Administration of Noninjectable Medications (Pharmacology and Administration of Medications) (Nursing) Part 5

Nasal or Respiratory Administration

Drugs may be given by drops, inhalation, or through aerosol delivery systems for disorders of the respiratory tract. Some nasal medications have systemic effects as well.

Inhalants and Aerosol Systems. Medications that are inhaled have a very rapid rate of absorption and onset of action. They may be delivered by an inhaler or aerosol delivery system.

Key Concept An inhaler or nebulizer setup is used for one client only It is kept in a sealed bag in the client’s medication drawer or other designated place. Rationale: This helps prevent cross-contamination.

Nursing Alert Never leave a client alone during aerosol breathing treatments, because of the effects of the medication. Encourage the client to breathe deeply but not rapidly Rationale: Should the client breathe too rapidly, he or she may experience dizziness or possibly tetany (muscle spasms). This is the result of hyperventilation, caused by excess oxygen in the system.

Handheld inhalers are devices that deliver a specific dose of topical medication to the mucous membranes of the respiratory system with each inhalation (Fig. 63-4). These inhalers are often called metered-dose inhalers (MDI). Some inhalers deliver aerosolized medication; Diskus inhalers deliver nonaerosol powdered medication.

Medications delivered by handheld inhalers include:

• Aerosol examples: albuterol (Proventil, Ventolin), metapro-terenol (Alupent), and pirbuterol (Maxair Autohaler).


Administering a nebulizer treatment (aerosol therapy), using a flexible tube-type spacer.

FIGURE 63-5 · Administering a nebulizer treatment (aerosol therapy), using a flexible tube-type spacer.

• Nonaerosol inhalation powder examples: salmeterol (Serevent Diskus) and Advair Diskus (a combination of fluticasone and salmeterol).

Aerosol/nebulizer treatments are based on the use of compressed air or oxygen, which forces a mist of medication through tubing to a mouthpiece or mask (Fig. 63-5). The client then inhales the medication. Most aerosol medications have bronchodilating effects and may be administered by respiratory therapy personnel. However, after the initial setup in acute care facilities, long-term facilities, and the client’s home, nurses often regularly administer nebulizer treatments. Medications used for nebulizer treatments include albuterol (Proventil, Ventolin), levalbuterol tartrate (Xopenex HFA), and metaproterenol (Alupent).

Key Concept As a nurse, you will often be required to teach clients or their families to perform nebulizer treatments. This is most common in pediatric nursing.

In Practice: Nursing Care Guidelines 63-5 provides more information about administering inhaler and nebulizer medications.

Special Considerations: LIFESPAN

Aerosol and Inhalation Therapy

To ensure that a young child receives an accurate dose, hold the mouthpiece closely to the nose and mouth or use a mask.

Nasal Sprays or Drops. Nasal sprays or drops may be ordered for conditions such as nasal congestion or after nasal surgery (see In Practice: Nursing Care Guidelines 63-6).

Key Concept Nose drops or sprays are used for one client only.They are labeled and kept in a plastic bag in the client’s medication drawer or other designated area.

Special Considerations : LIFESPAN

Administering Nasal Sprays or Drops

A child who must receive nasal medications may be more receptive if a family caregiver administers them. The child may be the most comfortable if held on a caregiver’s lap during the procedure. If a family caregiver is unavailable, hold the child with his or her head tilted back while you gently restrain the arms and legs. Make every effort to administer nasal medications with care. Be gentle and reassuring, especially for a small child.

Transdermal Administration

Many medications are now available in transdermal (TD) patches (Fig. 63-6). There are several types of TD patches. These include:

•    The reservoir membrane-modulated system

•    The microreservoir system

•    The drug-in-adhesive layer system

•    The matrix system

As a general rule, TD patches should not be cut. It can be very dangerous to cut a TD patch. For example, if a reservoir membrane-modulated system patch is cut, the entire dose of medication is available immediately. This could cause a life-threatening overdose. If a microreservoir patch is cut, there is no accurate way to measure the dose available to the client. In some cases, the manufacturer describes a safe way to cut a patch, but this is not a nursing decision.

Structure and mechanism of action of a transdermal (TD) disk medication. Be sure not to tear or cut a TD patch.

FIGURE 63-6 · Structure and mechanism of action of a transdermal (TD) disk medication. Be sure not to tear or cut a TD patch.

Many clients use nitroglycerin and hormone replacement patches (e.g., estrogen). Nicotine patches are commonly used for smoking cessation. Another common transdermal patch is the fentanyl patch, used to manage pain. The skin absorbs these medications systemically (Fig. 63-6). In Practice: Nursing Procedure 63-7 describes the steps in administering a transdermal patch.

Nursing Alert Some clients may tell you that their patch "fell off." It is important to make sure they do not have the old patch somewhere. Rationale: Some clients are seeking double doses of medications, particularly nicotine or pain medications.

IN PRACTICE :NURSING CARE GUIDELINES 63-6

ADMINISTERING NASAL SPRAYS OR DROPS

•    Follow the steps in Nursing Care Guidelines 63-1 and 63-2 before administering any medication.

•    Assist the client to a high Fowler’s or sitting position with the head tilted back.

•    Place the tip of the bottle just inside the nares, aimed toward the nose’s midline. Activate the nebulization or squeeze the bottle while the client inhales. Rationale: This position allows the medication to come into contact with the nasal mucous membranes for maximal therapeutic effect.

