14.5: Administering Other Medications

Learning Objectives

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

• Describe indications for vaginal route of medication administration
• Identify indications for rectal route of medication administration

Other routes of medication administration include per vagina (PV) and per rectum (PR). Medications administered via the vaginal or rectal route have a faster onset and higher bioavailability than oral medications because they bypass the gastrointestinal tract. Bypassing the the gastrointestinal (GI) tract allows for the avoidance of hepatic first-pass metabolism, which is the initial metabolism and chemical alteration of a drug that takes place in the liver before it enters the bloodstream. Bypassing the GI tract also allows for more of the medication to be absorbed by the body. It also reduces the risk of certain side effects, such as gastric irritation, nausea, and vomiting. This section will discuss common indications for vaginal and rectal medication administration, the various forms of medication preparations, and how to safely administer medications via these routes.

Indications for Vaginal Route of Medication Administration

Vaginal medications are inserted into the vagina. Typically, medications administered via this route are indicated for hormone therapy, antifungal treatment, and contraception. Hormonal therapy may be warranted after menopause or during breastfeeding. Low estrogen levels may cause vaginal dryness and itching, which can be relieved by vaginal medications. Antifungal treatments may be used to treat infections, such as yeast infections and bacterial vaginosis. Spermicides or contraceptive gels may be inserted into the vagina before sexual intercourse as a means of birth control. Vaginal medications may be used during menstruation cycles; however, tampons should not be used because they will absorb some of the medication and decrease the intended effects of the medication.

Patient Conversations: Educating a Patient on Vaginal Suppositories

Nurse: Mrs. Safrit, your provider has placed an order for you to start progesterone suppositories.

Patient: Suppositories?

Nurse: Yes, progesterone comes prepared as a vaginal suppository that you can easily insert yourself at home.

Patient: Can’t I just take a progesterone pill?

Nurse: Vaginal progesterone suppositories are the most effective delivery method for ensuring your body has the progesterone needed to get, and stay, pregnant. They work by slowly releasing progesterone into the body via the vagina.

Patient: How do I insert it?

Nurse: I have a sample here with me and will show you exactly what to do. You will open the suppository package, remove the suppository from the wrapper, and place the suppository at the end of the applicator. The rounded end of the suppository should be facing out of the applicator. Lubricate the applicator with a water-based lubricant. With your nondominant hand, spread the labia and place the applicator into the full length of the vagina, push the plunger, and then remove the applicator. After you insert it, lie in bed for ten to fifteen minutes to allow time for the suppository to dissolve and absorb into the body. It is recommended that you insert the suppository at night, so it has plenty of time to absorb while you are sleeping.

Patient: That doesn’t sound too bad. I think I can do that.

Nurse: I will provide you with a handout with instructions just in case you need a reminder after you get home. If you have any questions when you get home, feel free to send me a message in the patient portal and I will be happy to help.

Forms of Vaginal Medications

Vaginal medications come prepared as creams, foams, suppositories, and tablets. A cream is a semisolid emulsion that contains a suspended or dissolved medication. A foam is a liquid medication dispersed in gas that results in a light, frothy substance. Creams and foams are squeezed from the medication tube into an applicator that allows for easy insertion into the vagina (Figure 14.21).

Figure 14.21: The patient withdraws the vaginal cream from a medication tube into a vaginal applicator. (CC BY 4.0; Rice University & OpenStax)

Solid medications that melt inside the body and absorb into the bloodstream are known as suppositories. They are absorbed quickly and have a faster onset than oral medications. It is important to store suppositories in a cool, dry place to avoid accidental disintegration and melting. Compressed powders that have been formed into a solid are called tablets. Body warmth causes the tablet to disintegrate so that it may be absorbed into the bloodstream (Figure 14.22). Vaginal suppositories and tablets are placed onto the end of an applicator and then inserted into the vagina.

Figure 14.22: The patient places a vaginal suppository on the end of an insertion applicator. (CC BY 4.0; Rice University & OpenStax)

Cultural Context: Considerations for Male Nurses Administering Vaginal Suppositories

When a male nurse is tasked with administering a vaginal suppository to a female patient, several important considerations must be kept in mind to ensure that the patient’s privacy, comfort, and dignity are respected, and that professional and ethical standards are maintained. Some key considerations include the following:

• Cultural sensitivity: Be sensitive to the patient’s cultural background and beliefs. Some patients may have cultural or religious preferences regarding the gender of healthcare providers involved in intimate procedures. If possible and within the constraints of staffing and patient safety, consider accommodating such preferences.
• Privacy and dignity: Ensure that the patient’s privacy and dignity are preserved throughout the procedure. This includes providing a private area for the administration of the suppository, using appropriate draping, and ensuring that only necessary personnel are present.
• Clear communication: Open and clear communication is crucial. The nurse should explain each step of the procedure to the patient before proceeding, allowing the patient to express any concerns or discomfort.
• Professionalism: Maintain a high level of professionalism throughout the procedure. The nurse should focus on the clinical aspects of the task and approach it with empathy and respect.

