Chapter 13 Percutaneous Routes PDF

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Percutaneous Routes...

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Chapter 13: Percutaneous Routes

Introduction • •

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Absorbed through skin or mucous membranes Administration routes include: o buccal o sublingual o topical o transdermal Local or systemic effect What does percutaneous mean? (Absorbed through skin or mucous membranes.) Why might percutaneous routes for administering medications be chosen? (Used when direct contact of the medication with skin is desired, because of ease of administration and low risk of systemic adverse reactions.) Are percutaneous routes suitable for systemic action? Why or why not? (No, because of absorption rate differences of some topical agents, this route has unreliable systemic action and so is seldom used for treating systemic diseases.)

Topical Medications • • • • • • •

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Used for local effect or systemic action Important to apply as prescribed Wash skin only with water Keep skin hydrated for optimal absorption What are some examples of topical medications? (Calamine lotion, Bengay, etc.) Why is it important to apply topical medications only as prescribed? (Topical medications can cause systemic adverse reactions if not applied properly.) What steps should you take before applying any topical medication? (The area of skin should be clean, dry, and free of infection, rashes, encrustations, open areas, and dead tissue. Skin should be cleansed with water. Adequate skin hydration is necessary.) Why should skin be free from soap? (Soap can alter medication absorption.) Where would you apply a topical medication for quickest absorption? (Behind the ear.) What site absorbs medication the slowest? (The thigh and forearm.)

Applying Topical Medications •

Powders, Soaks, Compresses, and Wet Dressings o Powder applied in fine, thin layer o Extremities can be soaked in solution o Warm soaks no warmer than 115°F

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o Wet applications leave a mild astringent on the skin o Plastic wrap keeps dressings moist Why is it important for skin to be dry before applying powder? (To minimize crusting and caking of the powder.) Why is it better to apply a thin layer of powder than a thick layer? (A thin layer of powder is more absorbent than a thick layer, reducing friction by increasing evaporation of moisture.) How does the astringent in a wet dressing help blistered or oozing skin? (It provides a soothing, cooling, and antipyretic effect.) Creams, Ointments, Gels, and Lotions o Creams—semisolid; water based o Ointments—soft; oil, lanolin, or petroleum based o Gels—soft, thick; water-based for lubrication, or oil-based for longer lasting treatment o Lotions—soft; water-based What is nitroglycerin ointment used for? (Treatment of angina pectoris.) What advantages does the consistency of gel have over other topicals? (Better coverage that lasts for longer periods of time.) Equipment needed o Physician’s order o medication ordered o gloves o supplies to cleanse skin o dressing and bandages as needed See Procedure 13-1 Patches, Disks, and Transdermal Dots o Extended effect up to several days. o Medication passes through skin into circulatory system for continuous treatment. o Change as indicated to maintain desired dosage. o Handle carefully to prevent absorption through hands. Why are patches, disks, and dots used instead of other topical methods? (They provide extended effects – up to several days.) Why is it important not to touch the medication on a patch, disk, or dot while applying it to the site? (Medication may be accidentally absorbed.) Common Uses for Patches, Disks, and Transdermal Dots o Nitroglycerin—to treat angina o Female hormones—to alleviate menopausal symptoms o Scopolamine—for motion sickness o Duragesic—to treat chronic pain o Nicotine—for smoking cessation o Allergy testing o Contraceptives o Methylphenidate – Ritalin

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o Testosterone – male hormone Where are female hormones typically applied? (Applied to the thighs and buttocks for slow absorption.) Where is scopolamine applied? Why? (Applied behind the ear to treat motion sickness.) How long are patches containing allergens usually left in place? (24 to 48 hours.) Figure 13-1 What should you do if you accidentally touch the medication on a transdermal patch? (Wash your hands immediately.) What type of patch might be applied to the back, as shown in this photo? (Allergy patch.) Applying nitroglycerin ointment o Cleanse skin of any residual ointment. o Ensure site is dry, free from hair and scar tissue. o Apply prescribed amount in inches to applicator paper. See Procedure 13-2 Applying nitroglycerin ointment (cont’d.) o Check patient’s pulse. o Apply to skin, hold in place 10 seconds. o Add tape, plastic, or wax dressing if needed. o Typical documentation: o 7/13/XX 9:15 AM Pulse 72. Nitroglycerin ointment, 2 inches, applied to left upper chest after skin cleaned of residue. Tape applied to application paper. No apparent adverse reactions.-- G. Olive, CMA See Procedure 13-2 Sprays and Aerosols o Shake aerosols vigorously before applying. o Spray fine, even coating of medication specified distance from skin (usually 6 to 12 inches). o Have patient turn head if spraying medication near face. Why must aerosols be shaken? (To ensure medications and propellants are evenly distributed.) What happens if you hold the container too close while spraying? (May result in a thin, watery distribution.)

