Local Instillation of Drugs

Subject: Fundamentals of Nursing

Overview

Local Instillation of Drugs

An instillation is the administration of liquid medications by drop. This method is used for administration of liquid medication into the eye, ear and nose.

Instilling Medication into Ear

It is a method of administering ear drops into auditory canal to produce local effect.

Purposes

  • To soften ear wax.
  • To reduce localized inflammation and destroy infective organisms in the external ear canal.
  • To clean the ear.
  • To relieve pain.
  • To facilitate removal of foreign body.
  • To kill an insect lodged in the ear.
  • To anaesthetize.

Contraindication

  • Rupture of tympanic membrane.

Articles

  • Disposable gloves.
  • Cotton tipped applicators.
  • Medication bottle with dropper.
  • Cotton balls.
  • Kidney tray or paper bag.
  • Bowl with normal saline.

Special Considerations

  • Use sterile techniques in administration of medication in case of perforation of the tympanic membrane.
  • Hydrocortisone ear drops are contraindicated in the patients with fungal viral infection in the ear.

Instilling Medication into Eyes

It is a method of administering eye medication inside the eye by instillation.

Purposes

  • To treat infection
  • To instill medication before examination or surgery of eyes
  • To dilate / contract pupil
  • To lubricate eyes
  • To relieve pain and itching
  • To stain cornea for identifying abrasions and scars

Articles

  • Disposable gloves
  • Sterile cotton balls soaked in sterile normal saline
  • Medication
  • Dry cotton balls
  • Dry sterile dressing pad and paper tapes
  • Kidney tray

Special Considerations

  • If more than one eye drop (medication) is ordered, wait for 5 minutes between each medication.
  • Instruct the patient on safety precautions if drops are meant for dilation of pupils.
  • If medication needs to be instilled into both eyes, place in the unaffected eye first.

Administering Nasal Drops

Nasal instillation is the process by which a liquid is introduced into the nasal cavity by drop.

Purposes

  • To treat allergies
  • To treat nasal congestions
  • To treat sinus infections
  • To give local anesthesia
  • To relieve inflammation, swelling and
  • To prevent and control bleeding 

Articles

  • Prepared medication with clean dropper
  • Pen light
  • Gloves
  • Facial tissues
  • Small pillow
  • Kidney tray
  • Wash cloth (optional)
  • Medication card

Inserting Medication into Vagina

It is introduction of medications into the vagina in the form of creams, jellies, foams, or suppositories.

Purposes

  • To treat/prevent infections
  • To reduce inflammation
  • For contraception
  • To treat vaginal itching
  • Induce labour

Articles

  • Triangular drape
  • Prescribed medication
  • Applicator with plunger in case vaginal cream
  • Disposable gloves
  • Lubricant in case of suppository
  • Towel for wiping perineum
  • Makintosh and towel for placing under the buttocks

Procedure for Nasal, Eye and Ear Instiatin and Vaginal Insertion

S.N. Nursing Actions Rationale
1 Identify the patient's name and verify medication order. Ensures the correct administration of medication.
2

Explain the purpose of medication, the site of injection, expected effect and allow the patient  to clarify doubts.

 Explanation encourages cooperation and reduces anxiety.
3 Wash hands and don gloves on the dominant hand if needed. Reduces spread of microorganisms.
4 Prepare needed articles and arrange in bed side. Facilitate orderly performance of procedure and save the times.
5

Nasal Instillation

Assess the patient's history of hypertension; hyperthyroism. Determine whether the patient has any known allergic to nasal instillations.

Inspect the conditions of the nose and sinuses using a pen light. Palpate sinuses for tenderness. Explain to the patient the procedure including positioning and sensations to expect such as burning or stinging of mucosa or chocking sensation as medication trickles into throat.

Instruct the patient to clear or blow the nose gently unless contraindicated.

Remove mucous and secretions that can block distribution of medication.

Assist the patient to the supine position.

Support the client's head with non-dominant hand.

For access to posterior pharynx tilt patient's head backward.

Instruct the patient to breathe through mouth. Mouth breath reduces chance of aspirating nasal drops.

