12.1: Administering Oral Medications

Learning Objectives

By the end of this section, you will be able to:

• Explain the difference in various routes of oral medication
• Define various preparations of oral medications
• Demonstrate accurately the steps in medication administration

Medication administration routes refer to the way in which medications are given to the patient. The most common route of medication administration is the oral route (Ralston, 2018). Medications administered via the oral route may be supplied in a variety of forms. Depending on the drug and medication form, there are implications for practice that the nurse must be aware of and must follow. Following these implications are essential for nursing practice, because there are legal ramifications for not following the proper administration practices and techniques, including documenting the administration of medications. Within this section, we will explore aspects of proper administration for oral medications.

Clinical Safety and Procedures (QSEN): QSEN Competency: Administering Oral Medications

See the competency checklist for Administering Oral Medications. You can find the checklists on the Student resources tab of your book page on openstax.org.

Routes of Oral Medication

Administering medications via the oral route is simple and convenient. It is a widely acceptable route of administration that is the method by which most medications are administered in the home setting. Medications administered orally may begin in the mouth, enter the stomach, and usually end in the small intestine. While the oral route is the overarching umbrella, there are additional routes that fall under the oral umbrella, such as sublingual, buccal, and feeding tubes.

Oral

Medications ordered to be administered via the oral route (per os, or PO) are to be taken by mouth. After being swallowed, the medication is most often absorbed in the small intestine. Absorption of oral medications may be affected by factors such as the presence of gastric acid, food intake, absorption through the small bowel, and metabolism by liver enzymes (also known as first-pass drug metabolism) (Kim & De Jesus, 2023). Oral medications have a slow onset, typically about thirty to sixty minutes after administration.

Sublingual

Medications ordered to be administered via the sublingual route are placed under the tongue (Figure 12.2). These medications dissolve rapidly into the bloodstream for fast absorption and are not affected by first-pass drug metabolism, where the liver metabolizes or chemically alters the medication before it reaches the systemic circulation. Sublingual medications may be affected by eating, drinking, and smoking; therefore, they should not be swallowed, chewed, or taken with water. Due to the rapid absorption, medications administered via this route typically are used to treat emergencies, such as chest pain, allergies, or opioid dependence. Two medications commonly administered via the sublingual route are nitroglycerin (Nitrostat) and buprenorphine/naloxone (Suboxone). Suboxone, a combination medication used for long-term treatment of opioid dependence and opioid use disorder, is not to be confused with naloxone, an opioid antagonist used for the emergency treatment of opioid overdoses.

Figure 12.2: Sublingual medications are placed under the tongue for fast absorption. (credit: modification of “Latina: Frenulum linguae” by Klaus D. Peter, Wiehl, Germany/Wikimedia Commons, CC BY 3.0)

Buccal

Medications ordered to be administered via the buccal route are to be placed between the gum and the cheek (Figure 12.3). These medications dissolve rapidly into the bloodstream for fast absorption and are not affected by first-pass drug metabolism. Like sublingual medications, buccal medications may be affected by eating, drinking, and smoking; therefore, they should not be swallowed, chewed, or taken with water. Examples of medications that may be administered buccally include fentanyl (Sublimaze), naloxone (Narcan), and midazolam (Versed).

Figure 12.3: Buccal administration involves placing the medication between the gum and the cheek. (credit: modification of “Latina: Frenulum linguae” by Klaus D. Peter, Wiehl, Germany/Wikimedia Commons, CC BY 3.0)

Feeding Tubes

Some oral medications may also be administered via a feeding tube, such as a nasogastric tube (NG tube), gastrostomy tube (G tube), or jejunostomy tube (J tube). Not all oral medications are intended to be administered via a feeding tube; therefore, careful consideration should be given to the compatibility of the medication to be administered via the feeding tube route. Medications administered via a feeding tube need to be supplied in a liquid form, if available, or crushed and diluted if supplied in a solid form. To ensure safe practice of medication administration, it is recommended that an interdisciplinary team work together to form agency protocols for the medications administered via feeding tubes. It is also recommended that medications intended to be administered via a feeding tube be specifically ordered as such. The ordered route should state to administer the medication via the NG tube, G tube, or J tube, rather than PO.

Preparations of Oral Medication

Oral medications may be supplied in a variety of forms, such as solids, liquids, and suspensions. Within each form, there are several different preparation types, each with their own administration considerations. The nurse must be familiar with the various preparations and the techniques associated with each preparation to ensure that safe medication administration practices are followed.

