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Oral administration (1) (2) (2)

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NURSING
PRACTICE &
SKILL
Administration of Medication: Oral, Sublingual, and
Buccal
What is Involved in the Administration of Oral, Sublingual,
and Buccal Medication?
› The most commonly prescribed medications are those that are swallowed (i.e., via the
oral route) or those that are dissolved under the tongue (i.e., via the sublingual route) or
between the mucous membranes of the gum and cheek (i.e., via the buccal route)
• What: Oral medications are formulated in liquid suspension form or tablets that
are swallowed whole or chewed. These medications are digested and absorbed via
the gastrointestinal system; passing through the gastrointestinal system reduces the
concentration of the drug and delays its absorption into the bloodstream. Sublingual and
buccal medications are available in small, rapidly-dissolving tablets, sprays, lozenges, or
liquids; these medications are absorbed transmucosally (i.e., across the oral mucosa into
the bloodstream)
• How: The clinician who will administer the medication first verifies the patient’s
identity and the treating clinician’s order. The clinician then applies nonsterile gloves,
if necessary, and administers the medication as prescribed. For oral medications,
the patient is instructed to swallow (or chew, and then swallow) the medication. For
sublingual or buccal medications, the patient is instructed to hold the medication under
the tongue or against the mucous membranes of the gums and cheek, respectively, until
the medication is dissolved completely
• Where: Oral, sublingual, and buccal medication is administered in outpatient and
inpatient care areas and in the home-care setting
• Who: Physicians, nurses, and other licensed clinicians administer medications via the
oral, sublingual, and buccal routes. With appropriate patient and family education,
self-administration of these medications may occur in the home
What is the Desired Outcome of Administration of Oral,
Sublingual, and Buccal Medication?
Authors
Carita Caple, RN, BSN, MSHS
Cinahl Information Systems, Glendale, CA
Tanja Schub, BS
Cinahl Information Systems, Glendale, CA
Reviewers
Eliza Schub, RN, BSN
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
April 27, 2018
› The desired outcome of administration of oral, sublingual, and buccal medication is for
the medication to have the intended effect without adverse effects
Why is Administration of Oral, Sublingual, and Buccal
Medication Important?
› Oral, sublingual and buccal medications are convenient and easy for clinicians to
administer, and most patients are comfortable taking medication by these routes; even
children can be taught how to swallow medications in pill or liquid form. However,
there are certain considerations the clinician must take into account when administering
medications orally or transmucosally. (For details, see What You Need to Know Before
Administration of Oral, Sublingual, and Buccal Medications, below)
› Most medications are available in oral form, which offers convenient administration
and predictable absorption via the digestive tract in patients with normal gastrointestinal
functioning. Sublingual and buccal medications are ordered when more rapid delivery
of a medication is required due to the fact that the medication quickly traverses the
oral mucosa and enters the systemic circulation, or are ordered when absorption via
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
the gastrointestinal tract is not possible (e.g., when gastric enzymes would impair the
effectiveness of the medication)
Facts and Figures
› Increasingly, antineoplastic drugs are becoming available in oral form. In 2010, of the approximately 1.5% of health
insurance beneficiaries in the United States who received treatment with an antineoplastic drug, an estimated 16% received
oral chemotherapy. This percentage is expected to increase in the next few years because 25% of the approximately 400 new
chemotherapy drugs that are in development will be administered orally (Neuss et al., 2013)
• Oral chemotherapeutic drugs have several benefits over parenterally administered drugs, including reduced costs and
eliminating the need for needle placement and clinic visits for medication administration. Importantly, the increased use
of oral antineoplastic drugs shifts some of the responsibilities that have typically been borne by healthcare providers to
the patient and medication adherence has become an issue. Researchers in Japan surveyed 62 nurses and found that nurses
were less likely to discuss adherence with patients with refilled prescriptions than with new patients, suggesting that a more
systematic approach may be warranted (Komatsu et al., 2014)
• Standardized assessment tools can be used by nurses to assess patient-reported outcomes in response to oral antineoplastic
drugs and improve the quality of outpatient cancer care. Researchers who assessed1,235 patients using the revised
Edmonton Symptom Assessment System (ESAS-r) found that based on patient responses, 5% of symptoms were
categorized as mild, 11.9% of symptoms were categorized as moderate, and 5.6% of symptoms were categorized as severe
(Mackler et al., 2017)
• Nurse clinicians who administer oral chemotherapy drugs should be aware that many of the potential adverse effects of
antineoplastic medications are not diminished when the drugs are in oral form and that counseling on safe handling of oral
chemotherapeutic drugs must be given to patients and their families. For more information on guidelines for administration
of oral chemotherapy drugs, see the 2013 Updated American Society of Clinical Oncology/Oncology Nursing Society
Chemotherapy Administration Safety Standards Including Standards for the Safe Administration and Management of Oral
Chemotherapy (Neuss et al., 2013)
• The results of clinical trials indicate that edoxaban, a direct oral anticoagulant drug newly approved by the Food and
Drug Administration, is not inferior to warfarin for management of venous thromboembolism and stroke risk reduction in
patients with nonvalvular atrial fibrillation, but is associated with a higher risk for stroke than warfarin (Poulakos et al.,
2017)
What You Need to Know Before Administration of Oral, Sublingual, and Buccal
Medication
› Knowledge of the prescribed medication, including its indications, potential adverse effects, usual dosages, and method of
administration is important
• Verification of the 6 “rights” of medication administration, which are the right patient, right drug, right dose, right route,
right time, and right documentation following administration, is important to prevent medication administration errors.
