Instillation – Eye, Ear, Nasal,
Vaginal, Rectal and Painting of Throat.
A simple Nursing Procedure
Instillation:
An instillation is defined as a process by which a liquid (medication) is introduced into a cavity drop by drop.
INSTILLATION OF MEDICATION INTO THE EYE
Medication may be instilled in the form of eye drops or ointments.
Principles in the Administration of Eye Medications:
1. The cornea of the eye is very sensitive so avoid instilling eye medications directly on to the cornea.
2. Prevent transmission of infection from one eye to the other. For this avoid touching the eyelid or other eye structures with eye droppers or ointment tubes.
3. Use eye medication only for the affected eye.
4. Never allow a person to use another person’s eye medication.
Commonly Used Eye Drops and Ointment:
Medications may be instilled in the form of eye drops or ointments. The eye drops and ointments commonly used in the eye are:
1. Atrophine 1 Percent – dilate the pupil.
2. Eserine ½ Percent – to contract the pupil.
3. Adrenaline 1/1000 – to check bleeding.
4. Silver nitrate 1 to 2 percent – as an antiseptic and astringent especially used in gonococcal infection.
5. Mercurochrome 1 to 2 Percent – as an antiseptic.
6. Boric acid 2 to 4 Percent – as an antiseptic.
7. Novocaine and cocaine – as local anaesthetic.
8. Terramycin and soframycin – as antibiotics.
9. Betnovate eye ointment – anti-infective and ant-inflammatory.
Procedure:
Place the patient in a back lying position with the head slightly hyperextended with a pillow under the shoulders. Ask the patient to look upward while the nurse separates the lower lid by pressing it against the cheek bone. The drops are taken in a dropper and holding the dropper from 1 to 2 cm above the eye, instill the ordered number of drops in the centre of the lower lid. If ointment is to be applied apply the ointment from the inner aspect to the lateral aspect. Ask the patient to close the eyelids and move the eyeballs from side to spread the medications all over the conjunctival sac. Wipe off the excess medications that remains on the eye with a clean cotton swab.
The nurse discards a small amount of ointment on a sterile cotton ball and wipes the top of the tube before she replaces the cap.
GENERAL INSTRUCTIONS:
1. Be certain that you have the right patient, right medications and the right eye. Check the doctor’s orders to see which medication is to be instilled in which eye.
2. Know the diagnosis of the patient and the therapeutic effect of the medication. Certain medications are contraindicated for certain eye disorders.
3. Never instill any medication into the eye, unless it is ordered by the physician.
4. Check the expiry date of the medication. Never apply any medication with the date of expiry already over.
5. Never use any eye drops which are discoloured, cloudy and precipitated.
6. Ophthalmic solutions should be sterile and are prevented from contamination during its preparation or administration.
7. Use separate eye droppers for separate medications.
8. Do not allow medication in an eye dropper to flow back into the bulb of the dropper. Do not return the remaining medication of the eye dropper back into the bottle after instillation. To prevent wastage, take only the required amount of solution in the dropper.
9. Neither substitute a solution or medication of one strength with that of another strength nor substitute one medication for another, without permission of the doctor.
10. Read specific instructions given on the leaflets supplied with the medications.
11. Never use any solution or ointment which are unlabelled to instill in the eye.
12. Always wash hands before and after instilling the medications into the eyes.
13. While attending both the eyes, apply the medication to the least infected eye to minimize the chances of infecting it with infection from the badly infected eye.
14. Have separate tubes of ointments, drops and droppers for each patient.
15. Do not massage the eyeball after the instillation of medications. Ask the patient to close the eyes and move the eye balls from side to side, to help spreading the medication.
16. Injuries which may occur by the tip of the dropper or tube of ointment, should be prevented. Steady the head by having the patient rest his head on the back of the chair, if he is sitting.
17. Keep all strong solutions which should not be used on the eye away from the bedside of a patient and away from the area where ocular medicines are stored, to prevent accidental application of these medications into the eye.
18. Do all the procedures in an adequate light.
19. Always see that the eyes are absolutely clean before the application of medications into the eye.
20. Instruct the patient not to touch the eyes, eye dressings etc. if the patient is uncomfortable with the dressings, instruct him to call for a nurse to attend to it.
21. If the patient is on self medication, give him clear instructions and make sure that the instructions are clear to him.
