safe administrations of medications (draft chapter)

7/25/2019 Safe Administrations of Medications (Draft Chapter)

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Author: Tracy Levett-Jones

Clinical Reviewers: Natalie Govind and David Newby

Section 6.1 Introduction

Section 6.2 Oral medication administration

Section 6.3 Topical medication administration

Section 6.4 Parenteral medication administration

MEDICATIONADMINISTRATION

UNIT 6

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240

A medication (or drug) is a substance administered for

the diagnosis, cure, treatment, or relief of a symptom or

for prevention of disease. Preparation and administration

of medications are complex processes involving counting,

calculating, measuring, mixing and ensuring that the right

person receives the right medication in the right dose, at the

right time, by the right route, and for the right reason.In Australia, medications are dispensed on the order of

a doctor, dentist, eligible midwife or nurse practitioner. In

the health care context, the words medication and drugare

often used interchangeably. The written direction for the

preparation and administration of a medication is called a

prescription. Medications have chemical, generic and trade

names. The chemical namedescribes the constituents of the

drug. The generic nameis given by the manufacturer that

first develops the drug and is the name used on prescriptions

and on medication charts. Thetrade nameor brand name

is the name given to it by drug manufacturers. Because one

medication may be manufactured by several companies,

it may have several trade names. For example, N-acetyl-p-

aminophenol is the chemical name for paracetamol (generic

name) which has a number of trade names including

Panadol, Tylenol and Panamax.

LEGAL ASPECTS OF

MEDICATION ADMINISTRATION

The administration of drugs in the Australia is controlled

by law. Nurses need to (a) have a sound understanding of

the laws that govern their scope of practice in relation to

medication administration, and (b) recognise the limits of

their own knowledge and skill.

Under the law nurses are responsible for their own actions

regardless of whether there is a written medication order.

LEARNING OUTCOMES

On completion of this section you will be able to:

1. Define the key terms related to medication administration.

2. Describe the legal and professional aspects ofmedication administration.

3. Discuss the impact of person-centred care andinterprofessional communication on medication safety.

4. Identify the essential parts of a valid medication order.

5. Outline the types of medication preparations and routesof administration.

6. Outline the key components of a medication history.

7. List the five rights and three checks for safemedication administration.

INTRODUCTION

SECTION 6.1

KEY TERMS

adverse effect, 241

chemical name, 240

drug, 240

generic name, 240

medication, 240

medication error, 241

medication history, 246

near miss, 241

prescription, 240

side effect, 241

therapeutic effect, 241

trade name, 240

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UNIT 6 SECTION 6.1 INTRODUCTION

241

This means that if a medical officer writes an incorrect order

(e.g., morphine 100 mg instead of morphine 10 mg), the

nurse who administers the incorrect dosage is responsible

for the error as well as the medical officer. Therefore, nursesneed a sound foundation of pharmacological knowledge, the

skills to access reliable drug resources, and the confidence

to question any order that appears illegible, ambiguous,

unreasonable, or contraindicated by the persons condition.

The right to refuse to administer a medication is sometimes

referred to as one of the Rights of medication administration.

Another legal aspect of medication administration is the use

of controlled substances (listed under Schedule 8 of the Poisons

Standard 2012). In hospitals, controlled substances are kept

in a locked drawer, cupboard, medication cart or computer-controlled dispensing system, and an inventory of their use

is strictly maintained. Hospitals have clear protocols about

the storage, access and use of Schedule 8 medications. These

controlled substances require verification and documentation

of administration by two registered nurses.

MEDICATION SAFETY

Medication errors are the second most common type of

incident reported in Australian hospitals with error rates of over

18% (Johnson, Tran & Young, 2011) and only 421% of people

achieving the optimum therapeutic benefit of medications

(Garfield, Barber, Walley, Willson & Eliasson, 2009). In the

Australian public health system medication adverse events cost

approximately $6 billion dollars per year and inappropriate

use of medicines $380 million (National Health and Hospitals

Reform Commission, 2008). It is likely, however, that the

available figures underestimate the extent of the problem.STANDARDS FOR PRACTICE

The Nursing and Midwifery Board of Australia

(NMBA) Standards for Practice (2016) specify

that the registered nurse complies with legislation,

regulations, policies, guidelines and other standards or

requirements relevant to the context of practice when

making decisions (NMBA, 2016, p. 3).

TABLE 61 Effects of Drugs

Therapeutic effect The intended effect and the reason the drug is prescribed.Example: the therapeutic effect of morphine sulfate is analgesia.

Side effect An unintended effect of a drug that is usually predictable and may be either harmless or potentially harmful.Example: A side effect of morphine sulfate can be nausea and vomiting.

Adverse effect(reaction or event)

A severe side effect that may justify a dose reduction or discontinuation of a drug. An adverse drugeffect is a response to a medication, which is harmful and unintended, and which occurs at normal doses.Example: An adverse effect of morphine sulfate may be respiratory depression.

Medication error Any preventable medication event that leads to, or has the potential to lead to, harm to the person.Example: Administering 30 units of insulin instead of the 3 units ordered.

Near miss A medication error that was detected and corrected before it reached the person.Example: Amoxicillin is ordered for a person with an allergy to penicillin but identified by the nurse before

for the drug is administered.

CLINICAL SAFETY ALERT

In Australian hospitals, 38% of medication errors

occur at the administration stage, indicating the

critical need for nursing students to develop clinical

skills and knowledge that promote medication safety

(Roughead & Semple, 2009).

The impact of person-centredcare and interprofessionalcommunication on medicationsafetyThe safe, timely and effective administration of medicines is

dependent not only on individual responsibilities, but also

effective collaboration between all members of the medication

team (Madegowda et al., 2007). Medication incidents are

often related to a lack of effective communication among

health professionals such as doctors, nurses and pharmacists,and between health professionals, patients and family

members. Inadequate communication (verbal and written)

is the primary issue in the majority of medication errors,

adverse reactions and near-misses (Britten, 2011).

Miscommunication can result during telephone orders

if unclear or insufficient directions are given (Manias,

2014). Telephone orders should always be followed up by

documentation of the prescription within a defined period,

which is usually 24 hours. Research undertaken with nurses

(n = 1296) about telephone orders showed that only 75%

of nurses alwaysread back the persons name, the name of

the medication, the dose and the route to the prescriber. The

remainder of nurses either sometimes or neverperform these

tasks (Cohen & Shastay, 2008).

When taking a telephone order, it is important that the

health professional repeats the persons name, the medication

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SKILLS IN CLINICAL NURSING

242

name, which includes spelling the name to avoid an error

due to sound alike medications, the dosage, which includes

pronouncing the amount in single digits (e.g. 15 mg shouldbe read as one five), route, and frequency, which includes

stating the interval in full rather than using abbreviations

(e.g. three times daily, not TDS).

An individualised and person-centred approach to

medication administration, involving a dialogue between

nurses and patients, promotes patient safety by engaging

the person as a participative member of the medication

team (Bolster & Manias, 2010). There is clear evidence that

a person-centred approach to medication administration

can reduce the number of medication errors. For furtherinformation about the relationship between medication

safety, person-centred care and communication access the

Interprofessional Education for Quality Use of Medicines

modules at .

facilities use the 24-hour clock to eliminate confusion between

morning and afternoon times. Time with the 24-hour clock

starts at midnight, which is 0000 hours (Figure 61). In Australia

many facilities use the National Inpatient Medication Chart as a

consistent way of recording the ordering and administration of

medication for hospitalized adults (Figure 62).

