Welcome to the Pennsylvania Department of Public Welfare (DPW), Office of Developmental Programs (ODP) Medication Administration Course for life sharers. This course was developed by the ODP Office of the Medical Director in conjunction with the Lifesharing Coalition and with technical assistance from Community Health Connections, the Western Pennsylvania Healthcare Quality Unit. This is lesson 9 – How to take medication in different ways.

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Hello, I’m Jill Morrow and I am the Medical Director for the Office of Developmental Programs. I’ll be your presenter for this webcast.

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The learning objectives for lesson 9 appear on the slide. At the end of this lesson, you will be able to:

• Recognize that medication can be administered by routes other than the oral route. • Be familiar with the other routes of medication administration. • Know the basics on how to administer medication by other routes • Understand the requirements for training related to giving medication by other

routes.

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Many medications come in multiple forms. Some of these forms are not given by mouth also called the oral route. Sometimes the person you support may need to take medication by a route other than by mouth. As the person administering medication by another route, you must be taught how to do that by a licensed healthcare practitioner. The following information describes other ways that medication can be given.

The different ways to administer medications that we will talk about include:

• Sublingual, buccal, and translingual medications. • Pulmonary inhalants and topical medications. • Rectal and vaginal medications. • Transdermal medications. • Drops, gels or ointments to the eyes. • Medications into the ears and nose. • Medications via G-tube and J-tube.

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Let’s talk about three other routes that involve putting medication in the mouth: sublingual, buccal, and translingual. In each of these, the medication is not swallowed and thus the route is not considered to be oral. Sublingual means under the tongue. A sublingual medication is placed under the person’s tongue where it dissolves slowly. Buccal means inside the cheek. A buccal medication is placed inside the cheek where it dissolves. Translingual refers to spraying the medication onto the tongue. Let’s look at an example of one of these routes: Some acute symptoms of heart disease like chest pain or angina can be treated with sublingual medication. In this example, you will be giving a medication like nitroglycerin to relieve the person’s acute symptoms. It is important to make careful observations about both the symptoms and the response to the medication. You will report these findings. The outcome of the administration may determine the next steps in the person’s treatment. For example, the healthcare practitioner may order nitroglycerin to be given as needed or PRN and administered sublingually to the person with chest pain. The order reads “Give nitroglycerin 1 tablet sublingually for chest pain. If no relief, within 5 minutes administer another tablet sublingually. A third tablet may be administered if the chest pain continues after an additional 5 minutes. If chest pain continues after 3 doses, call for emergency medical help.”

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Now we are going to walk through the steps for administering sublingual, buccal, and translingual medications. You will begin by washing your hands. Use gloves if you need to keep your hands clean or protect your hands from the medication. The steps of administration are: Step 1: PULL MEDICATION OUT Check that you have the right medication for the right person. This is Check 1. Step 2: POUR MEDICATION Check again to be sure you have the right medication for the right person, the right dose, the right time, and the right route. This is Check 2. Step 3: RECAP MEDICATION Check again to be sure you have the right medication for the right person, the right dose, the right time, and the right route. This is Check 3. Step 4: Tell the person what medication you are administering. Administer the medication to the person. Provide assistance as needed. Next we will talk about the specifics of administering these three forms of medication.

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To administer a sublingual medication, you will place the medication under the tongue. For a buccal medication, place the medication on the inside of the cheek along the teeth. Translingual medication is put directly onto the tongue. You will ask the person to open their mouth, and then put the medication directly on the tongue. If the medication comes in the form of a spray, then you must hold the canister vertically so that the spray will go directly on the tongue. You will recap this type of medication after administration. Make sure the medication stays in place until it dissolves completely. If the medication is a tablet, then tell the person not to chew the tablet. You may ask the person to open their mouth to make sure the medication has dissolved. Typically the person should not eat, drink or smoke for about an hour after the medication is administered.

