2.3: Drug Administration Routes, Preparation, and Administration
By the end of this section, you should be able to:
- 2.3.1 Identify the different routes of drug administration.
- 2.3.2 Discuss sites for parenteral therapy.
- 2.3.3 Analyze nursing interventions related to drug administration.
- 2.3.4 Explain equipment and techniques for drug administration.
This section will discuss the different routes for medication administration, how to prepare for administration, and the various methods for administering drugs to the client. Both enteral and parenteral sites will be reviewed, along with the equipment needed for each type of drug administration. Techniques for drug administration will be described.
Forms and Routes of Drug Administration
There are many different forms of medication : liquid, suspensions, tablets, capsules, lotions, and ointment, to name a few. There are also many routes through which medications can be given and absorbed into the body. The routes of medication administration are broadly categorized as follows:
- Enteral administration : “Enteral” means “pertaining to the intestines.” Most enteral medications are absorbed in the intestines. The primary routes for enteral administration are oral and, to a lesser extent, rectal. Some clients have tubes placed directly into the gastrointestinal tract (e.g., nasogastric tubes or percutaneous endoscopic gastrostomy [PEG] tubes). Absorption will vary, but all will be affected by the first-pass effect.
-
Parenteral administration
:
“Parenteral” refers to any drug that is administered outside of the GI tract; however, it most commonly refers to injectable drugs administered via the subcutaneous, intramuscular, or intravenous routes. Drugs administered via these routes have improved bioavailability because they bypass the first-pass effect, making absorption and onset of action more rapid.
- Percutaneous administration : Some sources will define percutaneous administration as a separate category or a subcategory of parenteral routes. The percutaneous route refers to topical drugs absorbed through the skin—lotions, ointments, creams, or patches.
The following sections describe the equipment needed for the administration of medications. The various techniques of each route are detailed, along with their pertinent advantages and disadvantages. Nursing implications are also covered in relation to each route of administration.
Safety Alert
Medication Safety
The following are some tips for medication safety:
- It is best practice to prepare medications for only one client at a time. This safety practice reduces the risk of inadvertently administering medications to the incorrect client.
- Medications that require a focused assessment or monitoring should be kept separate from other medications. For example, if administering a medication that lowers blood pressure and heart rate, vital signs should be assessed before giving the drug. Because opioids may cause respiratory depression, respiratory rate and oxygen saturation should be assessed before and after administration of the drug.
- All unit-dose medications should be opened at the bedside rather than in the medication room.
- Never leave medications unattended at the bedside unless specifically ordered. Remain with the client until all medications have been administered.
Product (Drug) Labeling
Each prescription drug includes a package insert that provides clients with information about the drug. Many package inserts are developed by the manufacturer and approved by the FDA for use by clients and caregivers (FDA, 2023a). Some of the information contained in the inserts includes generic and trade names, routes, instructions for taking the drug, and how to store and dispose of the drug. Any side effects, especially if the drug has serious side effects, are listed, as are directions about what to do if adverse effects occur. General information about the safe use of the drug, how to report side effects, and ingredients are also listed. These package inserts are often one of the best resources for free information for the client.
Oral Medications
Oral administration encompasses several different drug forms. Liquids, elixirs, suspensions, tablets, capsules, and caplets may all be given orally. Oral administration is usually quick, easy, and convenient, but the onset of action is longer and unpredictable due to the first-pass effect, and not all drugs can be administered this way. Table 2.1 lists the advantages and disadvantages of oral administration.
| Advantages | Disadvantages |
|---|---|
|
|
Steps to administering an oral medication:
-
Assemble the appropriate equipment:
- Drinking cup
- Straw
- Disposable medication cup (souffle cup or calibrated plastic medication cup for liquids)
- Assess the client to determine if the drug is safe and appropriate to give.
- Check the medication, dose, and expiration date.
- Check NPO status and ensure the client does not have nausea or vomiting. (NPO is a Latin term meaning nil per os , or nothing by mouth. Sometimes this will include medications.)
