8. Percutaneous Administration



Percutaneous Administration


Objectives



Key Terms


creams (image) (p. 105)


lotions (image) (p. 105)


aqueous (ey-kwee-uhs) (p. 105)


ointments (image) (p. 105)


dressings (image) (p. 105)


seven RIGHTS (p. 106)


image http://evolve.elsevier.com/Clayton


The routes of drug administration can be classified into three categories: enteral, parenteral, and percutaneous. The term percutaneous administration refers to the application of medications to the skin or mucous membranes for absorption. The absorption of topical medications can be influenced by the drug’s concentration, how long the medication is in contact with the skin, the size of the affected area, the thickness of the skin, the hydration of the tissues, and the degree of skin disruption. Methods of percutaneous administration include the following: the topical application of ointments, creams, powders, or lotions to the skin; the instillation of solutions onto the mucous membranes of the mouth, eye, ear, nose, or vagina; and the inhalation of aerosolized liquids or gases for absorption through the lungs. The primary advantage of the percutaneous route is that the action of the drug, in general, is localized to the site of application, which reduces the incidence of systemic side effects. Unfortunately, the medications are sometimes messy and difficult to apply. In addition, they usually have a short duration of action and thus require more frequent reapplication.


Administration of Topical Medications to the Skin


Dose Forms


Creams

Creams are semisolid emulsions that contain medicinal agents for external application. The cream base is generally nongreasy, and it can be removed with water. Many over-the-counter creams are used as moisturizing agents.


Lotions

Lotions are aqueous (water-based) preparations that contain suspended materials. Lotions are commonly used as soothing agents to protect the skin and to relieve rashes and itching. Some lotions have a cleansing action, whereas others have an astringent or drawing effect. To prevent increased circulation and itching, lotions should be gently but firmly patted on the skin rather than rubbed into the skin. Shake all lotions thoroughly immediately before application, and use them sparingly to avoid waste.


Ointments

Ointments are semisolid preparations of medicinal substances in an oily base, such as lanolin or petrolatum. This type of preparation can be applied directly to the skin or mucous membrane, and it generally cannot be removed easily with water. The base helps to keep the medicinal substance in prolonged contact with the skin.


Dressings


There are several types of dressings used to treat wounds, such as dry gauze sponges, nonadherent gauze dressings (e.g., Telfa), self-adhesive transparent films that act as a second skin (e.g., OpSite), and hydrocolloid dressings (e.g., DuoDERM). Hydrogel dressings are used on partial-thickness and full-thickness wounds and on skin that has been damaged by burns. There are also exudate absorbers such as calcium alginate dressings (e.g., AlgiDERM, Kaltostat, Sorbsan) manufactured from seaweed that can be used on infected wounds.


Wound care products and wound care have become a complex science. (Refer to fundamentals of nursing, medical-surgical nursing, and geriatric nursing textbooks for discussions of the principles of wound care.) Dressing recommendations for treating pressure ulcers are available from the Agency for Health Care Research and Quality, the Public Health Service, and the U.S. Department of Health and Human Services.



image Clinical Goldmine


It is recognized that a major principle of wound healing is the need for a moist environment to propagate the epithelialization of the wound, which is further promoted by a diet that is high in protein, vitamin A, vitamin C, and zinc.


Procedure Protocol


The term procedure protocol will be used as part of the medication administration technique for this text. This term includes the following nursing interventions:



In addition, a nurse should perform a premedication assessment before applying any topical preparation. See individual drug monographs for more information.


Administration of Creams, Lotions, and Ointments


Topical preparations can be used to do the following:



Equipment



Sites


Skin surfaces affected by the disorder being treated.


Techniques



1 Follow the procedure protocol described previously.


2 Position the patient so that the surface where the topical materials are to be applied is exposed. Assess the current status of the patient’s symptoms. Provide for patient comfort before starting therapy.


3 Cleansing: Follow the specific orders of the health care provider or clinical site policies for cleansing the site of application. After the area is exposed and cleansed, perform a wound assessment.


4 Application: Wear gloves during the application process. Many of the agents used may be absorbed through the skin of both the patient and the person who is applying the medication.


• Lotions: Shake well until a uniform appearance of the suspension is obtained.