Solids

Solid preparations of oral medications include powders, tablets, capsules, caplets, gelcaps, and lozenges. A powder is made of fine particles created from grinding a solid. A tablet is comprised of compressed powder or granules. An enteric-coated tablet is covered in a substance that delays the medication from dissolving. Enteric-coated tablets often are marked with an EC at the end of the medication name to alert the nurse to the type of medication. A capsule is powder or granules contained in a gelatin shell. A time-released capsule or tablet contains granules that slowly release for prolonged action of the medication. Time-released capsules typically have the abbreviations CR (controlled release), SR (sustained release), or ER or XR (extended release). A caplet is a solid, compressed powder or granules that are sometimes coated to make it easier to swallow. A gelcap is a soft gelatin shell with a liquid drug inside. A lozenge is a medication in a candy base that is meant to dissolve in the mouth.

Solid medications usually come prepared in a blister pack or bottle (Figure 12.4). Blister packs typically come in single-use packaging, whereas bottles contain multiple doses of the medication (multidose packages). Medications that come prepared in a blister pack protect the pills from being handled until the medication is opened at the patient’s bedside. Medications that come prepared in a bottle require handling and the medication must be placed in a paper or graduated plastic cup or oral syringe in the medication preparatory area before taking it to the patient’s bedside.

Figure 12.4: (a) Solid medications may be packaged in blister packs or (b) bottles. (credit a: "Pildora lighht.JPG" by "Victor byckttor"/Wikimedia Commons, Public Domain; credit b: “EFFEXOR XR®” by Thomas Wilson Pratt Slatin/Wikimedia Commons, Public Domain)

Liquids

Liquid preparations of oral medications include syrups, elixirs, and emulsions. A syrup is a liquid form of a medication that contains added sugars and flavors. An elixir is a liquid form of a medication that contains added sugars, flavors, and alcohol. An emulsion is a solution that contains a medication, water, and oil mixture. Emulsions should not be administered to patients experiencing difficulty swallowing because of the risk of aspiration. When administering liquid medications, it is important to shake the medication well before measuring the dose.

Suspensions

A suspension requires undissolved drug particles to be mixed with a liquid agent before administration. It is important to shake the suspension well before administering the medication. Typically, liquid and suspension medications are prepared using an oral syringe, dosing cup, medication dropper, or medication spoon (Figure 12.5). Household spoons, such as flatware, are not recommended for measuring medications because they are not uniform in size.

Figure 12.5: (a) Common devices used to measure liquid and suspension medications include oral syringes, (b) dosing cups, (c) medicine droppers, and (d) dosing spoons. (CC BY 4.0; Rice University & OpenStax)

Steps for Oral Medication Administration

When administering medications, patient safety is the top priority. Therefore, considerations must be given throughout the medication process to ensure practices are in place that promote safe medication administration. This includes confirming the medication “rights” when collecting, preparing, and administering medications.

Before administering oral medications, the nurse should assess for contraindications that would prohibit the patient from being able to receive the medication, such as dysphagia, NG tube with gastric suctioning, NPO (nothing passed orally) status, or the inability to sit upright. After determining that oral medications may be safely administered, the nurse should verify the medication administration record (MAR) against the prescribing provider’s orders. The nurse should then remove the medications from the medication cabinet, drawer, or automated dispensing cabinet, confirming the medication rights for each medication. The medications should then be prepared, confirming the rights for each medication a second time.

After the medications have been prepared, the nurse is then ready to administer the medications. After confirming the rights for each medication for a third time, the nurse should assist the patient into an upright position (Figure 12.6). If the patient is unable to be placed in the upright position, a side-lying position may be used; however, the nurse should use caution to ensure the patient’s ability to swallow in this position. When positioned, the nurse should offer the patient something to drink. Consideration should be given to ensure the liquid offered is not contraindicated with any of the medications the patient is taking, and that the oral intake is accounted for within the medication record. Ask the patient if they prefer to take all medications at once or if they prefer the medications to be placed in the cup one at a time. Remain with the patient to ensure all medications are swallowed before documenting the medication administration. Perform any required post-assessments (e.g., blood pressure checks or pain reassessments) and document the patient's response to the medication.

Figure 12.6: The patient should be positioned upright when administering oral medications. (credit: “Nurse Administers Oral Chemotherapy” by Rhoda Baer/Wikimedia Commons, Public Domain)

Clinical Safety and Procedures (QSEN): QSEN Competency: Safety: Oral Medication Administration

Disclaimer: Always follow the agency’s policy for medication administration.

Definition: Reduce the risk of harm to patients through effective, efficient, and competent performance.

Knowledge: The nurse will analyze basic safety principles, understand evidence-based practice standards, and reflect on unsafe nursing practices (such as workarounds and dangerous abbreviations).

