Pharmacology, Chapter 8 Administration by the Gastrointestinal Route

Name [four] steps in administration of a rectal suppository that are different from PO administration.

- Lower the head of the bed if necessary and position the patient on the left side with the upper knee bent. Keep the patient covered, exposing only the rectal area. - Remove the suppository from the wrapper and lubricate the tapered end with a water-soluble lubricant. - With the nondominant hand, separate the patient's buttocks gently so you can see the anus. - Ask the patient to take a deep breath. Insert the lubricated suppository gently into the rectum and push gently with gloved index finger until the suppository has passed the internal sphincter. With infants, use the gloved little finger. - Urge the patient to retain the suppository for at least 20 minutes. If the patient is unable to cooperate, hold the buttocks together as required.

advantages of the nasogastric tube:

- ability to bypass the mouth and pharynx when necessary - elimination of numerous injections

advantages of the rectal route:

- bypassing the action of digestive enzymes - avoidance of irritation to the upper GI tract - usefulness with dysphagia

advantages of oral route:

- convenience and patient comfort - safety, because some medication can be retrieved in case of error or intentional overdose - economy, because there are few equipment costs and most medications are formulated for this route

disadvantages of the rectal route:

- many medications are unavailable in suppository form - some patients have difficulty retaining suppositories (e.g., older adults and children) - prolonged use of some rectal suppositories can cause rectal irritation (e.g., bisacodyl) - absorption may be irregular or incomplete if feces are present

Name [six] disadvantages of oral administration compared with administration by injection.

- slower onset of absorption and action - rate and degree of absorption vary with gastrointestinal contents and motility - some drugs (e.g., insulin and heparin) are destroyed by digestive fluids and must be administered by injection - difficult to use in patients with nausea or vomiting - dangerous to use if patient has difficulty swallowing (dysphagia), because of possible aspiration - cannot be used for unconscious patients - cannot be used if patient is NPO

disadvantages of oral route:

- slower onset of absorption and action - rate and degree of absorption vary with gastrointestinal contents and motility - some drugs (e.g., insulin and heparin) are destroyed by digestive fluids and must be administered by injection - difficult to use in patients with nausea or vomiting - dangerous to use if patient has difficulty swallowing (dysphagia), because of possible aspiration - cannot be used for unconscious patients - cannot be used if patient is NPO (e.g., before surgery or because of an acute medical condition); may not be able to be used if a patient is fasting for a test such as a lipid panel or scan, although often maintenance medications can still be taken with clear liquids - administration of medications by nasogastric tube, small-bore silicone gastric tube, or percutaneous endoscopic gastrostomy (PEG) tube is sometimes ordered when the patient is unable to swallow for periods of time because of illness, trauma, surgery, or unconsciousness; medications are usually administered intravenously when these conditions exist for short periods of times

When administering medication by nasogastric tube, check tube placement first with which two tests:

1) Verify tube is properly placed in the stomach and taped at the appropriate centimeter marking. 2) Aspirate with bulb or piston syringe for stomach contents and check the pH of the aspirated fluids; gastric juice is acidic (pH of 0.9-1.5). If the aspirate does not meet these parameters or if there is any question, do not instill any liquids; instead, report to the person in charge. If the criteria are met, flush the tube with normal saline solution or with water.

