ROUTES OF ADMINISTRATION P1

DRUG (APPROVED NAME)

Dose

Date

Route Start Date

Time

Signature

Additional Instructions/Indication

Pharm.Valid Period

Given by

Frequency

Dose

Route

PARACETAMOL

No more than 4 doses (4 g) in 24 hours

1 g 6hourly

Oral 25/09/19

DRUG (APPROVED NAME)

Dose

Date

Route Start Date

Time

Signature Pharm.Valid Period

Max.Frequency

Dose

PRESCRIPTION

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Medicines ManagementAdults

Routes of administrationEdited by Martina O’Brien, Associate Professor of Adult Nursing, London South Bank University

©2019 Clinical Skills Limited. All rights reserved

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

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Clinical Records Allergy Notes General Notes

Review PrescriptionSALBUTAMOL 100-200 MICROGRAMS

Max Frequency: 6 HOURLY Route: INHA Start Date: 14-July 2019 Time: 1144 Doses: End Date: Time:

Comment : NO MORE THAN 4 DOSES (800 MICROGRAMS) IN 24 HOURS

DC reason:DC Comment:

Prescribed By: SANUDERS, JAMES U25240 Order: E Entered : 14-July2019 11:45 By : SAUNDERS, JAMES Screened by : SHAH, HUSSEIN Pharmacy : 1

Overide reason: BENEFIT OUTWEIGHS RISK

ADT PATIENT CARE VIEWER DRUGS REQUESTS/RESULTS PATIENT FLAGS

10589325 STANBUF CW OCRXRCPP

ADT PATIENT CARE VIEWER DRUGS REQUESTS/RESULTS PATIENT FLAGS

Drug Allergies/Intolerances1 NO KNOWN DRUG ALLERGIES/INTOLERANCE23

BSA?Height?Weight Body Surface Area (m2): Height (cm): Weight (kg): 37.00

File Edit Patient Session Navigate Help01700914 DORIS, SHUTT MRS - F

Dose Schedule 5 1144 18-July2019 2 1144 15-July2019 4 1144 17-July2019 1 1144 14-July2019 3 1144 16-July2019

Finished reviewing this request

Back Out

Review Lab Results

AMITRIPTYLINE

DAISY PHARMACY 114 PARK ROAD

25mg TABLETS Take ONE at NIGHT Mr BLOCK 21 MAY/19 KEEP OUT OF REACH OF CHILDREN

GABAPENTINOral Solution

Each 5ml of oral solution contains250 mg of gabapentin, USP.

DOSAGE AND USEsee package for full prescribing information

Store refrigerated, 2° to 8°C (36° to 46°F)

Keep this and all drugs out of the reach of children

Net Contents16 fl oz (473ml)

Rx onlyRev. 11 2021

50 mg/ml

Glycerin

Glycerin

K

omycin Tablets 250mg be taken FOUR times daily allow whole, do not chew plete the prescribed course

KEEP OUT OF REACH OF CHILDREN

Prescriptions must specify the route of administration (a)

(b) Electronic prescription for an inhaled medicine Enteral routes

Pharmaceutical companies manufacture medicines in a range of different formulations, which they design to ensure that each medicine delivers an effective therapeutic response. Many factors will influence the prescriber’s choice of formulation and route of administration, including the response required, the accessibility of the target site and patient factors. Pharmacokinetics describes how the body utilises medicines via the processes of absorption, distribution, metabolism and excretion (commonly referred to as ADME); see Key reading list. The route of administration and the formulation of the medicine will affect these processes.

Enteral administration of medicines results in their absorption through the gastrointestinal tract, while parenteral administration encompasses all other routes, including injections, and absorption through the skin or via mucous membranes, such as in the respiratory tract or vagina. The circulatory system distributes systemic medicines, and these exert an effect on the body as a whole. Topical preparations usually provide a local action at the site of application, although some, such as transdermal patches and nasal sprays, have a systemic effect.

This procedure will describe the various enteral and parenteral routes of administration, as well as special considerations for administering different formulations via these routes, such as oral liquids and tablets. You should read this procedure in conjunction with the clinicalskills.net procedure, “Administration of medicines: key principles”.

