ENTERAL ADMINISTRATION METHODS
Oral Administration
The oral route of medication administration is used most frequently (see In Practice: Nursing Procedure 63-1). Medications administered orally (by mouth) are referred to as PO (Latin: “per os”). A PO medication can be in many forms, including tablets, capsules, caplets, or in liquid or gel form to be swallowed or sprayed on the tongue or applied to the mucous membranes of the mouth. Most oral medications are swallowed, but some are designed to be absorbed in the mouth.
Although the oral method is convenient, economical, and preferred by most clients, there are disadvantages to this method. Some medications have an unpleasant taste or odor; others are harmful to the teeth or mucous membranes of the mouth. Clients experiencing nausea and vomiting often cannot retain PO medications. Some clients have difficulty swallowing and, therefore, risk choking on PO medications; others have just had mouth or throat surgery; and some clients are noncompliant, refusing to swallow medications.
If a client is unable or unwilling to swallow tablets, in some cases, tablets can be crushed and dissolved in water or juice, or mixed with applesauce or other food (gelatin, ice cream). Some capsules may also be opened and the contents used in the same manner as crushed medications. Make sure there is an order to crush medications or to open capsules. Split tablets, if required, to obtain the correct dose. In Practice: Nursing Care Guidelines 63-3 describes the procedure for crushing or splitting tablets.
Nursing Alert Some medications cannot be crushed safely (e.g., enteric-coated tablets, time-release tablets, or orally disintegrating tablets). Some medications in capsules would not be effective if the capsule were opened (e.g., extended-release medications or those designed not to dissolve until reaching the small intestine). Always consult a pharmacist or reliable reference before crushing any medication or opening a capsule when giving any medication unfamiliar to you.
IN PRACTICE: NURSING CARE GUIDELINES 63-3
CRUSHING OR SPLITTING TABLETS
To Crush a Tablet
• Place the tablet within a paper soufflé cup and place this into a mortar Cover the tablet with another paper soufflé cup (placed inside the first one with the tablet between the two layers). Crush the tablet with the pestle until it is in powder form. If using a pill-crusher, place the tablet within the special plastic bag and lower the handle, or otherwise follow the manufacturer’s instructions. Unit-dose medications may also be crushed within their package. Remember that only certain types of tablets can safely be crushed. Rationale: This prevents medication from being left in the mortar or pill crusher. The medication must be in powder form to be mixed with food and swallowed. Crushing some types of tablets will deliver an inappropriate dose of medication.
• Dissolve crushed tablets in water or juice or mix with applesauce or other food, such as gelatin or ice cream, or administer via nasogastric (NG) tube. Rationale: Dissolving helps mask the taste and allows the powder to be swallowed.
• Clean the mortar pestle, and/or pill crusher after use. Rationale: In case some medication was left, this will prevent it from being mixed with another client’s medications.
Materials needed to crush or split tablets. Mortar and pestle, pill splitter, scored tablet, and opened capsule.
Instead of the traditional mortar and pestle, a “Pill Crusher,” such as that shown here, may be used. The tablet is placed into the supplied plastic bag and fitted into the device. When the handle is pulled down, the tablet is crushed evenly.
To Split a Tablet
• Cut tablets at the score mark only Place the tablet into the pill cutter; with the score mark exactly lined up with the blade. Lower the blade carefully Make sure the two halves are the same size. The blade is very sharp; prevent injury. Remember that certain types of medications cannot be safely split. Rationale: Using the score mark ensures accurate dosing. You cannot safely split an unscored tablet or split a tablet if the dose does not come out exactly. It is important to obtain the correct dose.
Some liquid medications are given full strength. Other liquid medications are diluted with water, juice, or milk. If a liquid medication has an unpleasant taste, a client may dull the taste buds by sucking on ice chips before taking it. Some liquid medications are best taken through a straw. Rationale: This helps minimize contact with the taste buds in the mouth. Nearly all liquid medications come in premeasured unitdose containers or oral syringes.
Special Considerations: LIFESPAN
Liquids and Children
Administer oral liquid medications to small children directly from the syringe or a calibrated pediatric dropper
Sublingual Administration
Sublingual (SL) medications are placed under the tongue, where they are dissolved and absorbed. Clients should not chew or swallow SL medications. Rationale: Chewing and/or swallowing speeds absorption too much. Tell clients to keep SL medications under the tongue until the medication dissolves. Nitroglycerin is an example of a commonly used SL medication.
Translingual Administration
Translingual (TL) medications are placed on the tongue, where they are absorbed or dissolve. These medications may be in the form of a spray or may be a troche, which dissolves slowly. The medication is absorbed through the tongue or is swallowed with saliva.
Orally Disintegrating Tablets
The orally disintegrating tablet (ODT) is an excellent choice for noncompliant clients and small children. This tablet is placed on the client’s tongue and dissolves instantly, thus ensuring medication compliance (see In Practice: Nursing Care Guidelines 63-4). The client should be instructed not to chew or break up the ODT tablet, because this interferes with the timing of the drug’s release.
IN PRACTICE :NURSING CARE GUIDELINES 63-4
ADMINISTERING ORALLY DISINTEGRATING TABLETS (ODT)
• Follow the steps in Nursing Care Guidelines 63-1 and 63-2 before administering any medication.
• Be sure to leave the tablet in its sealed bubble package until it is ready to be administered.
• Explain to the client that these tablets will dissolve immediately Ask the client not to touch the tablet with the fingers.
• Peel back the foil on top of the package, to expose the tablet.
• Do not push the tablet through the foil or the package. Rationale: This could crush the tablet and make it impossible to administer safely.
