Medication Administration 2

Medication Administration 2 Inhaled medications o Most patients taking inhaled medications have a chronic respiratory disease such as asthma or chronic obstructive pulmonary disease (COPD). Because they depend on these medications to help control these conditions, proper instruction about the use of inhaled medications is essential. o Metered-dose inhalers (MDIs) and small-volume nebulizers are the two most common ways to administer inhaled medications. MDIs disperse medications into the lungs through mist, aerosol spray, or a fine powder. Small-volume nebulizers also deliver aerosolized medication. o MDIs are handheld devices that deliver a measured dose of medication with each push of the canister. It is important to instruct patients to depress the inhaler as the patient inhales. This helps ensure that the medication reaches the lower airways and not just the back of the throat. If patients have difficulty coordinating the breathing cycle with depressing the canister, they should use a spacer device. o Small-volume nebulizers are handheld devices that deliver medication continuously for a short period of time. Liquid medication is placed in a small container, the nebulizer is attached to air or oxygen, and the patient breathes in the mist. Adding moisture to the respiratory system helps clear secretions from the lungs. Patients who are unable to hold the nebulizer mouthpiece in their mouth should use an aerosol mask instead. o Patients who are receiving corticosteroids and using a metered-dose inhaler or a small-volume nebulizer should rinse their mouth with warm water after each treatment. o This reduces the risk of developing thrush, a yeast infection of the mouth that is also called oral candidiasis. It is a common complication of inhaled corticosteroid treatment. o Pediatric and older adult considerations  Both pediatric and older adult patients often have problems using metereddose inhalers properly because of the coordination required for depressing the canister at the right time during the breathing cycle. To help alleviate this problem, it is a good practice to teach both how to use a spacer device. Nasal medications o Nasal drops or sprays help relieve sinus congestion and common upper respiratory symptoms. Nasal drops that contain antibiotics are available with a prescription. They are most often prescribed to treat sinus infections. o Nasal sprays are most often used to relieve nasal congestion and to moisten the mucous membranes of the nose. They are commonly available over the counter. o Before administering nasal medications, make sure the patient blows his nose gently to clear mucus and secretions and thus allow for distribution of the medication into the nasal passages. o To make sure nasal drops reach the affected sinus, place the patient in a supine position with his head positioned properly. For the posterior pharynx, tilt the head backward; for the ethmoid or sphenoid sinus, tilt the head backward over the edge of the bed or over a small pillow; for the frontal and maxillary sinuses, tilt the head over the edge of bed or pillow with the head turned to the side. When administering nasal drops, keep the dropper away from the nares to avoid contaminating the dropper and the medication. o To administer a nasal spray effectively, have the patient sit upright with his head slightly hyperextended. Have the patient inhale through the nose while spraying. Caution patients who use nasal sprays about using them for a prolonged period of time. Prolonged use can increase mucosal swelling and nasal congestion can worsen. This is known as a rebound effect. o Many older adult patients can administer nasal medications independently. For those who cannot, be sure to teach family members or caregivers how to administer the medication safely and correctly. Nasogastric medications o Patients who have a nasogastric (NG) tube, or other enteral tube, in place are commonly given medications through the tube. If a medication is not available in liquid form, you must first crush it or open the capsule and empty the powder or granules and then dissolve the medication in sterile water. In general, do not administer sustained-release, chewable, long-acting, or enteric-coated tablets and capsules through an NG or enteral tube. If you are unsure about whether or not you can safely crush a tablet or open a capsule, consult a medication guide or a pharmacist. o Before administering medications through an NG or enteral tube, place the patient in high Fowler’s position and verify the placement of the tube in the stomach or, for a nasoenteric tube, in the small intestines. In most facilities, you’d aspirate a small amount of gastric contents through the NG or enteral tube with a syringe and then check the pH of the gastric contents while observing the color and appearance of the gastric or intestinal contents. o In addition to verifying placement, check gastric residual. Connect a syringe, usually a 60-mL syringe, to the end of the nasogastric or enteral tube, then pull back evenly and gently on the syringe to aspirate contents. Return gastric contents to the stomach. If the aspirate is greater than 100 mL, follow the agency policy about returning contents to the stomach and