Additional rights to consider include the right reason, right response, right to refuse, and right to be educated
•
• The clinician should demonstrate competence in assessment of vital signs, EKG interpretation, and neurologic status
assessment prior to administration of vasoactive or sedative/analgesic drugs. The clinician should demonstrate competence
in adherence to standard precautions for infection control
› Understanding of contraindications and special considerations that must be made regarding administration of oral,
sublingual, and buccal medications is important
• Oral medications should not be administered to patients
–with impaired gastrointestinal functioning(e.g., decreased peristalsis)
–with impaired ability to swallow or altered level of consciousness because of the risk for vomiting and aspiration
–with NPO (nothing by mouth) status
–who are receiving gastric suction
• Chewable medications may not be practical for patients who do not have adequate dentition
• Sublingual and buccal medications should not be administered to patients with oral injuries or cognitive impairment
• Administering oral medications together with food or drink can aid swallowing in children
• When administering medications by the oral or transmucosal route, the clinician should verify that
–oral medications are administered prior to medications that are absorbed transmucosally
–certain solid pills (e.g., sustained-release or enteric-coated medications, capsules, gel caps) are swallowed whole and not
crushed, broken, or chewed (for details, see Red Flags , below)
–the medication is correctly taken with food or taken independent of food or other medications, as prescribed or directed
by the pharmacist
–the patient is capable of swallowing, chewing, or holding the medication against the mucous membranes, as prescribed
(for details, see Red Flags , below)
–the patient is closely monitored for adverse effects of the medication
› Preliminary steps that should be performed before administering oral, sublingual, or buccal medications include the
following:
• Review the facility/unit protocol for oral, sublingual, or buccal medication administration, if one is available
• Review the treating clinician’s order for the prescribed medication and the condition being treated
• Verify completion of facility informed consent documents
–Typically, the general consent for treatment that is executed by patients at admission to a healthcare facility includes
provisions that encompass administration of medically necessary pharmacologic agents
• Review the patient’s medical history/medical record for
–contraindications to oral medication administration
–information about allergies (e.g., to latex, medications, or other substances); use alternative materials, as appropriate
› Gather supplies, which typically include the following:
• PPE (e.g., nonsterile or neoprene gloves, gown, mask, eye protection) according to facility/unit protocol, the type of drug
being administered, and risk for exposure to body fluids
• Medication administration record (MAR)
• Prescribed medication
• Medication cup; a graduated medication cup and/or oral syringe should be used if administering liquid suspension
• Cup of water or other liquid
• Drinking straw (optional)
• Pill-crusher or a pill-cutter if necessary
• Soft food (e.g., applesauce, custard, gelatin) if medication will be crushed
• Facility-approved pain assessment tool
How to Administer Oral, Sublingual, and Buccal Medication
› Perform hand hygiene and don PPE as necessary
› Identify the patient according to facility protocol
› Establish privacy by closing the door to the patient’s room and/or drawing the curtain surrounding the patient’s bed
› Introduce yourself to the patient and family member(s), if present, and explain your clinical role; assess for knowledge
deficits and anxiety regarding administration of oral, sublingual, and/or buccal medication
• Determine if the patient/family requires special considerations regarding communication (e.g., due to illiteracy, language
barriers, or deafness); make arrangements to meet these needs if they are present
–Use a professional certified medical interpreter, either in person or via phone, when a language barrier exists
• Explain the procedure for administration of oral, sublingual, and/or buccal medication, its purpose, and potential adverse
effects; answer questions and provide emotional support as needed
› Assess the patient’s general health status, including his/her pain level using a facility-approved pain assessment tool
› Obtain verbal consent for initiating the procedure for administration of oral, sublingual, or buccal medication
› Prepare the medication, adhering to the first five of the 6 rights of medication administration
• Check the expiration date of the medication
• Compare the medication to the MAR to verify that the patient does not have a history of allergy to the drug
• Visually inspect the medication for loss of integrity
› Assess the patient according to the action of the drug (e.g., assess blood pressure and heart rate prior to administering a
vasoactive drug)
› If administering oral medication, obtain an adequate volume of water or other liquid to aid in swallowing
› Assist the patient to a sitting or high-Fowler’s position. If the patient is unable to elevate his or her torso, assist to a reverse
Trendelenburg position
›
› Administer prescribed medications in the following order: oral pills/capsules, followed by oral liquids, sublingual