The generic name (and sometimes the trade name) of

the drug to be administered must be clearly and accurately

written on the chart along with the dosage of the drug, the

amount or the strength of the medication, and the times orfrequency of administration. Because it is not unusual for a

drug to have several possible routes of administration the

route must be clearly specified in the order.For example,

tetracycline 250 mg (amount) four times a day (frequency)

orally (route); or potassium chloride 10% (strength) 5 mL

(amount) three times a day with meals (time and frequency)

orally (route). The medical officer ordering the drug or

the nurse who received the telephone order must sign the

medication chart to ensure the order is legal and valid.

A doctor will provide a written or oral order for a medication(prescription) often using a number of abbreviations. It is

important that only accepted abbreviations are used in order

to avert the potential for error due to misinterpretation by the

pharmacist or nurse. For example, AZT has been interpreted

as zidovudine or azathioprine and EPO can be interpreted

as evening primrose oil or epoetin-alpha. For these reasons,

it is important that only accepted abbreviations are used

or that medications are written in full when prescribing

and providing directions for use. See Table 62 for a list of

acceptable medication abbreviations.


Medication errors can be caused by

interpersonal and situational factors such as:

Unnecessary interruptions from colleagues during

medication preparation and administration activities.

Miscommunication of orders, misinterpretation of

orders or difficulties in reading orders.

Hierarchies within the health care team that

negatively influence nurses and pharmacists

decisions to seek advice or clarify of orders.

Failure to include the person receiving the medication

as an integral member of the medication team.

Failure to access an interpreter for a person who doesnot speak English.

FIGURE 61 The 24-hour clock

PM

AM

2400

1200

1300

1400

1500

1600

1700

1800

1900

2000

2100

2200

2300 121

2

3

4

5

6

7

8

9

10

11

0100

0200

0300

0400

0500

0600

0700

0800

0900

1000

1100

MEDICATION ORDERS

A valid medication order has seven essential parts, these include:

1. Full name of the person

2. Date and time the order is written

3. Name of the drug to be administered

4. Dosage of the drug5. Frequency of administration

6. Route of administration

7. Signature of the person writing the order.

In addition, unless it is a standing order, the medication

order should state the number of doses or the number of days

the drug is to be administered. To avoid confusion between

people with the same or similar last names most facilities use the

persons first and last names, and their medical record number

on the medication chart. The day, month, year and often the

time the order was written are also included on the chart. Most

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FIGURE6

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TABLE 62 Acceptable Medication Terms and Abbreviations

INTENTED MEANING ACCEPTED TERMS OR ABBREVIATIONS

Dose frequency or timing

(in the) morning Morning, mane

(at) midday Midday

(at) night Night, nocte

twice a day Bd

three times a day Tds

four times a day Qid

every 4 hours every 4 hrs, 4 hourly, 4 hrly



once a week once a week andspecify the day in full, e.g. once a week on Tuesdays

three times a week three times a week andspecify the exact days in full, e.g. three timesa week on Mondays, Wednesdays and Saturdays

when required prn

immediately stat

before food before food

after food after food

with food with food

Route of administration

epidural epidural

inhale, inhalation inhale, inhalation

intra-articular intra-articular

intramuscular IM

intrathecal intrathecal

intranasal intranasal

intravenous IV

irrigation irrigation

left left

nebulised NEB

naso-gastric NG

oral PO

percutaneous enteral gastrostomy PEG

per vagina PV

per rectum PR

peripherally inserted central catheter PICC

right Right

subcutaneous Subcut

sublingual Sublingtopical topical

Units of measure and concentation

gram(s) g

International unit(s) International unit(s)

unit(s) unit(s)

litre(s) L

milligram(s) mg

millilitre(s) mL

microgram(s) microgram, microg

percentage %

(Continued )

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TABLE 63 Types of Drug Preparation

TYPE DESCRIPTION

Aerosol spray or foam A liquid, powder or foam deposited in a thin layer on the skin by air pressure

Aqueous solution One or more drugs dissolved in water

Aqueous suspension One or more drugs finely divided in a liquid such as water

Caplet A solid form, shaped like a capsule, coated and easily swallowed

Capsule A gelatinous container to hold a drug in powder, liquid or oil form

Cream A nongreasy, semisolid preparation used on the skin

Elixir A sweetened and aromatic solution of alcohol used as a vehicle for medicinal agents

Extract A concentrated form of a drug made from vegetables or animals

Gel A clear or translucent semisolid that liquefies when applied to the skin

Liniment A medication mixed with a lcohol, oil or soapy emoll ient and appl ied to the sk in

Lotion A medication in a liquid suspension applied to the skin

Lozenge (troche) A flat, round or oval preparation that dissolves and releases a drug when held in the mouthOintment (salve) A semisolid preparation of one or more drugs used for application to the skin and mucous membrane

INTENTED MEANING ACCEPTED TERMS OR ABBREVIATIONS

millimole mmol

Dose forms

capsule cap

cream cream

ear drops ear drops

ear ointment ear ointment

eye drops eye drops

eye ointment eye ointment

injection inj

metered-dose inhaler metered-dose inhaler, inhaler, MDImixture mixture

ointment ointment, oint

pessary pess

powder powder

suppository supp

tablet tablet, tab

patient controlled analgesia PCA

TABLE 62 Acceptable Medication Terms and Abbreviations (Continued)

Source:Australian Commission on Safety and Quality in Health Care (ACSQHC) (2011a). Recommendations for Terminology, Abbreviations and SymbolsUsed in the Prescribing and Administration of Medicines.Canberra: Commonwealth Department of Communications, In formation Technology and the Arts.

Commonwealth of Australia. Reproduced with permission.

TYPES OF MEDICATION

PREPARATIONS AND ROUTES

OF ADMINISTRATION

Medications are available in a variety of forms and are

administered via a number of routes. See Table 63 for

examples of types of drug preparations. The route of

medication administration is documented on the prescription.When administering a drug, the nurse should ensure that

the type of medication is appropriate for the route specified.

Examples of routes of administration include:

Oral (including oral, sublingual and buccal)

Topical:

Dermatologic

Ophthalmic

Otic

Nasal

Metered-dose inhalers

Vaginal

Rectal

Parenteral: Subcutaneous (SCI)

Intramuscular (IMI)

Intravenous (IVI)

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Sections 6.26.4 in this unit describe these routes of

medication administration in detail.

Drug calculationsCalculating drug dosages safely and accurately is an important

nursing responsibility in medication administration. Careful and

accurate calculations are essential to the prevention of medication

errors. Sections 6.26.4 include an overview and examples of

drug calculations specific to the different routes described.

Taking a Medication HistoryNurses should assess a persons health status and obtain a

medication history prior to administering any medication.

The extent of the assessment depends on the persons condition

and the drug that has been ordered. For example, if a person

has dyspnoea, their respiratory rate and oxygen saturation level

should be assessed before administering any medication that

might affect breathing. It is also important to determine whether

the route of administration is suitable. For example, a person

who is nauseated may not be able to retain a drug taken orally.Additionally, individuals should be assessed to obtain baseline

data by which to evaluate the effectiveness of the medications

administered. A key nursing responsibility is monitoring the

effectiveness of medications administered. For example, a pain

assessment should be undertaken 30 minutes after administration

of an analgesic medication. Medications should have a therapeutic

effect but side effects are not uncommon and should also be

assessed, documented and reported to the medical officer.

