The basic procedure in administration of medication is the same, regardless of type or route of administration. The equipment available and the agency policies may vary because nurses work in many different settings. General principles that underlie all procedures include accuracy, taking responsibility, and asepsis (preventing of infection). The legal policies and rules, along with the nursing process and knowledge about the drug, are all part of giving medications. The steps in giving medications by the various routes are generally followed as outlined in the following sections. There are wide differences in the specific process and equipment used in administering medications and institutional procedures may require some changes in the recommended procedure. Procedure 10-1 shows the basic procedure for administering oral medications that may be used when there is no sophisticated equipment available for the process. Following these steps each time reduces the chance of medication error. This is a clean procedure and begins with cleanly washed hands.

Procedure 10-1

Administering Oral Medications

Step One: Getting Ready

1. Check the accuracy of the order as written and the time to be given. Clarify any information now known about the patient or the medication, such as allergies.

2. Wash the hands well. This is essential to avoid contaminating the medication. Although it seems an obvious step, it is often neglected by busy nurses.

3. Assemble the medication equipment. Obtain the plastic medication cups, paper souffle cup, glass, water or juice, and straw if needed (A through F). Unlock medication cart, if necessary.

Step Two: Preparing the Medication

1. Read the order on the medication form and obtain the correct medication from the cabinet or cart (G). Medications may come in a cardboard or plastic container, a bottle, or an individually wrapped package.

2. Compare medication order with label on container. First check for the right patient, drug, route, dosage, and time of administration.

3. Open the container and pour the correct number of tablets or capsules into the paper medication cup.

• Do not touch the medication, but pour the medication directly into the bottle lid or the cup.

• Return any extra medication to the container (H).

 To avoid errors, hold the medication cup at eye level when pouring liquids (I).

 If the unit-dose system, Pyxis dispensing machine, or nurse service is used, the medication will come in a labeled package. It is not removed from the wrapping until the nurse is at the patient’s bedside (J).

4. Compare the information on the medication card or the medication administration record (MAR) with the label on the container. This is the second check for accuracy.

5. Close the box or replace the lid on the container, and check the information on it for the third time with the medication card or MAR. Medication lids are always replaced immediately after use.

• Medication that requires special storage (such as refrigeration) is replaced immediately.

6. Put the medication container back on the shelf.

7. Place the cup containing the medication next to the medication card or MAR on the tray.

8. Repeat this process for each medication ordered for the patient. All of the tablets for one patient may be placed in the same medication cup.

Step Three: Administering the Medication

1. Go to the patient’s bedside. Help the patient into an upright position, if possible. Ask the patient his or her full name and birth date at the same time the nurse is checking the patient’s identification bracelet. Their name may also be on a tag on the bed or door. If possible, scan bar code of patient’s identification bracelet and each medication to help ensure the correct patient is getting the medication. Never give medication without identifying the patient. Confused or critically ill patients may answer to any name.

2. Explain what medicine is being given and answer any of the patient’s questions. Give any special instructions or teach the patient about the medication as needed. Make any special assessments required. If the patient makes any comment about the medication looking different from usual, having just taken the medication, or not having had that medication before, recheck the medication order.

3. Give the patient a glass of water or juice and have the patient place the medication in the back of his mouth, take a sip of water, and swallow. Most medication dissolves better and causes less stomach discomfort when it is taken with adequate liquid.

4. Remain at the beside until the medication is swallowed. Do not leave medication at the bedside for the patient to take later. The nurse is responsible for making certain the medication is given when ordered. The nurse cannot ensure the patient takes the medicine unless the nurse see him or her swallow it.

Step Four: Concluding

1. Throw away the medication cup. Wash hands.

2. Update electronic records of the MAR or note on the chart the time that the medication was given and sign their name or initials. Record accurately that the medication was given as ordered. Also record if the drug was refused or omitted and notify the charge nurse or the health care provider if the patient did not take the drug for some reason.

3. Later, check the patient again and note any responses or adverse effects that need to be recorded on the medication card or MAR and reported.

