Incorrect Medication Administration Route?

[Steveo123]

Being in nursing school, I am more than aware that "Right Route" is one of the Patient Rights in regards to medication administration. However, I have noticed through my clinical experiences that there are some orders written to give a medication inappropriately relating to the situation (example: the patient is unable to swallow and the medication should be given through his/her NG tube but the order states PO). Other orders for the patient will specify to give the medications per the correct route, however there always seems to be one that is incorrect and the nurse administers it to the patient in the way it should be. My question: is it appropriate for a nurse to give a medication through the intended route instead of what the order says, or does the nurse HAVE to have the order changed by the physician to state the correct route before the medication can be given legally?

[cjr2619]

Always go with the way the order is written, and if you have a question about the route, call the physician. Don't feel bad about calling a physician or their PA, that is what they are there for. While I was shadowing at a hospital, a nurse had misread an order for a pain med and she ended up getting fired because the patient almost died. The order was written 2-4mg of Dilaudid IM...she gave the med IV, which caused the patient to crash and a code was called. Be extremely cautious with the five rights, and never be afraid to ask for clarification because even doctors make mistakes when they write orders.

[Sorin]

Although the intentions may be good, even as a student nurse, I know that to "change an order" especially the route, will get you fired especially if the patient ends up being harmed. At the end of the day, the nurse changed the route against the doctor's orders. If the route is questionable then the physician needs to be notified. Changing the route is not within nursing scope of practice. Whatever is written in the order is what should be done but should always be questioned accordingly. If the patient were to end up getting hurt, then the nurse is the one in trouble not the doctor because the nurse is the one performing the action and the one who decided to change the route.

[classicdame, MSN, EdD]

think of it this way: if there is a negative outcome and you did not follow the order as written, who is getting blamed????

Call the person who wrote the order to get it clarified. Think of it as behavior modification. Maybe they will learn to do better.

[nurseprnRN, BSN, RN]

let me interject a bit of critical thinking born of long experience. when you take something po, where does it go? right, stomach. when you put something down an ng tube, where does it go? stomach again. we are looking at a med that is designed to be absorbed by going through the stomach first.

the question here is not whether or not it's an inappropriate route the likes of giving dilaudid iv vs im. it's whether the patient isn't safe for swallowing but has a safe substitute for the oral route. he used to take po meds, developed a swallowing problem, and now has his meds ng. he does have a safe substitute for the oral route.

i would give the stuff down the ng tube (with appropriate precautions-- check tube placement, check to be sure a med can be crushed and put into solution-- many can't, that the med hasn't already been replaced with an equivalent, etc.) and leave a note for the physician/np to rewrite it later. it certainly isn't worth a midnight call, or all this paranoia about "changing an order." again, there is a big, big difference in effect and dosage between im and iv opioids, and you should know that; there is no difference between oral or ng meds (given the precautions as above), and you should know that too.

now i completely realize that this is a student question. also, many of the answers come from students. i know that instructors have to be very doctrinaire about questions like this, because you don't have any real experience and have had little opportunity to develop judgment yet.

remember, though, part of your education is to learn critical thinking, not just rote. always ask why. that's how you learn how to make judgment calls. well, that and calling a physician to ask him this question and not getting such a measured answer.

[KelRN215, BSN, RN]

When I worked in the hospital, our surgeons rarely paid attention to whether or not a patient had a feeding tube. I could have a 12 yr old patient who'd been G-tube dependent since birth and all the child's meds would still be written PO. Did I ever give them PO? No. At this particular hospital, it was understood that these medications would be administered via enteral tube per nursing judgment. Someone who has a feeding tube has it for a reason. This isn't the same as deciding to give the IV formulation of a medication that was ordered orally. As GrnTea said, NG tube is just a different path to the stomach.

[Esme12, ASN, BSN, RN]

While I agree with my friend GrnTea.........I disagree that there should be understood. It should never be "just understood" or assumed what the patient should receive...... you get a new nurse, agency/traveler, or new employee that doesn't know this patient and they give the med "PO"....the patient aspirates, chokes and could die.

There are also some medicines that cannot be crushed.....such as timed release or sustained release capsules that if you crush them the patient is bolused with the med....Case in point.....MS Contin SR 50mg. If you crush it, it is no longer slow release over x amount of hours. The patient is overdosed at once, becomes snowed, but 6 hours from now is writhing in pain, but can't recive the next SR(sustained release tab) for another 3 hours. Not good. The goes for any SR/timed release meds...... B/P meds, anitarrythmia meds, breathing meds, pain meds.

My advice.........Don't fall into bad habits.........Get the order, be sure it can be crushed befoire givin it down the NGT.

[BostonFNP, APRN]

If you called me at 3am, what route would you ask me to write the order for in the case of the NGT?

The IM vs IVP is a huge error.

[decembergrad2011, BSN, RN]

Sometimes I will see "Per mouth or Per tube" on an order for clarification. Many times the MD does not think about diet orders or feeding tubes when it comes to medications. I've had plenty of NPO patients with PO orders over the years, and that's a definite call to the doctor :)

You are experiencing the disconnect between the ivory tower of nursing and the real world. Should the order be changed to reflect that? Of course. But if it's 9 am and the doctors are rounding, good luck on them getting that order to be changed in a timely manner while you wait to administer medications. If a nurse knows that a medication can be crushed safely, there's no real problem with giving it down the tube because, as others have stated, it's still going through the stomach. Drug books are helpful for this, especially with unfamiliar medications. Always, always, always ask if you are unsure about anything.

[bubblejet50]

i had to call and verify a med once. it was pradaxa. the bottle stated "take orally only" but the resident in question had a g-tube. he had a very hard time swallowing the pill even in pudding. i got a hold of the doctor who told me it was okay to open the capsule and send it down the g-tube. well that would have been fine and dandy if the innards of this pill were powder. the tiny little balls plugged up this g-tube left and right. i understand why the company said to give orally only! but one should not always assume you can give an oral med by a different means. some have reactions that are different than the intended one when broken up due to absorption not occurring as it is meant to.

[Esme12, ASN, BSN, RN]

If you called me at 3am, what route would you ask me to write the order for in the case of the NGT?

The IM vs IVP is a huge error.

I would ask before 3am........or clarify in the morning. Not all meds can be crushed and administered through the NGT.

[PunkBenRN]

let me interject a bit of critical thinking born of long experience. when you take something po, where does it go? right, stomach. when you put something down an ng tube, where does it go? stomach again. we are looking at a med that is designed to be absorbed by going through the stomach first.

exactly. this is okay to do; po/ng tube are essentially going to the same place, therefore its not a problem. however, if you need to crush the medications you generally need an order. some nurses will really get bent out of shape if you didn't get the "via ng tube" straight from the physician. if the physician wrote the med orders on the same sheet as the ng tube, he knows damn well they aren't going to swallow pills.