Adverse effects are less common but more serious side effects

and warrant immediate reporting and action. See Table 61.A more in depth medication history is usually taken

the first time a person presents for care (to a practice nurse

for example) or on admission to an acute care facility. A

medication history includes information about the drugs the

person is taking currently or has taken recently. This includes

prescription drugs; over-the-counter (OTC) drugs such as

analgesics or antacids; traditional medicines; complementary

therapies such as vitamins or herbal medicines; alcohol,

tobacco; and illicit substances such as marijuana. Because

many of these drugs have unknown or unpredictable actionsand side effects they need to be clearly documented. During

the medication history, the nurse should also try to elicit

information about possible drug dependencies. An important

part of the medication history is the persons knowledge of his

or her drug allergies. The nurse should also clarify any previous

drug side effects or adverse reactions. Medication that must be

taken with food or at a specific time should be documented as

well as foods that are incompatible with certain medications;

for example, milk is incompatible with tetracycline.

It is also important for the nurse to identify any problems the

person may have in self-administering a medication. A personwith poor eyesight, for example, may require special labels for

medication containers; and people with rheumatoid arthritis

may not be able to open some medication containers.

It is essential that the medication history includes an

appraisal of how much the person knows about their own

medications, including how medications should be stored

and administered, correct doses, possible side effects and

precautions. The nurse also needs to consider socioeconomic

factors. Two common problems are lack of transportation

to obtain medications and inadequate finances to purchasemedications. An understanding of these factors can help the

nurse to plan care that is individualised and person-centred.

THE PROCESS OF SAFE AND

EFFECTIVE MEDICATION

ADMINISTRATION

When administering any drug, regardless of the route of

administration, the nurse must ensure that they check theFive Rights of Medication Administration (see Box 61) and

check the medications they are administrating three times

(see Box 62). Following this sequential and logical approach

for all medications administered helps to ensure that

important steps in the process are not overlooked; importantly

this approach helps to prevent medication errors and

promote patient safety. It is important to note that in addition

to the Five Rights nurses should also check that:

Information about the medication has been explained

to the person including the reason for its administration,what to expect and any related precautions).

Paste A preparation like an ointment, but thicker and sti ff, that penetrates the skin less than an ointment

Pill One or more drugs mixed with a cohesive material, in oval, round or flattened shapes

Powder A finely ground drug or drugs; some are used internally, others externally

Suppository One or several drugs mixed with a firm base such as gelatin and shaped for insertion into the body(e.g. the rectum); the base dissolves gradually at body temperature, releasing the drug

Syrup An aqueous solution of sugar often used to disguise unpleasant-tasting drugs

Tablet A powdered drug compressed into a hard smal l disc; some are readi ly broken along a scored line; others areenteric coated to prevent them from dissolving in the stomach

Tincture An a lcoholic or water-and-alcohol solution prepared f rom drugs derived from plants

Transdermal patch A semipermeable membrane shaped in the form of a disc or patch that contains a drug to be absorbed throughthe skin over a long period of time

TABLE6.3 Types of Drug Preparation (Continued )

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SECTION 6.1Critical Thinking Questions

1. You have been caring for the same person for six

days. They laugh when you ask their name before

administering their medication and say to you, Do you

really need to ask my name again? It hasnt changed

since the last time you asked! How will you respond?

2. Your patient is ordered ibuprofen but the only medication

in the persons drawer is labelled Nurofen. Can you

explain this discrepancy?

3. You hand the person his medications and he says to you:

The pill I usually take for my blood pressure is not white,

its blue. How would you respond?

4. The medical officer writes an order for Frusemide 400 mg

orally BD. The RN administers 10 tablets of 40 mg each.

After administering the tablets the nurse realises that the

order should have been 40 mg. The nurse is:

a. Not legally responsible for this medication error

because the doctor ordered the wrong dose.

b. Legally responsible because nurses are supposed to

have the knowledge to recognise incorrect medication

orders and the confidence to question orders that

seems unreasonable.

5. A valid medication order has seven essential parts. What

is missing from the following list?

a. Full name of the patient

b. Date and time the order is written

c. Name of the drug to be administered

d. Dosage of the druge. Route of administration

BOX 62Check Three Times for Safe MedicationAdministration

FIRST CHECK

Read the medication chart and remove the medication(s) fromthe persons drawer or the medication trolley.

Compare the label of the medication against the medication chart.

Check the expiry date of the medication.

Determine whether you need to do a medication calculation.

SECOND CHECK

While preparing the medication (e.g., pouring, drawing up orplacing in a medication cup), look at the medication label andcompare it with the medication chart.

THIRD CHECK

Recheck the label on the container (e.g., vial, bottle or packet)against the medication chart before returning to its storage place.

Medication administration is correctly documented

after giving medication and that the students signature

is countersigned by the supervising RN.

When time of administration differs from prescribed

time this is documented along with the reason for

the delay.

Decisions not to administer a medication are

documented and the medical officer notified.

A persons right to refuse a medication is respected and

they are fully informed of the potential consequences

of their refusal. The persons refusal is documented and

their medical officer notified.

A nurses refusal to administer any medication theybelieve to be incorrect for the person is documented

and the medical officer notified.

Appropriate patient assessments are undertaken prior

to administration (e.g., apical pulse, blood pressure,

pathology results etc).

Effectiveness of the medication is evaluated (e.g., was the

desired effect achieved or not? Did the person experience

any side effects or adverse reactions?).

BOX 61The Five Rights of Medication Administration

1. RIGHT MEDICATION

The medication being administered is the medication thatwas ordered.

The person receiving the medication is asked to check andverify the medication (if appropriate).

2. RIGHT DOSE

The dose ordered is appropriate for the patient.

Calculations are correct and verified.

The ordered dose is within the usual dosage range for the

medication. Dosages outside of the usual dosage range are questionedand reported to pharmacist or medical officer.

3. RIGHT TIME

The medication is administered at the correct time, no morethan 30 minutes before or after the ordered time.

4. RIGHT ROUTE

The ordered route is appropriate for the medication and thepersons needs/condition.

5. RIGHT PERSON

The persons identification has been verified using arm band,their first and last name, date of birth and medical record number.

to clarify their concerns about their medications and

double check that the medication order and the person

for whom the medication is prescribed are both correct.

CLINICAL SAFETY ALERTAsking the right questions

Do not ask Are you John Jones? because the

person may answer yes to the wrong name. Instead

ask What is your name?

If a person raises questions about the medication you

give them this should be an alert. Stop! Ask the person

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mucous membranes of the cheek until the drug dissolves

(Figure 64). The drug may act locally on the mucous

membranes of the mouth or systemically when it is

swallowed in the saliva.The administration of oral medications may not appear to

be an overly complex procedure. However, safe and effective

oral medication administration requires not just psychomotor

skills but also integration of pharmacological, legal and

professional knowledge, sound critical thinking and clinical

reasoning skills, and well-developed communication skills. In

the clinical scenario below and in the critical thinking questions

that are asked throughout this section the importance of these

multifaceted issues and their application to the clinical skill of

oral medication administration is illustrated.

Oralmedications include tablets, capsules and liquids that

can be swallowed. Oral medication administration is the

most common, least expensive and most convenient route

for most people. The major disadvantages of this route areirritation of the gastric mucosa, irregular and sometimes

delayed absorption from the gastrointestinal tract.