Administration of Rectal Suppository

1) Wash hands. 2) If using an eMAR, scan and compare the label against the medication sheet or screen. Check the medication order using the Six Rights of Medication Administration. 3) Identify the medication (purpose, side effects, contraindications, cautions, and normal dose range). Research information, if necessary. 4) Assemble supplies: disposable gloves and water-soluble lubricant. 5) Select the medication as ordered, checking medication name and dosage again. Some suppositories are stored in a refrigerator, and some may be stored at room temperature, according to manufacturer's instructions. 6) Check the patient's identification bracelet and, if automated, scan the patient's wristband, ask patient for name and DOB, and explain the procedure. Answer any questions. 7) Close the door and curtain completely. 8) Lower the head of the bed if necessary and position the patient on the left side with the upper knee bent. Keep the patient covered, exposing only the rectal area. 9) Put on disposable gloves. 10) Remove the suppository from the wrapper and lubricate the tapered end with a water-soluble lubricant. 11) With the nondominant hand, separate the patient's buttocks gently so you can see the anus. 12) Ask the patient to take a deep breath. Insert the lubricated suppository gently into the rectum and push gently with gloved index finger until the suppository has passed the internal sphincter. With infants, use the gloved little finger. 13) Urge the patient to retain the suppository for at least 20 minutes. If the patient is unable to cooperate, hold the buttocks together as required. 14) Remove and dispose of gloves, turning them inside out as you remove them. 15) Be sure the patient is comfortable, with covers and bed adjusted appropriately. 16) Wash hands. 17) Record the medication in the appropriate place.

Guidelines for Oral Medications Administration

1) Wash your hands. 2) Locate the appropriate medication order, medication sheet, or (if using an eMAR) scan the patient's wristband, and check for completeness of the order. 3) Check for special circumstances (e.g., allergies or NPO) 4) Be sure that you know the purpose of the drug, possible side effects, contraindications, cautions, interactions, and normal dosage range. If unfamiliar with the drug, consult a reference source for this info. 5) Select the appropriate receptacle in which to place the medication (e.g., paper medicine cup for tablets or capsules and plastic medicine cup for liquids). 6) Locate medication in the medication cupboard or medication cart. If using an eMAR, scan it and compare the label screen, if using a paper record compare the medication to the chart, for the Six Rights of Medication Administration. Also be sure to check the drug's expiration date. 7) If the dose ordered differs from the dose on hand, complete calculations on paper and check for accuracy with your instructor or a co-worker in the clinical setting. 8) Prepare the dosage as ordered. Do not open unit-dose packages until you are with the patient. If medication is liquid, see "Preparation of Liquid Medications." 9) Take medication in a cup to the patient and place it on a table nearby. 10) Check the patient's identification bracelet. Ask the patient to tell you their name and date of birth (DOB). If the patient is unable to provide their name and/or DOB, use an alternate method to identify the patient such as a photograph or identity confirmation by a family member, friend, or coworker. Compare this information with the medication administration record to verify that you have the right patient. 11) Call the patient by name and explain what you are doing. Answer any questions. Recheck the medication order if the patient expresses any doubts. Use this opportunity for patient education about the medication. 12) Monitor the patient's vital signs if required for specific medication (e.g., blood pressure, apical pulse, or respiration). Blood pressure should always be taken and recorded before administering antihypertensives. 13) Open the unit-dose package and place the container in the patient's hand. Avoid touching the medication. 14) Provide a full glass of water and assist the patient as necessary (e.g., raise the head of the bed and provide a drinking straw if required). 15) Stay with the patient until the medication has been swallowed. Make the patient comfortable before you leave the room. 16) Discard the used medicine cup and wrappers in a wastebasket. 17) Record the medication, dosage, time, route, and your signature or initials in the correct place on the patient's record according to the rules of the facility. 18) Document on the patient's record and report if a medication is withheld or refused and the reason. Record and report any unusual circumstances associated with administration or any adverse side effects.

What are the six parts of a complete medication order?

1. date/time ordered 2. patient's name 3. medication name 4. dosage 5. route 6. time/frequency to be used

When administering oral medication, what do you do when a patient is NPO, refuses the medication, or vomits within 20-30 minutes of taking the medication?

ALWAYS report this to the person in charge. An order from the physician is required to change either the medication or the route of administration. Document on the patient's record the time of emesis and appearance of the emesis to check whether the medication remained intact.

Most important medicine:

Administer first (Watch closely for drug reactions)

Most medications:

Administer with water (Watch closely for drug reactions Elevate patient's head)

Why should you be aware of the components of combination products?

Being aware of the individual components of a combination product allows you to recognize if any elements of the product will lead to an allergic reaction, are contraindicated, etc.

