07. MA Administering medications per os…

MEDICATION ADMINISTRATION:

ADMINISTERING MEDICATIONS PER OS, BY INHALATIONS, IRRIGATIONS, TOPICAL APPLICATIONS

 

ADMINISTER ORAL DRUGS

Oral administration of drugs is the most common route; however, there are potential risk factors that the nurse must consider. Before administering oral drugs, the nurse should assess the client’s ability to take the medication as prescribed. This assessment includes the client’s gag reflex, state of consciousness, and presence of nausea and vomiting.

The nurse should protect the client against aspiration when administering any form of oral drug. Aspiration  refers to the inhalation of regurgitated gastric contents into the pulmonary system. If a client has a weak gag reflex or difficulty swallowing water, medication can be inhaled during medication administration.

To prevent aspiration, the nurse confirms the client’s gag reflex and ability to swallow. When administering an oral drug, the nurse prepares the medication, correctly identifies the client, and provides some form of liquid.

The nurse should remain with the client until all of the medications have been swallowed. If there is doubt that the client has swallowed the pill, the nurse should don a nonsterile glove and visually inspect the client’s mouth with a tongue depressor.

SUBLINGUAL AND BUCCAL DRUG ADMINISTRATION

Sublingual and buccal drugs are types of oral medications. Certain drugs are given by these routes to prevent their destruction or transformation in the stomach or small intestines. The nurse should assess the integrity of the mucous membranes by inspecting underneath the client’s tongue and in the buccal cavity. If the membranes are excoriated or painful, the nurse should withhold the medication and notify the health care practitioner. Some buccal drugs may irritate the mucosa, requiring the nurse to use alternate sides of the mouth to prevent irritation of the mucosa.

Sublingual and buccal administration of drugs (Figure 29-9) requires the nurse to use Standard Precautions because the nurse’s hand may come into contact with oral secretions. See the Nursing Checklist for administering sublingual and buccal drugs. Drugs given by these routes are quickly absorbed by the mucosa’s thin epithelium and the abundant blood supply.

ENTERAL INSTILLATION OF DRUGS

Enteral instillation  refers to the delivery of drugs through a gastrointestinal tube. Enteral tubes provide a means of direct instillation of medications into the gastrointestinal system of clients who cannot ingest it orally.

See Chapter 38 for a complete discussion of the purpose, insertion, and nursing care of clients with enteral tubes. Once the tube’s position has been radiographically verified, the nurse may administer drugs or nutrients as prescribed.

There are several types of enteral tubes. A nasogastric tube (NG) is a soft rubber or plastic tube that is inserted through a nostril and into the stomach. The gastrostomy tube is surgically inserted into the stomach through the creation of an artificial fistula. The physician uses an endoscope to insert a percutaneous endoscopic gastrostomy (PEG) tube into the stomach.

The nurse should assess the client for the presence of bowel sounds and check the tube for  patency (openness) and placement before administering a medication. The instillation of drugs is contraindicated when the tube is obstructed or improperly placed, when the client is vomiting, or if bowel sounds are absent.

The nurse prepares the medication for instillation as prescribed by the health care practitioner once the patency and placement of the tube have been determined. It is preferable to instill liquid medications into tubes, especially PEG tubes that have a small lumen.

Tablets can clog the tube unless they are finely crushed. When the health care practitioner orders a drug in the tablet or capsule form, the nurse should crush the tablet into minute particles and dissolve the crushed tablet in 15 to 30 ml of warm water before instillation. Some tablets cannot be crushed without altering their therapeutic effect. The nurse should check with the pharmacist if unsure. The instillation of cold solution may cause abdominal cramps. Capsules are prepared for administration by opening the capsule and emptying the contents into a liquid. When the drug is prepared, the nurse is ready to instill the medication (see the Nursing Checklist for instilling drugs into enteral tubes).

 

The nurse should question the health care practitioner if oily medications and enteric-coated or sustained-release tablets are ordered because these drug forms should not be given through a tube. Oily preparations may cling to the sides of the tube and resist mixing with the irrigating solution. Crushing enteric-coated or sustained-release tablets destroys their intended effect.