Rather than being swallowed and absorbed via the

gastrointestinal tract some drugs are absorbed from under

the tongue or from inside the cheek. In sublingual

administration, the drug is placed under the tongue, where

it dissolves and is quickly absorbed into the blood vessels

on the underside of the tongue (Figure 63). Buccal

means pertaining to the cheek. In buccal administration, a

medication (e.g., a tablet) is held in the mouth against the

KEY TERMS

buccal, 249

meniscus, 251

oral, 249

sublingual, 249

LEARNING OUTCOMES


1. Define the key terms used in oral medicationadministration.

2.Demonstrate the ability to read and interpret amedication chart.

3. Demonstrate accuracy when calculating oral medicationdosages.

4. Verbalise the steps required to administer oralmedications safely.

5. Demonstrate critical thinking when administering oralmedications.

6. Accurately document oral medication administration.

7. Monitor the effectiveness of oral medicationsadministered.

ORAL

MEDICATION

ADMINISTRATION

SECTION 6.2

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Calculating dosages fororal medicationsWhen calculating the number of tablets or amount of liquid

to administer orally there are three main formulas that are

commonly used.1. For tablets:

Number of tablets required = Strength (or dose) required

Strength in stock

2. For liquids:

Volume required =

Strength (or dose) required

Volume of stock solution

Strength in stock

Examples:1. A person is prescribed atenol 75 mg orally. The

strength in stock is 50 mg. How many tablets should be

administered?

Number of tablets required = Strength (or dose) requiredStrength in stock

Number of tablets required = 75 mg = 3= 11 tablets50 mg 2 2

2. A person i s prescribed erythromycin 750 mg orally. The

strength in stock is 250 mg/5 mL. What volume (in mL)should be administered?

Volume required =

Strength (or dose) required

Volume of stock solution

Strength in stock

Volume required = 750 mg 5 mL

250 mg

Volume required = 15 mL

FIGURE 64 Buccal administration of a tablet

FIGURE 63 Sublingual administration of a tablet

CLINICAL SCENARIO

Mr Giuseppe Esposito, 81 years, is a person on the

medical ward of Griffith Community Hospital (Levett-

Jones & Newby, 2013). He was admitted two days

ago with gastroenteritis and dehydration. At 0800

hours Madeline (Maddie) OBrien, a nursing student,

was administering Mr Espositos oral medications

(frusemide, digoxin and enalapril). The registered

nurse (RN) supervising Maddie was interrupted by

another nurse who needed assistance with a person in

a nearby bed. The RN said to Maddie, keep going

Ill keep an eye on what you are doing from over

here.

Critical Thinking Questions

1. What would you do if presented withthis situation?

2. What are the legal and professional issues relevant

to this situation?

3. How may Mr Espositos clinical safety be impacted

by the RNs and the nursing students actions?

4. Should Maddie assess Mr Esposito before

administering his medications?

5. Mr Esposito speaks limited English. How might this

impact safe medication administration practices?

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UNIT 6 SECTION 6.2 ORAL MEDICATION ADMINISTRATI ON

Note: Always check that you have used the same unit of

weights in medications calculations, for example all grams,

milligrams or micrograms.

Tablets that are scored (a line marked on the tablet)

may be broken in half or cut (see Figure 65) to obtain the

correct dosage but capsules cannot be divided. For people

who have difficulty swallowing, some medications can

be crushed to a fine powder by using a pill crusher. The

powder is then mixed with a small amount of soft food

(e.g., custard, apple sauce or honey) to improve palatability

and assist with swallowing.


Enteric-coated, slow release, sublingual and

buccal medications should not be crushed as

this changes the rate of absorption and can cause

an adverse drug effect. Always check the Australian

Medicines Handbookor a similar drug resource

to check whether it is appropriate to crush a

particular tablet.

FIGURE 66 Pouring a liquid medicationfrom a bottle

Critical Thinking Questions1. Calculate how many tablets Mr Esposito will be

given based on the following medication orders:

frusemide 80 mg orally; strength in stock 40 mg

digoxin 250 mg orally; strength in stock 125 micrograms

enalapril 20 mg orally; strength in stock 10 mg

2. Do you have any concerns about any of these orders? If

so what is the most appropriate nursing action?

FIGURE 65 A cutting device can be used todivide tablets

Liquid medications must be carefully measured using a

syringe, dropper or medicine cup. To ensure accurate dosages

the medicine cup should be placed on a flat surface at eye

level and filled to the desired level (see Figure 66). The

bottom of the meniscus(crescent-shaped upper surface of

a column of liquid) should align with the measurements

on the side of the medicine cup and be used to measure the

correct dose (see Figure 67).

STANDARDS FOR PRACTICE

The Nursing and Midwifery Board of Australia

(NMBA) Standards for Practice (2016) specify that

the registered nurse uses the appropriate processes

to identify and report potential and actual risk related

system issues and where practice may be below the

expected standards (NMBA, 2016, p. 5).

Base of

meniscus

4

3

2

1

FIGURE 67 The bottom of the curved meniscusis used to measure the correct dose

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252

Assess: Patient allergies, ability to swallow, and drug action side effects, interactions, and adverse reactions

Perform appropriate assessments specific to the medication as needed

Determine if the above assessment data will influence administration of the medication

Know why the patient is receiving the medication

THENdetermine if it can be crushed

because some medications (e.g.,enteric coated) cannot be crushed.Call the pharmacy if unsure. If themedication can be crushed, do soand mix with a small amount of softfood. Label the medication cup.

Help the patient to a sitting position

Administer the medications

Take the required assessment measures if not done previously (e.g., apical pulse)

Check the medication chart

Obtain and prepare the medications

Perform the three safety checks to reduce the risk of error

Ensure it is the correct patient, using agency protocol

Explain the purpose of the medication

Document each medication given on the MAR

Evaluate the effects of the medication

WHAT IF the medication needs to be crushed?

THENask for the reason. The

patient has a right to refuse.

Hold the medication and document

the reason why the patient refused.

If holding could have adverse effects,

notify the medical officer of refusal.

THENexplain the purpose of the

medication and how it will help.

Use language that the patient can

understand.

WHAT IFthe patient states

does not know why s/he istaking the medication?

THENdetermine if the symptoms are an adverse reaction or an allergic reaction. Inform the Medical officer. Hold future administrat ion of the medication until discussing with Medical officer.

WHAT IFthe patient begins

having adverse reactions to

the medication?

Organize supplies

Perform hand hygiene

WHAT IFthe patient refuses the medication?

What If Administering oral medications

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255

Examples can include the nitroglycerin patch to treat

coronary artery disease or a medication in a suppository

form to treat nausea. Topical skin or dermatological

preparations include ointments, pastes, creams, lotions,

powders, sprays and patches. A suppository is a solid

medication in a roughly conical or cylindrical shape,

which is designed to be inserted into the rectum or vagina

where it dissolves.

A topical medication is applied locally to the skin or to

the mucous membranes of the eye, ear, nose, lungs, vagina

and rectum. Many drugs are applied topically to produce

a local effect (e.g., an antibiotic cream for a skin infection

or a corticosteroid nasal spray to reduce inflammation

of nasal mucosa from allergies). Some medications

are applied topically for a systemic effect such as slow

absorption of the medication into the general circulation.

KEY TERMS

aerosolisation, 266

atomisation, 266

dermatologic

preparations, 256

metered-dose inhaler(MDI), 266

nebulisers, 266

ophthalmic, 259

otic, 261

suppositories, 255

transdermal patch, 256

LEARNING OUTCOMES


1. Define the key terms used in topical medicationadministration.

2. Verbalise the steps required to administer the followingtopical medications safely:

Dermatologic Ophthalmic Otic Nasal Metered-dose inhalersVaginal

Rectal3. Demonstrate safe and effective topical medication

administration.

