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05/02/2023 1
How to give Topical Medications - 1
(Inunction , Insertion and Inhalation )
A.M.Karunaratne AttanayakeSpecial Grade Nursing Tutor
College of Nursing Badulla - Sri Lanka.
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What are the topical medications?
Topical medications are administered directly to the SKIN and MUCOUS MEMBRANES by painting or spreading it over an area, applying moist dressings, soaking body parts in a solution, or giving medicated baths.
Applied to produce local effects, some topical preparations have systemic effects, absorbed through the skin and mucous membrane.
Systemic effects more, if skin – very thin and drug concentration high or skin contact – prolonged.
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What are the topical medications? Ctd…….. Medications such as Nitroglycerin , Estrogen
applied topically by transdermal disk or patch.
Mucous membrane used by route of administration of drugs for quickly absorbed.
Mention as above systemic effects occur, whenever the concentration of the drug is high or more quantity of drug is administered.
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What are the topical medications? Ctd……..
Mucous membrane at different regions differ in their sensitivity to drugs.
The cornea of the eye and nasal mucous membrane are very sensitive. The patient will be complain of burning sensation , when apply of eye and nasal drops.
Vaginal and rectal mucosa are not very sensitive and medications are less irritating.
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Methods of application of medications
1. Direct – liquid - EYE DROPS, SWABBING OF THROAT, GARGALING.
2. Insertion – drug into the body cavity – SUPPOSITARY TO THE RECTUM.
3. Instillation ( Slow introduction ) , fluid into a body cavity - EAR DROPS, NASAL DROPS
4. Irrigation ( washing out of body cavity) – BLADDER IRRIGATION.
5. Spaying – into the THROAT.
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Instillation ( Slow introduction ) , fluid into a body cavity -EAR DROPS
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Instillation ( Slow introduction ) , fluid into a body cavity - NASAL DROPS
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Irrigation ( washing out of body cavity) – BLADDER IRRIGATION.
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INNUNCTION is the act of rubbing an oily or fatty preparation into the skin make produce a local effect as CLEANING, SOOTHING , DISINFECTING or RELEAVING a local inflammation.
Lotions and Ointments are used for inunction.
What is the INUNCTION ?
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I. The area of the skin should be thoroughly cleaned before the application of an ointment or lotion.
II. The ointment or lotion should be ‘ rubbed in ’ instead of ‘painted on ’ to achieve a therapeutic effect.
III. A lotion should be shaken well first, then applied on the skin and allowed to dry.
next…..page
Considering instructions for Inunction.
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IV. The lotion tend to flake and fall off , they have to be reapplied as necessary. Before the re-application , the lotion or ointment should be completely removed from the skin.
V. The skin observe frequently after the application of ointment or lotion for any local skin irritation. Any skin irritation report immediately and application be discontinued.
VI. A thin coating of ointment is prefer to a thick layer, both for the economy of medications and for efficiency.
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VII. The nurse use a sterile/clean gloves depending upon the condition of the skin. The use of gloves of will prevent the cross infection and the effect of the treatment on the nurse.
VIII.When ointments are taken from large containers , prevent contamination of the stock jar. Take only sufficient medications for one application to the patient unit in order to prevent wastage. Once the applicator has touched the skin, never placed back into the container as contamination of the entire bottle may take place.
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IX. When lotion and ointments are applied , avoid introducing them into the EYES , MOUTH, RESPIRATORY PASSAGES
X. Look for the special instruction on the label. Follow these instructions carefully for a therapeutic effect.
XI. No ointment or lotion should be applied on any patient without the doctor’s orders.
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lotion should be ‘ rubbed in ’ instead of ‘painted on ’
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It is the method of placing medication into area of mucous membranes for either local or systemic effects is called “INSERTION” eg. NITROGLYCERIN tabs are inserted into tongue for – relief angina pain, suppositories into rectum or vagina as laxative or as antiseptics.
When keep the sublingual tabs – patient understand not to chew or swallow – must be slowly dissolved and absorbed through Blood vessels.
INSERTION
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The act of drawing an AIR, VAPOR, OR GAS into the Lungs.
