Module 3

Oral Route

The slowest route of absorption.

Oral Route Nursing Implications

Assess patient's swallow reflex, ensure they swallow the medication, assist as needed (especially in patients with stroke, muscle weakness, or cognitive impairment).

Oral Route Examples

Liquids (cough syrups), tablets (NSAIDs), capsules (multivitamins).

Buccal and Sublingual

Medications are absorbed transdermally, with local and systemic effects.

Buccal and Sublingual Nursing Implications

Ensure membranes are intact, clean, and moist; patient should not chew/swallow, keep in mouth for 5-10 minutes until fully dissolved.

Buccal and Sublingual Examples

Sublingual nitroglycerin, buccoadhesive film lidocaine, buccoadhesive patch Propranolol.

Buccal and Sublingual Caution

Patient should not chew or swallow.

Topical Route

Includes patches, creams, ointments, and gels with a local effect and fewer side effects.

Topical Route Nursing Implications

Wear gloves when handling; assess skin before/after use—ensure skin is intact, clean, and dry; watch for local inflammation or allergic reactions like hives, burning, and itching.

Topical Route Examples

Lidocaine patches, skin creams.

Topical Route Caution

Monitor for skin irritation and allergic reactions.

Transdermal Route

Medications are stronger with both local and systemic effects, leading to stronger side effects.

Transdermal Route Nursing Implications

Wear gloves when handling; do not touch the medicated side; rotate application sites; clean the area before applying a new patch and after removing an old one.

Transdermal Route Examples

Nicotine patches, fentanyl patches, nitroglycerin paste.

Transdermal Route Caution

Rotate patch sites, assess pain, vital signs, and labs pre/post-application.

Ophthalmic Route

Medications given in the eye (usually in the conjunctival sac).

Ophthalmic Route Administration

Offer tissue to patient; ensure patient is sitting or lying down; for gels/creams, apply from inner to outer canthus; for drops, place in lower conjunctival sac.

Ophthalmic Route Education

Patient should close their eyes and rotate eyes after administration; apply gentle pressure to inner canthus to prevent medication from entering tear duct.

Ophthalmic Route Nursing Implications

Wash hands before/after; keep container sterile; monitor for vision impairment post-admin.

Ophthalmic Route Examples

Artificial tears, antibiotic eye drops.

Ophthalmic Route Caution

Ensure patient safety if vision is impaired temporarily.

Otic Route

Medications given in the ear (aural).

Otic Route Administration

Warm medications to body temperature; patient should lie on their side; for patients age 4 and up, pull pinna up and back; for under 3, pull pinna down and back, then push tragus.

Otic Route Education

Inform patient to report pain, nausea, or dizziness. Instruct them to remain lying on their side for 10 minutes.

Otic Route Nursing Implications

Ears must be patent before administering; use separate droppers for each ear to avoid contamination; wait 5 minutes between ear administrations.

Otic Route Examples

Antibiotic ear drops.

Otic Route Caution

Monitor for discomfort or adverse reactions; assess ear for obstruction or wax buildup.

Nasal Route

Medications administered through the nose.

Nasal Route Administration

Have patient blow their nose before administration; shake the bottle, tilt head back, insert tip into one nostril, hold the other nostril closed, spray while inhaling slowly. Repeat for the other nostril.

Nasal Route Education

Explain the purpose of the medication, how to administer it, potential side effects like stinging, burning, or nosebleeds, and when to seek medical attention. Instruct patient to avoid blowing nose for 5-10 minutes after administration.

Nasal Route Nursing Implications

Monitor for rebound congestion or hypertension; teach safe use and proper storage.

Nasal Route Examples

Nasal decongestants like oxymetazoline.

Nasal Route Caution

Educate on side effects and monitor for rebound congestion.

Inhaled Route

Medications that are inhaled directly into the lungs.

Inhaled Route Administration

Instruct patient to sit in semi-Fowler's position, tilt head slightly back, inhale slowly and deeply through the mouth, exhale normally, then inhale normally while pressing down on the medication canister.

Inhaled Route Education

Teach proper inhaler technique (MDI, DPI, or SMI); inform patient to rinse mouth after use due to thrush

Inhaled Route Nursing Implications

Assess respiratory function before and after use (RR, P, HR, lung sounds). Ensure the patient knows the type of inhaler.

Inhaled Route Examples

Albuterol MDI, Advair DPI.

Inhaled Route Caution

Inhalers should not be shared; monitor for dizziness or lightheadedness.

Rectal Route

Medications inserted into the rectum for absorption through the rectal mucosa.

Rectal Route Patient Education

Wash hands before/after administration; lie on the left side (Sims position), lower leg straight, upper leg bent; insert suppository/enema tip gently.

Rectal Route Nursing Implications

Ensure proper technique and placement; monitor for absorption; educate on the importance of remaining lying down for 10-15 minutes.

Rectal Route Examples

Acetaminophen suppository.

Rectal Route Caution

Monitor for discomfort, irritation, and absorption issues.

Vaginal Route

Medications inserted into the vagina for absorption through the vaginal mucosa, often for infections or hormonal therapy.