The process for giving medications through a tube is similar to that given for oral medications, but with the following precautions:

Syringes, or instruments for injecting liquids, come in 1-, 3-, 5-, 10-, 20-, and 50-mL sizes and in plastic or glass. Plastic syringes are the preferred equipment because they may be used once and thrown away. This makes them convenient in terms of packaging and disposal, but they are more expensive than glass and cannot be used with some medications; also, dosage lines or calibration may be more difficult to read. Reusable glass syringes cost far less, but they may break, may become loose with constant use, and must be cleaned, repackaged, and sterilized each time they are used. Needleless syringe systems are also now available for use, consisting of a high-pressured delivery device, a needleless syringe, and a cartridge of pressurized air deliver the medication across the dermis. Needleless systems offer a pain-free alternative, although medications available for delivery through this method are limited. Cost and medication exposure (in the form of powdered or aerosolized compounds) are risks associated with the use of a needleless system (Figure 10-2).

Syringes are made up of three main parts (Figure 10-3). The tip is the portion that holds the needle. The needle screws onto the tip or fits tightly so it does not fall off. The barrel is the container for the medication. The calibrations are printed numbers on the barrel, and they indicate the amount or volume of medication in either minims (m), milliliters (mL), units, or cubic centimeters (cc) (Figure 10-4). The plunger is the inner portion that fits into the barrel. The medication is forced out through the needle when the plunger is pushed into the barrel.

The needle must be selected according to the needs of the medication. The needle is made up of the hub, or bottom part, which attaches to the syringe; the shaft, which is the hollow part through which the medication passes; and the pointed or beveled tip, which pierces the skin (Figure 10-5). The longer the pointed tip of the needle, the more easily the needle enters the skin. The diameter of the needle is called the gauge. The larger the number of the gauge, the smaller the hole. (For example, a 25-gauge needle is smaller than a 17-gauge needle.) Thick solutions require larger diameters for injection. The needle gauge is written on the needle hub and on the package. Needles also come in varying lengths, from inch to 3 inches. Generally, the smaller the needle (larger the gauge), the shorter the needle. The smallest needles are used for intradermal or subcutaneous injections because they do not need to go very far into the skin. Filter needles are also available for use when medication is drawn from an ampule to prevent uptake of glass shards and risk of injection. Needleless systems are a recent technology that allows the administration of medication through the dermis and into the bloodstream by way of a high-pressure needleless injection. Pressurized air drives aerosolized or powdered compounds through the skin, allowing for a pain-reduced or pain-free method of rapid administration. The needleless syringe or tip used in this procedure is disposable, as it does come in contact with the skin and is considered a one-time use component of the device.

There are also several specialized IV needles that are used when a needle is to be left in place in the vein for a long period (Figure 10-6). Short, small needles with plastic “wings” are used in infants and children, in the smaller veins of the hands in older adult patients, or in adults who are able to move around. These needles are referred to as scalp vein, butterfly, or wing-tipped needles, and all have small pieces of plastic on either side of the needle that can be pinched together when the needle is going in and then flattened against the skin and held in place with tape. These needles have a small, capped plastic tube attached to the hub that can be used when withdrawing blood specimens or injecting drugs such as heparin.

The sizes of the needle and syringe are determined by how viscous (thick) the medication is and by the amount to be injected. For example, blood is very thick and requires a 15- to 19-gauge needle. Sometimes when the volume is very small and the dosage must be very accurate (as with heparin or insulin), a small-gauge needle (such as a 27-gauge) is used so no medicine is lost. If more than 3 mL of medication is to be given IM, the medication must be divided and given in two injections so that a large pool of medicine does not form in the tissue, which would irritate the tissue. The hub of the syringe is to be to inch above the skin surface when the drug is injected. This allows the needle to be easily grabbed and pulled out if the patient jerks or the needle breaks. (This rarely happens.) A general guide for choosing the best syringe and needle sizes is presented in Table 10-1.

Table 10-1

Suggested Guide for Selecting Syringe and Needles

Route	Gauge (G)	Length (IN)	Volume to be Injected (mL)
Intradermal	25-27		0.01-0.1
Subcutaneous	25-27		0.5-2
Intramuscular	20-22	1-2	0.5-2
Intravenous	15-22		Unlimited

A needleless syringe (such as Dermo-Jet, Vitajet, AdvantaJet, Medi-Jector, and Preci-Jet 50) uses pressure to force aerosolized or powdered medication across the skin into the bloodstream, or directly into tissue, and can be used for some medications and immunizations. Various needleless infusion lines are also used (Figure 10-7). This type of delivery system is growing in popularity because it removes the risks associated with reusing needles and needle disposal.