Medications inhale for,LOCAL EFFECT ( Steam inhalations for relieve
congestion in the Respiratory Tract )GENERAL EFFECT ( Inhalation of Oxygen,
Anesthetics) Two Types of Inhalations
DRY INHALATION MOIST INHALATION.
INHALATIONS
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It is belonging the Inhalation of GASES, FUMES from volatile medications or Burning Medications. E.g.
i. Inhalation of General Anesthetics – Either, Chloroform, Nitrous Oxide ( using mask )
ii. O2 and CO2 Inhalation -(mask ,tent, catheter)iii. Inhalation of Volatile Medications – such as
menthol, aromatic spiritsiv. Inhalation of Strammonium and Belladonav. Aerosol Spray – a fine suspension of liquid –
Respiratory Tract. Nebulizers are used.
DRY INHALATIONS
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Breathing warm and moist air. The produced vaporizer – called STEAM /
MOIST INHALATION. The steam inhalation – moisture and the
heat , medicines also can use for acting as a respiratory antiseptics.
MOIST INHALATIONS
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MOIST INHALATION
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I. To relieve the Inflammation and Congestion of the mucous membrane of the respiratory tract and paranasal sinuses
II. To make symptomatic relief in acute cold and sinusitis.
III. To soften thick , tenacious mucous and help them expulsion from the respiratory tract.
IV. To relieve symptoms of cough in bronchitis , and in post operative cases.
Purpose of Steam Inhalation
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V. To provide heat and moisture and to prevent the dryness of the mucous membranes of the lung and upper respiratory passages following operations such as tracheostomy.
VI. To help in the absorption of Oxygen.VII. The relieve spasms of the larynx and
bronchus and bronchioles.VIII.To provide antiseptic action on the
respiratory tract. E.g. by using menthol , tincture benzoin etc.
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Tr. Benzoin – 5ml per 500ml of boiling water.
Methyl salicylate – few drops per 500ml of boiling water.
Menthol - few crystals per 500ml of boiling water.
Camphor – few crystals per 500ml of boiling water.
Which medications can be used for Moist Inhalations ?
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Now we see the methods using to give STEAM INHALATION.
Use 03 MethodsUsing by JUG METHOD.Using by STEAM TENT.Using by ELECTRIC STEAM
INHALER.
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A Nelson’s Inhaler is used. In this method inhalent require and the
boiling water filling the jug(inhaler) and the patient breaths vapour.
At the home ( no nelson’s inhaler) patient can be taught to modified the jug. A tea kettle or a mug fill with boiling water and the inhalent. A cone is made with cardboard and fit over the kettle or a mug.
A small hole cut on the top of cone and breaths in the steam.
JUG METHOD
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This method is used for when a high concentration of steam is required.
There are different methods use a making tent.
The quick and easy method – place a screen on either sides on the patient’s bed and stretch blankets or sheets across them and fix with safety pins and forming canopy. Steam can be directed in to the tent from the spout of a kettle.
Ctd…. With Next slide…….
Steam tent Method
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Care should be taken that the stove and the kettle are placed for AWAY FROM THE SCREEN and THE BED CLOTHES to prevent of fire.
Never point the spout towards the face of the patient.
A child never be near to the steam generating apparatus to get child’s hand into the steam jet.
The steam is given for 20 – 30minutes , repeat every 04hrly.
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Small electric vaporizer is used to give steam inhalation.
A small jar with a heating element extending into the jar. The jar is filled with water, top of the jar is a removable perforated cup to which is attached a small metal spout. Cotton saturated with medication is placed inside the cup and metal spout is fitted over the cup. As the water boils, the medication steam is directed through the spout is inhaled by the patient.
Method used in Electric Steam Inhaler
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Follow the instructions when giving THE STEAM INHALATION
REMEMBER – danger involved of scalding the patient by STEAM or BOILED WATER COMING OUT of the inhaler. Important when the patient is , very old, Very young, actually ill or in state of confusion. The spout of the inhaler placed in that the patient can’t touch it or put the patient’s face too near.
