Chapter 021

Chapter 21
ADMINISTRATION OF NONPARENTERAL MEDICATIONS
Copyright©2018,ElsevierInc.Allrightsreserved.

Nonparenteral
Medications
 Are given orally, enterally, and topically
 Medications that are not given by injection
 Route chosen depends on properties and desired
effects of the medication
2

Principles for Practice
 Patient safety is the major principle of practice
 Apply the six rights of medication administration
 Oral route is easiest and most desirable route
 Topical route applies drugs directly to the mucous
or tissue membranes
3

Principles for Practice
(Cont.)
 Administer topical medications by:
 Oral administration
 Sublingual
 Buccal
 Direct application to skin or mucosa
 Direct application of liquid
 Inhalation of medicated aerosol spray
 Inhalation of dry powder medication
 Inserting drug into a body cavity
4

Patient-Centered Care
 Provide patient education during
medication administration
 Goal is to improve medication adherence
 Develop printed materials to meet health literacy
levels of patients
 Medication issues include complex medication
regimens and medication discrepancies
 Health beliefs vary by culture and affects
adherence to medication therapy
 Vegetarian diets can affect Coumadin or
medications for glycemic control
5

Evidence-Based Practice
• Medication competency reduces
medication errors
• Technology knowledge and nurse
competencies increase patient safety
and promote best practices
• Automated dispensing units and
barcode-assisted medication
administration enhance verification of the
right drug, dosage, route, and time
6

Evidence-Based Practice
(Cont.)
• Best practice includes environment free of
distractions and interruptions while dispensing
medication
• Follow best practices for calculating doses,
check the calculations, and do NOT administer if
the dosage appears incorrect
• Best-practice guidelines for safe medication
administration require critical thinking, clinical
decision-making, and theoretic and clinical
practice competency
7

Safety Guidelines
1. Assess patient’s sensory functions,
including sight, hearing, touch, and
physical coordination.
2. Patients often receive more than one
oral medication at a time.
3. Always assess for drug allergies.
4. Evaluate whether patient can take
medication with food.
8

Safety Guidelines (Cont.)
5. For all medications administered, review the order
for patient’s name and drug, dosage, route, and
time of administration.
6. For all medications, use the correct equipment for
administering the medication.
7. For all medications administered, gather
information pertinent to the drug(s) ordered,
including purpose, normal dosage and route,
common side effects, time of onset and peak,
contraindications, and nursing implications.
9

Safety Guidelines (Cont.)
8. Determine whether medications require
any specific nursing actions before
administration.
9. If patients are mentally and physically able,
prepare them for discharge by instructing
them in self-administration techniques.
10.Check the expiration date for all
medications.
10

Quick Quiz!
The patient’s chart has an order for Lasix 20 mg IV
q12 hours. Upon reviewing the MAR, the nurse sees
that the medication order has been transcribed as
Lasix 40 mg IV once daily. What should the nurse’s
next action be?
A.Administer 40 mg of Lasix IV in one dose.
B.Hold the IV Lasix and call the health care
provider.
C.Administer 20 mg of Lasix IV at this time.
D.Ask the patient what his usual dose of
Lasix is.
11

Administering Oral
Medications
Skill 21-1 Patients usually can ingest/self-administer oral
medications
 If necessary, take precautions to protect patients
from aspiration
 Nurses usually prepare medications in areas
designed for medication preparation or at unit-
dose carts
 Absorption depends on the preparation form
12

Administering Oral Medications,
Skill 21-1 (Cont.)
 Other medications are absorbed in the intestinal track
 Enteric coated preparations resist being dissolved by gastric
juices
 Never crush or split enteric coated medication
13

Delegation and
Collaboration
 The task of administering oral medications cannot
be delegated to nursing assistive personnel (NAP)
 The nurse directs NAP about:
 Potential side effects of medications and that NAP
should report their occurrence
 Informing nurse if patient condition changes or
worsens after medication administration
14