administering medications. Flush with 15 mL of sterile water. o If the patient is receiving a continuous feeding, do not mix the medications in the enteral feeding solution. Instead, stop the feeding for 30 minutes, give the medications, flush the tube with 15 to 30 mL (5 to 10 mL for pediatric patients) of sterile water and then resume the feeding after at least 30 minutes. After you administer medications, keep the head of the patient’s bed elevated for at least 1 hour. When administering medication through an NG or enteral tube, be sure to check your agency’s policy about stopping and resuming feedings before and after administering medications. o To keep an NG or enteral tube from becoming occluded, flush it with at least 15 to 30 mL (5 to 10 mL for pediatric patients) of sterile water before and after administering each medication and 15 to 30 mL (5 to 10 mL for pediatric patients) after you have given all the patient’s medications. o If an NG or enteral tube does become occluded, your first step is to try to irrigate it gently with the appropriate flush solution. If neither is successful in unblocking the tube, a new tube may have to be placed. Because policies for flushing and unblocking NG or enteral tubes can vary from facility to facility, be sure to familiarize yourself with your facility’s policies and follow them each time you are caring for a patient with an NG or enteral tube. Opthalamic medications o Ophthalmic medications include drops, ointments, and intraocular disks. Always considered sterile, they are often prescribed following cataract removal and to treat such eye conditions as glaucoma and infections. They are also used to soothe irritated tissue, to dilate or constrict the pupils, and to provide anesthesia. Because ophthalmic medications are available in a variety of concentrations, it is important to ensure that the patient is receiving the correct one so that the eye does not become irritated or damaged. o The cornea of the eye contains many sensitive nerve fibers and is easily irritated. When instilling eye medications, do not instill the medication directly onto the cornea. Place drops, ointments, and intraocular disks in the conjunctival sac. This area of the eye is much less sensitive and provides a more appropriate site for instilling ophthalmic medications. o Before instilling an ophthalmic medication, gently wipe away any drainage or discharge along the eyelid margin or inner canthus, starting at the inner canthus and moving toward the outer canthus. o Leaving either in place can harbor microorganisms, increase the risk of infection, and interfere with proper absorption of the medication. o When instilling ophthalmic medications, avoid touching the tip of the medication bottle or tube to the eye to avoid the transfer of micro-organisms to the medication and injury to the eye. When exposing the conjunctival sac, do not push on the eyeball or touch the eye. To expose the conjunctival sac and avoid injuring the eye, use a cotton ball or tissue and place your thumb or index finger against the patient’s cheekbone just below the lower eyelid and then pull the eyelid gently downward. o If the medication has the potential to produce systemic effects, apply gentle pressure to the nasolacrimal duct for 30 to 60 seconds. This helps keep the medication from entering the nasal and pharyngeal passages and being absorbed by the systemic circulation. o Pediatric and older adult considerations  To instill ophthalmic medications in a pediatric patient, it is often helpful to have the parent’s help. Ask the parent to hold the child on her lap and gently restrain the child’s head. If the patient refuses to open his eyes, place the medication at the nasal corner where the eyelids meet, so that when the patient opens his eyes, the medication will go into the eye.  Instilling eye drops (child)  Many older adult patients can instill ophthalmic medications independently. For those who cannot, be sure to teach family members or caregivers how to administer the medication safely and correctly. Oral, sublingual, and buccal medications o The oral route is probably the easiest and most often used route for administering medications. These medications have the potential to exert both local and systemic effects, and patients are usually able to take oral medications o o o o independently with very few problems. However, situations may arise that keep a patient from taking medications by this route. If a patient is nauseated, is vomiting, has decreased intestinal motility, is NPO (receiving nothing by mouth), cannot swallow, or has a nasogastric tube in place, another route must be used. Before administering oral medications, assess your patient for any swallowing problems. Make sure he is in a sitting position or in a side-lying position if unable to sit, to reduce his risk of aspirating or choking. Cutting and crushing tablets  When administering oral medications, it is sometimes necessary to give only a portion of a tablet. To break a scored tablet in half, use a cutting device to improve accuracy. If the tablet does not break evenly, discard it if your facility’s policy allows it and cut another tablet. If it is a controlled substance, follow your facility’s policy for discarding these medications. Keep in mind that it is difficult to confirm that you are giving the correct dose after you divide a tablet, so this is a practice best avoided if at all possible. Policies about this practice vary widely, so be sure you understand what your facility requires should this situation arise. Some might allow this practice only in the pharmacy, for example, or might prohibit nurses from dividing unscored tablets.  