• Ask the client to touch his or her tongue to the medication while it is still in the package. The tablet will then be on the tongue and will not have been touched by the fingers. If the client refuses to do this, make sure his or her fingers are dry. Rationale: Moisture of any sort can begin to melt the tablet, making it very difficult to remove from the package and altering the dose.
• Place entire tablet in the mouth.
• Instruct the client not to chew the tablet. Rationale: Chewing is not necessary because the tablet will dissolve instantly. In some cases, breaking up or chewing the ODT tablet alters the effectiveness of the medication.
Note: ODT tablets cannot safely be split or crushed.
Buccal Administration
Buccal administration involves placing the medication between the client’s cheek and gum. Clients should not chew or swallow buccal medications, but should leave them between the cheek and gum until they dissolve or are discarded, as in the case of Nicorette gum. Rationale: These medications are designed to be absorbed via the mucous membranes of the cheek. Buccal administration may be in the form of a gel (e.g., dextrose for an insulin reaction) or may be a substance, such as Nicorette gum, used to aid in smoking cessation. Box 63-3 offers some suggestions for administering a nicotine replacement in chewing gum form (see also Fig.63-1). Some other medications, such as aspirin, are also available as chewing gum and follow most of the same general principles of administration.
Administration Through a Gastric Tube
Clients with nasogastric (NG) tubes or other types of gastrointestinal tubes generally receive their medications through the tube. Medications administered by this route should be in liquid form, although they can be quite thick (see In Practice: Nursing Procedure 63-2). If medications are unavailable in liquid form, obtain an order from the primary provider before crushing any medication and mixing it with liquid for administration (see In Practice: Nursing Care Guidelines 63-3). In some cases, capsules may be opened and the contents mixed with liquid and instilled into an NG tube; this also requires a specific order. Do not crush enteric-coated or time-release medications. Only medications specified as enteral may be given via gastrostomy tube (G-tubes). Medications to be given by NG tube are set up separately;they are not mixed together. Rationale: Crushed medications tend to clog gastrostomy tubes [G-tubes]. Crushing an enteric-coated or time-release medication may interfere with its desired action.
BOX 63-3. Administering Nicotine Replacement in Chewing Gum Form
• Instruct the client to chew the gum to soften it and then place it in the mouth between the cheek and the gums/teeth. Do not continue chewing. The medication will then be absorbed buccally. The absorption will be more even and will last longer if used in this way.
• Instruct the client not to swallow the gum. In the healthcare facility, dispose of used gum in the same manner as for other opened medications (hazardous waste).
• Nicorette gum is commonly available in 2- or 4-mg strengths. For smoking cessation, reduce the strength and lengthen the time between pieces of gum as much and as quickly as possible.
• The client should not smoke or use another type of nicotine replacement while using the gum.
• Do not touch the gum yourself. You would then be receiving nicotine through your skin and also would be contaminating the gum.
Nursing Alert To avoid undesired medication effects, consult a drug reference, pharmacist, or team leader with any doubts about restrictions or incompatibilities of medications.
Rectal Administration
Typically, medications given rectally are in the form of suppositories. A suppository is a bullet-shaped semisolid medication that is designed to melt at body temperature (see Fig.63-1). Suppositories are usually stored in the refrigerator until they are needed. Suppositories are usually prelubricated. If this is not the case, lubricate the pointed tip of the suppository with water-soluble lubricant (e.g., Κ-Y) before insertion. In Practice: Nursing Procedure 63-3 outlines the steps for administering a rectal suppository. Additionally, fluid or medication can be instilled into the rectum as an enema.
PARENTERAL ADMINISTRATION METHODS
Parenteral administration includes noninjection methods and injection methods. Noninjection methods are discussed here. Injection methods are discussed separately.
Vaginal Administration
Vaginal medications are supplied in the form of suppositories, foams, creams, and tablets that usually involve the use of an applicator, to ensure that the medication is placed correctly. In Practice: Nursing Procedure 63-4 highlights the steps for administering a vaginal suppository.
FIGURE 63-3 · Some types of eye drops are supplied in unit-dose modules (known as blister packs), as shown here. (Solutions for nebulization are often packaged the same way.)
Eye (Ophthalmic) Administration
Medications that may be instilled or administered directly into the eye (ophthalmic medications) include liquid medications, ointments, and medication-impregnated disks that resemble contact lenses (Fig. 63-3).
If applying an ointment or drops to both eyes, take great care to avoid spreading the infection from one eye to the other. Do not allow the applicator tip to touch either eye during administration. In some cases, a separate tube or blister pack is used for each eye. Many times, eye ointments are ordered at bedtime. Rationale: Ointments may cause blurred vision. See In Practice: Nursing Procedure 63-5.
Key Concept Eye drops and eye ointments are instilled for various reasons—to contract or dilate the pupils, treat an infection, provide lubrication, or produce a local effect (e.g., anesthesia). Nurses are often responsible for carrying out the procedure and for instructing clients and their families in the procedure.
Ear (Otic) Administration
Ear (otic) medications may be given by instillation from a squeeze bottle or dropper. Occasionally, ear suppositories are used. To better visualize the ear canal and help ensure proper medication delivery, position the auditory canal correctly (see In Practice: Nursing Procedure 63-6). Position the squeeze bottle tip or dropper slightly above the ear canal while instilling the drops. Never insert the dropper or applicator tip into the ear canal.
FIGURE 63-4 · Handheld metered-dose inhalers (MDIs). (Left) Aerosol type. (Right) Diskus powder type. The Diskus shown indicates the number of doses remaining.
