Medical Assistant Exam: Clinical Procedures - Preparing and Administering Medications

Medical assistants are expected to have a basic knowledge of medications. This includes knowledge of prescription drugs and over-the-counter drugs. To understand the important functions of these drugs, the medical assistant must understand pharmacological principles, be able to translate prescriptions, and be prepared to answer basic patient questions.

Pharmacology
Pharmacology is the study of drugs, including their properties and effects on living organisms. Drugs—substances that can modify one or more functions of a living organism—are used to treat, prevent, diagnose, and cure disease.
A healthcare provider will prescribe, or indicate, a drug to be administered or given to a patient. The prescription indicates the drug’s dosage, and the number of times the drug should be taken (such as twice per day or once per week). The medical assistant is responsible for understanding the various drugs that can be prescribed as well as the drug dispensing laws in the state where he or she works. The medical assistant must also have the skills to prepare and administer medications to patients safely.
Qualified medical practitioners who prescribe, dispense, or administer drugs must comply with federal and state laws. The laws govern the manufacture, sale, possession, administration, dispensing, and prescribing of drugs. All drugs available for legal use are controlled by the Food and Drug Administration (FDA).
Drugs that have the potential for abuse or addiction are regulated by the Controlled Substance Act of 1970. This act controls the manufacture, importation, compounding, selling, dealing in, and giving away of drugs that have the potential for abuse. These drugs are known as controlled substances and include heroin and cocaine and their derivatives and narcotics, stimulants, and depressants. The Drug Enforcement Agency of the U.S. Justice Department monitors and enforces the act. Under federal law, physicians who prescribe, administer, or dispense controlled substances must register with the DEA and renew their registration as required by state law.

Classes of Drugs
Drugs can be classified in a number of ways:
- drugs used to treat or prevent disease (e.g., hormones or vaccines)
- drugs that have a principal action on the body (e.g., analgesics and anti-inflammatory drugs)
- drugs that act on specific body systems or organs (e.g., respiratory and cardiovascular)

Drug Forms
There are two basic forms of drugs: solids and liquids, categorized based on how easily the medication dissolves.
- Solids include tablets, capsules, sustained-release capsules, caplets, lozenges, creams, ointments, suppositories, and transdermal patches. Some forms are actually semisolid but are placed in the solids category.
- Liquids include elixirs, emulsions, liniments, lotions, solutions, spirits, sprays, suspensions, aerosol suspensions, syrups, and tinctures. Tinctures and elixirs are preparations that contain alcohol; individuals recovering from substance abuse should be cautioned that such preparations contain alcohol and that an alternate preparation may be needed.

Drug Actions
A drug’s action is the ability of the drug to act on body processes at the cellular level. Drugs can stimulate (speed up) or depress (slow down) cellular function. Some drugs can destroy cells or replace substance. However, drugs cannot make a cell function in a new or different way. It is important for medical assistants to understand the action of a drug from the time it enters the patient’s body until the time it is excreted. A drug’s action and use can be broken down into three main categories: pharmacokinetics, pharmacodynamics, and pharmacotherapeutics.

Pharmacokinetics
Pharmacokinetics is the study of the action of drugs as they move through the body. These actions include absorption, distribution, metabolism, and excretion.
Absorption is the passage of medication through some surface or opening of the body at the site of administration of the drug into the body’s bloodstream. Key factors that affect absorption include:
- Type of drug. For example, adequate absorption of the beta-blocker propranolol depends on normal blood circulation through the liver. Thus, absorption of propranolol in patients with liver disease will be decreased, while absorption of other drugs in such patients will not be impaired.
- Amount of drug. For example, a physician will commonly prescribe a 'loading' dose, or large initial dose, of penicillin for a patient with an infection in order to establish therapeutic penicillin levels more quickly in the bloodstream.
- Route of administration. For example, the body will absorb more slowly a medication given by mouth than one injected because a medication given by mouth must go through the digestive system before it is absorbed into the bloodstream.
- Bioavailability of the drug, or a percentage that expresses the amount of the drug that reaches the bloodstream and the length of time needed for it to do so. For example, fluoxetine hydrochloride (Prozac) has a high bioavailability of 72% with a peak concentration in the bloodstream within six to eight hours of administration.

