Skill 109: Administering a Nasal Spray PDF

588 SKILL 109 ACTION RATIONALE 15. Remove equipment and Promotes patient comfort and return patient to a position safety. Removing gloves properly of comfort. Remove your reduces the risk for infection gloves. Raise sid...

588 SKILL 109 ACTION RATIONALE 15. Remove equipment and Promotes patient comfort and return patient to a position safety. Removing gloves properly of comfort. Remove your reduces the risk for infection gloves. Raise side rail and transmission and contamination lower bed. of other items. 16. Remove additional PPE, if Removing PPE properly reduces used. Perform hand the risk for infection transmission hygiene. and contamination of other items. Hand hygiene deters spread of microorganisms. EVALUATION Patient’s nails are trimmed and clean with smooth edges and intact cuticles, and are without evidence of trauma to nails or surrounding skin. Patient verbalizes feeling refreshed and demonstrates improved self- esteem. DOCUMENTATION Record your assessment, significant observations, and unusual find- ings, such as broken nails or inflammation. Document any teaching done. Document procedure and patient response. Nail care is often recorded on routine flow sheet.  ͕͔͝      Nasal instillations are used to treat allergies, sinus infections, and nasal congestion. Medications with a systemic effect, such as vasopressin, 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. DELEGATION CONSIDERATIONS The administration of medication using a nasal spray is not delegated to nursing assistive personnel (NAP) or to unlicensed assistive person- nel (UAP). Depending on the state’s nurse practice act and the organi- zation’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  ƒ•ƒŽ’”ƒ›ǡ†‹‹•–‡”‹‰ 589 whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A. EQUIPMENT Medication in nasal spray Computer-generated Medica- bottle tion Administration Record Gloves (CMAR) or Medication Additional PPE, as indicated Administration Record Tissue (MAR) ASSESSMENT Assess the nares for redness, erythema, edema, drainage, or tenderness. Assess the patient for allergies. Verify patient name, dose, route, and time of administration. Assess the patient’s knowledge of 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 cooperate with the procedure. NURSING DIAGNOSIS Deficient Knowledge Risk for Allergy Response OUTCOME IDENTIFICATION AND PLANNING Medication is administered successfully into the nose. Patient understands the rationale for the nose spray. Patient experiences no allergy response. Patient’s skin remains intact. Patient experiences minimal discomfort. IMPLEMENTATION ACTION RATIONALE 1. Gather equipment. Check This comparison helps to identify medication order against the errors that may have occurred original order in the medical when orders were transcribed. record, according to facility The primary care provider’s policy. Clarify any inconsis- order is the legal record of medi- tencies. Check the patient’s cation orders for each facility. chart for allergies. 2. Know the actions, special This knowledge aids the nurse nursing considerations, safe in evaluating the therapeutic dose ranges, purpose of effect of the medication in rela- administration, and adverse tion to the patient’s disorder and effects of the medication to can also be used to educate the be administered. Consider patient about the medication. 590 SKILL 109 ACTION RATIONALE the appropriateness of the medication for this patient. 3. Perform hand hygiene. Hand hygiene prevents the spread of microorganisms. 4. Move the medication cart to Organization facilitates error-free the outside of the patient’s administration and saves time. room or prepare for admin- istration in the medication area. 5. Unlock the medication cart Locking the cart or drawer safe- or drawer. Enter pass code guards each patient’s medication and scan employee identifi- supply. Hospital accrediting cation, if required. organizations require medica- tion carts to be locked when not in use. Entering pass code and scanning ID allows only autho- rized users into the system and identifies the user for documen- tation by the computer. 6. Prepare medications for This prevents errors in medica- one patient at a time. tion administration. 7. Read the CMAR/MAR and This is the first check of the select the proper medication label. from the patient’s medication drawer or unit stock. 8. Compare the label with the This is the second check of the CMAR/MAR. Check expira- label. Verify calculations with tion dates and perform cal- another nurse to ensure safety, if culations, if necessary. Scan necessary. the bar code on the package, if required. 9. Depending on facility This third check ensures accu- policy, the third check of racy and helps to prevent errors. the label may occur at Note: Many facilities require the this point. If so, when all third check to occur at the bed- medications for one patient side, after identifying the patient have been prepared, and before administration. recheck the labels with the CMAR/MAR before taking the medications to the patient.  