Enteral administration involves the gastrointestinal tract and includes any medicines administered via the oral route (e.g., oral tablets), the gastric route (e.g., liquid medicine via nasogastric tube), and the rectal route (e.g. suppositories/enemas). These medicines diffuse from the gastrointestinal tract into the bloodstream, and the circulatory system distributes them around the body (McFadden, 2014).

The prescription must indicate the route of administration for the prescribed medicine, as some have more than one route of administration. In order to avoid any possible confusion, the prescriber must write only one route on the prescription (not, for example, IV/oral). This handwritten prescription is for paracetamol, an analgesic used to treat mild pain, which is an example of a medicine that is commonly administered orally.

This electronic prescription for salbutamol, a medicine used to treat conditions associated with reversible airway obstruction such as asthma, specifies that administration is by the inhaled route.

Should we call it Enteral and parenteral routes of administration (or is that tautolo-gous?--are there any other routes of administration?)

Do you think it would be helpful to include a table up front to show common abbreviations for di�erent routes - or should this be avoided if possible (PR2 not keen on abbreviations)?

Medicines Management

Adults

(c) Sublingual

(b) Advise patients to swallow tablets whole

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Routes of administration Page 2

Absorption through the mouth (a) (b) Buccal

Mechanical actions such as chewing, and the effects of enzymes in salivary and gastric secretions can break down and partially deactivate oral medicines before the body has a chance to absorb them into the circulatory system. For these reasons, it may be necessary to give oral formulations in higher doses than medicines administered by other routes. Advise patients to swallow tablets whole to prevent premature breakdown of the medicine.

Do not crush or break coated or unscored tablets, or those labelled “slow-release” or “sustained-action”, as this may affect the delivered dose and absorption of the medicine into the body (Smyth, 2019). Use a tablet splitter (pictured) to break scored tablets, otherwise you could give an inaccurate dose. Crushing tablets will make their use unlicensed, so do so only with the approval of the pharmacist and/or prescriber.

(c) Scored tablets may be split

Orally absorbed medicine may take the the form of a tablet, lozenge or spray, e.g., nicotine replacement therapy, which is available in lozenge and spray formulations. Instruct the patient not to swallow the medicine, as they must absorb it through the oral mucosa (the lining of the mouth). Oral mucous membranes have a rich blood supply which enables rapid absorption of medicines into the circulatory system (Schellack, 2011). Do not give the patient any food or drink until they have absorbed the medicine.

Administer a buccal medicine by placing it in the oral cavity between the gums and inner lining of the cheek. Here, the medicine will dissolve and diffuse into the bloodstream via the buccal mucosa, bypassing the gastrointestinal tract and avoiding deactivation. Prochlorperazine, an anti-emetic used to relieve nausea and vomiting, is available in a buccal formulation (BNF, 2019). Patients may mistakenly swallow buccal medicines, and some patients find the taste of medicines administered in this way unpalatable.

Orally administered medicines include tablet, capsule and liquid formulations. The patient swallows the oral medicine which then passes into the bloodstream through the stomach or intestinal tract. Give solid medications, such as tablets, with a glass of water, to ensure that they get into the stomach and do not stick in the oesophagus. Oral formulations are easy to prepare and quick to administer, so they are a cost-effective and common method of medicine delivery.

You should place sublingual medicines under the tongue, from where they will undergo rapid absorption into the bloodstream. An example of a sublingual medicine is glyceryl trinitrate (GTN), which treats chest pain associated with angina and is available in sublingual tablet and spray formulations (BNF, 2019). Some patients find it difficult to hold the dose under the tongue and may inadvertently swallow it, which will affect the efficacy of the medicine.

Oral administration (a)

Adults

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Also consider interactions with other substances the patient may be taking, such as herbal medicines, e.g. St John’s Wort, or food products such as grapefruit juice. Grapefruit juice interacts with statins (medicines used to lower cholesterol), increasing their plasma concentration which increases the risk of adverse effects (Joint National Formulary, 2019).