Procedural Steps for Vaginal Medication Administration

The patient should be asked to void before placement of a vaginal medication. The nurse performs hand hygiene, dons gloves, performs the same rights of medication administration as is completed with other types of medications, and provides patient privacy. Position the patient on their back with knees flexed. The nurse performs perineal care before administering the medication. After perineal care, the nurse removes their gloves, performs hand hygiene, and dons a new pair of gloves.

Fill a vaginal applicator with cream or foam; or open the suppository packaging. Lubricate the applicator or your gloved finger with a water-based lubricant. With the nondominant hand, spread the labia, place the applicator into the full length of the vagina, push the plunger, and then remove the applicator (Figure 14.23). If a suppository is being placed with your finger, insert the rounded end of the suppository with your index finger, placing it along the posterior wall of the vagina. Ask the patient to remain in the supine position for five to ten minutes for optimal absorption. If possible, administer the medication at bedtime so the patient can remain in the supine position for an extended period of time to enhance absorption. Perform hand hygiene and assess the patient for any unexpected situations, such as the suppository coming out. Document administration of the medication as well as the patient’s tolerance of the medication and procedure.

Figure 14.23: The filled applicator should be inserted into the full length of the vagina before pushing in the plunger. (CC BY 4.0; Rice University & OpenStax)

Indications for Rectal Route of Medication Administration

Rectal medications are inserted into the rectum. Medications administered via the rectal route may be indicated based on gastrointestinal or systemic effects. For example, laxatives may be indicated to relieve the gastrointestinal symptom of constipation, whereas analgesics may be indicated for systemic pain relief when other medication routes are not available or effective. A potential complication of rectal medication insertion is the potential for bowel perforation. Therefore, rectal medications are contraindicated with rectal bleeding; diarrhea; rectal prolapse; low platelet count; or after rectal, bowel, or prostate surgery. Another potential complication of rectal medication insertion is unintended vagal stimulation that results in bradycardia. Therefore, the rectal route may be contraindicated for patients with certain cardiac conditions.

Patient Conversations: Administering an Acetaminophen Suppository to Reduce Fever

Scenario: Kathy Plaia is a registered nurse who worked at an outpatient pediatrician office in Savannah, Georgia. One day while working the after-hours nurse triage line, the nurse received a phone call from a parent stating their 5-year-old child, Marcus, had a fever of 101.2ºF (38.4ºC).

Nurse: I’m sorry to hear Marcus is not feeling well. Is Marcus experiencing any other symptoms besides the fever?

Parent: Yes, Marcus has complained of being nauseous for the past couple of hours. He has thrown up twice and can’t keep any liquids down.

Nurse: Since Marcus cannot keep liquids down, I recommend you give him a 120 mg acetaminophen (Tylenol) suppository. The suppository will be inserted into his rectum; therefore, he can’t throw it up as he would an oral tablet.

Parent: A suppository? Like put something in his bottom? Oh, I’m not sure I can do that.

Nurse: I will walk you through the process and hopefully it will help Marcus to feel better.

Parent: Well, okay. If it will make my child better, I will try it.

Nurse: Wonderful! Tylenol suppositories can be found at your local pharmacy or grocery store. Go to the medication aisle and it will be where the regular Tylenol is; however, the box will say “suppositories.” You will also want to pick up some lubrication jelly. Have Marcus lie on his side with his knees bent up. Once you are ready, wash your hands and open the suppository packet. The suppository will look like a bullet. Squirt some of the lubrication jelly on the pointed end of the bullet. Then, use your finger to gently insert the suppository, pointed end first, about 1 in (2.5 cm) into Marcus’ rectum, which is about to your top knuckle line. Then, wipe off any extra lubricant with a towel or tissue and wash your hands. Have Marcus continue lying down for about five to ten minutes to allow the medication time to absorb.

Parent: Is that it? That doesn’t sound too bad.

Nurse: That’s it. Can you repeat the instructions back to me?

Parent: I am going to go to the store to get the suppositories and some lube. I’ll have Marcus lie down on his side and tell him to pull his knees up. Then I will wash my hands, open the packet, and squirt the lube on the tip of the suppository. Then, push it about 1 in (2.5 cm) into his bottom, which is about where the tip of my finger bends. Then, wipe off his bottom, wash my hands, and have him lie there for five to ten minutes.