Hold dropper 1 cm above nares and instill the prescribed number of drops towards midline of ethmoid bone.

Have the patient remain in supine position for 5 minutes.

Give cotton swab to wipe.

Assist the patient to a comfortable position after medication is absorbed.

Observe the patient for onset of side effects 15 to 30 minutes after administration.

These conditions can contraindicate use of decongestants that stimulate heart disease, diabetes mellitus and CNS side effects of transient hypertension, trachycarda, palpitation and headache and prevents from complication.

Helps patient anticipate experience of procedure to reduce anxiety.

Removes mucous and secretions that can block distribution of medication.

Position provides access nasal passages. 

Mouth breathing reduces chance of aspirating nasal drops.

Avoid contamination of dropper. Prevents from loss of medicine.

Restore comfort.

Drugs absorbed through mucosa can cause systematic reactions.

 

 
6

Eye Instillation

Check medication order for preparation, strength of medication, number of drops, frequency of instillation of medication and eye to be treated.

Assess for allergy to medication, lesions, exudate, erythema or swelling, location and nature of any discharge, level of consciousness and willingness to cooperate and use of contract lens.

Assist the patient to a comfortable position, sitting or lying with the head slightly hyper extended.

Obtain assistance for immobilizing in case of young children.

Wash hands and don sterile gloves.

Clean the eyelid and lashes with a sterile moistened cotton ball, wipe from inner canthus to outer canthus. Discard cotton balls after each wipe.

Place the basin or kidney tray at the check on the side of the affected eye.

Instruct the patient to look up the ceiling. Give the patient a dry sterile absorption cotton ball.

Expose the lower conjunctival sac by placing thumb or fingers of your non-dominant hand just below the eye on the zygomatric arch and gently draw the skin on the cheek. If the tissues are edematous, handle the tissues carefully to avoid damaging them.

For liquid medication

  • Draw the required amount of medication into the dropper.
  • Discard the first drop of medication.
  • Approach the eye from the side and instill the correct number of drops in the center of the lower lid holding dropper 1-2 cm above the eye.

For ointment

  • Discard the first bead of ointment.
  • Hold the tube above the conjunctival sac, squeeze 2 cm of ointment from tube into the lower conjunctival sac from the inner canthus out ward.

Instruct the patient to close eyelid and not to squeeze them shut.

Instruct the patient to press on the nasolacrimal duct for at least 30 seconds after instilling liquid medication.

Clean the eyelid as needed by wiping from the inner canthus to outer canthus.

Apply an eye pad if required and secure it with tape and instruct the patient not to rub the eye.

Prevents medication error.

Reduces spread of microorganisms.

Cleaning the eye prevents secretion on eyelid and lashes being washed into the eye. Cleaning toward outer canthus prevents contaminations entering into the other eye and lacrimal duct.

Person is not likely to blinknif looking up and in this position the cornea is protected by upper lid. A cooton ball can be used to wipe off excess drug from eyelashes after instillation.

Placing finger on the bony prominence avoids pressure to the eyeball and prevents person from blinking or squinting.

The first drop is considered to be contaminated.

Patient is less likely to blink if a side approach is used. If drops fall directly on the cornea, it may cause injury.

Squeezing can injure eye and push out medication.

Pressure prevents medication running down the duct.

Prevents spread of organisms into lacrimal duct.

Reduces risk of injury.
7

Ear Instillation

Assess the patient for allergy to medication, types and amount of discharge, complaints of discomfort; ability to cooperate during procedure, the patient's knowledge about medication to be administered.

Check medication order for name, dose, time, amount and ear to be treated.

Identify the patient and explain the procedure, sudden purpose of medication and position to assume during and after instillation.

Obtain assistance in case of children or infants Removes to immobilize them. 

Assist the patient to a side lying position with ear being treated uppermost.

Clean meatus of ear canal, using cotton tipped applicator. Use normal saline if necessary. Warm the container in hand or by placing it for a short time in warm water.

Fill ear dropper partially with medication.

