Dosage Forms, Routes of Administration, and Dispensing Medications 81

© Jones & Bartlett Learning, LLC © Jones & Bartlett4 Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Dosage Forms, Routes © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONof Administration,NOT FOR SALE OR DISTRIBUTION and Dispensing © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTMedications FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Objectives

© Jones & BartlettAfter Learning,reading this chapter,LLC you will be able to: © Jones & Bartlett Learning, LLC NOT FOR SALE OR• Outline DISTRIBUTION the components of a prescription, includingNOT FOR commonly SALE used OR abbreviations. DISTRIBUTION • Understand the “rights” of correct drug administration. • Describe common dosage forms. • Explain the most common routes of administration. © Jones & Bartlett Learning, • LLCSummarize the factors that ©influence Jones the & effectsBartlett of drugs, Learning, particularly LLC in elderly NOT FOR SALE OR DISTRIBUTIONand pediatric populations. NOT FOR SALE OR DISTRIBUTION • Explain the difference between dosage form and route of administration. • Describe the properties of solid, semisolid, liquid, inhalation, and transdermal dosage forms. © Jones• Describe & Bartlett inactive ingredients,Learning, various LLC tablet coatings, and their© functions. Jones & Bartlett Learning, LLC NOT• FORDescribe SALE various OR delayed-release DISTRIBUTION dosage formulations. NOT FOR SALE OR DISTRIBUTION • Compare and contrast different types of emulsions such as ointments, creams, and gels. • Discuss the advantages of a transdermal dosage form. © Jones & Bartlett• ExplainLearning, the major LLC routes of administration and© Jonesthe advantages & Bartlett and disadvantages Learning, LLC NOT FOR SALE ORassociated DISTRIBUTION with each route of administration.NOT FOR SALE OR DISTRIBUTION • Explain the correct techniques for administration of eye drops, metered-dose inhalers, vaginal medications, and injections.

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Additives Immediate-release Rectal Aerosol Incontinence Ring Alcoholic solution Infection Route of administration © JonesAqueous & suspension Bartlett Learning,Infusion LLC Signa© Jones & Bartlett Learning, LLC NOTAromatic FOR SALE water OR DISTRIBUTIONInhalation SoluteNOT FOR SALE OR DISTRIBUTION Binders Inscription Solution Bolus dose Intradermal Solvent Buccal Intramuscular Sprinkles Caplet Intravenous Subcutaneous © Jones & BartlettCapsule Learning, LLC Irrigating solution© Jones &Sublingual Bartlett Learning, LLC NOT FOR SALEChewable OR DISTRIBUTION tablet Lotion NOT FOR Sugar-coatedSALE OR DISTRIBUTION Controlled-release Lozenges Suspension Cream Nasal Spansule Delayed-release Noncompliance Spirit Depot Oil-in-water (O/W) Spray © Jones & Bartlett Learning,Diluents LLC © Jonesemulsion & Bartlett Learning,Sprinkles LLC NOT FOR SALE OR DISTRIBUTIONDispersion OintmentNOT FOR SALE OR DISTRIBUTIONSuppository Dosage form Ophthalmic Sustained-release Elixir Oral disintegrating Syringe Emulsion tablet (ODT) Syrup Emulsifying agent Order Tablet © JonesEnteric-coated & Bartlett Learning,Otic LLC Tincture© Jones & Bartlett Learning, LLC NOTExcipients FOR SALE OR DISTRIBUTIONParenteral solution TopicalNOT FOR SALE OR DISTRIBUTION Extended-release Paste Transdermal patch Extract Peroral (PO) Urethral Film-coated Polypharmacy Vaginal Gel Powder Water-in-oil (W/O) © Jones & BartlettGranules Learning, LLC Prescription © Jones & Bartlettemulsion Learning, LLC NOT FOR SALEHomogenous OR DISTRIBUTION Preservatives NOT FOR SALE OR DISTRIBUTION Hydroalcoholic solution Reconstitution

© Jones & Bartlett Learning, LLCChapter Overview © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION77 NOT FOR SALE OR DISTRIBUTION The legal form that a prescriber utilizes to order a medication, medical device, or piece of medical equipment to be dispensed to a patient by a licensed pharmacist is called a prescription. A valid prescription must contain all the information necessary for a pharmacist to complete the prescriber’s order. A pharmacy technician plays a key role © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC in the preparation and dispensing of prescription products. This chapter covers the NOTlegally FOR required SALE elements OR DISTRIBUTION of a prescription, as well as many of NOTthe common FOR SALE abbrevia OR- DISTRIBUTION tions used by prescribers to create prescription orders. To effectively read prescriptions and prepare prescription orders, it is essential for a pharmacy technician to possess a thorough understanding of common prescription abbreviations. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77The Prescription A prescription is a legal order for a specific product, to be dispensed to a patient by a licensed pharmacist. A prescription order can be made by any healthcare profes- © Jones & Bartlett Learning,sional LLC with prescribing authority.© Jones Although & Bartlett the most Learning,common issuer LLC of prescription NOT FOR SALE OR DISTRIBUTIONorders is a physician, prescriptionNOT orders FOR canSALE also OR be issued DISTRIBUTION by dentists, podiatrists, optometrists, physician assistants, nurse practitioners, and veterinarians in all 50 states.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEAdditionally, OR DISTRIBUTION some states have granted limited NOTP FORatient SALEName OR DISTRIBUTIONPerscription Number prescribing authority to clinical psychologists and pharmacists. Physicians have broad prescribing authority, which means there are no REFILLS: (123) 456-7890 limitations to what prescription products they PHARMACY Pharmacy # 123 © Jones & Bartlett Learning, LLCWEGMANS FOOD MARKETS, INC. © Jones & Bartlett Learning, LLC may prescribe. Other healthcare professionals 1 MAIN STREET Rx# 6000561 NOT FOR SALE OR DISTRIBUTIONROCHESTER, NY 14624A W-6116861NOT(123) FOR 456-7890 SALE OR DISTRIBUTION may have limited prescribing authority, which SMARTFILL, MARY JANE 01/18/10 123 MAIN STREET, ROCHESTER, NY 14620 means there are specific restrictions in place TAKE ONE TABLET BY MOUTH EVERY 8 for these prescribers. These restrictions are HOURS AS NEEDED FOR PAIN. related to each professional’s individual scope of© practice Jones and & Bartlettvary from Learning,state to state. LLC For ex- IBUPROFEN© 800 Jones MG TABLET & Bartlett Learning, LLC ample,NOT aFOR dentist SALE cannot OR order DISTRIBUTION a medication for NOT FOR SALE ORQTY DISTRIBUTION: 90 a patient’s back pain and a veterinarian cannot ANDREW SMITH 2 REFILLS BY 01/18/11 order medications for a human patient. Prescription orders are sometimes given to patients by their prescriber. A patient might Number of Refills Remaining © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC then mail or hand-deliver a prescription to Figure 4.1 The essential components of a prescription. NOT FOR SALEa pharmacy. OR DISTRIBUTION Other times, prescriptions are NOT FOR SALE OR DISTRIBUTION transmitted by the prescriber or an agent of the prescriber (for example, a nurse in the prescriber’s practice) directly to the pharmacy. A prescriber has several options for transmitting prescription orders to a pharmacy. Prescribers© may Jones mail &prescriptions Bartlett Learning, to the pharmacy, LLC relay them via telephone,© Jones & Bartlett Learning, LLC transmit them viaNOT fax, FORor use SALEan e-prescribing OR DISTRIBUTION service, which is a secure system NOTthat FOR SALE OR DISTRIBUTION utilizes an Internet connection to deliver prescriptions directly to the pharmacy com- puter. Written prescription orders, whether given to the patient, faxed, or mailed to the pharmacy, must be signed by the prescriber. Telephone orders and e-prescribing orders are valid as long as they are relayed to the pharmacy by the prescriber or by an© authorizedJones & Bartlettagent of the Learning, prescriber. LLC There are many special laws© Jonesthat relate & Bartlettto pre- Learning, LLC scriptionNOT FOR orders SALE for controlled OR DISTRIBUTION substances, but these vary from stateNOT to state.FOR For SALE more OR DISTRIBUTION information on these regulations visit your state board of pharmacy’s Web site. In an institutional setting, the term prescription is not used. Instead, the prescriber’s request is referred to as an order or a medication order. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEThe ComponentsOR DISTRIBUTION of a Hard-Copy PrescriptionNOT FOR SALE OR DISTRIBUTION Prescription components may vary from state to state, but typically should contain the following information Figure 4.1 : 77 The prescriber’s name, address, and phone number© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 77 The name of NOTthe patient FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 The date the prescription was written 77 The name, strength, dosage form, and quantity of medication or product or- © Jonesdered (also & Bartlett called the Learning, inscription )LLC © Jones & Bartlett Learning, LLC NOT77 Directions FOR SALE for use OR (also DISTRIBUTION called the signa, NOT FOR SALE OR DISTRIBUTION often referred to as “sig”) 77 The number of refills allowed 77 If the prescriber requests “no generic sub- © Jones & Bartlettstitution,” Learning, it must LLC be clearly noted © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A medication bottle that has the Rx symbol can only be dispensed with a legal prescription.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION77 If it is a prescription for a NOTcontrolled FOR substance, SALE OR the DISTRIBUTION prescriber’s Drug Enforce- ment Administration (DEA) number 77 The prescriber’s hand-written signature When accepting a prescription order from a customer, the role of a pharmacy © technicianJones & beginsBartlett with Learning, double-checking LLC the prescription for ©accuracy Jones and & Bartlettensuring Learning, LLC NOTthat FORall legal SALE requirements OR DISTRIBUTION have been met. NOT FOR SALE OR DISTRIBUTION

The Components of a Patient Prescription Label Components of prescription labels may vary from state to state, but typically should © Jones & Bartlettcontain Learning, the following LLC information: © Jones & Bartlett Learning, LLC NOT FOR SALE7 7ORThe DISTRIBUTION name of the patient NOT FOR SALE OR DISTRIBUTION 77 The name of the prescriber 77 The date the prescription was filled 77 The number of refills remaining © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 77 The date the prescription expires NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 The date the product expires 77 The name, strength, dosage form, and quantity of product dispensed (also called the inscription) 77 Directions for use (also called the signa, often referred to as the “sig”) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 77 The name, address, and phone number of the pharmacy NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 The Rx number 77 If it is a prescription for a controlled substance, the statement “Caution: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed” must be printed on the label © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 77 Any necessary auxiliary labels NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION If a medication has the symbol Rx on the bottle, it can only be dispensed pursuant to a prescription.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Commonly Used Abbreviations NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION In most cases, the directions (signa) are written in shorthand, or an abbreviated form that allows for the easy writing of directions. Directions generally include how and when to take the medication ordered. To fill the prescription safely, the pharmacy © Jones & Bartlett Learning, LLCtechnician must have knowledge© Jones of & commonly Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONused abbreviations foundNOT in FORprescription SALE orOR- DISTRIBUTION ders. These abbreviations are standard usage for prescribers, pharmacists, and pharmacy technicians, but must be spelled out as simply © Jones & Bartlett Learning, LLC as possible© Jones for the & patient Bartlett to Learning,ensure that theLLC NOT FOR SALE OR DISTRIBUTION patientNOT uses FORthe medication SALE OR properly. DISTRIBUTION Never assume that directions are easily understood by a patient. Table 4.1 contains a list of abbreviations used in writing prescriptions. © Jones & Bartlett Learning, LLC © Jones &Here Bartlett are several Learning, examples LLC of the use of NOT FOR SALE OR DISTRIBUTION NOT FORcommonly SALE usedOR abbreviations,DISTRIBUTION and their trans- The label on a prescription bottle. lations:

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Abbreviation Translation ac Before meals am © Jones & Bartlett Learning,Morning LLC © Jones & Bartlett Learning, LLC AD NOT FOR SALE OR DISTRIBUTIONRight ear NOT FOR SALE OR DISTRIBUTION AS Left ear AU Both ears bid Twice a day ©c¯ Jones & Bartlett Learning, LLC With © Jones & Bartlett Learning, LLC NOTcap FOR SALE OR DISTRIBUTIONCapsule NOT FOR SALE OR DISTRIBUTION DAW Dispense as written D/C Discontinue g or gm Gram © Jones & Bartlettgr Learning, LLC Grain © Jones & Bartlett Learning, LLC NOT FOR SALEgtt OR DISTRIBUTION Drop NOT FOR SALE OR DISTRIBUTION h or hr or ° Hour IM Intramuscular INH Inhalation IV © Jones & Bartlett Learning,Intravenous LLC © Jones & Bartlett Learning, LLC L NOT FOR SALE OR DISTRIBUTIONLiter NOT FOR SALE OR DISTRIBUTION mcg Microgram mEq Milliequivalent mL Milliliter © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NKA No known allergies NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION NKDA No known drug allergies npo Nothing by mouth OD Right eye OS Left eye © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC OU Both eyes NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION pc After meals PO By mouth PR Per rectum prn As needed © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC q NOT FOR SALE OR DISTRIBUTIONEvery NOT FOR SALE OR DISTRIBUTION qid Four times a day qs A sufficient quantity SL Sublingual ©stat Jones & Bartlett Learning, LLC Immediately © Jones & Bartlett Learning, LLC NOTtab FOR SALE OR DISTRIBUTIONTablet NOT FOR SALE OR DISTRIBUTION tid Three times a day top Topically ud As directed © Jones & Bartlettwk Learning, LLC Week © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONExample: iii gtts OS qid udNOT FOR SALE OR DISTRIBUTION Translation: Instill three drops into the left eye, four times a day as directed.