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When jug or kettle is used , fill it only 2/3 of boiling water to prevent scalding of the patient. If the inhaler is filled to the brim, possible to draw water into the mouth and scalding the patient. The water must be remained just below the spout. If the spout is filled with the water , it will not act as an air inlet, the patient will not get warmed air.
Always remember the danger of fire. If a stove is used with a kettle to generate steam continuously ,as steam tent, the blankets used may fall on the stove and catch fire.
See Next slide.
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The temperature for jug method – 120 – 1600F , If water is cold, not produced steam. If water is too hot , cause scalding of the patient.
Keep the patient – warm and prevent DRAUGHT before, during and after the inhalation.Causing the treatment is the blood vessels of
the skin and mucous membrane dilate and the patient is easily chilled by exposed to draught. It will patient to more severe and prolonged attack of inflammation and congestion. The patient not to go into cold spaces for several hours after treatment. Remain in the bed.
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If volatile drugs are used ( e.g – Menthol ) warm the patient to keep his eyes closed to prevent the drug irritating the conjunctiva.
Observe the patient closely throughout the procedure for adverse effects.
When give inhalation by jug method , keep spout away from the patient.
Place the sputum cup in the reach of the patient to spit the coughed up during the inhalation.
Explain the procedure to the patient before preparation of the inhalation. Not during procedure.
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Preliminary Assessment: Check the patient’s Name, BHT ,
for identifications. Find the medical diagnosis and
general condition of the patient. See the physician’s orders to
find the specific precautions of movements and position.
Nurse’s Responsibility for Administration of Steam Inhalation.
USING A NELSON’S INHALER
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Assess the patient’s ability for self care , move, and maintain the relevant position.
Assess the level of consciousness and the ability to follow given instruction by nurse.
Find out the articles available in the patient’s unit.
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Articles Purpose 1. Nelson’s inhaler with mouth piece , tightly fit to the neck of the inhaler
1.To use as a vaporizer
2. Bowel or basin – hold the inhaler
2. To place the inhaler safety.
3. Flannel/Towel 3. To wrap the inhaler for prevent heat loss
4. Face towel 4. To wipe the face
Preparation of the Articles – A Tray Containing
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5. Bath Blanket or bath towel
Put over patient’s head ,
6. Tincture benzoin or any other inhalant ordered.
Used as a respiratory antiseptic.
7. Teaspoon or a minim glass.
To measure the inhalant.
8. Kettle- boiling water.
9. Gauze piece. To wrap the mouth.
10.Cotton swab To plug the spout.
11. Kidney tray /paper To collect wastes.
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Explain the procedure – get confidence and cooperation of the patient.
Explain sequence of the procedure and tell patient how can take the inhalation.
Make the patient understand that remain in the bed one – two hours more after inhalation.
Ask the patient want to go to the wash room and empty the bladder and bowels. For bed ridden patient , offer bedpan/urinal.
Patient and environment prepare
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Keep patient in a fowler’s position with bed table. If the movements are restricted, keep the patient in a side lying position or any position is comfortable to patient. ( eg. Sitting with a pillow on the lap )
Close the doors and windows and put off the fan to prevent draught.
Place the sputum cup in a convenient place within the easy reach of the patient.
Provide the face towel to wipe the sweating from the face during the inhalation.
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Steps of procedure Rationale1. Measure the capacity of inhaler with water. ½ - 2/3 filled capacity.
To determine the amount of inhalant.
2. Warm – inhaler by little hot water into the jug and emptying it.
To maintain the temperature of the water , constantly.
3. Pour the required amount of inhalant and filled the jug 2/3 with hot water, below spout.
If inhaler filled to the brim , possibility of drawing water to mouth and scalds.
Procedure
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4. Place the mouth piece and close the jug tightly . See the mouth piece is in the opposite direction to the spout.
Keep the spout away from the patient when inhalation is taken.
5. Cover the mouth piece and plug the spout with cotton ball.
To prevent burns of lip. Cotton ball in spout prevent escape steam.
6. Cover the jug with a flannel piece or a towel
To insulate the jug and to prevent the heat loss.
7. Place the inhaler in the bowel and take bed side without losing time
Placing the jug in the bowel reduces the chances for burns.