Straighten auditory canal. For infants or children less than 3 years, pull pinna down and back. For an adult or child older than 3 years, pull pinna upward and backward.

Instill correct number of drops alongside of the of canal. ear canal by holding the dropper one centimeter above the ear canal.

Press gently and firmly a few times on the tragus of the ear.

Instruct the patient to remain in side-lying position for about 5 minutes.

Plug the ear with cotton loosely at the meatus of the auditory canal for 15-20 minutes.

Assess for patient's comfort, response and check for discharge / drainage from the ear.

Identifies contraindication for ear  instillation.

Reduces risk of medication errors.

Reduces anxiety and promotes coopration of patient.

Prevents accidental injury due to sudden movement during the procedure.

Removes any discharge before instillation.

Promotes patient comfort and prevents vertigo and nausea.

Straightening the canal can ensure solution to flow the entire length of the canal.

It reduces risk of rupture of tympanic membrane.

Pressing on the tragus assists flow of medication into ear canal.

Prevents drops from escaping and enables medication to reach all sides of canal.

The cotton helps to retain medication when patient is upright.
8

Inserting Medication into Vagina

Assess the patient for allergy to medication, inflammation of external meatus/vagina, color, character and odour of vaginal discharge and complaints of vaginal discomfort.

Instruct the patient to empty bowel and bladder.

Provide privacy.

Position the patient in the dorsal recumbent position and drape using a triangular drape, so that only perineal area is exposed.

Prepare articles, unwrap suppository and keep it ready on the opened wrapper. Fill the applicator with prescribed cream, jelly or foam, as per manufacturer's instruction.

Put on clean gloves.

Inspect perineum/vagina for any odour, discharge.

Provide perineal

care to remove microorganism. Encourage the patient perform her own perineal care in the toilet if able. Administer vaginal suppository using the following methods.

Lubricate your gloved index finger.

Expose the vaginal orifice by separating the labia with your non dominant hand. Insert suppository about 8 to 10 cm along  posterior wall of vagina or as far as it will go.

Ask the patient to remain lying in the supine for 5 to 10 minutes following position for 5 to insertion. The hip may also be elevated on a pillow.

If using an applicator, gently insert the application about 5 cm and slowly push the plunger until the applicator is empty.

Dry the perineum using a towel.

Apply a perineal pad if there is excessive drainage.

Remove gloves and wash hands.

Reduces medication errors.

Provides comfort to patient and reduces injury to vaginal lining.

Reduces chance of microorganisms moving into vagina. 

Ensures patient comfort.
9 Dispose the soiled supplies in a proper container and perform hand hygiene. Reduces the risk of transmission of microorganisms.
10 Assist the patient to a comfortable position. Restores patient's comfort.
11 Wash hands. Reduces spread of microorganisms.
12 Document administration of medication, number of drops, patient's response etc. Promotes communication between staff members.
13

Assess effectiveness of medication.

Observe the patient for any allergic reaction.

 Adverse reaction after medication may necessitate emergency measures.
14 Report any unusual systemic effects to the nurse in-charge or physician.  

Rectal Route

Drugs in solid forms such as suppositories or in liquid forms such as enema are given by this route. This route is mostly used in old patients. Drugs may have local or systemic actions after absorption.

Advantages

  • This route is preferred in unconscious or uncooperative patients.
  • This route avoids nausea or vomiting
  • Drug cannot be destroyed by enzymes.
  • This route is preferred if drug is irritant.

Disadvantages

This route is generally not acceptable by the patients.

Administering Rectal Suppositories

A suppository is a small piece of oval shaped solid substance shaped for easy insertion into the rectum and designed to melt at body temperature. It is an introduction of medication into the rectum in the form of suppository.

Purposes

  • To stimulate peristalsis
  • To soften the fecal matter
  • To promote defecation
  • To act as analgesic and/or antipyretic

Articles

  • Rectal suppository
  • Lubricating jelly
  • Disposable gloves
  • Tissue paper
  • Kidney tray
  • Prescription sheet
  • Drape sheet

Procedure

S.N. Nursing Action Rationale
1

Identify the patient's name and verify medication order.