•    Offer the client a tissue. Instruct the client to maintain this position for approximately 1 to 2 minutes. Rationale: This position will inhibit drainage of the medication from the nares due to gravity flow.

•    When administration is completed, always perform handwashing and document the procedure.

IN PRACTICE NURSING CARE GUIDELINES 63-5

ADMINISTERING AEROSOLIZED AND POWDERED RESPIRATORY MEDICATIONS

General Information

•    Follow the steps in Nursing Care Guidelines 63-1 and 63-2 before administering any medication.

•    Teach the client how to use his or her particular device. Teach the client to check to see if the device has remaining medication or is empty The metered dose inhaler (MDI) can be shaken to see if medication remains. The Diskus shows a number indicating the number of remaining doses; if the number is zero, the device is empty (see Fig. 63-4).

•    Avoid treatments immediately before and after meals. Rationale: Avoiding these times helps decrease the chance of vomiting or appetite suppression, especially with medications that cause the client to cough or expectorate or those that are taken in conjunction with percussion/ bronchial drainage.

•    If the client is to continue treatments at home, be sure he or she completely understands the medication and has demonstrated the ability to perform the treatment. Rationale: At home, the client may not have access to teaching, which could result in incorrect dosing or inability to use or maintain the equipment.

•    Be sure to document all teaching and the client’s ability to return your demonstrations.

For an Inhaler

•    Shake the inhaler well immediately before use. Rationale: Shaking aerosolizes the fine particles.

•    Instruct the client to take a deep breath and then to exhale completely through the nose. Rationale: This empties the respiratory passages as much as possible so the medication will have the greatest effect.

•    Have the client position the inhaler to just in front of his or her mouth, push down on the canister and inhale as slowly and deeply as possible through the mouth. If the client is having difficulty with this, have the client grip the mouthpiece with the lips and then push down on the canister. Rationale: These steps allow the medication to come into contact with the mucous membranes of the respiratory system for the maximum amount of time. The inhaler will deliver a fine mist of medication into the oropharyngeal area, which the client will inhale into the lungs.

•    Extenders, also called spacers and chambers, are available to increase the volume of medication delivered (see also Fig. 63-5). They deliver the medication into a closed chamber and increase the effectiveness of the inhalation. They also help ensure that the client receives the complete dosage. When using a spacer; tell the client to close his or her lips around the mouthpiece and then to depress the canister, releasing the medication. Rationale: Closing the lips around the mouthpiece helps prevent the unwanted escape of any medication.

•    With either the inhaler alone, or when using a spacer, instruct the client to take and hold a deep breath or to take two to three short breaths. Each depression of the MDI directly into the client’s mouth or into a spacer is considered to be one "puff." The health care provider usually orders one or two inhalations (puffs) several times a day Rationale: Deep breaths are required to move the medication as far into the respiratory tree as possible.

A chamber-type spacer may be used with a hand-held inhaler, to increase the effectiveness of the inhalation.

A chamber-type spacer may be used with a hand-held inhaler, to increase the effectiveness of the inhalation.

•    Instruct the client to hold his or her breath for about 10 seconds and then slowly exhale with pursed lips. Rationale: This helps the medication to be absorbed.

•    Repeat the above steps for each ordered "puff" waiting 5 to 10 minutes or as prescribed between puffs. Rationale: This method achieves maximum benefits.

For a Nebulizer

•    Fill the nebulizer cup with the ordered amount of medication. In the healthcare facility, these medications are often supplied in a blister pack (see Fig. 63-3). In the home, a multiuse bottle is often provided. Rationale: Use of a blister pack or measuring ensures that the required medication amount is given.

•    Turn on the oxygen or air at the prescribed liter flow. The oxygen or air must be on before giving the mouthpiece to the client. Rationale: This aerosolizes the medication and forces it into the lungs.

•    Instruct the client to close the lips around the mouthpiece and to breathe through the mouth (see Fig. 63-5). If the client is using a mask, he or she should breathe normally, with the mouth closed. Rationale: Breathing through the mouth or normally with a mask helps the medication travel to the lungs.

•    Instruct the client to continue the treatment until he or she can no longer see a mist on exhalation (from the opposite end of the mouthpiece) or vent holes (in the mask). Rationale: Lack of mist indicates that the client has inhaled the entire dose.

•    Cleanse the nebulizer cup and mouthpiece with warm, soapy water Rinse and dry it after each use. Follow facility protocols for the frequency of changing the tubing and cup for each client. Rationale: Proper cleaning and following guidelines decreases the possibility of pathogens entering the client’s respiratory tract.

KEY POINTS

•    Because the administration of medications is perhaps the single most important and potentially dangerous nursing function, follow the rules of safe administration precisely.

•    The “Six (Seven) Rights” of administration are the right client, right medication, right dosage, right time, right route, and right documentation, as well as right programming of medication pumps.

•    Document all medications after administering them.

•    Local effects of a medication are restricted to the area in which they are administered. Topical medications often have local effects. Systemic effects spread throughout the body.

•    StAt medications are to be given immediately; PRN medications are given as needed; bedtime medications are given in the evening to help clients sleep.

•    Enteral administration means through the gastrointestinal system (most commonly, this is considered to be PO or via NG tube). Parenteral administration is administration by any other method; it most commonly refers to administration by injection.

•    Enteral medication administration methods include oral, sublingual, translingual, buccal, and through a gastric tube. Rectal administration is technically considered enteral administration as well.

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