(a) Standing Order - Definition

(b) Purposes of Standing Orders

1. Timely patient care - Nurses can intervene promptly in emergency or predictable situations without delay caused by waiting for a physician to arrive and write a fresh order.
2. Safe nurse practice - They give nurses legal and professional authorization to act, protecting both patient and nurse.
3. Consistency in treatment - They ensure all patients in similar situations receive the same standardized care based on established protocols.
4. Improved access to medicines - Especially in primary care, community health, and remote settings where doctors may not be immediately available (e.g., immunization programs, outreach clinics).
5. Coverage of common/routine situations - Frequently needed interventions (pain relief, antiemetics, antipyretics, laxatives, DVT prophylaxis post-surgery) are covered without the need for individual orders each time.
6. Team-based care - They allow the care team - nurses, paramedics, medical assistants - to function to their full capacity and share responsibilities.
7. Reduction of unnecessary interruptions - Physicians are freed from writing repetitive orders for predictable clinical scenarios.
8. Legal protection - A properly written and signed standing order protects the nurse legally if they administer a medicine in the described circumstances.
9. Accountability and audit - Standing orders must be signed, dated, and periodically reviewed, creating a traceable record.

(c) Care of the Medicine Almirah (Medicine Cupboard)

Physical Maintenance

• The almirah should be kept locked at all times when not in use. Only authorized staff (nurse in charge) should hold the key.
• It must be placed in a dry, cool, clean, and well-ventilated area, away from direct sunlight and moisture.
• The shelves should be cleaned regularly with a damp cloth - free of dust, spills, and expired stock.
• The almirah should be inspected daily for damage, leaks, or contamination.

Drug Organization

• Medicines should be arranged systematically - oral drugs separately from injectables, external preparations separate from internal ones.
• All drugs should be kept in their original labelled containers.
• Drugs should be arranged so that older stock is used first (FIFO - First In, First Out principle).
• Separate sections or shelves should be maintained for:
  • Oral medicines
  • Injectable preparations
  • External use preparations
  • Controlled/narcotic drugs (kept in a separate locked cupboard within the almirah, with a separate register)

Stock Management

• The stock should be checked regularly and replenished before it runs out.
• Expiry dates of all medicines must be checked routinely. Expired medicines should be removed immediately and disposed of as per institutional policy.
• A proper drug register/inventory should be maintained - recording all drugs received, issued, and their current balance.
• Broken, leaking, or discolored preparations should be discarded.

Safety and Access Control

• Controlled drugs (narcotics, sleeping pills) must be stored in a double-locked cupboard and their use recorded in a separate controlled drugs register, checked by two nurses at each shift.
• No unauthorized person should have access to the medicine almirah.
• The almirah key must be handed over formally during shift changes with a count of controlled drugs.

Temperature-Sensitive Drugs

• Drugs requiring refrigeration (vaccines, insulin, eye drops, certain antibiotics) should be stored in a dedicated medicine refrigerator at 2-8°C, not in the general almirah.
• The refrigerator temperature should be monitored and recorded daily.

(d) Special Points to Keep in Mind Before Administration of Drugs

1. Verify the Prescription/Order

• Check that the prescription is complete, legible, and signed by an authorized physician.
• Ensure all required components are present: patient name, drug name, dose, route, frequency, and date.

2. The Rights of Drug Administration (6 Rights - verified 3 times)

• Right Patient - Confirm patient identity using at least two identifiers (name + date of birth / hospital ID). Never rely on memory.
• Right Drug - Read the drug label carefully; check against the prescription. Do not use look-alike or sound-alike drugs without double-checking.
• Right Dose - Verify the prescribed dose is correct for this patient (consider age, weight, renal/hepatic function). Recalculate if any doubt.
• Right Route - Confirm the intended route (oral, IV, IM, SC, topical, etc.) and that it is appropriate for that drug and patient.
• Right Time - Give the drug at the prescribed time and frequency. Be aware of drugs that need to be given before meals, with food, or at specific intervals.
• Right Documentation - Record administration immediately after giving the drug on the Medication Administration Record (MAR).