Do not crush buccal or sublingual tablets. Never attempt to give whole or undissolved medications through an enteral tube. See the accompanying display for special considerations.

ADMINISTER TOPICAL MEDICATIONS

Topical medications may be administered to the skin, eyes, ears, nose, throat, rectum, and vagina. The medication generally provides a local effect but can also cause systemic effects. Drugs directly applied to the skin to produce a local effect include lotions, pastes, ointments, creams, powders, and aerosol sprays. The rate and degree of the drug’s absorption are determined by the vascularity of the area.

Topical drugs are usually given to provide continuous absorption to produce different effects: to relieve pruritus (itching), to protect the skin, to prevent or treat an infection, to provide local anesthesia, or to create a systemic effect. Topical medications are usually ordered two or three times a day to achieve their therapeutic effect.

Before applying a topical preparation, the nurse should assess the condition of the skin for any open lesions, rashes, or areas of erythema and skin breakdown. Because secretions are produced by the skin and mucous membranes, the nurse should always implement Standard Precautions when applying a topical drug. The medication can be transferred to the nurse if gloves are not worn or an applicator, such as a sterile tongue depressor, is not used. The nurse should check with the client and the medical record for any known allergies.

Body oils may interfere with the adhesive properties of the patch, disk, or tape. The skin harbors microorganisms, and lesions can cause encrustation. The nurse should cleanse the area by washing with soap and warm water, unless contraindicated by a specific order. The skin should be thoroughly dry before a topical medication is applied. Open wounds require the nurse to use surgical asepsis.

When the skin is dry, the nurse can apply the medication. When applying a paste, cream, or an ointment, the nurse should use a sterile tongue depressor to remove the medication from the container; this method prevents cross-contamination. The medication is transferred from the tongue blade to a gloved hand for application. The medication should be applied in long, smooth strokes in the direction of the hair follicles to prevent the medication from entering the hair follicles.

A new sterile tongue depressor should be used whenever more medication is removed from the container.

Two to 4 hours after the application, the nurse should assess the area for signs of an allergic reaction.

EYE MEDICATIONS

Eye medications, often referred to as ophthalmic medications, refer to drops, ointments, and disks. These drugs are used for diagnostic and therapeutic

purposes—to lubricate the eye or socket for a prosthetic eye and to prevent or treat eye conditions such as glaucoma (elevated pressure within the eye) and infection.

Diagnostically, eyedrops can be used to anesthetize the eye, dilate the pupil, and stain the cornea to identify abrasions and scars.

The nurse should review the abbreviations used in medication orders to ensure that the medication is instilled in the correct eye. Cross-contamination is a potential problem with eyedrops. The nurse should adhere to the following safety measures to prevent crosscontamination:

• Each client should have his or her own bottle of eyedrops. Clients should never share eye medications.

• Discard any solution remaining in the dropper after instillation.

• Discard the dropper if the tip is accidentally contaminated, as by touching the bottle or any part of the client’s eye. The risk of transferring infection from one eye to the other is increased if the tip touches any part of the client’s eye.

EAR MEDICATIONS

Solutions ordered to treat the ear are often referred to as  otic  (pertaining to the ear) drops or irrigations. Eardrops may be instilled to soften ear wax, to produce anesthesia, to treat infection or inflammation, or to facilitate removal of a forgien body, such as an insect.

External auditory canal irrigations are usually performed for cleaning purposes and less frequently for applying heat and antiseptic solutions. The internal ear is very sensitive to changes in temperature. Sudden changes can cause nausea and dizziness. Eardrops and irrigation fluids should be at room temperature.

Before instilling a solution into the ear, the nurse should inspect the ear for signs of drainage, an indication of a perforated tympanic membrane. Eardrops are usually contraindicated when the tympanic membrane is perforated. If the tympanic membrane is damaged, all procedures must be performed using sterile aseptic technique; otherwise, medical asepsis is used when instilling medications into the ear

Medication should never be forced into the ear canal especially if it is occluded (as by wax). Forcing medication into an occluded eardrum can injure the eardrum.

Certain conditions have contraindications for specific drugs; for example, hydrocortisone eardrops are contraindicated in clients with a fungal infection or a viral infection such as herpes.