Skill: Demonstrate effective strategies to reduce the risk of harm. The nurse will:

• Avoid distractions and minimize disruptions when administering medications.
• Perform hand hygiene before handling and administering medications.
• Prepare medications for one patient at a time.
• Transport medications carefully in your hands, not in your pockets.
• Listen to the patient and explore any concerns they may express.
• If difficulties in swallowing are noted, do not administer medications until the concern is discussed with the prescribing provider.
• If the patient is NPO, clarify with the prescribing provider whether oral medications should be administered.
• If the patient has a feeding tube, clarify the intended route of medication administration with the prescribing provider, and ensure the order correctly identifies the feeding tube route.
• Dispose of unused medication according to agency policy. Controlled substances must be wasted. The waste must be witnessed by another nurse and documented by both nurses.

Attitude: The nurse will accept their individual role in preventing errors by adhering to safe, evidence-based practice standards.

Special Techniques

Several special techniques may need to be applied when administering oral medications. Although most oral medications are swallowed, there may be special instructions for the patient, such as “swish and spit” or gargling the medication. Some medications (e.g., magic mouthwash formulated to prevent or treat mouth sores) are ordered for the patient to swish the medication around in the mouth to coat as much surface area in the mouth as possible and then spit it out without swallowing the medication. Other medications, such as lidocaine, may be ordered as a gargle. The medication is moved around in the mouth and throat and then spit out without swallowing any of the medication. Some medications, such as tetracycline, doxycycline, and chlorhexidine, are known to discolor or stain teeth. In these instances, the patient may be instructed to rinse their mouth or perform oral hygiene after swallowing the medication.

Sometimes a medication may need to be divided before being administered. Tablets that are scored (Figure 12.7) may be divided in half, thirds, or quarters, depending on how the tablet is scored. This technique may be used when the ordered dose is smaller than the supplied dose. For example, the prescribing provider may order enalapril maleate (Vasotec) 7.5 mg PO daily. The pharmacy supplies 5 mg tablets of enalapril maleate. After calculating the dose, the nurse determines that the patient should receive 1.5 tablets. Using the scored line, the nurse divides one tablet in half and disposes of the other half according to agency policy.

Figure 12.7: Scored tablet lines refer to the lines or grooves that are intentionally added to certain tablet medications during the manufacturing process. These lines create a breakable point, allowing the tablet to be easily and accurately divided into smaller doses, if needed. (credit a: “Drug Name: Azathioprine 50 mg oral tablet” by NLM/Wikimedia Commons, Public Domain; credit b: “Generic Levothyroxine” by NLM/Wikimedia Commons, Public Domain; attribution c: Copyright Rice University, OpenStax, under CC BY 4.0 license)

To properly divide the tablet, the nurse may use a pill splitter or break the tablet by hand (Figure 12.8). A pill splitter is preferred to ensure the most accurate splitting of the tablet. When using a pill splitter, align the scored marks on the tablet with the blade of the pill splitter and push down on the lid of the pill splitter. If a pill splitter is not available, tablets may be broken by hand by positioning the fingers on either side of the scored line and pressing down or by pressing down on the tablet on a solid surface. When breaking a tablet, it is important to ensure hand hygiene is performed and gloves are worn while handling the medication. Other forms of oral medications, such as capsules, caplets, and gelcaps are not scored; therefore, they cannot be divided.

Figure 12.8: (a) Pills must be properly divided. A nurse can use a pill splitter or (b) break the pill by hand. (CC BY 4.0; Rice University & OpenStax)

There may also be times when a medication needs to be crushed. For instance, if the patient is having difficulty swallowing, the medication needs to be crushed into a powder that can be dissolved in a liquid or administered via a feeding tube. Most tablets may be crushed; however, other forms of oral medications, such as capsules, caplets, and gelcaps cannot be crushed. Tablets that are designed to be controlled release (e.g., extended-release tablets) or that are coated (e.g., enteric-coated tablets) should never be crushed. Crushing medications that are not designed to be crushed may cause serious side effects, prevent the medication from working properly, or alter how the body processes the medication. Medications can be crushed using a pill crusher (Figure 12.9) and then mixed with applesauce, pudding, or another easily swallowed food or liquid. It is important to crush medications one pill at a time while at the patient’s bedside after ensuring the “rights” of medication administration.

