2.3 Drug Administration Routes, Preparation, and Administration

Steps to administering an oral medication:

1. Assemble the appropriate equipment:
   • Drinking cup
   • Straw
   • Disposable medication cup (souffle cup or calibrated plastic medication cup for liquids)
2. Assess the client to determine if the drug is safe and appropriate to give.
3. Check the medication, dose, and expiration date.
4. Check NPO status and ensure the client does not have nausea or vomiting. (NPO is a Latin term meaning nil per os, or nothing by mouth. Sometimes this will include medications.)
5. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
   • During verification of the contents of the medication administration record and the orders
   • When preparing the medication
   • At the bedside
6. Wait to open blister packs or oral unit doses until at the client’s bedside.
7. Perform hand hygiene.
8. Don gloves if you anticipate touching the pill or the client’s mouth during administration.
9. Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the blister pack using the protocol recommended by the institution.)
   • Perform the third medication check at the bedside. This check is completed by verifying that the medication name, dosage, route, and time match the medication administration record (this is the last opportunity to prevent an error from occurring). Most institutions now have barcode scanning at the bedside as an additional layer of security.
10. Explain the medication to the client:
    • Name (brand and generic)
    • Dosage
    • Indication, rationale, or reason for the drug to be given
    • Frequency
    • Route
    • Adverse effects
11. Position the client in an upright position or on side as condition allows.
12. Assess the client’s ability to swallow and the gag reflex by offering a sip of water.
13. Ask the client if they prefer all medications at once or one or two at a time.
14. Give the client the medication with a cup of water (approximately 8 ounces unless the client is on a fluid restriction).
15. Document administration within the medication administration record (MAR).
16. Perform hand hygiene.
17. Evaluate the client’s response to the drug(s) within the appropriate time frame.

Nursing Implications for Oral Medications

The nurse should do the following for clients who are taking oral medications:

• If a tablet needs to be split, split only tablets that are scored. If a client has difficulty swallowing a tablet or capsule, consult a pharmacist for advice about the technique of administration because some capsules may be opened and emptied into a food or liquid. Timed-release capsules or tablets should not be crushed or chewed because this may affect the rate of absorption and toxicity may occur. For this reason, timed-release capsules should not be opened and emptied into food for ease of swallowing.
• Use a hospital-approved device to split the tablet. (Some health systems split the tablets in the pharmacy and send them to the unit in unit-dosed packaging for safety purposes.)
• Discard any unused portion according to institutional policy.
  • If the drug is a controlled substance, document the waste with another nurse in the medication room.
• If a tablet needs to be crushed:
  • Ensure that it can be crushed.
  • Never crush sustained-release, extended-release, or enteric-coated tablets.
  • If crushing more than one tablet, keep them separate; do not combine them.
• When filling a calibrated plastic cup with liquids, fill at eye level.
• Always remain with the client until all medications are taken; do not leave drugs at the bedside unattended.

Steps to administering a sublingual or buccal medication:

1. Assemble the appropriate equipment:
   • Disposable medication cup (souffle cup)
   • Drinking cup
   • Straw
2. Assess the client to determine if the drug is safe and appropriate to give.
3. Check the medication, dose, and expiration date.
4. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
   • During medication reconciliation
   • When preparing the medication
   • At the bedside
5. Perform hand hygiene.
6. Don gloves if you anticipate touching the pill or the client’s mouth during administration.
7. Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the blister pack, using the protocol recommended by the institution.)
8. Perform the third medication check at the bedside.
9. Explain the medication to the client:
   • Name (brand and generic)
   • Dosage
   • Indication, rationale, or reason for the drug to be given
   • Frequency
   • Route
   • Adverse effects
10. Offer sips of water to moisten the oral cavity.
11. Assist the client in placing the medication sublingually (or between the cheek and gum for buccal drugs).
12. Instruct the client to allow the medication to dissolve completely. Discuss the importance of not swallowing or chewing the pill.
13. Educate the client about the importance of abstaining from food, drinking, or smoking until after the medication has dissolved.
14. Document administration within the MAR.
15. Perform hand hygiene.
16. Evaluate the client’s response to the drug(s) within the appropriate time frame.