Example: 1 tab po tid¥5 days Translation: Take one tablet by mouth three times a day for five days. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT Example:FOR SALE 1 supp OR pr DISTRIBUTION bid prn NOT FOR SALE OR DISTRIBUTION Translation: Insert one suppository rectally twice a day as needed. Example: 0.5 mL SQ tid prn Translation: Inject 0.5mL subcutaneously three times a day as needed. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORExample: DISTRIBUTION ii gtts OU qid NOT FOR SALE OR DISTRIBUTION Translation: Instill two drops into both eyes, four times a day. Example: 1 tab SL bid prn Translation: Place one tablet under the tongue twice a day as needed. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONBecause of the concern overNOT drug FOR errors SALE that have OR occurred DISTRIBUTION from misinterpretation of prescription orders, the Institute for Safe Medication Practices (ISMP) has compiled a list of the most common misread abbreviations Table 4.2 .

The ISMP has a list of error-prone abbreviations, symbols, and dose designations, which can © beJones found at& http://www.ismp.org/tools/errorproneabbreviations.pdf.Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Table 4.2 problematic Abbreviations Found on Prescription Orders

Abbreviations© Jones & Bartlett ILearning,ntended Meaning LLC Misinterpretation© Jones & BartlettCorrection Learning, LLC µg NOT FOR SALE ORMicrogram DISTRIBUTION Mistaken as “mg”NOT FOR SALEUse “mcg” OR DISTRIBUTION AD, AS, AU Right ear, left ear, each ear Mistaken as OD, OS, OU Use “right ear,” “left ear,” or (right eye, left eye, each “each ear” eye) OD, OS, OU Right eye, left eye, each eye Mistaken as AD, AS, AU Use “right eye,” “left eye,” © Jones & Bartlett Learning, LLC © Jones(right ear, & left Bartlett ear, each Learning,or “each LLC eye” NOT FOR SALE OR DISTRIBUTION NOTear) FOR SALE OR DISTRIBUTION BT Bedtime Mistaken as “BID” (twice Use “bedtime” daily) cc Cubic centimeters Mistaken as “u” (units) Use “mL” D/C © JonesDischarge & Bartlett or discontinue Learning,Premature LLC discontinuation Use© “discharge” Jones and& Bartlett Learning, LLC of medications if D/C “discontinue” NOT FOR SALE OR DISTRIBUTION(intended to mean NOT FOR SALE OR DISTRIBUTION “discharge”) has been misinterpreted as “discontinued” when followed by a list of © Jones & Bartlett Learning, LLC discharge medications© Jones & Bartlett Learning, LLC IJ NOT FOR SALE ORInjection DISTRIBUTION Mistaken as “IV”NOT or FOR SALEUse “injection” OR DISTRIBUTION “intrajugular” IN Intranasal Mistaken as “IM” or “IV” Use “intranasal” or “NAS” HS Half-strength, Mistaken as bedtime Use “half-strength” or © Jones &H Bartletts Learning, LLCAt bedtime, hours of sleep © JonesMistaken as & half-strength Bartlett Learning,“bedtime” LLC NOT FOR ISALEU** OR DISTRIBUTIONInternational unit NOTMistaken FOR as IVSALE (intravenous) OR DISTRIBUTION Use “units” or 10 (ten)

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Abbreviations Intended Meaning Misinterpretation Correction o.d. or OD Once daily Mistaken as “right eye” (OD- Use “daily” © Jones & Bartlett Learning, LLCoculus dexter), leading © Jones & Bartlett Learning, LLC to oral liquid medications NOT FOR SALE OR DISTRIBUTIONadministered in the eye NOT FOR SALE OR DISTRIBUTION OJ Orange juice Mistaken as OD or OS (right Use “orange juice” or left eye); drugs meant to be diluted in orange juice may be given in the © Jones & Bartlett Learning, LLC eye © Jones & Bartlett Learning, LLC NOTPer os FOR SALE OR DISTRIBUTIONBy mouth, orally The “os” canNOT be mistaken FOR SALEUse OR“PO,” DISTRIBUTION“by mouth,” or as “left eye” (OS-oculus “orally” sinister) q.d. or QD** Every day Mistaken as q.i.d., especially Use “daily” © Jones & Bartlett Learning, LLC © Jonesif the & period Bartlett after the Learning, “q” LLC or the tail of the “q” is NOT FOR SALE OR DISTRIBUTION NOT FORmisunderstood SALE asOR an “i”DISTRIBUTION qhs Nightly at bedtime Mistaken as “qhr” or every Use “nightly” hour qn Nightly or at bedtime Mistaken as “qh” (every Use “nightly” or “at © Jones & Bartlett Learning, LLChour) © Jonesbedtime” & Bartlett Learning, LLC q.o.d. or QOD** NOT FOREvery SALE other OR day DISTRIBUTIONMistaken as “q.d.” (daily) or NOTUse “every FOR other SALE day” OR DISTRIBUTION “q.i.d.” (four times daily) if the “o” is poorly written q1d Daily Mistaken as q.i.d. (four Use “daily” times daily) ©q6 JonesPM, etc. & Bartlett Learning,Every evening LLC at 6 PM Mistaken as© every Jones 6 hours & BartlettUse “daily Learning, at 6 PM” or “6LLC PM NOT FOR SALE OR DISTRIBUTION NOT FOR SALEdaily” OR DISTRIBUTION SC, SQ, sub q Subcutaneous SC mistaken as SL Use “subcut” or (sublingual); SQ Mistaken “subcutaneously” as “5 every”; the “q” in “sub q” has been mistaken © Jones & Bartlett Learning, LLC © Jonesas “every” & Bartlett (e.g., a heparin Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORdose orderedSALE “sub OR q 2 DISTRIBUTION hours before surgery” misunderstood as every 2 hours before surgery) ss Sliding scale (insulin) or ½ Mistaken as “55” Spell out “sliding scale;” use © Jones &(apothecary) Bartlett Learning, LLC © Jones“one-half” & or Bartlett“1/2” Learning, LLC SSRI NOT FORSliding SALE scale OR regular DISTRIBUTION insulin Mistaken as selective- NOTSpell outFOR “sliding SALE scale OR DISTRIBUTION serotonin reuptake (insulin)” inhibitor SSI Sliding scale insulin Mistaken as Strong Solution of Iodine (Lugol’s) ©i/d Jones & Bartlett Learning,One daily LLC Mistaken as© “tid” Jones & BartlettUse “1 daily”Learning, LLC NOTTIW or FOR tiw SALE OR DISTRIBUTIONTIW: 3 times a week T/W mistakenNOT as “3 FOR times aSALE Use OR “3 times DISTRIBUTION weekly” (also BIW or biw) day” or “twice in a week” BIW: 2 times a week B/W mistaken as “2 times Use “2 times weekly” a day”

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Abbreviations Intended Meaning Misinterpretation Correction U or u** Unit Mistaken as the number 0 Use “unit” © Jones & Bartlett Learning, orLLC 4, causing a 10-fold © Jones & Bartlett Learning, LLC overdose or greater (e.g., NOT FOR SALE OR DISTRIBUTION4U seen as “40” or 4u seen NOT FOR SALE OR DISTRIBUTION as “44”); mistaken as “cc” so dose given in volume instead of units (e.g., 4u seen as 4cc) UD © Jones & Bartlett AsLearning, directed (“ut LLCdictum”) Mistaken as unit ©dose Jones & UseBartlett “as directed” Learning, LLC NOT FOR SALE OR DISTRIBUTION (e.g., diltiazemNOT 125 FOR SALE OR DISTRIBUTION mg IV infusion “UD” misinterpreted as meaning to give the entire infusion as a unit [bolus] dose) © Jones &Dose Bartlett Designations Learning, and LLC © Jones & Bartlett Learning, LLC NOT FOR OtherSALE Information OR DISTRIBUTIONIntended Meaning NOTMisinterpretation FOR SALE OR DISTRIBUTIONCorrection Trailing zero after decimal 1 mg Mistaken as 10 mg if the Do not use trailing zeros for point (e.g., 1.0 mg)** decimal point is not seen doses expressed in whole numbers No leading zero before 0.5 mg Mistaken as 5 mg if the Use zero before a decimal a decimal point (e.g., .5© Jones & Bartlett Learning, decimalLLC point is not seen point© Jones when the & dose Bartlett is less Learning, LLC mg)** NOT FOR SALE OR DISTRIBUTION thanNOT a whole FOR unit SALE OR DISTRIBUTION Drug name and dose run Inderal 40 mg Mistaken as Inderal 140 mg Place adequate space together (especially Tegretol 300 mg Mistaken as Tegretol 1300 between the drug name, problematic for drug mg dose, and unit of measure names that end in “l” such© as Jones Inderal40 & mg; Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Tegretol300NOT FOR mg) SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Numerical dose and unit 10 mg The “m” is sometimes Place adequate space of measure run together 100 mL mistaken as a zero or two between the dose and unit (e.g., 10mg, 100mL) zeros, risking a 10- to 100- of measure fold overdose © Jones &A Bartlettbbreviations Learning, such as LLCmg, mL © JonesThe period & is unnecessaryBartlett Learning,Use mg, LLCmL, etc. without a NOT FOR mg.SALE or m LOR. with DISTRIBUTION a period NOTand FOR could beSALE mistaken OR as DISTRIBUTIONterminal period following the abbreviation the number 1 if written poorly Large doses without 100,000 units 100000 has been mistaken Use commas for dosing properly placed commas 1,000,000 units as 10,000 or 1,000,000; units at or above 1,000, (e.g., 100000 units; © Jones & Bartlett Learning,1000000 LLC has been or© use Jones words such & asBartlett 100 Learning, LLC 1000000 units) NOT FOR SALE OR DISTRIBUTIONmistaken as 100,000 “thousand”NOT FOR or 1 “million”SALE OR DISTRIBUTION to improve readability Drug Name Abbreviations Intended Meaning Misinterpretation Correction ARA A vidarabine Mistaken as cytarabine (ARA Use complete drug name C) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC AZT zidovudine (Retrovir) Mistaken as azathioprine or Use complete drug name NOT FOR SALE OR DISTRIBUTION aztreonam NOT FOR SALE OR DISTRIBUTION CPZ Compazine Mistaken as chlorpromazine Use complete drug name (prochlorperazine) DPT Demerol-Phenergan- Mistaken as diphtheria- Use complete drug name © Jones & Bartlett Learning, LLCThorazine © Jonespertussis-tetanus & Bartlett (vaccine) Learning, LLC NOT FOR DSALETO OR DISTRIBUTIONDiluted tincture of opium, NOTMistaken FOR as tinctureSALE of OR DISTRIBUTIONUse complete drug name or deodorized tincture of opium opium (Paregoric)

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Abbreviations Intended Meaning Misinterpretation Correction HCl hydrochloric acid or Mistaken as potassium Use complete drug name © Jones & hydrochlorideBartlett Learning, LLCchloride (The “H” is © Jonesunless expressed & Bartlett as a salt Learning, LLC misinterpreted as “K”) of a drug NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION HCT hydrocortisone Mistaken as Use complete drug name hydrochlorothiazide HCTZ hydrochlorothiazide Mistaken as hydrocortisone Use complete drug name (seen as HCT250 mg) ©M gJonesSO4** & Bartlett Learning,magnesium LLC sulfate Mistaken as© morphine Jones sulfate & BartlettUse complete Learning, drug name LLC NOTMS, MS FORO4** SALE OR DISTRIBUTIONmorphine sulfate Mistaken asNOT magnesium FOR SALEUse ORcomplete DISTRIBUTION drug name sulfate MTX methotrexate Mistaken as mitoxantrone Use complete drug name PCA procainamide Mistaken as patient Use complete drug name © Jones & Bartlett Learning, LLC © Jonescontrolled & Bartlett analgesia Learning, LLC NOT FOR SALEPTU OR DISTRIBUTIONpropylthiouracil NOT FORMistaken SALE as mercaptopurine OR DISTRIBUTIONUse complete drug name T3 Tylenol with codeine (No. 3) Mistaken as liothyronine Use complete drug name TAC triamcinolone Mistaken as tetracaine Use complete drug name Adrenalin, cocaine TNK © Jones &TNKase Bartlett Learning, LLCMistaken as “TPA” ©Use Jones complete & drug Bartlett name Learning, LLC ZnSO4 NOT FORzinc SALE sulfate OR DISTRIBUTIONMistaken as morphine sulfate NOTUse complete FOR SALEdrug name OR DISTRIBUTION Stemmed Drug Names Intended Meaning Misinterpretation Correction “Nitro” drip nitroglycerin infusion Mistaken as sodium Use complete drug name nitroprusside infusion ©“Norflox” Jones & Bartlett Learning,norfloxacin LLC Mistaken as© Norflex Jones & BartlettUse complete Learning, drug name LLC NOT“IV Vanc” FOR SALE OR DISTRIBUTIONintravenous vancomycin Mistaken asNOT Invanz FOR SALEUse OR complete DISTRIBUTION drug name Symbols Intended Meaning Misinterpretation Correction D Dram Symbol for dram mistaken Use the metric system as “3” m Minim Symbol for minim mistaken Use the metric system © Jones & Bartlett Learning, LLC © Jonesas “mL” & Bartlett Learning, LLC NOT FOR SALEx3d OR DISTRIBUTIONFor three days NOT FORMistaken SALE as “3 doses” OR DISTRIBUTIONUse “for three days” > and < Greater than and less than Mistaken as opposite of Use “greater than” or “less intended; Mistakenly use than” incorrect symbol; “< 10” Mistaken as “40” © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC / (slash mark) Separates two doses or Mistaken as the number 1 Use “per” rather than a slash NOT FOR SALEindicates OR“per” DISTRIBUTION(e.g., “25 units/10 units” NOTmark FOR to separate SALE doses OR DISTRIBUTION misread as “25 units and 110 units”) @ At Mistaken as “2” Use “at” ©& Jones & Bartlett Learning,And LLC Mistaken as© “2” Jones & BartlettUse “and” Learning, LLC NOT+ FOR SALE OR DISTRIBUTIONPlus or and Mistaken asNOT “4” FOR SALEUse OR “and” DISTRIBUTION ° Hour Mistaken as a zero (e.g., q2° Use “hr,” “h,” or “hour” seen as q 20) Ø zero, null sign Mistaken as the numerals 4, Use the number “0” or the © Jones & Bartlett Learning, LLC © Jones6, or & 9 Bartlett Learning,word LLC “zero” NOT FOR SALE**These OR abbreviations DISTRIBUTION are included on The Joint Commission’s “minimumNOT list” FOR of dangerous SALE abbreviations, OR DISTRIBUTION acronyms, and symbols that must be included on an organization’s “Do Not Use” list, effective January 1, 2004. Visit www.jcaho.org for more information about this Joint Commission requirement.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONMost pharmacies will alsoNOT give FORthe patient SALE an OR information DISTRIBUTION sheet with more de- tails regarding the proper administration of the medication, possible side effects, and adverse drug interactions. In some cases, the prescription directions may be difficult to interpret. If there is a question regarding the information on the prescription, the pharmacist should © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC be notified. In most cases, the pharmacist will be able to clarify the information or if NOTnecessary; FOR SALEcall the ORphysician DISTRIBUTION for clarification. NOT FOR SALE OR DISTRIBUTION