4. Demonstrate critical thinking when administering topicalmedications.

5. Accurately document topical medication administration.

6. Monitor the effectiveness of topical medications

administered.

TOPICAL

MEDICATION

ADMINISTRATION

SECTION 6.3

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256

films containing the drug and an adhesive layer. The rate

of delivery of the drug is controlled and varies with each

product (e.g., from 12 hours to 1 week). Generally, the

patch is applied to a hai rless, clean area of skin that is notsubject to excessive movement, friction (e.g., bra strap or

waistline areas) or wrinkling (i.e., the lower abdomen).

It may be applied on the upper arm, side, lower back or

buttocks (Figure 68). Remove lotion, sunscreen, powder,

or any other product that may impair absorption of the

medication in the patch. Use mild, nonirr itating soap and

water to cleanse, if necessary. Patches should not be applied

to areas with cuts, burns or abrasions, or on distal parts of

extremities (e.g., the forearms). Women who use a patch

containing oestrogen or nicotine should not apply the

patch to the breasts, per the manufacturers instructions.

If hair is likely to interfere with patch adhesion or

removal, clipping (not shaving) may be necessary before

application.

DERMATOLOGIC MEDICATIONS

Dermatologic preparationsmay be applied to the skin for

a variety of reasons, for example to:

decrease itching (pruritus)

lubricate and soften the skin

cause local vasoconstriction or vasodilation

increase or decrease secretions from the skin

provide a protective coating to the skin

apply an antibiotic or antiseptic to treat or prevent

infection

reduce local inflammation

an entry for medications that will be absorbed into

the systemic circulation

Before applying a dermatologic preparation, thoroughly

clean the area with soap and water and dry it with a patting

motion. Skin encrustations (i.e., crusts or scabs) harbour

microorganisms, and these as well as previously applied

applications can prevent the medication from coming in

contact with the area to be treated. Nurses should wear

gloves when administering skin applications and always use

surgical asepsis when an open wound is present.

Transdermal MedicationsA particular type of dermatologic medication delivery

system is the transdermal patch. This system administers

sustained-action medications (e.g., pain relievers,

nitroglycerin, oestrogen and nicotine) via multilayered

BOX 63General Guidelines for the Administration of Dermatologic Medications

POWDER

Make sure the skin surface is dry. Spread apart any skin folds, and sprinkle the site until the area is covered with a fine thinlayer. Cover thesite with a dressing if ordered.

SUSPENSION-BASED LOTION

Shake the container before use to distribute suspended particles. Put a little lotion on a small gauze dressing or pad, and apply the lotion tothe skin by stroking it evenly in the direction of the hair growth.

CREAMS, OINTMENTS, PASTES AND OIL-BASED LOTIONS

Warm and soften the preparation in gloved hands to make it easier to apply and to prevent chilling (if a large area is to be treated). Smearit evenly over the skin using long strokes that follow the direction of the hair growth. Explain that the skin may feel somewhat greasy after

application. Apply a sterile dressing if ordered by the primary care provider.AEROSOL SPRAY

Shake the container well to mix the contents. Hold the spray container at the recommended distance from the area (usually about 15 to 30cm [6 to 12 in.] but check the label). Cover the persons face with a towel if the upper chest or neck is to be sprayed. Spray the medicationover the specified area.

TRANSDERMAL PATCHES

Select a clean, dry area that is free of hair and matches the manufacturers recommendations. Remove the patch from its protective covering,holding it without touching the adhesive edges, and apply it by pressing firmly with the palm of the hand for about 10 seconds. Advise the person toavoid using a heating pad over the area to prevent an increase in circulation and the rate of absorption. Remove the patch at the appropriate time,folding it so that the medicated sticky sides are together. Some patches contain nonvisible metal in their backing. This may cause burning in thearea of the patch. Inform individuals to tell the MRI personnel that they are wearing a transdermal patch (U.S. Food and Drug Administration, 2009).

CLINICAL ALERTThe nurse should wear gloves when applying a

transdermal patch to avoid getting any of the

medication on his or her skin, which can result in the

nurse receiving the effect of the medication.

Reddening of the skin with or without mild local itching

or burning, as well as allergic contact dermatitis, may

occasionally occur with transdermal patches. Upon removal

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UNIT 6 SECTION 6.3 TOPICAL MEDICATION ADMINISTRATI ON

257

of the patch, any slight reddening of the skin usually

disappears within a few hours. All applications should be

changed regularly to prevent local irritation, and each

successive application should be placed on a different site.

All people need to be assessed for allergies to the drug and

to materials in the patch before the patch is applied.

When transdermal patches are removed, care needs to be

taken as to how and where they are discarded. In the home

environment, if they are simply discarded into a rubbish

bin, pets or children can be exposed to them, causing effectsfrom any drug remaining on the patch. When removed, they

should be folded with the medication side to the inside, put

into a closed container, and kept out of reach of children

and pets.

Transdermal ointment is another form of transdermal

medication. A common example is nitroglycerin ointment,

which is used to prevent chest pain. The nurse squeezes out

the ordered dose onto a paper dose-measuring applicator

(Figure 69). This paper applicator is placed with the

ointment side down onto a dry, hairless area of skin, similar

to the transdermal patch. Using the paper applicator, lightly

spread the ointment (do not rub) and tape the paper

applicator into place.

FIGURE 69 Using premeasured paper tomeasure medication dosage

DERMATOLOGIC MEDICATION ADMINISTRATIONTHE 3PS TABLEPREPARATION AND PLANNING

ACTION EXPLANATION AND RATIONALE

Review the medication chart and ensure that there is a valid order forthe drug/s to be administered.

Report and clarify any omissions, inconsistencies, inaccuracies orincomplete prescription orders to the supervising RN or MO.

Nurses are legally responsible for their practice. Orders thatare not valid, drugs that are contraindicated, a dose that is toohigh, previously unreported allergies, and other concerns shouldreported in order to prevent potential adverse effects.

Review the Australian Medicines Handbookor a similar drug resource ifunfamiliar with the medication/s ordered.

When administering medications nurses must be familiar with theusual dosage, indications, contraindications, potential side effects,interactions, and adverse effects of ordered medications.

Perform hand hygiene. Dermatological medication administration is a clean procedure.Hand hygiene is performed as an infection control precaution.

Gather the correct equipment:

Clean gloves (or sterile for nonintact skin)

Solution to wash area if indicated

Gauze pads for cleaning

Medication (e.g., lotion, cream, ointment, patch)

Application tube (if required)

FIGURE 68 Transdermal patch administration:A, protective coating removed from patch;B,patch immediately applied to clean, dry, hairless

skin and labelled with date, time, and initialsSource:From M. Adams, N. Holland & P. Bostwick (2008). Pharmacology forNurses: A Pathological Approach(2nd ed.), p. 35. Upper Saddle River, NJ:Pearson Education, Inc.

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PERFORMING THE PROCEDURE


Introduce yourself to the person. Use full name and designation. This is a professional expectation andhelps to promote a therapeutic relationship.

Demonstrate a person-centred approach to medication administrationand obtain the persons verbal consent

A person-centred approach enhances patient safety by creating anopportunity for the person to ask questions and for the nurse toprovide education.

Repeat hand hygiene and dons gloves. Hand hygiene should be conducted prior to touching the person.