22. Ask the patient to consult the doctor regularly.
INSTILLATION OF EAR DROPS
Ear drops are instilled into the auditory canal to produce the following local effects:
1. To combat infection.
2. To soften the ear wax.
3. To produce local anaesthesia and to reduce pain in the ear.
4. To kill an insect lodged in the auditory canal.
Procedure:
Explain the procedure to the patient to win his confidence and co-operation. If the patient is a child or an uncooperative adult, restrain his hands. Place the patient in position (side-lying position). Draw the medication in a dropper (take only minimum amount).
Straighten the auditory canal by pulling the ear pinna upward and backward in case of adults, downward and backward in case of children and instill the medication drop by drop. Instill the drops on the side wall of the auditory canal to allow the air to escape from the auditory canal. Instruct the patient to remain in the same position for few minutes. Plug the ear with a cotton or guaze piece, if indicated.
GENERAL INSTRUCTIONS:
1. The auditory canal should be thoroughly cleaned before instilling the ear drops.
2. Drops must be warm when they are instilled into the ear, otherwise it may cause vertigo. In order to warm the ear drops place the container in a bowel of warm water or rinse the dropper 3 or 4 times in hot water and then take the medications.
3. Place the patient in a side-lying position or in the dorsal recumbent position with the head turned to one side with the affected ear uppermost.
4. Allow 3 or 4 drops trickle down on one side of the canal so that the air may reach upto the ear drum.
5. Ask the patient to remain in the same position for few minutes following instillation.
6. Plug the ear with a small cotton ball or a small gauze piece.
7. Always secure a written prescription from a doctor to instill any medication into the ear.
8. Any complain made by the patient should not be ignored.
NASAL INSTILLATIONS
Purpose:
1. To combat infection.
2. To provide astringent effect.
3. To relieve inflammation and congestion in case of rhinitis.
4. To give local anaesthesia.
GENERAL INSTRUCTIONS
1. Medications are instilled only on written order from the doctor.
2. Avoid oil base solutions as nasal drops, since it interfere with the normal ciliary action and may cause aspiration pneumonia is aspirated into the lungs. (oily solutions if aspirated into the lungs, will not be absorbed and will act as a foreign body).
3. Avoid the use of decongestant drops for a long period or their frequent use or excessive use, because they become ineffective and may actually worsen a patient’s nasal congestion.
4. The patient should be instructed well regarding the use of nasal drops to avoid distressing and tension. E.g., vasoconstrictors are absorbed and cause systemic effects; these are harmful for a patient with hypertension. Therefore, these medications are avoided as far as possible. In case these have to be used, use minimum quantity (2 to 3 drops in each nostril).
5. Be careful to use drugs with correct concentration.
6. Identify the drug correctly. Follow the rules for administration of medication – ‘’right patient..” etc.
Place a patient in a correct position for the instillation of medication into the nasal cavity. The head should be held in such a way that the medication should reach the desired area, otherwise, the procedure becomes ineffective, since the drops will simply run down into the throat and are swallowed.
A – place the patient in a dorsal recumbent position with the head titled slightly to the affected side, if the drops reach the opening of the Eustachian tubes.
B – place the head of the patient turned towards the affected side beyond the edge of the bed if the drops are to be reached to the maxillary sinuses.
C – place the patient beyond the edge of the bed with the head hanging straight at the back. It will help the drops to reach ethmoid and sphenoid sinuses. If the patient is not able to assume a position with the head hanging beyond the bed, place him in the dorsal position, with a pillow under the shoulders.
8. Ask the patient to remain in the same position for sometime after the instillation of the drug. This allows the solution to flow into the posterior nares. It gives time for the medication to act on the mucus membranes of the anterior portion and then it can drain into the posterior nares.
9. Be careful not to infect the dropper by touching it on the tip of the nose. Contamination of the dropper will cause contamination of the medicine in the container.
10. See that the anterior nares are clean and free from discharges.
Procedure:
Explain the procedure to the patient. Place the patient in the desired position. Take the medication in the dropper and instill not more than 3 drops into the each nostril. Ask the patient to remain for few more minutes in the same position. Provide a handkerchief or a piece of rag piece to wipe off any medication that has escaped from the anterior nares. Provide a sputum mug to spit any medications that have reached the mouth and throat.
PAINTING OF THROAT
Medication is applied to the throat by way of spraying and painting. The medicines are applied for the following reasons:
To relieve pain, inflammation and congestion.