The “Rights” of Correct Drug Administration © Jones & Bartlett77 Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEWhen OR a DISTRIBUTION pharmacy technician fills a patient’s prescription,NOT FOR it SALE is important OR DISTRIBUTION to remember the basic “rights” of a patient with regard to medication safety. These rights offer useful guidelines when filling prescriptions. The rights of a patient to medication safety are as follows: © Jones & Bartlett Learning,7 7LLCThe right patient—Always© verify Jones that & the Bartlett medication Learning, prescribed LLC is for the cor- NOT FOR SALE OR DISTRIBUTIONrect patient. Use at least twoNOT patient FOR identifiers. SALE OR DISTRIBUTION 77 The right drug—Always check the medication bottle and medication against the original prescription, making sure to take into account the patient’s disease state. 77 The right dose—Always check the original prescription to verify the strength of © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the medication, paying particular attention to the age of the patient. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 The right route—Always check the prescriber’s prescription order to make sure it agrees with the drug’s specified route of administration. 77 The right time—Always check the prescription to determine the correct frequency and duration for the medication to be administered. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77Dosage Forms Drugs are seldom administered in pure form. They are formulated into various dosage forms to facilitate ease of administration and ensure safety and efficacy. A dosage form © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC is a system or device by which the drug is delivered to the body. In a dosage form, the NOT FOR SALE OR DISTRIBUTIONactive ingredient is combined NOTwith the FOR inert SALE ingredients OR DISTRIBUTION that facilitate administration of the drug. The most common dosage forms are those that are administered orally. Taking an oral medication is the most convenient method to deliver medication, which in turn ©makes Jones it the& Bartlett most in demand,Learning, which LLC leads to mass production© andJones ultimately & Bartlett lower Learning, LLC NOTmanufacturing FOR SALE costs. OR Some DISTRIBUTION medications are not available in oralNOT form FOR because SALE they OR DISTRIBUTION cannot be properly absorbed in the GI tract. For instance, heparin is only available as an injectable formulation because it is ineffective when administered orally. The route of administration and dosage form are also determined by other factors, including the age of the patient, the disease being treated, the area of the body that the drug needs © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC to reach, the ease of administration, and the characteristics of the drug. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The active ingredient is responsible for a drug’s therapeutic effect.

An inert ingredient has little or no therapeutic value. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONDosage forms may also containNOT theFOR following: SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE77 Additives— OR DISTRIBUTIONAdditives are inert ingredients thatNOT may FOR be needed SALE for OR a successful DISTRIBUTION preparation of the dosage form. 77 Binders—Binders promote adhesion of active and inactive ingredients in the tablets. 77 Diluents—Diluents© Jones are additives& Bartlett used Learning, to increase LLC the bulk weight or volume© of Jones & Bartlett Learning, LLC a dosage form.NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 Excipients—Excipients are inactive substances used as a carrier for the active ingredient. 77 Preservatives—Preservatives are substances that prevent or minimize the © Jonesgrowth of& bacteriaBartlett or Learning, other microorganisms LLC in the dosage form,© Jones typically & usedBartlett Learning, LLC in multi-dose vials. Single-dose vials are discarded immediately after use, while NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION multi-dose vials, once opened, may be stored for a period. After a vial has been opened, however, the risk of bacterial overgrowth increases. To prevent or minimize the risk of bacterial overgrowth, preservatives are added to the medication. Many top-selling drugs are available in several different dosage forms. It is im- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC portant to know what dosage form is being requested because the strength of the NOT FOR SALEmedication OR DISTRIBUTION may depend on the dosage form. It alsoNOT ensures FOR that SALE the patientOR DISTRIBUTION does not use a dosage form incorrectly, such as swallowing a suppository. Knowing the dosage form can serve as a double-check when a prescription calls for a certain strength of medication that is available in more than one dosage form. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The strength of theNOT same FORmedication SALE can ORvary fromDISTRIBUTION one dosage form to another. NOT FOR SALE OR DISTRIBUTION

Solid Dosage Forms Solid dosage forms include tablets, capsules, caplets, lozenges/troches, pastilles, powders,© Jones and granules. & Bartlett Solid Learning, dosage forms LLC offer several advantages:© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 Increased stability 77 Ease of packaging, storage, and dispensing 77 Convenience © Jones & Bartlett77 Little Learning, or no taste LLCor smell © Jones & Bartlett Learning, LLC NOT FOR SALESolid OR dosageDISTRIBUTION forms also allow for accurate dosing.NOT FOR The entireSALE dose OR is DISTRIBUTION contained within the contents of the solid dosage form, which minimizes measuring errors. Solid dosage forms may, however, be difficult to swallow, have a slow onset of action, and may be degraded by the acidic contents in the stomach. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Tablets/Caplets NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Tablets are available in variety of sizes, shapes, colors, and thicknesses. They are formed in molds or produced by compression, and are composed of one or more active ingredients and one or more inert substances. Some pharmaceutical manufacturers manufacture a hybrid of the capsule and tablet,© Jones called & aBartlett caplet. A Learning, caplet is a tablet LLC that is shaped like a capsule,© Jones but & smooth- Bartlett Learning, LLC sidedNOT like FOR a tablet. SALE It ORis often DISTRIBUTION easier to swallow than large tablets,NOT and FORis more SALE stable OR DISTRIBUTION than capsules (discussed in a moment). Most tablets and caplets are designed to be swallowed whole and dissolve in the gastrointestinal tract, but some are also made to be administered sublingually (under © Jones & Bartlettthe tongue), Learning, buccally, LLC or vaginally. Some tablets are© Jonesavailable & in Bartlett a scored Learning,form so they LLC NOT FOR SALEmay beOR easily DISTRIBUTION broken in halves or quarters. TabletsNOT can FOR be formulated SALE OR with DISTRIBUTION delayed- release characteristics to allow for less-frequent dosing and/or side effects.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR ASALE chewable OR tablet DISTRIBUTION is designed to be chewed. Chewable tablets contain a base that is flavored or colored. They are convenient for patients who have difficulty swallowing tablets or for children who are unable to swallow large tablets. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC An oral disintegrating tablet (ODT) is designed NOT FOR SALE OR DISTRIBUTIONto dissolve in the mouthNOT without FOR water. SALE These OR DISTRIBUTION tablets are useful for pediatric and geriatric patients who have difficulty swallowing medication and in patients who are experiencing © Jones & Bartlett Learning, LLC nausea ©and Jones vomiting. & Bartlett Another benefitLearning, of ODTs LLC NOT FOR SALE OR DISTRIBUTION is that NOTthey cannot FOR SALEbe “cheeked” OR DISTRIBUTION by patients who may attempt to be non-compliant with medication therapy that is administered by a caregiver, as with a nursing home patient.

© Jones & Bartlett Learning, LLC © JonesEnteric-Coated & Bartlett Learning, Tablets LLC NOT FORTablets SALE are ORmanufactured DISTRIBUTION in a variety of sizes and colors. NOT FOR SALE OR DISTRIBUTION Tablets may have a coating applied to the outside to mask unpleasant flavor or odor, or to protect the drug from stomach contents. Enteric-coated tablets are coated with a substance that prevents dissolution of the drug in the stomach. They are meant to dissolve in the intestine to protect the drug from ©being Jones broken & Bartlett down in Learning, the stomach LLC or to protect the stomach© lining Jones from & Bartlettthe drug. Learning, LLC NOTEnteric-coated FOR SALE dosage OR formsDISTRIBUTION should not be chewed, broken, orNOT crushed. FOR Examples SALE OR of DISTRIBUTION drugs that are available in enteric-coated formulations include aspirin and potassium chloride.

© Jones & Bartlett Learning, LLC Film-Coated Tablets© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Film-coated tabletsNOT are coatedFOR SALEwith a ORthin DISTRIBUTIONouter layer of water-soluble material that dissolves rapidly in the stomach. The coating is designed to cover the unpleasant taste or smell of the medication or protect sensitive drugs from deterioration due to air and light. Erythromycin is an ex- © Jones & Bartlett Learning, LLC ample© Jones of a medication & Bartlett available Learning, as a film-coated LLC tablet. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Sugar-Coated Tablets Sugar-coated tablets are coated with an outside layer of sugar that protects the medication and improves the taste © Jones & Bartlett Learning,and the LLC appearance of the medication.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Capsules Capsules are a solid dosage form in which the drug is en- closed within a hard or soft gelatin shell. The gelatin shell © Jones & Bartlett Learning, LLC dissolves in the stomach,© Jones releasing & Bartlett the drug. Learning, The gelatin LLC NOT FOR SALE OR DISTRIBUTION shell may be transparent,NOT FOR semitransparent, SALE OR DISTRIBUTION or opaque. A capsule may contain powders, granules, crushed tablets, or liquids with one or more active ingredients and one or more inert ingredients. Capsules can be formulated with delayed-release characteristics to allow for less-frequent © Jones &Enteric Bartlett coated tabletsLearning, prevent dissolutionLLC of the drug in © Jones & Bartlett Learning, LLC the stomach. dosing and/or side effects. NOT FOR SALE OR DISTRIBUTION NOTSpansules FOR SALEare capsules OR DISTRIBUTION that are filled with granules that dissolve at different rates, in effect causing a sustained

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALErelease OR of DISTRIBUTIONthe active ingredients. Sprinkles or NOT FOR SALE OR DISTRIBUTION sprinkle capsules are similar to spansules but unique in that they are designed to be pulled apart and the contents sprinkled onto food, making it easier to administer the medication. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The medication inside a sprinkle capsule is specially coated NOTto allow FOR the SALEmedication OR toDISTRIBUTION be NOT FOR SALE OR DISTRIBUTION delivered after the contents have been ingested. They are convenient for patients who have difficulty swallowing large capsules or for children who© Jones are unable & Bartlett to swallow Learning, capsules. LLC © Jones & Bartlett Learning, LLC NOTSizes FOR of capsules SALE ORrange DISTRIBUTION from 000 (largest) NOT FOR SALE OR DISTRIBUTION to 5 (smallest). The volume of powder that can be placed in a given capsule varies depending on the density of the powder being placed in the empty capsule. © Jones & Bartlett Learning, LLC ©Capsules Jones come & in Bartlett a variety of Learning, sizes. LLC NOT FOR SALEDosage OR FormulationsDISTRIBUTION Designed to Alter NOT FOR SALE OR DISTRIBUTION the Rate of Release Tablets and capsules can be designed in immediate-release formulations, in which the medication is released within a short period of time after the drug is taken. They can also be designed© Jones in delayed-release & Bartlett formulations, Learning, LLCwhich administer the drug ©over Jones & Bartlett Learning, LLC an extended periodNOT of FORtime. SALEA delayed-release OR DISTRIBUTION formulation may be enteric coated,NOT FOR SALE OR DISTRIBUTION thus delaying the release of the medication until the formulation has passed through the stomach. Dosage forms designed to vary the rate or extent of release include the following: ©77 JonesControlled & Bartlett release— Learning,Controlled-release LLC dosage forms regulate© theJones rate of& releaseBartlett Learning, LLC NOTof theFOR active SALE ingredient. OR DISTRIBUTION They are designed to vary the dissolutionNOT FORrate or SALE re- OR DISTRIBUTION lease of the active drug. These dosage forms are also referred to as long-acting and timed-release formulations. 77 Sustained release—Sustained-release dosage forms allow the frequency of dos- © Jones & Bartletting of Learning, a medication LLC to be reduced compared© to Jones that of immediate-release& Bartlett Learning, dosage LLC forms. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 Extended release—Extended-release dosage forms are formulated so that the active ingredient is released at a constant rate for a prolonged period so that the frequency of dosing is less than that of immediate-release dosage forms. They usually allow for once-daily dosing, as the contained medication is available over an extended© Jones period & of Bartlett time following Learning, ingestion LLC of the formulation. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Compared to immediate-release preparations, advantages of extended-release dosage forms include the following: 77 Constant drug levels following long-term administration ©7 7JonesReduction & Bartlett in adverse Learning, side effects LLC © Jones & Bartlett Learning, LLC NOT77 Reduction FOR SALE in the ORfrequency DISTRIBUTION of administration NOT FOR SALE OR DISTRIBUTION 77 Increased patient compliance

Immediate-release formulations are designed to release the medication within a short period © Jones & Bartlettof time. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONLozenges, Troches, or PastillesNOT FOR SALE OR DISTRIBUTION Lozenges, also known as troches or pastilles, are hard, oval, or discoid solid dosage forms with a drug contained in a flavored sugar base. They are dissolved in the mouth and generally have local therapeutic effects. Over-the-counter lozenges for relief of © soreJones throat & areBartlett a common Learning, example LLCof this dosage form. Antibiotics,© Jones analgesics, & Bartlett cough Learning, LLC NOTsuppressants, FOR SALE and ORantiseptics DISTRIBUTION are also available as lozenges. TrocheNOT FOR sizes SALEvary; they OR DISTRIBUTION usually have a chalky consistency in order to dissolve in the mouth.

