1. ADMINISTRATION OF MEDICINES Chapter 28 Tracey Harrington and Carol Barron

2. Introduction This presentation examines and describes a variety of methods for administering medication. Part 1 – Administering Oral Medication Part 2 – Administering Rectal Medications Part 3 – Administering Suppositories and Enemas Part 4 – Administration of Ear Drops Part 5 – Administration of Eye Drops and Eye Ointment Part 6 – Administration of a Nebuliser Part 7 – Administration of a Subcutaneous Injection Part 8 – Administration of an Intramuscular Injection Part 9 – Administration of an Intradermal Injection Part 10 – Administration of Nasal Medications Part 11 – Administration of Topical Medications

3. PART 1: Administering Oral Medication

4. Oral Medications Oral medications refer to any medications the patient swallows. This includes: pills, tablets, capsules, syrups, elixirs, suspensions and drugs in spray form. Oral administration of medication is the most common route via which medications are administered.

5. Administering Oral Medications You will need: Prescription chart Formulary to check drug dosage, such as the BNF Clean work surface Medication pots of appropriate measured volumes Medicine spoons with appropriate measured volumes Variety of sizes of oral syringes Tablet crusher, tablet divider Drink (such as water) for the patient, if allowed

6. Procedure Wash hands before commencement of the procedure Consult patient’s prescription and ascertain that you are dealing with the: -Right drug -Right dose -Right route of administration -Right date and time of administration -Right patient These checks are done to avoid drug errors. Check the drug is in the appropriate volume, dilution or dosage and check expiry date Prepare the drug according to pharmaceutical and health care setting guidelines

7. Empty the required dose into the drug container ensuring your hands do not come into contact with the medication Take prescribed dose of medication and prescription chart to the patient Check the patient’s identity Administer the drug and offer the patient a drink such as water to wash the medication down if allowed Record the medication given in the prescription chart Wash hands

8. PART 2: Administering Rectal Medications

9. Rectal Medications Rectal medications are administrated mainly in suppository and enema forms. Creams or ointments may also be prescribed.

10. Administering Rectal Medications You will need: Prescription chart Formulary to check drug dosage such as the BNF Clean work surface Disposable gloves Medicine tray Topical swabs Lubricating gel Disposable incontinence pad Bedpan, commode or toilet to hand

11. Procedure Hands should be washed (decontaminated) before and after patient contact to prevent cross infection and gloves should be worn. (NICE 2003, DOH 2003). Consult patient’s prescription and ascertain that you are dealing with the: -Right drug -Right dose -Right route of administration -Right date and time of administration -Right patient Select the drug in the appropriate volume, dilution or dosage and check expiry date Proceed with preparation of the drug according to pharmaceutical and health care setting guidelines

12. Take prescribed dose of medication and prescription chart to the patient Discuss and explain procedure to patient, gain patient’s consent Ensure patient privacy and ensure bedpan or commode to hand or toilet in close proximity Position patient on the left lateral position with the patient’s buttocks close to the edge of bed (Dougherty and Lister 2005) Place an incontinence pad underneath patient

13. PART 3: Administering Suppositories and Enemas

14. Suppositories Apply lubricating gel to tip of topical swab and then use the tip of swab to lubricate suppository Separate patients buttock and insert suppository, rounded end first 2-4 cm into the anal canal Advise the patient to try and retain the suppositories for at least 20 minutes Dispose of gloves, incontinence pad and wash hands (NICE 2003, DOH 2003) Record the medication given in the prescription chart and any other place necessary as indicated by individual hospital policy

15. Enemas Follow steps already outlined then: Apply lubricating gel to topical swab and use the swab to lubricate the tip of the rectal funnel (neck of enema) Separate patient’s buttock and insert the funnel gently through the anus between 2-4 cm, following the manufacturer’s recommendations Gently administer contents of enema into the rectum Advise the patient to try and retain the enema for as long as possible Dispose of gloves and wash hands (NICE 2003, DOH 2003) Record the medication given in the prescription chart and any other place necessary as indicated by individual hospital policy (NMC, 2004)

16. PART 4: Administration of Ear Drops

17. Administration of Ear Drops You will need: Clean Towel Prescription chart Medication Medication tray Cotton wool ball if required