Nursing Implications for Sublingual or Buccal Medications

The nurse should do the following for clients who are taking sublingual or buccal medications:

• Always remain with the client until all medications are taken; do not leave drugs at the bedside unattended unless the provider has ordered the medication to be left at the bedside.
  • Exception: Sublingual nitroglycerin tablets or sprays are often ordered to be left at the bedside so that a client may take them as needed in the event of chest pain.

Steps to administering a nasal spray:

1. Assemble the appropriate equipment:
   • Clean gloves
   • Tissue
   • Medication
2. Assess the client to determine if the drug is safe and appropriate to give.
3. Check medication, dose, and expiration date.
4. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
   • During medication reconciliation
   • When preparing the medication
   • At the bedside
5. Educate the client.
   • Explain the method for administering the medication. (This route may be self-administered in the future; however, the nurse should observe this in order to provide appropriate documentation in the MAR.)
   • Inform the client that they may experience a burning or stinging sensation with administration.
6. Instruct the client to gently blow their nose (unless it is contraindicated for the client).
7. Assess the nostrils for erythema, edema, drainage, or tenderness.
8. Client should be upright in a sitting position with their head tilted back.
9. Block one nostril.
10. Hold the medication bottle upright and shake.
11. Immediately insert the tip of the applicator into the nostril.
12. Ask the client to inhale while simultaneously squeezing a spray into the nostril.
13. Once the bottle has been squeezed to deliver the medication, do not release the squeeze until the spray bottle has been removed from the nares. Ensure that the nozzle of the nasal spray does not touch the nasal turbinates or septum because pain or injury could occur.
14. Repeat the process in the other nostril if indicated.
15. Have tissue available if needed to blot the nostril. The client should avoid blowing their nose immediately.
16. Wipe the spray applicator with a clean, dry cloth or tissue.
17. Remove gloves and perform hand hygiene.
18. Document administration within the MAR.
19. Evaluate the client’s response to the drug(s) within the appropriate time frame.

Be aware that some nasal medications may vary from this procedure; it is important to consult the product labeling to confirm the appropriate administration technique.

Nursing Implications for Nasal Sprays

The nurse should do the following for clients who are taking nasal sprays:

• Do not readminister the drug if the client sneezes following the administration of the nasal spray because there is no way to assess how much of the drug has been absorbed.

Steps to withdrawing medication from a vial:

1. Perform hand hygiene and don clean gloves (not sterile).
2. Inspect and verify the medication, dose, volume, and expiration date.
3. Verify the dosage calculation.
4. Remove the plastic cap from the top of the unused vial with a flick of the thumb.
5. Wipe the rubber stopper or port with an alcohol swab and allow it to air dry for approximately 10 seconds.
   • The cap does not keep the top of the port sterile. Dust and microbial contaminants can collect under the cap, so it is important to cleanse with alcohol.
6. Insulin and tuberculin syringes have preattached needles. If drawing up insulin, insulin syringes have preattached needles with orange caps (see Figure 2.6). Insulin syringes are marked in unit measures rather than in milliliters (mL). The needles on these syringes are fragile and bend very easily, so it is important to be careful when inserting and withdrawing the needles from the vial.
7. When drawing up medications into syringes that are not insulin or tuberculin syringes:
   1. Attach a blunt-tipped needle to the syringe of choice. The syringe choice should be large enough to hold the dose of medication, but the smallest syringe closest to that measurement (i.e., if administering 4 mL, draw it up in a 5 mL syringe rather than a 10 mL, 20 mL, etc.).
   2. Remove the needle cap and draw air into the empty syringe to the volume of medication to be given (e.g., if giving 2 mL of medication, then draw up 2 mL of air).
   3. Insert the air into the vial of medication through the center of the rubber port at the top of the vial.
      • Ensuring that the tip of the needle is above the fluid level of the vial will help avoid the presence of bubbles. (It prevents agitation of the drug.)
      • Be sure to maintain the sterility of the needle.
      • Do not touch the needle.
      • Be careful not to bend the needle.
   4. Inject the air into the vial.
   5. Invert the vial and hold it at eye level to slowly withdraw the desired volume of medication.
      • If the medication is withdrawn too quickly, air bubbles may enter the syringe.
      • Important tip: Ensure that the tip of the needle is below the fluid level in the vial so that no air is drawn into the syringe.
      • Withdraw slightly more of the medication than needed.
      • Express any air bubbles and the excess medication back into the vial until the desired amount of medication is in the syringe.
      • Withdraw the needle from the vial, being careful not to bend the needle.
      • Exchange the blunt needle for a regular needle prior to administration.