NASAL INSTILLATIONS

Nasal instillations can be performed with different preparations: drops or nebulizers (atomizer or aerosol). Nasal drugs are administered to produce one or more of the following effects: to shrink swollen mucous membranes, to loosen secretions and facilitate drainage, to treat infections of the nasal cavity or sinuses. Because many of these products are nonprescription drugs, clients should be taught their correct usage. For example, nasal decongestants are common over-the-counter drugs used to shrink swollen mucous membranes; however, when these drugs are used in excess, they may have a reverse or rebound effect by increasing nasal congestion.

The nasal sinuses (frontal, ethmoid, maxillary, and sphenoid sinuses) communicate with the nasal fossae and are lined with mucous membranes similar to those that line the nose. Nose drops can be instilled to remain in the nasal passage, to reach the ethmoid and sphenoid sinuses, or to reach the frontal or maxillary sinuses. Location is determined by the degree of hyperextension and position of the head during instillation (Figure 29-36).

Although the nose is considered a clean (not sterile) cavity, because of its connection with the sinuses, the nurse uses medical asepsis when performing nasal instillations.

Nebulizers (inhalers) are used to deliver a fine mist containing medication droplets.

 

The nurse should administer or assist clients with the usage of atomizers and aerosols:

Ø Instruct the client to clear the nostrils by blowing the nose.

Ø Client should be in an upright position with head tilted back slightly.

Atomizer

Ø Occlude one nostril to prevent air from entering the nasal cavity and to allow the medication to flow freely in the opeostril.

Ø Insert the atomizer tip into the open nostril and instruct the client to inhale, then squeeze the atomizer once, and instruct the client to exhale.

Aerosol

Ø Shake the aerosol well before each use.

Ø Grasp between thumb and index finger and insert the adapter tip into one nostril while occluding the other nostril with a finger, then press the adapter cartridge firmly to release one measured dose of medication.

Ø Repeat the above steps as ordered for the other nostril.

Ø Instruct the client to keep head tilted backward for 2 to 3 minutes and to breathe through the nose while the medication is being absorbed.

 

THE  RESPIRATORY INHALANTS

Respiratory inhalants are delivered by devices that produce fine droplets that are inhaled deep into the respiratory tract. These medication droplets are absorbed almost immediately through the alveolar epithelium into the bloodstream.

Oropharyngeal hand-held inhalers deliver medications that produce both local and systemic effects, suchas bronchodilators and mucolytics. Bronchodilators improve airway patency and are used to prevent or treat bronchospasms, asthma, and allergic reactions.

Mucolytics are used to liquify tenacious (thick) bronchial secretions. There are three types of oropharyngeal hand-held inhalers: metered-dose inhaler, turbo-inhaler, and the nasal inhaler (previously discussed).

Clients must be able to form an airtight seal around the inhaling devices and be able to assemble the turboinhaler. This requirement prevents some clients, such as clients with visual or coordination impairments, from using these devices. Bronchodilators are contraindicated in clients who have a history of tachycardia.

The nurse should ensure that the client knows how to use the inhaler correctly so that the prescribed medication dose is delivered.

See Procedure 29-12 for teaching a client how to use a metered-dose inhaler.

A metered-dose inhaler delivers a measured dose of the medication with each push of the canister. The nurse needs to evaluate the client’s ability to adequately compress the inhaler to deliver a full dose and to inhale at the same time as the dose is expressed. Failure to do either could prevent the client from receiving the full benefit of the inhaler. The ability to compress the inhaler for dose delivery can be affected by hand strength (which diminishes with age), flexibility (as in arthritic changes), and disease related to weakness (such as chronic respiratory disease). Careful discharge instructions and observation of the client performing the task are important to continued therapeutic effect at home (see the accompanying display for home care application).

 

RECTAL INSTILLATIONS

Suppositories provide a safe and convenient route for administering drugs that interact poorly with digestive enzymes or have a bad taste or odor. They are also used to provide temporary relief for clients who cannot tolerate oral preparations: for example, to relieve nausea and vomiting. Suppositories are also used to induce relaxation, relieve pain and local irritation, reduce fever, and stimulate peristalsis and defecation in clients who are constipated.