• Ointments or creams: Use a tongue blade to remove the desired amount from a wide-mouthed container. Alternatively, squeeze the amount needed onto a tongue blade or cotton-tipped applicator from a tube-type container. Apply lotion firmly but gently by dabbing the surface. Apply ointments and creams with a gloved hand using firm but gentle strokes. Creams are to be gently rubbed into the area.


5 Dressings: Check specific orders regarding the type of dressing to be used. If a dressing is to be applied, spread the prescribed amount of ointment directly onto the dressing material with a tongue blade; the impregnated dressing material can then be applied to the affected skin surface. Secure the dressing in place.


6 Wet dressings: Always completely remove the previous dressing. Wring out wet dressings to prevent dripping, and apply the gauze in a single layer directly to the wound surface. For deeper wounds, pack the wound loosely with moist gauze sponges so that all surfaces are in contact with the moisture. Apply a layer of dry gauze sponges and an absorbent pad to the area. To secure a dressing that requires repeated changes, apply a binder, or use Montgomery’s tapes.


7 Clean the area and the equipment used, and make sure that the patient is comfortable after the application procedure. (NOTE: Sterile supplies, gloves, and equipment are used for some wounds; however, clean rather than sterile items [e.g., gauze, gloves] may be used when applying most types of dressings [e.g., to a pressure ulcer]. Always check institutional policies and use clinical judgment.)


8 Perform hand hygiene.


Patient Teaching



Documentation


Provide the RIGHT DOCUMENTATION of the medication administered and the patient’s response to drug therapy.



1 Chart the date, time, drug name, dosage, and route of administration.


2 Perform and record regular patient assessments for the evaluation of the treatment’s therapeutic effectiveness (e.g., change in size of affected area, reduced drainage, decreased itching, lowered temperature with an infection).


3 On the patient’s record, document any signs and symptoms of adverse drug effects, and provide a narrative description of the area being treated.


4 Develop a written record for the patient to use when charting progress for the evaluation of the effectiveness of the treatments being used. List the patient’s symptoms (e.g., rash on the lower leg with redness and vesicles present, decubitus ulcer on the sacrum). List the data to be collected regarding the medication prescribed and its effectiveness (e.g., vesicles now crusted, weeping, or appear to be drying; redness in lower leg is lessening; measure the area of decubitus in cm and indicate if the wound is extending, remaining the same, or shrinking).


5 Perform and validate essential patient education regarding the drug therapy and other important aspects of intervention for the disease process that is affecting the patient.


Patch Testing For Allergens


Objectives



Key Terms



Patch testing is a method that is used to identify a patient’s sensitivity to contact materials (e.g., soaps, pollens, dyes). The suspected allergens (antigens) are placed in direct contact with the skin surface and covered with nonsensitizing, nonabsorbent tape. Unless pronounced irritation appears, the patch is usually left in place for 48 hours and then removed. The site is left open to air for 15 minutes and then “read.” A positive reaction is noted by the presence of redness and swelling, called a wheal, which indicates an allergy to the specific allergen. It may be necessary to read the areas after 3 days and again after 7 days to detect delayed reactions.


Intradermal tests may also be used to determine allergenicity to specific antigens. See Chapter 11 for more information about the intradermal administration of allergens.


Perform premedication assessments. See individual drug monographs.


Equipment



Sites


The back, arms, or thighs are commonly used. (DO NOT use the face or areas that are susceptible to friction from clothing.) Selected areas are spaced 2 to 3 inches apart. The type of allergen applied and the site of application are documented on the patient’s chart (Figure 8-1). Hair is clipped from sites to ensure that the allergen is kept in close contact with the skin surface, thereby preventing a false-negative reaction.



Technique


CAUTION: DO NOT begin any type of allergy testing unless emergency equipment is available in the immediate area in case of an anaphylactic response. Personnel should be familiar with the procedure to follow if an emergency does arise.



1 Check with the patient before starting the testing to ensure that no antihistamines or anti-inflammatory agents (e.g., aspirin, ibuprofen, diphenhydramine, corticosteroids) have been taken for 24 to 48 hours before the test. If the patient has taken an antihistamine or an anti-inflammatory agent, consult the health care provider before proceeding with the testing. Review the chart to ensure that the patient is not in an immunocompromised state as a result of disease or treatments such as chemotherapy or radiation therapy.


