Administering Nasal Medication

Nursing Procedure 5.4

Administering Nasal Medication

Delivers medication for local or systemic absorption through nasal membranes for such therapeutic effects as resolving infections, treating inflammation, and relieving congestion.

Doctor's order
Computerized medication administration record (or manual record if computerized record not available)
Barcode or electronic client and medication identification scanner, if available
Medication to be administered
Nonsterile gloves
Tissue
Pillow roll (or large towel made into pillow roll)
Wet washcloth
Pen

Assessment should focus on the following:

Condition of nasal mucosa
Patency of nasal airway
Evidence of bleeding or discharge
Respiratory character
Contraindications, if any, to client blowing nose
Client's ability to administer nasal medication
Client's knowledge about nasal medication and reason for use
Medication allergies or sensitivity to latex (if latex gloves used)

Nursing diagnoses may include the following:

Ineffective breathing pattern related to bronchial congestion and nasal inflammation

Outcome Identification and Planning

Desired Outcomes

Sample desired outcomes include the following:

Client's respirations are even and smooth, at rate of 16 breaths/min.
Client demonstrates clear nasal passage with pink septum.

Special Considerations in Planning and Implementation

Pediatric

If necessary, obtain the assistance of a parent to hold the child in position.

Geriatric

For older clients who have difficulty remembering, use a calendar to remind them when to use nose drops.

Home Health

Instruct client on how to administer nasal medications and provide information about the drugs involved. Caution client against overuse of nasal medications.

Transcultural

Instilling nasal medications involves touching the client's head, and in some cultures (e.g., Vietnamese), touching the head may be viewed as taking away the spirit. Consult the client, or parent if a child is involved, regarding what is culturally appropriate. Ask a family member to assist in positioning the client's head if necessary or desired.

Delegation

As a basic standard, medication preparation, teaching, and administration are done by a licensed registered or vocational nurse. Some drugs may be given by registered nurses only. Policies vary by agency and state. A registered nurse should observe the client for untoward reactions if there are potential medication side effects. BE SURE TO NOTE SPECIFIC AGENCY POLICIES FOR A GIVEN ROUTE AND DRUG BEFORE DELEGATING ADMINISTRATION!

[Outline]

Desired Outcomes
Special Considerations in Planning and Implementation

Action		Rationale
1	Perform hand hygiene and organize equipment.	Reduces microorganism transfer; promotes efficiency
2	Prepare medication to be administered, adhering to the five rights of drug administration (see Nursing Procedure 5.1). Use barcode scanning, if available.	Promotes safe drug administration
3	Identify client by scanning or visually checking (if scanning unavailable) identification bracelet and by addressing client by name.	Verifies identity of client
4	Explain procedure and purpose of medication to client.	Reduces anxiety; promotes cooperation
5	Verify any client allergies.	Prevents allergic reactions and injury
6	Don gloves.	Prevents contamination of hands; reduces risk of infection transmission
7	If excess mucus is noted in nares, instruct client to blow nose gently (unless contraindicated).	Clears nares for proper medication absorption
8	Wipe excess secretions with tissue.	Removes secretions and cleans skin
9	Lower side rails and place client in sitting position with head tilted slightly backward, or supine with head tilted back in a slightly hyperextended position (it may be necessary to place a pillow roll or rolled towel under client’s neck).	Facilitates channeling of drug through nasal passage for optimal absorption
10	Squeeze top of medication dropper with dominant hand.	Suctions solution into dropper
11	Stabilize client’s forehead with palm of nondominant hand while gently lifting nose open.	Prevents accidental damage to nasal mucosa if client suddenly tries to move head when dropper is in place
12	Without touching client’s nose or skin with dropper, hold dropper about ¼ to ½ in. above naris and tilt tip of dropper toward nasal septum (center of nose; Fig. 5.4).	Directs dropper to center of nose for proper placement of drug; avoids contaminating solution remaining in bottle
13	Squeeze top of dropper and deliver the appropriate number of drops.	Delivers correct dose of medication
14	Instruct client to take one short, deep breath and to remain in position for 3–5 min.	Facilitates full absorption of drug
15	Replace dropper in bottle.	Maintains medication sterility
16	Remove nasal secretions or solution from client’s skin (use warm, wet washcloth, if necessary).	Prevents local skin irritation and discomfort
17	Remove gloves and discard with soiled materials.	Reduces microorganism transfer
18	Perform hand hygiene.
19	Raise side rails and place call light within reach.	Reduces microorganism transfer Promotes safety; facilitates communication
20	Restore or discard all equipment appropriately.	Reduces microorganism transfer among clients; prepares equipment for future use
21	Document administration on medication record.	Provides legal record of medication administration; prevents accidental remedication

Were desired outcomes achieved? Examples of evaluation include:

Desired outcome met: Client exhibits respirations that are even and smooth, at rate of 16 breaths/min.
Desired outcome met: Nasal passage is clear; septum is pink.

The following should be noted on the client's record:

Name of drug, amount, route, and date and time administered
Assessment data relevant to purpose of medication
Effects of medication
Teaching of information about drug used and techniques of self-administration of medication

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Purpose ⬇

Equipment ⬆ ⬇

Assessment ⬆ ⬇

Nursing Diagnoses ⬆ ⬇

Outcome Id ⬆ ⬇

Implementation ⬆ ⬇

Evaluation ⬆ ⬇

Documentation ⬆