If a patient is unable to swallow pills, you may have to crush the medication and mix it with food or a beverage before administering it. When mixing the medication, use the smallest amount of food or fluid possible. Because medications can alter the taste of food, avoid mixing it with the patient’s favorite foods and beverages as this might diminish the patient’s desire to eat or drink them.  Whenever you cut or crush a medication, clean the pill cutter or mortar and pestle before and after use. It is a good practice to check with a pharmacist or a medication guide before cutting or crushing a medication. Some medications, such as sublingual, enteric-coated, and timed-release preparations, must not be cut or crushed. Buccal and sublingual medications  Sublingual medications are given under the tongue. Buccal medications are placed towards the back of the mouth between the upper or lower molars and the cheek. Both of these types of medication are absorbed through the mucous membranes of the mouth for rapid systemic effects. It is important to alternate from right to left sides to avoid mucosal irritation.  These medications are not to be chewed or swallowed, but instead should dissolve completely in the patient’s mouth to assure reaching therapeutic blood levels. If the patient is NPO, check your agency’s policy, but in most cases you can still give sublingual and buccal medications. Most patients can place these medications in their mouth by themselves. If you do have to place one of these medications in a patient’s mouth, be sure to wear gloves to avoid contact with the patient’s saliva. Liquid medications  Holding the medication bottle with the label toward the palm of your hand and the medicine cup at eye level, pour the prescribed dose into the cup.  To ensure accuracy, measure the medication at the base of the meniscus, not at the edges. After pouring the medication into the medicine cup, recap the container until the next time you administer it to this patient. Be sure you do not touch the container with the inside of the cap.  Stay at the bedside until the patient has taken the medication. Do not leave it at the bedside for the patient to take later. If the patient refuses the medication, follow facility policy for disposal. o Pediatric and older adult considerations  When administering oral medications to pediatric patients, liquids are often easier and safer to administer. If the medication has a bitter or bad taste, it may be helpful to mix it with a small amount of food, such as applesauce, pudding, or ice cream. Avoid mixing the medication with milk or formula as this may make the child refuse it later. If you’re administering a small amount of a medication, usually less than 1 teaspoon, use an oral dosing syringe or medicine spoon to measure the medication accurately. If the child’s parents are available and willing, ask them to give it to the child. Pediatric patients often take medications more willingly from a parent than from a nurse.  Most older adult patients can take oral medications without any problems. However, age-related physiological changes can influence how oral medications are distributed, absorbed, and excreted. Because of these changes, older adult patients can be at higher risk for medication toxicity. Otic medications o Medications instilled into the ear are called otic medications. They soften wax, relieve pain, and treat infection. Even though the outer ear is not considered sterile, sterile drops and solutions are used because, should the eardrum rupture, nonsterile drops or solutions placed in the ear could cause serious infections. o Before instilling otic medications, gently remove any cerumen or drainage blocking the outermost portion of the ear canal with a cotton-tipped applicator. The applicator should not be inserted in the ear canal. This prevents damage to the tympanic membrane. Both cerumen and drainage can harbor micro-organisms and prevent proper distribution of the medication. o To prevent dizziness and nausea, otic medications should be at room temperature before placing them in a patient’s ear. To help instill the medication in the right place, pull the pinna up and outward for adults and for children over the age of 3 years. When instilling the medication, avoid touching the ear with the dropper as this will contaminate the dropper and the medication. o Pediatric and older adult considerations  To instill otic medications in the ears of children younger than 3 years, gently pull the pinna down and back. It is often helpful to have the parents assist by asking them to hold the child in a supine position with the affected ear facing up. To help ensure that the medication is absorbed, keep the child in a supine position with head turned to the side for a short period of time. This ensures the medication reaches all areas of the ear canal.  