ƒ•ƒŽ’”ƒ›ǡ†‹‹•–‡”‹‰ ǦǦǦ 591 ACTION RATIONALE 10. Lock the medication cart Locking the cart or drawer before leaving it. safeguards the patient’s medica- tion supply. Hospital accrediting organizations require medication carts to be locked when not in use. 11. Transport medications to the Careful handling and close patient’s bedside carefully, observation prevent accidental and keep the medications in or deliberate disarrangement of sight at all times. medications. 12. Ensure that the patient Check agency policy, which may receives the medications at allow for administration within the correct time. a period of 30 minutes before or 30 minutes after the designated time. 13. Perform hand hygiene and Hand hygiene and PPE prevent put on PPE, if the spread of microorganisms. indicated. PPE is required based on transmission precautions. 14. Identify the patient. Identifying the patient ensures Compare the the right patient receives the information with medications and helps prevent the CMAR/MAR. errors. The patient’s room The patient should number or physical location is be identified using at least not used as an identifier (The two methods (The Joint Joint Commission, 2013). Commission, 2013): Replace the identification band if it is missing or inaccurate in any way. a. Check the name on the patient’s identification band. 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 his This requires a response from the or her name and birth date, patient, but illness and strange based on facility policy. surroundings often cause patients to be confused. 592 SKILL 109 ACTION RATIONALE 15. Complete necessary assess- Assessment is a prerequisite to ments before administering administration of medications. medications. Check the patient’s allergy bracelet or ask the patient about aller- gies. Explain the purpose and action of each medica- tion to the patient. 16. Scan the patient’s bar code Provides an additional check on the identification band, if to ensure that the medication is required. given to the right patient. 17. Based on facility policy, Many facilities require the third the third check of the label check to occur at the bedside, after may occur at this point. If identifying the patient and before so, recheck the labels with administration. If facility policy the CMAR/MAR before directs the third check at this time, administering the medica- this third check ensures accuracy tions to the patient. and helps to prevent errors. 18. Put on gloves. Gloves protect the nurse from potential contact with contami- nants and body fluids. 19. Provide the patient with paper Blowing the nose clears the tissues and ask the patient to nasal mucosa prior to medication blow his or her nose. administration. 20. Have the patient sit up with Allows the spray to flow into the head tilted back. Tilting the nares. Tilting the head is con- patient’s head should be traindicated with cervical spine avoided if the patient has a injury. cervical spine injury. 21. Instruct the patient to inhale Inhalation helps to distribute gently through the nose as the spray in the nares. Inhala- the spray is being adminis- tion during administration is not tered or not to inhale gently recommended for some medica- as the spray is being admin- tions. istered. Your instruction to the patient will depend on the medication being admin- istered. Consult the manufac- turer’s instructions for each medication. 22. Agitate the bottle gently, if Mixes medication thoroughly required for specific medi- to ensure a consistent dose of cation. Insert the tip of the medication. nosepiece of the bottle into  ƒ•ƒŽ’”ƒ›ǡ†‹‹•–‡”‹‰ ǦǦǦ 593 ACTION RATIONALE one nostril. Close the oppo- site 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. 23. Keep the medication con- Prevents contamination of the tainer compressed and contents of the container. 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. 24. Have the patient hold his or Allows medication to remain in her breath for a few seconds, contact with mucous membranes and then breathe out slowly of nose. through the mouth. Repeat in the other nostril, as pre- scribed or indicated. 25. Wipe the outside of the Keeps the end of the bottle clean. bottle nose piece with a Keeps the medication in contact clean dry tissue or cloth with the mucous membranes of and replace the cap. Instruct the nose. the patient to avoid blowing his or her nose for 5 to 10 minutes, depending on the medication. 26. Remove gloves. Assist the This ensures patient comfort. patient to a comfortable position. 27. Remove additional PPE, if Removing PPE properly reduces used. Perform hand the risk for infection transmission hygiene. and contamination of other items. Hand hygiene prevents the spread of microorganisms. 28. Document the administration Timely documentation helps to of the medication immedi- ensure patient safety. ately after administration. See Documentation section below.