medications, and buccal medications
›
• Using aseptic technique, place pills/capsules in the medication cup. Hand the medication to the patient and observe as he/
she places the medication in the mouth. Give the patient a cup of water to sip to aid in swallowing. Observe as the patient
drinks enough of the liquid to swallow the medication
–If the patient is at risk for aspiration due to unilateral weakness, place the pills/capsules in the stronger side of the mouth,
administering one pill/capsule at a time
–If necessary based on patient characteristics (e.g., age/developmental level, anticipated level of cooperation), check
patient’s mouth to make sure the medication has been swallowed
• If the patient has difficulty swallowing and a liquid formulation of the prescribed drug is not available, use a clean
pill-crushingdevice to grind the tablet, mix it in a teaspoon of soft food (e.g., applesauce, custard, gelatin), and ask the
patient to swallow it (for more information, see Red Flags , below)
•
• Draw up the prescribed amount of liquid suspension in an oral syringe or pour the medication into a graduated medicine
cup . Administer the liquid medication, and observe as the patient swallows all of the suspension
•
• Administer the sublingual or buccal medication by instructing the patient to hold the medication under the tongue for
sublingual medication or in the pocket between the gum and cheek for buccal medication until it is completely dissolved
–The patient may continue to swallow saliva that is in the mouth as the medication dissolves, but instruct him/her not to
swallow the pill itself
–If a sublingual spray is being administered, advise the patient not to inhale as the spray is being delivered
–If the patient has a dry mouth, he/she should take a sip of liquid prior to taking the sublingual or buccal medication
–When administering buccal medication, advise the patient to alternate between the left and right cheek pocket with each
subsequent dose to prevent mucosal irritation
–If two or more buccal medications are to be administered, instruct the patient to alternate between the left and right cheek
pocket so that the medication does not irritate the mucosa. If nitroglycerine is being administered, wait at least 5 minutes
before administering another pill to observe the full effect of the medication
› Remain with the patient until all medications have been swallowed
› Provide patient education regarding expected and adverse reactions of the medication
› Assist the patient to a comfortable position in the bed or chair
› Discard oral syringe, gloves, medicine cup, and other used materials in the appropriate receptacles
› Discard PPE, if worn, and perform hand hygiene
› Update the patient’s plan of care, as appropriate, make the appropriate notation in the MAR, and document the following
information in the patient’s medical record:
• Date and time the medication was prepared and administered
• Name of the medication, dose, and route of administration
• Patient assessment findings such as
–patient status prior to and after administration of the medication
–level of pain
• Patient’s response to the medication
• Any unexpected patient events, interventions performed, whether or not the treating clinician was notified, and patient
outcome
• All patient/family member education provided, including topics presented, response to education, plan for follow-up
education, barriers to communication, and techniques that promoted successful communication
Other Tests, Treatments, or Procedures That May be Necessary Before or After
Administration of Oral, Sublingual, and Buccal Medication
› Observe the patient for a response to the medication. Monitor for sensitivity or allergy after administering the first dose of a
new medication
What to Expect After Administration of Oral, Sublingual, and Buccal Medication
› Oral, sublingual, and buccal medications are administered according to the treating clinician’s orders and manufacturer
directions
› Standard precautions are maintained and the medication is administered without adverse effects
Red Flags
› If the patient is unable to take the medication as prescribed, notify the prescriber so that an adjustment to the medication can
be made
› Certain medications cannot be chewed, crushed, or broken because doing so leads to GI irritation and increased risk for
gastrointestinal bleeding, causes the medication to be absorbed too rapidly, and/or inactivates or lowers the effectiveness of
the drug. Refer to a drug information resource or licensed pharmacist if unsure whether or not a medication can be crushed
• The Institute for Safe Medication Practices (ISMP) has published a “Do Not Crush” list that specifies more than 300 oral
dosage forms of medications that should not be crushed and includes comments or reasons why the medication should be
administered intact. The Australian General Practice Network has published a list of medicines that should not be crushed
that includes suggestions for alternative forms of the drugs (see “Do Not Crush” and “Medicines that Should Not Be
Crushed” lists at https://www.ismp.org/recommendations/do-not-crush)
› Make sure to draw up liquid suspensions using an oral syringe and not a parenteral syringe. Unlike parenteral syringes, oral
syringes do not have Luer-lock tips to prevent accidentally connecting them to an I.V. port and administering by an incorrect
route
What Do I Need to Tell the Patient/Patient’s Family?