Special Considerations for Topical Medications in Geriatric Patients • • •

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Apply with minimal friction. Observe for excoriated skin caused by irritation from medication. Why is it important to apply topical medications very carefully to an older person’s skin? (The skin is fragile, and the blood supply is closer to the surface with thin skin, increasing the risk of bruising.) What does “excoriated” mean? Why might an elderly person not be aware of problems caused by applying a topical medication? (The elderly have diminished sensations of pain, temperature, and itching.)

Buccal and Sublingual Medications •

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Sublingual medications o tiny, porous tablets, liquid from capsules, aerosol sprays o placed under tongue for rapid absorption into bloodstream Figure 13-2A What is a common medication that is delivered sublingually? (Nitroglycerin.) Figure 13-2 A, Sublingual administration of medication. (From Leahy JM, Kizilay PE: Foundations of nursing practice: a nursing process approach, Philadelphia, 1998, WB Saunders.) Buccal medications o placed between teeth and gums for local absorption o when saliva swallowed, systemic absorption occurs o medication should be allowed to dissolve completely What happens if buccal medication is swallowed instead of allowed to dissolve completely? (The time for absorption will be prolonged or the medication may be changed by gastric juices and be ineffective.) Figure 13-2B Through what type of tissue are buccal and sublingual medications absorbed? (Mucous membranes.) Figure 13-2 B, Buccal administration of medication. (From Leahy JM, Kizilay PE: Foundations of nursing practice: a nursing process approach, Philadelphia, 1998, WB Saunders.)

Ophthalmic Medications • • • • •

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Ointments, drops, intraocular disks Most for topical administration but some absorbed systemically Must be sterile; label marked “ophthalmic” Why is it important for “ophthalmic” to appear on the medication label? (To ensure that the drops are used properly.) Instilling Eye Drops o Cleanse any eye drainage, moving from inner to outer canthus. o Warm drops, check for ophthalmic label. o Hold dropper 1/4 to 1/2 inch above conjunctival sac. o Do not touch eye with dropper tip. See Procedure 13-3 Why is it important to avoid the cornea? (The cornea has a rich supply of nerve fibers.) Why is it important not to touch the eye with the dropper tip? (To avoid contaminating the dropper.) See Procedure 13-3 What does warming the drops accomplish? (It prevents excessive irritation.) Drop the prescribed medication amount into the conjunctival sac. If the patient blinks or closes the eye, repeat the procedure. Instilling Eye Drops (cont’d.) o Drop prescribed amount into conjunctival sac. o Repeat if patient blinks or closes eye. o Apply gentle pressure to nasolacrimal duct for 30 to 60 seconds. o Typical documentation o 7/22/XX 3:15 PM Pilocarpine hydrochloride ophthalmic drops, gtt i OU, with no apparent adverse reaction. --G. Olive, CMA See Procedure 13-3 Instilling Eye Ointment o Cleanse any eye drainage. o Check for ophthalmic label. o Ask patient to look up to ceiling. o Hold applicator above lower lid; apply thin ointment stream along inner edge of lower lid from inner to outer canthus. o Ask patient to close eye slowly, then blink several times. See Procedure 13-3 What is the purpose of having the patient blink after ointment is applied? (To further melt the ointment and distribute the medication across the eye.)

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See Procedure 13-3 Hold the ointment applicator above the lower lid and apply a thin stream of ointment along the inner edge of the lower lid from the inner to outer canthus. Instilling Eye Ointment o Repeat several times to further melt ointment, distribute medication. o Wipe excess ointment away. o Apply eye patch as needed. o Document the procedure. See Procedure 13-3 How do ointments affect vision immediately after application? (May blur vision for up to 30 minutes.)

Otic Medications • • • • • • • •

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Administer at room temperature to prevent vertigo and nausea. Use sterile medication if physician suspects ruptured eardrum, or if tubes are present. Can use sterile ophthalmologic drops in ears, but do not use otic medication in eyes. How can you warm otic medications? (By holding the medication bottle between the hands for approximately 2 minutes.) Never force solution into ear. Never fill ear canal with medication dropper. Wipe away excess cerumen from outer ear with cotton-tipped swab. What could happen if you use a medicine dropper to administer otic medication? (This can cause pressure in the canal and can cause further injury to the eardrum.) Instilling Otic Medications o Have patient lie on side, with affected ear up. o Warm the medication. o Administer medication slowly, holding dropper about 1/2 inch above ear. o Aim toward canal wall, rather than eardrum. See Procedure 13-4 How do you hold the ear of an adult as you administer the medication? (Straighten the ear canal by pulling external ear up and out of back.) How do you hold the ear of a child 3 years old or younger? (Gently pull the external ear down and back.) See Procedure 13-4