Figure 2.6 An insulin syringe has a pre-attached needle and an orange cap. (credit: modification of work “Standard insulin syringe” by Matanya/Wikimedia Commons, Public Domain)

Steps to withdrawing medication from an ampule:

1. Wash hands and don clean gloves.
2. Medication may be seen in both the bottom and top portion of the ampule (see Figure 2.7). Thump or flick the top of the ampule to bring the medication to the bottom portion of the ampule.

Figure 2.7 An example of what an ampule looks like; note the top and bottom portion. (credit: “Group of modern plastic ampules on blue background” by Marco Verch/Flickr, CC BY 2.0)

3. Place an unopened alcohol swab packet or gauze pad between the thumb and fingers and wrap around the neck of the glass ampule. Snap the neck quickly and firmly away from you (and anyone around you).
4. Dispose of the top of the ampule in a sharps container.
5. Attach a blunt filter needle to the appropriate syringe.
6. Remove the cap of the filter needle and insert the needle into the center of the opened ampule, being careful to avoid touching the rim of the ampule with the needle.
7. Do not inject air into the ampule.
8. Gently pull back on the plunger to draw the medication into the syringe, keeping the needle tip in the fluid. The ampule can be tipped to the side to aid in the process of drawing the medication into the syringe.
9. If bubbles are aspirated into the syringe, do not expel the bubbles back into the ampule. Simply remove all of the fluid, withdraw the needle, and hold the syringe in a vertical position (at a 90-degree angle). Tap the side of the syringe to move the air bubbles to the top of the syringe and expel the excess air without wasting the medication.
10. Scoop the needle cap onto the needle, twist and remove the filter needle from the syringe, and dispose of the filter needle in a sharps container.
11. If the volume in the syringe is greater than needed, discard according to institutional policy.
12. Place a sterile tip or the appropriate needle for parenteral administration onto the syringe.
13. Do not administer the medication using the filter needle used to draw up the medication.
14. Proceed with labeling and administering the medication according to the administration technique needed.

Steps to administering a subcutaneous medication:

1. Assemble the appropriate equipment:
   • Medication
   • Sterile syringe (1–3 mL)
   • Small-gauge needles (3/8–5/8 inch) (tuberculin and insulin syringes have preattached needles)
   • Alcohol swabs
   • Gloves (clean gloves, not sterile)
2. Assess the client to determine if the drug is safe and appropriate to give.
3. Check the medication, dose, volume, and expiration date.
4. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
   • During medication reconciliation
   • When drawing up the medication
   • At the bedside
5. Perform hand hygiene.
6. Don gloves.
7. Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the vial or unit dose, using the protocol recommended by the institution.)
8. Perform the third medication check at the bedside.
9. Explain the medication to the client:
   • Name (brand and generic)
   • Dosage
   • Indication, rationale, or reason for the drug to be given
   • Frequency
   • Route
   • Adverse effects
10. Prepare medication using the correct needle length (3/8–5/8 inches), gauge (25–29 gauge), and syringe (usually no more than 1.5 mL can be given via this route). For clients with little adipose tissue, use the smaller needle.
11. Select an injection site with an adequate fat pad.
    • Avoid bruises, rashes, inflammation, or areas of injury.
    • Ensure that the injection site is a minimum of 2 inches away from the umbilicus, a stoma, or an incision.
    • Preferred sites include the abdomen, upper arms, and anterior thighs.
12. Assist the client into a position in which the site or extremity can be relaxed.
13. Cleanse the area with an alcohol swab using a circular motion by starting at the center and working outward in a widening circle to about 2–3 inches. Allow to air dry.
14. Grasp the skinfold between your thumb and index or third finger of the nondominant hand. (A new alcohol swab or gauze can be placed between the fourth and fifth fingers of this hand to use after injection.)
15. Remove the needle cap carefully and dispose.
16. Instruct the client that they will feel a “pinch.”
17. Quickly and smoothly insert the needle into the skin and adipose tissue at a 45- to 90-degree angle. The anticoagulant enoxaparin is a subcutaneous injection that should be given at a 90-degree angle.
18. Inject the medication with the dominant hand depressing the plunger with slow and even pressure, while holding the barrel of the syringe steady with the nondominant hand.
19. Do not aspirate for subcutaneous injections.
20. Withdraw the needle smoothly at the same angle that it was inserted to prevent trauma at the injection site.
21. Apply gentle pressure with the alcohol swab, but do not massage the site, especially if the medication given was an anticoagulant such as heparin or enoxaparin, because this may cause extensive bruising.
22. Activate the safety device on the syringe and dispose of the syringe in the sharps container or a puncture-resistant needle disposal container according to institutional policy. Never throw it into the trash.
23. Do not recap the needle! This is a safety hazard for the nurse. Recapping needles may lead to needle sticks and exposure to pathogens.
24. Remove gloves and perform hand hygiene.
25. Document in the MAR. When documenting a subcutaneous injection, be sure to document the site the medication was administered to allow for the rotation of sites.
26. Evaluate the client’s response to the drug(s) within the appropriate time frame.