Small, single- or multiple-dose glass or plastic containers of medication are called vials. The top of the glass container is covered first with a rubber diaphragm and then with a small aluminum lid. A tightly fitting metal band holds the rubber diaphragm in place. First the metal lid is removed, then the rubber diaphragm is cleansed with an alcohol wipe, and the needle is inserted through the rubber diaphragm into the medication. An amount of air equal to the amount of solution to be withdrawn is injected into the vial to assist the withdrawal of the medication (Figure 10-8).

The vial may contain a solution, or it may contain a powder to which a liquid must be added just before administration to make a solution. Read the label carefully to determine the type and amount of diluent that is required.

Needles are always inserted into the vial with the bevel up so the nurse may inspect the needle as it goes into the rubber stopper. The needle is always changed before administering the medication to the patient because forcing the needle through the rubber stopper may make it dull or create sharp, irregular edges called “burrs” that would produce pain when inserted into the patient.

Ampules contain one dose of medicine in a small, breakable glass container. The narrow neck of the ampule may have to be cut with a small ampule file, or may have a line (score) or ring around it, indicating a weakened area where the top can be broken off. All the medicine can be shifted to the bottom of the ampule by flicking the top lightly with a finger. Grasp the top above the scored or ringed area with an alcohol wipe or gauze pad and pull down sharply on the glass top. The top should easily fall off, allowing insertion of the needle into the ampule to draw up the medicine (Figure 10-9). A filter needle is used to prevent glass shards from being drawn up into the syringe with the medication. Ampules were very common forms of medication storage in the 1960s and 1970s, after which their popularity decreased because of the availability of less expensive vials. There is interest in using ampules again as a way to reduce allergic reactions to the latex stoppers in the vials. Therefore the American Society of Health Systems Pharmacists has recommended the use of ampules whenever possible.

Occasionally two medications may be ordered that may be given in the same syringe. Two compatible medications are often ordered to be given together as a preoperative medication before surgery (for example, meperidine [Demerol] and promethazine HCl [Phenergan]). Another example is the common practice of ordering two types of insulin (for example, regular and neutral protamine Hagedorn [NPH]) to be given together. In contrast, many antibiotics must be given in separate syringes because they chemically precipitate (harden and separate into layers) or become inactive if mixed together. It is important when mixing medications in one syringe to remember the following:

Medications that come as a powder must have a solution added immediately before use. The diluent for the powder and the amount to be used are to be specified on the label. Frequently, normal saline solution or sterile water is used. The diluent may be drawn into a 1- or 2-mL syringe and added to the powder. Roll the vial carefully to make certain all the powder is dissolved in the liquid. If the powder does not completely dissolve, do not give the medication. Some of these medications come in a two-compartment vial called a Mix-o-vial. The top compartment contains a sterile solution; the bottom compartment contains the medication powder. A rubber stopper separates the two areas. Pressure on the rubber plunger of the top compartment forces the rubber stopper below to fall into the bottom compartment, letting in the solution to dissolve the powder. The vial is gently rolled to help dissolve the powder, and then a needle may be inserted to withdraw the solution (Figure 10-10).

Any multiple-dose vial or newly mixed (reconstituted) powder solution must be clearly labeled when it is first opened. The date, time, and concentration are to be included, as well as the expiration time of the medication. The nurse who opened or mixed the medication also initials the label.

Many narcotics and emergency drugs (such as adrenalin) come in prefilled syringes and cartridges. These medication cartridges may be quickly slipped into a plastic holder and screwed into place; after the needle is added, the medication is administered (Figure 10-11). Prefilled syringes are particularly helpful when time is important (such as during a cardiac arrest) or when the dosage of medication rarely varies.

