6.3 Administering Medications by Mouth and Gastric Tube

Renée Anderson; Glynda Rees Doyle; Jodie Anita McCutcheon

Chapter 6. Non-Parenteral Medication Administration

6.3 Administering Medications by Mouth and Gastric Tube

Administering Medication by Mouth

Medication is usually given orally, which is generally the most comfortable and convenient route for the patient. Medication given orally has a slower onset and a more prolonged, but less potent, effect than medication administered by other routes (Lynn, 2011). Prior to oral administration of medications, ensure that the patient has no contraindications to receiving oral medication, is able to swallow, and is not on gastric suction. If the patient is having difficulty swallowing (dysphagia), some tablets may be crushed using a clean mortar and pestle or pill crusher. Verify that a tablet may be crushed by consulting a drug reference or a pharmacist.

Medications such as enteric-coated (EC) tablets, capsules, and sustained-release (SR) or long-acting (LA) drugs should never be crushed because doing so will affect the intended action of the medication (Lilley et al., 2016). EC medications are designed to be absorbed in the small bowel. Crushing it would cause absorption in the stomach, potentially causing adverse events. SR and LA medications if crushed would result in high doses being absorbed quickly potentially causing adverse events—some of which could be fatal. If medications are able to be crushed and must be in order to allow the patient to swallow them, they should be crushed one at a time and not mixed. This will allow the administrator to tell drugs apart if there is a spill or if the patient refuses some of them. Mixing crushed medications in a small amount of soft food, such as applesauce or pudding may facilitate easier swallowing.

Position the patient in a side-lying or upright position to decrease the risk of aspiration. Offer a glass of water or other oral fluid (that is not contraindicated with the medication) to ease swallowing and improve absorption and dissolution of the medication, taking any fluid restrictions into account. Remain with the patient until all medication has been swallowed. Sign for the medication AFTER the medication has been swallowed / administered.

Checklist 45 outlines the steps for administering medication by mouth.

Checklist 45: Administering Medication by Mouth

Disclaimer: Always review and follow your agency policy regarding this specific skill.

Safety considerations:

Review everything in Table 6.1 Principles for Safer Medication Administration
Ensure the patient can swallow and that there are no contraindications to receiving oral medications.
Consider timing—some medications are to be given on an empty stomach.
Scored tablets can be safely cut.
EC, LA, SR medications cannot be crushed or chewed.
Remain with the patient until all medications have been swallowed.
Be knowledgeable about pharmacokinetics and pharmacodynamics of the medications being administered.

Steps

Additional Information

1. Perform hand hygiene before medication preparation.

Check MAR to guide you to which medications you are preparing. Follow agency policy to ensure MARs are accurate and verified appropriately.

An MAR that is checked by more than one healthcare professional provides a very reliable record for administering medications. Agencies may vary in relation to MAR verification processes.

2 a. As you are removing medications from the dispensing system, perform the SEVEN rights three times with each individual medication: (single dose packaging is not opened at this time)

The right patient
The right medication (drug)
The right dose
The right route
The right time
The right reason
The right documentation

Perform any necessary medication calculations.

Medication calculation: D/H × S = A

D (desired dosage) / H (have available) × S (stock) = A (amount prepared)

Example order: Liquid sunshine 5 mg PO now.

Desired 5 mg/Have 1 mg × Stock 4 ml = A 20 ml

The right patient: Check that you have the correct patient using two patient identifiers (e.g., name and date of birth).

The right medication (drug): Check that you have the correct medication and that it is appropriate for the patient in the current context.

The right dose: Check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions.

The right route: Check that the route is appropriate for the patient’s current condition.

The right time: Adhere to the prescribed dose and schedule. Determine if oral meds should be taken on an empty stomach.

The right reason: Check that the patient is receiving the medication for the appropriate reason.

The right documentation: Always verify any unclear or inaccurate documentation prior to administering medications.

2 b. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:

When the medication is taken out of the dispensing system / drawer
Prior to the package being opened
After the package is opened and medication put into a medication cup but PRIOR to the patient receiving the medication.

Perform 7 checks 3 times before administering medication — Perform seven checks three times BEFORE administering medication

Whenever possible, take the MARs to the bedside and open medication packages at the bedside.

Some liquid medications require shaking prior to dispensing.

If using an oral syringe, ISMP recommends the use of a special oral medication syringe. These are different than the Luer lock syringes used for parenteral medication administration.

2 c. As medications are taken from the drawer / dispensing system, identify on the MAR when a medication is obtained.

Single dose packages are not opened at this time.

Liquids or meds from bulk containers can be poured into med cups and labeled.

