When using a turbo-inhaler or nasal inhaler, make sure the pressurized cartridge isn't punctured or incinerated. Store the medication cartridge below 120В° F (48.9В° C).
If you're using a turbo-inhaler, keep the medication capsules wrapped until needed to keep them from deteriorating.
Spacer inhalers may be recommended to provide greater therapeutic benefit for children and for patients who have difficulty with coordination. A spacer attachment is an extension to the inhaler's mouthpiece that provides more dead-air space for mixing the medication. Some inhalers have built-in spacers.
Teach the patient how to use the inhaler so that he can continue treatments himself after discharge, if necessary. Explain that overdosage—which is common—can cause the medication to lose its effectiveness. Tell him to record the date and time of each inhalation as well as his response to prevent overdosage and to help the physician determine the drug's effectiveness. Also, note whether the patient uses an unusual amount of medication—for example, more than one cartridge for a metered-dose nebulizer every 3 weeks. Inform the patient of possible adverse reactions.
If more than one inhalation is ordered, advise the patient to wait at least 2 minutes before repeating the procedure.
If the patient is also using a steroid inhaler, instruct him to use the bronchodilator first and then wait 5 minutes before using the steroid. This allows the bronchodilator to open the air passages for maximum effectiveness.
Documentation
Record the inhalant administered as well as the dose and time. Note any significant change in the patient's heart rate and any other adverse reactions.
NASAL MEDICATIONS
Nasal medications may be instilled by means of drops, a spray (using an atomizer), or an aerosol (using a nebulizer). Most drugs instilled by these methods produce local rather than systemic effects. Drops can be directed at a specific area; sprays and aerosols diffuse medication throughout the nasal passages.
Most nasal medications, such as phenylephrine, are vasoconstrictors, which relieve nasal congestion by coating and shrinking swollen mucous membranes. Because vasoconstrictors may be absorbed systemically, they are usually contraindicated in hypersensitive patients. Other types of nasal medications include antiseptics, anesthetics, and corticosteroids. Local anesthetics may be administered to promote patient comfort during rhinolaryngologic examination, laryngoscopy, bronchoscopy, and endotracheal intubation. Corticosteroids reduce inflammation in allergic or inflammatory conditions and nasal polyps.
POSITIONING THE PATIENT FOR NOSE DROP INSTILLATION
To reach the ethmoid and sphenoid sinuses, have the patient lie on her back with her neck hyperextended and her head tilted back over the edge of the bed. Support her head with one hand to prevent neck strain.
To reach the maxillary and frontal sinuses, have the patient lie on her back with her head toward the affected side and hanging slightly over the edge of the bed. Ask her to rotate her head laterally after hyperextension, and support her head with one hand to prevent neck strain.
To administer drops for relief of ordinary nasal congestion, help the patient to a reclining or supine position with her head tilted slightly toward the affected side. Aim the dropper upward, toward the patient's eye, rather than downward, toward her ear.
Equipment
Prescribed medication • patient's medication record and chart • emesis basin (with nose drops only) • facial tissues • optional: pillow, small piece of soft rubber or plastic tubing, gloves.
Implementation
Verify the order on the patient's medication record by checking it against the physician's order. Note the concentration of the medication. Phenylephrine, for example, is available in various concentrations from 0.125% to 1%. Verify 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.
Explain the procedure and provide privacy.
Wash your hands. Put on gloves if you notice drainage from the nostrils.
Instilling nose drops
When possible, position the patient so that the drops flow back into the nostrils, toward the affected area. (See Positioning the patient for nose drop instillation.)
Draw up some medication into the dropper.
Push up the tip of the patient's nose slightly. Position the dropper just above the nostril, and direct its tip toward the midline of the nose so that the drops flow toward the back of the nasal cavity rather than down the throat.
Insert the dropper about 3/8″ (1 cm) into the nostril. Don't let the dropper touch the sides of the nostril because this would contaminate the dropper or could cause the patient to sneeze.
Instill the prescribed number of drops, observing the patient carefully for signs of discomfort.
To prevent the drops from leaking out of the nostrils, ask the patient to keep his head tilted back for at least 5 minutes and to breathe through his mouth. This also allows sufficient time for the medication to constrict mucous membranes.
Keep an emesis basin handy so that the patient can expectorate any medication that flows into the oropharynx and mouth. Use a facial tissue to wipe any excess medication from the patient's nostrils and face.
Clean the dropper by separating the plunger and pipette and flushing them with warm water. Allow them to air-dry.
Using a nasal spray
Have the patient sit upright with his head tilted back slightly. Alternatively, have the patient lie on his back with his shoulders elevated, neck hyperextended, and head tilted back over the edge of the bed. Support his head with one hand to prevent neck strain.
Remove the protective cap from the atomizer.
To prevent air from entering the nasal cavity and to allow the medication to flow properly, occlude one of the patient's nostrils with your finger. Insert the atomizer tip into the open nostril.
Instruct the patient to inhale, and as he does so, squeeze the atomizer once, quickly and firmly. Use just enough force to coat the inside of the patient's nose with medication. Then tell the patient to exhale through his mouth.
If ordered, spray the nostril again. Then repeat the procedure in the other nostril.
Instruct the patient to keep his head tilted back for several minutes and to breathe slowly through his nose so that the medication has time to work. Tell him not to blow his nose for several minutes.
Using a nasal aerosol
Instruct the patient to blow his nose gently to clear his nostrils.
