Never apply medication without first removing previous applications to prevent skin irritation from an accumulation of medication.
Be sure to wear gloves to prevent absorption by your own skin. If the patient has an infectious skin condition, use sterile gloves and dispose of old dressings according to your facility's policy.
Don't apply ointments to mucous membranes as liberally as you would to skin because mucous membranes are usually moist and absorb ointment more quickly than skin does. Also, don't apply too much ointment to any skin area because it might cause irritation and discomfort, stain clothing and bedding, and make removal difficult.
Never apply ointment to the eyelids or ear canal unless ordered. The ointment might congeal and occlude the tear duct or ear canal.
Inspect the treated area frequently for adverse effects, such as signs of an allergic reaction.
Complications
Skin irritation, a rash, or an allergic reaction may occur.
Documentation
Record the medication applied; time, date, and site of application; and condition of the patient's skin at the time of application. Note the patient's tolerance and subsequent effects of the medication, if any.
TRANSDERMAL DRUGS
Through an adhesive patch or a measured dose of ointment applied to the skin, transdermal drugs deliver constant, controlled medication directly into the bloodstream for a prolonged systemic effect.
Medications available in transdermal form include nitroglycerin, used to control angina; scopolamine, used to treat motion sickness; estradiol, used for postmenopausal hormone replacement; clonidine, used to treat hypertension; nicotine, used for smoking cessation; and fentanyl, an opioid analgesic used to control chronic pain. Nitroglycerin ointment dilates coronary vessels for up to 4 hours; a nitroglycerin disk or pad can produce the same effect for as long as 24 hours. A scopolamine patch can relieve motion sickness for as long as 72 hours, transdermal estradiol lasts for up to 1 week, clonidine and nicotine patches last for 24 hours, and a fentanyl patch can last for up to 72 hours.
Contraindications for transdermal drug application include skin allergies or skin reactions to the drug. Transdermal drugs shouldn't be applied to broken or irritated skin because they would increase irritation, or to scarred or callused skin, which might impair absorption.
Implementation
Verify the order on the patient's medication record by checking it against the physician's order.
Wash your hands and, if necessary, put on gloves.
Check the label on the medication to make sure you'll be giving the correct drug in the correct dose. Note the expiration date.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Explain the procedure to the patient and provide privacy.
Remove any previously applied medication.
Applying transdermal ointment
Place the prescribed amount of ointment on the application strip or measuring paper, taking care not to get any on your skin. (See Applying nitroglycerin ointment, page 217.)
Apply the strip to any dry, hairless area of the body. Don't rub the ointment into the skin.
Tape the strip and ointment to the skin.
If desired, cover the application strip with the plastic wrap, and tape the wrap in place.
Applying a transdermal patch
Open the package and remove the patch.
Without touching the adhesive surface, remove the clear plastic backing.
Apply the patch to a dry, hairless area—behind the ear, for example, as with scopolamine. (See Applying a transdermal medication patch.)
Write the date, time, and your initials on the dressing.
After applying transdermal medications
Store the medication as ordered.
Instruct the patient to keep the area around the patch or ointment as dry as possible.
If you didn't wear gloves, wash your hands immediately after applying the patch or ointment to avoid absorbing the drug yourself.
Special considerations
Reapply daily transdermal medications at the same time every day to ensure a continuous effect, but alternate the application sites to avoid skin irritation. Before reapplying nitroglycerin ointment, remove the plastic wrap, application strip, and any remaining ointment from the patient's skin at the previous site.
When applying a scopolamine or fentanyl patch, instruct the patient not to drive or operate machinery until his response to the drug has been determined.
Warn a patient using a clonidine patch to check with his physician before taking an over-the-counter cough preparation because such drugs may counteract clonidine's effects.
Complications
Topical medications may cause skin irritation, such as pruritus and a rash. The patient may also suffer adverse effects of the specific drug administered. For example, transdermal nitroglycerin medications may cause headaches and, in elderly patients, orthostatic hypotension. Scopolamine has various adverse effects; dry mouth and drowsiness are the most common. Transdermal estradiol carries an increased risk of endometrial cancer, thromboembolic disease, and birth defects. Clonidine may cause severe rebound hypertension, especially if withdrawn suddenly.