Medications or solutions to be given intravenously come in large plastic or glass containers that hold from 50 to 1000 mL. The opening to the glass container is plugged with a hard rubber stopper, a thin rubber diaphragm, and a metal cover. The metal cover and diaphragm are removed just before inserting the infusion tube that connects the bottle to the tube through a small hole in the hard rubber stopper. In many products, there is also a second small hole in the rubber stopper that allows air to enter the container to replace the amount of medication being infused. Plastic containers come sealed in another plastic bag, which is not opened until the infusion is to begin. Air may enter the plastic bag either at the bag opening or farther down on the infusion tubing (Figure 10-12).

Some medications, such as antibiotics, are ordered to be given every few hours. This medication comes from the pharmacy already mixed or as a solution to be injected into a smaller bottle or plastic bag, usually containing 50 to 250 mL of fluid, and hung with new tubing that is “piggybacked” or “secondary” to an infusion that is already running. The existing solution is clamped off while the piggyback medication is administered, usually over 20 to 60 minutes, and then the original solution is restarted. The piggyback medication being added must be compatible with the original solution.

After studying these general procedures for administering parenteral medications, examine specific techniques necessary for administration of intradermal, subcutaneous, IM, and IV medications. The equipment, sites of injection, and technique must be completely understood.

Intradermal injections are used to determine if someone has an allergy (allergy sensitivity testing), for tuberculosis testing, for vaccination, and for allergy desensitization shots. They are also used for injection of local anesthetics before wart removal, during suturing of the skin for minor cuts, and for minor procedures. The medication is injected into the intradermal space between the upper two layers of the skin, the epidermis, and the dermis (Figure 10-13). Injections are made into the inner aspect of the forearm, the scapular area of the back, and the upper chest, if these areas are reasonably hairless. Usually, just a small volume is injected, producing a small bump like a mosquito bite, called a bleb. The blood supply to this area of the skin is less than in other areas, so there is very slow absorption from the intradermal layer. Once the medication has been injected, the patient should not wear tight clothing over the area.

Equipment and Technique

Usually 0.01 to 0.1 mL is injected, so a needle that is both small (25 gauge) and short ( inch) is used. The needle is inserted firmly at a 15-degree angle. The bevel or slanted tip of the needle is pointing upward. The medication is injected, and the needle is swiftly removed. The small bleb should be seen on the skin at the point where the medication was injected into the intradermal space.

If the injection was given for allergy or sensitivity testing, it is important to record the concentration of the medication used and the site of the injection (Figure 10-14). Many reactions to intradermal injections are not apparent for several hours or even days after injection. It is sometimes helpful to draw a circle around the injection site with a pen to help identify the site accurately at a later date when it is inspected for any reaction. The patient has an allergic reaction, or a clinically significant reaction to testing, if there is a wheal (elevated area) at the site where the diluted dose of medication was injected. The amount of swelling is measured at 5, 10, and 15 mm.

If the patient has an allergy, the injection site may also become red, swollen, and very itchy (pruritic). The patient should not scratch this area and should use cool, wet compresses to reduce the irritation. The patient should call the health care provider or go to an emergency room if he has any symptoms in any other body systems, particularly trouble breathing, shortness of breath, puffiness of the face, or hives.

Skin reactions to intradermal allergy injections or to testing for tuberculosis (purified protein derivative test) must be checked at a predetermined time after the injection. Each agency has a policy on how the patient reaction is to be evaluated and recorded. When testing is done on an outpatient basis, a reliable patient is often told to look at injection site and mail in a postcard showing a picture that is most similar to the reaction. Table 10-2 shows common reactions to intradermal injections and how they are described.

Table 10-2

Description of Intradermal Skin Reactions

Observation of Skin	Recording Symbols	Reaction
	(0)	No reaction
	(1)	Redness or erythema of skin
	(2)	Redness and elevated lesions or papules up to 5 mm in diameter
	(3)	Redness, papules, and vesicles (fluid-filled elevated lesions) up to 5 mm
	(4)	Generalized blister larger than 5 mm

Subcutaneous injections involve placing no more than 2 mL of fluid into the loose connective tissue between the dermis of the skin and the muscle layer (Figure 10-15). (This is a little deeper than the intradermal injections we have been discussing.) Because less blood is normally supplied to this area than to muscle, any medication injected here will be slowly, but completely, absorbed. This means there will be a slow onset of medication action but a long duration of drug action. Medications injected into the subcutaneous tissue are usually very strong, but concentrated into small doses. For example, insulin and heparin are the most frequently given subcutaneous injections. Because these medications are often given daily for a long time in patients with chronic illnesses, special care must be taken not to irritate the tissue with repeated injections in the same area.