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Complete the administration as you learned previously. Check to be sure that you administered the right medication in the right dose to the right person at the right time using the right route. Return the medication to the storage area, document the administration, and wash your hands. Remember to observe the person for medication effects and side effects. By observing the person after you administer a medication you can prevent a potentially serious problem if the person has an adverse effect or an allergic reaction.

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Pulmonary medications are inhaled into the lungs through the air passageways. These are also called inhalants. They are often used for people with respiratory problems like asthma or emphysema. Let’s learn more about pulmonary inhalants.

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Pulmonary inhalant medication typically comes in two different forms. Inhalers are sealed containers under pressure that contain the medication. Liquid inhalant medication is designed to be administered using a special machine called a nebulizer. Pulmonary medications that come in a sealed pressurized container are administered by discharging the canister into the mouthpiece. In order to receive the medication, the person must breath in as the medication is discharged from the canister. This requires some coordination and some people will be unable to do this. Spacers can be used by people who have difficulty controlling breathing in and out. A spacer is a chamber attached to the mouthpiece that helps the medication get into the air passageway better. Sometimes the mouthpiece will get clogged. If no “puff” or mist comes out, you can unclog the spray nozzle by soaking the mouthpiece in water for a few minutes. It is difficult to know whether or not the canister is empty. The best way to know when the canister is empty is to track the number of doses given. However you can try to see if the canister is empty by putting the canister without the mouthpiece into a cup of water. If the canister floats sideways on the surface, it is empty or close to empty. If the canister sinks to the bottom, then there is medication in it. Some pulmonary inhalant medications come in a liquid form. This liquid is administered using a special machine. If someone you support requires this kind of medication, then the healthcare practitioner will order the machine and give you instructions on how to use it correctly. Pulmonary inhalant medication like any medication can cause side effects. Specifically inhalant medication can affect the mucus membranes in the mouth. If the medication you administer has this side effect, having the person do good mouth care after each dose can minimize this. Don’t forget to document the need for good mouth care so that you remember to do it after each administration. You can do this where you document the medication administration.

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Now we are going to walk through the steps for administering pulmonary inhalant medication. You will begin by washing your hands. Use gloves if you need to keep your hands clean or protect your hands from the medication. The steps of administration are: Step 1: PULL MEDICATION OUT Check that you have the right medication for the right person. This is Check 1. Step 2: POUR MEDICATION Check again to be sure you have the right medication for the right person, the right dose, the right time, and the right route. This is Check 2. Step 3: RECAP MEDICATION Check again to be sure you have the right medication for the right person, the right dose, the right time, and the right route. This is Check 3. Step 4: Read and follow the directions that come with the medication. For inhalers, if the person is able, hand the canister to them and have them follow the instructions. If you are assisting the person, read the directions to them. If they can hold the canister, have them hold it and you administer the medication by discharging the canister. If they cannot hold the canister, you will need to administer the medication yourself. If you are using a nebulizer, then you will put the medication into the well of the nebulizer and either hand the mouthpiece to the person or place the mask over their nose and mouth. You will turn the nebulizer on and allow it to run until all of the medication is gone. At the end, you may have to tap the well that the medication is in to make sure that it is all administered. Step 5: Tell the person what medication they are taking and you administer it or have them do it.

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Inhalers can be a little tricky to use and take time and practice to master. Let’s review some instructions that will help you understand how to use an inhaler. In using an inhaler, it is important to: • Hold the canister so that the writing and mouthpiece are facing the person. Don’t

forget to remove the protective cap from the mouthpiece. • Shake the canister and place the mouthpiece in the person’s mouth. • Have the person breathe out. Press down on the container to release a “puff” or a

spray of fine mist as you have the person take a deep breathe in. • Have the person hold their breath for at least 10 seconds to allow the medication to

be inhaled into the lungs and absorbed. • If you are administering more than one puff, then wait at least one minute between

puffs for adequate absorption. The prescription and pharmacy label will indicate the number of puffs the person will take which is the dose. For example, the pharmacy label may say to take two puffs of the albuterol inhaler every 6 hours.