Nursing Implications for Subcutaneous Administration

The nurse should do the following for clients receiving a subcutaneous injection:

• For heparins and insulins: Both are high-alert medications. A second nurse will need to verify the dose. Do not draw up the dose until a witness is available to verify.
• Never draw heparin up into an insulin syringe. (Fortunately, many heparins come in prefilled syringes for safety reasons.)
  • Insulin, and only insulin, should be drawn up into an insulin syringe. Never draw up insulin into a regular syringe with milliliter (mL) markings because this will cause an overdose of insulin.
• Administer subcutaneous injections at a 45- to 90-degree angle depending upon the body habitus of the individual. For extremely thin individuals and children, ensure that the angle is shallow enough that the medication is not given intramuscularly

Steps to administering an intramuscular medication:

1. Assemble the appropriate equipment:
   • Medication
   • Syringe (3 mL)
   • Needles (unless preattached)
   • Alcohol swabs
   • Gloves (clean gloves, not sterile)
2. Assess the client to determine if the drug is safe and appropriate to give.
3. Check the medication, dose, volume, and expiration date.
4. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
   • During medication reconciliation
   • When drawing up the medication
   • At the bedside
5. Perform hand hygiene.
6. Don gloves.
7. Identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the vial or package, using the protocol recommended by the institution.)
8. Perform the third medication check at the bedside.
9. Explain the medication to the client.
   • Name (brand and generic)
   • Dosage
   • Indication, rationale, or reason for the drug to be given
   • Frequency
   • Route
   • Adverse effects
10. Prepare medication using the correct needle length (1–1.5 inches), gauge (18–27 gauge), and syringe (no more than 3 mL can be given via the ventrogluteal route, and no more than 1 mL can be given in the deltoid). (See Figure 2.9.)
11. Select an injection site.
    • Avoid areas of hardness, bruising, rashes, inflammation, injury, or infection.
    • Assess muscle size and integrity.
12. Assist the client into a position in which the site or extremity can be relaxed.
13. Cleanse the area with an alcohol swab using a circular motion by starting at the center and working outward in a widening circle to about 2 inches. Allow to air dry for 10 seconds.
14. Remove the needle cap carefully.
15. Instruct the client that they will feel a “stick.”
16. Grasp the syringe like a dart with the dominant hand.
17. Quickly and smoothly insert the needle through the skin and adipose tissue to the muscular layer at a 90-degree angle.
18. Inject the medication with the dominant hand depressing the plunger with slow and even pressure, while holding the barrel of the syringe near the hub steady with the nondominant hand.
19. Withdraw the needle smoothly at the same angle that it was inserted.
20. Apply gentle pressure with the alcohol swab, but do not massage the site.
21. Activate the safety device on the syringe and dispose of the syringe in the sharps container or in a puncture-resistant needle disposal container according to institutional policy. Never throw it into the trash.
22. Do not recap the needle! This is a safety hazard for the nurse. Recapping needles may lead to needle sticks and exposure to pathogens.
23. Remove gloves and perform hand hygiene.
24. Document in the MAR. When documenting an IM injection, be sure to document the site the medication was administered to allow for the rotation of sites if other doses are necessary.
25. Evaluate the client’s response to the drug(s) within the appropriate time frame.

