Administering a Nasal Spray

Skill 5-19

Administering a Nasal Spray

Skill Variation: Administering Medication via Nasal Drops

Nasal instillations are used to treat allergies, sinus infections, and nasal congestion. Medications with a systemic effect, such as vasopressin or naloxone, may also be prepared as a nasal instillation. The nose is normally not a sterile cavity, but because of its connection with the sinuses, it is important to observe medical asepsis carefully when using nasal instillations.

The following skill describes the steps to administer a nasal spray. Medications may also be applied to the nasal mucous membrane via nasal drops. Refer to the accompanying Skill Variation for guidelines to administer medication via nasal drops.

Delegation Considerations

The administration of medication using a nasal spray is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, administration of a nasal spray may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Prescribed medication in nasal spray bottle
Gloves
Additional PPE, as indicated
Tissue
Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR)

Assessment

Assess the appropriateness of the drug for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Assess the nares for redness, erythema, edema, drainage, or tenderness. Assess the patient's knowledge of the medication and the procedure. If the patient has a knowledge deficit about the medication, this may be an appropriate time to begin education about the procedure. Assess the patient's ability to participate with the procedure. Verify patient name, dose, route, and time of administration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Knowledge deficiency
Risk for medication side effect
Impaired comfort

Outcome Identification and Planning

The expected outcomes to achieve are that the medication is administered successfully into the nose, and the patient experiences the intended effect of the medication. Other outcomes that may be appropriate include the following: the patient verbalizes an understanding of the medication regimen, the patient experiences no allergic response, and the patient experiences minimal discomfort.

Implementation

Action	Rationale
1. Gather equipment. Check each medication prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medication to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Perform hand hygiene.	Hand hygiene prevents the spread of microorganisms.
4. Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.	Organization facilitates error-free administration and saves time.
5. Unlock the medication supply system or drawer. Enter the passcode and scan employee identification, if required.	Locking the medication supply system or drawer safeguards each patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use. Entering the passcode and scanning ID allows only authorized users into the system and identifies the user for documentation by the computer.
6. Prepare medications for one patient at a time.	This prevents errors in medication administration.
7. Read the eMAR/MAR and read the label when selecting the proper medication from the patient's medication drawer or medication supply system.	This is the first check of the label.
8. Read the label and compare the label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.	This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary.
9. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, read the label and recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.	This third check ensures accuracy and helps to prevent errors. Note: Many facilities require the third check to occur at the bedside, after identifying the patient and before administration.
10. Log out of and/or lock the medication supply system before leaving it.	Locking the medication supply system or drawer safeguards the patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use.
11. Transport medications to the patient's bedside carefully and keep the medications in sight at all times.	Careful handling and close observation prevent accidental or deliberate disarrangement of medications.
12. Ensure that the patient receives the medications at the correct time.	Check facility policy, which may allow for administration within a period of 30 minutes before or 30 minutes after the designated time.
13. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
14. Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods (The Joint Commission, 2021):	Identifying the patient ensures the right patient receives the medications and helps prevent errors. The patient's room number or physical location is not used as an identifier (The Joint Commission, 2021). Replace the identification band if it is missing or inaccurate in any way.
a. Check the name on the patient's identification band.	This requires a response from the patient, but illness and strange surroundings often cause patients to be confused.
b. Check the identification number on the patient's identification band.
c. Check the birth date on the patient's identification band.
d. Ask the patient to state their name and birth date, based on facility policy.
15. Close the door to the room or pull the bedside curtain.	This provides patient privacy.
16. Complete necessary assessments before administering medications. Check the patient's allergy bracelet, if present, or ask the patient about allergies. Explain the purpose and action of each medication to the patient.	Assessment is a prerequisite to administration of medications.
17. Scan the bar code on the patient's identification band, if required (The Joint Commission, 2021) (Figure 1).	This provides an additional check to ensure that the medication is given to the right patient.
18. Based on facility policy, the third check of the label may occur at this point. If so, read the label and recheck the labels with the eMAR/MAR before administering the medications to the patient.	Many facilities require the third check to occur at the bedside, after identifying the patient and before administration. If facility policy directs the third check at this time, this third check ensures accuracy and helps to prevent errors.
19. Put on gloves.	Gloves protect the nurse from potential contact with contaminants and body fluids.
20. Provide the patient with paper tissues and ask them to blow their nose.	Blowing the nose clears the nasal mucosa prior to medication administration.
21. Assist the patient to the appropriate position for the specific medication; some nasal sprays are administered with the patient's head tilted back, while others are administered with the patient's head tilted forward. Refer to the package insert or a drug resource for the specific medication, or consult a pharmacist. Tilting the patient's head should be avoided if the patient has a cervical spine injury or other condition resulting in limited range of notion.	This positioning allows the spray to flow into the nares and maximize absorption. Patients requiring administration of intranasal corticosteroids are asked to tilt their head forward while the nurse sprays the medication laterally away from the septum (Sedaghat, 2017). Tilting the head is contraindicated with cervical spine injury.
22. Instruct the patient that it is necessary to inhale gently through the nose as the spray is being administered or not to inhale gently as the spray is being administered. Your instruction to the patient will depend on the medication being administered. Consult the manufacturer's instructions for each medication.	Inhalation helps to distribute the spray in the nares. Inhalation during administration is not recommended for some medications.
23. Agitate the bottle gently, if required for the specific medication. Insert the tip of the nosepiece of the bottle into one nostril (Figure 2). Close the opposite nostril with a finger. Instruct the patient to breathe in gently through the nostril, if required. Compress or activate the bottle to release one spray at the same time the patient breathes in.	This mixes the medication thoroughly to ensure a consistent dose of medication.
24. Keep the medication container compressed and remove it from the nostril. Release the container from the compressed state. Do not allow the container to return to its original position until it is removed from the patient's nose.	This prevents contamination of the contents of the container.
25. Have the patient hold their breath for a few seconds, and then breathe out slowly through their mouth. Repeat in the other nostril, as prescribed or indicated.	This allows the medication to remain in contact with nasal mucous membranes.
26. Wipe the outside of the bottle nose piece with a clean, dry tissue or cloth and replace the cap. Instruct the patient to avoid blowing their nose for 5 to 10 minutes, depending on the medication.	This keeps the end of the bottle clean. Avoiding nose blowing keeps the medication in contact with nasal mucous membranes.
27. Remove gloves. Perform hand hygiene. Assist the patient to a comfortable position.	Removing gloves and performing hand hygiene reduces the risk of contamination of other items and the spread of microorganisms. Assisting the patient to a comfortable position promotes patient comfort.
28. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk of infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
29. Document the administration of the medication immediately after administration. See Documentation section below.	Timely documentation helps to ensure patient safety.
30. Evaluate the patient's response to the procedure and medication within an appropriate time frame.	The patient needs to be evaluated for therapeutic and adverse effects from the medication.