 Ensures the correct administration of medication.
2

Explain the purpose of medication to the patient and allow the patient to clarify doubts.

 Explanation encourages cooperation and reduces anxiety.
3 Screen the patient. Provides privacy.
4 Wash hands. Reduces spread of microorganisms.
5 Prepare needed articles and arrange in bed side. Facilitates orderly performance of procedure and save the times.
6 Check medication card/form with the physician's written order for accuracy, completeness etc. Check the patient's name, name of drug, dose, route and time of administration. Physician's order is the most legal source of information and eliminates medication error.
7 Perform necessary pre-administration assessment for specific medication. Gives information as to whether medications should be given at that time.
8 Review the patient's knowledge and purpose of drug therapy and interest in self-administration. If the patient is interested and capable of self-administration, provide instructions for it and send him to the toilet with the articles. Allows nurse to monitor patient's response.
9 If the patient is not capable for self-administration, assist the patient in assuming the left lateral position with the upper leg flexed. This position helps to xposes anus and relax external anal sphincter.
10 Wear gloves. Prevents from contamination.
11 Keep the patient draped with only the anal area exposed. Maintains privacy.
12

Examine the condition of the anus externally and palpate rectal walls as needed.

 Determines condition of anal area.

13

 

 Remove suppository from halt wrap and lubricate rounded end with jelly. Lubricate the gloved index finger of the dominant hand. Lubrication reduces friction.
14 Ask the patient to take slow deep breaths through  the mouth and to relax the anal sphincter. Inserting suppository through constricted sphincter causes pain.
15 Retract the patient's buttocks with the non-dominant hand. With the gloved index finger of the  dominant hand, insert suppository gently through the anus, past the internal sphincter and against the rectal wall 10 cm in adults, 5 cm in children and infants. Suppository must be placed against rectal mucosa for eventual absorption and therapeutic action.
16 Withdraw the finger and wipe the patient's anal area. Ensures comfort of the patient.
17 Discard gloves and dispose in appropriate  receptacles and wash hands. Reduces the transfer of microorganisms.
18 Ask the patient to remain flat or on side for 5 minutes. Prevents expolsion of suppository.
19 Check within 5 minutes to determine if the suppository is in place. Instruct the patient to remain suppository for 30 to 45 minutes. Reinsertion may be necessary if expelled.
20

Replace articles and returns medication cards to appropriate files.

Dispose of soiled supplied and wash hands. Clean work area.

Loss of record can lead to errors in administration.

Reduces transmission of microorganisms.

 
21

Record the medication administration with date, time and signature.

Record and report the patient's response to medication including any unusual reaction.

 Prompt documentation prevents errors such as repeated doses.

Responsibilities of a Nurse in Administrating Drugs

Nurses are responsible for ensuring safety and quality of patient care at all times. Many nursing tasks involve a degree of risk, and medication administration arguably carries the greatest risk. Unfortunately, patients are frequently harmed or injured by medication errors. Some suffer permanent disability and for others the errors are fatal.

  • Nurses have followed the rights of medication administration to help prevent errors. The nurse should know the following:
    • The nature of the drug, that is, the name, classification, types of preparation, effects, dosage, routes and time of administration.
    • Preparation of solutions and calculation of fractional dose.
    • Storing of medications in proper containers.
    • Ethical and legal aspects.
    • Rules for the administration of medicines.
    • Abbreviation and symbols used in writing medication order.
    • Allergy and reason for taking medicine
    • Patient's right regarding medications i. e. refusal, privacy, respect.
  • Check the diagnosis and age of the patient.
  • Check the purpose of medication.
  • Check the identification of the patient, the name and bed number.
  • Check the physician's orders for the correct name of the drug, dosage and method of administration.
  • Check the nurse's record for the time at which the last dose was given.
  • Check for any contraindications present in the patient e.g. nausea, vomiting, allergic reactions.
  • Check the form of the drug available and the correct method of administration.
  • Know the difference between generic and brand name of drug.