If the patient refuses a medication, omit the medication and move on. (T/F)

False. If the patient refuses a medication, determine the reason. Report the refusal and reason to the person in charge and record all information on the patient's record.

How do you proceed with oral administration of medication if the patient is NPO?

Check with the person in charge regarding the appropriate procedure, based on the reason for NPO. - If patient is fasting for tests, medication can usually be given at a later time with possible modification of time schedule or with clear liquids if the physician approves. - If patient is NPO for surgery, nausea, or dysphagia, it may be necessary to consult the doctor regarding a change of route. - Do not omit the medications completely without specific instructions to that effect; abrupt withdrawal of some medications may lead to dangerous conditions.

Tablet cannot be swallowed:

Crush tablet, mix with applesauce

If the pill can safely be crushed, you can utilize that fact whenever you need to for ease of administration. (T/F)

False. In some areas a physician's order is required for pill crushing. It is important to check first.

Administration of Medications by Gastric Tube

Directions for "Administration of Medications by Nasogastric Tube" can be followed, only omitting number 8. No test for placement of tube is necessary. The rest of the directions regarding flushing the tube afterward and positioning the patient, and so on, should be followed carefully. Remember to document appropriately.

To facilitate swallowing:

Elevate patient's head (Administer with water)

You don't always need to check the patient's record for allergies; checking on the initial visit is enough, and you can base all later medication administrations on that. (T/F)

False. ALWAYS check the patient's record CAREFULLY for allergies. In addition, be aware of the components of combination products, to determine if there's an allergy to any of them.

You can administer oral medication with any drink: water, fruit juice, milk, or any other liquid. The liquid has no affect on the medication. (T/F)

False. Administer oral medications with water unless ordered otherwise. Do NOT give medicine with fruit juice, milk, or any other liquid unless indicated by specific directions. The absorption of many medicines (e.g., antibiotics) is inhibited by interaction with acid or alkaline products.

Blood pressure should always be taken and recorded after administering antihypertensives. (T/F)

False. Blood pressure should be taken and recorded BEFORE administering antihypertensives.

If a pill-cutter or knife is unavailable, you can break a tablet by hand. (T/F)

False. Do NOT break a tablet by hand if it must be divided. If available, use a pill-cutter. In a home care setting, use a knife only on score marks.

If a patient is NPO, you can simply omit the oral medication completely without consulting anyone. (T/F)

False. Do NOT omit the medication completely without specific instructions to that effect. Abrupt withdrawals of some medications (e.g., phenytoin [Dilantin] or diazepam [Valium]) may lead to dangerous conditions (such as seizures).

If too much medication is poured into the medicine cup, pour the extra medication back into the bottle. (T/F)

False. Do NOT pour the extra medication pack into the bottle; instead, discard the extra medication.

When removing tablets or capsules from a stock bottle, you can pour them into your hand and pick out the number you need. (T/F)

False. Do NOT touch tablets or capsules. Instead, when removing tablets or capsules from a stock bottle, pour them into the lid and from there the medicine cup.

When administering medication by nasogastric tube, medication should be cold. (T/F)

False. Do not administer cold medication through the nasogastric tube; it should be at room temperature.

After administering a retention enema, it is recommended to tape the buttocks together with a 2-inch paper adhesive for 30 minutes. (T/F)

False. Do not use this method unless absolutely necessary, e.g., if the patient is uncooperative, unconscious, or has poor sphincter control

All tablets may be crushed with mortar and pestle or pill-crusher. (T/F)

False. Enteric coated and sustained-release tablets cannot be crushed.

There is no need to explain what you are doing and why when administering a retention enema, especially when the patient is unconscious or unable to speak. (T/F)

False. It is important to ALWAYS explain what you are doing and why when administering a retention enema. Even if patients are unconscious or unable to speak, they may be able to hear and cooperate in some way if they understand.

A nasogastric tube is inserted solely for the purpose of administrating medication. (T/F)

False. Medications are sometimes ordered for this route when a nasogastric is ALREADY in place for tube feeding or for suction.

