14.3: Administering Nasal Medications

Learning Objectives

By the end of this section, you will be able to:

• Identify different forms of nasal medications
• Describe categories of nasal inhalation medications
• Describe procedural steps for nasal medication administration

Allergies, sinus infections, and nasal congestion are typically treated by nasal medications, which are administered via the nose (i.e., nostrils, external or anterior nares). The absorption surface area of the nasal cavity is large and has high vascularization and permeability; therefore, typically medications are absorbed faster via the nasal passage then the oral route. Medications administered via the nasal route come in a variety of forms and belong to several different categories of medications. Although the nose is not a sterile cavity, asepsis is required to safeguard the connection to the sinuses. It is important for the nurse to understand the indications for use and procedural steps required to safely administer nasal medications.

Forms of Nasal Instillations

Medications administered via the nasal passage come prepared in a variety of forms, including powders, sprays, and washes. The nose has a large mucosal surface area and is highly vascular; therefore, medications administered via the nasal route are absorbed rapidly into the systemic system. As such, it is important to understand how nasal medications are packaged to ensure the right amount of the medication is safely administered.

Nasal Powders

Nasal powders come prepared as a powder inside a device that is used to spray the powder into the nose. Nasal powder formulations benefit from enhanced bioavailability and drug absorption, reduction in the need for preservatives, and allowance for larger doses of medication to be administered than liquid preparations. Examples of nasal powders include glucagon nasal powder (Baqsimi), which is used to treat hypoglycemia (very low blood sugar), and sumatriptan nasal powder (Onzetra Xsail), which is used to treat migraine headaches.

Nasal Sprays

Nasal sprays come prepared as a liquid inside a device that sprays the liquid into the nose. Nasal sprays are indicated for the nasal route and should never be sprayed into the eyes or mouth. Nasal sprays are only used on a single patient to reduce the risk of contamination. Each spray contains one dose of the medication. It is important to note how many sprays are ordered and if they are to be administered in one or both nostrils. Before using a nasal spray for the first time, it is important to prime the pump. To do so, pump the spray bottle several times until you see the medication mist from the bottle (Figure 14.13). Examples of nasal sprays include fluticasone propionate nasal spray (Flonase) and oxymetazoline nasal spray (Afrin).

Figure 14.13: The nurse is priming the nasal spray before administering the first dose by pumping the spray bottle several times until the medication mists from the bottle. (credit: "Action photo of nasal spray on a black background" by robin_29, CC BY 2.0)

Patient Conversations: Educating a Patient on Nasal Sprays

Nurse: Mr. Floyd, your provider has sent in a prescription for a nasal spray. Have you ever taken a nasal spray before?

Patient: No, I’ve never taken a nasal spray before.

Nurse: Nasal sprays are liquid medications that you inhale through your nose. Each spray of the medication is equal to one dose of the medication.

Patient: How many sprays I am supposed to take?

Nurse: Your provider has ordered that once a day you do one spray in each side of your nose, which are called the nostrils.

Patient: How do I use it?

Nurse: Before using the nasal spray for the first time, you will prime the medication bottle. To do this, pump the spray bottle several times until you see the medication mist from the bottle. After you see the mist, it is primed and ready to use. Before you take the medication, blow your nose. Then, you tilt your head backward and insert the tip of the spray bottle in one side of your nose. Position the bottle so the tip is aimed toward the ear located on the same side as that nostril. Using your other hand, press down on the other side of your nose. While the other side of your nose is blocked, press down on the spray applicator while you inhale. Hold your breath for a few seconds and then exhale. Then, do it again on the other side. Try to avoid blowing your nose for five to ten minutes after administration so you do not blow the medication out.

Patient: Okay, I understand.

Nurse: Mr. Floyd, can you show me which way you will point the tip of the medication bottle after you put it in your nose?

Patient: If it is going in the right side, I point it toward the right ear. If it is going in the left side, I point it toward the left ear.

Nurse: You are correct! What questions do you have about how to use the nasal spray?

Patient: I do not have any questions at this time.

Nasal Washes

Nasal irrigation, also known as anasal wash, help to clean mucus, allergens, irritants, bacteria, and viruses from the nose. Nasal irrigation decreases swelling in the nose, increases airflow, decreases the risk of infection, and enhances the effectiveness of medications. When performing a nasal wash, a saline solution of distilled or sterilized water is used. Tap and well water should not be used because of the risk of introducing bacteria into the sinus cavity. While leaning over a sink, the patient squirts the solution into one nostril, rinses the sinus cavity, and allows the solution to come out of the other nostril (Figure 14.14). A variety of techniques may be used, including a sinus rinse kit, bulb syringe, or neti pot. To prevent bacterial growth, it is important to clean the nasal wash equipment after each use. To prevent cross contamination, the nasal wash equipment is intended only for a single patient.

Figure 14.14: When performing a nasal wash, the solution should flow freely from the opposite nostril. (CC BY 4.0; Rice University & OpenStax)

Categories of Nasal Inhalation Medications

Medications may also be administered using a nasal inhaler to deliver medication to the respiratory tract. The mucosal lining of the respiratory tract rapidly absorbs the medication, producing both local and systemic effects. Consistent use of nasal medications of any kind has the potential to injure the nasal tissue and affect the sense of smell. Categories of nasal inhalation medications include the following:

• Antihistamines relieve symptoms of allergies.
• Steroids reduce inflammation.
• Decongestants provide relief of nasal congestion.
• Mast cell inhibitors treat allergic symptoms by blocking mast cells.
• Anticholinergics block the action of acetylcholine.
• Opioid antagonists reverse opioid overdoses.