Many older adult patients can administer otic medications independently. For those who cannot, be sure to teach family members or caregivers how to administer the medication safely and correctly. Rectal medications o Rectal medications are usually administered either for their local effect on the gastrointestinal mucosa to promote defecation or for their systemic effects for relieving nausea, providing analgesia, or reducing fever. Rectal medications should not be used for patients who have had rectal surgery or have active rectal bleeding. Most rectal medications are available with a prescription with a few, such as those to treat constipation or hemorrhoids, available over the counter. o Rectal suppositories are bullet-shaped and individually packaged. They should be refrigerated to keep them from melting. A suppository inserted into the rectum melts as a result of the patient’s body temperature and is thus distributed to rectal tissue. Suppositories should not be cut in half to divide the dose because the active medication might not be distributed evenly within the suppository, thus the intended dose might not be the dose given. o Most patients prefer inserting rectal medication themselves. This is acceptable for patients who are able to do so. Be sure to give them specific instructions for inserting a suppository properly to help ensure that the medication is instilled correctly and absorbed effectively. o For patients who cannot self-administer the medication, don gloves and then and then instill the medication by placing it past the internal anal sphincter and against the rectal mucosa, avoiding insertion into feces. If the suppository is inserted improperly, the patient might expel it before the medication can dissolve and be absorbed. Have the patient remain in left lateral or left Sims’ position for approximately 5 minutes afterward to ensure absorption of the medication. o When inserting rectal medications, use aseptic technique. Lubricate the rounded end of the suppository with a water-soluble lubricant before insertion. Instruct the patient to take slow, deep breaths through the mouth and to try to relax the anal sphincter. Doing this minimizes the discomfort of the insertion. o Pediatric and older adult considerations  Pediatric patients are often given rectal medications to reduce fever, to relieve nausea and vomiting, to provide analgesia, and sometimes to relieve constipation. Because children might have a difficult time keeping the suppository in place, hold the child’s buttocks together gently 5 to 10 minutes to keep the suppository in place.  Older adult patients might also have difficulty keeping the suppository in place due to a loss of sphincter control. In this situation, you might also have to hold the buttocks together gently so that the medication can dissolve and be absorbed. Teach patients who are inserting suppositories themselves about infection-control techniques for avoiding contact with and spreading fecal material. 6 rights o Learning to prepare and administer medications safely and accurately is an essential component of your nursing practice. It requires that you follow your facility’s policies and procedures carefully and always implement the six rights of medication administration: the right medication, the right dose, the right route, the right time, the right patient, and the right documentation. o The right medication  Determining that you have the right medication involves checking the medication label against the medication administration record (MAR) at least three times before you administer the medication. The exact times you perform these three checks depend on how the medication is stored and your facility’s policy, but in most situations you would check as you remove each medication from the storage area, as you prepare each medication, and at the patient’s bedside before you administer each medication. In addition to checking the label against the MAR to make sure you have the right medication, check also that you have the right dose, are planning to give it by the right route, and that it is the right time. Verify the medication’s expiration date at this time as well. o The right dose  Many facilities use a unit-dose system to help reduce the risk of medication errors. However, if your facility does not have a unit-dose system or you must prepare a medication from a larger volume or a different strength, you must perform conversions and dosage calculations. When you are new to practice or if you rarely perform calculations or are at all unsure about the dose, have another nurse double-check your work before you give the medication. Although policies differ from facility to facility, many require double-checking of doses of some medications, such as insulin and anticoagulants.  When administering oral medications, it is sometimes necessary to give only a portion of a tablet. To break a scored tablet in half, use a cutting device to improve accuracy. If the tablet does not break evenly, discard it, if your facility’s policy allows it, and cut another tablet. If it is a controlled substance, follow your facility’s policy for discarding these medications. Keep in mind that it is difficult to confirm that you are giving the correct dose after you divide a tablet, so this is a practice best avoided if at all possible. To promote patient safety in inpatient settings, pharmacists split the medication, label and package them, and send them to the unit for dispensing.  