2015105

Oralsyringe

Bung

2.5

2

1.5

1

0.5

Tick or Enter Times Required

Drug08

14

18

Route Other directions

Start dateSignature Pharmacy

Dose

Drug08

14

18



Dose

Drug08

14

18


Start dateSignatureGPrescott14.9.19

NAPROXEN

Oral

1g

125micrograms

Oral

Oral

MF

GPrescott CTres14.9.19

DIGOXIN

MF

GPrescott14.9.19 MF

TO BE GIVENAFTER FOOD

Pharmacy

Dose

Drug08

14

18



Dose

Drug08

Dose

14

18


Start date14.9.19GPrescott CTres MF

14.9.19

Oral

GPrescott MF

1g

TO BE GIVEN AFTER FOOD

NAPROXEN

Signature Pharmacy

Drug08

14

18



Dose

Drug08

14

18



Dose

Lorem ipsum

Tick or Enter Times Required

Drug08

14

18



Dose

Drug08

14

18



Dose

Drug08

14

18


Start dateSignatureGPrescott14.9.19

6ALENDRONIC ACID

Oral

10 mg

125micrograms

Oral

Oral

MF

GPrescott CTres14.9.19

DIGOXIN

MF

GPrescott14.9.19 MF

TO BE GIVEN ONAN EMPTY STOMACH

Pharmacy

Dose

Drug08

14

18



Dose

Drug08

Dose

14

18


Start date14.9.19GPrescott CTres MF

14.9.19

Oral

GPrescott MF

10 mg 6

TO BE GIVEN ON AN EMPTY STOMACH

ALENDRONIC ACID

Signature Pharmacy

Drug08

14

18



Dose

Drug08

14

18



Dose

Lorem ipsum

2.5

2

1.5

1

0.5

2.5 2 1.5 1 0.5Liquid medications via the oral route Giving liquid medication using an oral syringe (a)

To administer liquid preparations orally, shake the bottle before pouring the liquid. Pour the liquid into a measuring pot on a flat surface and read the graduations at eye level for accuracy (see also NPSA, 2007).

Wash your hands. Remove the lid from the bottle and fit the bung from the oral syringe. Push the syringe into the hole on the top of the bung. These syringes do not work with Luer lock needles. Never use a parenteral syringe for giving oral medicines; instead, use a specific oral syringe (HSIB, 2019).

Special instructions for oral medicines: (a)

Check the medication administration record for any special instructions from the pharmacist about how to administer the medicine. For example, “to be given after food”, if the patient is taking medicines that could cause irritation or ulceration of the stomach lining, such as non-steroidal anti-inflammatory drugs (NSAIDs).

The pharmacist will give an additional instruction such as “to be given on an empty stomach” when the presence of food in the stomach may affect the absorption rate of the medicine, making it less effective. Bisphosphonates, commonly used to slow bone loss and reduce the risk of fractures, are a group of medicines that should be taken on an empty stomach (BNF, 2019). However, you may allow the patient to have water in order to ensure the medication reaches the stomach.

(b) (c)

Turn the bottle upside down and slowly withdraw the correct amount of liquid. Check that the syringe contains no air bubbles. Give the medicine immediately after drawing it from the bottle.

With the patient sitting upright, gently tip the patient’s head back and administer the medicine under or above the tongue. If the patient is unable to sit, assist them into a side-lying position to ease swallowing and prevent aspiration.

(b) Medicines to be taken on an empty stomach


70 +6 8

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6 2+ 60

+

80+

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70+

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66+

64+

62+

--60

+58

+56

+

2 4

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(b)Nasogastric, nasojejunal and gastrostomy tubes (a)

It is possible to administer medicines via enteral feeding tubes that provide direct access to the stomach or small intestine (CQC, 2018). Nasogastric tubes pass via the nose directly into the stomach; nasojejunal tubes pass via the nose and into the jejenum (small intestine); and gastrostomy tubes pass through the abdominal wall directly into the stomach. Liquid preparations are the easiest to administer via these routes. Do not crush tablets to administer medication via these routes unless advised to do so by a pharmacist; not all tablets are suitable for crushing, as this can affect absorption. In addition, small-bore tubes can block if used to give crushed tablets. If in any doubt, consult a pharmacist (Downie et al., 2008).

