be
clearly written. In some settings only generic names are
permitted; however, trade names are widely used in
hospitals and health agencies.

12. Essential Parts of a Medication Order
 4. The dosage of the drug includes the amount, the times
or frequency of administration, and in many instances the
strength;
for example, tetracycline 250 mg (amount) four times a day
(frequency);
potassiumchloride10%(strength)5mL(amount) three times a
day with meals (time and frequency).
 Dosages can be written in apothecary or metric systems.

13. Essential Parts of a Medication Order

14. Essential Parts of a Medication Order
 5. The name of the drug to be administered must be
clearly written.
 In some settings only generic names are permitted;
however, trade names are widely used in hospitals and
health agencies.

15. Essential Parts of a Medication Order
 6. Also included in the order is the route of administration
of the drug.
 This part of the order, like other parts, is frequently
abbreviated. It is not unusual for a drug to have several
possible routes of administration; therefore, it is
important that the route be included in the order.

16. Essential Parts of a Medication Order
 7. The signature of the ordering primary care
provider or nurse makes the drug order a legal
request.
 An unsigned order has no validity, and the
ordering physician or nurse practitioner needs
to be notified if the order is unsigned.

18. Communicating a Medication Order
 A drug order is written on the client’s chart by a primary
care provider or by a nurse receiving a telephone or
verbal order from a primary care provider. Most acute
care agencies have a specified time frame (e.g., 24 or 48
hours) in which the primary care provider issuing the
telephone or verbal order must cosign the order written
by the nurse.

19. Communicating a Medication Order
 The medication order is then copied by a nurse or clerk to
a Kardex or medication administration record (MAR).
Increasingly, nurses receive computer printouts of a
client’s medications instead of a copy of the primary care
provider’s order. This method avoids errors and saves
nursing time.

20. Methods of Calculating Dosages
 Four common formulas are used to calculate drug
dosages.
 Any of the formulas can be used. Nursing students are
encouraged to review all four and to choose the method
that works best for them.
 It is important to use one method consistently to avoid
confusion in calculations and, thus, promote client safety.

21. Guidelines for Rounding
When calculating drug dosages, there are times when the
nurse may need to round numbers.
 Quantities greater than 1 are rounded to the nearest
tenth.
 Quantities less than 1 are rounded to the nearest
hundredth

22. ORAL MEDICATIONS
 ■ A capsule cannot be divided.
 ■ Tablets that are scored (a line marked on the tablet) may be
divided. A tablet must be scored by the manufacturer to be
divided properly.
 ■ For tablets that are not scored and capsules, it may not be
realistic to administer the exact amount as calculated. For
example, if the calculation for x results in 1.9 tablets or
capsules, the nurse gives 2 tablets or capsules because it is
unrealistic to accurately administer 1.9 tablets or capsules.

23.  ■ If the oral medication is a liquid, the nurse checks to see if it is
possible to administer an accurate dosage. This often depends on
the syringes used to draw up the medication. For example, a
tuberculin (TB) syringe is a 1-mL syringe that includes markings
for hundredths of a milliliter.

24. PARENTERAL MEDICATIONS
 ■ Rounding depends on the amount (i.e., less than or
more than 1) and the syringe used. As indicated above, a
TB syringe can be used for very small amounts (e.g., to
the hundredth of a mL). Larger syringes would be used for
rounding to a tenth of a milliliter.

25.  IV INFUSION
 ■ By gravity: • Round to the nearest whole number. For
example, if the flow rate calculation equals 37.5
drops/minute, the nurse adjusts the flow rate to 38
drops/minute.
 ■ By IV pump: • If the IV pump uses only whole numbers,
round to the nearest whole number.

35. Calculation for Individualized Drug Dosages
 Nurses often need to individualize the dosage of a
medication for pediatric clients. Other clients who may
require an individualized dosage include those receiving
chemotherapy and clients who are critically ill. The two
methods for individualizing drug dosages are body weight
and body surface area.