To treat infection.
To anaesthetize the part.
Articles Required:
1. Head mirror and spot light to visualize the throat.
2. Sterile cotton applicators in a container to apply the medication.
3. Tongue depressor to visualize the throat by depressing the tongue.
4. Kidney tray and paper bag to receive the wastes and the used articles.
5. Towel to protect the garments.
6. Medications (e.g. Mandle’s paint) as ordered.
Procedure:
Explain the procedure to the patient. Make the patient sit on a chair with a back support so that he can lean backward with the head titled backward. Place a towel around the neck to protect the garments. Adjust the spot light behind the patient, so that reflection from the head mirror can be directed to the throat. Take the medication on the cotton applicators and squeeze off the excess medication from the applicator.
Instruct the patient to open the mouth and say ‘Aha’. Place the tongue depressor over the tongue and apply a slight pressure. The throat is painted gently and quickly using half circle movement and reaching all parts of the throat. Paint on one side first and repeat on the other side using separate swab sticks. Record the procedure in the nurse’s record with date and time. Record the type of medication applied and the condition of the throat.
VAGINAL INSTILLATION
Vaginal medications are available as suppositories, foam, jellies, or creams. The suppository, which is inserted into the vaginal cavity, melts at body temperature and get distributed and absorbed. To prevent damage, the suppository must be kept preferably in a refrigerator.
Foams, jellies and creams are administered with a inserter or applicator. Suppository is inserted with a gloved hand. Many clients prefer to insert their own suppositories. Perineal pads may be used to collect excess drainage after inserting a suppository, especially if there is infection. Good aseptic technique must be followed and good perineal hygiene is maintained.
Administering Vaginal Instillations:
Procedure:
1. Review, physician’s order, patient’s name, name of suppository/cream, dosage, time of administration.
Rationale: ensure safe and correct administration of medication.
2. Wash hands.
Rationale: reduces infection.
3. Preparation of articles.
a. Suppository insertion
i. Vaginal suppository
ii. Clean disposable gloves.
iii. Lubricating jelly.
iv. Perineal pad.
Rationale: vaginal suppository is stored in refrigerator to preserve the solid shape. Lubricating Jelly helps to eases insertion.
b. Cream or foam instillation.
i. Vaginal cream or foam.
ii. Plastic applicator.
iii. Clean disposable gloves.
iv. Perineal pad.
4. Check the identification of the client.
Rationale: ensures the right patient receives the medication.
5. Observe the external genitalia and vaginal canal.
Rationale: baseline data helps to monitor the effect of treatment.
6. Explain the procedure.
Rationale: Improves I.P.R.
7. Arrange the articles at bedside.
Rationale: helps in smooth procedure.
8. Provide privacy.
9. Help the patient to lie in dorsal recumbent position.
Rationale: provide easy access and good exposure of vaginal canal. Also prevent escape of suppository through vaginal orifice.
10. Drape the abdomen and lower extremities.
Rationale: reduces embarrassment.
11. Put on disposable gloves.
Rationale: prevents transmission of infection between nurse and patient.
12. Identify the vaginal orifice. Have sufficient light.
Rationale: visualization is necessary in order to insert properly.
13. Insert suppository with gloved hand.
a. Remove the suppository from foil wrapper and apply lubricant to the smooth or rounded end. Lubricate the gloved index finger of the right hand.
Rationale: lubrication reduces friction against mucosal surface during insertion.
b. With right hand gently retract labial folds.
Rationale: expose vaginal orifice.
c. Insert rounded end of suppository along posterior wall of vaginal canal entire length of finger.
Rationale: proper placement ensures equal distribution of medication along walls of vaginal cavity.
d. Withdraw finger and wipe away remaining lubricant from around orifice and labia.
Rationale: maintains comfort.
14. Apply cream or foam.
a. Fill cream or foam applicator following package direction.
Rationale: dosage is prescribed by volume in applicator.
b. With gloved right hand insert applicator plunger to deposit medication into the vagina.
Rationale: exposes vaginal orifice.
c. With gloved right hand insert applicator plunger to deposit medication into the vagina.
Rationale: allow equal distribution of medication along vaginal walls.
d. Withdraw applicator and place on paper towel. Wipe off residual cream from labia or vaginal orifice.
Rationale: residual cream or applicator may contain microorganisms.