-
Follow the seven rights of medication administration
throughout
the procedure (at least three times or according to institutional policy).
- During verification of the contents of the medication administration record and the orders
- When preparing the medication
- At the bedside
- Wait to open blister packs or oral unit doses until at the client’s bedside.
- Perform hand hygiene.
- Don gloves if you anticipate touching the pill or the client’s mouth during administration.
-
Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the blister pack using the protocol recommended by the institution.)
- Perform the third medication check at the bedside. This check is completed by verifying that the medication name, dosage, route, and time match the medication administration record (this is the last opportunity to prevent an error from occurring). Most institutions now have barcode scanning at the bedside as an additional layer of security.
-
Explain the medication to the client:
- Name (brand and generic)
- Dosage
- Indication, rationale, or reason for the drug to be given
- Frequency
- Route
- Adverse effects
- Position the client in an upright position or on side as condition allows.
- Assess the client’s ability to swallow and the gag reflex by offering a sip of water.
- Ask the client if they prefer all medications at once or one or two at a time.
- Give the client the medication with a cup of water (approximately 8 ounces unless the client is on a fluid restriction).
- Document administration within the medication administration record (MAR).
- Perform hand hygiene.
- Evaluate the client’s response to the drug(s) within the appropriate time frame.
Nursing Implications for Oral Medications
The nurse should do the following for clients who are taking oral medications:
- If a tablet needs to be split, split only tablets that are scored. If a client has difficulty swallowing a tablet or capsule, consult a pharmacist for advice about the technique of administration because some capsules may be opened and emptied into a food or liquid. Timed-release capsules or tablets should not be crushed or chewed because this may affect the rate of absorption and toxicity may occur. For this reason, timed-release capsules should not be opened and emptied into food for ease of swallowing.
- Use a hospital-approved device to split the tablet. (Some health systems split the tablets in the pharmacy and send them to the unit in unit-dosed packaging for safety purposes.)
-
Discard any unused portion according to institutional policy.
- If the drug is a controlled substance, document the waste with another nurse in the medication room.
-
If a tablet needs to be crushed:
- Ensure that it can be crushed.
- Never crush sustained-release, extended-release, or enteric-coated tablets.
- If crushing more than one tablet, keep them separate; do not combine them.
- When filling a calibrated plastic cup with liquids, fill at eye level.
- Always remain with the client until all medications are taken; do not leave drugs at the bedside unattended.
Sublingual and Buccal Administration
Absorption of sublingual medications occurs in the area under the tongue, whereas buccal medications are absorbed in the oral mucosa, generally between the cheek and gums. These are vascular areas, and medications administered here are absorbed rapidly because they do not undergo the first-pass effect. Table 2.2 lists the advantages and disadvantages of sublingual and buccal administration .
| Advantages | Disadvantages |
|---|---|
|
|
Steps to administering a sublingual or buccal medication:
-
Assemble the appropriate equipment:
- Disposable medication cup (souffle cup)
- Drinking cup
- Straw
- Assess the client to determine if the drug is safe and appropriate to give.
- Check the medication, dose, and expiration date.
-
Follow the seven rights of medication administration
throughout
the procedure (at least three times or according to institutional policy).
- During medication reconciliation
- When preparing the medication
- At the bedside
- Perform hand hygiene.
- Don gloves if you anticipate touching the pill or the client’s mouth during administration.
- Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the blister pack, using the protocol recommended by the institution.)
- Perform the third medication check at the bedside.
-
Explain the medication to the client:
- Name (brand and generic)
- Dosage
- Indication, rationale, or reason for the drug to be given
- Frequency
- Route
- Adverse effects
- Offer sips of water to moisten the oral cavity.
- Assist the client in placing the medication sublingually (or between the cheek and gum for buccal drugs).
- Instruct the client to allow the medication to dissolve completely. Discuss the importance of not swallowing or chewing the pill.
- Educate the client about the importance of abstaining from food, drinking, or smoking until after the medication has dissolved.
- Document administration within the MAR.
- Perform hand hygiene.
- Evaluate the client’s response to the drug(s) within the appropriate time frame.