• Recap the container after administration.

Then complete the administration as we discussed previously.

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Let’s move on to talk about administering topical medication. These are medications that are applied directly to the skin. They come in many forms including creams, ointments, lotions, solutions, suspensions, powders and sprays. Topical medications are typically administered on the skin for a specific part of the body.

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Next we’ll review the steps to administer topical medications. First you will wash your hands. Gloves are commonly used to administer topical medications. Then you will follow similar steps to other routes we have previously discussed: Step 1: PULL MEDICATION OUT Check that you have the right medication for the right person. This is Check 1. Step 2: POUR MEDICATION Check again to be sure you have the right medication for the right person, the right dose, the right time, and the right route. This is Check 2. Step 3: RECAP MEDICATION Check again to be sure you have the right medication for the right person, the right dose, the right time, and the right route. This is Check 3. Step 4: Tell the person what medication you are administering. Hand the medication to the person if they are able to apply it. Provide assistance as needed.

Now we will talk about the specifics of administering topical medications.

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Some general information that you should think about when applying topical medication appears on this slide. You should put on gloves to prevent infection and to keep the medication from absorbing into your own skin. Clean any medication left from previous applications by wiping the area with a clean gauze or cloth. When administering, make sure you read and follow the instructions. Be sure not to touch the tube or bottle after touching the affected skin. This will prevent the transfer of germs to the medication. Cover the area after the application if instructed by the healthcare practitioner.

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Let’s look at some specifics for applying different forms of topical medications. When Applying Creams and Ointments • Apply ointments and creams with your gloved hand. • Apply a thin layer using light, smooth strokes. • Do not massage the medication into the skin, unless directed by the healthcare practitioner.

Avoid putting pressure on the skin. • To apply cream or ointment to a female’s labia, outside the vaginal area, use your gloved hand

always remembering to maintain privacy. • Do not bandage the area unless directed by the healthcare practitioner. • Recap the medication after application. When Applying Lotions • Shake the medication container. • Pat the medication onto the specified area of the person’s body with your gloved hand. • Do not massage or rub the area unless directed by the healthcare practitioner. • Allow the medication to dry before covering the area if directed. • Recap the medication after application. When Applying Powder • Apply a small amount of powder to clean, dry skin. • Do not shake the powder into the air as you or the person might inhale it. • Recap the medication after application. When Applying Topical Sprays • Read the instructions for applying the topical spray first. • Clean the area to be sprayed. • Spray the topical medication onto the skin. • Recap the medication after application. For each of these applications you will complete the administration as we have discussed previously including observing for any changes. Now let’s discuss topical medication that is applied to the scalp and hair.

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A variety of conditions or problems require medication to be applied to the scalp and hair. Scalp and hair problems that are treated with medication include dry skin or dandruff, psoriasis, and head lice also called pediculosis. Application of topical medication to the scalp and hair follow the same steps as other topical medications. There are some differences related to how the medication is applied or administered. Let’s look at those differences.

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For applying medications to the scalp, you need to read the instructions carefully. Some medications need to stay in the hair for a period of time before rinsing, while others can be put in and rinsed out without waiting. In particular, medications used to treat head lice must stay in the hair for a period of time in order to work. Make sure that the person has clean hair when you apply the medication. You will want to use gloves to prevent contact between your hands and the medication. Using your fingertips, begin by applying the medication to the person’s natural part. Spread the medication evenly. Continue to apply the medication every half inch or so to the entire scalp or affected area. If the medication needs to be massaged into the scalp, then do it gently.

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Medicated shampoos are typically applied while the person is in the shower or at the sink. Make sure the person is comfortable. Remember to put on gloves and then wet the person’s hair. Shake the shampoo before applying. Put the shampoo on evenly and massage it gently into a lather. Be careful not to get medicated shampoo in the person’s eyes, nose, or mouth. If you accidentally get it into their eyes, then you will need to flush their eyes as you learned in first aid. Then rinse the person’s hair. Remove your gloves and properly dispose of them. After that, you can help the person dry and style their hair.