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8. Place the apparatus conveniently in front of the patient with the spout opposite to the patient. Remove cotton plug.
To reduces the chances of burns. Removing cotton plug helps to keep up patency of spout for the air.
9. Instruct - place the lip on mouth piece and breath in the vapor. Breath Steam - nostrils
Relieve the congestion of mucous membrane.
Cover the patient’s head and jug with a bath blanket or a towel
To help collect steam around the face, steam concentration increase
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Continue treatment for - 15 to 20 minutes. Remove the inhaler , after stated time,
Wipe off the perspiration from the face. Remove – back rest , bed table. Adjust
position of the patient in bed. Make comfortable. Tidy up the bed.
Instruct patient to remain in bed for 1-2hrs to prevent draught.
see next slide…
After care – patient and Articles
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Take the articles to the utility room. Empty the inhaler, clean, wash with warm soapy water. Rinse with clean water. Removing the gauze covering the mouth piece and clean the mouth piece thoroughly. Boil mouth piece to prevent cross infection. All the other articles are washed soapy water and clean water. Dry and replace proper place. Wash hands.
Record the procedure on nurse’s notes with date ,time, patient’s response to the procedure.
Return to patient, assess comfort, offer hot drink if needed.
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OXYGEN INHALATIONS Patients with respiratory impairment are treated
by Oxygen Inhalation – relieve HYPOXAEMIA ( deficiency O2 in the blood)
The normal amount of O2 in arterial blood – 80-100mmHg.
If fall these to below 60mmHg - irreversible physiologic effect occur.
Tissues vary O2 requirements. Cerebral cell get 20% of body body’s O2 supply and live only few minutes ( 5-7min) for cutoff O2
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1. Cyanosis : bluish colour of the skin, nail beds and mucous membranes, resulting from a decreased amount of oxygen in the Hemoglobin of the blood.
2. Breathlessness : caused by disease such as asthma, emphysema, pulmonary embolism, coronary thrombosis, cardiac insufficiencies.
3. An environment low in oxygen content : high altitudes
Oxygen therapy – Indications
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4. Anemia : deficiency of either quality or quantity of red corpuscles in the blood giving rise to symptoms of anemia.
5. Diseases or condition in the oxygen across the alveolar-capillary membranes – pulmonary edema, pneumonia, chest trauma.
6. Patient with respiratory capacity is diminished by diseases or conditions : atelectasis , pneumenectomy, thoracoplasty.
7. Poisoning – chemical alter the tissue’s ability to utilize oxygen , cyanide poisoning.
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8. Shock and respiratory failure.9. Hemorrhage and air hunger.10. Patient under anesthesia.11. Patients who are critically ill.12. Patients with psychologically induced
breathlessness.13. Asphyxia :condition in lack of oxygen in
the lungs leading to unconsciousness caused by blocking of the air passage by foreign bodies, drowning, electrical shock, strangulation, inhalation of poisonous gases.
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Depending factors
Oxygen administration - Methods
1. Condition of the patient
2. The concentration to be given
3. The facillitate available
4. Preference of the physician
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A simple comfortable device. The two cannula about 1.5cm (1/2inch) long, protrude from the center on the tube end and insert into the nares. Flow rate up to 4L/min.
Nasal Cannula
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Most common Method. Catheter inserted into the nostril reaching
up to the uvula. Catheter not interfere the patients freedom
to eat , talk , move on the bed. Flow – 1 -4 L/min – 22% - 30% oxygen. Catheter changed – 8hrly.
Oxygen by Nasal Catheter
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A devised used to administer oxygen , humidity or heated humidity.
Two primary types of mask.High concentrationLow concentration
Masks are advantageous for patient with unable to breath through the nose.
B.L.B. ( Boothby , Lovelace and Bullbulian) masks - rebreathing bags consisting of a face mask attached to a reservoir bag.
Oxygen by Mask
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A plastic face mask with a reservoir bag and a venturi mask – capable of delivering higher concentration of oxygen. When use as a non – breather , the plastic face mask with a reservoir can deliver from 80% - 90% oxygen, ( 70% when used as rebreather ) with a flow rate of 10L/min.