› Explain the purpose of medication administration and the steps involved, and address patient questions or concerns
› Educate patients taking sublingual or buccal medications to avoid eating or drinking until the medication is completely
dissolved. Smoking should be avoided because it causes vasoconstriction of blood vessels and slows transmucosal
absorption
› Provide contact information so that the treating clinician can be notified of discomfort or adverse medication effects as they
arise
References
1. Fyfe, K. P., & Nowak, A. K. (2014). Oral chemotherapy nurse: A trial position at Sir Charles Gairdner Hospital (SCGH), Perth, Western Australia. The Australian Journal of
Cancer Nursing, 15(1), 14-22. (RV)
2. Institute for Safe Medication Practices (ISMP). (2010). Preventing errors when administering drugs via an enteral feeding tube. Retrieved April 19, 2018, from
https://www.ismp.org/resources/preventing-errors-when-administering-drugs-enteral-feeding-tube (GI)
3. Komatsu, H., Yagasaki, K., & Yoshimura, K. (2014). Current nursing practice for patients on oral chemotherapy: A multicenter survey in Japan. BMC Research Notes, 7, 259.
doi:10.1186/1756-0500-7-259 (R)
4. Lynn, P. (2015). Administering oral medications. In Taylor’s clinical nursing skills: a nursing process approach (4th ed., pp. 169-182). Philadelphia, PA: Wolters Kluwer. (GI)
5. Mackler, E., Petersen, L., Severson, J, Blayney, D. W., Benitez, L. L., Early, C. R., ... Griggs, J. J. (2017). Implementing a method for evaluating patient-reported outcomes
associated with oral oncolytic therapy. Journal of Oncology Practice, 13(4), e395-e400. doi:10.1200/JOP.2016.018390 (R)
6. Neuss, M. N., Polovich, M., McNiff, K., Esper, P., Gilmore, T. R., LeFebvre, T. R., ... Joseph, O. (2013). 2013 updated American Society of Clinical Oncology/Oncology Nursing
Society chemotherapy administration safety standards including standards for the safe administration and management or oral chemotherapy. Journal of Oncology Practice,
9(2s), 5s-13s. doi:10.1200/JOP.2013.000874 (G)
7. Ostendorf, W. R. (2018). Safe medication preparation. In A. G. Perry, P. A. Potter, & W. R. Ostendorf (Eds.), Clinical nursing skills & techniques (9th ed., pp. 503-509). St.
Louis, MO: Elsevier Mosby. (GI)
8. Ostendorf, W. R., & Hall, A. M. (2017). Medication administration. In P. A. Potter, A. G. Perry, P. A. Stockert, & A. M. Hall (Eds.), Fundamentals of nursing (9th ed., pp.
615-616, 634-637, 655-659). St. Louis, MO: Elsevier Mosby. (GI)
9. Poulakos, M., Walker, J. N., Baig, U., & David, T. (2017). Edoxaban: A direct oral anticoagulant. American Journal of Health-System Pharmacy, 74(3), 117-129. doi:10.2146/
ajhp150821 (RV)
10. van Riet-Nales, D. A., Ferreira, J. A., Schobben, A. F., de Neef, B. J., Egberts, T. C., & Rademaker, C. M. (2015). Methods of administering oral formulations and child
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