Figure 12.9: Pill crushers may be used to crush certain tablets. The pill crusher typically consists of a container or reservoir where the pill is placed and a grinding mechanism or crusher that helps crush the pill into a powder. (CC BY 4.0; Rice University & OpenStax)

Administering oral medications to children requires special considerations. For instance, precise medication dosing is required for pediatric patients. Furthermore, children may be reluctant or unable to swallow medications. These and other factors require attention to detail and patience on the nurse’s part.

Life-Stage Context: Administering Oral Medications to Children

Several factors should be kept in mind when administering oral medications to children. Sometimes, children are reluctant to take medications. In these instances, it may be helpful to mix the medication with a soft food (e.g., applesauce) when possible or have the child’s caregiver assist with administering the medication. Medications may need to be prescribed in a liquid or chewable form if the child is unable to swallow medications in a solid form. When administering liquid medications to a child, an oral syringe or medication dropper may be used to provide a precise measurement of the medication. Liquid medications should be squirted between the child’s gum and cheek to avoid aspiration. It is important for the nurse to be patient when administering medications to children and to try to address the child’s and caregiver’s fears.

Nursing Roles and Responsibilities

When administering medications, one of the key responsibilities of the nurse is to assess the patient. Assessment is required before administering medications, during administration, as well as after administration. As previously noted, the nurse must assess the patient’s current status, ability to swallow, and whether they are NPO before administering medications. Also, at times, vital signs should be assessed before administration. For example, heart rate and blood pressure should be assessed before administering cardiac medications. If the blood pressure or heart rate is low, then the medication may need to be held to prevent the vital signs from dropping even further. Laboratory results may also need to be reviewed. For example, if the patient’s potassium level is high, administering more potassium likely will increase the potassium level even higher and can lead to toxicity. In addition, an assessment is needed before administering PRN (pro re nata, or as needed) medications. For example, the nurse should assess pain prior to administering pain medications and assess sleep patterns prior to administering a sleep aid. Should the nurse’s clinical judgment warrant holding the medication, the prescribing provider must be notified.

During administration, the nurse should assess the patient’s safety. This assessment should include confirming the patient’s identity, checking allergies, reviewing the medication “rights,” assessing the patient’s ability to safely swallow medications, and identifying any sudden changes in the patient’s condition. Should the patient begin to show signs of difficulty swallowing (i.e., coughing, choking, gurgling), the nurse should not administer any additional medications until the patient is further assessed and can safely swallow.

Post-administration, the nurse should assess the patient’s response to medications. This assessment should include the patient’s tolerance to the medications, whether the intended response occurred, re-assessing indications for PRN medications, as well as monitoring for adverse reactions. The post-administration assessment is important and may be used for clinical decision-making to determine next steps in the patient’s care. For example, if the patient is still experiencing pain after receiving pain medications, perhaps a different medication may be warranted, or additional nonpharmacological strategies may be needed. If the patient experiences an adverse reaction, the nurse may anticipate the medication to be discontinued and new orders may be required.

Other roles of the nurse include educating the patient and reporting medication errors. It is important to educate patients and their caregivers on the medications being administered, potential side effects, and special precautions that must be taken. Educating the patient on the correct process of medication administration helps the patient know what to expect and how to identify any discrepancies in the process. Should any medication errors, or potential errors occur, it is important for the nurse to report these errors according to the agency policy. Reporting medication errors encourages transparency, which allows for proper follow-up and identification of root causes. This is necessary for process and practice improvements to be made.

Nurses are legally responsible for ensuring safe and accurate administration of medications and may be held liable for medication errors. The nurse is also legally responsible for delegated tasks. Some states may allow the nurse to delegate medication administration to unlicensed assistive personnel (UAP) (Carder & O’Keeffe, 2016). In these instances, the nurse is responsible for supervising the UAP throughout the medication administration process. Although some tasks may be delegated to the UAP, the nurse remains responsible for the assessment, planning, teaching, evaluation, and nursing judgment associated with the administration of medications.

Delegation Considerations

When delegating medication administration to the UAP, the nurse must ensure the five rights of delegation: right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. In determining the right task, it is important for the nurse to ensure the UAP has received the appropriate training and has been deemed competent in the skill. In determining the right circumstance, the nurse should consider the patient’s circumstances before delegating the task. Instances in which the results are unpredictable, risks are involved, or medication administration challenges are predicted should not be delegated to the UAP. The right person involves delegating the right task for the right person. It is important for the nurse to be aware of which UAPs have been credentialed to administer medications and correctly identify the patient to receive the medication. In ensuring the right directions and communication, the nurse should provide clear instructions regarding the task that needs to be completed, when it should be completed, as well as any additional expectations associated with the task. The right supervision and evaluation requires the nurse to provide appropriate monitoring, evaluation, intervention, and feedback.