The venturi mask – deliver oxygen concentration of 24% to 28% , 30%,35%, 40%, 55% with oxygen flow rates of 2 to 3,4,6,8.14L.min
Simple face mask – short oxygen therapy. 30 – 50% , flow rate 8 to 12L/min
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Canopy over the patient’s bed that may cover the patient fully or partially , and connected to a supply of oxygen.
Canopy – transparent , observe for nurses. Advantages of using oxygen tent:
Provide environment for the patient with controlled oxygen concentration , temperature regulation and humidity controlled.
Allows freedom for free movement in bed.
Oxygen Tent
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Disadvantages of using oxygen tent:Create a feeling of isolation.Requires high volume of oxygen ( 10 – 12
L/min ) , cannot be made available ordinarily.Loss of desired concentration occurs each
time the tent is opened to provide care for the patient.
There is an increased chances of fire.Requires much time and effort to clean an
maintain a tent.The “infant incubator” is like an oxygen tent designed to maintain a constant temperature.
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A method used for delivery of oxygen to chronic lung diseases, insert – small IV catheter directly into the trachea through a surgical tract in the lower neck.
Advantage in patient with require continuous oxygen administration for following reasons.Less expensive – No loss of oxygenOxygen reaches directly – adequate oxygenation.Patient tend to use oxygen – mobility, comfort and
cosmetic improvement.Additional humidification is not needed.
Transtracheal Oxygen
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O2 Supply by,
Cylinder of Tanks
Store under pressure of 2200pounds ( 1000kgs) per sq.inch.
Hospital provide piped in oxygen.
How to supply of Oxygen
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Use the cylinders with a metal case to prevent the danger of falling and breaking
Placed at the head end of the bed, away from the traffic areas likely to be knocked down.
Any sources of fire should be kept away from the cylinder. Oxygen is not explosive, but it supports combustion, that a spark of flames can cause a major fire.
Care of the Oxygen Cylinders
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Store – cool , away from heaters. ( high Temp. expansion of the gas, loss gas through safety valves )
The supply of oxygen must always be equipped with a regulator to control flow.
Avoid grease on the regulator – in high O2 concentration tend to fire and explode.
Every Nurse , PATIENT, his FAMILY members and VISITORS aware of the danger of fire and explosion in an oxygen therapy unit. WARNING SIGNS indicate - NO SMOKING , ultra sound electric devices and open flames banned. Teach the patient/visitors- danger.
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CYLINDER – EMPTY , MARK – ‘ EMPTY’ and Send for filling.
Inspect the apparatus at frequent interval and make sure for its good working condition.
The nurse should learn working of cylinders, regulators, etc. The cylinder is opened by turning the large valve at the end of the cylinder with a spanner, by turning it anti-clock wise. The wheel valve at the side of regulator is opened by turning at anti-clockwise.
To test any leakage – regulator , soap lather used , if leak – bubbles are seen.
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Infection Combustion ( fire ) Dry – mucous membrane of respiratory tract Oxygen toxicity Atelectasis Oxygen induced apnea Retrolental fibroplasia – for premature infant Asphyxia
Hazards related to Oxygen Inhalation
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Since O2 acts as a drug, must be prescribed and administered in specific dose in order to avoid O2 toxicity. ( concentration and rate of flow )
Using an oxygen cylinder , use a regulator and humidifier.Regulator – to reduce the pressure of the oxygen in
cylinder to a safer level. Flow 2-4L/mHumidifier – saturate the O2 with water vapor to
prevent the drying of the mucous membrane of respiratory tract.
General instruction to give Oxygen Inhalation
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Every part of the apparatus – clean to prevent infection. Use disposable catheter.
Change the nasal catheters – at least 8hrs. During the administration of oxygen –
valve controlling the rate of flow should not be handled.
Oxygen administration never stop until the factors that caused hypoxia are reversed.
When oxygen therapy is discontinued, done gradually. The patient is weaned from dependence on oxygen by reducing the dosage and then administering it intermittently.
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All patients receiving oxygen inhalation , Temp. taken rectally to get an accurate record of body temperature.