2 Follow the procedure protocol described on p. 106.


3 Position the patient so that the surface on which the test materials are to be applied is horizontal. Provide for patient’s comfort before beginning the testing.


4 Cleanse the selected area thoroughly with the use of an alcohol wipe. Use circular motions starting at the planned site of application and continuing outward to the periphery. Allow the area to air-dry.


5 Prepare the designated solutions with the use of aseptic technique.


6 Follow the specific directions of the employing health care agency regarding the application of liquid and solid forms of suspected allergens. A dropper is usually used to apply suspected liquid contact-type materials; solid materials are applied directly to the skin surface and then moistened with mineral or olive oil.


7 The following methods may be used:


• After application, follow institutional policy for covering the test site.


• Designated amounts of standardized-strength chemical solutions are arranged in metal receptacles that are backed with hypoallergenic adhesive. These solutions are then applied to the selected site. It is important to identify the contents of each receptacle correctly.


• Patches that are impregnated with designated allergens are available for direct application to the prepared sites.


• A patch test series kit is available that contains nonirritating concentrations of allergens that are packaged in syringes for dispersal. Although the kit contains 20 allergens, any number of them may be applied to individual patches or holding devices, which are then applied to the patient’s skin.


8 Chart the times, agents, concentrations, and amounts applied. Make a diagram in the patient’s chart, and number each location. Record which agent and concentration were placed at each site. Subsequent readings of each area are then performed and charted on this record.


9 Follow directions regarding the time of the reading of the skin testing being performed. The testing sites should be inspected in good light. Generally, a positive reaction (i.e., the development of a wheal) to a dilute strength of a suspected allergen is considered clinically significant. Measure the diameter of erythema in millimeters, and palpate and measure the size of any induration (i.e., the hardening of an area of the body that has reacted to inflammation). Record this information in the patient’s chart. The control site should have no reaction, which should be noted. The following is a list of commonly used readings of reactions and appropriate symbols:
















+ (1+) No wheal, 3-mm flare
++ (2+) 2- to 3-mm wheal with flare
+++ (3+) 3- to 5-mm wheal with flare
++++ (4+) >5-mm wheal

Patient Teaching



Documentation


Provide the RIGHT DOCUMENTATION of the allergen testing sites and the patient’s responses to the allergens that were applied.



Administration of Nitroglycerin Ointment


Objectives



Dose Form


Nitroglycerin ointment (Nitro-Bid) provides relief of anginal pain for several hours longer than sublingual preparations. When properly applied, nitroglycerin ointment is particularly effective against nocturnal attacks of anginal pain. Specific instructions for nitroglycerin ointment are reviewed in this text, because it is the only ointment that is currently available for which dosage is critical to the success of use (see Chapter 25).


Perform premedication assessments. See individual drug monographs.


Equipment



Sites


Any area without hair may be used. Most people prefer the chest, flank, or upper arm area (Figure 8-2). DO NOT shave an area to apply the ointment; shaving may cause skin irritation.



Techniques



1 Follow the procedure protocol described on p. 106.


2 Don gloves.


3 Position the patient so that the surface to which the topical materials are to be applied is exposed. Provide for the patient’s comfort before starting therapy. NOTE: When reapplying ointment, first remove the plastic wrap and dose-measuring applicator paper from previous dose, and cleanse the area of remaining ointment on the skin surface. Select a new site for the application of the medication, and then proceed with steps 4 through 7.


4 Lay the dose-measuring applicator paper with the print side DOWN on the site (Figure 8-3, A). The ointment will smear the print.


5 Squeeze a ribbon of ointment of the proper length onto the applicator paper.


6 Place the measuring applicator on the skin surface at the site chosen on the rotation schedule, ointment side DOWN. Spread in a thin, uniform layer under the applicator. DO NOT RUB IN. Leave the paper in place. NOTE: Use of the applicator paper allows you to measure the prescribed dose and prevents absorption through the fingertips as you apply the medication (see Figure 8-3, B).


7 Cover the area where the paper is placed in accordance with institutional policy (this may include covering the paper with plastic wrap), and then tape the paper in place.