Rectal suppositories are contraindicated in cardiac clients because insertion may stimulate the vagus nerve, causing cardiac dysrhythmias (abnormal heart patterns).

These drugs are also avoided in clients recovering from rectal or prostate surgery because they may cause pain on insertion and trauma to the tissues.

The nurse should assess the rectum for irritation or bleeding and check sphincter control. Some clients may experience problems in retaining the suppository. The nurse should instruct such a client to remain in the Sims’ position for at least 15 minutes or should place the client on the abdomen, if the condition allows, and hold the buttocks closed. The health care practitioner should be notified when the client is unable to retain a suppository so that another route can be ordered.

Suppositories are often stored in the refrigerator to preserve the integrity of the drug form. A softened suppository is difficult to insert; to harden a suppository, place it under cold running water while it is still in its original wrapper. The nurse should follow the five rights of medication administration and Standard Precautions when administering rectal instillations.

VAGINAL INSTILLATIONS

Medications inserted into the vagina are in the form of suppositories, creams, gels, ointments, foams, or douches. These medications may be used to treat inflammation, infections, and discomfort, or as a contraceptive measure. Vaginal creams, gels, or ointments usually come with a disposable tubular applicator with a plunger to insert the drug. Standard Precautions are always used by the nurse when inserting suppositories.  Body temperature causes the suppository to melt and be absorbed. Suppositories are usually inserted with the index finger of a gloved hand; however, small suppositories may come with an applicator and the suppository is placed in the applicator’s tip. Many clients prefer to insert their own vaginal suppository. In this case, provide privacy for the client.

After insertion of these preparations, the client may notice drainage and should be informed that this is expected. If a suppository is given to treat infection, tell the client that the drainage may be foul smelling. The nurse should advise the client to wear a perineal pad to prevent soiling of the underpants.

Sterile technique is usually required by agency policy, especially if there is an open wound when administering a vaginal douche (irrigation). Douches are ordered to apply antimicrobial solutions, to remove offensive or irritating discharge, to reduce inflammation, and to prevent hemorrhage with warm or cold irrigations. The nurse should ensure that the client does not have an allergy to iodine because many vaginal preparations contain povidone-iodine.

 

PROCEDURE CHECKLIST

Administering Oral Medications

 

Check (ü) Yes or No

PROCEDURE STEPS	Yes	No	COMMENTS
1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
Tablets and Capsules
2. If pouring from a multi-dose container, does not touch the medication. Pours the tablet into the cap of the bottle, then into the medication cup.
3. Pours correct number into medication cup.
4. If necessary to give less than a whole tablet, breaks scored tablet with hands; uses a pill cutter if necessary. Does not break unscored tablet.
5. If drug is unit-dose, does not open package; places entire package in paper (soufflé) cup.
6. If patient has difficulty swallowing, checks to see if the pill can be crushed. If so, mixes with soft food, such as applesauce.
7. Pours all medications scheduled at the same time into the same cup, except uses separate cup for any medications requiring pre-administration assessment (e.g., digoxin).
8. If patient is able to hold it, places tablet or medication cup in her hand. If unable to hold it, places medication cup to her lips and tips the pill(s) into her mouth.
9. Provides liquid to swallow the pills.
Sublingual Medications
10. Places, or has patient place, the tablet under the tongue and hold there until completely dissolved.
Buccal Medications
11. Places, or has patient place, the tablet between cheek and teeth and hold there until completely dissolved.
Liquids
12. Shakes the liquid, if necessary, before opening the container.
13. Places bottle lid upside down on the counter.
14. Holds bottle with label in palm of the hand.
15. Pours medication, slightly twists bottle when finished to prevent dripping.
16. If medication drips over bottle lip when pouring, wipes with a clean tissue or paper towel—only the outside lip of the bottle.
17. Holds medication cup at eye level to measure dosage.
18. Positions patient in high Fowler’s position if possible; or raises head of bed as much as allowed; or uses side-lying position.