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Rectal medication is applied either by inserting the medication into the rectum or applying it around the anal/rectal area. The most common forms of rectal medications used are suppositories, creams, and ointments. Constipation is a common condition that is sometimes treated with rectal suppositories. Administering rectal medication may cause the person to feel uncomfortable or embarrassed. Be mindful of how this affects the person. Be sure to make them feel comfortable and always provide privacy. You may need assistance to help you administer a rectal medication.

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To administer a rectal medication you will follow the four steps that we have discussed for each previous route of administration. These steps appear on the slide. The specific information that you need to know to administer rectal medication includes information about how to give suppositories as well as how to apply topical rectal medications. Remember when administering rectal medication you should always wear gloves. Administration of rectal medication requires that the person lower or remove their clothing from the waist down. It is helpful to have them lie on a bed, on their side, with their back to you. Place a protective pad under the buttocks and a sheet over the person for privacy. Clean the rectal area stroking from front to back using different sections of a washcloth for each stroke. For women, these measures help prevent infection of the vagina with bacteria from the rectal area.

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In order to insert a rectal suppository, you will remove the suppository from the wrapper and apply a water-soluble lubricant to it. With one hand, lift up the person’s buttock to expose the anal/rectal area. If the person seems anxious, ask them to take a few deep breaths and relax. Insert the suppository into the rectum with the tapered or pointed end first. Using your index finger, gently push the suppository upward about 1 to 3 inches. Wipe off any leftover lubricant from the area and assist the person to a comfortable position. If the rectal suppository is administered to relieve constipation, encourage the person to hold the suppository in the rectum for at least 20 minutes to make sure it is effective. Rectal suppositories are temperature sensitive. If the suppository gets too soft to insert, then run it under cool water while keeping it in the wrapper. In general, suppositories should be kept in the refrigerator. Sometimes only half of a suppository is prescribed. When this is the case, cut the suppository in half length-wise.

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When applying ointment or cream to the anal/rectal area, you will complete the initial steps in the same manner as administering a suppository. You need to clean the area using the same procedure as for a rectal suppository to remove any cream or ointment left over from previous applications. Next, place the cream or ointment on a disposable gauze pad or on the tip of one of your gloved fingers and apply it to the anal/rectal area.

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Vaginal medications are usually prescribed to treat vaginal infections or inflammation. You will apply vaginal medication on and into the vagina. Vaginal medications are inserted into the vagina using an applicator that comes in the box with the medication. Vaginal medications come in different forms such as creams, suppositories, gels, foams, and ointments. The application can be uncomfortable and embarrassing to the person. Be mindful of this and make the person feel as comfortable as possible. You may need assistance administering vaginal medications. You will follow the same steps for administration as with other routes of medication. Now we will talk about the specific information needed to administer vaginal medication.

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Vaginal medication should be administered in a private area such as a bedroom. Have the person urinate prior to administering the medication. As with rectal medication, the person will need to lower her clothing from the waist down. Have her lie on her back on the bed and place a protective pad under the buttocks. Cover her with a sheet or towel for privacy. Put on gloves and ask the person to bend her knees and spread her legs apart. Clean the perineal or vaginal area by washing front to back from the vagina toward the anal/rectal area. Use different corners of the washcloth for each stroke to reduce the chance of spreading infection. Vaginal medication is administered either on the skin in the perineal area or into the vagina. • To apply cream or ointment to the outside of the vagina, place a small amount on a

disposable gauze or your gloved fingertip and apply it to the area. • To insert medication into the vagina, carefully and gently insert the lubricated

applicator into the vagina and press on the plunger to release the medication. Withdraw the applicator from the vagina. You may need to lubricate the applicator with water soluble lubricant to allow for an easier, painless insertion of the medication. Don’t use petroleum jelly for lubrication.