Figure 2.9 Needles come in a variety of gauges and lengths. The larger the number of the gauge, the smaller the needle. The number designating the length of the needle will be the actual length of the needle in inches. (credit: “Needles of various gauge and length” by Sean/Rx-wiki, CC BY 3.0)

Follow institutional policy about aspiration with IM injections. The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) no longer recommend the practice of aspiration for vaccinations because no large blood vessels lie close to the area of injection (CDC, 2023). It is thought that it may cause pain at the site if the syringe is not stable and may actually cause damage to the tissue. At this point in time, there is not enough evidence-based information to support or abort the process of aspiration. Most studies look at the potential discomfort felt with aspiration rather than the safety of intramuscular administration. If the institution recommends aspiration, follow these steps:

1. Quickly and smoothly insert the needle through the skin and adipose tissue into the muscular layer at a 90-degree angle.
2. With the dominant hand, pull back on the plunger to aspirate for blood return for 5 seconds. If blood enters the hub of the needle/syringe, stop. Pull the needle out and begin again using a new needle and a different site.
3. If no blood return is seen with aspiration, inject the medication with the dominant hand depressing the plunger with slow and even pressure, while holding the barrel of the syringe near the hub steady with the nondominant hand.
4. Continue, using the instructions above.

Z-Track Method

Some institutions require all IM injections to be given with the Z-track method. It is particularly helpful with medications that stain the skin or are irritating, such as iron preparations. The Z-track method is never wrong, but it isn’t always necessary. For this reason, know the institutional policy and proceed accordingly.

1. Use the nondominant hand to displace the skin tissue laterally approximately 1 inch.
2. Hold the tissue laterally and insert the needle.
3. Gently inject the medication into the muscle and wait 10 seconds.
4. Remove the needle and then release the skin and allow it to return to its normal position after withdrawing the needle.

Deltoid Injections

To give a deltoid injection, remove clothing to expose the upper arm and shoulder area. Discuss the preferred arm with the client. They may prefer the nondominant arm to be used due to potential soreness; however, many individuals prefer the dominant arm because the increased movement with that arm may work the soreness out earlier. The client may bend the elbow to assist with relaxation of the muscle. To determine landmarks, find the acromion process, which will be the base of an upside-down triangle. Locate the lateral midpoint on the arm in line with the axilla. The injection site will be located in the center of the triangle, approximately 1.5 inches below the acromion process. (See Figure 2.10.)

Figure 2.10 The deltoid injection site is located within the triangle shown here. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Ventrogluteal Injections

To give an injection at the ventrogluteal site, position the client on their side with the knees bent (upper leg slightly ahead of the lower leg). Use the left hand to find landmarks when injecting into the right ventrogluteal site, and use the right hand to find landmarks when injecting into the left ventrogluteal site. Locate the greater trochanter at the head of the femur and place the palm of the hand over the greater trochanter and the index finger on the anterosuperior iliac spine. Aim the middle finger and ring finger toward the iliac crest. Point the thumb toward the client’s groin with the fingers toward the client’s head. Spread the middle finger along the iliac crest toward the buttocks. The injection site is in the center of the triangle formed by the middle and index fingers. (See Figure 2.11.)

Figure 2.11 The proper placement for determining the injection site for a ventrogluteal IM injection. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Steps to administering an IVP medication:

1. Assemble the appropriate equipment:
   • Medication
   • Syringe with a needleless device
   • Needles
   • Normal saline flushes
   • Diluent, if needed
   • Alcohol swabs
   • Gloves
2. Assess the client to determine if the drug is safe and appropriate to give.
3. Check the medication, dose, volume, and expiration date.
4. Check the compatibility of the medication with the IV fluids that are hanging.
5. Double-check dosage calculations.
6. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
   • During medication reconciliation
   • When drawing up the medication
   • At the bedside
7. Perform hand hygiene.
8. Don gloves.
9. In the medication room (or possibly the client’s room in some institutions), use aseptic technique to draw the medication into the syringe as described in the previous section.
   1. Use a syringe size closest to the amount of the drug needed (e.g., a 3 mL syringe to draw up 1–3 mL or a 5 mL syringe to draw up 4–5 mL).
   2. Double-check the rate of administration.
   3. Label the medication syringe with the client’s name, date of birth, medication name, dosage and volume, time, and initials. (This may vary slightly between institutions.)
10. Once in the client’s room, identify the client, and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the vial or package, using the protocol recommended by the institution.)
11. Perform the third medication check at the bedside.
12. Explain the medication to the client:
    • Name (brand and generic)
    • Dosage
    • Indication, rationale, or reason for the drug to be given
    • Frequency
    • Route
    • Adverse effects
13. Assess the IV site. Check for redness, swelling, or tenderness. Assess local skin temperature for warmth.
14. Unclamp the saline lock and expel air bubbles from a saline flush. Then remove the disinfecting cap from the port.
15. Scrub the hub of the port and the threads with an alcohol swab or the institution’s preferred cleanser for 15 seconds.
16. Remove the tip from the flush (see Figure 2.12) and insert the saline flush by twisting and pushing to the right. Once the flush is engaged with the saline lock, gently aspirate for blood return to assess for patency of IV.