Documentation
Record the type of medication; date, time, and site of application; and dose. Also note any adverse effects and the patient's response.
APPLYING NITROGLYCERIN OINTMENT
Unlike most topical medications, nitroglycerin ointment is used for its transdermal systemic effect. It's used to dilate the veins and arteries, thus improving cardiac perfusion in a patient with cardiac ischemia or angina pectoris.
To apply nitroglycerin ointment, start by taking the patient's baseline blood pressure so that you can compare it with later readings. Remove any previously applied nitroglycerin ointment. Gather your equipment. Nitroglycerin ointment, which is prescribed by the inch, comes with a rectangular piece of ruled paper to be used in applying the medication. Squeeze the prescribed amount of ointment onto the ruled paper (as shown below). Put on gloves, if desired, to avoid contact with the medication.
After measuring the correct amount of ointment, tape the paper—drug side down—directly to the skin (as shown at right). (Some facilities require you to use the paper to apply the medication to the patient's skin, usually on the chest or arm. Spread a thin layer of the ointment over a 3″ [7.6-cm] area.) For increased absorption, the physician may request that you cover the site with plastic wrap or a transparent semipermeable dressing.
After 5 minutes, record the patient's blood pressure. If it has dropped significantly and he has a headache (from vasodilation of blood vessels in his head), notify the physician immediately. He may reduce the dose. If the patient's blood pressure has dropped but he has no symptoms, instruct him to lie still until it returns to normal.
EYE MEDICATIONS
Eye medications—drops, ointments, and disks—serve diagnostic and therapeutic purposes. During an eye examination, eyedrops can be used to anesthetize the eye, dilate the pupil to facilitate examination, and stain the cornea to identify corneal abrasions, scars, and other anomalies. Eye medications can also be used to lubricate the eye, treat certain eye conditions (such as glaucoma and infections), protect the vision of neonates, and lubricate the eye socket for insertion of a prosthetic eye.
Understanding the ocular effects of medications is important because certain drugs may cause eye disorders or have serious ocular effects. For example, anticholinergics, which are commonly used during eye examinations, can precipitate acute glaucoma in patients with a predisposition to the disorder.
Equipment
Prescribed eye medication • patient's medication record and chart • gloves • warm water or normal saline solution • sterile gauze pads • facial tissues • optional: ocular dressing.
Preparation of equipment
Make sure the medication is labeled for ophthalmic use. Then check the expiration date. Remember to date the container the first time you use the medication. After it's opened, an eye medication may be used for a maximum of 2 weeks to avoid contamination.
Inspect ocular solutions for cloudiness, discoloration, and precipitation, but remember that some eye medications are suspensions and normally appear cloudy. Don't use any solution that appears abnormal. If the tip of an eye ointment tube has crusted, turn the tip on a sterile gauze pad to remove the crust.
Implementation
Verify the order on the patient's medication record by checking it against the physician's order on his chart.
Wash your hands.
Check the medication label against the patient's medication record.
NURSING ALERT Make sure you know which eye to treat because different medications or doses may be ordered for each eye.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Explain the procedure to the patient and provide privacy. Put on gloves.
If the patient is wearing an eye dressing, remove it by gently pulling it down and away from his forehead. Take care not to contaminate your hands.
Remove any discharge by cleaning around the eye with sterile gauze pads moistened with warm water or normal saline solution. With the patient's eye closed, clean from the inner to the outer canthus, using a fresh sterile gauze pad for each stroke.
To remove crusted secretions around the eye, moisten a gauze pad with warm water or normal saline solution. Ask the patient to close the eye, and then place the gauze pad over it for 1 or 2 minutes. Remove the pad, and then reapply moist sterile gauze pads, as necessary, until the secretions are soft enough to be removed without traumatizing the mucosa.
Have the patient sit or lie in the supine position. Instruct him to tilt his head back and toward the side of the affected eye so that excess medication can flow away from the tear duct, minimizing systemic absorption through the nasal mucosa.