Nursing Implications for Sublingual or Buccal Medications
The nurse should do the following for clients who are taking sublingual or buccal medications:
-
Always remain with the client until all medications are taken; do not leave drugs at the bedside unattended unless the provider has ordered the medication to be left at the bedside.
- Exception: Sublingual nitroglycerin tablets or sprays are often ordered to be left at the bedside so that a client may take them as needed in the event of chest pain.
Nasal Spray Administration
Nasal sprays can be rapidly absorbed into the mucous membranes of the nasal cavity. Table 2.3 lists the advantages and disadvantages of nasal sprays.
| Advantages | Disadvantages |
|---|---|
|
|
Steps to administering a nasal spray:
-
Assemble the appropriate equipment:
- Clean gloves
- Tissue
- Medication
- Assess the client to determine if the drug is safe and appropriate to give.
- Check medication, dose, and expiration date.
-
Follow the seven rights of medication administration
throughout
the procedure (at least three times or according to institutional policy).
- During medication reconciliation
- When preparing the medication
- At the bedside
-
Educate the client.
- Explain the method for administering the medication. (This route may be self-administered in the future; however, the nurse should observe this in order to provide appropriate documentation in the MAR.)
- Inform the client that they may experience a burning or stinging sensation with administration.
- Instruct the client to gently blow their nose (unless it is contraindicated for the client).
- Assess the nostrils for erythema, edema, drainage, or tenderness.
- Client should be upright in a sitting position with their head tilted back.
- Block one nostril.
- Hold the medication bottle upright and shake.
- Immediately insert the tip of the applicator into the nostril.
- Ask the client to inhale while simultaneously squeezing a spray into the nostril.
- Once the bottle has been squeezed to deliver the medication, do not release the squeeze until the spray bottle has been removed from the nares. Ensure that the nozzle of the nasal spray does not touch the nasal turbinates or septum because pain or injury could occur.
- Repeat the process in the other nostril if indicated.
- Have tissue available if needed to blot the nostril. The client should avoid blowing their nose immediately.
- Wipe the spray applicator with a clean, dry cloth or tissue.
- Remove gloves and perform hand hygiene.
- Document administration within the MAR.
- Evaluate the client’s response to the drug(s) within the appropriate time frame.
Be aware that some nasal medications may vary from this procedure; it is important to consult the product labeling to confirm the appropriate administration technique.
Nursing Implications for Nasal Sprays
The nurse should do the following for clients who are taking nasal sprays:
- Do not readminister the drug if the client sneezes following the administration of the nasal spray because there is no way to assess how much of the drug has been absorbed.
Removing Parenteral Medication from a Vial
When administering a parenteral medication , such as a subcutaneous or intramuscular injection, it is important to remember that this is an invasive procedure (a needle is inserted into the client). The medication may come in a prefilled syringe; however, it is usually drawn up by the nurse from a vial of medication. The nurse should be very alert during the process of drawing up and administering the medication to keep the needle and contents sterile.
Steps to withdrawing medication from a vial:
- Perform hand hygiene and don clean gloves (not sterile).
- Inspect and verify the medication, dose, volume, and expiration date.
- Verify the dosage calculation.
- Remove the plastic cap from the top of the unused vial with a flick of the thumb.
-
Wipe the rubber stopper or port with an alcohol swab and allow it to air dry for approximately 10 seconds.
- The cap does not keep the top of the port sterile. Dust and microbial contaminants can collect under the cap, so it is important to cleanse with alcohol.
- Insulin and tuberculin syringes have preattached needles. If drawing up insulin, insulin syringes have preattached needles with orange caps (see Figure 2.6). Insulin syringes are marked in unit measures rather than in milliliters (mL). The needles on these syringes are fragile and bend very easily, so it is important to be careful when inserting and withdrawing the needles from the vial.
-
When drawing up medications into syringes that are not insulin or tuberculin syringes:
- Attach a blunt-tipped needle to the syringe of choice. The syringe choice should be large enough to hold the dose of medication, but the smallest syringe closest to that measurement (i.e., if administering 4 mL, draw it up in a 5 mL syringe rather than a 10 mL, 20 mL, etc.).