18. Procedure – Administration of Ear Drops Wash hands before starting the procedure Consult patient’s prescription and ascertain that you are dealing with the right: drug, dose, route of administration, date and time of administration, patient Check the drug is in the appropriate volume, dilution or dosage and check expiry date Prepare the drug according to pharmaceutical and health care setting guidelines Check the patient’s identity Place the patient lying on their side with the ear requiring the medication uppermost Put a towel or a protective cover over the patient’s clothing to ensure that they are kept clean and dry Lift the ear cartilage of the pinna backwards and upwards

19. Hold dropper 6mm above ear canal and insert prescribed number of drops Ensure the patient stays in this position for 1 – 2 minutes to ensure medication reaches the ear drum Complete records and wash your hands

20. PART 5: Administration of Eye Drops and Eye Ointment

21. Eye Medications The two main forms of eye medications are eye drops and eye ointments. Medication administered directly onto the eye may cause a significant amount of discomfort, visual blurring and irritation to the patient.

22. You will need: Clean Towel Prescription chart Medication Medication tray Tissues Waste bag Administering Eye Medications

23. Procedure Wash hands before starting the procedure Consult patient’s prescription and ascertain that you are dealing with the right: drug, dose, route of administration, date and time of administration, patient Check the drug is in the appropriate volume, dilution or dosage and check expiry date Prepare the drug according to pharmaceutical and health care setting guidelines Take prescribed dose of medication and prescription chart to the patient Check the patient’s identity and put on disposable gloves Ask the patient to lie in the supine position or to sit with head slightly tilted back and to look up

24. Pull lower lid down gently to expose the conjunctival sac, creating a pocket Hold eyedropper 3 to 6 mm above the conjunctival sac (pocket) Place hand holding dropper on the patient’s cheek or forehead to stabilize as needed Drop prescribed number of drops into the centre of the pocket (conjunctival sac). Avoid touching eye or conjunctival sac with tip of eyedropper Instruct the patient to gently close their eye

25. Eye Ointment Apply a thin line of ointment evenly along inner edge of lower lid margin, from inner to outer canthus Avoid touching tip of applicator to eyelid or eye Instruct the patient to close eyelids and to roll eyes in all directions to distribute medication Dispose of clinical waste and gloves. Wash hands (DOH, 2003) Complete relevant documentation (NMC, 2004)

26. PART 6: Administration of a Nebuliser

27. Nebuliser A nebuliser is a device which turns an aqueous solution of a drug into a mist of fine particles for inhalation. The aim of nebuliser therapy is to deliver a therapeutic dose of the desired drug within a short delivery time. Nebulised therapy should be delivered by a mouthpiece whenever possible as it provides increased lung drug deposition.

28. You will need: Nebuliser pot, mouthpiece/mask and filter/valve set Vial of saline Medication Syringe Medicine tray Prescription chart Adminstering a Nebuliser

29. Wash hands before starting the procedure Consult patient’s prescription and ascertain that you are dealing with the right: drug, dose, route of administration, date and time of administration, patient Check the drug is in the appropriate volume, dilution or dosage and check expiry date Prepare the drug according to pharmaceutical and health care setting guidelines Note only Sodium Chloride 0.9% for injection should be used as a dilutant Ensure you have identified the correct patient and assist them into a sitting position, leaning slightly forwards whenever possible. Ensure the mask fits properly and is comfortable Air flow rate of 8 litres per minute *Note: in acute asthma use oxygen as the gas. At all other times use air.* Procedure

30. The nebuliser chamber needs to remains upright at all times The delivery time should not exceed 10 minutes. Wash the patients face after using a facemask – especially for steroids To clean equipment after use: Disconnect the nebuliser chamber from the tubing Wash nebuliser chamber and mask/mouthpiece in warm water and detergent Rinse thoroughly and dry well Re-assemble and then run the nebuliser empty to dry the tubing Wash hands (DOH, 2003) Complete relevant documentation (NMC, 2004)

31. PART 7: Administration of a Subcutaneous Injection

32. Subcutaneous Injection (S.C) Many medications must be injected subcutaneously. A subcutaneous injection is the administration of medication into the flesh just under the skin. You will use a very small needle that causes very little discomfort.