When administering medication by nasogastric tube, medication should be pushed through the nasogastric tube by pressure on the barrel of a syringe. (T/F)

False. NEVER force fluids down a nasogastric tube. Instead, medication should flow through the nasogastric tube by gravity.

Two liquids can be mixed together in the same medicine cup. (T/F)

False. NEVER mix two liquids together in the same medicine cup.

Tact and consideration are not required for successful administration of rectal medications. (T/F)

False. Tact and consideration will lead to cooperation from the patient, leading to successful administration of rectal medications.

When administering medication by nasogastric tube, the patient should be placed in the Trendelenburg position. (T/F)

False. The Trendelenburg position is where the patient's head is down are feet are elevated; it should NOT be used when administering medication by nasogastric tube. Instead, the patient's head should be elevated.

If a patient is unable to swallow a tablet or capsule whole, you can just disrupt the original dosage form into something the patient can intake. (T/F)

False. You cannot "just" disrupt the original dosage form; the package insert should be reviewed or a pharmacist should be consulted beforehand to make sure it is allowable.

Administration of Liquid Medications Orally Via Syringe

Follow the "Guidelines for Administration of Oral Medications." Administration of liquid medications orally via syringe requires these additional steps: 1) Pour the prescribed medication into the medicine cup. If automated, scan it and compare the label against the medication sheet or automated screen for the Six Rights of Medication Administration. 2) Withdraw the prescribed amount with a syringe. 3) Check the medication and order using the Six Rights of Medication Administration. 4) Identify the patient and scan wristband if using an eMAR, verify name and date of birth (DOB), and elevate the patient's head. 5) Be sure the patient is alert and able to swallow. 6) Place the syringe tip in the pocket between the cheek and the gums. (When administering large amounts of liquid, it helps to fit a 2-inch length of latex tubing on the syringe tip to facilitate installation of the medication into the cheek pocket.) 7) Instill the medication slowly to lessen chances of aspiration. 8) Be sure the patient swallows all the medication completely. 9) Proceed with "Guidelines for Administration of Oral Medications." 10) Remember the "sixth right" and document appropriately.

Preparation of Liquid Medications

Follow the "Guidelines for Administration of Oral Medications." Preparation of liquid medications requires these additional steps: 1) Shake bottle if indicated. Remove cap and place cap upside down on table. 2) Hold the medicine bottle with the label side upward to prevent smearing of label while pouring. 3) Place medicine cup at eye level. You may place your thumbnail on level to which medication will be poured. 4) While holding the medicine cup straight at eye level, pour the prescribed amount of medication. 5) Replace the cap on the bottle. 6) Compare the information on the medication sheet against the label on the stock bottle and the quantity of drug in the cup. 7) Replace the medication bottle in the cupboard or the medicine cart. 8) Recheck the Six Rights of Medication Administration. 9) Proceed with the "Guidelines for Administration of Oral Medications."

If a pill consistently requires crushing, what action could you take?

If available, ask for the medication to be ordered in liquid or powdered form. This negates the need to crush the pill every time.

If NPO for laboratory tests:

Modify schedule, give medicine later

Dilantin ordered PO, patient NPO for surgery:

Notify person in charge

Patient vomits 15 minutes after:

Notify person in charge

Which medication should be given first?

The most important medicine. For example, cardiac medicine before a vitamin.

Sustained-release capsules:

Usually cannot be opened (Watch closely for drug reactions Elevate patient's head)

Patient is allergic to penicillin:

Watch closely for drug reactions (Notify person in charge)

Do not administer any medication that is discolored, has precipitated, is contaminated, or is outdated. (T/F)

True

Patients with a history of allergy should be watched carefully for possible drug reactions when any new medication is administered. (T/F)

True

Rectal administration is more effective with the patient's cooperation. (T/F)

True

The retention enema is administered in the same way as a cleansing enema. (T/F)

True

When pouring medication, never touch the medicine cup with the medication bottle. (T/F)

True

Medication can be administered via the gastric tube directly into the stomach. (T/F)

True. The gastric tube is inserted through the skin of the abdomen, directly into the stomach; it can be used indefinitely for feeding purposes, but also to administer medications.