Figure 6.4 Liquids prepared away from the bedside are labeled

Circle medication once it has been poured — Circle or put a dot on the MAR to show that medication has been obtained.

Helps you to keep track of what you’ve obtained and what you haven’t.

Meds that are prepared away from the bedside (i.e., liquids, injectables) are labeled before being brought to the bedside.

Figure 6.5 Meds & MARs are taken to the bedside whenever possible

3. Take medications and MARs to the bedside:

Packages are taken to the bedside unopened.
Identify the patient using two identifiers.
Confirm allergies.
Inform the patient of the medication and its intended action.
Complete any necessary assessment.

MARs cannot be taken into rooms where additional precautions are required.

Compare MAR with patient name band — Use two patient identifiers, compare the MAR with the patient’s wrist band.

The patient has the right to be informed, and providing reasons for medication, actions, and potential adverse effects may improve adherence to medication therapy and patient reporting of adverse effects.

4. Open packages, putting them into an appropriate medication cup. Complete three checks.

Do not touch any medication with ungloved hands. Use clean gloved hands if it is necessary to touch the medication.

Scored tablets can be cut and reliably provide accurate dosing because of evenly dispersed medication in each half of the medication.

Chemotherapy drugs are toxic to the administrator. Use gloves when preparing these kinds of medications.

If a patient expresses concerns over medications, STOP. Do not give medication. Verify prescriber’s order and explore patient concerns. Notify prescriber if necessary.

5. Positioning

Help patient to sitting position. If patient is unable to sit, use the side-lying position.
Have patient stay in this position for 30 minutes after administering medication.
Offer patient water or desired oral fluid.
Ensure proper body mechanics for health care provider.

Position patient appropriately for medication administration

Correct positioning reduces risk of aspiration during swallowing. Water or other oral fluids will help with swallowing of medication.

Proper body mechanics reduces risk of injury to health care provider.

6. Administer medication orally as prescribed.

Tablets: Place in mouth and swallow using water or other fluids.
Orally disintegrating medications: Remove carefully from packaging. Place medication on top of patient’s tongue, and have patient avoid chewing the medication. Water is not needed.
Sublingually: Place medication under patient’s tongue and allow to dissolve completely. Ensure patient avoids swallowing the medication.
Buccal: Place medication in mouth and against inner cheek and gums and allow to dissolve completely.
Powdered medication: Mix at bedside with water to avoid thickening of medication that may occur with time.

Follow any specific descriptions for administration of the medication.

Wear gloves if placing the medication inside the patient’s mouth to protect the healthcare worker from BBF exposure and to reduce risk of absorbing the medication through the skin.

7. Post-medication safety check:

Stay with patient until all medications are swallowed or dissolved.
Perform post assessments and/or vital signs if applicable.
Sign MAR.
Perform hand hygiene.

Right documentation includes signing for medications after administration.

Document any additional information, such as patient education, reasons why medication not administered, and adverse effects, as per agency policy.

Post assessments determine effectiveness and potential adverse effects of medications.

8. Return within appropriate time to evaluate patient’s response to the medications and to check for possible adverse effects.

If patient presents with any adverse effects:

Withhold further doses.
Assess vital signs.
Notify prescriber.
Notify pharmacy.
Document as per agency policy.

Most sublingual medications act in 15 minutes, and most oral medications act in 30 to 40 minutes.

Data sources: BCIT, 2015; ISMP, 2011; Lilley et al., 2016; Perry et al., 2018

Administering Medication via a Gastric Tube

Patients with a gastric tube (nasogastric, nasointestinal, percutaneous endoscopic gastrostomy [PEG], or jejenostomy [J] tube) will often receive medication through this tube (Lynn, 2011). Liquid medications should be used when possible because absorption is better and less likely to cause blockage of the tube. Liquid forms of medication should be used when possible. However, some solid forms of medication can be crushed and mixed with water for administration. Important safety considerations for administering medications via this route include knowing which medications can be crushed and which can’t; verify tube placement; elevate the head of bed to at least 30 degrees to decrease risk of aspiration; flush with water before and after each medication to reduce risk of blockage; dilute medications with water and administer one medication at a time to prevent tube blockage.

If a tube feed is infusing, temporarily stop it for medication administration. If medications need to be given on an empty stomach, stop the tube feed for approximately 30 minutes prior and resume the feed 30 to 40 minutes after. If the patient has one of these tubes for gastric decompression, you will need an order to administer medications via this route. It is also important to keep the tube clamped for 30 to 40 minutes afterward to allow for medication absorption.

Checklist 46 outlines the steps for administering medication via a gastric tube.