- Remove the needle cap and draw air into the empty syringe to the volume of medication to be given (e.g., if giving 2 mL of medication, then draw up 2 mL of air).
-
Insert the air into the vial of medication through the center of the rubber port at the top of the vial.
- Ensuring that the tip of the needle is above the fluid level of the vial will help avoid the presence of bubbles. (It prevents agitation of the drug.)
- Be sure to maintain the sterility of the needle.
- Do not touch the needle.
- Be careful not to bend the needle.
- Inject the air into the vial.
-
Invert the vial and hold it at eye level to slowly withdraw the desired volume of medication.
- If the medication is withdrawn too quickly, air bubbles may enter the syringe.
- Important tip: Ensure that the tip of the needle is below the fluid level in the vial so that no air is drawn into the syringe.
- Withdraw slightly more of the medication than needed.
- Express any air bubbles and the excess medication back into the vial until the desired amount of medication is in the syringe.
- Withdraw the needle from the vial, being careful not to bend the needle.
- Exchange the blunt needle for a regular needle prior to administration.
Steps to administering a subcutaneous medication:
-
Assemble the appropriate equipment:
- Medication
- Sterile syringe (1–3 mL)
- Small-gauge needles (3/8–5/8 inch) (tuberculin and insulin syringes have preattached needles)
- Alcohol swabs
- Gloves (clean gloves, not sterile)
- Assess the client to determine if the drug is safe and appropriate to give.
- Check the medication, dose, volume, and expiration date.
-
Follow the seven rights of medication administration
throughout
the procedure (at least three times or according to institutional policy).
- During medication reconciliation
- When drawing up the medication
- At the bedside
- Perform hand hygiene.
- Don gloves.
- Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the vial or unit dose, using the protocol recommended by the institution.)
- Perform the third medication check at the bedside.
-
Explain the medication to the client:
- Name (brand and generic)
- Dosage
- Indication, rationale, or reason for the drug to be given
- Frequency
- Route
- Adverse effects
- Prepare medication using the correct needle length (3/8–5/8 inches), gauge (25–29 gauge), and syringe (usually no more than 1.5 mL can be given via this route). For clients with little adipose tissue, use the smaller needle.
-
Select an injection site with an adequate fat pad.
- Avoid bruises, rashes, inflammation, or areas of injury.
- Ensure that the injection site is a minimum of 2 inches away from the umbilicus, a stoma, or an incision.
- Preferred sites include the abdomen, upper arms, and anterior thighs.
- Assist the client into a position in which the site or extremity can be relaxed.
- Cleanse the area with an alcohol swab using a circular motion by starting at the center and working outward in a widening circle to about 2–3 inches. Allow to air dry.
- Grasp the skinfold between your thumb and index or third finger of the nondominant hand. (A new alcohol swab or gauze can be placed between the fourth and fifth fingers of this hand to use after injection.)
- Remove the needle cap carefully and dispose.
- Instruct the client that they will feel a “pinch.”
- Quickly and smoothly insert the needle into the skin and adipose tissue at a 45- to 90-degree angle. The anticoagulant enoxaparin is a subcutaneous injection that should be given at a 90-degree angle.
- Inject the medication with the dominant hand depressing the plunger with slow and even pressure, while holding the barrel of the syringe steady with the nondominant hand.
- Do not aspirate for subcutaneous injections.
- Withdraw the needle smoothly at the same angle that it was inserted to prevent trauma at the injection site.
- Apply gentle pressure with the alcohol swab, but do not massage the site, especially if the medication given was an anticoagulant such as heparin or enoxaparin, because this may cause extensive bruising.
- Activate the safety device on the syringe and dispose of the syringe in the sharps container or a puncture-resistant needle disposal container according to institutional policy. Never throw it into the trash.
- Do not recap the needle! This is a safety hazard for the nurse. Recapping needles may lead to needle sticks and exposure to pathogens.
