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14.1 Administering Eye Medications

Ophthalmic medications are commonly used to treat allergies, dry eyes, viral or bacterial infections, and glaucoma. Medications administered via the ophthalmic route include eye drops, ointments, and medication disks. Eye drops are prepared in liquid solutions, ointments are greasy semisolids that melt after being placed in the eye, and disks are flexible medication disks that release medication over one week’s time and then must be removed. Medications administered via the eye should never be used if expired.

Irrigations are a treatment for flushing secretions, chemicals, and foreign bodies from the eye. Typically, a local anesthetic eye drop will be placed into the affected eye and then normal saline is injected with a syringe onto the front surface of the eye, inside the lower eyelid, and under the upper eyelid. When irrigating an eye, the patient should be lying down with the affected eye down. The irrigant should be brought to room temperature and be held no more than 2 in (5 cm) away from the eye. To maintain sterility, the tip of the syringe should be kept sterile at all times and should never touch the surface of the eye or eyelid.

When confirming the rights of medication administration, it is important to note the number of drops to be administered and in which eye to place the drop. Before administering eye medications, assess the patient’s eyes and gently cleanse any dirt, debris, or crust with a gauze or washcloth dampened with warm water or normal saline. Wipe the eye from the inner canthus of the eye to the outer canthus and use a new gauze or corner of the washcloth with each stroke. Shake the medication, if indicated. Instruct the patient to tilt their head back, or lie down, and look upward. Using the thumb and/or index finger, gently pinch the eyelid and pull downward to form a pocket. Gently squeeze the medication into the conjunctival sac and instruct the patient to keep their eye closed for one minute. Press one finger against the inner canthus of the eye to prevent the medication from going into the tear duct.

14.2 Administering Ear Medications

Ear (i.e., otic, auricle) medications may be indicated for treating infections or inflammation, providing local anesthesia, softening cerumen for removal, and facilitating removal of objects from the ear canal. Ear medications may be prepared as ear drops or a medicated ear wicks. Ear drops are placed in the ear canal, whereas medications administered via medicated ear wicks are placed on the end of the wick that has been placed at the entrance of the ear canal. Ear medications may be used for people with surgically placed ear tubes; however, ear medications should not be used for patients with ruptured eardrums, unless otherwise indicated by the provider. The risk of experiencing an infection is increased if the eardrum is ruptured; therefore, aseptic technique should be followed (e.g., ensuring the tip of the ear medication bottle and inside of the bottle cap remain sterile).

Ear irrigation may be warranted to remove foreign objects or wax buildup from the ear canal. Side effects of ear irrigations include dizziness, pain, nausea, and ringing in the ears. Ear irrigations should not be performed on patients with damaged eardrums, tubes in their ears, or an active infection in their ear canal, unless otherwise indicated by the provider. Risks of ear irrigation include ear infections, a perforated eardrum, vertigo, and hearing loss.

The provider should assess the ear canal with an otoscope before irrigating the ear. Position the patient upright and hold an irrigation basin under the affected ear. Gently pull the ear upward and back for an adult patient or downward and back for a pediatric patient. Room temperature normal saline or saline and hydrogen peroxide is then injected slowly into the ear canal, away from the tympanic membrane, using a needless syringe or catheter. Solutions that are too hot or too cold may cause the patient discomfort, dizziness, or vertigo. Place a cotton ball in the ear and position the patient on the side toward the affected ear.

Medications administered via the ear must be labeled for otic use. After confirming the rights of medication administration, performing hand hygiene, and donning gloves, instruct the patient to lie on the side opposite the affected ear. Then clean the external ear of any debris. Ensure the medication is at room temperature to prevent discomfort, dizziness, vertigo, and nausea. Straighten the patient’s ear canal by pulling the auricle up and back for an adult patient and down and back for a pediatric patient. Gently squeeze the medication toward the side of the auditory canal and away from the tympanic membrane, ensuring the tip of the medication bottle remains sterile. Massage the tragus and instruct the patient to continue lying on their side for five minutes. Remove and dispose of the gloves and perform hand hygiene when finished.

14.3 Administering Nasal Medications

Nasal medications are absorbed into the systemic system faster than oral medications. Nasally administered medication may be used to treat a variety of conditions, such as allergies, sinus infections, and nasal congestion. Nasal medications come prepared as powders or liquids inside a spray device, or as a nasal wash. Powders and sprays are delivered as one dose per spray in the nostril. Nasal washes are used to irrigate mucus, irritants, allergens, bacteria, and viruses from the nose. While leaning over the sink, a saline solution with distilled or sterilized water is squirted into one nostril, passes through the sinus cavity, and exits the other nostril. Devices used for nasal administration should be kept clean and used on a single patient.