Insert the medication cartridge according to the manufacturer's directions. With some models, you'll fit the medication cartridge over a small hole in the adapter. When inserting a refill cartridge, first remove the protective cap from the stem. Spacer inhalers may be recommended. (See “Handheld oropharyngeal inhalers,” page 223.)
Shake the aerosol well before each use, and remove the protective cap from the adapter tip.
Hold the aerosol between your thumb and index finger, with your index finger positioned on top of the medication cartridge.
Tilt the patient's head back, and carefully insert the adapter tip in one nostril while sealing the other nostril with your finger.
Press the adapter and cartridge together firmly to release one measured dose of medication.
Shake the aerosol and repeat the procedure to instill medication into the other nostril.
Remove the medication cartridge, and wash the nasal adapter in lukewarm water daily. Allow the adapter to dry before reinserting the cartridge.
Complications
Some nasal medications may cause restlessness, palpitations, nervousness, and other systemic effects. For example, excessive use of corticosteroid aerosols may cause hyperadrenocorticism and adrenal suppression.
Documentation
Record the medication instilled and its concentration, number of drops or instillations administered, and whether the medication was instilled in one or both nostrils. Also note the time and date of instillation and any resulting adverse effects.
VAGINAL MEDICATIONS
Vaginal medications include suppositories, creams, gels, and ointments. These medications can be inserted as a topical treatment for infection (particularly Trichomonas vaginalis and monilial vaginitis) or inflammation or as a contraceptive. Suppositories melt when they contact the vaginal mucosa, and their medication diffuses topically (as effectively as creams, gels, and ointments).
Vaginal medications usually come with a disposable applicator that enables placement of medication in the anterior and posterior fornices. Vaginal administration is most effective when the patient can remain lying down afterward to retain the medication.
HOW TO INSERT A VAGINAL SUPPOSITORY
If the suppository is small, place it in the tip of an applicator. Then lubricate the applicator, hold it by the cylinder, and insert it into the vagina. To ensure the patient's comfort, direct the applicator down initially, toward the spine, and then up and back, toward the cervix (as shown below).
When the suppository reaches the distal end of the vagina, depress the plunger. Remove the applicator while the plunger is still depressed.
Equipment
Patient's medication record and chart • prescribed medication and applicator, if necessary • water-soluble lubricant • gloves • small sanitary pad.
Implementation
If possible, plan to insert vaginal medications at bedtime, when the patient is recumbent.
Verify the order on the patient's medication record by checking it against the physician's order.
Confirm the patient's identity by asking her name and checking the name, room number, and bed number on her 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.
Wash your hands, explain the procedure to the patient, and provide privacy.
Ask the patient to void.
Ask the patient if she would rather insert the medication herself. If so, provide appropriate instructions. If not, proceed with the following steps.
Help her into the lithotomy position.
Expose only the perineum.
Inserting a suppository
Remove the suppository from the wrapper, and lubricate it with water-soluble lubricant.
Put on gloves and expose the vagina.
With an applicator or the forefinger of your free hand, insert the suppository about 2″ (5 cm) into the vagina. (See How to insert a vaginal suppository.)
Inserting ointments, creams, or gels
Insert the plunger into the applicator. Then attach the applicator to the tube of medication.
Gently squeeze the tube to fill the applicator with the prescribed amount of medication. Detach the applicator from the tube, and lubricate the applicator.
Put on gloves and expose the vagina.
Insert the applicator as you would a small suppository, and administer the medication by depressing the plunger on the applicator.
After vaginal insertion
Remove and discard your gloves.
Wash the applicator with soap and warm water and store it, unless it's disposable. If the applicator can be used again, label it so that it will be used only for the same patient.
To prevent the medication from soiling the patient's clothing and bedding, provide a sanitary pad.
Help the patient return to a comfortable position, and advise her to remain in bed as much as possible for the next several hours.
Wash your hands thoroughly.
Special considerations
Refrigerate vaginal suppositories that melt at room temperature.
If possible, teach the patient how to insert the vaginal medication because she may have to administer it herself after discharge. Give her a patient-teaching sheet if one is available.
Instruct the patient not to wear a tampon after inserting vaginal medication because it would absorb the medication and decrease its effectiveness.
Instruct the patient to avoid sexual intercourse during treatment.
Complications
Vaginal medications may cause local irritation.
Documentation
Record the medication administered as well as time and date. Note adverse effects and any other pertinent information.
ENTERAL ADMINISTRATION
Part of "5 - Drug Administration"
ORAL DRUGS
Because oral administration is usually the safest, most convenient, and least expensive method, most drugs are administered by this route. Drugs for oral administration are available in many forms: tablets, enteric-coated tablets, capsules, syrups, elixirs, oils, liquids, suspensions, powders, and granules. Some require special preparation before administration, such as mixing with juice to make them more palatable; oils, powders, and granules most often require such preparation.
Sometimes oral drugs are prescribed in higher dosages than their parenteral equivalents because after absorption through the GI system, they are immediately broken down by the liver before they reach the systemic circulation.
ELDER ALERT Oral dosages normally prescribed for adults may be dangerous for elderly patients.
Oral administration is contraindicated for unconscious patients; it may also be contraindicated in patients with nausea and vomiting and in those unable to swallow.
Equipment
Patient's medication record and chart • prescribed medication • medication cup • optional: appropriate vehicle, such as jelly or applesauce, for crushed pills commonly used with children or elderly patients, and juice, water, or milk for liquid medications; drinking straw; mortar and pestle for crushing pills.
Implementation