Distribution: After absorption of the drug into the bloodstream, the circulatory system distributes it into the body fluids, tissues, and cells, carrying it to the intended site of action. Distribution of the drug may be slow or fast, depending on the patient’s size and the amount of the drug given. Circulation impairment can also affect the ability of the medication to be distributed to the intended site.
Metabolism: After the body uses the drug, it must inactivate it (or break it down chemically) in order to eliminate it. This process is called metabolism or biotransformation. Chemical reactions break down the drug into different substances that the body can easily use and excrete. If these substances are harmful to the body, the body must also detoxify the substances before elimination. The liver is the major organ involved in drug metabolism. Several factors can affect metabolism, including age, the presence of liver disease, and characteristics of the drug.
Excretion is how the body eliminates a drug. Similar to food, after the body has used the drug, it must be eliminated. Most drugs are excreted in urine; thus, the kidneys are the major organs involved in drug excretion. However, the body may also excrete drugs through feces, hair, lungs, breast milk, and skin.

Pharmacodynamics
Pharmacodynamics is the study of the body’s biochemical and physiological response to a drug. In other words, pharmacodynamics studies what the drug does to a person’s body and how that effect is achieved. Many factors affect pharmacodynamics, or the drug’s action in a person’s body, including the patient’s size, age, and genetic makeup.

Pharmacotherapeutics
Pharmacotherapeutics is the study of the use and effect of drugs in the treatment and prevention of disease. The medical reasons physicians and other health professionals prescribe drugs are:
- to cure disease
- to treat symptoms of a disease
- to diagnose disorders and diseases
- to replace a deficiency
- to prevent disease

DRUG CLASSIFICATIONS

Drug Classification - Common Use - Example
analgesic - relieves pain - ibuprofen; acetaminophen
anesthetic - decreases sensation - lidocaine (Xylocaine)
antacid - neutralizes acid - Tums; Mylanta
antibiotic - inhibits or eradicates the growth of microbes - penicillin; augmentin
anticoagulant - prevents clotting - heparin; coumadin
anticonvulsant - prevents seizures - Dilantin; Tegretol
antidepressant - decreases or inhibits depression - Prozac; Elavil
antidiarrheal - decreases or inhibits diarrhea - Lomotil; Kaopectate
antiemetic - decreases or inhibits nausea - Compazine; Dramamine
antihistamine - controls symptoms of allergies - Benadryl; Claritin
antihypertensive - controls high blood pressure - Lopressor; Aldomet
anti-inflammatory - controls inflammation - ibuprofen; Celebrex
antipyretic - decreases fever - acetaminophen; ibuprofen
antiarrhythemic - controls arrhythmia - Norpace; digoxin
cathartics - accelerates defecations - Castor oil; Epsom salts
diuretic - decreases body fluid by increasing urination - Lasix
fungicides - decreases fungal infections - nystatin

This list of drug classifications includes both common uses and examples of each drug type. Some drugs listed in the table are prescribed for off-label use—that is, purposes other than those approved by the FDA.