Determine and conduct appropriate patient assessments:

Inspect skin or mucous membranes for lesions, rashes, erythema,and breakdown. Note size, colour, distribution and configurationof lesions.

Determine the presence of symptoms of skin irritation (e.g.,

pruritus, burning sensation, pain). Note the presence of excessive body hair that may require

clipping before the application of a topical medication.

If a transdermal patch is to be applied, ask the person if they arealready wearing a patch, and if so, where it is located.

This is a clinical expectation.

Close curtain or door. Assist the person to a comfortable position,either sitting or lying. Expose the area to be treated and ensure privacy.

To ensure privacy, comfort and dignity.

Unlock the dispensing system and obtain the correct medication.

FIRST CHECK!

Compare the label on the medication container and packagingagainst the order on the medication chart to ensure that the right

medication is given.

Use only medications that have clear, legible labels. Notify the RN orpharmacist if a discrepancy is identified.

Check the expiry date of the medication. Out of date medications will reduce the therapeutic benefit of medications.

If necessary, calculate the correct dosage of the medication ifrequired.

Students must ensure that their calculations are checked by theirsupervising RN.

SECOND CHECK!

Check the five rights of medication administration.

Prevent errors by confirming right drug, right dose, right time, rightroute and right person.

Confirm the persons identification by asking them to state their nameand date of birth and checking they are consistent with the personschart. Confirm that the medical record number on the medicationchart accords with the ID band.

Check whether the person has any drug allergies. This is a safety precaution.

THIRD CHECK!

Recheck the label on the container against the medication chart.

Apply the medication and dressing as ordered.

Place a small amount of cream or ointment on the gloved hand,and spread it evenly on the skin.

or

Apply sterile gloves if indicated (i.e., nonintact skin). Pour somelotion on the gauze, and pat the skin area with it.

Apply a sterile dressing if necessary.

or

Apply a prepackaged transdermal patch. Write the date and time on the label beforeapplication.

or

Squeeze out transdermal ointment onto premeasured medicationadministration paper.

Place the applicator paper with ointment side down onto the skin.

Lightly spread the ointment.

Tape the paper applicator into place.

Knowing the date and time ensures safety and communication whenthere are multiple caregivers. Writing on the patch could puncture it.

Remove gloves and repeat hand hygiene. This is an infection control precaution.

Sign the medication chart. Supervising RN to countersign. Most health care facilities and universities require RNs to countersignany medication administered by students.

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259


Record the type of preparation used, the site to which it was applied,the time, and the response of the person, including data about theappearance of the site, discomfort, itching, etc.

For transdermal patches, document both removal and application ofthe patch including location.

Conclude encounter, reposition the person comfortably and informthem of follow up.

This is a professional expectation and helps to maintain a therapeuticrelationship.

PRIORITIES POST PROCEDURE


Dispose of used equipment appropriately.

Repeat hand hygiene.

Return to the person to monitor effectiveness of the medicationadministered.

Return at a time by which the preparation should have absorbed to assessthe reaction (e.g., relief of itching, burning, swelling or discomfort).

OPHTHALMIC MEDICATIONS

Ophthalmic medications may be administered by

slowly pouring or dropping liquids or ointments

onto the surface of the eye. Eye drops are packaged in

monodrip plastic containers and ointments are usually

supplied in small tubes. All containers must state that the

medication is for ophthalmic use. Sterile preparations and

a sterile technique are used to administer ophthalmic

medications.

ADMINISTERING OPHTHALMIC MEDICATIONSTHE 3PS TABLEPREPARATION AND PLANNING


Review the medication chart and ensure that there is a valid order forthe drug/s to be administered.


Nurses are legally responsible for their practice. Orders thatare not valid, drugs that are contraindicated, a dose that is toohigh, previously unreported allergies, and other concerns shouldreported in order to prevent potential adverse effects.

Review the Australian Medicines Handbook or a similar drug resource ifunfamiliar with the medication/s ordered.

When administering medications nurses must be familiar with theusual dosage, indications, contraindications, potential side effects,interactions and adverse effects of ordered medications.

Perform hand hygiene. Ophthalmic medication administration is a sterile procedure. Handhygiene is performed as an infection control precaution.


Clean gloves

Sterile absorbent sponges soaked in sterile normal saline

Medication

Sterile eye dressing (pad) as needed and paper tape to secure it



Introduce yourself to the person. Use full name and designation. This is a professional expectationand helps to promote a therapeutic relationship.

Close curtain or door. Assist the person to a comfortable position,usually lying.

To ensure privacy, comfort and dignity.

Demonstrate a person-centred approach to medication administrationand obtain the persons verbal consent.

A person-centred approach enhances patient safety by creatingan opportunity for the person to ask questions and for the nurseto provide education.

Repeat hand hygiene. Hand hygiene should be conducted prior to touching the person.

Determine and conduct appropriate assessments of the person:

Appearance of the eye and surrounding structures for lesions,exudate, erythema, or swelling.

The location and nature of any discharge, lacrimation and swelling ofthe eyelids or of the lacrimal gland.


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Complaints (e.g., itching, burning pain, blurred vision, and photophobia).

Behaviour (e.g., squinting, blinking excessively, frowning, or rubbingthe eyes).


FIRST CHECK!

Compare the label on the medication container and packagingagainst the order on the medication chart to ensure that the rightmedication is given.

Use only medications that have clear, legible labels. Notify the RNor pharmacist if a discrepancy is identified.

Check the expiry date of the medication. Out of date medications will reduce the therapeutic benefit ofmedications.

SECOND CHECK!


Confirm which eye is to be treated.

Prevent errors by confirming right drug, right dose, right time,right route, right person and right eye.

Confirm the persons identification by asking them to state theirname and date of birth and checking they are consistent with thepersons chart. Confirm that the medical record number on themedication chart accords with the ID band.


Repeat hand hygiene and don gloves. This is an infection control precaution.

Clean the eyelid and the eyelashes using sterile cotton balls moistenedwith sterile irrigating solution or sterile normal saline.

Wipe from the inner canthus to the outer canthus.

If not removed, material on the eyelid and lashes can be washedinto the eye.

Cleaning towards the outer canthus prevents contamination of theother eye and the lacrimal duct.

THIRD CHECK!


Apply the medication as ordered.

Draw the correct number of drops into the shaft of the dropper if adropper is used.

Instruct the person to look up to the ceiling.

Give the person a dry sterile absorbent sponge.

Expose the lower conjunctival sac by placing the thumb or fingersof your nondominant hand on the persons cheekbone just belowthe eye and gently drawing down the skin on the cheek. If thetissues are oedematous, handle the tissues carefully to avoiddamaging them.

Holding the medication in the dominant hand, place the hand on thepatients forehead to stabilise the hand.

The person is less likely to blink if looking up. While the personlooks up, the cornea is partially protected by the upper eyelid.

A sponge is needed to press on the nasolacrimal duct after aliquid instillation to prevent systemic absorption or to wipe excessointment from the eyelashes after an ointment is instilled.

Placing the fingers on the cheekbone minimises the possibility oftouching the cornea, avoids putting any pressure on the eyeballand prevents the person from blinking or squinting.

The person is less likely to blink if a side approach is used. Wheninstilled into the conjunctival sac, drops will not harm the cornea asthey might if dropped directly on it. The dropper must not touchthe sac or the cornea.

Instilling eye drops

Approach the eye from the side and instil the correct number of dropsonto the outer third of the lower conjunctival sac. Hold the dropper1 to 2 cm (0.4 to 0.8 in.) above the sac.