36. Calculation for Individualized Drug Dosages
 BODY WEIGHT Unlike adult dosages, children’s dosages are
not always standard. Body weight significantly affects
dosage; therefore, dosages are calculated. Dosages based
on weight use kilograms of body weight and per kilogram
medication recommendations to arrive at appropriate and
safe doses.

37. Calculation for Individualized Drug Dosages
 The steps involved in calculating an individualized dose
are as follows:
1. Convert pounds to kilograms.
2. Determine the drug dose per body weight by multiplying
drug dose x body weight x frequency.
3. Choose a method of drug calculation to determine the
amount of medication to administer.

38. Calculation for Individualized Drug Dosages
 Example Order:Keflex, 20 mg/kg/day in three divided doses. The
client weighs 20 pounds. On hand: Keflex oral suspension 125 mg
per 5 mL
 1. Convert pounds to kilograms:
 20 / 2.2 x 9 kg
 2. Multiply drug dose x body weight x frequency:
 20 mg x 9 kg x 1 day x 180 mg/day
 180 3 divided doses = 60 mg per dose

39. Calculation for Individualized Drug Dosages
 3. The nurse chooses his or her preferred method of
calculation (e.g., basic formula, ratio and proportion,
fractional, dimensional analysis) to determine how many
milliliters per dose of medication.

40. Calculation for Individualized Drug Dosages
 BODY SURFACE AREA Sometimes the body surface
calculation may be used instead of body weight to
individualize the medication dosage. It is considered to be
the most accurate method of calculating a child’s dose.
 Body surface area is determined by using a nomogram and
the child’s height and weight.

41. This shows the standard
nomogram that will give a
child’s body surface area
based on the weight and
height of the child.

42.  The formula is the ratio of the child’s body surface area
to the surface area of an average adult (1.7 square
meters, or 1.7 m2), multiplied by the normal adult dose
of the drug:

43.  For example, a child who weighs 10 kg and is 50 cm tall
has a body surface area of 0.4 m2. Therefore, the child’s
dose of tetracycline corresponding to an adult dose of 250
mg would be?
= 0.2 * 250 = 50 mg

44. Administering Medications
 Nurses who administer medications are responsible for
their own actions. Question any order that is illegible or
that you consider incorrect. Call the person who
prescribed the medication for clarification.
 Be knowledgeable about the medications you administer.
You need to know why the client is receiving the
medication. Look up the necessary information if you are
not familiar with the medication.

45.  Federal laws govern the use of narcotics and
barbiturates. Keep these medications in a locked place.
 Use only medications that are in a clearly labeled
container.
 Do not use liquid medications that are cloudy or have
changed color.
 Calculate drug doses accurately. If you are uncertain, ask
another nurse to double-check your calculations.

46.  Administer only medications personally prepared.
 Before administering a medication, identify the client
correctly using the appropriate means of identification,
such as checking the identification bracelet.
 Do not leave medications at the bedside, with certain
exceptions (e.g., nitroglycerin, cough syrup). Check
agency policy.

47.  If a client vomits after taking an oral medication, report
this to the nurse in charge, or the primary care provider,
or both.
 Take special precautions when administering certain
medications; for example, have another nurse check the
dosages of anticoagulants, insulin, and certain IV
preparations.

48.  Most hospital policies require new orders from the
primary care provider for a client’s postsurgery care.
 When a medication is omitted for any reason, record the
fact together with the reason.
 When a medication error is made, report it immediately
to the nurse in charge, the primary care provider, or both.
 Always check the medication’s expiration date.

49. Medication Reconciliation
 Another safety issue that affects the nurse is to ensure
that clients receive the appropriate medications and
dosages as they move or transition through a facility (e.g.,
on admission, during transfer, and at discharge).

50.  medication reconciliation as “the process of creating the
most accurate list possible of all medications a patient is
taking—including drug name, dosage, frequency, and
route—and comparing that list against the physician’s
admission, transfer, and/or discharge orders, with the
goal of providing correct medications to the patient at all
transition points within the hospital” The Institute for
Healthcare Improvement(IHI, n.d.).