Nasal medications may also be inhaled into the respiratory system. Categories of nasal inhalation medications include antihistamines, steroids, decongestants, mast cell inhibitors, anticholinergics, and opioid antagonists. These medications may be used to treat allergy symptoms, treat opioid overdose, and reverse respiratory depression.

Medications administered via the nasal route are administered using clean technique. After confirming the rights of medication administration and performing hand hygiene, instruct the patient to blow their nose. Position the patient so they are either sitting with the head tilted backward or lying supine looking up. Insert the tip of the spray bottle in one nostril, occlude the other nostril, and press down on the spray applicator while the patient inhales. The patient should be instructed to hold their breath for a few seconds and to avoid blowing their nose for five to ten minutes after administration.

14.4 Administering Inhaled Medications

Inhaled medications can be administered to treat respiratory illness, reduce inflammation, and open the lungs. Inhaled medications are absorbed by the lungs and have a quicker onset than oral medications. Medications administered by inhalation may be administered by nebulizers or hand atomizers.

Nebulizers are electric or battery-powered machines that use oxygen or compressed air to mist medication into the lungs via a face mask or mouthpiece. Nebulizers are beneficial for administering multiple medications at once and do not require coordinated breaths; however, they are not easy to transport, require a power source, and take ten to fifteen minutes to administer the medications. Bronchodilators and antibiotics may be administered via nebulizer; however, steroids cannot.

Hand atomizers are handheld devices that do not require a power source for administration. There are three main types of hand atomizers: metered-dose inhalers, dry powdered inhalers, and soft-mist inhalers. Inhalers should be cleaned frequently to prevent bacterial growth.

Metered-dose inhalers (MDI) contain a canister attached to a mouthpiece that is used to create an aerosolized mist of medication. Medication waste is common with MDIs because mist particles stick to the tongue or aerosolize in the air.

Dry powder inhalers (DPI) use an inward breath to move the powdered medication into the lungs. DPIs require a harder breath; however, they are easy to use and do not require coordinated breathing efforts.

Soft-mist inhalers are handheld devices that turn liquid medications into a mist cloud that can then be inhaled without a propellant. This type of inhaler does not require coordinated breathing efforts or a spacer.

There are four categories of inhaled medications: bronchodilators, steroids, antibiotics, and dornase alfa. Bronchodilators relax the muscles in the lungs and widen the airways. Bronchodilators may be short-acting or long-acting and are used to treat long-term conditions, such as asthma and COPD. Steroids reduce inflammation and prevent flare-ups of respiratory conditions. Antibiotics may be warranted to deliver antibiotics directly into the respiratory tract for patients with chronic respiratory diseases, such as cystic fibrosis (CF), non-CF bronchiectasis, and ventilator-associated pneumonia. Dornase alfa is used to thin the mucus in the airways for patients with CF. When administering more than one category of inhaled medications, administer the medications in the following order: bronchodilators, dornase alfa, antibiotics, and steroids.

14.5 Administering Other Medications

Hormone therapies, antifungal treatments, and contraception may be ordered via the vaginal route. Vaginal medications come prepared in a variety of forms, such as creams, foams, suppositories, and tablets. The medication is either squeezed into an applicator (i.e., creams, foams) or placed at the end of the applicator (i.e., suppositories, tablets) and inserted into the vagina. Prior to administering medications via the vaginal route, instruct the patient to void. Position the patient on their back with their knees flexed, and perform perineal care. Prepare the medication and lubricate the applicator with a water-based lubricant. Insert the applicator into the full length of the vagina and push the plunger to release the medication. Instruct the patient to remain lying down for at least five to ten minutes to prevent the medication from leaking out.

Medications ordered via the rectal route may be indicated for constipation, analgesia, nausea and vomiting, or certain bowel conditions. Rectal medications are contraindicated with rectal bleeding; diarrhea; rectal prolapse; low platelet count; or after rectal, bowel, or prostate surgery because of the risk of perforation. Rectal medications are prepared as suppositories and liquid enemas. Instruct the patient to defecate, if possible, before administering rectal medications. Position the patient on their left side with their upper leg flexed over their lower leg toward their waist. Lubricate the suppository or enema with a water-based lubricant, instruct the patient to take slow deep breaths in and out to help relax the anal sphincter, and insert the medication into the rectum approximately 2 in (5 cm) beyond the anal sphincter. When administering an enema, expel the air before insertion and roll the bottle until all contents have been instilled.

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