Evaluation

The expected outcomes have been met when the medication was administered successfully into the nose, the patient has experienced the intended effect of the medication, the patient has verbalized an understanding of the medication regimen, the patient experienced no allergic response, and the patient experienced minimal discomfort.

Documentation

Guidelines

Document the administration of the medication, including date, time, dose, route of administration, and site of administration, specifically right, left, or both nares, on the eMAR/MAR or record using the required format. If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. Document pre- and post-administration assessments, characteristics of any drainage, and the patient's response to the treatment, if appropriate. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the health care team as appropriate. This verifies the reason medication was omitted and ensures that health care personnel providing care for the patient are aware of the occurrence.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient sneezes immediately after receiving nose spray: Do not repeat the dosage, because you cannot determine how much medication was actually absorbed.

Special Considerations

Ongoing assessment is an important part of nursing care to evaluate patient response to administered medications and early detection of adverse drug reactions. If an adverse effect is suspected, withhold further medication doses and notify the patient's health care team. Additional intervention is based on type of reaction and patient assessment.
Naloxone is a medication used to rapidly reverse opioid overdose (SAMHSA, 2020). Naloxone is given immediately when a suspected or known opioid overdose has occurred (MFMER, 2021d).Do not prime or test the nasal spray; it contains a single dose of naloxone and cannot be reused.The medication is inserted into each naris until the side of the nozzle is against the naris (MFMER, 2021d). The plunger is compressed to administer the dose and may be repeated every 2 to 3 minutes until the patient is responsive or additional emergency medical personnel arrive (MFMER, 2021d). Naloxone is also available for intramuscular, subcutaneous, and IV administration (SAMHSA, 2020).

Administering Medication via Nasal Drops

Prepare medication as outlined in Steps 1-18 above (Skill 5-19).

Put on gloves. Assist the patient to an upright position with their head tilted back.
Draw sufficient solution into the dropper for both nares. Do not return excess solution to the bottle to avoid contamination.
Have the patient breathe through their mouth. Hold the tip of the nose up and place the dropper just above the naris, about 1/3 inch. Instill the prescribed number of drops in one naris and then into the other. Avoid touching the naris with the dropper.
Have the patient remain in position with their head tilted back for 5 minutes to prevent the escape of the medication.
Remove gloves and any additional PPE, if used. Perform hand hygiene.
Document administration of the medication on the eMAR/MAR immediately after administering the medication. Document the site, if only one nostril is used.
Evaluate the patient's response to the medication within an appropriate time frame.

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Skill 5-19