5.3: Preparing and Administering Topical Medications

While the administration of topical medications may appear to be simple and harmless, it is associated with many side effects if not performed properly. Topical medications are an important and common mode of drug delivery, often offering continuous absorption of the medication over several hours. There are many classes of topical medications, such as creams, ointments, lotions, patches, and aerosol sprays.

This video will demonstrate techniques of the safe administration of topical medications, including transdermal patches, optical formulations, and otic drops.

First, let's review the steps that one needs to perform before administration of any of these medications. In the patient's room, review the patient's medical history for medication allergies and previous administration times in the electronic medication administration record. Confirm any patient preferences regarding topical administration and address any patient concerns such as preferred site of application or any previous side effects noted.

Before handling any medication, disinfect the hands with soap and warm water and vigorous friction for at least 20 seconds, or apply a hand sanitizer with friction if the hands are not visibly soiled. Next, acquire the topical medications from the medication dispensing device using the ten "rights" during the first safety check, as indicated in the video, "Safety Checks and Ten Rights of Medication Administration." After obtaining the medication, complete the second safety check, again using the same ten "rights" of medication administration.

Note that some topical medications are available in different concentrations depending on the location where they are to be applied. It is the nurse's responsibility to verify that the concentration of the topical medication provided is appropriate for the location specified in the prescription. Review information regarding the proper application of topical medications with a nursing drug guide and institutional policies.

Now, gather necessary supplies, such as clean gloves and sterile gauze for cleaning, and take the medications and supplies with you to the patient's room. Upon entering the patient's room, perform hand hygiene as described previously. At this point, complete the third safety check. Like before any medication administration, tell the patient the medication name, indication, and action. Review any side effects and discuss any concerns they might have. If the patient refuses the medication, ensure that they are aware of the potential physiologic or psychologic impact of the refusal on their health and recovery.

After the review of the common preparatory steps, let's get in the details of topical administration, starting with transdermal patch application. To begin, inform the patient that the application of the patch will require exposing an application site. Ask the patient if they have a preferred site. Ensure the patient's privacy and dignity by covering their intimate body sites as much as possible with a blanket or towel.

Don clean gloves and carefully remove the previously applied patch, if present. Then clean the site, according to institutional policy and standards of nursing practice, in order to remove any remaining medication. Now remove the gloves, wash hands thoroughly, and don a new pair of gloves for medicine application. Wearing gloves for any topical administration is important, as it protects the nurse from any accidental exposure and absorption of the medication.

To apply the new patch, carefully remove the outer packaging. Remove the clear protective liner and place it in an area free of movement and hair. This placement should be compliant with the instructions provided on the MAR, institutional policy, and the description in the nursing drug guide.

If using an ointment topical medication, such as nitroglycerin, squeeze out the appropriate amount onto the measurement or application device provided by the manufacturer. Place it on the skin and apply a clear occlusive dressing over the device, securing it to the surface. Never rub or massage the medication into the skin, as this will alter the absorption rate.

For both types of patches, the last step is to label the transdermal patch with initials, time, and date of application using an indelible marker. Remove the gloves and wash the hands with vigorous friction for at least 20 seconds.

Next, let's review ophthalmic medication administration process, which includes eye drops and ointments. Start by describing the application process. Then wash hands and don clean gloves. To start, assist the patient in lying back, with head tilted and neck extended. Note, in case of current or prior neck injury, do not extend the neck. Assess the eyelids, inner and outer canthus for crust or drainage. If present, cleanse the area with a gauze pad soaked in normal saline.

For eye drops, pick the bottle up in the dominant hand. Softly rest the heal of the hand on the patient's forehead while holding the medication approximately 1-2 cm above the lower lid. With the non-dominant hand, carefully pull the lower lid down to expose the conjunctival sac. Now, ask the patient to look up towards the ceiling. Point the bottle tip towards the conjunctival sac, and while keeping it 1-2 cm above the eye, allow the prescribed number of drops to fall into the conjunctival sac. Finally, release the lower eyelid and instruct the patient to gently close the eyes. Never allow the bottle tip to touch the conjunctival sac or eye, and if the drops fall outside the lid, or if the patient blinks, causing a drop to miss the eye, repeat the procedure.

Administration of ophthalmic ointment is similar. First, rest the dominant hand on the patient's forehead, while holding the ointment tube 1-2 cm above the lower lid, and with the non-dominant hand, expose the inner conjunctiva of the lower lid. Now apply a thin line of ointment along the inner conjunctiva, from the inner canthus to the outer canthus. Break the ribbon of ointment by spinning the hand upwards before lifting the hand away, thus avoiding pulling the medication off the conjunctiva. Then release the lower eyelid and instruct the patient to blink and gently rub the eyelid to disperse the medication.

This completes the administration process. Now remove gloves and complete hand hygiene, as described before.

Now, let's review how a nurse should administer otic drops. Begin with medication education; inform the patient that they may experience a feeling of water or bubbling in the ear when the drops enter the ear canal. Next, perform good hand hygiene and don a clean pair of gloves.

Now, ask the patient to lay on their side, with the affected ear towards the ceiling. Gently roll the medication between both hands for 10-20 seconds to both re-suspend particles and warm the medication prior to administration, as cold ear medications may cause dizziness or nausea when administered. Using the non-dominant hand, gently pull the auricle up and outward to straighten the ear canal. For children 3 years old and younger, grasp the pinna and pull down and back to straighten the canal.

Hold the bottle with the dominant hand approximately 1 cm above the ear canal and instill the prescribed number of drops. Never allow the bottle tip to touch the ear or the canal. Release the auricle. Then, rub the tragus or tug the pinna to help the drops flow down the ear canal. Ask the patient to remain on their side for 2-3 minutes. As with all medication administration and patient contact, remove gloves and complete hand hygiene.

Documentation of topical medications should include the name of the medication, topical medication application site, date, exact time administered, and your initials. Safe medication practice for transdermal patch administration also requires removal of previous patch documentation.

Prior to leaving the room, remind the patient about any side effects, adverse effects, or considerations for which they should notify the nurse. Upon exiting the patient's room, disinfect your hands again, as has been described earlier.

"While the administration of topical medications may appear to be simple and harmless, it is associated with many side effects if not performed properly. A common mistake is a failure to remove the previous patch medication before applying a new one, resulting in higher dose of the medication and medication error. In cases of many transdermal patch pain medications, such as Fentanyl, this can be harmful, even deadly. These patches can sometimes be transparent and difficult to find. Never assume the patch has fallen off or been removed by the patient."

"Assessment of the application site prior to administration is also critical to prevent the skin irritation by the medication. Unexpected inflammation and irritation should be reported to medical staff to prevent further tissue damage."

"Another common mistake is administrating the topical medication in a concentration unsuitable for the application site. For instance, a topical antibiotic has formulations for both skin and eyes and, if applied incorrectly, could result in loss of vision."

"In case of eardrops, cool or cold otic medications may cause dizziness and nausea. Therefore, warming them before administration is important."

You've just watched JoVE's introduction to preparing and administering topical medications. You should now understand the different types of topical medications and the safe and effective application of each different type. As always, thanks for watching!