33. You will need: Clean gloves Appropriate size syringe and needle MedicationGauze pad or cotton ball and plaster if required Medicine tray Prescription chart Sharps container Administering a Subcutaneous Injection

34. Wash hands before starting the procedure Consult patient’s prescription and ascertain that you are dealing with the right: drug, dose, route of administration, date and time of administration, patient Check the drug is in the appropriate volume, dilution or dosage and check expiry date Prepare the drug according to pharmaceutical and health care setting guidelines Wash hands and put on disposable gloves (DOH, 2003) Remove the needle cover, inverting the syringe, and expelling any excess air Proceed with preparation of the drug according to pharmaceutical and health care setting guidelines Identify the correct patient

35. Assist the patient into a position which is comfortable and practical for access to the chosen injection site Follow the individual health care setting’s policy and procedure with regard to cleansing of the injection site Locate the correct area for injecting With your non-dominant hand pinch a fold of skin and hold it up

36. Using your dominant hand pick up the syringe, hold like a pencil and insert it in to the skin fold at a 45 degree angle Inject the medication and quickly withdraw the needle Dispose of syringe and needles in the sharps box (never recap a needle) Dispose of clinical waste and gloves. Wash hands (DOH, 2003) Complete relevant documentation (NMC, 2004) Procedure

37. PART 8: Administration of an Intramuscular Injection

38. Intramuscular Injection (I.M) Intramuscular (IM) injections are given directly into the central area of selected muscles. The most common sites used are: Deltoid muscle Vastus lateralis muscle Ventrogluteal muscle Dorsol gluteal muscle The intramuscular route offers a faster rate of absorption than the oral or subcutaneous route.

39. You will need: Clean gloves Appropriately sized syringe Appropriate needles to draw up and then administer medication Medication Gauze pad/cotton ball and plaster if required Medicine tray Prescription chart Sharps container Administering an Intramuscular Injection (I.M)

40. Procedure Wash hands and. put on disposable gloves as there is the potential for exposure to blood in the administration of I.M injections (DOH, 2003) Prepare the syringe by removing the needle cover, inverting the syringe, and expelling any excess air Select the drug in the appropriate volume, dilution or dosage and check expiry date Proceed with preparation of the drug according to pharmaceutical and health care setting guidelines Ensure you have identified the correct patient and assist them into a position which is comfortable and practical for access to the injection site you have chosen Follow the individual health care setting’s policy and procedure with regard to cleansing of the injection site

41. Land-Marking the Injection Site VENTROGLUTEAL SITE Position the patient in the supine lateral position Place heel of the left hand on right greater trochanter Index finger touches iliac crest Stretch middle finger as far as possible to form a V Accesses gluteus medius muscle The ventrogluteal site is the safest site for administering I.M. injections (Beyea & Nicol 1995) as it is furthest away from major blood vessels and nerves

42. DORSOGLUTEAL SITE Draw a line horizontally from centre of cleft of buttock Draw 2nd line vertically midway along first line. This is referred to as the upper outer quadrant Adaptation: the ‘double cross’ Divide the buttock with an imaginary cross THEN divide the upper outer quadrant by another imaginary cross Inject into the upper outer quadrant of the upper outer quadrant Insert the needle at a 90 degree angle using the Z track technique

43. Spread the skin using the fingers of the non-dominant hand. Holding the syringe with the thumb and forefinger of the dominant hand at a 90 degree angle, pierce the skin and enter the muscle Aspirate at the injection site by holding the barrel of the syringe with the non- dominant hand and pulling back on the syringe plunger with the dominant hand -If blood appears in the syringe, withdraw the needle and prepare a new injection -If no blood is aspirated, continue by slowly injecting the medication at a constant rate until all medication has been delivered. (Soanes 2000)

44. Withdraw the needle and syringe quickly to minimize discomfort. Do not massage the site after injection, as it reduces the effect of the medication Dispose of syringe and needles in the sharps box (never recap a needle) Dispose of clinical waste and gloves. Wash hands (DOH, 2003) Complete relevant documentation (NMC, 2004)

45. PART 9: Administration of an Intradermal Injection

46. Intradermal Injection (I.D.) An intradermal injection is an injection most commonly given into the Ventral (volar) forearm which is the inner aspect of the lower arm. I.D injections can be given to test for hypersensitivity, extrinsic allergens and TB sensitivity

47. You will need: Clean gloves Appropriately sized syringe and needle Medication Gauze pad or cotton ball and plaster if required Medicine tray Prescription chart Sharps container Administering an Intradermal Injection (I.D.)