3. Check Allergies

• Before any drug administration, review the patient's allergy status thoroughly. Check the chart, wristband, and ask the patient directly. Never administer a drug to a patient who is known to be allergic to it.

4. Check the Expiry Date

• Always check the expiry date on the label. Expired medications must never be used.

5. Inspect the Drug

• Check for visible signs of deterioration: discoloration, precipitation, cloudiness, unusual odor, or damaged packaging. Discard if any abnormality is found.

6. Know the Drug

• The nurse must have adequate knowledge of the drug: its action, therapeutic use, normal dose range, side effects, adverse reactions, contraindications, and drug interactions.

7. Assess the Patient

• Do a relevant pre-administration assessment - e.g., check pulse before giving digoxin, check blood pressure before antihypertensives, check blood glucose before insulin. Do not administer if the patient's condition contraindicates it.

8. Explain to the Patient

• Inform and educate the patient about the drug being given - its name, purpose, and what to expect. Obtain the patient's co-operation. Respect the patient's right to refuse.

9. Observe Aseptic Technique

• Maintain sterility during preparation of injectables. Wash hands properly before preparing and administering any medication.

10. Double-Check High-Alert Drugs

• Drugs such as insulin, heparin, concentrated electrolytes (KCl), and opioids should be double-checked by a second nurse before administration.

11. Proper Preparation

• Reconstitute injectables correctly. Use the right diluent and volume. Label prepared syringes clearly.

12. Post-Administration Observation

• After giving the drug, monitor the patient for therapeutic effect, adverse reactions, and allergic responses (especially with new drugs or the first dose).

Sources: Fundamentals of Nursing - OpenStax (11.1 Medication Orders); Nursing Skills 2e - WTCS Pressbooks (15.2 Basic Concepts of Administering Medications); NCBI Bookshelf - Chapter 15 Administration of Enteral Medications; 10 Rights of Medication Administration - Health PEI/College of Registered Nurses.

Routes of Drug Administration - Advantages, Disadvantages & Appropriate Conditions

1. ORAL ROUTE (Per Oral / P.O.)

Advantages

• Most convenient, simple, and easiest route - can be self-administered
• Painless and non-invasive
• Cheapest and most economical method
• Safest - overdose can sometimes be managed with activated charcoal or emesis
• Wide range of formulations available (enteric-coated, slow-release, chewable, liquid)
• Absorption occurs over the entire length of the GI tract
• No risk of infection at the administration site

Disadvantages

• Slow onset of action - not suitable for emergencies
• Absorption is variable and often incomplete
• First-pass metabolism - drugs absorbed via the portal vein pass through the liver first, significantly reducing bioavailability (e.g., glyceryl trinitrate, lignocaine are almost entirely destroyed)
• Some drugs are destroyed by gastric acid (e.g., Penicillin G, insulin) or digestive enzymes
• May cause nausea, vomiting, or gastric irritation
• Cannot be used in unconscious, uncooperative, or vomiting patients
• Not suitable for drugs with poor oral absorption (e.g., heparin)
• Food and other drugs may interfere with absorption

When is it Appropriate?

• Conscious, cooperative patients who can swallow
• Long-term therapy (chronic conditions like hypertension, diabetes, epilepsy)
• Non-emergency situations where a slower onset is acceptable
• Outpatient and community settings
• When cost and convenience are priorities

2. SUBLINGUAL ROUTE (Under the Tongue)

Advantages

• Rapid absorption and quick onset of action (within minutes)
• Bypasses first-pass hepatic metabolism - 100% bioavailability for some drugs
• Drug is not destroyed by gastric acid or enzymes
• Easy to administer
• Action can be terminated by spitting out the tablet

Disadvantages

• Only suitable for small doses (tablet must fit comfortably under the tongue)
• Drug must be lipid-soluble enough to penetrate the mucous membrane
• Some drugs have an unpleasant taste
• Cannot eat, drink, or talk while the drug is under the tongue
• Limited number of drugs suitable for this route
• Irritation of the oral mucosa with prolonged use
• Not suitable for children who cannot cooperate

When is it Appropriate?