- Remove gloves and perform hand hygiene.
- Document in the MAR. When documenting a subcutaneous injection, be sure to document the site the medication was administered to allow for the rotation of sites.
- Evaluate the client’s response to the drug(s) within the appropriate time frame.
Nursing Implications for Subcutaneous Administration
The nurse should do the following for clients receiving a subcutaneous injection:
- For heparins and insulins: Both are high-alert medications. A second nurse will need to verify the dose. Do not draw up the dose until a witness is available to verify.
-
Never draw heparin up into an insulin syringe. (Fortunately, many heparins come in prefilled syringes for safety reasons.)
- Insulin, and only insulin, should be drawn up into an insulin syringe. Never draw up insulin into a regular syringe with milliliter (mL) markings because this will cause an overdose of insulin.
- Administer subcutaneous injections at a 45- to 90-degree angle depending upon the body habitus of the individual. For extremely thin individuals and children, ensure that the angle is shallow enough that the medication is not given intramuscularly
Link to Learning
ISMP Guidelines for Safe Subcutaneous Insulin Use
Review the ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults . According to the Institute for Safe Medication Practices (ISMP), insulin is associated with more medication errors than any other type or class of drugs.
Intramuscular Injections
Intramuscular injections (IM) are administered deep into the muscular tissue beneath the dermis and subcutaneous layers (see Figure 2.9). The most common sites for IM injections are the ventrogluteal and deltoid areas. Vastus lateralis landmarks are preferred for infants and children under age 2. Table 2.5 lists the advantages and disadvantages of intramuscular administration.
| Advantages | Disadvantages |
|---|---|
|
|
Steps to administering an intramuscular medication:
-
Assemble the appropriate equipment:
- Medication
- Syringe (3 mL)
- Needles (unless preattached)
- Alcohol swabs
- Gloves (clean gloves, not sterile)
- Assess the client to determine if the drug is safe and appropriate to give.
- Check the medication, dose, volume, and expiration date.
-
Follow the seven rights of medication administration
throughout
the procedure (at least three times or according to institutional policy).
- During medication reconciliation
- When drawing up the medication
- At the bedside
- Perform hand hygiene.
- Don gloves.
- Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the vial or package, using the protocol recommended by the institution.)
- Perform the third medication check at the bedside.
-
Explain the medication to the client.
- Name (brand and generic)
- Dosage
- Indication, rationale, or reason for the drug to be given
- Frequency
- Route
- Adverse effects
- Prepare medication using the correct needle length (1–1.5 inches), gauge (18–27 gauge), and syringe (no more than 3 mL can be given via the ventrogluteal route, and no more than 1 mL can be given in the deltoid). (See Figure 2.9.)
-
Select an injection site.
- Avoid areas of hardness, bruising, rashes, inflammation, injury, or infection.
- Assess muscle size and integrity.
- Assist the client into a position in which the site or extremity can be relaxed.
- Cleanse the area with an alcohol swab using a circular motion by starting at the center and working outward in a widening circle to about 2 inches. Allow to air dry for 10 seconds.
- Remove the needle cap carefully.
- Instruct the client that they will feel a “stick.”
- Grasp the syringe like a dart with the dominant hand.
- Quickly and smoothly insert the needle through the skin and adipose tissue to the muscular layer at a 90-degree angle.
- Inject the medication with the dominant hand depressing the plunger with slow and even pressure, while holding the barrel of the syringe near the hub steady with the nondominant hand.
- Withdraw the needle smoothly at the same angle that it was inserted.
- Apply gentle pressure with the alcohol swab, but do not massage the site.
- Activate the safety device on the syringe and dispose of the syringe in the sharps container or in a puncture-resistant needle disposal container according to institutional policy. Never throw it into the trash.
- Do not recap the needle! This is a safety hazard for the nurse. Recapping needles may lead to needle sticks and exposure to pathogens.
- Remove gloves and perform hand hygiene.
- Document in the MAR. When documenting an IM injection, be sure to document the site the medication was administered to allow for the rotation of sites if other doses are necessary.