48. Procedure Wash hands, put on disposable gloves as there is the potential for exposure to blood in the administration of subcutaneous injections (DOH, 2003) Prepare the syringe by removing the needle cover, inverting the syringe and expelling any excess air Select the drug in the appropriate volume, dilution or dosage and check expiry date

49. Proceed with preparation of the drug according to pharmaceutical and health care setting guidelines Ensure you have identified the correct patient and assist them into a position which is comfortable and practical for access to the injection site you have chosen Follow the individual health care setting’s policy and procedure with regard to cleansing of the injection site

50. Locate the correct area for injecting Angle the syringe at 15 degrees along long axis of arm (parallel) Inject with bevel facing up, ensuring the entire bevel penetrates the skin Inject the medication, raising a “bleb” with injected solution under the skin Dispose of syringe and needles in the sharps box (never recap a needle) Dispose of clinical waste and gloves. Wash hands. (DOH, 2003) Complete relevant documentation (NMC, 2004)

51. PART 10: Administration of Nasal Medications

52. Nasal Medications Nasal medications are administered into the nose using either drops or sprays. The medication is absorbed via the mucous membrane lining of the nose.

53. Administering Nasal Medications You will need: Prescription chart Formulary to check drug dosage such as the BNF Clean work surface Medication Tissues Disposable gloves Towel, to protect patient’s clothes

54. Procedure Hands should be washed (decontaminated) before and after patient contact, to prevent cross infection and apply gloves (NICE 2003, DOH 2003) Consult patient’s prescription and ascertain the following: Right drug Right dose Right route Right date and time of administration Right patient Select the required medication and check the expiry date Take prescribed dose of medication and prescription chart to the patient

55. Explain and discuss the procedure with the patient to gain their cooperation and consent Check the patient’s identity by asking them to state their name and date of birth. If patient is unable to confirm details then check these details with the patient identity band Ensure patient’s nasal passages are clean and clear prior to administration by getting the patient to clear their nasal passages Ensure the patient is sitting comfortably and hyperextend the neck unless contra- indicated

56. Avoid touching the external nares with the nasal dropper as it may cause the patient to sneeze (Trigg and Mohammed 2006) Insert the required number of drops into nare(s) as prescribed Clean any secretions or medication with the tissues/swab Ensure the patient stays in this position for 1 – 2 minutes to allow for absorption of the medication (Dougherty and Lister 2005)

57. Hands should be washed (decontaminated) before and after patient contact, to prevent cross infection and apply gloves (NICE 2003, DOH 2003) Consult patient’s prescription and check you are using the right: drug, dose, route, date and time of administration and patient Select the required medication and check the expiry date Take prescribed dose and prescription chart to the patient Explain and discuss the procedure with the patient to gain their cooperation and consent Check the patient’s identity by asking them to state their name and date of birth. If patient is unable to confirm details then check these details with the patient identity band Ensure patient’s nasal passages are clean and clear prior to administration Ensure the patient is sitting comfortably and hyperextend the neck unless contra-indicated Insert tip pf spray inside nasal passage and administer correct number of spray Remove gloves and wash hands (NICE 2003, DOH 2003) Record the medication given as required Nasal Sprays

58. PART 11: Administration of Topical Medications

59. Topical Medications Topical administration of medication refers to the direct application of medication directly to the surface of the skin where required (Trounce 2004). Topical medication may include patches, creams or ointments applied directly to the skin. The absorption of medication may vary with age due to reduced skin density and integrity (Trigg and Mohammad 2006).

60. You will need: Prescription chart. Formulary to check drug dosage such as the BNF Clean work surface Disposable gloves Topical medication Sterile topical swabs Medication tray Dressings / bandages if required Administering Topical Medications

61. Procedure Hands should be washed (decontaminated) before and after patient contact, to prevent cross infection and apply gloves (NICE 2003, DOH 2003) Consult patient’s prescription and ascertain the following: right drug, right dose, right route, right date and time of administration, right patient Select the required medication and check the expiry date Take prescribed dose of medication and prescription chart to the patient Explain and discuss the procedure with the patient to gain their cooperation and consent

62. Check the patient’s identity by asking them to state their name and date of birth Using a gloved hand remove semi-solid/stiff ointment and apply to area as prescribed, following manufacturer’s recommendations In the case of a transdermal patch, follow manufacture’s guidelines and apply the patch to clean, smooth skin. Ensure the plastic protective coating is removed Remove gloves, dispose of clinical waste receptacle and wash hands (NICE 2003, DOH, 2003) Record the medication given in the prescription chart and any other place necessary as indicated by individual hospital policy (NMC, 2007).