Powders and Granules © Jones & BartlettPowders Learning, are finely LLCground mixtures of dry drugs© Jones and inactive & Bartlett ingredients Learning, that can LLCbe used topically or internally. When used internally, they should be dissolved in water NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION prior to ingestion. Granules are larger than powders and are wetted, allowed to dry, and ground into coarse, irregularly shaped pieces. Granules are generally more stable than powders and are more suitable for use in solutions because they are not as likely to float on the surface of a liquid. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONSemisolid Dosage Forms NOT FOR SALE OR DISTRIBUTION Semisolid agents are different in their composition from liquids or solids. They are usually intended for topical application. They may be applied to the skin, placed on mucous membranes, or used in the nasal, rectal, or vaginal cavity. These dosage ©forms Jones are & too Bartlett thick to Learning,be considered LLC a liquid dosage form and© not Jones solid enough & Bartlett to be Learning, LLC NOTconsidered FOR SALE a solid ORdosage DISTRIBUTION form. Examples include ointments,NOT creams, FOR lotions, SALE gels, OR DISTRIBUTION pastes, and suppositories. An emulsion is a type of semi-solid dosage form. It is a mixture of two substances that are unblendable. One substance is dispersed in the other. An oil-in-water (O/W) emulsion contains a small amount of oil dispersed in water. A water-in-oil (W/O) © Jones & Bartlettemulsion Learning, contains LLCa small amount of water dispersed© Jones in oil.& Bartlett An emulsion, Learning, which hasLLC NOT FOR SALEa differentOR DISTRIBUTION composition than the two individualNOT liquids FOR thatSALE are ORmixed DISTRIBUTION together, is dispensed in containers that hold liquids.

An emulsion is a mixture of two liquids that do not blend. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONOintments NOT FOR SALE OR DISTRIBUTION An ointment is applied externally to the skin or mucous membranes. An ointment is an example of a W/O emulsion because it contains a small amount of water dispersed throughout oil. Ointments can also be formulated and sterilized for use in the eye. ©Ointments Jones & containBartlett medication Learning, in LLCa glycol or oil base and can© effectivelyJones & coverBartlett the Learning, LLC NOTsurface FOR of the SALE skin. ORExamples DISTRIBUTION of ointments include erythromycinNOT ophthalmic FOR SALE ointment OR DISTRIBUTION and Neosporin. Ointments are generally greasier than creams or gels, and can leave an oily residue at the site of application.

An ointment is an example of a water-in-oil (W/O) emulsion. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Creams A cream contains suspensions or solutions of drugs intended for external use. A cream is an example of an O/W emulsion because it contains a small amount of oil © Jones & Bartlett Learning,dispersed LLC in water. Creams can© beJones easily &massaged Bartlett into Learning, the skin, withoutLLC leaving an NOT FOR SALE OR DISTRIBUTIONoily residue. They usually haveNOT medications FOR SALE in a base OR thatDISTRIBUTION is part oil and part water.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALECreams OR can DISTRIBUTION also be formulated for vaginal or rectalNOT use. FOR Examples SALE of OR creams DISTRIBUTION include hydrocortisone cream, benzoyl peroxide cream, and betamethasone valerate cream.

A cream is an example of an oil-in-water (O/W) emulsion. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Lotions NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A lotion is an O/W emulsion that is thinner than a cream because its base contains more water. Lotions penetrate into the skin and can cover large areas without leaving an oily residue. Examples of lotions include calamine lotion and hydrocortisone lotion. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ANOT lotion FOR is an exampleSALE ofOR an DISTRIBUTIONoil-in-water (O/W) emulsion that is thinnerNOT than a FOR cream. SALE OR DISTRIBUTION

Gels A gel contains solid medication particles, like a suspension, in a thick liquid. It can © Jones & Bartlettbe used internallyLearning, and LLC externally. The particles in© a Jonesgel are ultrafine& Bartlett and Learning,are linked to LLC NOT FOR SALEform ORa semisolid. DISTRIBUTION Gels penetrate the skin withoutNOT leaving FOR a residue. SALE Examples OR DISTRIBUTION of gels include aluminum hydroxide gel and benzocaine gel.

Pastes A paste contains© more Jones solid & material Bartlett and Learning, less liquid baseLLC than a solid. Pastes are© like Jones & Bartlett Learning, LLC ointments, but areNOT stiffer, FOR less SALE greasy, OR and DISTRIBUTION applied more thickly. One example NOT of a FOR SALE OR DISTRIBUTION paste is zinc oxide.

Suppositories A© suppository Jones & Bartlettis designed Learning, to be inserted LLC rectally, vaginally, or urethrally.© Jones The & supposi Bartlett- Learning, LLC toryNOT base FOR is an SALE inactive OR ingredient, DISTRIBUTION which melts or dissolves in theNOT body FOR cavity, SALE releas -OR DISTRIBUTION ing the medication. Some suppositories are designed for local action, while others are used as vehicles for systemic drugs. A hydrocortisone rectal suppository is used for local relief. Suppositories are often used in children and in adults who are unable to take oral medications. Rectal suppositories bypass the stomach, which is helpful if © Jones & Bartlettthe patient Learning, has nausea LLC or vomiting. They are also© usedJones to treat& Bartlett inflammatory Learning, bowel LLC NOT FOR SALEdisease OR or DISTRIBUTIONpain. Vaginal suppositories are used NOTto treat FOR yeast SALE infections OR andDISTRIBUTION vaginal atrophy. Examples of suppositories include miconazole vaginal suppositories and bisacodyl rectal suppositories.

Liquid Dosage ©Forms Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Liquid dosage formsNOT contain FOR SALEone or moreOR DISTRIBUTIONactive ingredients in a liquid vehicle suchNOT FOR SALE OR DISTRIBUTION as a solution, suspension, or emulsion. The drug may be dissolved in the vehicle or suspended as very fine particles. They can be administered by many routes, but are often less stable than medications in solid dosage forms. Liquid dosage forms offer several advantages: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT77 They FOR allow SALE for easier OR DISTRIBUTIONdosage adjustments, particularly for pediatricNOT FOR patients. SALE OR DISTRIBUTION 77 They are easier to swallow, particularly for pediatric and geriatric patients. 77 The onset of action is faster than that of solid dosage forms. 77 They are easier to place down a feeding tube. © Jones & BartlettLiquid dosage Learning, forms haveLLC several disadvantages:© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 Loss of potency occurs faster than with solid dosage forms.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION77 There is difficulty in maskingNOT bitter FOR taste SALE or odor. OR DISTRIBUTION 77 There is a need for preservatives because liquid doses provide an excellent me- dium for the growth of microorganisms. 77 There is a potential for dosing inaccuracy. © Jones77 They &are Bartlett inconvenient. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Solutions A solution is an evenly distributed (homogenous) mixture of one or more dissolved medications (solutes) in a liquid vehicle (solvent). Solutions can be classified by © Jones & Bartlettvehicle Learning, as an aqueous LLC solution (water-based),© an Jones alcoholic & Bartlettsolution (alcohol-based), Learning, LLC NOT FOR SALEor ORa hydroalcoholic DISTRIBUTION solution (water- and alcohol-based).NOT FOR Solutions SALE ORcan beDISTRIBUTION for internal and external use. Solutions can also be classified by their contents: 77 Aromatic water—Aromatic water is a solution of water that contains oil or © Jones & Bartlett Learning, LLCother substances that are volatile.© Jones They & Bartlettusually have Learning, a pleasant LLC smell. NOT FOR SALE OR DISTRIBUTION77 Elixir—An elixir is a clear,NOT sweet FOR solution SALE that ORcontains DISTRIBUTION dissolved medication in a base of water and ethanol (hydroalcoholic). 77 Syrup—Syrup is a sugar-based solution that may be medicated or non-medicated. Syrups mask the taste of the drug. © Jones77 Extract—An & Bartlett extract Learning, is a powder LLC or liquid derived from animal© Jones or plant & Bartlett sources Learning, LLC NOT inFOR which SALE all or OR most DISTRIBUTION of the solvent has been evaporated. NOT FOR SALE OR DISTRIBUTION 77 Tincture—A tincture is an alcoholic or hydroalcoholic solution that contains plant extracts. 77 Spirit—A spirit is an alcoholic or hy- © Jones & Bartlett Learning, LLC droalcoholic© Jones solution& Bartlett that Learning,contains vola LLC- NOT FOR SALE OR DISTRIBUTION tile,NOT aromatic FOR ingredients. SALE OR DISTRIBUTION 77 Irrigating solution—An irrigating solution is a solution that is used for cleans- ing an area of the body.

© Jones & Bartlett Learning, LLC © Jones &Solutions Bartlett canLearning, also be LLCclassified by their method of administration as topical, systemic, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION epicutaneous, percutaneous, oral, otic, ophthalmic, parenteral, vaginal, or urethral. A parenteral solution is a sterile solution that is administered by a needle or catheter via © Jones & Bartlett Learning, LLCinjection or infusion. It© can Jones be administered & Bartlett in Learning, LLC NOT FOR SALE OR DISTRIBUTIONan intravenous (IV), intramuscularNOT FOR (IM) SALE, subcu OR- DISTRIBUTION taneous (SC), or intradermal (ID) manner. Injectable dosage forms are marketed in ampules, vials, pre-filled syringes, and pre- © Jones & Bartlett Learning, LLC filled infusion© Jones bags. & BartlettMost vials Learning, contain solu LLC- tions up to 50mL. A vial will contain either a NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION single dose, which is meant for withdrawal of one dose before the vial is discarded, or multi- dose, which means the vial can be pierced multiple times to retrieve multiple doses. Some © Jones & Bartlett Learning, LLC © Jonesvials & Bartlettcome in powderLearning, form LLC and will need to NOT FOR SALE OR DISTRIBUTION NOT FORhave SALE diluents OR added DISTRIBUTION before administration. The Various injectable dosage forms. addition of a diluent to a powder vial is called

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEreconstitution OR DISTRIBUTION. The vial will give information asNOT to how FOR SALE OR DISTRIBUTION much and which diluent is needed to obtain a specific concentration. Pre-filled syringes or infusion bags have the medication in ready-to-administer form. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Dispersions NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Some drugs do not dissolve in the solvents that are used to prepare liquid dosage forms. In a dispersion, the medication is not dissolved, but distributed throughout the vehicle. A suspension is a mixture of undissolved, very fine,© Jones solid particles & Bartlett distributed Learning, through LLC a gas, liquid, or © Jones & Bartlett Learning, LLC solid.NOT Most FOR suspensions SALE OR contain DISTRIBUTION medications distributed NOT FOR SALE OR DISTRIBUTION in water; this type of suspension is called an aqueous suspension. Suspensions are used for drugs that are not able to dissolve readily into a solution. Suspensions need to © Jones & Bartlettbe shaken Learning, prior to use LLC and should contain a “shake© Jones well” & Bartlett Learning, LLC NOT FOR SALEauxiliary OR label.DISTRIBUTION The pharmacy tech must shake aNOT suspen FOR- SALE OR DISTRIBUTION sion prior to pouring an amount from a stock bottle into a bottle for dispensing. Injectable suspensions allow for insoluble drugs to be administered intramuscularly or subcutaneously. They are often used for depot© Jones therapy, & whereBartlett the Learning,drug is released LLC © Jones & Bartlett Learning, LLC Enemas can be used to evacuate the lower intestine. over a long periodNOT of time. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Suspensions have the following characteristics: 77 The suspended material should be evenly distributed when the container is shaken. ©77 JonesIt should & pourBartlett freely Learning, from the bottle LLC or pass easily through a© syringe Jones or & needle. Bartlett Learning, LLC NOT77 When FOR used SALE externally, OR DISTRIBUTION it should dry quickly and spread easilyNOT over FOR the affected SALE OR DISTRIBUTION area. As mentioned, an emulsion is a mixture of two liquids that are immiscible (do not blend). It is a dispersion, with one liquid being dispersed in the other. They © Jones & Bartlettvary in their Learning, viscosity LLC from liquids such as lotions© toJones semisolid & Bartlett dosage forms Learning, such as LLC NOT FOR SALEointments OR DISTRIBUTION and creams. In an emulsion, one liquidNOT is broken FOR SALEinto small OR particles DISTRIBUTION and evenly scattered throughout the other liquid. The liquid that is in small particles is called the internal phase, and the other liquid is called the external phase. The two liquids will separate into two phases unless an emulsifying agent, an ingredient used to bind together ©substances Jones &that Bartlett normally Learning, do not mix, LLC is used. An emulsifying agent© Jones & Bartlett Learning, LLC is a chemical thatNOT has water-lovingFOR SALE and OR lipid-loving DISTRIBUTION properties that can keep oilNOT and FOR SALE OR DISTRIBUTION water together.