- Evaluate the client’s response to the drug(s) within the appropriate time frame.
Steps to administering an IVP medication:
-
Assemble the appropriate equipment:
- Medication
- Syringe with a needleless device
- Needles
- Normal saline flushes
- Diluent, if needed
- Alcohol swabs
- Gloves
- Assess the client to determine if the drug is safe and appropriate to give.
- Check the medication, dose, volume, and expiration date.
- Check the compatibility of the medication with the IV fluids that are hanging.
- Double-check dosage calculations.
-
Follow the seven rights of medication administration
throughout
the procedure (at least three times or according to institutional policy).
- During medication reconciliation
- When drawing up the medication
- At the bedside
- Perform hand hygiene.
- Don gloves.
-
In the medication room (or possibly the client’s room in some institutions), use aseptic technique to draw the medication into the syringe as described in the previous section.
- Use a syringe size closest to the amount of the drug needed (e.g., a 3 mL syringe to draw up 1–3 mL or a 5 mL syringe to draw up 4–5 mL).
- Double-check the rate of administration.
- Label the medication syringe with the client’s name, date of birth, medication name, dosage and volume, time, and initials. (This may vary slightly between institutions.)
- Once in the client’s room, identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the vial or package, using the protocol recommended by the institution.)
- Perform the third medication check at the bedside.
-
Explain the medication to the client:
- Name (brand and generic)
- Dosage
- Indication, rationale, or reason for the drug to be given
- Frequency
- Route
- Adverse effects
- Assess the IV site. Check for redness, swelling, or tenderness. Assess local skin temperature for warmth.
- Unclamp the saline lock and expel air bubbles from a saline flush. Then remove the disinfecting cap from the port.
- Scrub the hub of the port and the threads with an alcohol swab or the institution’s preferred cleanser for 15 seconds.
- Remove the tip from the flush (see Figure 2.12) and insert the saline flush by twisting and pushing to the right. Once the flush is engaged with the saline lock, gently aspirate for blood return to assess for patency of IV.
Steps to administering a transdermal medication:
- Assess the client to determine if the drug is safe and appropriate to give.
- Check the medication, dose, volume, and expiration date.
-
Follow the seven rights of medication administration
throughout
the procedure (at least three times or according to institutional policy).
- During medication reconciliation
- When preparing the medication
- At the bedside
- Wait to open the patch or disk until at the client’s bedside.
- Perform hand hygiene.
- Don clean gloves for the administration of any patch or ointment. Never apply a patch or ointment with the bare hand because the medication can be transferred to you in the process.
- Identify the client and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the blister pack, tube, or package, using the protocol recommended by the institution.)
- Perform the third medication check at the bedside.
-
Explain the medication to the client:
- Name (brand and generic)
- Dosage
- Indication, rationale, or reason for the drug to be given
- Frequency
- Route
- Adverse effects
-
Remove any old patches that remain on the skin.
- Many patches are small, clear, transparent disks, so some are difficult to find.
- Assess the skin for irritation at the site of the old patch.
- Cleanse the skin with soap and water and allow it to dry before applying patches or ointments.
- Ensure that the site of the new patch is free of irritation, scrapes, open sores, or bruises. It is best if it is located on an area with little to no hair.
- Rotate sites each time a new patch is placed.
- Label the patch prior to placing it on the client with the nurse’s initials, the date, and the time administered.
- Perform hand hygiene.
- Document in the MAR.
- Evaluate the client’s response to the drug(s) within the appropriate time frame.
Nursing Implications for Transdermal Administration
The nurse should do the following for clients receiving a transdermal patch:
- Educate the client to administer the patch at the same time each day.
- Administer after a shower or bath.
- Always remain with the client until all medications are taken; do not leave drugs at the bedside unattended.
- Educate the client to develop a schedule for rotating the sites of application.
- Never cut a patch in half (unless allowed per the drug product’s labeling) because this may release all of the medication at once, resulting in an overdose. Patches are developed with special technology to release the medication slowly over a long period of time. Some patches may only need to be replaced once each week.