Adults

Routes of administration

Page 4 of 6


10

20

30

40

50

60ml

2 E

nteral

(c) Flush the tube between each medicine

Administer each medicine separately with a flush of water between each (CQC, 2018). (See also the clinicalskills.net procedures, “Medicines administration via a gastrostomy/PEG tube” and “Administration of medicines: key principles”.)

pH 3

.0

3.5

4

.0

4.5

5

.0

5.5

6

.0

LOT Expiry date

Store cool and dry. (15 - 25 °C) Place

2-3 d

rops o

f asp

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onto

the te

st zo

nes.

Allow

any e

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on th

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strip

to ru

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read

off th

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pH.

HC771304 SEP 2021

10

20

30

40

50

60

pH 3.0 3.5 4.0 4.5 5.0 5.5 6.0LO

T Expiry date

Store cool and dry. (15 - 25 °C)

Place 2-3 drops of aspirate onto the test zones.Allow any excess aspirate on the indicator strip to run off onto a paper towel.

Within 20 to 60 seconds read off the corresponding pH.

HC

771304 SEP 21

(b) Check positioning of enteral feeding tubes

Follow local policy for checking the position of enteral tubes. Ensure that a nasogastric tube is correctly positioned in the stomach before administering medicines by this route (NHS Improvement, 2016). (Also, see clinicalskills.net procedure, “Inserting a fine-bore nasogastric tube”.) Check the position of nasojejunal tubes by comparing the position of external markers at the nostril to the position documented at insertion (NICE, 2017).

(b)

You may use the rectal route to administer medicine when the patient is unable to take medication orally, for example because of nausea or vomiting. Patients should have an empty bowel before rectal administration of medicines as faeces may inhibit their absorption. (See also the clinicalskills.net procedures on “inserting a rectal suppository” and “Administration of an enema”.)

Rectal route (a)

Administer rectal medication by inserting it into the rectum via the anus, for absorption through the rectal mucosa to act systemically, or for a local effect, e.g., to relieve the symptoms of haemorrhoids. Available rectal medications include solid (suppository) and liquid (enema) formulations. Medications that you may administer via the rectal route include anti-inflammatory medicines, e.g., diclofenac, and anti-emetics, e.g., domperidone.

illustrate blue text with separate picture of �ushing tube from PEG CARE - FLUSHING THE TUBE PAGE 2, PIC 4- becomes page 4, picture 3


118202 2021

EXP: 10ml

118202 2021

EXP: 10ml

KEEP OUT OF THE REACH AND SIGHT OF CHILDR

EN

CHLORHEXIDINE ACETATE 1%

DUSTING POWDER

Dust the armpits, groin and any skin folds ONCE a day

for 5 days after washing with the Chlorhexidine

Gluconate 4% Liquid. Discard 14 days after o

pening

Follow the instructions in the information leaflet provided

Patient.................. Date................

.....

Do not use after 30 10 24

250G M LIQ PARAFFIN 50% IN SOFT PARAFFIN

KEEP OUT OF REACH OF CHILDREN

4g Chloramphenicol Eye Ointment BP

1.0% w/w

Bactroban Nasal OintmentmupirocinApply to the nostrils as prescribed by your doctorTake care to avoid the eyesKeep out of reach and sight of childrenTube contains calcium mupirocin equivalent mupirocin2% w/w in a white, soft-paraffin-based ointment alsocontaining a mixed diglycerin ester of fatty acids

Store at room temperature (below 25ϒC)

PHOSPHATE ENEMA READY TO USE DISPOSABLE SINGLE DOSE ENEMA PHOSPHATE ENEMA BP FORMULA 128ml

Adults

Aural administration in adults and children

Aural medication, which is inserted into the ear, has only local effects. The prescription should state the number of drops to be administered and whether the patient needs the drops in the right, left or both ears. The patient should tilt their head to one side so that the drops administered into the external auditory canal will run downwards into the auditory canal. To ensure the medication is accurately administered in adults (left), gently pull the outermost part of the ear (the pinna) in an upward and backward direction to straighten the ear canal (British Society of Audiology, 2016). In children (right), you should pull the pinna in a downward and backward direction (British Society of Audiology, 2016). (See also the clinicalskills.net procedure, “Instillation of ear drops”.)

Parenteral routes of administration bypass the gastrointestinal tract (McFadden, 2014). Parenteral formulations include patches, creams, sprays, drops, inhalers, nebulisers and injections. Sometimes these formulations have a systemic action while others deliver the medicine directly to the site of action (topical administration), e.g., lignocaine, a local anaesthetic which is used to numb the skin and subcutaneous layers before suturing.