Recording and Reporting
• Record drug, dose, route, and time administered on
patient’s MAR immediately after administration, not
before. Include initials or signature. Record in nurses’
notes patient teaching and validation of
understanding
• If drug is withheld, record the reason and follow
agency policy for noting withheld doses
• Report adverse effects/patient response and/or
withheld drugs to nurse in charge or health care
provider. Depending on medication, immediate
health care provider notification may be required
15

Special Considerations
 Teaching
 Explain the drug regimen and basic guidelines for
drug safety
 Pediatric
 Liquids are preferred over pills
 Sweeten bitter oral preparations
 Do not use a molded medicine cup for amounts less
than a teaspoon
16

(Cont.)
 Gerontological
 Age-related changes
 Polypharmacy concerns
 Water
 Home care
 Use measuring spoons to measure liquid
medications at home
17

Quick Quiz!
A 54-year-old woman has left-sided weakness due to a
recent ischemic stroke. How can the nurse safely
administer PO medications to avoid aspiration in this
patient?
A.Give the patient a minimum of two pills at one
time.
B.Supply the patient with a straw to sip all
medication.
C.Place the medication in the stronger side of
the mouth.
D.Administer medications only in the late
evening.
18

Administering Medications
Through a Feeding Tube
Skill 21-2
 Patients with enteral feeding tubes are unable to take
medications by mouth
 Do not administer medications into nasogastric (NG) tubes
inserted for decompression
 Medications administered by enteral tubes should be liquid,
but oral medication tablets may be administered if crushed or
dissolved first
19

Delegation and
Collaboration
 The task of administering medications by enteral
feeding tubes cannot be delegated to NAP
 The nurse directs NAP to:
 Keep patient’s head of bed elevated 30 to 45
degrees for 1 hour (per agency) after medication
administration
 Report immediately to the nurse signs of aspiration
 Report to the nurse occurrence of possible
medication side effects
20

• Record in nurses’ notes and EHR the method used
to check placement of enteral tube, GRV, and pH of
stomach aspirate. Record actual time that each
drug was administered on MAR immediately after
administration, not before. Include initials or
signature. Record patient teaching and validation of
understanding on flow sheet or nurses’ notes in
EHR or chart
• Record on proper I&O form total amount of water
used for medication administration
• Report adverse effects, patient response, and/or
withheld drugs
21

 Teaching
 Storage and preparation of medications and
supplements
 Verification of tube placement
 Importance of flushing tube
 Pediatric
 Volumes should be small enough to clear tubing
22

Applying Topical
Medications to the Skin
Skill 21-3
 Topical drugs primarily produce local effects, but they can
create systemic effects if absorbed through the skin
 Wear gloves to protect against accidental exposure
 Clean the skin or wound thoroughly before applying a new
dose of topical medication
23

Delegation and
Collaboration
 The task of administering topical medications
cannot be delegated to NAP
 Report immediately to the nurse any skin irritation,
burning, blistering, or increased itching
 Not applying any dressing over the topical
medication, unless instructed to do so
24

• Record actual time each drug that was administered,
type of agent applied, strength, and site of application
in nurses’ on MAR immediately after administration,
not before. Include initials or signature.
• Record patient teaching and validation of
understanding on flow sheet or nurses’ notes in EHR
or chart.
• Describe condition of skin before each application on
flow sheet or nurses’ notes in EHR or chart.
provider
25

 Teaching
 Clean inflamed skin by rinsing with warm water, no
soap
 If a transdermal patch peels before the next dose is
due, do not tape it down; remove it, clean the skin,
and apply new patch to a different area
26

(Cont.)
 Gerontological
 Be aware of age-related skin changes when
applying topical medication
 Handle older skin gently
 Home care
 Wrap applicators and used patches before
disposing of them in cardboard or plastic
disposable containers
27

Quick Quiz!
Topical drugs such as lotions, patches, pastes, and
ointments will not create systemic effects. True or
False?
A.True.
B.False.
28

Administering Ophthalmic
Medications
Skill 21-4
 Eye medications include eyedrops, ointments, and intraocular
discs
 Administer eye medications to the conjunctival sac, not the
cornea
 Teach correct self-administration of medication
29