Enemas Enemas© Jones are & used Bartlett to deliver Learning, medication, LLC rectally, a way that bypasses© Jones the &stomach. Bartlett Learning, LLC Enemas are manufactured in a water base and can also be used to evacuate the lower intestineNOT FOR to prepare SALE forOR surgeries DISTRIBUTION or examinations involving the NOTintestine. FOR SALE OR DISTRIBUTION

An enema can be used to deliver medication to bypass the stomach.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORInhalation SALE ORDosage DISTRIBUTION Forms Some patient populations, such as asthmatic patients, need to have their medications delivered to a specific site in the body, such as the bron- © Jones & Bartlett Learning, LLCchial tree. Gases, vapors,© Jones aerosols, & Bartlettpowders, Learning, LLC NOT FOR SALE OR DISTRIBUTIONsprays, solutions, and suspensionsNOT FOR intended SALE OR to DISTRIBUTION be inhaled via the nose or mouth are known as inhalations, after the term inhalation, or the acts of inhaling or breathing in. The medication particles must be extremely fine to reach © Jones & Bartlett Learning, LLC these areas© Jones effectively. & Bartlett Devices Learning,that enable theLLC NOT FOR SALE OR DISTRIBUTION medicationNOT to FOR reach SALE the lungs OR easilyDISTRIBUTION include vaporizers, humidifiers, and nebulizers. An aerosol is a spray that contains very fine liquid or solid drug particles in a gas propellant that is packaged under pressure. An © Jones &Nitroglycerin Bartlett is Learning,available in a transdermalLLC patch formulation. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORaerosol SALE dosage OR form DISTRIBUTION consists of the medication, the container, and the propellant. Pressurized aerosol containers should be stored away from heat. The medication may be released as a spray, foam, or solid, depending on the formulation of the product and on the design of the valve. Aerosols have a rapid onset of action because the drug bypasses ©the Jones gastrointestinal & Bartlett tract. Learning, LLC © Jones & Bartlett Learning, LLC NOT AFOR spray SALE consists OR of aDISTRIBUTION container that has a valve assembly unitNOT that FOR contains SALE various OR DISTRIBUTION bases, such as alcohol or water, in a pump-type dispenser. When activated, it emits a fine dispersion of liquid, solid, or gaseous material.

© Jones & BartlettTransdermal Learning, Dosage LLC Forms © Jones & Bartlett Learning, LLC NOT FOR SALEA transdermalOR DISTRIBUTION patch dosage form is designed NOTto hold FOR a specific SALE amount OR DISTRIBUTIONof medication to be released into the skin and absorbed into the bloodstream over time via a patch or disk. The patch consists of a backing, drug reservoir, control membrane, and adhesive layer. The backing is removed and the adhesive layer is applied to the skin. The drug is slowly absorbed across the membranes of the skin and into the skin where optimal © Jones & Bartlett Learning,absorption LLC into the bloodstream© Joneswill occur. & BartlettPatches are Learning, convenient LLC because they can NOT FOR SALE OR DISTRIBUTIONbe applied easily and minimizeNOT stomach FOR upset.SALE They OR canDISTRIBUTION also improve compliance because they eliminate the need for more frequent dosing that is often associated with oral dosage forms. Drugs such as nitroglycerin, fentanyl, scopolamine, and nicotine are administered in this manner for their systemic effects. © JonesNot all & medicationsBartlett Learning, designed to LLC be administered transdermally© Jones are in & the Bartlett form of Learning, LLC NOTpatches. FOR Some SALE gels OR are alsoDISTRIBUTION formulated to be administered transdermally.NOT FOR TheseSALE gels OR DISTRIBUTION are also designed to hold a specific amount of medication to be absorbed into the skin and bloodstream over time. The drug is slowly absorbed across the membranes of the skin and into the skin, where optimal absorption in the bloodstream will occur. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE7 OR7R outesDISTRIBUTION of Administration NOT FOR SALE OR DISTRIBUTION Medications can be administered by many different routes. A route of administration is the way to get a drug into or onto the body. Sometimes, combinations of routes © Jones & Bartlett Learning,are LLC used at the same time. The© age Jones and condition & Bartlett of the Learning, patient often LLC determines the route of administration. The oral route is the most common route of administration. NOT FOR SALE OR DISTRIBUTIONFollowing is a list of routes ofNOT administration: FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE77 Buccal—Administered OR DISTRIBUTION inside the mouth on theNOT mucosa FOR ofSALE the cheek OR DISTRIBUTION 77 Dental—Application to teeth or gums 77 Epidural—Injection on or outside the dura meter of the spinal cord 77 External—Applied externally to the skin or hair 77 Implant—Placing© Jones a drug & form, Bartlett drug-delivery Learning, device, LLC or other device at the de© -Jones & Bartlett Learning, LLC sired administrationNOT FOR site bySALE insertion OR inDISTRIBUTION a body tissue or body cavity by surgicalNOT FOR SALE OR DISTRIBUTION or other appropriate insertion procedures 77 In vitro—Occurs within the laboratory or controlled experimental environment rather than in the body ©77 JonesInhalation—Drug & Bartlett administration Learning, LLCinto the lungs (either during© Jonesa drawn & or Bartlett Learning, LLC NOTforced FOR breath) SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 Injection—A set of one or more injectable routes or the route of injection is not specified 77 Intra-arterial—Injection into an artery or intra-arterial port © Jones & Bartlett77 Intra-articular—Injection Learning, LLC into a joint © Jones & Bartlett Learning, LLC NOT FOR SALE77 Intracavernosal—Injection OR DISTRIBUTION into the corpora NOTcavernosa FOR SALE OR DISTRIBUTION 77 Intradermal—Injection within the epidermis (skin) 77 Intramuscular—Injection into a muscle group 77 Intraocular—Injection, implantation, or surgical irrigation within the eyeball 77 Intraperitoneal—Administration© Jones & Bartlett into Learning, the intraperitoneal LLC cavity, commonly by© Jones & Bartlett Learning, LLC injection or instillationNOT FOR into SALE an intraperitoneal OR DISTRIBUTION catheter port NOT FOR SALE OR DISTRIBUTION 77 Intrapleural—Injection into the pleura or pleural cavity 77 Intrathecal—Injection into a subarachnoid or subdural space 77 Intrauterine—Administered into the uterus ©77 JonesIntravenous—Injection & Bartlett Learning, directly into LLC a vein or into a venous ©line Jones port & Bartlett Learning, LLC NOT77 Intravesical—Administered FOR SALE OR DISTRIBUTION into the bladder NOT FOR SALE OR DISTRIBUTION 77 Irrigation—To flush a body cavity or site with a stream of liquid 77 Mouth/Throat—Applied to a mucus membrane of the oral cavity or throat 77 Nasal—Administered via the nose © Jones & Bartlett77 Ophthalmic—Administered Learning, LLC onto the surface© of Jones the eyeball & Bartlett or into the Learning, conjucti- LLC NOT FOR SALEval OR sac DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 Oral—Taken by mouth 77 Otic—Commonly administered into the external ear canal 77 Perfusion—Administration (pumping) of a fluid through an organ or tissue 77 Rectal—Administered© Jones into & Bartlett the rectum Learning, (in the anal LLC canal beyond the anal © Jones & Bartlett Learning, LLC sphincter) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 Subcutaneous—Injection through the skin into the loose subcutaneous tissue under the skin 77 Sublingual—Administered under the tongue ©7 7JonesTransdermal—Applied & Bartlett Learning, topically (e.g.,LLC a patch or ointment),© with Jones absorption & Bartlett Learning, LLC NOTthrough FOR theSALE skin ORfor localDISTRIBUTION or systemic effect NOT FOR SALE OR DISTRIBUTION 77 Translingual—Drug absorption through the tongue into systemic circulation after application on the tongue 77 Urethral—Administered via insertion or instillation into the urethra © Jones & Bartlett77 Vaginal—Administered Learning, LLC into the vagina © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONPeroral NOT FOR SALE OR DISTRIBUTION The peroral (PO) route is commonly referred to as the oral route. It means that the drug is administered orally through the mouth and swallowed to reach the stomach. It must then undergo dissolution in the stomach, absorption in either the stomach or © smallJones intestine, & Bartlett activation Learning, in the liver, LLC and distribution to the© tissue Jones before & Bartlett it exerts Learning, LLC NOTits therapeutic FOR SALE effect. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Advantages of the oral route are that it is safe and convenient and easy to tol- erate. In addition, the medications are usually less expensive, and are available in extended-release forms. A patient can take one or more tablets or, if the tablet is scored, a portion of the tablet. Sustained-release and extended-release tablets provide © Jones & Bartletta longer Learning, duration ofLLC action and, in some cases,© Jonesfewer side & Bartlett effects. Liquid Learning, solutions LLC NOT FOR SALEand OR suspensions DISTRIBUTION are useful in those patients NOTwho haveFOR difficulty SALE ORswallowing. DISTRIBUTION They also work more quickly than tablets and capsules because they are already in liquid form and ready to be absorbed. Disadvantages include a time delay between administration of the drug and the © Jones & Bartlett Learning,onset LLC of action, the possible interference© Jones &of Bartlettfood and Learning,other drugs withLLC absorption of NOT FOR SALE OR DISTRIBUTIONthe drug, and the possible degradationNOT FOR of theSALE drug OR by gastrointestinalDISTRIBUTION fluids. Side effects that occur with sustained-releaseAuthor medications alsoISBN take# longer toAuthor's subside. review Liquid Shah 5954 (if needed) formulations sometimes have an unpleasantFig. # taste,Document which name may make compliance moreOK Correx difficult. Patients who are experiencing5954.04.02 nausea 5954_F04.02.eps or vomiting or who are sedated or Artist Date Initials Date otherwise unable to swallow should not take medications07/12/2011 via the oral route. PD & PS © JonesSublingual & Bartlett (under Learning,the tongue) LLCand buccal (betweenCheck if revision the check© Jones andCE's gum) &review Bartlett routes Learning, LLC NOTof administration FOR SALE areOR used DISTRIBUTION when aB rapidx W onset 2/C of action 4/C is needed.NOT The FOR medication SALEOK OR isCorrex DISTRIBUTION absorbed directly by the blood vesselsFinal Size under (Width xthe Depth tongue in Picas) or in the lining of the mouth. When taking the medication sublingually,25w x 14d the patient should hold the tabletInitials underDate the tongue until the medication dissolves Figure 4.2 . Nitroglycerin is the most commonly © Jones & Bartlettused sublingualLearning, tablet. LLC Drugs administered sublingually© Jones &have Bartlett a rapid Learning,onset of action LLC NOT FOR SALEbecause OR DISTRIBUTION they enter the bloodstream directly. NOTWhen FOR taking SALE the medication OR DISTRIBUTION buccally, the patient should place the tablet between the gums and cheek and hold the tablet there until it dissolves.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Figure 4.2 The correct way to take a medication that is administered sublingually.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEFollowing OR DISTRIBUTION Directions with Oral NOT FOR SALE OR DISTRIBUTION Medications Patients should receive verbal and written instructions from the pharmacist about what foods and behaviors© Jones to avoid & while Bartlett taking Learning, their LLC © Jones & Bartlett Learning, LLC medication. AuxiliaryNOT labels FOR added SALE to theOR medi DISTRIBUTION- NOT FOR SALE OR DISTRIBUTION cation container can help ensure that the drug is taken correctly.