• Acute angina attacks (GTN tablet or spray)
• Hypertensive emergencies (Nifedipine)
• Acute pain relief (Buprenorphine)
• Drugs with high first-pass metabolism that would be ineffective if swallowed
• When rapid action is needed and IV access is unavailable

3. INHALATION ROUTE

Advantages

• Rapid onset of action - almost as fast as IV (large surface area of alveoli ~70 m², rich blood supply)
• Direct delivery to the target organ (lungs) - ideal for respiratory diseases
• Local effect with minimal systemic side effects
• Small doses needed compared to oral route
• Convenient for patients with respiratory disorders
• Ideal for volatile gases (general anesthetics - halothane, isoflurane)

Disadvantages

• Difficult to control the exact dose delivered (technique-dependent)
• Requires patient cooperation and proper inhalation technique - many patients use inhalers incorrectly
• May cause local irritation to the airway, throat irritation, cough
• Not suitable for all types of drugs
• Risk of paradoxical bronchospasm
• Systemic absorption can occur leading to systemic side effects
• Expensive devices (nebulizers, inhalers)
• Considered the most addictive route as drugs enter the brain very rapidly

When is it Appropriate?

• Bronchial asthma (Salbutamol, Budesonide, Ipratropium)
• COPD (chronic obstructive pulmonary disease)
• Induction and maintenance of general anesthesia (volatile anesthetics)
• Croup and respiratory infections requiring nebulization
• Pulmonary hypertension (inhaled nitric oxide)
• Delivery of drugs directly to the lungs to minimize systemic effects

4. INSUFFLATION ROUTE

Advantages

• Rapid absorption through nasal mucosa - good blood supply
• Bypasses first-pass metabolism
• Non-invasive and relatively easy to use
• Suitable for drugs that need to reach the brain quickly (proximity of nasal mucosa to the CNS)
• Useful when oral route is unavailable
• Naloxone nasal spray is used in emergency reversal of opioid overdose

Disadvantages

• Irritation of the nasal mucosa with repeated use
• Variable absorption - affected by nasal congestion, rhinitis, secretions
• Only small volumes/amounts can be administered
• Risk of systemic absorption causing side effects
• Patient may find it uncomfortable
• May cause sneezing, which expels the drug before absorption
• Not suitable for drugs that are irritating to mucosa

When is it Appropriate?

• Allergic rhinitis (nasal corticosteroids - Fluticasone)
• Nasal decongestants (Xylometazoline)
• Hormonal therapy (Desmopressin for diabetes insipidus; Calcitonin for osteoporosis)
• Emergency reversal of opioid overdose (Naloxone nasal spray)
• Cocaine in ENT procedures (local anesthetic + vasoconstrictor)
• Migraine (Sumatriptan nasal spray)

5. INSERTIONS (Rectal / Vaginal / Urethral Route)

• Rectal: Suppositories, enemas (e.g., Paracetamol, Diazepam, Bisacodyl suppositories)
• Vaginal: Pessaries/vaginal tablets (e.g., Clotrimazole, Misoprostol, progesterone)
• Urethral: Urethral bougies/gels (e.g., MUSE - Alprostadil for erectile dysfunction; Lignocaine gel)

Advantages

• Can be used when the patient is unconscious, vomiting, or unable to swallow
• Avoids first-pass hepatic metabolism partially (lower rectal veins drain into systemic circulation)
• Avoids gastric irritation and destruction by gastric acid
• Useful for local effects (hemorrhoids, vaginal infections, constipation)
• No cooperation of the patient needed for rectal route
• Useful in children (e.g., rectal diazepam for febrile seizures)
• Drug can be removed if necessary (rectal suppository)

Disadvantages

• Absorption is irregular and incomplete in rectal route
• Patient finds it inconvenient, embarrassing, and psychologically unacceptable
• May cause local irritation, rectal mucosal damage
• Rectal route is contraindicated in rectal bleeding, diarrhea, or recent rectal surgery
• Vaginal route requires patient self-administration (may be difficult for elderly)
• Limited drug options available in these forms
• Suppositories may melt before insertion in hot climates if not stored properly

When is it Appropriate?