Equipment and Sites for Injection

In preparing the subcutaneous injection, only a small syringe and needle are needed. Usually a 25- or 27-gauge needle is used, and one that is no longer than inch in length.

The sites used for subcutaneous injection depend on whether the nurse or the patient is giving the injection. Commonly, the nurse gives subcutaneous injections in the upper arms, upper back, or scapular region. The nurse in the hospital will often need to teach the patient how to give herself or himself the subcutaneous injection while the patient is in the hospital and can practice under the nurse’s supervision. The patient is able to inject herself or himself most easily in the upper arms, anterior thighs, and abdomen. The patient should develop a rotation plan for injection sites, and this is posted with the patient’s medications or by the patient’s bedside. The front view in figure 10-16 shows areas usually used for self-injection. The back view shows less commonly used areas that may be used by the nurse. The site used is part of the information recorded about the injection.

Insulin injections are absorbed 50% faster from the abdomen than from other areas. Other sites for injection include arms, thighs, and buttocks. Because it may be difficult for patients to remember where they last injected the insulin, a “tape-dot” method has been developed. Using the face of a clock, patients inject themselves in the abdomen at 3, 6, 9, and then 12 o’clock. After each injection they put a small dot of tape over the injection site. When they get around to the 3 o’clock position again, they move to the extremities and then back to the abdomen, 1 inch to the side of their previous injection, and start their new series of dots. Thus the sites are rotated in an organized manner. Teach diabetic patients to avoid injecting within 1 inch of a previous injection site for 1 month in order to avoid tissue damage.

The IM route is a common route for parenteral injections. Many antibiotics, preoperative sedatives, and narcotics are administered intramuscularly. In intramuscular (IM) injections, the medication is deposited deep into the muscle mass, past the dermis and subcutaneous tissue and into the very deepest layers of the muscle (Figure 10-17), where the rich blood supply allows for rapid and full absorption. The muscles also contain large blood vessels and nerves, so it is important to place the needle correctly to avoid damage to these structures.

Sites for Injection

Five muscles are commonly used for IM injections: the deltoid, dorsogluteal, rectus femoris, vastus lateralis, and ventrogluteal muscles. Each site has advantages and disadvantages, and must be correctly identified for safe administration. These sites have been selected because they are usually away from major blood vessels and nerves, and so are safer to use. Some of these sites are not used for children. Use of the dorsogluteal site most often results in accidental injury to patients because it is close to the sciatic nerve. It is rarely used for IM injections because there have been so many lawsuits related to permanent nerve damage caused by a needle. However, if care is taken to properly identify landmarks, it is a site that may be used when other sites cannot be used. Box 10-3 summarizes the five sites for IM injections and how to identify them.

Box 10-3

Sites for Intramuscular Injections

Deltoid Muscle

The deltoid muscle is easily reached but used infrequently because the muscle is small and can accommodate only small doses of medications. The deltoid is also near the radial nerve. No more than 2 mL may be injected here (less in children), and the medication should not be irritating and absorbed quickly. For this site, seat the patient upright or have the patient lie flat with the arms apart. Two imaginary lines can be drawn across the armpit at the level of the axilla and the lower edge of the acromion, the sharp point of the shoulder. Two more imaginary lines are then drawn down on either side, one-third and two-thirds of the way around the outer lateral aspect of the arm. This creates a small rectangle in which medication can be safely given.

Dorsogluteal Muscle

The dorsogluteal muscle is a common injection site for adults because it is relatively free from nerves and major blood vessels. However, the muscles are not developed enough for this site to be used for children younger than 3 years of age. The patient must lie prone (on stomach) on a flat surface and point the toes inward to relax the muscles. An imaginary cross can be drawn from the anus laterally, and from the posterior superior iliac spine down the leg. The injection is given in the upper, outer quadrant of the cross. Hold the syringe perpendicular to the flat surface and inject the medication. Many nurses are afraid to use this site because the sciatic nerve may be injured when nurses fail to properly identify the landmarks.

