Accepted Practice

Premedication assessment

Nurses are responsible for knowing the implications of IV medication administration and applying critical thinking to support positive outcomes and to reduce the risk of adverse events. Assessing your patient prior to administering any medication provides you with information necessary for effective planning and implementation of care, as well as a baseline from which you can evaluate post-administration response. Premedication assessment should include a review of the patient’s health history, medication data, vital signs, physical assessment, psychosocial and cultural considerations, and learning needs.

Health history


Review the patient’s health history for any conditions that might affect IV drug absorption, distribution, metabolism, or excretion. This information will help you assess for the desired action of the medication and predict any possible adverse effects. Sources for this information include the patient’s history and physical exam, current laboratory data, and medication and allergy lists.

Pharmacokinetics


Drug distribution relies on blood flow to the intended sites of action, biological barriers, and protein-binding capacity. If the patient has a medical condition that limits blood flow to or perfusion of target tissues, the medication’s distribution is likely to be altered.

The ability of a medication to pass through an organ’s biological barrier depends on the organ and the medication’s composition. For example, the blood-brain barrier is selective for fat-soluble medications, while the placenta is nonselective, creating a higher risk of medication-induced fetal complications. Serum proteins such as albumin affect distribution by binding to medications. Low serum protein, as found with malnutrition and advanced age, allows more unbound medication to circulate, creating the potential for increased medication activity or toxicity.

Metabolism is primarily the function of the liver, although the kidneys, lungs, intestines, and blood also play a role. Any disease process that impairs the ability of these organs to detoxify and remove biologically active chemicals will affect metabolism.

Sites for the excretion of metabolized medications are determined by the chemical composition of the medication. Drugs can be excreted through the kidneys, liver, bowel, lungs, or exocrine glands, including the skin and mammary glands. Evaluate the patient’s renal and hepatic function, bowel motility, ventilatory ability, and skin integrity, as these determine the rate of excretion and the potential for prolonging the mediation’s actions. Lactation is a special consideration, since there is a risk that a breastfeeding infant will ingest drug metabolites excreted by the mammary glands.

Medication data


The patient’s medication history, including allergies, provides information that guides medication choice and helps achieve optimal patient response. Find out if your patient has taken a drug similar to that prescribed, and if the patient has had any adverse reactions to similar drugs. Check the patient’s medication history for prolonged use of medications for a chronic condition, and find out if they must be continued. Check for any medications that could create issues of drug tolerance or drug withdrawal.

Review current medications prior to administering any IV medication. You are responsible for knowing as much as possible about each medication you give. This knowledge includes therapeutic intent, possible actions, drug interactions and compatibilities, normal dose ranges, the usual route, side effects, and nursing implications for administration and monitoring. Sources of this information include drug guides, textbooks, medication package inserts, electronic sources, and the agency’s pharmacists.

Physical assessment and vital signs


Ongoing assessment of your patient’s physical condition may affect when and how to administer a prescribed or a PRN medication. It also provides a baseline for post-medication evaluation. Patient assessment may include a complete or focused physical exam, vital signs, sedation score, and pain score.

The physical assessment can be directed toward a specific system or value. For example, always check your patient’s heart rate and blood pressure prior to administering antihypertensive medications or any drugs that decrease or increase the heart rate. The provider may have specified parameters for when to give or withhold those drugs. Also, be aware of medications that are known to cause problems like bronchospasm, rash, flushing, or mental-status changes. Check for these findings before giving the drug so that you can identify any changes after drug administration.

Include an assessment of the patient’s IV access. Some IV medications cause pain and venous irritation if administered into small peripheral veins, in a concentrated solution, or at too rapid an infusion rate. It might be necessary to access a larger vein, request a dilution more appropriate for peripheral administration, or adjust the IV rate (with the provider’s approval). Central IV access should be established for vasoconstrictive medications and for medications and solutions that can cause tissue damage with extravasation. Learn about a medication’s implications for administration, and ensure that your patient’s venous access line is patent and will accommodate the medication as ordered.

Take the patient’s vital signs before giving any IV medication. IV medication administration can alter blood pressure, heart rate or rhythm, respiratory rate, or ventilatory function. Be sure to obtain a pain score prior to giving analgesics and a sedation score prior to giving medications that cause mental-status changes. Follow your agency’s policy for using any specific scoring or assessment tools.

Psychosocial and cultural considerations


Apply psychosocial considerations and culturally congruent nursing care to all forms of medication administration. Cultural beliefs, attitudes, and social values may differ in areas such as expression of pain, acceptance of “western” medicine, and issues surrounding end-of-life care. The use of IV medications can cause additional anxiety or concern related to fears of addiction or needles. Your awareness and understanding will promote medication compliance and improved patient outcomes.

Patient teaching


Evaluate your patient’s level of understanding and develop an individual teaching plan. If appropriate, include family members in medication teaching. Pre-administration teaching for IV medications includes the medication’s name and dose, desired action, frequency of administration, and possible adverse effects specific to your patient. Also include teaching about IV therapy; instruct patients and family members to report pain or swelling at or distal to the IV catheter’s insertion site.