• Assist the person with dressing. Most vaginal medications are administered at bedtime because they must remain in the vagina for a period of time to be effective. If the person has to change position, provide a sanitary pad and clean underwear.

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Many medications are available in a transdermal or patch form. These patches, applied to a specific area of the body, deliver medication through the skin. The benefit of transdermal medications is that the person receives a constant, controlled amount of medication over time. Daily patches should be administered at the same time each day. For the best results, patches should not be placed on hairy skin as they will not stick well and the medication will not be absorbed properly. You should use different sites for the application of patches and keep patched areas dry at all times. Occasionally people have difficulty with redness, swelling or blistering under a patch. This should be reported to the healthcare practitioner. If a patch falls off, then the healthcare practitioner should be called for instructions about what to do.

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Application of transdermal patches follows the same steps as other routes of medication administration. You should always wear gloves when administering patches so that you will not absorb medication through your skin if you touch the patch. When placing the patch, do not peel off the back of the patch. Clean the area of the body where the patch will be applied with soap and water, dry thoroughly and inspect the skin carefully for any abnormalities. Apply the patch to the area being careful to place the patch where the person will not be able to remove it and it will not rub against clothing. Remember to document the site where the patch was placed.

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Medications are inserted into the eyes for many reasons. Glaucoma, dry eyes and eye infections are some of these reasons. Eye medication comes in drops, gels, and ointments. Administering eye medication requires some special steps. When administering eye medication, it is important to keep the tip of the bottle or tube from touching the eye or any object or surface that would contaminate the medication. Therefore, you should always wear gloves and be sure to have a clean surface on which to place the cap of the bottle or tube. Now let’s talk about how to administer eye medication including how to most effectively position the person for administration.

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It is helpful to position the person to administer eye drops, gels or ointments. Tip the person’s head back as this may help them blink less. Hold the medication bottle or tube in one hand. With the other hand, lower the bottom eyelid to form a pocket for the medication. Then apply the medication. For drops you will gently apply the right number of drops into the eye. For ointments or gels, you will put a ribbon of gel along the edge of the eye from the inside to the outside of the eyelid pocket. Twist the tube to break the stream of ointment or gel. Ask the person to blink their eyes gently to spread the medication over the entire eye. Have them close their eyes for one or two minutes to let the medication absorb. Clean off any excess medication from the tip of the medication container using a clean gauze pad. Wipe any excess eye ointment, gel, or drops from the eyelid, lashes, or face.

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Ear medications are commonly used to soften earwax or treat problems such as inflammation and infection. Remember you will begin by washing your hands and consider using gloves if appropriate. You will follow the same steps; step 1, pull the medication out and step 2, pour the medication. Step 3 is recapping the medication and in this case step 3 is the third check to make sure you have the right medication for the right person because you will administer the medication directly from the container. Step 4 is administration. Have the person lie on their side with the affected ear up. Remember when you remove the cap from the medication make sure you place it on a clean surface. To administer, hold the medication bottle in one hand. With the other hand, gently pull on the outside of the ear up and toward the back of the head to straighten the ear canal. Put the correct dose of medication into the ear canal. Hold the position of the ear until you see the medication disappear into the canal. Then, release the ear. Instruct the person to stay on their side for 5-10 minutes to allow the medication to be absorbed. Wipe off any excess ear medication from the outside of the ear. Do not put a cotton ball in the ear. If needed, repeat these steps for the other ear. Recap the medication after administration.

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Nasal medication is most commonly used to coat and shrink the nasal mucous membrane which is the lining of the nose. Some people who have allergies use nasal medication to treat their allergies. You will follow the steps as we have previously discussed. For nasal medication, you will again remove the cap from the medication container and set it on a clean surface. The person should be in a comfortable position such as sitting in a reclining chair or lying down. To administer the medication, it is best to have the person’s head tilted back. If they are sitting, they can tilt their head back themselves. If they are lying down, then place a pillow under the person’s shoulders so that the head is tilted back. Gently place the correct dose ordered into each nostril. Be careful not to touch the tip of the medication bottle to the nose so that you do not contaminate the medication. Keep the person’s head tilted back for about 5 minutes allowing time for the medication to be absorbed. Recap the medication after administration.