Rectus Femoris Muscle

The rectus femoris muscle lies medial to (toward the middle of the body from) the vastus lateralis muscle, but does not cross the midline of the anterior thigh. It is used in both children and adults, especially for self-injection. Injections here may be painful if the muscle is not well developed. For this site, position the patient in bed either sitting up or lying flat.

Vastus Lateralis Muscle

The vastus lateralis muscle is located on the anterior lateral thigh away from blood vessels and nerves. It can absorb a large volume of medication. This is the preferred site for intramuscular (IM) injections in infants; it is also a good site for healthy, ambulatory adults because there are few near major blood vessels and nerves. The muscle mass here tends to shrink or become smaller in elderly or very ill patients and may be inadequate. The muscle extends from one handbreadth below the greater trochanter to one handbreadth above the knee.

Ventrogluteal Muscle

The ventrogluteal muscle is a large muscle mass that is free of major nerves and adipose tissue, and is also remote from the rectum (minimizing the risk of contamination). Whether the site may be used for children depends on the extent of muscle development. The patient lies on the side with the upper leg flexed, or lies prone (on stomach) and points the toes inward to relax the muscles. The palm of the nurse’s hand is placed on the lateral portion of the greater trochanter, the index finger on the anterior superior iliac spine, and the middle finger extended to the iliac crest. The injection is made into the center of the V formed between the index and middle fingers, with the needle directed slightly upward toward the crest of the ilium.

Technique

The process for giving of IM injections is the same as that for other parenteral medications, except for several additional items:

1. Carefully select the site and identify the landmarks before picking up the syringe. Have all equipment ready. This is especially true for children, who will not hold still for a prolonged time after the nurse finds the site.

2. Insert the needle firmly, usually at a 90-degree angle, and give the injection. The policy over the years when giving an IM injection is to always make sure that the needle is in the muscle and that you have not accidentally entered a vein or artery. To do this, the nurse will pull back on the plunger and check the syringe for any blood (aspirate) before injecting the medication. More recent research suggests that there is little chance of having the needle in a vein or artery and to reduce the pain of injection, the nurse does not pull back on the plunger to aspirate and, instead, injects the solution as quickly as possible. Some hospitals also suggest that the skin next to the needle be pinched to focus pain perception on the pinched area and “trick” the brain into not recognizing the pain from the injection. The nurse will need to follow the hospital policy in giving IM injections as the policy is in a state of change in many schools.

3. After withdrawing the needle, apply gentle pressure to the site with a dry cotton pad. (Use of an alcohol swab may cause burning.) Massaging the area may increase pain if a large amount of medication has been injected. Because bleeding often occurs after IM injections, a small bandage may be necessary. Rotate the site of injection when repeated injections are needed.

4. Some medications are irritating or may stain the skin (for example, iron). Use the “Z-track technique” of injection (Figure 10-18) for these medications. The Z-track technique uses the skin itself as a “door” to seal in the drug and prevent it from leaking back out. Medications of the type that require the Z-track technique are injected into the ventrogluteal site. Use a long needle and add 0.5 mL of air to the syringe after drawing up the medication to ensure that all of the medication is injected from the needle. Stretch or pull the skin approximately 1 inch to one side. Insert the needle, aspirate, inject the medication slowly, and wait approximately 5 seconds. Remove the needle and let the skin slide back to its normal position. Do not massage the injection site. The patient should avoid putting pressure on the area from clothing, although walking helps increase absorption.

Topical medications are applied directly to the area of skin requiring treatment. The most common forms of topical medications include creams, lotions, and ointments, although there are many others. Each form of topical application has specific advantages and characteristics. Several forms are discussed in Box 10-4.

Technique for Nitroglycerin Ointment

Medicated ointment is an increasingly common method of giving nitroglycerin to patients with chest pain from angina. When properly applied, nitroglycerin ointment (Nitrol or Nitro-Bid) can provide constant medication to help prevent anginal attacks.