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Why should you avoid the eardrum? (Aim drops toward wall of canal.) Slowly administer the prescribed medication amount, holding the dropper about ½ inch above the ear, and aiming the drops toward the wall of the canal. Instilling otic medications (cont’d.) o Massage out ear. o Ask patient to retain position for 5 minutes. o Typical documentation o 7/13/XX 2:45 PM Cortisporin Otic Solution, gtts iii in Lt ear, with no apparent adverse reaction. Patient instructed in proper method of instilling ear drops at home. --G. Olive, CMA What does massaging the outer ear accomplish? (Moves medication inward.) What is the purpose of having the patient remain still? (Allows medication to be absorbed.)

Nasal Medications •

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Anatomic structure of the nasal cavity. From Seidel HM et al (2003). Mosby’s guide to physical examination (5th ed.). St. Louis: Mosby. Administer by dropper, atomizer, or aerosol Used for local or systemic effect Relatively safe if given in small doses Repeated use of decongestant sprays can worsen nasal congestion What are some examples of local conditions treated with nasal medications? (Stop nosebleeds, sinusitis, upper respiratory symptoms, etc.) What are some examples of systemic conditions treated with nasal medications? (Migraine headaches, smoke cessation agents, etc.) Instructions for Administering Nasal Spray o Clear nasal passages as much as possible. o Sit upright. o Tilt head back. o Occlude one nostril, inhale through other. o Ensure spray tip is centered in nostril. o Squeeze to deliver medication. Why is it important for nasal passages to be clear of mucus? Figure 13-3

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Figure 13-3 Administration of nasal medication. (From Chester GA: Modern medical assisting, Philadelphia, 1998, WB Saunders.) Administering Nasal Spray (cont’d.) o Keep head tilted back for about 5 minutes. o Do not blow nose. o Expectorate any medication that spills into throat. What instruction is missing here for the patient receiving medication from an aerosol? (Have patient hold breath.) How do instructions for administering nose drops differ from instructions for nasal sprays? (See textbook for comparisons.)

Vaginal Medications • • • • •

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Suppositories, tablets, creams, solutions Treat local infections, contraception Many over-the-counter medications available; typically self-administered Often used at bedtime What are the pros and cons of douches? (Pros – They are anti infectant solutions; Cons – May change acidity in the vaginal canal, making women more prone to vaginal infections.) Why are vaginal medications used a bedtime? (They are best used when lying down. Women should remain flat for at least 10 minutes after insertion of a cream or suppository.)

Inhaled Medications • • • • •

Gases, sprays, powders, and liquids inhaled into respiratory tract via vapor or mist Absorbed rapidly Metered-dose inhaler (MDI): handheld device that disperses medication to lungs What accounts for the rapid absorption of inhaled medications? (The rich blood supply of the respiratory tract through the alveolar-capillary network.) What age groups should not be treated with an MDI? Why? (Elderly patients may have difficulty because the use of an MDI requires coordination and strength to push the canister and breathe at the same time.)

Metered Dose Inhaler • •

Figure 13-4 How much push is required to activate an MDI? (5 to 10 pounds of pressure.)

Inhaled Medications •

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Administration of Medication Using Metered Dose Inhaler o Remove cover from MDI, gently shake. o Take deep breath, exhale. o Position inhaler in mouth, 1 to 2 inches from mouth, or with spacer attached. o Place middle finger at top of inhaler. See Procedure 13-5

Administration of Medication Using Metered Dose Inhaler o Tilt head back slightly. o Inhale slowly and deeply through mouth. o Depress medication canister fully. o Hold breath 10 seconds. o Exhale through pursed lips. See Procedure 13-5 Why should the patient exhale through pursed lips? (To keep airways open during exhalation.) Administration of Medication Using Metered Dose Inhaler o If second dose indicated, wait 2 to 5 minutes between doses. o Cleanse MDI after each use. o Review instructions for home use. o Typical documentation o 7/12/XX 9:15 AM Albuterol inhaler, 2 puffs as directed, with no apparent adverse reactions. Return demonstration by patient and instructions given for use at home.-- G. Olive, CMA Why is cleansing the MDI after each use important? (An accumulation of medication around the mouthpiece may interfere with medication reaching desired locations.) How can you ensure the patient will follow your instructions when using the MDI at home? (Have patient repeat instructions to you and provide patient with printed instructions.)...