Be sure that any equipment used to crush medication is wiped clean. (T/F)

True. Do not leave the equipment with any medication remnants; wipe it clean.

Some capsules (even sustained-release capsules) may be opened and the contents mixed with applesauce, pudding, or ice cream to facilitate administration for patients with difficulty swallowing (e.g., children and the elderly). (T/F)

True. However, do not crush the contents of a sustained-release capsule or allow patients to chew them. In addition, check diet to be sure these foods are allowed.

Gastric tube administration of medications is a simple matter. (T/F)

True. If a patient has a gastric tube in place in the abdomen, medication can be administered per order in this way.

Always make sure to check the drug's expiration date. (T/F)

True. It is always important to check the expiration date on a drug.

It is integral to ensure that the patient understands that the suppository needs to be unwrapped prior to administration. (T/F)

True. While it may seem like common sense to a health professional, it may not be to an uneducated patient. They may fear it would ruin the medication, so it is important to inform them it is a wrapper that can and needs to be removed prior to administration.

Administration of Medications by Nasogastric Tube

When medications are ordered by nasogastric tube, follow the "Guidelines for Oral Medications Administration" and "Preparation of Liquid Medications." Nasogastric tube administration of medication requires these additional steps: 1) Check the medication order using the Six Rights of Medication Administration. If using an eMAR, scan it and compare the label against the medication sheet or automated sheet. 2) If the medication must be administered on an empty stomach and the patient is receiving a tube feeding, hold the medication, stop the tube feeding for 30-60 minutes depending upon the medication being administered, and return at the appropriate time to administer the medication. 3) If the patient is not receiving a tube feeding or the medication can be administered with the tube feeding, continue with medication administration. 4) Wash hands. Wear gloves when handling tubes. 5) Prepare the medication as ordered and take it to the patient's room. Be sure the medication is at room temperature. 6) Check the identification bracelet and, if automated, scan the patient's wristband, ask the patient their name and verify it, and explain the procedure. Elevate the head of the bed, if not contraindicated. 7) Hold the end of the tube up and remove the clamp, plug, or adapter. 8) Verify that the tube is properly placed in the stomach and verify that the tube is taped at the appropriate centimeter marking. Aspirate with bulb or piston syringe for stomach contents and check the pH of the aspirated fluids. Gastric juice is acidic (pH of 0.9-1.5). If the aspirate does not meet these parameters or if there is any question, do not instill any liquids. Instead, report to the person in charge. If the criteria are met, flush the tube with normal saline solution or with water. 9) Clamp the tube with your fingers by bending it over upon itself or by pinching it. After the tube is closed, remove the plunger or the bulb from the syringe, leaving the syringe attached firmly to the tubing. Flush the tube with water. 10) Pour the medication into the syringe. Release or unclamp the tubing and let the medication flow through by gravity. Never force fluids down a nasogastric tube. Watch the patient during the procedure and stop immediately at any sign of discomfort, coughing, or shortness of breath by pinching the tube. Holding the syringe too high causes fluid to run in too quickly, possibly causing nausea and vomiting. The syringe should be at the level of the patient's shoulders. 11) Before the syringe empties completely, flush the tube by adding 60-100 mL of water to the syringe or the amount ordered. If the patient's input and output are being monitored, be sure to add this amount to the patient's record. 12) After the water has run in, pinch the rube, remove the syringe, and clamp or plug the tube. If the patient is ordered suction, be sure to leave the suction turned off for at least 30 minutes until medication is absorbed, then restart suction as ordered. If the patient is receiving a tube feeding, be sure to leave the tube feeding turned off for 30-60 minutes, depending upon the medication, until the medication is absorbed; then restart the tube feeding. 13) Position the patient on the right side and/or elevate the head of the bed to encourage the stomach to remain empty. Make the patient comfortable. 14) Proceed with "Guidelines for Administration of Oral Medications" for documentation.