To apply nitroglycerin ointment, select a site on the chest, upper arm, or flank areas. Use an area without hair. Adhesive tape applied to the skin and removed quickly will help remove small hairs. Do not shave the skin because this may cause skin irritation when medication is applied. Clean the skin gently with an alcohol wipe. The physician or health care provider will order the patient to apply a certain number of inches of nitroglycerin ointment. A measuring applicator paper that looks like a ruler is provided with the medication (Figure 10-31). The correct number of inches of medication is squeezed onto the applicator paper as a small ribbon. The applicator paper is then laid on top of the skin where the medication is to be applied. There are several ways to proceed:

1. The applicator paper is laid on the skin, ointment side down, and left in place. The area is not rubbed.

2. The applicator paper may be covered with plastic wrap that is taped in place to prevent stains on clothing. It must be changed every 3 to 6 hours, depending upon the prescriber’s order.

3. The applicator paper is removed, and the area is covered with plastic wrap, spreading the nitroglycerin over a larger area.

Transdermal Delivery Systems

Disks or transdermal patches are another method of giving constant medication through the skin. Some medications using a transdermal delivery system include fentanyl, nitroglycerin, birth control pills, scopolamine, testosterone, and clonidine. Various antismoking programs also use nicotine patches. The principles for administration are similar to those for applying nitroglycerin ointment.

The medication comes packed over a semipermeable membrane and an adhesive patch. A site is chosen for application according to a standard rotation pattern. The patch is carefully picked up, and the clear plastic backing is removed from the patch, showing the medication (Figure 10-32). The medicated side is then pressed firmly onto the skin. The outer edge of the patch is adhesive and will hold the patch tightly to the skin. Patches are changed on a regular schedule, as indicated by the product, unless they become loose or come off and require replacement. Transderm-Nitro, Fentanyl patches, Nitro-Dur, and birth control patches may be worn while showering; all other medicated patches are to be applied after bathing.

The procedure for applying medications to mucous membranes follows the general format already discussed. Different mucous membranes require minor changes in technique, which are listed in Procedure 10-6.

Procedure 10-6

Administering Medications to Mucous Membranes

Buccal Area of Cheek

The patient holds the medication between the cheek and molar teeth (A),

where it is rapidly absorbed into the bloodstream and reaches the systemic circulation without being metabolized by the liver. This site is used for nitroglycerin tablets to relieve chest pain.

Ear

Localized infection or inflammation of the ear is treated by dropping a small amount of a sterile medicated solution into the ear. Very low dosages of medication are required, and the medication label must indicate that it is for otic (ear) usage. Have the medication at room temperature. The patient lies on the side with the affected ear up. Shake the medication well and draw the medication up into the dropper. In children younger than 3 years, gently pull the earlobe down and back (B); in adults, gently pull the earlobe up and out (C)

. This will straighten the external canal so that the medication may be dropped into the canal. Do not touch the dropper to the ear. The patient is to remain in the same position for 5 minutes to allow the medication to coat the surface of the inner canal. A cotton ball may also be inserted, if ordered. Repeat in the other ear if indicated.

Eye

Sterile drops or ointments in very low dosage and specifically labeled for ophthalmic (eye) use may be applied to the eye. Gloves are used during the procedure. The eye may be cleaned with normal saline and cotton balls to remove exudate (discharge) or previous medication. Wipe from the nasal side out. Have the medication at room temperature. Infants may need to be restrained. Have the patient look up, and pull out the lower lid to show the conjunctival sac (D). Never touch the eye with the dropper or the ointment tip. Drop the medication or squeeze the ointment into the conjunctival sac, not onto the eye itself. Using a cotton ball, apply gentle pressure to the inner corner of the eyelid on the bone for 1 to 2 minutes to ensure adequate concentration of medication and prevent medication from draining rapidly into the nose (E)

. Instruct the patient to move their eyes around with eyelids closed to spread the ointment over the surface of the eye. Sterile dressings may be ordered to cover the eye at conclusion of treatment.

Nose

Nasal solutions act locally to treat minor congestion or infection. To instill nasal drops, draw the medication into the dropper (F). Have the patient gently blow the nose and then lie down with the head hanging back over the side of the bed (G). Hold the dropper just over one nostril, taking care not to touch the dropper to the skin, and administer the required number of nose drops. Have the patient turn the head slightly. The procedure is repeated for the other nostril. Infants may need to be restrained.