If a patient is unable to swallow pills, use a crushing device to crush a medication and mix it with food or a beverage before administering it. When mixing the medication, use the smallest amount of food or fluid possible. Because medications can alter the taste of food, avoid mixing it with the patient’s favorite foods and beverages as this might diminish the patient’s desire to eat or drink them.  Whenever you cut or crush a medication, clean the pill cutter or medication crusher before and after use. It is a good practice to check with a pharmacist or a medication guide before cutting or crushing a medication. Some medications, such as sublingual, enteric-coated, and timed-release preparations, must not be cut or crushed. Refer to the Institute for Safe Medication Practices (ISMP) website for a "Do Not Crush List". o The right route  The route you will use to administer the medication is indicated on the medication prescription. If this information is missing or the specified route is not the recommended route, notify the prescriber and ask for clarification. When giving an injection, verify that the preparation of the medication is intended for parenteral use. If you inject a preparation not intended for parenteral use, complications can result. Most medication manufacturers label parenteral medications “for injectable use only” to help prevent errors, so check the label carefully. o The right time  Medications are usually ordered to be given at certain frequencies, intervals, or times of day (such as “hour of sleep”). Become familiar with the medications you are giving, why they are ordered for certain times, and whether or not the time schedule is flexible. Some medications must be given around-the-clock to maintain a therapeutic blood level. Other medications should be given during the patient’s waking hours to allow uninterrupted sleep. Most facilities recommend a time schedule for administering medications ordered at specific intervals (q4h, q6h, q8h). Most facilities also have a policy indicating how soon before or how long after the scheduled time a medication can be administered. For routinely ordered medications, such as antibiotics, 30 minutes before or after the scheduled time is commonly acceptable. For example, if a medication is to be given at 0700, you can give it between 0630 and 0730 and still be administering it at the right time.  In certain situations, medications must be administered at times other than those indicated by the facility’s time schedule. For example, a preoperative medication might be ordered to be given “stat” (immediately) or “on call” (right before a procedure). When medications are ordered on a PRN (as needed) basis, use your clinical judgment to determine the right time. For example, when a pain medication is ordered q4-6h, assess your patient’s pain level to determine whether your patient needs another dose after 4 hours or can comfortably wait longer. o The right patient  Before giving a medication, make sure that you are giving it to the right patient. Check the patient’s identification band, name, and identification against the MAR. Ask the patient to state his or her full name. If the patient is confused or unresponsive, your two identifiers can consist of comparing the medical record number and the birth date on the MAR with the information on the patient’s identification band. If your patient is a child, ask the parents or legal guardian to identify the patient, in addition to comparing the information on the MAR with the information on the patient’s identification band. No matter how long you have been caring for the patient or how well you know the patient, each time you enter the room to administer a medication, you must use a minimum of two identifiers to confirm that you have the right patient. For facilities that use a barcoding system, the scanner may be used at this point by scanning the client’s wrist band, the nurse’s identification badge, and the medication label just prior to administering the medication. Importantly, these systems do not replace the nurse’s responsibility for safe medication administration. o The right documentation  Accurate documentation must be available before and after a medication is administered to ensure that it is prepared and administered safely. Medication orders should clearly state the patient’s first and last name, the name of the medication ordered, the dose, the route, the time the medication is to be administered, and the signature of the prescriber. If any of this information is missing, notify the prescriber before giving the medication. After you give a medication, document it in the MAR per agency policy. Never document that you gave a medication until you've actually given it. Failure to document or incorrect documentation can be considered a medication error in itself and can cause an error as well.  If the time of medication administration differs from the prescribed time, note the time on the MAR and explain the reason (e.g., pharmacy states medication will be available in 2 hours) in the nurse’s notes.  