Why is it very important to educate the patient on the route of administration when they receive a medication for self-administration?

While it may seem arbitrary to a health professional, many times patients assume all medications are to be taken orally; this would of course be a problem if, for example, the prescribed medication is a suppository meant for rectal administration.

How does the administering process change when administrating medications whose actions depend on contact with the mucous membranes of the mouth or throat (e.g., topical anesthetics or fungicides)?

You do NOT administer the medication with ANY fluid or food.

How might liquid medication be administered to someone who is unable to drink from a cup (e.g., infants and persons with wired jaws)?

a syringe may be used

oral medication administration

administering medications by mouth

What is the preferred route or form of medication administration for children less than 5 years old?

administration of liquid oral medications; in addition, young children often prefer and better tolerate flavored medications

retention enema

an enema that may be used to provide nourishment, medication, or anesthetic

When pouring liquid medicine, the medicine cup should be held:

at eye level; the thumbnail can be placed on the level to which medication will be poured

When pouring liquid medicine, if medication is in suspension, the bottle should first be:

shaken well

What way are medications most often administered?

by the gastrointestinal route

What are some ways to respect the patient's dignity and privacy when administering medication rectally?

close the door and curtains completely, and do not expose the patient unnecessarily

dysphagia

difficulty swallowing

What are common suppositories that are prescribed for self-administration?

hydrocortisone suppositories used for hemorrhoids and acetaminophen suppositories used for pain and fever

What will the surgeon sometimes do when a patient is unable to take nourishment by mouth for a long period of time?

insert a gastric tube through the skin of the abdomen, directly into the stomach; it is secured into place and can remain there for feeding purposes indefinitely; it can also be used to administer medications directly into the stomach

When pouring liquid medicine, the bottle should be held:

label side upward, to prevent smearing of label while pouring

gastric tube administration

medication administered through a tube in the abdomen to the stomach

nasogastric tube administration

medication administered through a tube inserted through the nose and extending into the stomach

rectal medications

medication in suppository or liquid form administered as a retention enema

Medication documentation should include:

medication name, dosage, time, route, and your signature or initials. in addition, document and report if a medication is withheld or refused and the reason; and record and report any unusual circumstances associated with administration or any adverse side effects.

What four categories does gastrointestinal administration include?

oral, nasogastric tube, gastric tube, and rectal

G-tube

otherwise known as a gastric tube or PEG tube

What kind of medicine cup do you use for tablets, capsules, and liquids?

paper medicine cup for tablets or capsules; plastic medicine cup for liquids

PEG tube

percutaneous endoscopic gastrostomy tube. otherwise known as a gastric tube or G-tube

What are the Six Rights of Medication Administration?

right medicine, right amount, right time, right route, right patient, right documentation

aspiration

the inhalation of a foreign substance or regurgitated gastric contents, which can cause severe lung damage

How long must the retention enema be retained?

the retention enema must be retained approximately 30 minutes or more for absorption of the medication

How should a patient be instructed to behave after receiving a retention enema?

they should be instructed to lie quietly on either side to aid in retention; additionally, the retention enema should be retained for approximately 30 minutes or more for absorption of the medication

nasogastric tube

tube inserted through the nose into the stomach

gastric tube

tube inserted through the skin of the abdomen, directly into the stomach; it can be used indefinitely for feeding purposes, and to administer medications. also known as a G-tube or PEG tube

When pouring liquid medicine, the bottle cap should be placed

upside down on the table

When can you NOT elevate the patient's head to aid in swallowing when administering oral medication?

when elevating the patient's head is contraindicated by the patient's condition

When are medications sometimes administered by the rectal route?

when nausea or vomiting is present, or the patient is unconscious or unable to swallow

disadvantage of the nasogastric tube:

with a conscious patient, the discomfort of the tube in the nose and throat for prolonged periods of time

Stay with the patient until the medication is swallowed; do not leave the medication at the bedside or in the patient's possession except in what circumstance?

you can leave the medication at the bedside or in the patient's possession if ordered by the physician