Antihistamines

Nasal antihistamine sprays are commonly prescribed to treat allergy symptoms, such as congestion, itchiness, runny nose, and sneezing. They work by blocking the effects of histamine. Typically, they cause less drowsiness than oral antihistamines. Examples of nasal antihistamine sprays include azelastine nasal (Astelin) and olopatadine nasal (Patanase).

Steroids

Allergy symptoms, such as congestion, sneezing, and itchy, watery eyes are often treated by steroid nasal sprays. They work by reducing inflammation within the nasal cavity. Unlike antihistamines and decongestants, steroids typically take approximately a week to begin relieving symptoms. Side effects of nasal steroid sprays include headache, sore throat, cough, and nosebleeds. Steroid sprays are available by prescription, as well as over the counter. Examples of prescription steroid sprays include beclomethasone nasal (Beconase) and fluticasone nasal (Veramyst). Examples of over-the-counter steroid sprays include budesonide nasal (Rhinocort Allergy) and triamcinolone nasal (Nasacort 24 hour).

Decongestants

Over-the-counter medications like decongestant sprays are also used to treat allergy symptoms. They work by causing the blood vessels and tissues in the nose to shrink, thereby relieving nasal congestion. Nasal decongestants should not be used for longer than three days because doing so may inadvertently cause increased congestion, also called rebound congestion. Other potential side effects include nasal dryness and irritation, nasal bleeding, headache, increased heart rate and blood pressure, nervousness or restlessness, and difficulty sleeping. Typically, decongestant sprays are not advised for patients with uncontrolled high blood pressure or glaucoma, as nasal decongestants cause narrowing of the blood vessels, which may further increase the blood pressure and cause increased ocular pressure that can potentially cause the glaucoma to worsen. Examples of nasal decongestants include oxymetazoline nasal (Afrin) and phenylephrine nasal (Neo-Synephrine).

Mast Cell Inhibitors

Allergy symptoms can be relieved by mast cell inhibitors, which stabilize mast cells. Mast cells release histamines; therefore, stabilizing mast cells blocks histamine release. Mast cell inhibitors block histamine release, so they are most effective if taken one to two weeks before allergy season begins. Side effects of mast cell inhibitors include headache, unpleasant taste, hoarseness, nosebleeds, and temporary nasal stinging. An example of a mast cell inhibitor spray is cromolyn sodium (NasalCrom), which can be purchased over the counter without a prescription.

Anticholinergics

Symptoms of a runny nose can be treated by anticholinergic sprays. They block acetylcholine in the nose to dry up extra mucus. Anticholinergics can be used for approximately three weeks and are not intended for long-term use. Common side effects include dry mouth, nasal irritation, headache, nosebleeds, and unpleasant taste in the mouth. Patients with glaucoma or enlarged prostates may be advised to avoid this medication; these medications can lead to increased intraocular pressure that may worsen glaucoma or cause urinary retention due to relaxation of the bladder. Currently, the only anticholinergic spray available is ipratropium inhalation (Atrovent), which is available by prescription only.

Opioid Antagonists

Opioid overdose and reversal of respiratory depression associated with opioid use are often treated by opioid antagonists. These work by blocking one or more of the opioid receptors in the central or peripheral nervous system. Each dose of opioid antagonist spray includes one dose of medication and should be used only once. Common side effects include headache, nasal dryness, nasal swelling, congestion, and muscle pain. An example of an opioid antagonist available in a nasal spray is naloxone (Narcan) (Figure 14.15).

Figure 14.15: To administer nasal naloxone (Narcan), place the nozzle in the nostril and press the plunger all the way up. (credit: “How to Administer Narcan” by Oshkosh Public Health & WIC, Public Domain)

Procedural Steps for Nasal Medication Administration

Nasal instillations should be administered via the nasal passage using a clean technique. The nurse should perform hand hygiene, don gloves, and perform the same rights of medication administration as is completed with other types of medications. The patient should be given tissues and asked to blow their nose. Position the patient so they are either sitting with their head tilted backward or lying supine looking upward. The nurse should insert the tip of the spray bottle or the nasal dropper into one nostril while occluding the other nostril and then activate the spray as the patient inhales. When administering a nasal spray, direct the spray away from the nasal septum to reduce potential irritation and allow the full dose of medication to take effect (Figure 14.16). The bottle should remain compressed as it is removed from the nose to prevent contamination. The patient should be instructed to hold their breath for a few seconds and then breathe through their mouth. Repeat this procedure in the other nostril, if ordered. Wipe the outside of the bottle with clean tissue before storing it and advise the patient to avoid blowing their nose for five to ten minutes after nasal instillation. Perform hand hygiene and note any unexpected situations, such as nosebleeds or increased congestion. Document administration of the medication as well as the patient’s tolerance of the medication and procedure.

Figure 14.16: When administering nasal medication, aim the nasal medication bottle toward the ear, away from the septum. (CC BY 4.0; Rice University & OpenStax)

Link to Learning

Watch this demonstrational video about nasal medications to learn how to administer them.