Vaginal Route Patient Education

Wash hands before/after; lie on back with knees bent, spread apart; insert the suppository, tablet, or cream into the vagina using an applicator or fingers.

Vaginal Route Nursing Implications

Ensure proper technique, monitor placement and absorption, educate the patient on the importance of lying down post-administration.

Vaginal Route Examples

Antifungal creams, estrogen suppositories.

Vaginal Route Caution

Monitor for irritation, discomfort, or adverse reactions in the vaginal area.

Intradermal Needle

Length- ⅜" to ⅝" or 1-1.5 cm, Gauge- 25G, Syringe Size- ½ mL to 1 mL (tuberculin)

Intradermal Sites

Volar aspect of the forearm (inner aspect) or upper back

Intradermal Landmarks

Inner aspect of the forearm- 2-3 inches below antecubital fossa, Upper back- just below the scapula

Intradermal Medications

Sensitivity tests (allergy or TB)

Intradermal Nursing Implications

Ensure proper site selection, aseptic technique, observe reactions, avoid medication aspiration.

Intradermal Why Performed at These Sites

High accessibility, thin skin (easy to inspect).

Subcutaneous Needle

Length- ⅜" to 1" (commonly ⅝" for adults), Gauge- 25G to 30G, Syringe Size- 1 mL

Subcutaneous Sites

Abdomen (fastest absorption, most common), Upper lateral part of the arm

Subcutaneous Landmarks

Abdomen- 2 inches away from the umbilicus, Upper lateral part of the arm- 2-3 inches away from the deltoid muscle

Subcutaneous Medications

Insulin, morphine, heparin

Subcutaneous Nursing Implications

Verify provider's order, assess for allergies, rotate injection sites, check for allergies, use proper aseptic technique.

Subcutaneous Why Performed at These Sites

The abdomen has a rapid absorption rate, and the upper lateral arm is easy to access, with sufficient fat for absorption.

Intramuscular Needle

Length- 1" to 1.5", Gauge- 21G to 23G, Syringe Size- 1-3 mL

Intramuscular Sites

Deltoid muscle, Vastus lateralis, Ventrogluteal

Intramuscular Landmarks

Deltoid- 2-3 finger widths below the acromion process, Vastus lateralis- One hand-width below the greater trochanter and one hand-width above the knee, Ventrogluteal- Palm on the greater trochanter, index finger pointing to the anterior superior iliac spine, middle finger pointing toward the iliac crest

Intramuscular Medications

Vaccines (e.g., flu vaccine), antibiotics (e.g., penicillin), hormone injections (e.g., progesterone)

Intramuscular Nursing Implications

Select the correct site based on medication and patient's muscle mass, 90-degree angle for injection, ensure proper technique to avoid injury to blood vessels or nerves, assess for irritation post-injection.

Intramuscular Why Performed at These Sites

The deltoid is easily accessible for smaller volumes, the vastus lateralis is preferred for infants and children, and the ventrogluteal site is safer for larger volumes due to its distance from major nerves.

Intravenous Needle

Length- 1" to 1.5" (depending on patient size and vein depth), Gauge- 18G to 22G, Syringe Size- 10 mL to 50 mL

Intravenous Sites

Forearm veins, Hand veins, Antecubital fossa

Intravenous Landmarks

Forearm veins: Located along the inner aspect of the forearm, Hand veins: Located on the back of the hand, Antecubital fossa: In the bend of the elbow

Intravenous Medications

Antibiotics, chemotherapy, fluid replacement (e.g., saline, glucose solutions), and electrolytes

Intravenous Nursing Implications

Verify the provider's order, aseptic technique, select appropriate vein, monitor for infiltration, phlebitis, air embolism, or infection. Secure the IV line and monitor infusion rate.

Intravenous Why Performed at These Sites

Forearm veins are larger and more accessible, hand veins are used in emergencies or difficult access situations, and the antecubital fossa is used for larger volumes of fluids.

Infants Sleep Patterns

Require 12-16 hours each day, including naps. Sleep is typically in 4-hour segments. By age 8 to 16 weeks, infants usually sleep through the night. Their sleep consists primarily of REM sleep.

Toddlers Sleep Patterns

Require 11-14 hours of sleep with one nap per day. Napping may decrease as toddlers resist bedtime. Establishing a bedtime routine is important. Sleep patterns fluctuate due to growth spurts.

Preschoolers Sleep Patterns

Require 10-13 hours of sleep. Sleep pattern is similar to adults with REM sleep. Naps decrease and stop by age 5. Night terrors and a nightlight may be needed.

School-Age Children Sleep Patterns

Require 9-12 hours of sleep. Physical growth increases the need for sleep, but stress (such as starting school) may disrupt sleep. Bedtime routines are still essential.

Adolescents Sleep Patterns

Require 8-10 hours of sleep but tend to stay up late and sleep in late. The use of cell phones and laptops can cause daytime tiredness and poor attention. Males may experience nocturnal emissions (wet dreams). Excessive exercise before bed can affect sleep.