Figure 2.12 A syringe is attached to a saline lock by twisting and pushing to the right. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

17. Using gentle force, attempt to flush the IV with 2–3 mL of saline to assess for IV patency. If resistance is felt, do not force! Stop flushing immediately because the catheter may be occluded. The saline lock may need to be restarted.
18. If the catheter flushes easily, disconnect the flush from the saline lock, keeping the hub of the saline lock sterile. Keep the tip of the used saline flush sterile while attaching the syringe of medication to the saline lock. If the hub is dropped and no longer sterile, wipe the hub thoroughly for 15 seconds before attaching the syringe with the drug in it.
19. Administer the medication in a smooth, continuous manner through the saline lock at the recommended rate of administration for that particular drug until the appropriate dose is given.
20. Remember that IV medications have 100% bioavailability and an immediate onset of action. It is important to assess for adverse reactions during and after administration.
21. Disconnect the syringe and reconnect the saline flush. (Ensure that the tip is still uncontaminated.) Infuse 2–3 mL of saline through the saline lock at the same rate of infusion that the drug was given (medication is still in the saline lock) to clear the remainder of the drug from the line.
22. Place a new disinfecting cap on the port per institutional policy.
23. Remove gloves and perform hand hygiene.
24. Document in the medication administration record.
25. Evaluate the client’s response to the drug(s) within the appropriate time frame.

Steps to administering a transdermal medication:

1. Assess the client to determine if the drug is safe and appropriate to give.
2. Check the medication, dose, volume, and expiration date.
3. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
   • During medication reconciliation
   • When preparing the medication
   • At the bedside
4. Wait to open the patch or disk until at the client’s bedside.
5. Perform hand hygiene.
6. Don clean gloves for the administration of any patch or ointment. Never apply a patch or ointment with the bare hand because the medication can be transferred to you in the process.
7. Identify the client and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the blister pack, tube, or package, using the protocol recommended by the institution.)
8. Perform the third medication check at the bedside.
9. Explain the medication to the client:
   • Name (brand and generic)
   • Dosage
   • Indication, rationale, or reason for the drug to be given
   • Frequency
   • Route
   • Adverse effects
10. Remove any old patches that remain on the skin.
    • Many patches are small, clear, transparent disks, so some are difficult to find.
    • Assess the skin for irritation at the site of the old patch.
11. Cleanse the skin with soap and water and allow it to dry before applying patches or ointments.
12. Ensure that the site of the new patch is free of irritation, scrapes, open sores, or bruises. It is best if it is located on an area with little to no hair.
13. Rotate sites each time a new patch is placed.
14. Label the patch prior to placing it on the client with the nurse’s initials, the date, and the time administered.
15. Perform hand hygiene.
16. Document in the MAR.
17. Evaluate the client’s response to the drug(s) within the appropriate time frame.

Nursing Implications for Transdermal Administration

The nurse should do the following for clients receiving a transdermal patch:

• Educate the client to administer the patch at the same time each day.
• Administer after a shower or bath.
• Always remain with the client until all medications are taken; do not leave drugs at the bedside unattended.
• Educate the client to develop a schedule for rotating the sites of application.
• Never cut a patch in half (unless allowed per the drug product’s labeling) because this may release all of the medication at once, resulting in an overdose. Patches are developed with special technology to release the medication slowly over a long period of time. Some patches may only need to be replaced once each week.
• Don gloves to remove a patch and dispose of according to institutional policy. Never dispose of a patch in the trash. Children have removed them from the trash thinking they were stickers, and this resulted in harm to the child. Pets also have eaten them.
• Educate the client that the patch’s effects may last for many hours following its removal (up to 72 hours).