 

 

 

PROCEDURE CHECKLIST

Administering Otic Medications

 

Check (ü) Yes or No

 

PROCEDURE STEPS	Yes	No	COMMENTS
1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
2. Warms solution to be instilled (e.g., in hand or in warm, not hot, water).
3. Assists patient to side-lying position, with appropriate ear facing up.
4. Fills dropper with the correct amount of medication.
5. Cleans external ear with cotton tipped applicator if needed.
6. For infants and young children, asks another caregiver to immobilize the child while administering the medication.
7. Straightens the ear canal. a. For patients older than 3 years, pulls pinna upward and back. b. For children less than 3 years old, pulls pinna down and back.
8. Instills correct number of drops along the side of the ear canal.
9. Does not touch the end of the dropper to any part of the ear.
10. Massages or presses on the tragus of the ear.
11. Instructs patient to remain on his side for 5 to 10 min.
12. Places cotton loosely at the opening of the auditory canal for 15 minutes.

 

 

PROCEDURE CHECKLIST

Administering Nasal Medications

 

Check (ü) Yes or No

 

PROCEDURE STEPS	Yes	No	COMMENTS
1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
2. Determines head position. Considers the indication for the medication and the patient’s ability to assume the position.
3. Asks patient to blow his nose.
4. Positions patient:     a. Nose drops or spray: To get head down and forward, has patient sit and lean forward or kneel on the bed with head dependent.     b. If unable to assume one of those positions, has patient tilt his head back.     c. To medicate ethmoid and sphenoid sinuses, assists patient into supine position with head over edge of the bed. Supports head. Alternatively, places a towel roll behind the shoulders, allowing the head to drop back.     d. To medicate frontal and maxillary sinuses, positions as in step c, but tilts the head toward the affected side.
5. Explains to the patient that the medication may cause some burning, tingling, or unusual taste.
6. Has patient close one nostril and exhale; then inhale through the mouth.
7. Administers spray or drops while the patient is inhaling through the mouth.
8. Repeats steps 6 and 7 on other nostril.
9. Does not touch dropper to the sides of the nostril.
10. If nose drops are used, asks the patient to stay in the same position for approximately 5 minutes (follow manufacturer’s guidelines).
11. Instructs patient not to blow his nose for several minutes.

 

 

 

 

 

 

PROCEDURE CHECKLIST

Inserting a Rectal Suppository

 

Check (ü) Yes or No

 

PROCEDURE STEPS	Yes	No	COMMENTS
1.  Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
2.  Asks if the patient needs to defecate prior to the suppository insertion.
3.  Assists patient to Sims’ position.
4.  If patient is uncooperative (e.g., confused, child) obtains help to immobilize the patient while inserting the suppository.
5.  Removes suppository wrapper and lubricates smooth end of the suppository and tip of the gloved index finger.
6.  Explains that there will be a cool feeling from the lubricant and a feeling of pressure during insertion.
7.  Uses nondominant hand to separate the buttocks.
8.  Asks patient to take deep breaths in and out through the mouth.
9.  Uses index finger of dominant hand, to gently insert suppository, lubricated smooth end first; or follows manufacturers’ instructions.
10.   Does not force suppository during insertion.
11.   Pushes the suppository past the internal sphincter and along the rectal wall (about 4 inches or 10 cm in an adult; 2 inches or 5 cm for a child).
12.   If the client has difficulty retaining the suppository, after removing the finger from the anus, holds client’s buttocks together for a few seconds or asks the patient to try to retain the suppository if he is able.
13.   Wipes anus with toilet tissue.
14.   Explains to patient the need to remain in side-lying position for 5 to 10 minutes.
15.   Leaves call light and bedpan within reach if suppository was a laxative.

 

 

 

PROCEDURE CHECKLIST

 Administering Ophthalmic Medications

 

Check (ü) Yes or No

 