Instilling an eye drop into the lower conjunctival sac.

Instilling eye ointment

Discard the first bead of ointment. Holding the tube above the lowerconjunctival sac, squeeze 2 cm (0.8 in.) of ointment from the tube into the

lower conjunctival sac from the inner canthus outward.

The first bead of ointment from a tube is considered to becontaminated.

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ACTION EXPLANATION AND RATIONALEDispose of used equipment appropriately.


Return to the person to monitor effectiveness of or reaction to themedication administered.

OTIC MEDICATIONS

Instillationsinto the external auditory canal are referred to

as oticinstillations.

LIFESPAN CONSIDERATIONS

The position of the external auditory canal varies

with age. In the adult, the external auditory canal is

an S-shaped structure about 2.5 cm long. In the child under

3 years of age, it is directed upward. For this reason, to

administer otic medications to infants and young children

gently pull the pinna down and back. For a child older

than 3 years of age, pull the pinna upward and backward. Straightening the ear canal of a child younger than 3 years by pulling

the pinna down and back.


Instilling an eye ointment into the lower conjunctival sac.

Instruct the person to close the eyelids but not to squeeze them shut. Closing the eye spreads the medication over the eyeball.Squeezing can injure the eye and push out the medication.

For liquid medications, press firmly or have the person press firmly on

the nasolacrimal duct for at least 30 seconds.

Pressing on the nasolacrimal duct.

Pressing on the nasolacrimal duct prevents the medication from

running out of the eye and down the duct, preventing systemicabsorption.

Apply an eye pad if needed, and secure it with paper eye tape.

Remove gloves and repeat hand hygiene. This is aninfection control precaution.

Assess and document the procedure, character and amount ofdischarge, appearance of the eye, discomfort, and the personsresponse immediately after the instillation.

Sign the medication chart. Supervising RN to countersign. Most health care facilities and universities require RNs tocountersign any medication administered by students.

Conclude encounter, ensure the persons comfort and inform them offollow up

This is a professional expectation and helps to maintain atherapeutic relationship.

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PERFORMING THE PROCEDUREACTION EXPLANATION AND RATIONALE


Close curtain or door. Assist the person to a comfortable position,usually lying with the ear to be treated uppermost.

To ensure the persons privacy, comfort and dignity.

Demonstrate a person-centred approach to medication administrationand obtain the persons verbal consent.

A person-centred approach enhances patient safety by creatingan opportunity for the person to ask questions and for the nurse toprovide education.


Determine and conduct appropriate assessments of the person: Appearance of the pinna of the ear and meatus for signs ofredness and abrasions.

Type and amount of any discharge.


Unlock the dispensing system and obtain the correctmedication.

FIRST CHECK!



Check the expiry date of the medication. Out o f date medications w ill r educe the therapeutic benefit o fmedications.

SECOND CHECK!


Prevent errors by confirming right drug, right dos e, right time, rightroute, right person and right ear. Confirm the persons identificationby asking them to state their name and date of birth and checkingthey are consistent with the persons chart. Confirm that the medicalrecord number on the medication chart accords with the ID band.


Repeat hand hygiene and don gloves. This is an infection control precaution.

Clean the pinna of the ear and the meatus of the ear canal withcotton-tipped applicators and cotton balls moistened with sterilenormal saline. Ensure that the applicator does not go into theear canal.

This removes any discharge present before the instillation so that itwont be washed into the ear canal.

This avoids damage to the tympanic membrane or wax becomingimpacted within the canal.

ADMINISTERING OTIC MEDICATIONSTHE 3PS TABLEPREPARATION AND PLANNING


Review the medication chart and ensure that there is a valid orderfor the drug/s to be administered.


Nurses are legally responsible for their practice. Orders that are notvalid, drugs that are contraindicated, a dose that is too high, previouslyunreported allergies, and other concerns should reported in order toprevent potential adverse effects.

Review the Australian Medicines Handbook or a similar drugresource if unfamiliar with the medication/s ordered.


Perform hand hygiene. Otic medication administration is a clean process. However, if thetympanic membrane is perforated sterile technique is needed. Hand

hygiene is performed as an infection control precaution.Gather the correct equipment:

Clean gloves

Cotton-tipped applicator

Correct medication bottle with a dropper

Flexible rubber tip (optional) for the end of the dropper, whichprevents injury from sudden motion, for example, by a personwho is disoriented

Cotton wool

Normal saline

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THIRD CHECK!

Recheck the label on the container against the medication chart.Administer the as ordered.

Warm the medication container in your hand, or place it in warmwater for a short time.

Straighten the auditory canal. Pull the pinna upward andbackward for persons over 3 years of age.

Straightening the adult ear canal by pulling the pinna upwardand backward.

Instil the correct number of drops along the side of the ear canal.

Instilling ear drops.

Press gently but firmly a few times on the tragus of the ear

(the cartilaginous projection in front of the exterior meatusof the ear).

Ask the person to remain in the side-lying position for about5 minutes.

Insert a small piece of cotton wool loosely at the meatus of theauditory canal for 15 to 20 minutes.

Do not press it into the canal.

This promotes the persons comfort and pre-vents nerve stimulationand pain.

The auditory canal is straightened so that the solution can flow theentire length of the canal.

Pressing on the tragus assists the flow of medication into the ear canal.

This prevents the drops from escaping and allows the medication to

reach all sides of the canal cavity.

The cotton helps retain the medication when the person is up.

If pressed tightly into the canal, the cotton would interfere with theaction of the drug and the outward movement of normal secretions.


Assess and document the procedure, character and amountof discharge, appearance of the canal, discomfort the personsresponse immediately after the instillation.


Conclude encounter, ensure the persons comfort and inform themof follow up.






Return to the person to monitor effectiveness of or reaction to the

medication administered.

Normalposition

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ADMINISTERING NASAL MEDICATIONSTHE 3PS TABLEPREPARATION AND PLANNING







Perform hand hygiene. Nasal medication administration is a clean process. Hand hygiene isperformed as an infection control precaution.


Tissues

Clean gloves

Correct medication bottle with a dropper




Demonstrate a person-centred approach to medication administrationand obtain the persons verbal consent

A person-centred approach enhances patient safety by creating anopportunity for the person to ask questions and for the nurse to provideeducation.

Close curtain or door. Assist the person to a comfortable position:

To treat the opening of the eustachian tube, have the personassume a back-lying position.

To treat the ethmoid and sphenoid sinuses, ask the person to lie in abackwards position with the head over the edge of the bed or a pillowunder the shoulders so that the head is tipped backward.

Position of the head to instil drops into the ethmoid andsphenoid sinuses.

To ensure the persons privacy, comfort and dignity.

Correct positioning allows the drops to flow into the correct sinus.

Ethmoid

sinuses

Sphenoid

sinus

Nasopharynx

NASAL MEDICATIONS

Nasal instillations (nose drops and sprays) are instilled

for their astringent effect (to shrink swollen mucousmembranes), to loosen secretions and facilitate drainage,

or to treat infections of the nasal cavity or sinuses. Nasal

decongestants are the most common nasal instillations.

Many of these products are available without a prescription

and people need to be taught to use these medications with

caution as chronic use of nasal decongestants may lead to

a rebound effect and increased nasal congestion. It is notunusual to swallow a small amount of the nasal medication,

however, if excess decongestant solution is swallowed

systemic effects may develop, especially in children.

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To treat the maxillary and frontal sinuses, have the person assumethe same back-lying position, with the head turned towards theside to be treated.