Drug Uses
A drug’s use is the therapeutic effect it has on a person’s body.
Drugs that cure: Some drugs can cure disease. For example, a bacterial throat infection known as strep throat can be cured by taking an antibiotic, such as penicillin. Also, the fungal infection ringworm can be cured after a full course of an antifungal drug.
Drugs for palliative care: Drugs used to treat a disease without curing it seek to relieve or alleviate symptoms of that disease. This type of treatment is sometimes called palliative care. For example, at present, there is no cure for arthritis. However, the physician may prescribe an anti-inflammatory drug to reduce the inflammation caused by arthritis, thereby decreasing pain. Although the patient’s pain decreases, she still has arthritis. Similarly, an antihistamine will not cure allergies but will reduce and relieve some symptoms associated with allergies.
Drugs for prevention: Drugs can help prevent conditions and diseases. Such drugs are commonly called prophylactic drugs. For example, oral contraceptives help prevent pregnancy and vaccinations prevent tetanus, diphtheria, measles, mumps, rubella, hepatitis B, and chicken pox.
Drugs as supplements: Drugs can replace a deficient substance in the body. For example, a diabetic patient, whose pancreas lacks the ability to produce adequate insulin, may take replacement insulin by injection. Calcium supplements help achieve adequate levels of calcium when the patient’s diet does not contain a sufficient amount. Patients with hypothyroidism (low thyroid hormone production) can take levothyroxine (Synthroid), a synthetic form of thyroid hormone.
Drugs for diagnostic purposes: Drugs can help diagnose a disease or disorder. For example, a radiopaque dye, also called a contrast medium, is injected into patients for certain tests. The dye aids visualization of glands and organs, helping the physician make a diagnosis.
Drugs used in an emergency: Emergency pharmaceutical supplies should include certain basic drugs. Details on these drugs are covered in this chapter in the section called 'Common Emergency and First-Aid Supplies and Equipment.'

Side Effects and Adverse Reactions
Unfortunately, even if a prescribed drug provides the desired therapeutic effect, it can also produce effects other than the therapeutic or desired effect.

An adverse reaction is an unexpected, usually dangerous, response to a drug. Adverse reactions can occur as a result of a patient’s health status, the number of drugs the patient is taking, or the length of time the patient has been taking the drugs. Such reactions can be classified as an allergic reaction, idiosyncratic effect, cumulative effect, toxic effect, or tolerance.
- Allergic reaction. An allergic reaction is an immune response to a drug that results in inflammation and organ dysfunction. Reactions can occur immediately or even days after drug use. Reactions range from itching, sneezing, or a mild rash to life-threatening symptoms.
- Idiosyncratic effect. An idiosyncratic effect is an abnormal drug response in a patient with a peculiar defect in his body chemistry. Because of the defect, administration of the drug causes effects that are totally unrelated to the drug’s normal pharmacological action.
- Toxic effect. Sometimes the body cannot metabolize and properly excrete a drug, causing a cumulative drug action. The drug stays in the body and when the patient takes subsequent doses, the drug level in the blood rises, becoming unsafe for the patient and causing symptoms of overdose. This can cause a toxic effect that is harmful to the patient. Some drugs are inherently toxic, such as chemotherapeutic drugs, which cause the death of healthy tissue and may cause heart attack and brain inflammation.
- Tolerance. When a patient has taken a drug for an extended period of time, the desired effect may lessen or will not occur at all. This effect is called tolerance. Because the body of a patient who has developed a tolerance is accustomed to the drug, the physician may have to increase the dose to achieve the desired effect or change the drug completely.

Drug Interactions
A drug interaction happens when the combination of a drug with food or other drugs creates an effect in the body. When patients take more than one drug, the combination of drugs can affect the actions of the drugs in harmful or beneficial ways. The combination of two or more drugs can cause three difference effects: synergism, antagonism, and potentation.
- Synergism, or a synergistic drug effect, occurs when two drugs have a greater therapeutic effect together than the expected effects of each drug alone.
- Antagonism, or an antagonistic drug effect, happens when drugs work in opposition to one another. For example, antibiotics negate the effects of most oral contraceptives. When the physician prescribes antibiotics to a patient taking oral contraceptives, the patient should be advised to use an alternative form of birth control during the course of antibiotic therapy.
- Potentiation is an interaction between two drugs that enhances the effect of either drug, producing a heightened response similar to an overdose. Unlike synergism, in potentiation, the two drugs are taken for different conditions. For example, a patient taking the anticoagulant warfarin (Coumadin) may wish to take aspirin for a headache. However, the asprin will heighten the patient’s response to the anticoagulant and this may be harmful to the patient.