• Unconscious patients requiring anticonvulsants (e.g., rectal diazepam)
• Patients with severe vomiting or nausea (antiemetics via suppository - Prochlorperazine)
• Pediatric febrile seizures (rectal diazepam)
• Post-operative patients who cannot take oral drugs
• Local treatment: hemorrhoids, vaginal candidiasis (Clotrimazole pessary), induction of labor (Misoprostol)
• Patients near end-of-life/hospice care
• Constipation (bisacodyl, glycerin suppositories)

6. INSTILLATION ROUTE

Advantages

• Delivers drug directly to the site of action - high local concentration with minimal systemic effects
• Simple, non-invasive, and easy to self-administer
• Rapid local action
• Economical - small quantities needed
• Wide variety of drugs available in these forms

Disadvantages

• Some drug may drain into the nasolacrimal duct (from eyes) and be absorbed systemically causing side effects (e.g., timolol eye drops causing bradycardia)
• Technique-sensitive - many patients instill drops incorrectly
• Risk of contamination of the dropper tip causing infection
• Requires good eyesight and dexterity for self-administration
• Frequent instillation needed (short duration of action for most eye/ear drops)
• May cause local stinging, burning, or irritation

When is it Appropriate?

• Eye conditions: conjunctivitis, glaucoma (Timolol, Latanoprost), allergic eye disease, local anesthesia for eye procedures
• Ear conditions: otitis externa, ear wax removal (Cerumol, Sofradex drops)
• Nasal conditions: nasal congestion, sinusitis (nasal drops)
• Pre-operative mydriasis (dilating eye drops - Tropicamide, Phenylephrine)
• Post-operative eye care after cataract surgery

7. INUNCTION ROUTE (Topical / Transdermal Route)

Advantages

• Easy and painless self-administration
• Avoids first-pass metabolism (transdermal patches deliver drug directly to systemic circulation)
• Provides prolonged and sustained drug release (patches can last 24 hours to 7 days)
• Drug effect can be terminated by removing the patch/application
• Minimal systemic side effects for locally applied drugs
• Useful for patients who cannot take oral medications
• Improves compliance (less frequent dosing)

Disadvantages

• Absorption through normal skin is slow and unpredictable
• Only lipid-soluble drugs can be absorbed transdermally
• Only suitable for potent drugs (low doses needed) as the amount that can be absorbed is limited
• May cause local skin irritation, contact dermatitis, or redness at the application site
• Rate of absorption varies with site of application, skin condition (thin vs. thick, damaged skin absorbs more), temperature, and age
• Cannot deliver large doses
• Some patients develop sensitization/allergy to the adhesive in patches
• Slow onset - not suitable for emergencies

When is it Appropriate?

• Chronic pain management (Fentanyl patch, Buprenorphine patch)
• Angina prophylaxis (Glyceryl trinitrate patch)
• Smoking cessation (Nicotine patch)
• Motion sickness/nausea prevention (Scopolamine patch behind the ear)
• Hormone replacement therapy (Estradiol patch)
• Local skin conditions: eczema, psoriasis, fungal infections (antifungal cream), bacterial skin infections
• EMLA cream for skin anesthesia before procedures in children

8. IMPLANTATION ROUTE

Advantages

• Provides very prolonged, steady, and continuous drug release over weeks to months (up to 3 years)
• Excellent patient compliance - no need to remember daily doses
• Avoids first-pass metabolism
• Very precise and consistent drug plasma levels
• Ideal for long-term contraception or hormonal therapy
• Removes patient's ability to forget or self-discontinue treatment

Disadvantages

• Requires a minor surgical procedure for both insertion and removal
• Irreversible in the short term - cannot be easily stopped if side effects occur (until removed)
• Risk of infection, hematoma, or local tissue reaction at the implant site
• Expensive
• Not widely available for many drug types
• Requires trained healthcare professional for insertion/removal
• May cause local discomfort, migration of the implant

When is it Appropriate?