Dispensing Oral Medications © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Dispensing measuring spoons, oral syringes, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION droppers, and cups with the liquid medication can help ensure that the patient or caregiver measures the dose correctly. Many directions, both on prescription and over-the-counter © Jones & Bartlettproducts, Learning, include use LLC of teaspoonful or table- © Jones & Bartlett Learning, LLC NOT FOR SALEspoonful, OR butDISTRIBUTION most household utensils are often NOT FOR SALE OR DISTRIBUTION inaccurate. Many over-the-counter liquid preparations come with a measuring cup for ease of administration. Most pharmacies will provide Auxiliary labels provide important information to help the patient take measuring spoons© orJones cups, &syringes, Bartlett or Learning,drop- the drug LLC correctly. © Jones & Bartlett Learning, LLC pers with the medication. An oral syringeNOT is FORoften usedSALE to ORdeliver DISTRIBUTION a NOT FOR SALE OR DISTRIBUTION precise amount of liquid medication to children. It is a calibrated syringe that has a plunger and barrel, which is used to slowly administer liquid medication to infants and small children or to patients who have difficulty opening their mouth. © JonesDroppers & canBartlett be used Learning, to deliver LLCa small amount of medication© Jones to an &infant. Bartlett It Learning, LLC consistsNOT FOR of a smallSALE squeezable OR DISTRIBUTION bulb and a hollow tube with a narrowNOT point.FOR TheSALE size OR DISTRIBUTION of the drop can vary from one medication to another, depending on the thickness or viscosity of the medication. Some solutions and suspensions have specific storage requirements and limited dates of expiration. Some antibiotics must be refrigerated after reconstitution and © Jones & Bartlettare only Learning,good for 7 to LLC 14 days. Suspensions must© be Jones shaken & before Bartlett administration Learning, to LLC NOT FOR SALEensure OR that DISTRIBUTION the medication is uniformly distributedNOT into FOR solution. SALE OR DISTRIBUTION

Suspensions must have an auxiliary label, “Shake Well,” to ensure that the medication is shaken before administration.© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Parenteral The parenteral route of administration bypasses the gastrointestinal tract. Drugs that are administered© Jones &by Bartlettthis route Learning, can be given LLC over a © Jones & Bartlett Learning, LLC shortNOT (seconds FOR SALE to minutes) OR DISTRIBUTION or extended (days) NOT FOR SALE OR DISTRIBUTION period of time. This route of administration dis- tributes the drug systemically throughout the body to exert a systemic effect. Parenteral ad- © Jones & Bartlettministration Learning, may be necessaryLLC when drugs are © Jones & Bartlett Learning, LLC NOT FOR SALEinactivated OR DISTRIBUTION in the stomach or undergo signifi- NOT FOR SALE OR DISTRIBUTION cant first-pass metabolism, so swallowing them Use of dosing aids can promote more accurate dosing for infants and young children who need to take liquid medications.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FORwould SALE be ineffective. OR DISTRIBUTION The majority of drugs for parenteral administration are formulated as solutions, but they may also be emulsions or suspensions. Drugs that are administered by this route are given via injection and must be © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC sterile and free from particles. Drugs that are NOT FOR SALE OR DISTRIBUTIONadministered by this routeNOT are administeredFOR SALE into OR DISTRIBUTION the vein (IV), subcutaneously (SC), intradermally (ID) or intramuscularly (IM). When a drug is given all at once or over a short period © Jones & Bartlett Learning, LLC of time,© it Jonesis called & a Bartlettbolus dose Learning, and is admin LLC- NOT FOR SALE OR DISTRIBUTION istered NOTby IV pushFOR via SALE a syringe OR orDISTRIBUTION needle. If it is infused into a vein over hours or days, it is called a constant infusion. Advantages of this route include that it can Some drugs can be administered intramuscularly. be used in patients who cannot take medica- © Jones & Bartlett Learning, LLC © Jonestions & Bartlettorally, it hasLearning, a faster onset LLC of action, and NOT FOR SALE OR DISTRIBUTIONit can be used for drugs that areNOT unstable FOR inSALE the acidic OR DISTRIBUTIONenvironment of the stomach. The IV route is the fastest route of drug administration. Disadvantages of this route include pain at the injection site, risk of infection, and the drugs are usually more expensive. Another disadvantage is that, because inject- ©able Jones drugs & exertBartlett their Learning,action quickly, LLC there is little or no time© to Jones alter its & availability Bartlett Learning, LLC NOTif the FOR wrong SALE dose ORis given DISTRIBUTION or an adverse reaction occurs. IV NOTinjections FOR must SALE be free OR DISTRIBUTION from air bubbles and particulate matter to prevent an embolism or blockage. Absorp- tion of the drug by the IM or SC route is not as predictable as the IV route, but drugs administered via this route may have a longer duration of action because they can be given as depot formulations, and thus are not metabolized quickly. © Jones & BartlettWhen Learning, a drug is LLC administered by injection ©into Jones a muscle, & Bartlett it is called Learning, intramuscular LLC NOT FOR SALE(IM). OR The DISTRIBUTION most common sites for intramuscularNOT injection FOR are SALE the upper OR arm,DISTRIBUTION the thigh, or the buttock. The advantages of IM injection include a more rapid onset of action than oral dosage forms. The disadvantages of this route of administration include that it is difficult to reverse, it may cause pain or bruising, absorption may be incomplete, © Jones & Bartlett Learning,and LLC only a small volume of drug© Jonescan be injected.& Bartlett It should Learning, also be LLCused cautiously in NOT FOR SALE OR DISTRIBUTIONpatients with decreased muscleNOT mass. FOR SALE OR DISTRIBUTION When a drug is administered below the skin, it is called subcutaneous (SC, SQ, or subQ). Drugs that are administered by this route are absorbed more slowly than by IV or IM routes. The main advantage of this route is that patients can be taught to self-administer their medication. © JonesDisadvantages & Bartlett include Learning, only a limited LLC volume of drug can be© injected Jones and & Bartlett it should Learning, LLC NOTalso beFOR used SALE cautiously OR DISTRIBUTIONin patients with bleeding disorders or thoseNOT who FOR are SALE receiving OR DISTRIBUTION anticoagulants.

Drugs that are available in injectable formulations and given parenterally can be administered © Jones & Bartlettintravenously, Learning, subcutaneously, LLC or intramuscularly. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Using Injectable Medications Most parenteral preparations are prepared in a sterile-water, normal saline, or other sterile solution. Only trained healthcare professionals or patients who have been taught © Jones & Bartlett Learning,how LLC to administer injectable medications© Jones & should Bartlett give Learning, injections. LLC NOT FOR SALE OR DISTRIBUTIONA syringe is a calibrated medicalNOT FOR instrument SALE thatOR isDISTRIBUTION used to accurately draw up, measure, or deliver medication to a patient. The two types of syringes that are com-

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEmonly OR used DISTRIBUTION for injections are glass syringes andNOT plastic FOR SALE OR DISTRIBUTION syringes. Glass syringes are expensive and must be sterilized prior to use. Plastic syringes are easier to use because they are disposable and do not need to be sterilized prior to use. Syringe barrels can vary in size, depending upon the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC volume of medication needed. A needle is attached to the syringe to facilitateNOT delivery FOR of SALE medication OR toDISTRIBUTION the patient or NOT FOR SALE OR DISTRIBUTION to pierce the core of a vial to draw up the medication.

All drugs administered IV, SC, or IM must be sterile. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC IntravenousNOT FOR SALEInjections OR orDISTRIBUTION Infusions NOT FOR SALE OR DISTRIBUTION A medication can be given via an intravenous injection or as an infusion. It can be used to deliver antibiotics, IV fluids, pain medications, or nutritional supplements. © Jones & BartlettThese medications Learning, are LLC usually administered into ©the Jones vein & Bartlett Learning, LLC NOT FOR SALEof the OR arm. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Intramuscular Injections Intramuscular injections (IM) can be used to deliver a small volume of medication© Jones & (2 Bartlett to 3mL). Learning,It can be used LLC to © Jones & Bartlett Learning, LLC deliver antibiotics,NOT pain FOR medications, SALE OR vitamins, DISTRIBUTION iron, and NOT FOR SALE OR DISTRIBUTION some vaccines. IM injections are usually injected into the upper, outer portion of the buttock. In children, it can also be given in the deltoid muscles of the shoulder. IM injections are administered at a 90-degree angle with a 22 © Jones &1 Bartlett Learning, LLC © Jones & Bartlett Learning, LLC to 25 gauge, /2- to 1-inch needle Figure 4.3 . NOT FOR SALE OR DISTRIBUTION SyringesNOT come FOR in a variety SALE of sizes.OR TheDISTRIBUTION syringe that should be used will depend on the volume of medication Subcutaneous Injections needed. Subcutaneous injections (SC) can be used to deliver a small volume of medication (less than 1mL) into the subcutaneous tissue. SC injec- © Jones & Bartletttions are Learning,usually injected LLC on the outside of the upper© Jones arm, the & Bartletttop of the Learning,thigh, or the LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning,90 degrees LLC © Jones & Bartlett Learning, LLC NOTEpidermis FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Dermis Subcutaneous tissue © Jones & BartlettMuscle Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Figure 4.3 The correct way to administer an IM injection.

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45 degrees © JonesEpidermis & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORDermis SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Subcutaneous tissue Muscle © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Figure 4.4 The correct way to administer an SC injection. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

lower part of the abdomen. SC injections are administered at a 45 degree angle with a 25 to 26 gauge needle (with diabetic needle gauges now available up to 31 gauge) 3 5 © Jones & Bartlett Learning,and LLC a /8- to /8-inch needle Fig©ure Jones 4.4 . In &lean Bartlett or obese Learning, patients, the LLC injections should NOT FOR SALE OR DISTRIBUTIONbe administered closer to a 90-degreeNOT FOR angle. SALE OR DISTRIBUTION

Topical Topical route of administration refers to the application of a drug to the surface of ©the Jones skin or& Bartlettmucous membranes. Learning, Drug LLC forms administered this© wayJones include & Bartlett creams, Learning, LLC NOTointments, FOR SALEgels, lotions, OR DISTRIBUTION sprays, powders, aerosols, and transdermalNOT formulations. FOR SALE The OR DISTRIBUTION effects of topical preparations range from systemic (affecting the entire body) to localized (affecting a small area). The skin has many openings, including sweat glands, hair follicles, and pores through which drugs can pass through the skin. Topical agents can be used to fight skin infections, reduce inflammation, and protect the skin. © Jones & Bartlett Learning, LLC Advantages© Jones of & topical Bartlett agents Learning, include ease LLC NOT FOR SALE OR DISTRIBUTION of application,NOT FOR fewer SALE adverse OR effects DISTRIBUTION than the same drug administered orally, and rapidity of action at the site of application. Most drugs that are applied topically are not well absorbed © Jones & Bartlett Learning, LLC © Jonessystemically, & Bartlett thereby Learning, reducing LLC the incidence of side effects. Creams and gels are more cosmeti- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION cally appealing and less greasy than ointments. Lotions can be applied easily and are easiest to use on hairy parts of the body. Transdermal formulations are convenient to use, and patient © Jones & Bartlett Learning, LLCcompliance is improved.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONTopical drugs mayNOT cause FOR skin SALEirritation. OR DISTRIBUTION Many topical agents are not adequately absorbed transdermally and therefore cannot be given topically. Ointments are generally sticky © Jones & Bartlett Learning, LLC and leave© Jones an oily &residue, Bartlett but Learning, have a longer LLC duration of action because of their prolonged NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION contact time with the skin. Medications can be administered via the ophthalmic route by instilling one drop or drops of medication into the conjunctival sac of the © Jones & Bartlett Learning, LLC © Joneseye. & All Bartlett ophthalmic Learning, preparations LLC must be sterile NOT FOR SALE OR DISTRIBUTION NOT FORand SALEare available OR DISTRIBUTION in cream, ointment, or liquid A patient receives medication intravenously. formulations. Most ophthalmic medications are

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEused toOR treat DISTRIBUTION eye infections, inflammation, or conditionsNOT FOR such SALEas glaucoma. OR DISTRIBUTION Drugs can also be administered via the otic route by instilling one drop or drops of medication into the ear. Medications used to treat ear conditions do not need to be sterile because they do not typically penetrate a sterile environment. They can be used to treat an ear infection, remove earwax buildup or reduce pain. If the patient has a tube in the ear, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC a suspension should be used instead of a solution. Most medications administered via this route areNOT solutions FOR and SALE suspensions. OR DISTRIBUTION Ophthalmic medications can be usedNOT to FOR SALE OR DISTRIBUTION treat ear conditions, but otic medications cannot be used in the eye. Medications can also be administered via the nasal route by instilling one or more drops of medication or one or more sprays into the nasal passages. Most nasal sprays are© Jonesused to treat& Bartlett symptoms Learning, of colds and LLC allergies. © Jones & Bartlett Learning, LLC NOTMedications FOR SALE administered OR DISTRIBUTION by the rectal route, through theNOT anus FOR and intoSALE the OR DISTRIBUTION rectum, are commonly in the form of a suppository or an enema. They can be used if a person is vomiting and cannot take the medication orally or if the person is unconscious and needs medication. Rectal administration is preferred for drugs that are destroyed by stomach contents or that are metabolized too quickly by the liver. © Jones & BartlettOintments Learning, and creams LLC are available for use rectally© Jones to treat &inflammation. Bartlett Learning, Drugs ad- LLC NOT FOR SALEministered OR DISTRIBUTION by this route may provide a local or NOTsystemic FOR effect. SALE The ORdisadvantage DISTRIBUTION of this route is that most people don’t feel comfortable using this route of administration. The amount of drug absorbed rectally is also unpredictable and varies from one person to another depending on the retention time of the suppository. Medications ©administered Jones & Bartlettby the vaginal Learning, or urethral LLC route come in suppositories,© Jones & Bartlett Learning, LLC creams, ointments,NOT foams, FOR gels, SALE and rings OR, DISTRIBUTIONwhich are vaginal dosage forms used toNOT ad- FOR SALE OR DISTRIBUTION minister hormones for birth control or hormone-replacement therapy. An etonogestrel/ ethinyl estradiol vaginal ring (Nuvaring) is considered birth control, while the estradiol acetate vaginal ring (Femring) is considered hormone-replacement therapy. Drugs must be inserted into the vagina or urethra to exert either a local or systemic effect. When used© Jones for a local & Bartlett effect, the Learning, drug provides LLC a higher concentration ©of Jonesmedication & Bartlett at the Learning, LLC siteNOT and FOR minimizes SALE side OR effects DISTRIBUTION seen when the drug is absorbed systemically.NOT FOR They SALE can OR DISTRIBUTION be used to treat infection, to treat inflammation, or for local or systemic birth control. These medications are sometimes difficult to use and can be uncomfortable. Proper application or use of topical medications can ensure that the desired thera- © Jones & Bartlettpeutic effect Learning, is achieved. LLC Improper technique or ©use Jones can increase & Bartlett the risk Learning, of systemic LLC NOT FOR SALEabsorption OR DISTRIBUTION and side effects. NOT FOR SALE OR DISTRIBUTION Ointments, Creams, Lotions, Gels Some topical preparations have special instructions for use. In order to use them safely, patients should receive proper instructions on how to use them. For example, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC capsaicin cream, available over the counter, should be applied with gloves because the active ingredientNOT can FOR cause SALE burning OR and DISTRIBUTION irritation if accidentally rubbed nearNOT the FOR SALE OR DISTRIBUTION eyes. Some drugs such as topical corticosteroids should be applied sparingly because using a thick layer can increase systemic absorption and increase the incidence of adverse effects. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC TransdermalNOT FOR SALE Patches OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Patches can be applied to the arm, chest, back and behind the ear, usually in a hair- free area. The site of application should be rotated to minimize skin reactions. The duration of action for each transdermal formulation varies from one drug to another. © Jones & BartlettSome patches Learning, should LLCbe changed daily, while others© Jones are changed & Bartlett every three Learning, to seven LLC NOT FOR SALEdays. OR Some DISTRIBUTION patches, such as nitroglycerin patches,NOT exert FOR their SALE effect OR for DISTRIBUTION 24 hours when worn for only 12 hours. Doctors recommend removing the patch at bedtime to