Substance Abuse
Drug abuse, also called substance abuse, is the misuse of alcohol and other drugs. Abuse of drugs may involve legal or illegal medications and can occur suddenly or develop over time. Psychological dependence (when a person merely thinks he or she needs the drug) can turn into physical dependence (when a person’s body needs the drug to prevent adverse effects, including death). Commonly abused drugs include:
- alcohol
- marijuana
- nicotine
- central nervous system stimulants (such as methylphenidate)
- central nervous system depressants (such as opiates)
The medical assistant can direct a patient who abuses drugs to a treatment facility or a support group, such as Alcoholics Anonymous or Narcotics Anonymous.

Prescriptions
A prescription is a physician’s order authorizing the dispensing of a drug by a pharmacist. Prescriptions can be authorized in different forms, including handwritten, computer-generated, and telephoned or faxed to a pharmacy.
A prescription is written on a specially designed form, supplies for which must be kept in a safe place, that includes directions to the pharmacist for filling the prescription and instructions to the patient for taking the medication. The specific information must include:

- Date. A pharmacist cannot fill a prescription unless the date the prescription was issued is indicated on the form. The reason for this is that a prescription expires after a certain length of time. In most states, a prescription for a drug (except controlled drugs) expires one year from the date of issue.
- Physician’s name, address, telephone number, and fax number. This information is preprinted on the prescription form. It identifies the physician issuing the prescription and provides the necessary information should the pharmacist have a question and need to contact the medical office.
- Patient’s name and address. This information is important for insurance billing and for properly dispensing the medication.
- Patient’s age. The patient’s age is important to the pharmacists when they are double checking the physician’s order to ensure the proper dosage is being dispensed.
- Superscription. The superscription consists of the abbreviation Rx, which comes from the Latin word recipe and means 'take.'
- Inscription. The inscription states the name of the drug and the dose.
- Subscription. The subscription gives directions to the pharmacist. This generally is used to designate the number of doses to be dispensed. It is recommended that numbers and letters be used to indicate the quantity to be dispensed.
- Signatura. The signatura (abbreviated Sig.) is a Latin term that means 'write' or 'label' and indicates the information to be included on the medication label. It consists of directions to the patient for taking the medication. The name of the medication is also included on the label.
- Refill. This part of the prescription indicates the number of times the prescription may be refilled.
- Physician’s signature. A prescription cannot be filled unless it is signed by the physician.
- DEA number. The number assigned to the physician by the DEA must appear on the prescription for a controlled drug.

Common prescription abbreviations include:
- q: every
- bid: twice a day
- tid: three times per day
- qid: four times per day
- qh: every hour
- po: by mouth

Preparing and Administering Medications
Before a medical assistant can administer a drug, he or she may need to calculate the dose prescribed by the physician. To do so, the medical assistant must understand various systems of measurement and ways to convert from one system to another.

Calculation of Dosage
When a physician orders dosages, the medical assistant must administer the correct amount of medication. Because the dosage ordered will not always match the available doses, the medical assistant must calculate the proper dosage for the patient.

Systems of Measurement
In order to accurately calculate dosages, the medical assistant must have an understanding of the metric, household, and apothecary systems of measurement. No matter what system is used, medications dispensed to patients are measured in quantities of liquid (volume) or solid (weight).
Metric system: The metric system is a system of weights and measures based on the units of ten. For instance, the basic unit of length—the meter—can be divided into 10 or 1,000 units, to arrive at smaller units called decimeters or millimeters; or can be multiplied by 10 or 1,000, to arrive at larger units called decameters or kilometers.

The metric system is the most commonly used system for drug dosages, using the basic unit of mass, or weight—the gram—and the basic unit of volume—the liter.
- solid medication: measured by mass, or weight; common unit is milligram (mg)
- liquid medication: measured by volume; common unit is the milliliter (mL), sometimes called the cubic centimeter (cc)

Apothecary and household systems: Although the metric units of milligrams and milliliters are most common in medication dosages, the apothecary and household systems are sometimes used.
- The apothecary system. The units of weight in this system include grain and ounce. Volume measures in the apothecary system include minim, fluidram, pint, and quart.
- The household system. The measures for liquids are drop, teaspoon, tablespoon, fluid ounce, pint, cup, and quart. Household measures for weight are ounce and pound.