• Long-term contraception (Nexplanon - single rod lasts 3 years)
• Hormone replacement therapy
• Alcohol deterrent therapy (disulfiram implant)
• Palliative care - subcutaneous drug delivery systems
• Sustained drug delivery in psychiatric patients (poor compliance)
• Ocular conditions requiring sustained drug release (intravitreal implants - Ozurdex for uveitis, Vitrasert for CMV retinitis)

9. PARENTERAL ROUTE (Injection)

A. Intravenous (IV) Route

• Fastest onset of action - effects within seconds (ideal for emergencies)
• 100% bioavailability - entire dose reaches systemic circulation
• Precise and predictable control over drug plasma levels
• Large volumes can be administered (fluids, blood, nutrients)
• Drugs with unpleasant taste or poor oral absorption can be given
• Can be used in unconscious, vomiting, or uncooperative patients
• Continuous infusion maintains steady drug levels (e.g., dopamine, heparin)

• Requires trained personnel and sterile technique
• Painful and requires IV access (cannula insertion)
• Once injected, the drug CANNOT be recalled or removed - if an error is made or adverse reaction occurs, it is irreversible
• Risk of thrombophlebitis, infection, embolism, extravasation
• Most expensive route
• Anaphylaxis risk is highest via IV
• Drug must be water-soluble and compatible with blood

• Emergency situations (cardiac arrest - Adrenaline IV; status epilepticus - Diazepam IV)
• Rapid effect needed (anaphylaxis - Adrenaline)
• Drugs not absorbed orally (heparin, insulin, many antibiotics in severe infections)
• Unconscious patients
• Fluid replacement and parenteral nutrition
• Oncology - chemotherapy infusions
• Precise titration needed (e.g., IV morphine for pain, IV insulin infusion)

B. Intramuscular (IM) Route

• Faster absorption than subcutaneous route (muscles have richer blood supply)
• Can be given as depot preparations for prolonged effect (e.g., haloperidol decanoate monthly)
• Can accommodate larger volumes than SC (up to 3-5 mL depending on site)
• Avoids first-pass metabolism
• Easier to administer than IV
• Moderately rapid onset

• Painful
• Requires trained personnel
• Variable absorption depending on site and muscle blood flow
• Risk of abscess, nerve damage, hematoma at injection site
• Cannot be used in patients with bleeding disorders (coagulopathy, thrombocytopenia)
• Drug cannot be recalled once injected
• Contraindicated in patients on anticoagulants

• Vaccines (e.g., Hepatitis B, Tetanus toxoid, COVID-19 vaccines)
• Depot antipsychotics (Fluphenazine, Haloperidol decanoate - monthly injections)
• Antibiotics when IV access is unavailable (e.g., Benzylpenicillin, Ceftriaxone)
• Analgesia (Diclofenac, Tramadol IM)
• Non-compliant patients requiring long-acting preparations
• When oral absorption is erratic

C. Subcutaneous (SC) Route

• Slower, more sustained absorption than IM - longer duration of action
• Can be self-administered (insulin, heparin)
• Suitable for slow, continuous infusions (syringe drivers in palliative care)
• Less risk of vascular complications compared to IV
• Depot effects possible

• Slower onset than IM or IV
• Limited to small volumes (max 1-2 mL per injection)
• Irritating drugs cause pain, necrosis, or abscess
• Absorption may be variable and affected by local blood flow, temperature, and lipodystrophy (with repeated injections)
• Not suitable for large doses

• Insulin administration (diabetes mellitus)
• Low molecular weight heparin (e.g., Enoxaparin for DVT prophylaxis/treatment)
• Vaccines (e.g., MMR, Varicella)
• Palliative care syringe drivers (continuous SC infusion of morphine, midazolam)
• Immunotherapy (allergy desensitization)
• Epinephrine auto-injector (Epipen) for anaphylaxis in self-administration

D. Intradermal (ID) Route

• Ideal for diagnostic tests - provides a visible wheal for reading
• Very small amounts of drug needed
• Local effect can be clearly observed

• Very small volumes only (0.1-0.2 mL)
• Technique-sensitive - very shallow angle required; difficult
• Slow absorption - not suitable for therapeutic drug delivery
• Painful

• Tuberculin skin test (Mantoux test)
• Allergy skin testing
• BCG vaccine
• Local skin anesthesia (intradermal lignocaine before procedures)

Summary Table

Sources: Lippincott Illustrated Reviews: Pharmacology; Goodman & Gilman's The Pharmacological Basis of Therapeutics; StatPearls - Medication Routes of Administration (NCBI); OpenStax Pharmacology for Nurses.