Rules for Administration of Medicine

Rules Regarding Labels

  • Always administer medications only from the properly labelled container.
  • Poisonous drugs should be labelled in red ink.
  • Read the labels of medicine 3 times and compare with the doctor's order.

Rules Regarding Measuring Medicine

  • Always use a calibrated ounce glass or medicine glass to measure medicine.
  • Always give exactly what is ordered.
  • Make sure that the medicine glasses are clean and dry before pouring medicine.
  • Hold the ounce glass at eye level and place thumb nail of the hand at the required level and then pour the medicine.
  • Pour the medicine just before the time of administration into the medicine glass.
  • Do not pour back extra medicine into bottle to prevent contamination of the whole medicine.
  • Shake the liquid medicine before pouring into the medicine glass.
  • Wipe the mouth of bottle, close it tightly and replace the bottle in proper place after use.
  • Never touch the medicine with hands. Keep them in a container or at least in a piece of paper.
  • Pour the medicine from the bottle on the side opposite the label.

Rules Regarding Administration

  • Observe the rights in giving each medication.
  • Give medicines only after checking a medication order by the doctor.
  • Accept verbal orders only in emergency to save the life of the patient.
  • A drug order or prescription has six essential parts e.g. (i) Name, OPD No, IP No, (2) Name of ordered drug, (3) Dosage of drug, (4) Routes, (5) Date, (6) Doctor's signature.
  • Always identify the patient before giving medication.
  • Stay with the patient until he has taken medicine completely.
  • Never give more than one drug at a time.
  • Have knowledge about the minimum and maximum dose of the drug that is given.
  • Always give the medicine that you have prepared yourself. Do not give medicine prepared by other or without label.
  • Do not use medicine that is different in colour, test, odour, and consistency.
  • An error in medication should be immediately reported to the ward sister.
  • Use proper light while giving medicines.
  • Never give water after giving cough syrups. It leaves a soothing effect to prevent cough.
  • Drugs which stimulate appetite should be given before food.
  • If a patient refuses a medicine, do not force it and inform to the senior or record it.

Rules Regarding Recording of Drugs

  • Record each dose of medicine soon after it is administered.
  • Record only those medicines, which have been administered.
  • Record unusual effects such as allergic reactions.
  • Record time, dose and route of the medicine given.

Medication Errors

Medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.

Some of the factors associated with medication errors include the following:

  • Medications with similar names or similar packaging
  • Medications that are not commonly used or prescribed
  • Commonly used medications to which many patients are allergic (e.g. antibiotics, opiates, and non-steroidal anti-inflammatory drugs)
  • Medications that require testing to ensure proper (i.e. nontoxic) therapeutic levels are maintained (e.g. lithium, warfarin, theophylline, and digoxin)

Care of Medicine and Medicine Cupboard

  • Each ward needs to have a medicine cabinet to properly store medications.
  • It ought to be big enough to hold all medications.
  • All pharmaceuticals must be kept in a secured cabinet because they all have the potential to be harmful.
  • As soon as the pills and medications are received from the dispensary, they must all be inspected.
  • Every dose of dangerous medications must be precise and must be given by specific order.
  • A room close to the ward should contain a medicine cabinet.
  • All dangerous medications must be kept in a separate closet that is locked and whose keys belong to the ward sister.
  • Medications intended for exterior use should be housed in a different section of the cabinet.
  • The poison bottles need to be prominently marked, and the closet needs to be well-lit.
  • Separate compartments should be provided for mixtures, tablets, powders, etc.
  • For ease of use, the containers ought to be organized alphabetically.
  • Maintaining a registry is necessary to keep track of the harmful medications.
  • Examine each drug's expiration date and utilize it before that time.
  • The location of the emergency medications should be easily accessible in case of an emergency.
  • To effectively see the labels on the bottles and medications, there should be sufficient lighting within the cabinet.
  • Drugs with strange color, odor, or consistency should be taken back to the pharmacy and thrown out.
  • Serum, vaccinations, and antibiotics like penicillin should all be stored in refrigerators along with oils like castor oil.
  • After usage, all equipment needs to be cleaned and put back where it belongs.
Things to remember

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