Administering drugs is one of your most crucial nursing responsibilities. To ensure safe and effective drug therapy for your patients, you need to be familiar with the indications, customary dosages, and intended effects of prescribed drugs. And you need to assess each patient before administering a drug, delaying or withholding it if necessary. Just as important, you need the skills to be able to administer a drug capably, minimizing your patient's anxiety and maximizing the drug's effectiveness.

Drugs may be administered by many routes. The topical, or dermatomucosal, route includes aural, ocular, nasal, and vaginal administration; oropharyngeal inhalation; and transdermal absorption. The enteral route, the most commonly used one, involves drug absorption through the GI tract. The parenteral route includes intradermal, subcutaneous, I.M., I.V., intrathecal, and intraosseous infusions or injections. The endotracheal route involves administering a drug into the respiratory system through an endotracheal tube. The epidural route involves giving a drug (usually an anesthetic or an opioid analgesic) through a catheter inserted near the spinal cord by a lumbar puncture. The intrapleural route involves injecting a drug through the chest wall into the pleural space.

More than any other factor, the administration route determines the onset of a drug's effect. For example, drugs administered I.V. act almost instantly because they're immediately available in the bloodstream. Antibiotics, for instance, are commonly given I.V. to provoke a quick, continuous response. Other drugs must be given I.V. because they're ineffective, or even dangerous, when given by other routes.

Before you administer any medication, always compare the physician's order with the order on the patient's medication record. Then mentally check off the first five “rights” of drug administration: right patient, right drug, right dose, right route, and right time. If the physician's order and the patient's medication record match, then compare the label on the medication with the medication record. If you find any discrepancies, withhold the drug and verify the order with the physician or pharmacist. If a patient questions any of his drugs, double-check the orders and the dose before administration. Also check the drug's expiration date.

After administering a drug, document the following on the patient's Kardex or computer file: drug name, dosage, route and time of administration, and your signature and title. In the nurses' notes, include any assessment data that refer to the patient's response to the medication or any adverse effects of the medication.

SKIN MEDICATIONS

Topical drugs are applied directly to the skin surface. They include lotions, pastes, ointments, creams, powders, shampoos, patches, and aerosol sprays. Topical medications are absorbed through the epidermal layer into the dermis. The extent of absorption depends on the vascularity of the region.

Nitroglycerin, fentanyl, nicotine, and certain supplemental hormone replacements are used for systemic effects. Most other topical medications are used for local effects. Ointments have a fatty base, which is an ideal vehicle for drugs such as antimicrobials and antiseptics. Typically, topical medications should be applied two or three times per day to achieve their therapeutic effect.

Implementation

• Verify the order on the patient's medication record by checking it against the physician's order on the chart.

• Make sure the label on the medication agrees with the medication order. Read the label again before you open the container and as you remove the medication from the container. Check the expiration date.

• Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.

• If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.

• Provide privacy.

• Explain the procedure thoroughly to the patient because he may have to apply the medication by himself after discharge.

• Wash your hands to prevent cross-contamination, and glove your dominant hand. Use gloves on both hands if exposure to body fluids is likely.

• Help the patient assume a comfortable position that provides access to the area to be treated.

• Expose the area to be treated. Make sure the skin or mucous membrane is intact (unless the medication has been ordered to treat a skin lesion, such as an ulcer). Applying medication to broken or abraded skin may cause unwanted systemic absorption and result in further irritation.

• If necessary, clean the skin of debris, including crusts, epidermal scales, and old medication. You may have to change the glove if it becomes soiled.

Applying paste, cream, or ointment

• Open the container. Place the lid or cap upside down to prevent contamination of the inside surface.

• Remove a tongue blade from its sterile wrapper, and cover one end with medication from the tube or jar. Then transfer the medication from the tongue blade to your gloved hand.

• Apply the medication to the affected area with long, smooth strokes that follow the direction of hair growth. This technique avoids forcing medication into hair follicles, which can cause irritation and lead to folliculitis. Avoid excessive pressure when applying the medication because it could abrade the skin.

• To prevent contamination of the medication, use a new tongue blade each time you remove medication from the container.

Removing ointment

• Wash your hands and apply gloves. Then rub solvent on them and apply it liberally to the ointment-treated area in the direction of hair growth. Alternatively, saturate a sterile gauze pad with the solvent and use the pad to gently remove the ointment. Remove excess oil by gently wiping the area with a sterile gauze pad. Don't rub too hard to remove the medication because you could irritate the skin.

Applying other topical medications

• To apply shampoos, follow package directions. (See Using medicated shampoos.)

• To apply aerosol sprays, shake the container, if indicated, to completely mix the medication. Hold the container 6″ to 12″ (15 to 30 cm) from the skin, or follow the manufacturer's recommendation. Spray a thin film of the medication evenly over the treatment area.

• To apply powders, dry the skin surface, making sure to spread skin folds where moisture collects. Then apply a thin layer of powder over the treatment area.

• To protect applied medications and prevent them from soiling the patient's clothes, tape an appropriate amount of sterile gauze pad or a transparent semipermeable dressing over the treated area. With certain medications (such as topical steroids), semipermeable dressings may be contraindicated. Check medication information and cautions. If you're applying a topical medication to the patient's hands or feet, cover the site with white cotton gloves for the hands or terry cloth scuffs for the feet.

Special considerations