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Inhalations (a)

(c) Difficulties with rectal administration

The rectal route is a useful route of administration, but many patients find it embarrassing and unacceptable (Crouch & Chapelhow, 2008). Some patients find it difficult to retain rectal medication. To encourage retention and absorption, the patient should lie on the left side, as the rectum runs downward when in this position; expulsion of medication may still occur.

(b) Inhalers and nebulisers

Inhalers deliver a single dose of medication under pressure. Nebulisers deliver a continuous stream of medication over a limited period of time: the liquid medication becomes a fine spray as pressurised air or oxygen is passed through it. The patient inhales the spray via a face mask or mouth piece. (For more information, see the procedure on “Nebulisers”.)

Administration via the inhaled route delivers medication into the lungs. The respiratory membrane in the lungs has a very large surface area with an excellent blood supply, so the body rapidly absorbs these medications. Inhaled medications have local effects on the bronchial mucosa or smooth muscle of the respiratory tract. Examples include inhaled bronchodilators, e.g., salbutamol, which treat the symptoms of asthma and COPD (NICE, 2019).


Parenteral routes


Transdermal/topical skin preparations

skin cleansing swabsIsopropyl Alcohol 70%External Use onlyR Registered TrademarkBSN medical gambit0-22771 Hamburg Germany

REF No. 72383-01 BSN

2

Cutisoft wipes

1ml

1321

.15

PROC

HLOR

PERA

ZINE

Inje

ctio

n B.

P.

Applicator

Pessary

Intranasal route Injections

Optical route Vaginal route

Adults

Routes of administration

Page 6 of 6


Intranasal medications include sprays, ointments and powder formulations. An example is an intranasal formulation of the steroid fluticasone, which is administered via droplets into each nostril in order to treat rhinitis. Intranasal medicines can enter the circulatory system via the nasal mucosa, with its rich blood supply, and exert a systemic effect. Intranasal medicines work best when the nasal passages are clear (Andrews & O’Brien, 2014).

In order to administer medication by injection, it is necessary to penetrate the skin using a needle and syringe, unless the patient has a device in place, such as a cannula. The different injection routes include: subcutaneous, intramuscular, intradermal and intravenous. For more information about the different injection routes, see the clinicalskills.net procedures in the “Injection Administration” section.

Medicines that are administered into the eye exert a local (topical) effect. The prescription should state the number of drops required and whether the patient needs the drops in the right, left or both eyes. Using a separate bottle/tube of medicine for each eye can reduce the risk of cross-contamination. For more details, see the clinicalskills.net procedure, “Instillation of eye medication”.

Vaginal medicines exert a topical effect. Normally, the patient will use an applicator to insert the medicine high into the vagina, either in the form of a pessary (vaginal suppository) or a cream. An example of a medicine administered via the vaginal route is clotrimazole, which is available in cream and pessary formulations to treat fungal infections such as candidiasis (BNF, 2019).

Formulations that are applied to the skin include pastes, creams, ointments and patches: some, such as fentanyl, pass through the skin into the bloodstream and have a systemic effect, while others act locally, such as emollients used to treat eczema. Prescriptions for dermal creams and ointments often state the amount to be applied as weight in grams; as an approximate guide, 2 g is a 10 cm length from a standard tube nozzle (Greenstein, 2009). It is important to use the correct amount, and ensure that you apply certain ointments and creams sparingly, e.g., steroid creams. Healthcare professionals should wear gloves when applying dermal preparations, to prevent absorption of the medicine into their own skin (Andrews & O’Brien, 2014). Administering medicines such as the analgesic fentanyl or hormone replacement therapy via impregnated, adhesive transdermal patches, ensures slow absorption of medicine through the skin resulting in steady blood levels. Place the patch on clean, dry and relatively hairless skin, where it will not get dislodged. Rotate the application site when applying a new patch, and document that you have done so (Andrews & O’Brien, 2014). To reduce the risk of adverse incidents when using transdermal patches, do not cut patches, avoid exposing them to heat (including hot water from baths and showers), and always remove old patches before applying a new one (MHRA, 2018).


ROUTES OF ADMINISTRATION P1

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