Following the six rights of medication administration and checking the medication label against the MAR three times each time you prepare and administer a medication might seem redundant and unnecessary. However, taking shortcuts and not following procedures greatly increases your chances of making a medication error. Even if your facility uses a barcoding system, the three check system for safe medication administration can be easily incorporated into any workflow. Topical medications o Topical medications include lotions, creams, ointments, patches, and pastes. They are applied to the skin on various parts of the body depending on the reason for the medication. Lotions, ointments, and creams usually produce a local effect. Transdermal medications, usually in the form of a patch, produce a systemic effect. o When applying a topical medication, cleanse the area first by gently washing it with soap and water to remove previously applied medication and any debris. Because dead tissue and encrustations can harbor microorganisms and keep the medication from absorbing, simply applying new medication over previously applied medication can increase the risk of infection and reduce the therapeutic effect of the medication. Assess the sites where topical medications prescribed for systemic effects have previously been applied; check for irritation and skin breakdown. Rotate the application site on a regular basis to prevent skin irritation. o Because topical medications are absorbed by the skin, wear gloves when applying them to protect yourself against accidental exposure. If the patient’s skin is intact, cleanse the skin using soap and water. However, if an open wound is present, surgical asepsis should be used. It is also important to follow the manufacturer’s instructions to ensure proper absorption of the medication. When using transdermal patches or nitroglycerin ointment, remove the previous dose before applying the new one to prevent an inadvertent overdose. o Nitroglycerin ointment  When the medication is in the form of an ointment or cream, such as in the case of nitroglycerin ointment, the order usually calls for applying a particular length of it. Each tube of medication comes with a special pad of measuring strips marked in inches or centimeters. You must use them to make sure you are administering an accurate dose. Secure the measuring strip to the skin to allow it to absorb gradually. Always label the patch or dressing with date, time, and initials. Do not massage or rub the ointment into the skin as this can cause the medication to be absorbed too rapidly. Document the removal of the patch or dressing and the location of the new patch or dressing in the MAR. Alert: Make sure you wear gloves when applying topical medications or patches to avoid receiving the effect of the medication. o Older adult considerations  Be aware of the many changes associated with aging skin and take them into consideration when applying topical medications. Apply lotions and creams gently to avoid bruising or damaging the skin. When removing a patch, do so slowly and carefully to avoid tearing or removing skin. Also, because skin becomes thinner with age, older patients tend to absorb topical medication more rapidly than younger patients do. Therefore, it is important when teaching older adult patients about their medications to make sure they are aware of the signs of toxicity. For those who use transdermal patches, emphasize the importance of removing the used patch before applying a new one. Vaginal medications o Vaginal medications treat vaginal infections, relieve discomfort, and alter the vagina’s pH to maintain normal flora. They are available as jellies, foams, creams, or suppositories. Medicated douches or irrigations are sometimes used. Some vaginal medications are available over the counter. o Vaginal suppositories are oval-shaped and individually packaged. They should be refrigerated to keep them from melting. A suppository inserted into the vagina melts as a result of the patient’s body temperature and is thus distributed to vaginal tissue. o Vaginal medications available as jellies, creams, or foams are usually instilled with an inserter or applicator. After instillation, patients may want to wear a perineal pad to absorb any excess medication. o Most patients prefer instilling a vaginal medication themselves. This is acceptable for patients who are able to do so. For patients who cannot, don gloves and then, using either an applicator or your gloved finger, instill the medication. Have the patient remain in a supine position for approximately 10 minutes afterward to ensure absorption of the medication. o When instillling vaginal medications, use clean technique and give the patient frequent opportunities to perform perineal hygiene. o Instruct patients who use vaginal medications to insert or apply all of the medication as prescribed, for the prescribed amount of time, to help ensure effective treatment. Advise them to continue using the medication even if they are actively menstruating. Tell patients taking antifungal medications to abstain from sexual intercourse until they have completed the entire medication course and the infection has resolved. Documentation