CHART OF COMMON CONVERSIONS
Metric Measure - Apothecary or Household Measure
1 gram (g, gm) - 15 grains (gr) or 1,000 milligrams (mg)
60 milligrams (mg) - 1 grain (gr)
1 kilogram (kg) - 2.2 pounds (lb)or 1,000 grams (g, gm)
1 milliliter (mL, ml) - 15 drops (gtt)
5 milliliters (mL) - 1 teaspoon (tsp) or 60 drops (gtt)

Some of the units of measure for apothecary and household units are the same, which can cause confusion. In addition, teaspoon and tablespoon containers are commonly poorly calibrated; thus, the patient may get too much or too little of the medication. These units of measure also are used to measure both liquid and dry ingredients, adding more confusion. In addition, household measures do not provide precise measurement of smaller quantities of prescribed drugs. For example, 60 mg of a drug would equal less than one-fourth of a teaspoon, the smallest unit in the household system. For these reasons, medications are most commonly ordered in metric doses and should be calculated in metric doses.

Calculation Methods
To administer the correct amount of medication to the patient, the medical assistant must calculate the correct dose. There are several methods for calculating the dose.
- dose on hand method
- ratio and proportion method
- fractional equation method
To understand these three methods, the following example will be applied.

Example
The physician orders medication to be given in the office, before the patient leaves, as follows:
Phenytoin 50 mg PO t.i.d.
The office only stocks the drug in the following dose and form:
Phenytoin 125 mg/5 mL (125 mg in every 5 mL unit).

For each method, the medical assistant must remember a formula containing these elements:
- D = dose ordered or desired dose
- H = dose on container label or dose on hand
- Q = amount, or quantity, in which the drug is available
- A = amount to give

Dose on hand method: To calculate the dose using the dose on hand method, the medical assistant must remember this formula:
D × Q/H = A
50 mg × 5 mL/25 mg = A
250 mL/125 mg = 2 mL

Ratio and proportion method: To calculate the dose using the ratio and proportion method, the medical assistant must remember this formula:
HA = DQ
125 mg × A = 50 mg × 5 mL
125 mg × A = 250 mg/mL
A = 250 mg/mL/125 mg
A = 2 mL

Fractional equation method: To calculate the dose using the fractional method, the medical assistant must remember this formula:
H/Q = D/A
125 mg/5 mL = 50 mg/A
125 mg × A = 50 mg × 5 mL
A = 50 mg × 4 mL/125 mg
A = 2 mL

Using Conversions
If the dose on hand and the dose ordered are measured with different systems, the medical assistant must perform some conversions before he or she can calculate the correct dose. Virtually all medical offices have conversion tables readily available.

Example: If the order contains the dosage nitroglycerin gr 1/400 prn for angina pain and the dose on hand is nitroglycerin 0.3 mg tablets, the medical assistant must first convert grains to milligrams. Using conversion tables, the medical assistant will know that 1 grain equals 60 mg. Using this conversion, the medical assistant can calculate the dose using the dose on hand method:
1 grain = 60 mg
gr 1/400 = 60 mg/400 = 3 mg/20 = 0.15 mg

0.15 mg/0.3 mg = 0.5 tablet
Also, some doses are measured with the same system but with different units within the system. The medical assistant must also perform conversions in this case.

Example: If the order says 0.5 g amoxicillin and the dose on hand is 250 mg tablets, the medical assistant must first convert grams to milligrams. Using conversion tables, the medical assistant will know that 0.5 g equals 500 mg. Using this conversion, the medical assistant can calculate the dose:
500 mg/250 mg = 2 tablets

Calculating Infant and Child Dosages
The medical assistant must calculate dosages for pediatric patients according to the pediatric patient’s body size. Administering an adult dose of a medication to an infant or child would increase the risk of overdose and would not be therapeutic. Two main methods of calculating pediatric dosages include the weight method and the body surface area method, although the weight method is the most common.