Steps to administering nitroglycerin ointment (nitroglycerin paste):

1. Assemble the appropriate equipment:
   • Gloves
   • Nitroglycerin ointment and application paper
   • Paper tape
2. Assess the client to determine if the drug is safe and appropriate to give.
3. Check the medication, dose, volume, and expiration date.
4. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
   • During medication reconciliation
   • When measuring the medication
   • At the bedside
5. Perform hand hygiene.
6. It is important to don clean gloves for the administration of ointment. Never apply ointment with bare hands because the medication can be transferred to you in the process.
7. Identify the client and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the tube of ointment, using the protocol recommended by the institution.)
8. Perform the third medication check at the bedside.
9. Explain the medication to the client:
   • Name (brand and generic)
   • Dosage
   • Indication, rationale, or reason for the drug to be given
   • Frequency
   • Route
   • Adverse effects
10. Remove any old nitroglycerin doses that remain on the skin.
    • Assess the skin for irritation at the site of the old nitroglycerin applicator paper.
11. Cleanse the skin with soap and water and allow it to dry before applying the ointment.
12. Ensure that the site of the new dose is free of irritation, open sores, scrapes, or bruises. It is best if it is located on an area with little to no hair.
13. Rotate sites each time ointment is applied.
14. To administer the drug, lay the applicator paper down on the counter with the print side facing down.
15. Measure the amount of ointment to be used on the applicator paper, which is marked in a 2-inch strip with marks every half inch. The ointment is in a tube similar to that of toothpaste and should be gently squeezed so that a strip of ointment is placed on the applicator paper in the appropriate measurement. For example, the provider may order “nitroglycerin ointment 1 inch every 6 hours.” So, a one-inch ribbon of ointment would then be placed on the paper (see Figure 2.13).

Figure 2.13 Nitroglycerin ointment is drawn up for administration on applicator paper. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

16. Apply the applicator paper with the ointment side closest to the skin.
17. Tape in place using nonallergenic tape. Plastic wrap may be taped over the applicator paper to protect clothes.
18. Label the applicator paper if this was not done prior to placing it on the client with the nurse’s initials, the date, and the time administered.
19. Remove gloves and perform hand hygiene.
20. Document in the medication administration record.
21. Evaluate the client’s response to the drug(s) within the appropriate time frame.

Nursing Implications for Cutaneous Application

The nurse should do the following for clients who are taking a cutaneous medication:

• Administer after a shower or bath.
• Educate the client to develop a schedule for rotating the sites of the application.
• Do not rub the ointment into the skin.
• For nitroglycerin ointment: Allow a nitro-free time period every 24 hours (this is usually done at night). Some providers will order “nitroglycerin ointment 1 inch every 6 hours. Take off at 10 p.m. Reapply at 6 a.m.”
• As with transdermal patches, it is important to dispose of old ointment in a container safe from children or pets. A large dose of the medication will remain in the ointment, which may be toxic to children or pets.

Steps to administering vaginal medications:

1. Assemble the appropriate equipment
   • Clean gloves
   • Water-soluble lubricant for vaginal suppositories
   • Vaginal applicator
   • Perineal pad
   • Medication
2. Assess the client to determine if the drug is safe and appropriate to give.
3. Check the medication, dose, and expiration date.
4. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
   • During medication reconciliation
   • When preparing the medication
   • At the bedside
5. Perform hand hygiene.
6. Don clean gloves for the administration of vaginal suppositories.
7. Request that the client void prior to inserting the medication.
8. Identify the client and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the blister pack, container, tube, or package, using the protocol recommended by the institution.)
9. Perform the third medication check at the bedside.
10. Explain the medication to the client:
    • Name (brand and generic)
    • Dosage
    • Indication, rationale, or reason for the drug to be given
    • Frequency
    • Route
    • Adverse effects
11. Provide privacy and drape the client with a sheet.
12. Position the client supine, hips elevated, knees bent, with the feet flat on the bed near the hips.
13. Provide perineal care as necessary.
14. Fill the applicator with the prescribed medication.
15. Lubricate with water-soluble lubricant.
16. Spread the labia, using the nondominant hand, and expose the vagina. Gently insert the applicator into the vagina approximately 2 inches using the dominant hand.
17. Push the plunger to deposit the medication into the vagina.
18. Remove the applicator and wrap it in a paper towel for cleaning later or disposal.
19. For suppositories, remove the wrapping and lubricate the room-temperature suppository with water-soluble jelly. Use an applicator if available; otherwise, use a finger on the dominant hand to insert the suppository about 3–4 inches into the vagina along its posterior wall. For creams or foams, insert 2–3 inches.
20. Client should remain in position for 10 minutes.
21. Apply a perineal pad if the client wishes.
22. Wash the applicator after each use.
23. Remove gloves.
24. Perform hand hygiene.
25. Document in the medication administration record.
26. Evaluate the client’s response to the drug(s) within the appropriate time frame.

