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Medicines Administration 1: Understanding Routes of Administration

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Medicines Administration 1: Understanding Routes of Administration Copyright EMAP Publishing 2020 This article is not for distribution except for journal club use Clinical Practice Keywords Medicines/Administration/ Administration route/Patient safety Review Medicines management In this article... l Different routes used to administer medicines l Benefits and limitations of the different administration routes l Points to consider before administering medicines Medicines administration 1: understanding routes of administration Key points Authors Martin Shepherd is clinical director of pharmacy and therapy, Chesterfield Bioavailability is Royal Hospital NHS Foundation Trust. Updated in 2020 by Eileen Shepherd, clinical the proportion of editor, Nursing Times. a medicine that reaches the systemic Abstract Medicines administration is a core responsibility of registered nurses in circulation healthcare settings and is increasingly being undertaken by nursing associates. Before administering any medicine, the person carrying out the procedure must be familiar The chosen route with the advantages and limitations of the prescribed route and know the indications, of administration contraindications and side-effects of the medicine they intend to give. This article, the will influence a first in a two-part series, provides an update on the routes of administration. Part 2 will medicine’s outline the procedure for administering medicines to patients. effectiveness and the patient’s Citation Shepherd M, Shepherd E (2020) Medicines administration 1: understanding experience routes of administration. Nursing Times [online]; 116: 6, 42-44. Care should be taken before edicine administration is a core terms tend to be used interchangeably. Ide- crushing medicines, responsibility of registered ally, any medicine should be effective, safe and advice should nurses in healthcare settings; and selective in its mode of action. always be sought increasingly, the task is also Effectiveness refers to how the body from the pharmacist M being carried out by nursing associates. To responds to a medicine; if a medicine fails or prescribing ensure patient safety, it is essential the cor- to lead to its intended result, there is no doctor rect procedure is implemented so the cor- benefit to prescribing it (Burcham and rect medicine is given in the prescribed Rosenthal, 2016). In the UK, the National Crushing modified- amount using the most appropriate route. Institute for Health and Care Excellence release tablets can Before administering any medicine, the carries out technology appraisals on the result in the full dose person carrying out the procedure must be use of new and existing medicines and of medicine being familiar with the advantages and limita- treatments in the NHS (Bit.ly/NICE released at once tions of the prescribed route, and know the TechAppraisal); these use clinical evidence rather than gradually indications, contraindications and side- on effectiveness and economic evidence on effects of the medicine they intend to give. whether the medicine/treatment repre- Administering sents value for money. medicines directly Medicine use and safety All medicines are evaluated to assess into the systemic A drug is defined as any chemical that can their safety, but no medicine is entirely circulation by affect living processes (Burchum and risk free. Nurses should: injection or infusion Rosenthal, 2016); this article focuses on l Be aware of any potential problems that means the medicine those that are administered for thera- patients may experience when taking is rapidly distributed peutic effect. To make it suitable for any medication; to its sites of action administration to a patient, a drug has to l Know how and when to report these. be formulated into a preparation that ena- In the UK, the Yellow Card scheme (Bit. bles it to be taken or given – such as a tablet ly/MHRAYellowCard) collects and moni- or injection. Once formulated, the drug tors information on suspected safety con- becomes a medicine; however, the two cerns or incidents involving medicines Nursing Times [online] June 2020 / Vol 116 Issue 6 42 www.nursingtimes.net Copyright EMAP Publishing 2020 This article is not for distribution except for journal club use Clinical Practice Review and medical devices. The scheme is run by Box 1. Administration routes Non-oral routes the Medicines and Healthcare products While the oral route is most frequently Regulatory Authority and relies on health Enteral: oral, via enteral feeding tubes used for medicine administration, it is not professionals and patients voluntarily Topical: via skin, eyes, ears, nose, always appropriate. In such situations a reporting suspected adverse drug reac- vagina, rectum, lungs (inhaled) range of alternatives is available to treat tions; it aims to provide an early warning Parenteral: intravenous, intramuscular, the patient effectively. that the safety of a product may require subcutaneous further investigation. Sublingual administration Ideally, a medicine should be selective The sublingual mucosa offers a rich supply in its action on the body. However, most understood in terms of their implications of blood vessels through which medicines medicines have side-effects and it is for the effectiveness of the drug therapy can be absorbed. This is not a common important to inform patients about these and the patient’s experience. route of administration but it offers rapid risks – as an example, antihistamines can absorption into the systemic circulation. cause drowsiness. Sometimes a decision Oral route The most common medicine given via has to be made by the patient and pre- The oral route is the most frequently used sublingual administration is glyceryl trini- scriber as to whether symptom relief is route of medicines administration and is trate in the treatment of acute angina. balanced against potential side-effects; in the most convenient and cost-effective The pharmaceutical industry has formu- some situations, the side-effects may out- (Dougherty and Lister, 2015). lated ‘wafer-based’ versions of medicines, weigh the benefits of the medicine. Although solid-dose forms such as tab- which dissolve rapidly under the tongue. lets and capsules have a high degree of These are aimed at particular groups of Administration drug stability and provide accurate patients who have difficulty taking tablets, The way in which medicines are dosage, the oral route is problematic such as rizatriptan for people with migraines administered will, to some extent, because of the unpredictable nature of gas- that are sometimes accompanied by nausea influence their clinical benefit and trointestinal absorption. For example, as this may prevent them from taking oral whether patients experience any adverse food in the gastrointestinal tract may alter treatments. Wafers are also used to treat con- effects. For example, if intravenous (IV) the gut pH, gastric motility and emptying ditions in which adherence is an issue; for furosemide is administered too quickly, it time, as well as the rate and extent of drug example, olanzapine can be administered by can cause deafness, while oral penicillin V absorption. the sublingual route when used to treat will not be well absorbed if given with Patients’ tolerance of solid-dose forms schizophrenia (Montgomery et al, 2012). food) (bnf.org). Two main factors also varies, particularly in very young and determine whether a medicine will reach older patients, for whom liquids or solu- Rectal administration its intended site of action in the body: tions may be preferable. However, many The rectal route has considerable disadvan- l Its bioavailability; medicines are not stable in solution; in tages in terms of patient acceptability due l How it is given (route of such cases, an alternative should be con- to cultural issues and the potential for dis- administration). sidered. Key points are outlined in Box 2. comfort, leakage and unpredictable absorption; however, it does offer a number Bioavailability Modified-release preparations of benefits (Hua, 2019). Drug delivery can Bioavailability is the proportion of a medi- Modified-release formulations can delay, be localised into the large bowel – for cine that reaches the systemic circulation prolong or target drug delivery. The aim is example, the use of rectal steroids in the and is therefore available for distribution to maintain plasma drug concentrations form of enemas or suppositories in the to the intended site of action (Burchum and for extended periods above the minimum treatment of inflammatory bowel disease. Rosenthal, 2016). The route of administra- effective concentration. Their main advan- Antiemetics can be administered rectally tion and formulation – tablet, capsule, tage for patients is that doses usually only to treat nausea and vomiting, and paracet- liquid – can influence its bioavailability. need to be taken once or twice daily. amol can be given to treat patients with a Medicines given by IV injection are said pyrexia who are unable to swallow. to have 100% bioavailability. Some medi- Crushing tablets cines that are particularly well absorbed by The process of crushing tablets is usually Box 2. Key points on oral the gastrointestinal mucosa, for example outside of the product licence and nurses route for administration the antibiotic ciprofloxacin, may have bio- should seek advice from a pharmacist or availability close to that of an IV dose (bnf. the prescribing doctor if they are uncer- l The oral route is convenient and org). However, most medicines do not have tain about a tablet and whether it
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