Weight Method
The medical assistant can calculate infant and child dosages according to the patient’s weight. Because most dosages are expressed using kilograms (kg), the medical assistant must also convert pounds to kilograms in order to calculate correctly.
Example: The medical assistant is calculating a dosage for a 6-year-old patient who weighs 55 lb. The physician’s order reads lidocaine 1 mg/kg. In order to provide the accurate dose, the medical assistant must convert 55 lb. into equivalent kilograms. Using the conversion table, she or he will know that 1 kg equals 2.2 lb. Using this conversion, the medical assistant can calculate the dose:
55 ÷ 2.2 kg = 25 kg
25 × 1 mg = 25 mg

Routes of Administration
Drugs may be administered for either local or systemic effects. Generally, drugs that have local effects are applied directly to the skin, tissues, or mucous membranes. Drugs that produce systemic effects are administered by routes that allow the drug to be absorbed and distributed in the bloodstream throughout the body.

Oral Route
The oral, or enteral, route is defined as ingestion through the mouth and into the GI tract; it is the most common route of medication administration. It is safe and convenient and most patients are able to take medications in this manner. In addition, it requires no special equipment. However, a patient with dysphagia (difficulty swallowing) should not take oral medications because of the risk of aspirating an oral medication into the respiratory tract.

Oral drug forms include:
- Tablets—compressed, disk-like masses of medication manufactured from a powder form that require the patient to drink enough liquid so that the tablet does not stick in his or her throat.
- Capsules—medication surrounded by a gelatin container that will not dissolve until it reaches the acidic environment of the stomach, thus preventing the patient from tasting the medication.
- Syrups—concentrated solutions of sugar, water, and the medication that make it easier for the patient to tolerate swallowing drugs with a bitter flavor.
- Suspensions—solid particles mixed in a liquid but not dissolved that require shaking before use so that the medication will be equally dispersed in the liquid.

Physicians commonly prescribe syrups and suspensions to young children because young children may not be able to swallow tablets or capsules. When a liquid medication is poured into a container, the surface of the liquid, called the meniscus, will curve slightly due to surface tension with the sides of the container. When measuring a liquid dose, the medical assistant must be at eye level with the meniscus to ensure accurate dosing.
The stomach or small intestine digests and absorbs an oral drug. The rate of absorption for oral drugs is fairly slow (approximately 20 minutes). Other factors may cause acceleration or delay of oral drug action, including food in the stomach, the patient’s emotions, or physical activity.
The medical assistant must pay careful attention to recommendations regarding food with oral medications. Some oral drugs can be irritating to the stomach, causing nausea or heartburn. Enteric-coated capsules or tablets are coated with a compound that does not dissolve until exposed to the fluids of the small intestine. The medication passes through the stomach into the intestines without causing irritation to the upper GI tract. The medical assistant must never cut an enteric-coated tablet or capsule or the medication could produce irritation and change the intended site for absorption.

Parenteral Routes
Any route other than oral is considered a parenteral route. Parenteral routes of administration include:
- sublingual
- buccal
- inhalation
- injection
- topical
- vaginal
- rectal

Sublingual (under the tongue) and buccal (between the cheek and gum): This type of administration of drugs involves placing the medication in the patient’s mouth without the patient swallowing it. Unlike oral drugs, sublingual and buccal medications do not travel to the GI tract for absorption. Instead, the mucous membranes in the interior of the mouth absorb the drug and deliver it to the bloodstream. Thus, absorption through these routes is more immediate.
Examples: Nitroglycerin, a strong vasodilator, is commonly administered sublingually for patients experiencing acute angina pectoris. Opiate analgesics are commonly administered buccally for severe breakthrough pain in cancer patients.

Inhalation: Patients can inhale medications (inhalants) for delivery to the respiratory tract using a nebulizer, a machine that mixes room air with a medication. The nebulizer uses an atomizer to mix the medication with water to create a vapor that the patient can inhale. The patient can sleep or sit quietly in the room with the nebulizer and breathe in the medication with the humidified air. Patients with asthma or emphysema can also use portable metered-dose inhalers (MDIs) for immediate relief of respiratory distress.
Examples: Nebulizers for asthma patients.