Delegation and
Collaboration
 The task of administering ophthalmic cannot be
delegated to NAP
 Potential side effects of medications and the need
to report their occurrence
 The potential for temporary burning or blurring of
vision after administration of eye medications
30

• Record drug, concentration, dose or strength, number
of drops, site of application (left, right, or both eyes),
and time of administration on MAR immediately after
administration, not before.
• Record objective data related to tissues involved
(e.g., redness, drainage, irritation), any subjective
data (e.g., pain, itching, altered vision), and patient’s
response to medications
provider
31

 Teaching
 What to expect from mydriatics and medications
that paralyze the ciliary muscles of the eye
 Pediatric
 Place the eyedrops at the nasal corner where the
lids meet with the infant supine
32

(Cont.)
 Gerontological
 Before discharge, assess ability to administer
medications
 Remove cerumen by irrigation before
administration
 Home care
 Do not share over-the-counter (OTC) eyedrops with
family members
33

Administering Ear
Medications
Skill 21-5 Ear medications are usually in a solution and
instilled by drops
 Follow safety precautions
 Do not administer cold drops
 Avoid forcing any solution into the ear
34

• Record drug, concentration, dose or strength, number of
drops, site of application (left, right, or both ears), and time
of administration on MAR immediately after administration,
not before. Include initials or signature
• Record objective data related to tissues involved (e.g.,
drainage, tenderness, irritation), any subjective data (e.g.,
ear pain, ringing in ears, change in hearing acuity), and
patient’s response to medications
• Report adverse effects/patient response and/or withheld
drugs to nurse in charge or health care provider
35

Delegation and
Collaboration
 The skill of administering ear medications cannot
be delegated to NAP
to report their occurrence to the nurse
 The potential for dizziness or irritation after
administration of ear medications
36

 Pediatric
 Insert cotton pledgets loosely into ear canal to
prevent medication from flowing out
 To prevent cotton from absorbing medication,
premoisten it with a few drops of medication
37

Administering Nasal
Instillations
Skill 21-6 Nasal instillations may be administered as sprays,
drops, or tampons
 Sprays and drops are used to relieve sinus
congestion and cold symptoms
 Nasal packing or tampons treated with
epinephrine to slow bleeding are used to
treat severe nosebleeds
38

Delegation and
Collaboration
 The task of administering nasal instillations cannot
be delegated to NAP
 Reporting any bloody nasal drainage
39

• Record drug name, concentration, number of
drops, nares into which drug was instilled, and
actual time of administration on MAR immediately
after administration, not before. Include initials or
signature
• Record in nurses’ notes patient teaching and
validation of understanding
• Report any unusual systemic or adverse
effects/patient response and/or withheld drugs to
nurse in charge or health care provider
40

 Teaching
 Each family caregiver should have a different
dropper or spray applicator
 Use OTC nasal sprays or nose drops for only one
illness
 Overuse of nasal sprays can cause rebound sinus
congestion
 Pediatric
 Administer nose drops 20 to 30 minutes before
feedings
41

Using Metered-Dose
Inhalers (MDI)
Skill 21-7 An MDI is a small handheld device that disperses
medication into the airways through an aerosol
spray or mist by activation of a propellant
 Dosage is usually delivered in 1 to 2 puffs
 A spacer or a breath-activated MDI may be used
to ensure correct delivery of medication to the
lower airways
42

Delegation and
Collaboration
 The task of administering MDIs cannot be
delegated to NAP
 Reporting breathing difficulty
43

• Immediately after administration, not before,
record on the MAR the drug administered, dose
or strength, route, number of inhalations, and
actual time administered. Include initials or
signature
• Record in nurses’ notes patient’s response to
MDI, evidence of side effects, and patient’s
ability to use MDI
withheld drugs
44

 Teaching
 Allow for supervised practice
 Teach dosage tracking and use of handheld peak
flowmeters
 Pediatric
 Spacers benefit young children
 Coordinate the availability and use of inhalers
during school hours, per policy
45

(Cont.)
 Gerontological
 Spacers benefit older adults with weakened grasp
or inability to coordinate actuation of canister with
inhalation
 Home care
 Remind patients to carry prescribed inhalers in case
of acute asthma attack
46

