LESSON THREE Administering oral, topical and inhaled medications Introduction The most common route of medication administration is oral, although perhaps an easier one to prepare it still warrants careful procedural skills to avoid medication errors. Clients should be aware of what each pill or tablet is for, and what adverse effects or signs of toxicity to monitor. To ensure client-centered care it is essential the nurse involve the client when changes in doses or medications are made. Other routes of administration such as nasogastric, transdermal, optic and inhaled are also becoming more common, as more and more of the population live with chronic illnesses. The nurse must be aware of what assessment data to collect and considerations to review when administrating administrations through any of these routes. The following lesson reviews the procedure and rationale for nursing actions for the routes of oral, nasogastric, transdermal, optic and inhaled medication administration. Learning Outcomes 1. Describe the various forms of medications, and explain why a particular form or route may be the one of choice for a specific client. 2. Demonstrate how to safely and competently prepare and administer oral medications. 3. Describe how to safely and competently prepare and administer nasogastric medications. 4. Discuss how to safely and competently prepare and administer transdermal medications. 5. Understand how to safely and competently prepare and administer optic medications. 6. Explain how to safely and competently prepare and administer inhaled medications. 7. Describe the client education involved with administering oral, nasogastric, transdermal, optic and inhaled medications. Required Readings See required reading list January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 1
Routes of Administration The route of administration of a drug affects the amount given and the rate at which the drug is absorbed into, and distributed through the body. These variations affect the action of the drug and the client s response. Although the prescriber will specify the route in which the medication is to be administered, the nurse must be able to use his or her clinical judgment to determine if that is indeed the best choice. For example, the physician may prescribe and oral route to a client who is vomiting. A rectal or parenteral route would be a better choice in this situation, as the client will not be able to tolerate the oral dose. The following summarizes the advantages and disadvantages of various routes of medications, as described in your required reading. Advantages Disadvantages Oral, Buccal and Sublingual Routes: Comfortable Convenient Less expensive Easy to take Can produce systemic or local effects Usually don t cause client anxiety Cannot give when client has GI upset such as nausea or vomiting, or reduced motility Some medications are destroyed by stomach acid/secretions Cannot give to clients with swallowing problems May irritate the GI system, discolor teeth or leave unpleasant taste in the mouth Difficult to give to confused client (have them hold under the tongue) Cannot be given to clients with gastric suction, and before some tests and surgeries Parenteral Routes: (IV, IM, ID, sub-cut) Offers another route of administration when oral contraindicated Has the most rapid absorption IV therapy useful for critical or long-term illness Higher risk of infection Some medications are expensive Clients experience pain/discomfort with injections/needlesticks/ivs Avoid sub-cut, IM and ID in clients with bleeding tendencies Sub-cut injections can damage tissue IM and IV are absorbed easier, which increases the risk of adverse client reactions Can cause anxiety, especially in children January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 2
Advantages Disadvantages Dermal Route: (topical, transdermal, mucous) Topical- local effects, painless, limited side effects Transdermal- prolonged systemic effects with limited adverse effects Mucous Membranes- (ears, eyes, vaginal, rectal), local effects, some aqueous medications are capable of causing systemic effects, offers alternative route to oral Topical- slow absorption, skin abrasions increase risk of rapid med absorption and systemic effects Transdermal- can leave substance on skin, may stain clothing Mucous Membranes- can be highly sensitive to certain medication concentrations, insertion of rectal and vaginal medications may cause embarrassment, cannot give rectal suppositories to clients with rectal bleeding or surgery Inhalation: Offers rapid relief from respiratory problems Can be used for anesthesia Some inhalant medications can cause serious adverse effects Please Read: Lesson Three: Required Reading 1 January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 3
Oral Administration The oral route is the most common method of drug administration, medication are given in tablets, capsules and liquids. You may sometimes be required to crush a tablet or dissolve a capsule, in order to mix it in juice or applesauce. This is often required to make the medications more palatable for the young child, or to make it easier for a client, such as the older adult, to swallow. Take a moment to review some important points about medications that are administered orally: Tablets: can be crushed and mixed with appropriate additives, can be split only if scored Scored Line, where you would split tab Enteric-coated tablets: are coated with a hard shell that prevents the medication from being released in the acidic environment of the stomach, instead the coating will dissolve in the more basic environment of the small intestine. This is useful for medications that are irritating to the stomach, or for those that will be rendered inactive by the stomach s acidity. Enteric-coated tablets should not be crushed, chewed or scored. January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 4
Capsules: should also not be opened as disrupting the coating interferes can interfere with the absorption of the medication or irritate the stomach. In certain circumstances, such as with specific routes, (e.g., nasogastric tubes) and specific medications, capsules may be opened up and dissolved in water for administration. Consult your pharmacist to ensure that this practice is appropriate. Sustained-release, or long-acting tablets or capsules: Some medications also come in sustained-release or long-acting preparations. These medications are released gradually but continuously into the bloodstream, and thus exert their effects over a longer period. Benefits include steadier control and improved adherence, as clients take less medication. These medications cannot be split, crushed, chewed or opened and added to anything administered to the client. This may alter its rate of absorption, reduce overall effect, or put too much medication into the client s blood stream at one time. It is also important to note that these medications often have similar names as their short-acting counterparts, with perhaps a different prefix or abbreviation after the drug name. o Terms associated with sustained-release