51.  All facilities accredited by The Joint Commission must
have protocols and processes in place for medication
reconciliation, particularly in the following transition
areas: on admission; during transfer between units, in
shift reports, and in new MARs; and at discharge.
 The nurse needs to make a complete list of the client’s
medications (including prescriptions, vitamins,
supplements, and OTC) on admission.

52.  Maintaining their list of current medications helps improve
communication and avoid potential errors in medication
administration. The FDA(2007) developed a form called
“MyMedicineRecord” to help consumers keep track of
their prescription medications, OTC drugs, and dietary
supplements

53. Medication Dispensing Systems
 Medical facilities vary in their medication dispensing systems.
The systems can include the following:
 Medication cart.
The medication cart is on wheels allowing the nurse to move the
cart to outside the client’s room. The cart contains small
numbered drawers that correlate to the room numbers on the
nursing unit. The small drawer is labeled with the name of the
client currently in that room and holds the client’s medications
for the shift or 24 hours.

55.  Medication cabinet.
Some facilities have a locked cabinet in the client’s room.
This cabinet holds the client’s unit-dose medications and
MAR. Controlled substances are not kept in this cabinet but
at another location on the nursing unit. The nurse uses
either a key or a special code for opening the client’s
medication cabinet, because it must be locked when not in
use

57.  Medication room.
Depending on the facility, a medication room may be used
for a variety of purposes. For example, the medication carts,
when not in use, may be placed in this room. The
medication room may also be the central location for stock
medications, controlled medications, and/or drugs used for
emergencies. The medication room may have a refrigerator
for IV and other medications needing a cold environment.

59.  Automated dispensing cabinet (ADC). This computerized
access system automates the distribution, management,
and control of medications. Similar to automated teller
machines, the nurse uses a password to access the
system, selects the client’s name from an on-screen list,
and selects the medication(s)

61. Process of Administering Medications
 1. Identify the client.
Errors can and do occur, usually because one client gets a
drug intended for another. One of The Joint Commission’s
National Patient Safety Goals is to improve the accuracy of
client identification. This goal requires a nurse to use at
least two client identifiers whenever administering
medications.

63. Process of Administering Medications
 2. Inform the client.
If the client is unfamiliar with the medication, the nurse
should explain the intended action as well as any side
effects or adverse effects that might occur. Listen to the
client. It is easy to get so focused on the task of timely
medication administration that the nurse may miss relevant
information provided by the client.

64.  3. Administer the drug.
Read the MAR carefully and perform three checks with the
labeled medications. Then administer the medication in the
prescribed dosage, by the route ordered, at the correct
time. Certain aspects of medication administration are
important for the nurse to check each time a medication is
administered. These are referred to as the “rights.”
Traditionally, there were five rights to medication
administration.

66.  4. Provide adjunctive interventions as indicated.
Clients may need help when receiving medications. They
may require physical assistance, for instance, in assuming
positions for intramuscular injections, or they may need
guidance about measures to enhance drug effectiveness and
prevent complications, such as drinking fluids.

67.  5. Record the drug administered.
The facts recorded in the chart, in ink or by computer
printout, are name of the drug, dosage, method of
administration, specific relevant data such as pulse rate
(taken in most settings prior to the administration of
digitalis), and any other pertinent information.

68.  6. Evaluate the client’s response to the drug.
The kinds of behavior that reflect the action or lack of
action of a drug and its untoward effects (both minor and
major) are as variable as the purposes of the drugs
themselves. The anxious client may show the desired effects
of a tranquilizer by behavior that reflects a lowered stress
level (e.g.,slower speech or fewer random movements).

70. References:
• Audrey Berman . . . [et al.]. – 9th
ed. (2012) KOZIER & ERB’S
Fundamentals of NURSING
Concepts, Process, and Practice.
• James M Ritter, L.Lewis, T. Mant
and A.Ferro. 5th ed. (2008) A
Textbook of Clinical
Pharmacology and Therapeutics