PROCEDURE STEPS	Yes	No	COMMENTS
1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
2. If possible, assists patient to high Fowler’s position with head slightly tilted back.
3. If needed, cleans edges of eyelid from inner to outer canthus.
Instilling Eye Drops
4a. Holding eyedropper, rests dominant hand on patient’s forehead.
4b. With nondominant hand, pulls the lower lid down to expose the conjunctival sac.
4c. Positions eyedropper 1/2 to 3/4 inch (13 to 19 mm) above patient’s eye; does not let dropper touch the eye.
4d. Asks patient to look up; drops correct number of drops into conjunctival sac. Does not drop onto cornea.
4e. Asks patient to gently close and move the eyes.
5. If medication has systemic effects, presses gently against the same side of the nose to close the lacrimal ducts for 1 to 2 minutes.
Administering Eye Ointment
6a. Rests dominant hand, with eye ointment, on patient’s forehead.
6b. With nondominant hand, pulls the lower lid down to expose the conjunctival sac.
6c. Asks patient to look up.
6d. Applies a thin strip of ointment (about 1 inch; 2 to 2.5 cm) in conjunctival sac; twists wrist to break off the strip.
6e. Does not let tube touch the eye.
6f. Asks patient to gently close eyes for 2 to 3 minutes.
7. Explains that vision will be blurred for a short time.

 

 

 

 

PROCEDURE CEHCKLIST

Administering Vaginal Medications

 

Check (ü) Yes or No

 

PROCEDURE STEPS	Yes	No	COMMENTS
For All Vaginal Medications
1.  Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
2.  Has patient void before procedure.
3.  Positions patient in dorsal recumbent or Sims’ position.
4.  Drapes patient with bath blanket so that only the perineum is exposed.
5.  Prepares medication: a. Removes wrapper from suppository and places loosely in wrapper container. b. Or fills applicator according to manufacturer’s instructions.
6.               For irrigations, uses warm solution (temperature approximately 105°F).
7.  Uses only water-soluble lubricant.
8.  Inspects and cleans around vaginal orifice.
Administering a Suppository
9.  Applies water-soluble lubricant to the rounded end of the suppository and to gloved index finger on the dominant hand.
10.           Separates labia with gloved nondominant hand.
11.         Inserts the suppository as far as possible along the posterior vaginal wall (about 3 inches, or 8 cm). If the suppository comes with an applicator, places the suppository in the end of the applicator, inserts the applicator into the vagina and presses plunger.
12.         Has patient remain in supine position for 5 to 15 minutes. May elevate her hips on a pillow.
Applicator Insertion of Cream, Foam, or Jelly
13.   Separates labia with nondominant hand.
14.   Inserts applicator approximately 3 inches into vagina along the posterior vaginal wall.
15.   Depresses plunger, emptying medication into vagina.
16.   Disposes of applicator or places on paper towel if reusable.
17.   Has patient remain supine for 5 to 15 minutes.
Vaginal Irrigation
18.   Hangs irrigation solution approximately 1 to 2 feet (30 to 60 cm) above the level of the patient’s vagina.
19.   Assists patient into dorsal-recumbent position.
20.   Places waterproof pad and bedpan under patient.
21.   If using a vaginal irrigation set with tubing, opens the clamp to allow the solution to completely fill the tubing.
22.   Lubricates end of irrigatioozzle.
23.   Inserts nozzle approximately 3 inches (7 to 8 cm) into the vagina, directing it toward the sacrum.
24.   Starts the flow of the irrigation solution, rotates nozzle intermittently as solution is flowing.
25.   If labia are reddened, runs some of the solution over the labia.
26.   After all irrigating solution has been used, removes nozzle and assists patient to a sitting position on the bedpan (to drain all the solution).
27.   Removes bedpan.
28.   Cleanses perineum with toilet tissue or warm water and washcloth. Dries the perineum.
29.   Applies perineal pad if there is excessive drainage.

 

PROCEDURE CHECKLIST

Chapter 23: Irrigating the Eyes

 

Check (ü) Yes or No

PROCEDURE STEPS	Yes	No	COMMENTS
1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
2. Assists patient to low Fowler’s position (if possible), with head tilted toward affected eye.
3. Places towel and basin under patient’s cheek.
4. Checks pH by gently touching pH paper to secretions in the conjunctival sac (normal is approximately 7.1).
5. Instills ocular anesthetic drops, if ordered or on protocol.
6. Connects IV solution and tubing; primes the tubing.
7. Holds IV tubing about 1 inch (2.5 cm) from the eye; does not touch the eye.
8. Separates eyelids with thumb and index finger.
9. Directs flow of solution over the eye from inner to outer canthus.
10. Rechecks pH and continues to irrigate eye as needed.