Adults Sleep Patterns

Require 7-9 hours of sleep. Sleep patterns are established. Males tend to have more awakenings. Decreased sleep during stage 4 sleep and increased awareness of sleep disturbances. Avoid spicy foods and alcohol before bed. Sleep medications can become addictive.

Older Adults Sleep Patterns

Require 7-8 hours of sleep. They experience difficulty falling asleep or staying asleep (insomnia). Stage 4 sleep is absent, and REM sleep is shortened. Physical health, polypharmacy, and environmental factors can affect sleep quality. Educate about maintaining a bedtime routine and using nightlights. Underlying health issues may impact sleep.

Pain Definition

Unpleasant physiological or psychological feeling that can arise from a direct or indirect occurrence. A way for the body to alert that there is a problem.

Verbal Pain Cues

Moaning, groaning, and other subjective data. If in pain, have the patient point to the area of discomfort.

Nonverbal Pain Cues

Facial expressions, grimacing, holding the affected area, hunched over, or in a fetal position.

Acute Pain

Pain that has mild to severe intensity with a rapid onset, lasting from a few days to a couple of weeks. It usually occurs due to a one-time injury or event. Ex. Broken bones, sore throat, surgery

Chronic Pain

Pain lasting more than 3 months, persistent or recurring. Patients may seem like they are not in pain but tolerate it. Ex. Fibromyalgia, back pain

Pain Assessment - PQRST

Provocation- What caused the pain? What makes it better or worse? Quality- What does the pain feel like? Sharp, dull, stabbing, burning, etc. Region- Where is the pain located? Does it radiate or travel? Severity- Rate pain on a scale of 0-10. Timing- When did the pain start? How long does it last? Does it happen at the same time daily?

Consequences of Untreated Pain

Inability to exercise, immobility, increased heart rate and respirations, depression, anxiety, sleeplessness, hormone imbalances, lower immune functions, altered cognitive functions, decreased motility, hopelessness, tachypnea.

Neonatal Pain Scale (NIPS)

Used for children under 1 year old, assesses facial expression, cry, breathing pattern, arms, legs, and state of arousal with a score >3 indicating pain. Numerical rating (0 or 1).

FACES Pain Scale (Wong-Baker)

Used for children and adults with cognitive impairments. Patients match a face picture to their pain level (0-5). A happy face means "no hurt," and a sad face with tears indicates "hurts worst."

Verbal Descriptor Pain Scale

Uses simple descriptors like no pain, mild, moderate, severe, very severe, and worst possible pain. Mostly used for acute post-procedure or trauma pain.

Numerical Likert Scale (NRS)

Rates pain on a scale from 0 (no pain) to 10 (worst pain possible). Mostly used for adults who are not cognitively impaired.

Visceral Pain

Pain caused by disease, arising from internal organs undergoing abnormal stretching, ischemia, or inflammation, such as pancreatitis or cholecystitis; treated with NSAIDs, antibiotics (for infections), opioids, and non-pharmacological methods like relaxation and stress management. Ex. Pancreatitis.

Somatic Pain

Pain originating from the skin, muscles, bones, and joints, usually aching, caused by tissue damage or pressure, such as in sprains, treated with muscle relaxers, massage, physical therapy, muscle relaxation, and acupuncture. Ex. Sprained ankle.

Radiating Pain

Pain that spreads from one body part to another, such as chest pain radiating to the left arm or back pain radiating down the sciatic nerve, caused by nerve damage, infection, or trauma, treated with NSAIDs, analgesics, muscle relaxants, and non-pharmacological methods like massage, hot/cold compresses, and physical therapy. Ex. Chest pain radiating to the left arm.

Referred Pain

Pain felt in a body region distant from the actual pain source, like chest pain (angina) felt in the back, caused by nerve damage, infection, or trauma, treated with NSAIDs, antibiotics, surgical interventions, analgesics, muscle relaxants, and non-pharmacological methods like yoga, meditation, and massages. Ex. Angina pectoris felt in the back.

Phantom Pain

Pain felt in a missing limb or body part, often due to nerve misfiring, such as pain in a missing foot after amputation, treated with antidepressants, nerve blockers, opioids, NSAIDs, and non-pharmacological methods like acupuncture, TENS, and mirror therapy. Ex. Pain in a missing foot after amputation.

Neuropathic Pain

Pain caused by nerve damage or dysfunction, such as burning or tingling in the feet from diabetes, treated with anticonvulsants, antidepressants, topical agents, and non-pharmacological methods like acupuncture. Ex. Diabetic neuropathy in feet.

Psychogenic Pain

Psychological pain with no identifiable physical cause, often experienced by individuals with psychological distress, treated with therapy, medications, and group therapy. Ex. Pain without a physical cause in individuals with hypochondriasis.

Complementary and Alternative Medicine (CAM)

A broad range of healthcare practices not considered part of conventional medicine, used either alongside (complementary) or instead of (alternative) traditional treatments. Ex. Herbal medicine, acupuncture.

Biologically Based Therapies (Natural Therapies)

Involve the use of substances from nature, such as herbs, vitamins, and dietary supplements, to treat illnesses and promote health. Ex. Ginseng for energy, echinacea for immune support.