- Don gloves to remove a patch and dispose of according to institutional policy. Never dispose of a patch in the trash. Children have removed them from the trash thinking they were stickers, and this resulted in harm to the child. Pets also have eaten them.
- Educate the client that the patch’s effects may last for many hours following its removal (up to 72 hours).
Cutaneous Administration
Ointments and lotions are medications that can be applied to the skin. Some are used for local therapy (e.g., hydrocortisone lotion applied to a rash), whereas some are used for systemic absorption. A common medication that is delivered via an ointment for systemic absorption is nitroglycerin (for angina). This medication will be discussed specifically due to its unique formulation.
Steps to administering nitroglycerin ointment (nitroglycerin paste):
-
Assemble the appropriate equipment:
- Gloves
- Nitroglycerin ointment and application paper
- Paper tape
- Assess the client to determine if the drug is safe and appropriate to give.
- Check the medication, dose, volume, and expiration date.
-
Follow the seven rights of medication administration
throughout
the procedure (at least three times or according to institutional policy).
- During medication reconciliation
- When measuring the medication
- At the bedside
- Perform hand hygiene.
- It is important to don clean gloves for the administration of ointment. Never apply ointment with bare hands because the medication can be transferred to you in the process.
- Identify the client and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the tube of ointment, using the protocol recommended by the institution.)
- Perform the third medication check at the bedside.
-
Explain the medication to the client:
- Name (brand and generic)
- Dosage
- Indication, rationale, or reason for the drug to be given
- Frequency
- Route
- Adverse effects
-
Remove any old nitroglycerin doses that remain on the skin.
- Assess the skin for irritation at the site of the old nitroglycerin applicator paper.
- Cleanse the skin with soap and water and allow it to dry before applying the ointment.
- Ensure that the site of the new dose is free of irritation, open sores, scrapes, or bruises. It is best if it is located on an area with little to no hair.
- Rotate sites each time ointment is applied.
- To administer the drug, lay the applicator paper down on the counter with the print side facing down.
- Measure the amount of ointment to be used on the applicator paper, which is marked in a 2-inch strip with marks every half inch. The ointment is in a tube similar to that of toothpaste and should be gently squeezed so that a strip of ointment is placed on the applicator paper in the appropriate measurement. For example, the provider may order “nitroglycerin ointment 1 inch every 6 hours.” So, a one-inch ribbon of ointment would then be placed on the paper (see Figure 2.13).
Steps to administering vaginal medications:
-
Assemble the appropriate equipment
- Clean gloves
- Water-soluble lubricant for vaginal suppositories
- Vaginal applicator
- Perineal pad
- Medication
- Assess the client to determine if the drug is safe and appropriate to give.
- Check the medication, dose, and expiration date.
-
Follow the seven rights of medication administration
throughout
the procedure (at least three times or according to institutional policy).
- During medication reconciliation
- When preparing the medication
- At the bedside
- Perform hand hygiene.
- Don clean gloves for the administration of vaginal suppositories.
- Request that the client void prior to inserting the medication.
- Identify the client and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the blister pack, container, tube, or package, using the protocol recommended by the institution.)
- Perform the third medication check at the bedside.
-
Explain the medication to the client:
- Name (brand and generic)
- Dosage
- Indication, rationale, or reason for the drug to be given
- Frequency
- Route
- Adverse effects
- Provide privacy and drape the client with a sheet.
- Position the client supine, hips elevated, knees bent, with the feet flat on the bed near the hips.
- Provide perineal care as necessary.
- Fill the applicator with the prescribed medication.
- Lubricate with water-soluble lubricant.
- Spread the labia, using the nondominant hand, and expose the vagina. Gently insert the applicator into the vagina approximately 2 inches using the dominant hand.
- Push the plunger to deposit the medication into the vagina.
- Remove the applicator and wrap it in a paper towel for cleaning later or disposal.
- For suppositories, remove the wrapping and lubricate the room-temperature suppository with water-soluble jelly. Use an applicator if available; otherwise, use a finger on the dominant hand to insert the suppository about 3–4 inches into the vagina along its posterior wall. For creams or foams, insert 2–3 inches.