Position of the head to instil drops into the maxillary and frontalsinuses.

Repeat hand hygiene. Hand hygiene should be conducted prior to touching the patient.


If nasal secretions are excessive, ask the person to blow the noseto clear the nasal passages.

Inspect the discharge on the t issues for color, odour andthickness.

Assess appearance of nasal cavities.

Assess congestion of the mucous membranes and any obstructionto breathing. Ask the person to hold one nostril closed and blowout gently through the other nostril. Listen for the sound of anyobstruction to airflow. Repeat for the other nostril.

Assess signs of distress when nares are occluded. Block eachnaris and observe for signs of greater distress when the naris isobstructed.

Facial discomfort with or without palpation. An infected orcongested sinus can cause an aching, full feeling over the area ofthe sinus and facial tenderness on palpation.

Assess any crusting, redness, bleeding, or discharge of themucous membranes of the nostrils.



FIRST CHECK!




SECOND CHECK!


Prevent errors by confirming right drug, right dose, right time, right

route, and right person. Confirm the persons identification by askingthem to state their name and date of birth and checking they areconsistent with the persons chart. Confirm that the medical recordnumber on the medication chart accords with the ID band.


Repeat hand hygiene and don gloves. This is an infection control precaution

THIRD CHECK!


Administer the as ordered.

Draw up the required amount of solution into the dropper. If the solution is directed towards the base of the nasal cavity, it will rundown the eustachian tube.

Maxillary

sinuses

Frontal

sinuses

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the medication canister by hand to release medication

through a mouthpiece. An extender or spacer should

be attached to the mouthpiece to facilitate medication

absorption for better results (see Figure 611). Spacers

are holding chambers into which the medication is fired

and from which the person inhales, so that the dose is

not lost by exhalation. There are also dry powder inhalers

(DPIs) that either have the powder in a reservoir at the

bottom (e.g. Symbicort) or that use a disk with little

blisters containing the powder.


Hold the tip of the dropper just above the nostril, and direct thesolution laterally towards the midline of the superior concha ofthe ethmoid bone as the person breathes through the mouth. Donot touch the mucous membrane of the nostril.

Repeat for the other nostril if indicated.

Ask the person to remain in the position for 5 minutes

Touching the mucous membrane with the dropper could damage themembrane and cause the person to sneeze.

The person remains in the same position to help the solution come incontact with all of the nasal surface or flow into the desired area.


Assess and document the procedure, the persons condition,and discomfort experienced by the person and their responseimmediately after the instillation.


Conclude encounter, ensure the person is comfortable and informthem of follow up.






Return to the person to monitor effectiveness of or reaction to themedication administered

INHALED MEDICATIONS

Nebulisersdeliver most medications administered through

the inhaled route. A nebuliser is used to deliver a fine spray

(fog or mist) of medication or moisture to a person.

There are two kinds of nebulisation: atomisation and

aerosolisation. In atomisation, a device called an atomizer

produces droplets for inhalation. In aerosolisation,

the droplets are suspended in a gas, such as oxygen. The

smaller the droplets, the further they can be inhaled into the

respiratory tract. When a medication is intended for the nasal

mucosa, it is inhaled through the nose; when it is intended

for the trachea, bronchi and/or lungs, it is inhaled through

the mouth. A large-volume nebulisercan provide a heated or cool

mist and is generally used for long-term therapy such as that

following a tracheostomy.

A metered-dose inhaler (MDI) (Figure 610) is a

pressurised container of medication that can be used bya person to release medication through a mouthpiece. The

force with which the air moves through the nebuliser causes

the large particles of medicated solution to break up into

finer particles, forming a mist or fine spray. MDIs can deliver

accurate doses, provide for target action at the needed sites,

and sustain fewer systemic effects than medication delivered

by other routes.

To ensure correct delivery of the prescr ibed medication

by MDIs, nurses need to instruct the person t how to

use the inhaler correctly. The person needs to compress

FIGURE 610 A Metered-dose inhaler

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FIGURE 611 Extender or spacer

CLINICAL ALERT

A persons ability to use an MDI correctly

determines the effectiveness of the medication

delivery. It is important for the nurse to assess whether

the person is able to use the MDI correctly.

LIFESPAN CONSIDERATIONS

Children Spacers are recommended for children (as well as

adults) as they hold a medication in suspension and

allow the child to take several deep breaths in order to

inhale all the medication.

Learning how to use a spacer can be a frightening

experience for a young child. Use a doll or stuffed animalto demonstrate its use, and allow the child to play with

the equipment before putting it in place. Having the

child sit in a parents lap during the procedure can help

the child relax and be more cooperative.

ADMINISTERING METERED-DOSEINHALER MEDICATIONS

THE 3PS TABLE

PREPARATION AND PLANNING







Perform hand hygiene. Metered dose inhaler medication administration is a clean process.

Hand hygiene is performed as an infection control precaution.Gather the correct equipment:

Metered-dose inhaler (MDI) with medication canister and spacerif indicated




Demonstrate a person-centred approach to medicationadministration and obtain the persons verbal consent.

A person-centred approach enhances the safety of the person bycreating an opportunity for the person to ask questions and for the

nurse to provide education.Close curtain or door. Assist the person to a sitting position. To ensure the persons privacy, comfort and dignity.

CLINICAL SCENARIOTrent Fulton, 35 years, is being discharged from hospital

today following a two week admission for pneumonia

and acute exacerbation of asthma. The RN caring for

Trent asks you to educate him about the use of his

discharge medications (ventolin inhaler and symbicort

dry powder inhaler).

Critical Thinking Questions

1. What advice would you give Trent in

regards to the following medications?

2. How would you know if Trent understood the

education provided by you?

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Lung sounds.

Respiratory rate and depth.

Cough (productive or nonproductive); amount, colour and characterof expectorations.

Presence of dyspnoea.

Vital signs.



FIRST CHECK!




SECOND CHECK!


Prevent errors by confirming right drug, right dose, right time, rightroute, and right person. Confirm the persons identification by askingthem to state their name and date of birth and checking they areconsistent with the persons chart. Confirm that the medical recordnumber on the medication chart accords with the ID band.


Repeat hand hygiene. This is an infection control precaution.

THIRD CHECK!


Educate the person about the purpose of the medication and howthe inhaler is to be used (as follows):

Ensure that the canister is firmly and fully inserted into the inhaler.

Remove the cap, holding inhaler upright, shake vigorously for 3to 5 seconds.

Exhale comfortably (as in a normal full breath) away from theinhaler.

Hold the inhaler with the canister on top and the mouthpiece atthe bottom.

Slightly tilt chin to ensure open airway.

Place the MDI inhaler mouthpiece in the mouth between theteeth and close lips to create a seal.

If using a spacer with the metered-dose inhaler:

Shake the MDI for 3 to 5 seconds and insert the mouthpiece intothe spacer.

Place the spacer in the mouth between the teeth and close lipsto create a seal.

Unless the persons mouth is closed around the MDI the prescribed

dosage may not be inhaled and the person may not receive therequired therapeutic dose.

Administering the medication

Instruct person to:

Whilst breathing in press down onceon the MDI canister andinhale slowly and deeply.

Remove the inhaler from mouth, close mouth and hold yourbreath for a few seconds or as long as possible.

Exhale slowly away from the mouth piece. Replace cap.

Repeat the inhalation if ordered. Wait 1 to 2 minutes betweeninhalations of broncho

safe administrations of medications (draft chapter)

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