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONminimize the development ofNOT tolerance. FOR Localized SALE OR heat DISTRIBUTION from sun exposure, heating pads, electric blankets, hot tubs, and hot lamps should be avoided when using some transdermal formulations because it can increase absorption of the active drug into the bloodstream, resulting in an increase in adverse effects or toxicity. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The duration of therapeutic effect of a transdermal formulation varies from one drug to NOTanother. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Ophthalmic Medications Author ISBN # Author's review Shah 5954 (if needed) © Jones & BartlettProper Learning, instillation ofLLC an ophthalmicAuthor preparation© is Jones necessaryISBN #& Bartlettto avoid contamination Learning,Author's LLC reviewof Fig. # Document name OK Correx NOT FOR SALEthe OR eye. DISTRIBUTION Ophthalmic medications must be at roomNOT or FORbody temperatureSALE OR beforeDISTRIBUTION (ifinstilla needed)- Shah 5954 5954.04.05b 5954_F04.05b.eps tion into the eye. Follow the manufacturer’s recommendations for storage of ophthalmic OK Fig. # Document name Correx Date preparations to ensure drug stability and minimize bacterial overgrowth. Artist Date Initials 5954.05.05a 5954_F05.05a.eps 07/12/2011 Proper hand-washing techniques should be followed to prevent contamination ofPD & PS Artist Date Initials Date Check if revision CE's review the application site or the medication container. The tip of07/12/2011 the medication container © Jones & Bartlett Learning, LLC PD© & Jones PS & Bartlett Learning, LLC B x W 2/C 4/C OK Correx should not touch the eye; this will help minimize Checkcontamination if revision of the medication.CE's review NOT FOR SALE OR DISTRIBUTIONTo instill a drop into the eye,NOT the FOR patient’s SALE head OR should DISTRIBUTION be tilted back Figure 4.5A . B x W 2/C 4/C Final SizeOK (WidthCorrex x Depth in Picas) A finger should be placed in the corner of the eye to prevent loss of the medication11w x 15d Initials Date through the tear duct. OnlyFinal one Size drop (Width of medication x Depth in Picas) should be administered at a time, and the eye should be kept closed11w x for 14d one to two minutes after application. If instillingInitials Date ©more Jones than & oneBartlett medication, Learning, wait at LLC least five to 10 minutes between© Jones administrations & Bartlett Learning, LLC NOTof different FOR SALE drugs. ORIf a DISTRIBUTIONsolution or suspension and ointment NOTare to FORbe administered SALE OR DISTRIBUTION at the same time, administer the solution or suspension first and then wait five to 10 minutes before applying the ointment. To apply an ointment into the eye, the lower eyelid should be pulled down with one or two fingers to create a pouch Figure 4.5B . Only one thin layer of medication should be applied in the pouch at a time, and the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning,A. LLC © Jones & BartlettB. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Figure 4.5 The correct way to administer an ophthalmic medication. A. Drops. B. Ointment.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEeye should OR DISTRIBUTION be kept closed for 30 seconds after NOTAn otic FOR preparation SALE should OR neverDISTRIBUTION be used in the application to let the ointment absorb. eye, but an ophthalmic preparation can be used in the ear. Otic Medications Otic preparations© must Jones be at& roomBartlett or body Learning, LLC © Jones & Bartlett Learning, LLC temperature beforeNOT instillation FOR SALE into theOR ear. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Otics that are too hot could rupture the eardrum; those that are too cold can cause discomfort or pain. To instill a drop into the ear, the patient’s head should be tilted to the side so that the ear faces up. Patients who are under three years old should have their earlobes pulled© Jones back &and Bartlett down and Learning, those older LLC than three should have their© Jones earlobes & Bartlettpulled Learning, LLC backNOT and FOR up. SALE After instillation,OR DISTRIBUTION the patient should remain in thisNOT position FOR SALEfor five OR DISTRIBUTION minutes.

Inhaled Medications © Jones & BartlettMedications Learning, can also LLC be administered via inhalation.© Jones This & Bartlettroute Learning, LLC NOT FOR SALEdelivers OR the DISTRIBUTION medication from the mouth to the NOTrespiratory FOR system. SALE OR DISTRIBUTION There are two types of inhalers: those that use a propellant to push the drug into the lungs (metered-dose inhaler) and those that use a dry powder to release the medication as the patient takes a deep, quick breath. The© typeJones of inhaler& Bartlett needed Learning, depends on LLC the medica- © Jones & Bartlett Learning, LLC tion and the level of convenience required. Advantages of inhalants include convenienceNOT and FOR portability. SALE ORThe DISTRIBUTIONonset of action is usually NOT FOR SALE OR DISTRIBUTION quick, but when used incorrectly, the medication will not be able to reach the lungs. Proper administration of inhaled medications is necessary to ensure© Jones that &the Bartlett medication Learning, reaches LLCthe lungs. Some medications© Jones & Bartlett Learning, LLC requireNOT FOR that patients SALE rinseOR DISTRIBUTION their mouths thoroughly after each dose,NOT FOR SALE OR DISTRIBUTION not only to remove the aftertaste, but more importantly, to avoid developing an oral fungal infection. Spacer devices can ensure that A metered-dose inhaler delivers a specific a higher concentration of medication is inhaled and help improve amount of medicine in aerosol form. drug delivery to the lungs. © Jones & BartlettHere Learning, is the proper LLC technique for using a metered-dose© Jones inhaler:& Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. Take off the cap and shake the container. 2. Breathe out all the way. 3. Hold the inhaler 1 to 2 inches in front of mouth. 4. Breathe in slowly© Jones through & Bartlettyour mouth Learning, and press LLCdown on the inhaler. Breathe© Jones & Bartlett Learning, LLC in as deeply asNOT you FORcan. SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 5. Hold your breath and count to 10. 6. Repeat if more than one puff is required.

Vaginal© Jones Medications & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC TheNOT vaginal FOR route SALE is used OR toDISTRIBUTION treat bacterial or fungal infections or NOTto provide FOR hormone- SALE OR DISTRIBUTION replacement therapy. Some vaginal creams or ointments require the use of an applicator tube. This route is also used for some forms of contraception. Here is the proper technique for the administration of vaginal medications: © Jones & Bartlett1. Empty Learning, the bladder. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE2. Wash OR DISTRIBUTIONthe vaginal area and dry thoroughly. NOT FOR SALE OR DISTRIBUTION 3. Wash hands thoroughly.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION4. Attach the applicator to theNOT opening FOR of SALE the tube OR and DISTRIBUTION squeeze the medication into the applicator until it reaches the recommended dose. 5. Lie down, spread your legs, and open the labia with your free hand. (You can also stand with your feet apart and knees bent.) © Jones6. Gently & insertBartlett the applicatorLearning, about LLC 2 inches into the vagina© andJones release & Bartlettthe labia. Learning, LLC NOT7. PushFOR the SALE plunger OR of DISTRIBUTION the applicator until it stops. NOT FOR SALE OR DISTRIBUTION 8. Remove the applicator from the vagina and wash hands. 9. If the applicator is reusable, wash and dry the applicator.

© Jones & BartlettRectal Learning, Medications LLC © Jones & Bartlett Learning, LLC NOT FOR SALERectal OR medicationsDISTRIBUTION are administered for a localizedNOT effectFOR onSALE the rectum OR DISTRIBUTION or for a systemic effect when a patient is vomiting, unable to swallow, or unconscious. Rectal medicine is most commonly used as a localized treatment for constipation or as a topical treatment for rectal inflammation or infection. © Jones & Bartlett Learning, LLCHere is the proper technique© Jones for the &administration Bartlett Learning, of rectal suppositories: LLC NOT FOR SALE OR DISTRIBUTION 1. Wash hands thoroughly. NOT FOR SALE OR DISTRIBUTION 2. If the suppository is soft, place in cold water to harden it before removing it from the wrapper. 3. Remove the suppository from the foil wrapper. © Jones4. Lubricate & Bartlett the suppository Learning, with LLC Vaseline or K-Y Jelly. © Jones & Bartlett Learning, LLC NOT 5. LieFOR on SALEyour side OR with DISTRIBUTION the lower leg straightened out and theNOT upper FOR leg SALE bent in OR DISTRIBUTION toward the stomach. 6. Lift the upper buttock to expose the rectum. 7. Insert the pointed end of the suppository into the rectum. © Jones & Bartlett 8. Hold Learning, the buttocks LLC together for a few seconds.© Jones & Bartlett Learning, LLC NOT FOR SALE 9. OR Remain DISTRIBUTION lying down for 15 minutes. NOT FOR SALE OR DISTRIBUTION 10. Wash hands thoroughly.

© Jones & Bartlett Learning, LLCFactors That Influence© Jones Drug & A Bartlettction Learning, LLC NOT FOR SALE OR DISTRIBUTION77 NOT FOR SALE OR DISTRIBUTION Many factors can influence the effect that a drug has on the body. For example, age, gender, and the presence of disease can affect the metabolism and elimination of a drug in the body. Children and the elderly often require a reduced dose because of their reduced weight or because of the inability of the liver to metabolize the medica- ©tion Jones adequately. & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT PatientsFOR SALE with concomitantOR DISTRIBUTION diseases are often unable to NOT absorb, FOR metabolize, SALE OR or DISTRIBUTION eliminate certain medications. Diseases that alter the normal gastrointestinal flora or change the environment of the stomach may also adversely affect the metabolism of drugs. In addition, impaired liver or kidney function may affect the metabolism and © Jones & Bartlettelimination Learning, of some LLC drugs. Finally, nutritional© Jonesstatus can & Bartlettaffect the Learning, metabolism LLC of NOT FOR SALEsome OR drugs. DISTRIBUTION Before a medication is prescribed,NOT the FOR patient SALE should OR have DISTRIBUTION a medical evaluation. Psychological and genetic factors can also influence the way a drug is metabolized in the body or eliminated from the body. Genes can control the release of chemicals and enhance or decrease the metabolism of certain drugs. Psychological factors can © Jones & Bartlett Learning,influence LLC the body’s ability to ©release Jones certain & Bartlett chemicals Learning, necessary forLLC the metabolism NOT FOR SALE OR DISTRIBUTIONof certain drugs, or may interfereNOT with FOR the SALEbody’s abilityOR DISTRIBUTION to absorb a drug.