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Some people use a gastrostomy tube or a jejunostomy tube to eat and take medication. A gastrostomy or G-tube is a tube that is surgically placed in a person’s stomach for a medical reason. A jejunostomy or J-tube is one that is surgically placed in the small intestine. The tube is usually 12 to 15 inches long and made of flexible material. It is held in place by a balloon on the inside of the body and by a disk on the skin outside the body. Some types of G-tubes have a disc on the surface of the belly with a tube that gets placed each time the G-tube is used and then removed. Medications given through a G-tube or J-tube are generally in liquid form although sometimes they may be crushed or dissolved in liquid. In order to change the form of medication by crushing it, you must have written instructions either on the pharmacy label or from the healthcare practitioner. Remember that you need to know when medication has to be given related to eating. You will need to have the following equipment available when giving medication through a G-tube or J-tube. In addition to the medication to be given, you will need a large syringe such as a 60 cc syringe, water for flushing and gloves. Next we will talk about the procedures for administering medications through a G-tube or J-tube. Remember this procedure may need to be modified depending upon a person’s unique situation or instructions from the healthcare practitioner.

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To Administer the Medication Via G-Tube and J-Tube the first three steps are the same. Step 1: PULL MEDICATION OUT Check that you have the right medication for the right person. This is Check 1. Step 2: POUR MEDICATION Check again to be sure you have the right medication for the right person, the right dose, the right time, and the right route. This is Check 2 Step 3: RECAP MEDICATION Check again to be sure you have the right medication for the right person, the right dose, the right time, and the right route. This is Check 3 Step 4: Elevate the person’s head and upper body. The person must stay in this upright position for 45 to 60 minutes after receiving the medication to prevent fluid from getting into the lungs. Step 5: Wash your hands. Step 6: Put on gloves. Step 7: Check to be sure the tube has not shifted by looking for the permanent mark on the tube or by measuring the tube length and comparing it to the original measurement. Note, if the tube is a button type, you do not have to measure it. Step 8: Pinch off the tube. Step 9: Remove the plug, cap, or clamp and place it on a clean surface nearby. On the next slide, we’ll move to step 10.

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Step 10: Insert the 60 cc syringe with the plunger removed into the tube. Step 11: Unpinch the tube. Step 12: Gently flush with 50 cc of warm water. Do not force the water or liquid into the tube. When the syringe is almost empty, pinch the tube off. Do not allow the syringe to empty out completely. Step 13: Unpinch the tube, instill the medication, and repinch the tube. Step 14: If you need to give another medication through the tube, pour 5 to 10 cc of warm water into the tube to clean it before you administer the next medication. Step 15: Do not allow the syringe to empty. Pinch the tube off. Step 16: Repeat this procedure until you have given all the medications. Step 17: After the last medication, you will again flush the tube with 50 cc of warm water. Allow the syringe to empty completely. Step 18: Pinch the tube and reinsert the plug, close the cap, or reclamp the tube. Remember to complete the administration as we discussed previously.

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When completing an administration, regardless of the route of administration, remember that you must check to make sure you have administered the right medication and right dose to the right person at the right time by the right route. Don’t forget to document the administration and wash your hands after returning the medication to the storage area. By observing the person for medication effects and side effects after you administer a medication, you can prevent a potentially serious problem if the person has an adverse effect or an allergic reaction.

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This concludes Lesson 9 For those completing the course through the Provider Information Center, a Certificate of Achievement will be available after completing all course requirements. Please return to where you launched this webcast to complete the course requirements and access your Certificate. Thank you for watching these webcasts about how to safely administer medications.

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