Nursing Implications for Vaginal Applications

The nurse should do the following for clients who are taking vaginal medications:

• Administer at bedtime, when possible, to allow the medication to remain in place for as long as possible.
• Assess for vaginal discharge and any other symptoms.
• Be clear in your teaching of the process because vaginal medications may be administered by the client.
• Educate the client to refrain from using douches and abstain from sexual intercourse after inserting medication.

Steps to administering rectal suppositories:

1. Assemble the appropriate equipment:
   • Gloves
   • Water-soluble lubricant
   • Medication
   • Bedpan, if client is on bed rest
2. Assess the client to determine if the drug is safe and appropriate to give. Assess for rectal bleeding or diarrhea.
3. Check the medication, dose, volume, and expiration date.
4. Follow the seven rights of medication administration throughout the procedure (at least three times or according to institutional policy).
   • During medication reconciliation
   • When preparing the medication
   • At the bedside
5. Perform hand hygiene.
6. Don clean gloves for the administration of rectal suppositories. Never apply with a bare hand.
7. Identify the client and verify allergies and reaction. (If the institution uses barcode scanning, scan the client’s ID band and the barcode on the package using the protocol recommended by the institution.)
8. Perform the third medication check at the bedside.
9. Explain the medication to the client:
   • Name (brand and generic)
   • Dosage
   • Indication, rationale, or reason for the drug to be given
   • Frequency
   • Route
   • Adverse effects
10. Position the client on their left side with the uppermost leg flexed toward the waist. (This position is called the Sim’s position or left lateral position.)
11. Provide privacy. Drape the client with a sheet.
12. Remove the foil or plastic wrapping from the medication (see Figure 2.14).

Figure 2.14 Suppositories, like the ones shown here, need to be removed from the wrapping before inserting in the client’s rectum. (credit: “Suppositories in blister and one without packaging on white background” by Marco Verch/Flickr, CC BY 2.0)

13. Lubricate the suppository with the water-soluble gel. Consider lubricating your gloved finger to support the client’s comfort during this process. Never use petroleum-based products for lubrication because this may affect the absorption of the medication.
14. The suppository is usually shaped similarly to a bullet. Insert the rounded end into the rectum while instructing the client to take a deep breath and then exhale.
15. Insert the suppository along the side of the rectal wall, at least 1 inch beyond the internal rectal sphincter.
16. Instruct the client to remain on their left side for approximately 20 minutes to allow the suppository to be absorbed. If the medication is being given to stimulate defecation, it may take 20–30 minutes for that to occur. If the medication is given for other reasons, such as fever or nausea, it may take as long as an hour. Check the pharmaceutical information for specifics.
17. Remove gloves and perform hand hygiene.
18. Document in the medication administration record.
19. Evaluate the client’s response to the drug(s) within the appropriate time frame.

Nursing Implications for Rectal Administration

The nurse should do the following for clients who are taking drugs rectally:

• Do not insert a rectal suppository into stool. Palpate the rectal wall for the presence of feces.
• Have the client defecate prior to inserting the suppository, if possible.
• Never divide suppositories.
• Loss of sphincter control may be seen in older clients. Have a bedpan handy.
• Suppositories may be administered by the client. Be clear in your teaching of the process.
• It is important to educate clients who are self-administering suppositories that these drugs are to be given rectally, not orally.