o Documentation is an essential component of patient care. Not only does it provide information about the care you give and the status of your patient, but it also communicates information to other healthcare workers to help assure both quality and continuity. SBAR (Situation, Background, Assessment, Recommendation) is a form of charting used for handoffs, telephone prescriptions, or change-of-shift reporting. o The format used for documentation varies from agency to agency, so be sure to familiarize yourself with your agency’s format and follow it. Use only approved abbreviations and make sure all documentation is clear, concise, and legible. Maintain the privacy and confidentiality of patient information at all times. o Mandatory compliance with the privacy rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was introduced in 2003 to help ensure that patient information is kept confidential and to give patients more control over their personal healthcare information and who has access to it. HIPAA originally required written consent for disclosure of all patient information. Because this sometimes delayed the process of giving patients timely care, the act was revised. Now healthcare providers are only required to notify patients of their privacy policy and to make a reasonable effort to obtain written acknowledgment of this notification. o All healthcare providers, including students, have a legal and ethical obligation to follow HIPAA regulations. In clinical settings, students should gather the information from the patient’s medical record that they need to provide safe and efficient care. Any written material students prepare and share, submit, or distribute must exclude the patient’s name, room number, date of birth, medical record number, and any other identifiable demographic information. o Tips for documentation  In your documentation of medication administration, always include the name of the drug, the dose, the route, the time, your initials or signature, and any other information relevant to medication administration. If you withhold a drug or the patient refuses it, indicate this on the medication administration record (MAR) and document the reason in your nurses’ notes. Always document the patient’s response to the medication or treatment as well as the following information specific to each route of medication administration. o Oral, sublingual, and buccal medications  Appearance of the sublingual or buccal area  Any problems the patient has with swallowing  If the medication was crushed or mixed with a liquid or with food  o o o o o o o Response to the medication at times that correlate with onset, peak, and duration of the medication. Topical medications  Appearance of the skin before applying the topical medication  Site of application of the medication  Time the medication is to be removed, if it is to be removed  If removed, the appearance of the skin after removal Ophthalmic medications  Appearance of the eye(s) (redness, swelling)  Any drainage: amount, color, odor  If instilled in one eye only (and which one)  Changes in vision  Response to the medication at times that correlate with onset, peak, and duration of the medication. Otic medications  Appearance of the outer ear and ear canal  Any drainage: amount, color, odor  If instilled in one ear only (and which one)  Any changes in hearing  Response to the medication at times that correlate with onset, peak, and duration of the medication. Otic irrigations  Appearance of the outer ear and ear canal  Any drainage: amount, color, odor  If instilled in one ear only (and which one)  Any changes in hearing  Response to the medication at times that correlate with onset, peak, and duration of the medication. Nasal medications  Appearance of the inside and outside of the nose  Any drainage: amount, color, odor  Response to the medication at times that correlate with onset, peak, and duration of the medication. Nasogastric tube medications  Method used to confirm placement of the nasogastric tube  Amount of residual  Appearance and pH of gastric contents  Total amount of fluid used for administering the medication(s)  Response to the medication at times that correlate with onset, peak, and duration of the medication. Metered-dose inhaler (MDI)  Lungs sounds before and after the medication is administered  Respiratory rate and rhythm before and after the medication is administered  Color and consistency of sputum  Teaching done for proper use of the device o Small-volume nebulizer  Lungs sounds before and after the treatment  Respiratory rate and rhythm before and after the treatment  Color and consistency of sputum  Peak-flow measurement before and after the treatment, if ordered o Vaginal medications  Appearance of the genitalia and vaginal canal  Any discharge: amount, color, odor, consistency  Teaching done for self-administration of the medication  Response to the medication at times that correlate with onset, peak, and duration of the medication. o Rectal medications  Appearance of the anus (redness, swelling, hemorrhoids)  Any pain, bleeding, or discharge  Teaching done for self-administration of the medication  Response to the medication at times that correlate with onset, peak, and duration of the medication.