Injection: For a parenteral administration given by injection, the medical assistant must first measure the correct amount of the drug by drawing it into a syringe from a vial, a small bottle with a thin metal or rubber top, or an ampule, small all-glass container. The medical assistant must also have an understanding of, and develop skill with, the different methods of injection, of which there are four:
- subcutaneous
- intradermal
- intramuscular (IM)
- intravenous (IV)

Information on these types of injections are covered in the section immediately following this one.

Topical: Topical medication can be administered by placing the medication on top of the skin, enabling absorption into the bloodstream through the skin. Examples of topical medications include creams and ointments. Cleaning the skin with soap and water enhances absorption of topical creams and ointments. Another method of topical medication administration is the transdermal method, which involves placing a patch made of a semipermeable membrane that releases the medication into the skin. Transdermal medication is absorbed more slowly, over a period of 12 to 24 hours.
Examples: Nicotine smoking cessation patches, nitroglycerine patches for angina, and patches for contraception.

Vaginal: The medical assistant may administer medications vaginally by inserting them into the vaginal cavity in the form of a cream, foam, or suppository. Patients may need specific instructions on inserting the medication. Administration of foams and creams involves insertion with an applicator. The medical assistant should be sure to give the patient the written instructions that accompany the medication. Insertion of suppositories, which are hard, is similar to the insertion of a tampon. The patient may need to lie in a recumbent position after inserting the medication to ensure absorption. Thus, physicians commonly order vaginal medication administration at bedtime.
Examples: Antifungal creams and estrogen replacement therapy.

Rectal: The medical assistant may administer medications by inserting them into the rectum for localized or systemic action. Rectal medications are in suppository form, which melt from the patient’s body heat. Rectal administration is common for medications to treat nausea and vomiting when the patient cannot tolerate anything taken orally. Pain relievers and fever reducers are also available in suppository form.
Rectal drug action takes 15 to 30 minutes after insertion, so the patient should lie quietly for this time period. The medical assistant should always provide written instructions to the patient and instruct the patient to call the office if further questions arise. In addition, the patient should be advised to store the medication in a cool, dry place to avoid melting before administration.
Examples: Anti-nausea medications; other drugs, such as pain relievers and fever, are also available in suppository form.

Types of Injections and Injection Sites
Subcutaneous: When administering subcutaneous injections, the medical assistant injects the drug into the subcutaneous layer of the integument (skin), the fatty layer beneath the dermis and above the muscle tissue. Because the fatty layer is less vascular, meaning it has fewer blood vessels, than muscle, the drug absorption rate is moderate with this type of injection. However, the site of subcutaneous injection can affect the rate of absorption. For example, injection of a drug in the abdomen or arm offers quicker absorption than one in the thigh or upper buttocks. Subcutaneous injection sites are in areas where a substantial amount of connective tissue is present between the muscle and skin to absorb the medication without hitting nerves, muscle, bone, or blood vessels.
Examples: Insulin is an example of a subcutaneously injected drug. Because patients or caregivers commonly administer subcutaneous insulin injections daily, they must rotate injection sites to prevent lipodystrophy (atrophy or hypertrophy of fat tissue), bruising, swelling, or infection.
Intradermal: The medical assistant administers intradermal injections into the dermis, the layer of skin under the epidermis (surface of the skin). The quantity of medication given intradermally is small because the medication is not intended to be absorbed beyond the local site but should remain just under the surface for the patient’s body to react to the allergen or TB test. The physician then reads the reaction on the surface of the skin.
Examples: The intradermal route is most common in performing allergy testing or tuberculosis testing. Common intradermal injection sites are the upper arms for TB screening and the upper back for allergy testing.
Intramuscular: When the medical assistant administers an intramuscular injection, he or she injects the drug directly into the muscle. Absorption happens quickly because of the rich blood supply of the muscle. The muscle can be injected with much more medication than in the intradermal or subcutaneous methods because the muscle is capable of retaining more liquid. Careful measurement of medications into syringes is necessary to ensure proper dosage. Common IM sites of administration include the ventrogluteal, deltoid, and vastus lateralis muscles.
The z-track injection method is a modification of IM injection technique. To use the z-track method, the medical assistant must pull the skin to one side and hold it while inserting the needle at a 90 degree angle. After administering the medication, he or she must wait 10 seconds and then withdraw the needle and release the skin. This technique leaves a zigzag needle track from the surface of the skin to the muscular layer, which stops the medication from leaking out into the subcutaneous tissue and onto the skin’s surface. The preferred sites for the z-track method are the vastus lateralis and ventrogluteal muscles. This method is used for medications that may discolor or irritate subcutaneous tissues.
Examples: Medications administered IM include antibiotics, vaccines, and drugs to treat a severe allergic reaction. When the medical assistant must administer multiple IM injections, he or she should use sites on hips, arms, and legs to avoid excessive soreness in one area.
Patients with severe allergies to such foods as peanuts, tree nuts, or shellfish may need to carry an epinephrine injection (Epi-Pen), which is a device that delivers an IM injection of a premeasured amount of epinephrine to counteract the effects of a severe allergic reaction.