Using Dry Powder Inhaler (DPI)
Medications
Procedural Guideline 21-1
 DPIs hold dry powdered medication and create an aerosol
when the patient inhales through a reservoir containing
medication
 DPIs require little manual dexterity
 The device is breath activated; there is no need to
coordinate puffs with inhalation
 Compared with MDIs, DPIs deliver more medication to the
lungs
47

Delegation and
Collaboration
 The task of administering DPI medications cannot
be delegated to NAP
 Reporting paroxysmal coughing, audible wheezing,
and patient’s report of breathlessness or difficulty
breathing
48

Using Small-Volume
Nebulizers
Skill 21-8 Nebulization is a process of adding medications
or moisture to inspired air by mixing particles of
various sizes with air
 Droplets in the mist are much finer than those
created by MDIs or DPIs
 A face mask or a mouthpiece held between the
teeth delivers nebulized mist
49

Delegation and
Collaboration
 The task of administering medications by
nebulizer cannot be delegated to NAP
 Reporting paroxysmal coughing, ineffective
breathing patterns, and other respiratory difficulties
50

• Record drug, dose and strength, route, length of
treatment, and time administered on MAR
immediately after administration, not before. Include
initials or signature. Record patient teaching and
validation of understanding on flow sheet or nurses’
notes in EHR or chart
• Record patient’s response to treatment on flow
sheet or nurses’ notes in EHR or chart
provider
51

 Teaching
 Do not store medication in nebulizer
 Potential adverse effects of long-acting beta-
agonists
 Use of handheld peak flowmeters
 Pediatric
 Use of mask for younger children
 Use of nebulizer during school hours
52

(Cont.)
 Gerontological
 Older adults with a weak grasp, hand tremors, or
coordination problems may not be able to
manipulate or hold a nebulizer
 Home care
 Rinse parts after each use
 Clean parts daily with soap and water
53

Administering Vaginal
Instillations
Skill 21-9 Vaginal
medications are
available in foam,
jelly, cream, or
suppository form
 Medicated
irrigations or
douches can also
be given
54

Delegation and
Collaboration
 The task of administering vaginal medications
to report their occurrence
 Reporting to the nurse any change in comfort level
or new or increased vaginal discharge or bleeding
55

• Immediately after administration, not before, record
on the MAR the drug administered, dose, type of
instillation, and time administered. Include initials or
signature
• Report to health care provider if patient states that
symptoms do not disappear or states that
symptoms get worse
• Report to nurse in charge or health care provider
adverse effects/patient response and/or withheld
drugs
56

 Teaching
 Encourage patient to take all medication as
prescribed
 Gerontological
 Older adults may have difficulty manipulating
suppository, applicator, or irrigating equipment; a
family caregiver may need instruction on how to
insert medication
57

Administering Rectal
Suppositories
Skill 21-10 A rectal suppository is a form of medication that
acts when it melts and is absorbed into rectal
mucosa
 Rectal medications may exert local effects on
gastrointestinal (GI) mucosa or systemic effects
 The rectal route is not as reliable as the oral or
parenteral route in terms of drug absorption and
distribution
58

Delegation and
Collaboration
 The task of rectal medication administration
 Reporting to the nurse expected fecal discharge or
bowel movement
 Informing nurse of any rectal discharge, pain, or
bleeding
59

• Immediately after administration, not before,
record in the MAR the drug, dosage, route,
and actual time and date of administration.
Include initials or signature
• Record in nurses’ notes patient teaching
and validation of understanding and self-
administration of suppository
• Report to nurse in charge or health care
provider adverse effects/patient response
and/or withheld drugs
60

 Teaching
 Teach correct medication application and
techniques of infection control
 Pediatric
 It is often necessary to hold or tape buttocks
together for 5 to 10 minutes to relieve pressure on
anal sphincter until urge to expel suppository is gone
61

(Cont.)
 Gerontological
 Older adults with loss of sphincter control may have
difficulty retaining suppository
 Older adults may have difficulty manipulating
suppository, applicator, or irrigating equipment; a
family caregiver may need instruction on how to
insert the medication
62

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