If a nasal spray or inhaler is used, the solution is shaken, the patient sits upright, one nostril is blocked, and the tip of the nasal spray is inserted into the nostril (H). As the patient takes a deep breath, squeeze a puff of spray into the nostril (I).

Wipe tip of spray bottle if medication is to be sprayed into both nostrils. Less medication is required with the spray, and the medication is rapidly absorbed into the vascular areas of the nose for prompt action.

Respiratory Mucosa

Medication may be carried through the mouth or nose and down into the respiratory tract through use of aerosol nebulizers, or metered-dose inhalers. These techniques require special equipment that must be kept very clean, and that breaks the medication up into very small particles, which can be carried with air down into the lungs where the desired action takes place.

Aerosols

Aerosols use a special nebulizer mouthpiece, and medications are diluted according to a special concentration. Oxygen is used to deliver the medication. The patient sits upright, places the nebulizer mouthpiece loosely in the mouth, and breathes in and out slowly and deeply while the oxygen is directed through the nebulizer until the medication is gone. The equipment must be cleaned after it is used.

Metered-Dose Inhalers

Metered-dose inhalers are used to deliver specific amounts of corticosteroids or bronchodilators to nasal or lung tissue. These small canisters are pressurized with gas, which propels the medication out and breaks it up into small particles that can be carried deep down into the lungs as the patient takes a deep breath. The medication is carried directly to the site of action with very little systemic effect. The onset of action is rapid. Some medications are designed to be administered through the mouth, and others through the nose. It is important to read the directions completely. Shake the medication before use. If a patient can stand, he or she then leans slightly forward so his or her feet are visible. If a patient must sit upright, have the patient hold the nebulizer in the hand 1 to 2 inches in front of the mouth or at the opening of the nose (J). If the patient cannot cooperate, he or she may place his lips around the mouthpiece. Have the patient exhale, then squeeze the canister in its holder as the next inspiration begins. This will carry medication down into the lungs. Have the patient hold her or his breath as long as possible before exhaling to allow the medication to settle before administering in the other nostril or taking another puff. It is important to time the squeezing of the nebulizer to ensure that medication travels in with the next breath and is not just squirted on the back of the throat or nose. The nebulizer must be cleaned with water after each use. It is important that the patient keep an adequate supply of medication on hand. Check a metered-dose canister for medication by placing it in a glass of water. K, Canister is full. L, Canister is partially filled. M,

Canister is nearly empty.

Sublingual Mucosa

The patient places the tablet under the tongue (N),

where it dissolves, is rapidly absorbed through the blood vessels, and enters the systemic circulation. This site is used for nitroglycerin tablets to relieve chest pain.

Vagina

Medication to treat local infections or irritation may be applied vaginally through creams, jellies, tablets, foams, suppositories, or irrigations (douches). Room-temperature suppositories are inserted into the vagina with a gloved hand, much like a rectal suppository is inserted. Creams, jellies, tablets, and foams are inserted with a special applicator that comes with the medication. With the patient lying down, the filled vaginal applicator is inserted as far into the vaginal canal as possible and the plunger is pushed, depositing the medication (O).

The patient is instructed to remain lying down for 10 to 15 minutes so all the medication can melt and coat the vaginal walls. The patient may need a perineal pad to catch any drainage or prevent staining. Gloves must be carefully discarded according to hospital regulations.

Some medicated solutions are used to wash the internal vaginal area when infection and irritation are present. These solutions are administered as douches. The patient may be on a bedpan or reclining in a bathtub. A douche bag containing a medicated solution is hung from an IV pole or shower head so that it is placed approximately 12 inches above the patient’s hips. The tubing is clamped shut. The vulva is gently washed by slowly unclamping the tubing, and then the douche nozzle is inserted into the vaginal canal 3 to 4 inches and pointed downward toward the patient’s tail bone (coccyx). The labia are held shut while the solution is gently introduced. As much solution as possible is allowed to fill the vaginal canal before the labia are opened and the solution flows out. Rotate the nozzle gently to allow the solution to reach and wash all areas. When all the solution has been used, the nozzle is withdrawn, all the equipment is cleaned and put away, and the gloves are discarded.