Prescriptions
Any drug that is not available over the counter (OTC) requires a prescription. According to the Controlled Substances Act, doctors may issue prescriptions for controlled drugs only in the schedules for which they are registered with the DEA.

Safekeeping
If a physician’s office keeps a supply of controlled substances, the staff must conduct a controlled substances inventory at the date of DEA registration and every two years thereafter. In addition, the office must keep a separate inventory record for Schedule II drugs. With the inventories, the office must include the name of the physician or practice, the address of the medical office, the DEA number, and the date and time of inventories. The office must keep these inventory records on file for two years. The office must keep controlled substances in a locked cabinet, separate from other drugs, such as samples and OTC drugs. Because the inventory must be complete and accurate, the medical assistant and other staff members should log the administration of a controlled substance in the inventory log at the time of administration to avoid forgetting to log the drugs. If an opioid analgesic is accidentally broken or spilled, two staff members must witness the disposal and sign the inventory log. The office must report any theft of a controlled substance to local police and the DEA and complete a police report and Form DEA-116.

Medication Record Keeping
In addition to obtaining a DEA registration number, physicians who prescribe controlled substances must keep records for two years of drugs dispensed, including the patient’s full name and address, date prescribed, dosage (amount to be taken), route of administration, and the reason the drug was given. The physician must also maintain proper security for these records, which are subject to inspection by the DEA. In addition, the medical office must keep a progress note in the patient’s medical record that includes the prescription.

Controlled Substance Guidelines
The Controlled Substances Act of 1990, which updated a 1970 law of the same name, identifies five schedules, or categories, of drugs that have potential for abuse and illegal use. Thus, when a physician prescribes opiates for severe pain, he or she must do so thoughtfully and cautiously. The legislation provides regulations for prescribing, refilling, dispensing, and medical use of these drugs. The drugs have mood-altering effects and the potential for physical dependence; therefore, they have the potential for abuse. For example, although physicians can prescribe opiates for severe pain, they should take care to avoid overprescribing opiates and causing addiction in the patient.

THE "SEVEN RIGHTS" OF DRUG ADMINISTRATION
Whenever administering drugs, the medical assistant must always confirm the 'seven rights.'
- Right patient—check the name of the patient with the physician’s order to avoid medication errors.
- Right drug—check the drug label three times: when removing the drug container from storage, after preparing the medication, and before returning the drug container to storage.
- Right route—check the route the physician ordered against the route prepared.
- Right dose—check the dose on the physician’s order against the dose prepared.
- Right time—check when the medication is to be given.
- Right technique—follow the procedure to administer the medication.
- Right documentation—record the procedure in the patient’s medical record on completion. The medical assistant should be sure to include the date, time, drug, dose, route, site, lot number, expiration date, patient education, and how well the patient tolerated the procedure.