The nurse leaves the patient - call signal near patient.
Pay attention to condition that can interfere with the flow of oxygen from the source to a patient., kinks in the tubing, loose connection , faulty humidifying ,
To prevent the deprivation of oxygen resulting from the depletion of oxygen from the cylinder, - get new one ready at hand
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For fear of rectolental fibroplasia the premature babies are given oxygen inhalation only for a short period at a very low concentration.
Watch the patients receiving oxygen therapy continuously to detect the early sigs of oxygen toxicity.
When oxygen is administered through nasal catheters, the catheter is not directed beyond the uvula to prevent distention of abdomen.
Fire precautions are taken when O2 on flow.
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PRELIMINARY ASSESSMENTCheck – Name, BHT, identification of patientSee –diagnosis and the need for O2 therapy.Check the doctor’s orders for the initiation
of the of the therapy, the dosage ( L/minute)Check the specific precautions regarding
the movement and positioning of the patient.Assess the patient – signs of clinical anoxia
NURSES RESPONSIBILITY IN THE ADMINISTRATION OF OXYGEN BY
CATHETER METHOD
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Assess the patient’s vital signs and the breathing patterns carefully before starting the therapy.
Check the results of arterial blood gas analysis.
Note any signs of pulmonary dysfunction. Inspect the anterior nares for encrustation
and irritation. Inspect the skin on the nose and the
surrounding areas for any skin lesions. Check – patient’s mental state and ability to
follow instructions. Check – articles available in the unit.
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Articles Purpose A. Oxygen Cylinder- stand, regulator, flow meter, humidifier, connecting tube )B. A Tray containing:i. Nasal catheterii. Lubri: jelly (W.S.)iii. Adhesive tapeiv. Bowl of waterv. Flash light
To administration O2.To lubricate catheter.Catheter in place.To test O2 flow.Assess placement.
Preparation of Articles
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vi. Tongue depressorvii.Cotton applicators
and normal saline in a container.
viii.Kidney tray and paper bag.
ix. Mackintosh and towel.
x. Rag piece or gauze piece in a container.
To clean the nostrils
To receive the wastes and used tongue dep.To protect the garment and clothesTo wipe off the secretions from the nose and mouth during the procedure.
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Explain procedure – get co operation and confidence. Explain sequence of procedure. Relieve anxiety. Explain purposes.
Instruct – patient, family , visitors, safety… Remove – cigar, matches , electric app. Assemble – articles conveniently in the unit. Place patient –comfortable fowler’s position Clean nostrils – if crust Protect the bed and garments - towel
Preparation of the patient and Environment
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Steps of procedure Rationale 1. Wash hands
2. Measure – catheter. Tip of the nose to ear lobe.Mark length
3. Check – apparatus working, open main valve, open wheel valve. Adjust flow.
To prevent cross infectionFrom anterior nares to level of uvula. If not reach oropharynx O2 loss by open mouth.Checking apparatus before inserting the catheter. Find oxygen.
procedure
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4. Lubricate the tip of catheter sparingly with water soluble jelly and check flow.
5. Introduce catheter slowly one nares. Never use force
6. Check – position catheter in oropharynx.
7. Fix the catheter- forehead/cheek
Lubricate prevent irritation of nasal mucosa. Check flow of oxygen again under the water.Force cause injury. Also can kinking of tube in nasal cavity.Make sure catheter is correct place and not kinked.Prevents displacement when patient move.
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Stay with patient till – ease. Keep – warm and comfortable of patient. Evaluate – patient’s progress, by checking
vital signs and colour. Record the procedure- date, time, on nurses
notes, patient’s response also record. Check apparatus - flow, level of humidifier,
safety measures.
After care of the patient and articles
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Arrange – blood gas analysis , state of anoxaemia is treated.
Change – nasal catheter – every 8hours or more frequently.
When the oxygen is to be stopped, do it gradually. Reduce the volume of oxygen 1st, then give it intermittently.
To discontinue – loosen adhesive tape and take out catheter. Close main valve. Discontinued catheter put the kidney tray.
Watch – patient for any deteriorating symptoms after remove oxygen inhaltion.