15. Remove gloves by pulling them inside out and discard it. Wash hands.
Rationale: reduces transfer of microorganisms.
16. Encourage the client to lie down for at least 10 minutes.
Rationale: prevent loss of medication through vaginal orifice and helps in equal distribution.
17. Wash the applicator with soap and warm water, rinse and store for future use.
Rationale: helps to wash off any organism present and also the remains of cream.
18. Offer perineal pad on assuming ambulant position.
Rationale: provide comfort.
19. Observe the vaginal canal and external genitalia.
Rationale: helps to detect improvement of the vaginal condition.
20. Document the drug name, dosage, route and time of administration on client’s record.
Rationale: prevents drug errors.
RECTAL INSTILLATIONS
Rectal suppositories are thinner and bullet shaped. The rounded end prevents anal trauma during insertion. Rectal suppositories contain medications that exert local effects, such as promoting defecation or systemic effects such as reducing nausea. To maintain its shape, they are stored in refrigerator.
The suppository must be inserted past the internal anal sphincter and against the rectal mucosa. If not, the suppository may be expelled before it is dissolved and absorbed into the mucosa. In case of a loaded rectum, it is preferable to give a cleansing enema before introducing the suppository.
Administration of Rectal Suppositories:
Procedure:
1. Check the physician’s order, client’s name, drug name, route and time of administration.
Rationale: ensure safe and correct administration of medication.
2. Review the medical record for any history of rectal surgery or bleeding.
Rationale: these conditions are contra indications for suppository.
3. Wash hands.
Rationale: reduces the chance of infection.
4. Prepare articles.
i. Rectal suppository.
ii. Lubricating jelly.
iii. Clean disposable gloves.
iv. Rag pieces.
5. Put on gloves.
Rationale: prevents contact with fecal matter.
6. Identify the patient.
Rationale: avoid errors in medication.
7. Explain the procedure, if the patient want, allow self-administration.
Rationale: promote better I.P.R. and cooperation.
8. Arrange supplies at bedside and provide privacy.
Rationale: ensure smooth procedure.
9. Drape the patient, exposing only the anal area. Give Slims position.
Rationale: prevent embarrassment and promote relaxation.
10. Examine the external condition of the anus and palpate the rectal walls. Change the gloves if soiled.
Rationale: helps to detect any active rectal bleeding. Palpation helps to find out if the rectum is loaded with faeces.
11. Remove the suppository from the wrapper and lubricate the rounded end. Lubricate the index finger of right hand.
Rationale: lubrication reduces friction.
12. Instruct the patient to take slow deep breaths through mouth and relax the anal sphincter.
Rationale: relaxation of anal sphincter prevents pain on introduction of suppository.
13. Retract buttocks with gloved left hand. Insert suppository gently through anus past internal sphincter and against rectal wall, 10 cm ( 4 in ) in adults and 5 cm (2 in) in children and infants.
Rationale: for adequate absorption and therapeutic action suppository must be placed against the rectal mucosa.
14. Withdraw finger and wipe anal area.
Rationale: provide comfort.
15. Discard the gloves into appropriate container.
Rationale: prevent transfer of microorganisms.
16. Tell the patient to remain flat or adopt side-lying position for 5 min.
Rationale: prevents expulsion of suppository.
17. Wash hand.
Rationale: prevents infection.
18. Check after 5 minutes to determine whether the suppository is expelled.
Rationale: reinsertion may be needed.
19. Document name of the drug, route, time of administration and effect.
Rationale: reduce errors.
20. Observe the effect of suppository (bowel movements) after 30 min of administration.
Rationale: to ascertain whether the required result is obtained.
ADMINISTRATION OF DRUGS BY INHALATION
Drugs can be administered through hand held inhalers, which disperse drug through an aerosol spray, mist or powder that penetrate lung airways. The drug is absorbed rapidly by the alveolar-capillary network. Metered dose inhalers (MDIs) are used to deliver medications that produce local effects such as broncho dilatation. The advantage with MDI is that higher concentration of drug can be delivered into the airways and systemic side effects are very less. The main disadvantage is training and skill which is needed to administer the MDI correctly.
An MDI delivers a measured dose of drug with each push of a canister. In order to activate the aerosol, 5 to 10 pounds of pressure must be used. MDI work best when clients use a three-point or lateral hand position to activate canisters.