8 Remove gloves and dispose of them in accordance with institutional policy.


9 Perform hand hygiene.





image Clinical Pitfall


Applying Nitroglycerin


To promote personal safety, the nurse should always wear gloves, whether applying nitroglycerin ointment paper or handling transdermal patches. When nitroglycerin transdermal patches are applied, chart the specific site of the application. Occasionally, patients may move the transdermal patch themselves because of convenience, skin irritation, or confusion. If the patch is not found at the original location at the scheduled time of removal, examine other areas of the body to find it; do not assume that the patch fell off or was removed. Tolerance and loss of antianginal response could develop if another patch is placed on the patient while the first patch is still on. Always dispose of used nitroglycerin paper or transdermal patches in a receptacle in which the patient, children, and pets will not have access. A substantial amount of nitroglycerin remains on the patch and can be toxic.


Patient Teaching



1 Help the patient learn how to apply the ointment.


2 Tell the patient that the medication may discolor clothing. The use of clear plastic wrap protects clothing.


3 When the dosage is regulated properly, the ointment may be used every 3 to 4 hours and at bedtime. Remind the patient that there should be a drug-free period (usually 10 to 12 hours) every 24 hours as recommended by the health care provider.


4 Tell the patient to wash her or his hands after application to remove any nitroglycerin that came into contact with the fingers.


5 When terminating the use of this topical ointment, the dosage and frequency of application should be gradually reduced over a 4- to 6-week period. Tell the patient to contact the health care provider if adjustment is thought to be necessary. Encourage the patient not to discontinue the medication abruptly (see Chapter 25).


Documentation


Provide the RIGHT DOCUMENTATION of the medication administration and the patient’s responses to drug therapy.



Administration of Transdermal Drug Delivery Systems


Objective



Key Term



Dose Form


The transdermal patch provides for the controlled release of a prescribed medication (e.g., nitroglycerin, clonidine, estrogen, nicotine, scopolamine, fentanyl) through a semipermeable membrane for several hours to 3 weeks when applied to intact skin. The dose released depends on the surface area of the disk in contact with the skin surface and the individual drug. See specific monographs for the onset and duration of action of drugs that make use of this delivery system.


Perform premedication assessments. See individual drug monographs.


Equipment



Sites


Any area without hair may be used. Most people prefer the chest, flank, or upper arm area. Develop a rotation schedule for use (see Figure 8-2 for an example of a nitroglycerin rotation schedule). See manufacturer’s recommendations for location and frequency of application of patches other than nitroglycerin.


Techniques



1 Follow the procedure protocol described on p. 106.


2 Label the disk with the date, the time, and the nurse’s initials. If the dosage of the medication is not printed on the patch applied, it is useful to include the dosage as part of the labeling process.


3 Don gloves.


4 Position the patient so that the surface on which the topical materials are to be applied is exposed. Provide for the patient’s comfort. NOTE: When reapplying a transdermal disk or patch, remove the old disk or patch, and cleanse the skin thoroughly. Select a new site for application. It is especially important in the older adult or the confused patient to look for the old disk if it is not where the prior application is charted. The confused patient may have moved it elsewhere on the body or removed it. The old disk can be encased in the glove as the nurse removes it; this should then be disposed of in a receptacle on the medication cart rather than in the patient’s room.


5 Apply the small adhesive topical disk. Figure 8-4 illustrates nitroglycerin being applied to one of the sites recommended by the rotation schedule. The frequency of application depends on the specific medication being applied via the transdermal disk and the duration of action of the prescribed medication. Nitroglycerin is applied once daily, whereas fentanyl is reapplied every 3 days; clonidine and Ortho Evra are reapplied once every 7 days. Hormone replacement therapies may be applied every 4 to 7 days.


6 Remove gloves and dispose of them in accordance with institutional policy.


7 Perform hand hygiene.

< div class='tao-gold-member'>

Related posts:

  1. 5. Patient Education to Promote Health
  2. 28. Drugs Used to Treat Heart Failure
  3. 30. Drugs Used to Treat Upper Respiratory Disease
  4. 24. Drugs Used to Treat Dysrhythmias

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 11, 2016 | Posted by in NURSING | Comments Off on 8. Percutaneous Administration

Full access? Get Clinical Tree
Get Clinical Tree app for offline access