medications: SR, e.g., verapamil SR Contin, e.g., MS Contin (morphine sulphate) XR, e.g., Effexor XR (venlafaxine) CC, e.g., Adalat CC (nifedipine) Liquids: Some medications are in a liquid form, while others can be converted into a liquid form for ease of administration (e.g., for children or via nasogastric tube). It is important to shake liquid well to resuspend medication, and ensure proper measurement of the medication. To ensure accuracy, use a calibrated oral syringe for doses less than 10 ml, do not use a hypodermic syringe or needle. Use of a hypodermic syringe may result in inadvertently administering the mediation parenterally, or the needle falling off and being aspirated by the client. For larger doses, use a medication cup. Teach clients and families to use calibrated measuring spoons instead of regular eating utensils for home administration. It is imperative that you conduct your nursing assessments, health history and physical examination, prior to administering any oral medications. Pay particular attention to assessment January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 5
findings that will be effective by certain medications, for example, pulse rate, blood pressure, pain levels and blood glucose levels. If your client is having difficulty swallowing, you can crush the mediation and mix it with apple sauce or pudding. Remember to mix and label each pill individually, that way if it is spilled or refused you know which medication it was. Ensure that the pill-crushing device is clean when you use it. Sit client in an upright position. Clients should be given the medications with a full glass of water, or their fluid of preference. Remain with the client until all medications have been swallowed. Now that you are aware of these important considerations with the various forms of oral medications, please review how to administer medications through an oral route. The following readings also review how to properly administer medication via the topical, transdermal, nasogastric and mucous membranous routes. Remember, administering medications via the topical, transdermal, nasogastric and mucous membranous routes will not be tested on the practical exam; however the theoretical knowledge regarding these skills will be tested on the quizzes and the final theoretical exam. Please Read: Lesson Three: Required Reading 2 January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 6
Skill Checklist The following is the step-by-step skills checklist that you will practice in the classroom sessions for administration of oral medications. Your required readings contain the rationale for each step, which will be tested in your theoretical exam. Your practical exam will test your ability to perform this skill. Administration of Oral Medications (unit dose-tabs) 1) Ensures accurate assessment data collected for medication administration. 2) Performs thorough hand hygiene. 3) (First Check) Read the medication administration record (MAR) and remove the medications from the patient s drug cupboard. Verify that the patient s name and room number match the MAR. 4) Compare the label of the medication against the MAR. If dosage does not match the MAR, math calculations may be necessary. 5) Check the expiration date of the medication. 6) (Second Check) Check medication label against the MAR. Opens one medication package at a time and places medication in med cup, do not discard packages. 7) Maintains clean technique when pouring medications. 8) (Third Check) Recheck label on the empty package and poured medication with MAR. Discard empty packages. Place a small DOT on the MAR to indicate you have poured that medication. 9) Takes medications and drink to client, identifies client by checking armband with MAR and asking client their name. 10) Positions client appropriately. 11) Ensures client swallows each medication. 12) Disposes of soiled supplies appropriately. 13) Performs thorough hand hygiene, documents medication administration. January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 7
Activity 1 Review 1. Why should you never cut or crush an enteric coated tablet? 2. What is meant by parenteral? 3. What are the advantages and disadvantages of taking medications by mouth? 4. PRESCRIPTION: nitroglycerin (Nitrostat) 0.6 mg sublingual STAT. You HAVE: 0.3-mg strength tablets. How many tablets will you administer for a dose of 0.6 mg? January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 8
5. PRESCRIPTION: warfarin sodium (Coumadin) 7.5 mg po once daily. You HAVE: 5-mg strength tablets. How many tablets will you administer for a dose of 7.5 mg? 6. PRESCRIPTION: valsartan (Diovan) 80 mg po once daily You HAVE: 80-mg strength tablets. How many tablets will you administer for a dose of 80 mg? 7. PRESCRIPTION: glyburide (DiaBeta) 2.5 mg po ac breakfast. You HAVE: 5-mg strength tablets. How many tablets will you administer for a dose of 2.5 mg? 8. Is it safe to use a hypodermic syringe and needle to administer liquid medications orally? Explain the rationale below. 9. Why should you not score a medication that is not pre-scored? January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 9
10. You are administering medications to Mr. Smith through his nasogastric tube. Some of his medications require you to crush them and dilute in tepid water. What actions can you take to ensure that the nasogastric tube does not become clogged? 11. Why should nasogastric tube feedings be held 15 to 30 minutes prior to medication administration? 12. You check for placement and for gastric residual by aspirating Mr. Smith s gastric contents. You are able to aspirate 250 cc of aspirate, what should you do? What does this finding indicate? 13. You are now going to change Mr. Smith s transdermal medication patch that he is prescribed as part of his pain management. Describe the steps that you would take to ensure the patch is correctly and safely applied. January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 10
14. You are now to administer an eye medication that can cause systemic effects. Describe what you would do to prevent the medication from entering the systemic circulation. 15. List the common problems that client s experience when administering inhaled medications using metered-dose inhalers. 16. Your client is prescribed the following, fluticasone propionate 2 puffs bid via MDI. There are a total of 200 inhalations in the MDI. Approximately how many days will the MDI last the client? January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 11
Conclusion Administration of oral medications is a very common practice for the Registered Nurses and is a simple skill to master. Despite this, the nurse must maintain judicious safety checks and gather appropriate assessment data. This includes the client s ability to swallow, tolerate the medication and other parameters specific to the medication. Other routes of administration including nasogastric, topical, transdermal, inhaled and via various mucous membranes also require specific knowledge and consideration. January 2016 RN Professional Development Centre & Nova Scotia DHW, Halifax, NS 12