Nurse: Perfect, it sounds like you know what to do. If Marcus’s fever doesn’t go down or gets any higher, you should take Marcus to an urgent care or emergency room for further evaluation and treatment.

Parent: I sure will.

Nurse: Do you have any questions for me?

Parent: No, I appreciate you explaining what I need to do. I just hope it helps my baby.

Nurse: As do I. If you have any questions later on or have any trouble with the suppository, please feel free to call me back and I will walk you through what to do.

Parent: I sure will. Thank you, again.

Scenario follow-up: Thankfully, the child’s fever was reduced to 99.4ºF (37.4ºC) after administering the suppository. The child was seen at the clinic the next day for further assessment and diagnostics to determine the cause of the fever.

Forms of Rectal Medications

Rectal medications are prepared as suppositories or liquids. Suppositories are solid medications that melt and absorb into the bloodstream after being placed in the rectum. Usually, suppositories are narrowed and rounded at one end to allow easy entrance into the rectum (Figure 14.24). Examples of medications that may be administered as rectal suppositories for fever and pain (acetaminophen [Tylenol]), constipation (glycerin rectal suppositories [Fleet Glycerin]), nausea and vomiting (promethazine rectal [Phenergan]), or certain bowel conditions (mesalamine rectal [Canasa]).

Figure 14.24: Suppositories are rounded on one end to allow for easy entry into the rectum. (credit: "Suppositories three different sizes" by Alcibiades, Public Domain)

Typically, rectal medications prepared in liquid form have a faster rate of absorption than suppositories because they do not require the body to melt the medication before being absorbed. The most common liquid medications administered via the rectal route are enemas. Enemas may contain a liquid solution that is placed in a disposable plastic squeeze bottle and then instilled into the rectum. Other forms of enemas (e.g., soap suds enemas) contain the solution in a bag that is connected to tubing that is inserted in the rectum and instilled by gravity. Enemas may be used to treat constipation, seizures, and certain bowel conditions; they are also used for bowel preparation before gastrointestinal diagnostic or surgical procedures.

Clinical Safety and Procedures (QSEN): QSEN Competency: Administering a Large-Volume Cleansing Enema

See the competency checklist for Administering a Large-Volume Cleansing Enema. You can find the checklists on the Student resources tab of your book page on openstax.org.

Procedural Steps for Rectal Medication Administration

Before administering rectal medications, the nurse assesses potential contraindications (e.g., recent rectal or prostate surgery). The nurse should ask the patient to defecate before rectal medication administration. The nurse should perform hand hygiene, don gloves, perform the same rights of medication administration as is completed with other types of medications, and provide the patient privacy. Position the patient in the Sims position (i.e., on their left side with the upper leg flexed over the lower leg toward the waist) (Figure 14.25). Place a drape under the patient’s buttocks to protect the linens from potential contamination. Assess the patient for contraindications, such as diarrhea or active rectal bleeding. If gloves become soiled, remove the soiled gloves and don new nonsterile gloves.

Figure 14.25: The Sims position is the appropriate position for the patient for inserting a suppository. (CC BY 4.0; Rice University & OpenStax)

If administering a suppository, remove the medication from the wrapper and lubricate the rounded tip of the suppository and index finger of the dominant hand with a water-based lubricant. If administering an enema, lubricate only the tip of the enema. With the nondominant hand, separate the buttocks and insert the rounded end of the suppository with the index finger, inserting it into the rectum toward the umbilicus (Figure 14.26). While inserting the suppository, instruct the patient to take slow deep breaths in and out to help relax the anal sphincter. Insert the suppository approximately 2 in (5 cm) beyond the anal sphincter to promote absorption of the medication. If an enema is being administered, follow the same procedure; however, expel the air from the enema container before inserting it into the rectum. Roll the plastic bottle from bottom to top until all the contents have been inserted into the rectum.

Figure 14.26: The nurse inserts the suppository into the rectum toward the umbilicus. (attribution: “Administering Medication Rectally” by British Columbia Institute of Technology, CC BY 4.0)

After inserting a suppository, the nurse removes their finger and wipes the excess lubricant from the anal area. The nurse instructs the patient to remain on their side for five to ten minutes to prevent accidental expulsion of the medication. Suppositories may also be administered via the colostomy stoma, depending on the patient’s condition. The nurse performs hand hygiene and assesses the patient for any unexpected situations (e.g., the suppository coming out). The nurse then documents administration of the medication as well as the patient’s tolerance of the medication and procedure.