- Client should remain in position for 10 minutes.
- Apply a perineal pad if the client wishes.
- Wash the applicator after each use.
- Remove gloves.
- Perform hand hygiene.
- Document in the medication administration record.
- Evaluate the client’s response to the drug(s) within the appropriate time frame.
Nursing Implications for Vaginal Applications
The nurse should do the following for clients who are taking vaginal medications:
- Administer at bedtime, when possible, to allow the medication to remain in place for as long as possible.
- Assess for vaginal discharge and any other symptoms.
- Be clear in your teaching of the process because vaginal medications may be administered by the client.
- Educate the client to refrain from using douches and abstain from sexual intercourse after inserting medication.
Rectal Administration
Several medications can be given via the rectal route. This route can be used if clients are suffering from nausea and vomiting, especially if no IV is in place. This route has both a mixed first-pass effect and a non-first-pass effect. There are capillaries in the rectum that feed the portal circulation, which causes some of the medication to undergo first-pass effect; however, some of the medication will also be absorbed into the perirectal tissues locally.
Suppositories are medications that are solid at room temperature but soften and dissolve once in the rectal cavity. These medications are wrapped in foil or plastic packaging (see Figure 2.14), and it is important to remove the packaging prior to inserting the suppository in the client.
Table 2.9 lists the advantages and disadvantages of rectal administration .
| Advantages | Disadvantages |
|---|---|
|
|
Steps to administering rectal suppositories:
-
Assemble the appropriate equipment:
- Gloves
- Water-soluble lubricant
- Medication
- Bedpan, if client is on bed rest
- Assess the client to determine if the drug is safe and appropriate to give. Assess for rectal bleeding or diarrhea.
- Check the medication, dose, volume, and expiration date.
-
Follow the seven rights of medication administration
throughout
the procedure (at least three times or according to institutional policy).
- During medication reconciliation
- When preparing the medication
- At the bedside
- Perform hand hygiene.
- Don clean gloves for the administration of rectal suppositories. Never apply with a bare hand.
- Identify the client and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the package using the protocol recommended by the institution.)
- Perform the third medication check at the bedside.
-
Explain the medication to the client:
- Name (brand and generic)
- Dosage
- Indication, rationale, or reason for the drug to be given
- Frequency
- Route
- Adverse effects
- Position the client on their left side with the uppermost leg flexed toward the waist. (This position is called the Sim’s position or left lateral position.)
- Provide privacy. Drape the client with a sheet.
- Remove the foil or plastic wrapping from the medication (see Figure 2.14).
- Lubricate the suppository with the water-soluble gel. Consider lubricating your gloved finger to support the client’s comfort during this process. Never use petroleum-based products for lubrication because this may affect the absorption of the medication.
- The suppository is usually shaped similarly to a bullet. Insert the rounded end into the rectum while instructing the client to take a deep breath and then exhale.
- Insert the suppository along the side of the rectal wall, at least 1 inch beyond the internal rectal sphincter.
- Instruct the client to remain on their left side for approximately 20 minutes to allow the suppository to be absorbed. If the medication is being given to stimulate defecation, it may take 20–30 minutes for that to occur. If the medication is given for other reasons, such as fever or nausea, it may take as long as an hour. Check the pharmaceutical information for specifics.
- Remove gloves and perform hand hygiene.
- Document in the medication administration record.
- Evaluate the client’s response to the drug(s) within the appropriate time frame.
Nursing Implications for Rectal Administration
The nurse should do the following for clients who are taking drugs rectally:
- Do not insert a rectal suppository into stool. Palpate the rectal wall for the presence of feces.
- Have the client defecate prior to inserting the suppository, if possible.
- Never divide suppositories.
- Loss of sphincter control may be seen in older clients. Have a bedpan handy.
- Suppositories may be administered by the client. Be clear in your teaching of the process.
- It is important to educate clients who are self-administering suppositories that these drugs are to be given rectally, not orally.