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEElderly OR Patients DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Aging affects both the physiological processes in the body as well as the pharmacoki- netic and pharmacodynamic processes that drugs undergo in the body. Elderly patients also tend to take more medications because they tend to have multiple chronic diseases. This can also increase© Jones the risk & Bartlett of drug-drug Learning, interactions LLC and adverse side effects.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Changes in Physiology Physiological changes that occur in the body do not occur at the same rate for each individual. The normal changes that occur in physiologic function with age are not related© Jones to disease. & Bartlett It is often Learning, difficult to LLC predict when these changes© will Jones occur. & Changes Bartlett Learning, LLC that occur as a result of aging can affect the metabolism and elimination of some drugs. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Following is a list of some of the changes that can occur with age: 77 Optic changes—Visual changes can occur and acuity can be compromised as the lenses of the eye become less elastic and more dense. Macular degeneration and cataracts can also occur in the elderly. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 7 NOT FOR SALE7 Auditory OR DISTRIBUTION changes—Hearing loss, especially inNOT higher FOR frequencies, SALE OR can DISTRIBUTION occur. Impairment of perception is common, which also results in a delay in the pro- cessing of auditory stimulation. 77 Gastrointestinal changes—Decreases in esophageal motility, rate of gastric emptying, and saliva production are common complaints in the elderly. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 77 Pulmonary changes—Reduced oxygen in the blood, increased carbon dioxide in the blood,NOT and a FOR decrease SALE in maximum OR DISTRIBUTION intake and exhalation can occur asNOT FOR SALE OR DISTRIBUTION a result of increased rigidity of the chest wall. Complicating matters is the fact that many elderly patients have diseases such as chronic obstructive pulmonary disease (COPD) and cardiac disease. ©77 JonesCardiovascular & Bartlett changes—Elderly Learning, LLC patients with cardiovascular© Jonesdisease have& Bartlett Learning, LLC NOTlimited FOR ability SALE to ORmeet DISTRIBUTION the demand for increased oxygen to maintainNOT FOR cardiac SALE OR DISTRIBUTION output. 77 Urinary changes—Instability of the bladder muscle, overflow, and sphincter weakness can result in incontinence (inability to hold urine in the bladder) or © Jones & Bartlettleakage. Learning, Elderly patientsLLC also have a higher incidence© Jones of & renal Bartlett insufficiency. Learning, LLC NOT FOR SALE77 Hormonal OR DISTRIBUTION changes—Changes in hormone levelsNOT are FOR a normal SALE part OR of DISTRIBUTIONthe aging process. 77 Body changes—The amount of lean body mass and total body mass decreases with age, while the proportion of fat increases. The production of albumin, a blood plasma protein, also decreases with age. This can affect the amount of drug that is bound© Jones to plasma & Bartlett protein Learning, and the amount LLC of free drug available ©to Jones & Bartlett Learning, LLC exert a therapeuticNOT FOReffect. SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Response to Medication Changes in the body can alter the response to medication. These physiological changes that© Jones occur as & a Bartlett result of agingLearning, can also LLC affect the absorption, distribution,© Jones metabolism & Bartlett Learning, LLC andNOT elimination FOR SALE of some OR drugs.DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 77 Absorption—Decreases in GI fluid secretion and motility can delay the absorption of some drugs. Absorption of some drugs can also be delayed by a reduction in the rate of gastric emptying. Changes in the gastrointestinal flora and © Jones & Bartlettenvironment Learning, of the LLC stomach can also affect the© Jones dissolution & Bartlett and degradation Learning, of LLC NOT FOR SALEcertain OR DISTRIBUTION drugs. NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION77 Distribution—The amountNOT of free FOR drug SALE that is OR available DISTRIBUTION can be altered by changes in body composition. In the elderly, a drug that is highly protein- bound can be toxic even when administered at normal doses because the amount of albumin decreases with age. © Jones77 Metabolism—Blood & Bartlett Learning, flow decreases LLC by about 1% a year, beginning© Jones at & age Bartlett 35. Learning, LLC NOT ThisFOR decline SALE results OR DISTRIBUTION in a decrease in clearance of the drug,NOT allowing FOR the SALE drugs ORto DISTRIBUTION accumulate to potentially toxic levels. 77 Elimination—Most elderly patients have some degree of renal or hepatic dys- function. The reduced filtration rate and reduction in blood flow and tubular secretions that result with aging can also affect the amount of drug that can be © Jones & Bartletteliminated Learning, by theLLC kidney. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Elderly patients tend to have multiple, chronic diseases that require long-term treatment with multiple medications. As a result, they are more likely to experience multiple ad- © Jones & Bartlett Learning, LLC © Jonesverse & Bartlett drug reactions. Learning, The term LLC used to describe NOT FOR SALE OR DISTRIBUTION NOT FORconcurrent SALE useOR of DISTRIBUTION multiple medications is poly pharmacy. When many drugs are prescribed for a patient, the potential for drug interactions is also high. The majority of adverse drug reac- © Jones & Bartlett Learning, LLCtions in the elderly are the© Jonesresult of &three Bartlett drugs: Learning, LLC NOT FOR SALE OR DISTRIBUTIONwarfarin, insulin, and digoxin.NOT FOR SALE OR DISTRIBUTION The Beers list was initially created to help clinicians determine which medications should be avoided in nursing-home patients because Tools such as a pillbox can help patients who take multiple medications seniors in nursing homes are particularly at remember when to take them. © Jones & Bartlett Learning, LLC risk for© suffering Jones medication-related & Bartlett Learning, problems. LLC NOT FOR SALE OR DISTRIBUTION It was writtenNOT FOR by Dr. SALE Mark ORBeers, DISTRIBUTION a physician specializing in medical issues pertaining to the elderly. It is now useful for elderly patients in other settings. This list is periodically updated. Aging can also affect the memory. The inability to adequately understand or remember © Jones & Bartlett TheLearning, Beers list isLLC a list of medications that should© Jones & Bartlett Learning, LLC be avoided or used cautiously in the elderly. directions for medication administration can NOT FOR SALE OR DISTRIBUTION NOT FORlead SALE to unintentional OR DISTRIBUTION underdosing or overdosing, failure to take the drug, or taking a drug prescribed for another person. Noncom- pliance or failure to adhere to the prescribed ©drug Jones regimen & Bartlett is especially Learning, common LLC in the elderly. The pharmacy© Jones technician & Bartlett can play Learning, LLC NOTan important FOR SALE role in OR ensuring DISTRIBUTION that elderly patients get written informationNOT FOR andSALE dosing OR DISTRIBUTION aids that can help them remember to take their medication.

Noncompliance is the failure to adhere to the prescribed drug regimen. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEChildren OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION As children grow, their bodies undergo physiologic changes that can affect the absorption, distribution, metabolism, and elimination of a drug. Understanding these changes can help eliminate underdosing or overdosing that can occur in this patient © Jones & Bartlett Learning,population. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONBody-surface area is the bestNOT measure FOR to SALE use to ORdetermine DISTRIBUTION a dose because it corre- lates with all body parameters. Age is often used to determine the dose of a medication,

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEbut it ORdoes DISTRIBUTION not take into account the weight NOTAlways FOR double-check SALE allOR calculations, DISTRIBUTION make sure of a child or the variation in the relationship the dose is appropriate for the child’s age, and between age and the degree of physiologic reevaluate all dosages. development. Body weight is most often used because it is easy to obtain. Children who © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC are small for their age should receive doses at the lower end NOTof the FORrecommended SALE OR dosage DISTRIBUTION range, and those who are large for theirNOT FOR SALE OR DISTRIBUTION age should receive doses at the higher end of the recommended dosage range. Larger children may also need a dose that is recommended for the next-higher age bracket.

Question: Calculate the quantity to dispense for the following: sig: one tablet tid for 30 days. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Answer: The abbreviation tid means three times a day. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 3 tablets/day ¥ 30 days = 90 tablets.

Question: Calculate the quantity to dispense for the following: Dispense© Jones a 10-day & supply. Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Sig: 3 NOTcap bid. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Answer: The abbreviation bid means twice a day. 3 capsules/dose ¥ 2 doses/day = 6 capsules/day. 6 capsules/day ¥ 10 days = 60 capsules. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTQuestion: FOR Calculate SALE the OR quantity DISTRIBUTION to dispense for the following: NOT FOR SALE OR DISTRIBUTION Dispense a 30-day supply. 1 Sig: 1 /2 tab bid. Answer: The abbreviation bid means twice a day. 1 © Jones & Bartlett1 /2 tablets/dose Learning, ¥ 2 doses/dayLLC = 3 tablets/day. © Jones & Bartlett Learning, LLC NOT FOR SALE 3 tablets/day OR DISTRIBUTION ¥ 30 days = 90 tablets. NOT FOR SALE OR DISTRIBUTION

Question: Calculate the quantity to dispense for the following: Dispense a 15-day supply. 1 Sig: /2© tab Jones bid po. & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Answer: The abbreviationNOT FOR bid means SALE twice OR a day.DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1 /2 tab/dose ¥ 2 doses/day = 1 tab/day. 1 tab/day ¥ 15 days = 15 tablets.

©Question: Jones C&alculate Bartlett the quantityLearning, to dispense LLC for the following: © Jones & Bartlett Learning, LLC NOT FORDispense SALE aOR 30-day DISTRIBUTION supply. NOT FOR SALE OR DISTRIBUTION 1 Sig: 1 /2 tab qid po. Answer: The abbreviation qid means four times a day. 1 1 /2 tablets/dose ¥ 4 doses/day = 6 tablets/day. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 6 tablets/day ¥ 30 days = 180 tablets. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTIONQuestion: A prescription for an ophthalmic solution reads “Instill one drop in affected eye twice a day” and instructs the pharmacy to dispense a 10-day supply. The medication is available as 20gtts/mL in a 1mL and 5mL bottle. Which bottle size should be dispensed? © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Answer: 1 drop/dose 2 doses/day = 2 drops/day. NOT FOR SALE OR¥ DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2 drops/day ¥ 10 days = 20 drops. 20 drops ÷ 20gtts/mL = 1mL. The 1mL size bottle should be dispensed.

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Chapter Summary C. The patient cannot take medication by 77 mouth. 7 7 A prescription© isJones a written & Bartlett or verbal Learning,request for LLC D. All of the above. © Jones & Bartlett Learning, LLC a medication. NOT FOR SALE OR DISTRIBUTION 2. Administration of a medicationNOT FOR between SALE ORthe DISTRIBUTION 77 The “rights” for correct drug administration cheek and gum is called which of the follow- offer useful guidelines when filling prescrip- ing? tions. A. Buccal 77 Drugs can be administered in a variety of dos- © Jonesage forms. & BartlettThe choice Learning, of dosage formLLC will B. Sublingual© Jones & Bartlett Learning, LLC NOTdepend FOR on SALE the patient, OR DISTRIBUTION the desired effect, the C. TopicalNOT FOR SALE OR DISTRIBUTION dose required, the duration of desired effect, D. Intramuscular and the properties of the medication. 3. An ointment is an example of which of the fol- 77 Solid dosage forms include tablets, capsules, lowing? © Jones & Bartlettand caplets.Learning, They LLC can be coated to mask the© Jones & Bartlett Learning, LLC A. W/O emulsion NOT FOR SALEtaste, OR prolongDISTRIBUTION the duration of action, or to NOT FOR SALE OR DISTRIBUTION protect the medication from degradation in the B. O/W emulsion stomach. C. Dispersion 77 Liquid dosage forms include suspensions, D. Elixir solutions, and© emulsions.Jones & TheyBartlett have Learning, a faster LLC 4. Which of the following© Jones routes of& administraBartlett Learning,- LLC onset of actionNOT than FOR solid SALE dosage ORforms. DISTRIBUTIONtion has the fastest onsetNOT of FOR action? SALE OR DISTRIBUTION 7 7 Topical dosage forms include creams, gels, A. Oral ointments, and transdermal patches. B. Intravenous 77 Routes of administration include oral, topical and parenteral. The decision of which route C. Transdermal © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC to use will depend on the site, medication, de- D. Sublingual NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION sired effect, and duration of action. 5. To what does the abbreviation PO refer? 77 Topical administration includes the ophthal- A. By mouth or orally mic, inhalation, nasal, vaginal, urethral, and B. Rectally rectal routes of administration. C. Intradermally © Jones & Bartlett77 Parenteral Learning, administration LLC includes IV, IM, and© Jones & Bartlett Learning, LLC NOT FOR SALESC OR routes DISTRIBUTION of administration. NOT FORD. SALE Subcutaneously OR DISTRIBUTION 77 Elderly and pediatric patients have special 6. The parenteral route of administration by- needs that can affect the way their medication passes which of the following? should be administered and the way their bod- A. Veins ies react to drugs.© Jones & Bartlett Learning, LLC B. Gastrointestinal tract© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONC. Heart NOT FOR SALE OR DISTRIBUTION Learning Assessment Questions D. All of the above 77 7. Lozenges are also known as which of the fol- 1. Parenteral medications are often used for lowing? © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC which of the following reasons? A. Capsules NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A. They have a faster onset of action. B. Pastilles B. They bypass the acidic secretions of the C. Suppositories stomach. D. All of the above © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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8. Drugs administered into the eye are given by B. SC what route? C. IV A. Otic © Jones & Bartlett Learning, LLCD. ID © Jones & Bartlett Learning, LLC B. Rectal NOT FOR SALE OR DISTRIBUTION 15. A prescription label mustNOT have FOR which SALE of the OR DISTRIBUTION C. Ophthalmic following? D. Oral A. The patient’s name 9. Which of the following is not a solid dosage B. The name of the drug form?© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION C. The nameNOT and FOR address SALE of ORthe pharmacyDISTRIBUTION A. Emulsion D. All of the above B. Tablet 16. Which of the following drugs causes the most C. Capsule ADRs in the elderly? © Jones & BartlettD. Powder Learning, LLC © JonesA. Warfarin& Bartlett Learning, LLC NOT FOR 10. SALE Medication OR DISTRIBUTION dosage forms include which of the NOT FORB. Heparin SALE OR DISTRIBUTION following? C. Nitroglycerin A. Liquids D. Aspirin B. Solids 17. If the prescriber directs usage, a drug prepared C. Semisolids © Jones & Bartlett Learning, LLCfor the ophthalmic route© may Jones also be& usedBartlett Learning, LLC D. All of the aboveNOT FOR SALE OR DISTRIBUTIONwhere ? NOT FOR SALE OR DISTRIBUTION 11. The rectal route of administration is useful if A. In the ear the patient is which of the following? B. In the nose A. Unconscious C. In the rectum © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC B. Vomiting D. In the vagina NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION C. Nauseated 18. Drugs administered into the ear are given by D. All of the above what route? 12. Where are intramuscular injections given? A. Rectally © Jones & BartlettA. Under Learning, the skin LLC © JonesB. Ophthalmic& Bartlett Learning, LLC NOT FOR SALEB. In OR the muscleDISTRIBUTION NOT FORC. Otic SALE OR DISTRIBUTION C. In the vein D. Buccal D. In the artery 19. Advantages of transdermal patches include which of the following? 13. Extended-release tablets should not be which of the following?© Jones & Bartlett Learning, LLCA. Convenience © Jones & Bartlett Learning, LLC A. Crushed NOT FOR SALE OR DISTRIBUTIONB. Improved patient complianceNOT FOR SALE OR DISTRIBUTION B. Cut without specific directions from the C. Ease of administration manufacturer for cutting along a scored D. All of the above tablet 20. The abbreviation TID means which of the fol- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC C. Chewed lowing? NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION D. All of the above A. Three times daily 14. Injection of a drug into the subcutaneous layer B. Twice a day of fat is known as what route of administra- C. Four times a day tion? © Jones & Bartlett Learning, LLC © JonesD. Immediately& Bartlett Learning, LLC A. IM NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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