Routes of medication

For drug administration, the route is how a drug enters the body. As discussed in a prior chapter, the dose of medication can differ based on the route. The following sections discuss common routes of medication. There are many other routes that are not commonly used in the ambulatory care environment.

Oral route

Medications taken by the oral (po) route are those we take by mouth. Special administration techniques may be required for oral medications. These may include the following:

• Oral medications that coat the mouth or throat should not be immediately followed with water.

• Oral medications that require water for swallowing call for more than a sip. Some medications require a glass of water after taking the medication.

• A straw should be used for liquid medications that stain the teeth.

• Liquid medications should be measured only with a plastic medication cup or an oral

  medication syringe. Household measuring devices, such as spoons, are not accurate.

It is important to notify the provider if the patient is unable to take the medication due to nausea, vomiting, or problems swallowing. Do not attempt to see if the patient can swallow the pill. It is better to talk with the provider if the patient is concerned. Some medications can be crushed safely, whereas others cannot.

Crushing medications

Children, older adults, and others may have problems swallowing solid medications. Crushing medications is sometimes an option. The medication should be placed in a small amount of food or liquid (e.g., pudding or jam). It is important to eat or drink all the food or liquid to get the entire dose of medication.

Solid medications typically have an unpleasant taste. It is important to share with parents that children sometimes shy away from foods with an unpleasant taste. For instance, if a parent mixes the medication with the milk in a bottle, the baby may not want to drink the milk. This can be a problem if the baby drinks only milk.

Medications that cannot be crushed include the following:

• Slow- or extended-release tablets: Crushing, chewing, or cutting the tablet can cause a person to get the dose faster than they should, resulting in an overdose.
• Enteric-coated tablets: Crushing, chewing, or cutting the tablet causes the protective nature of the coating to be lost. The person could have more stomach distress.

Sublingual and buccal routes

Sublingual (SL) medications are placed under the tongue. Buccal medications are placed between the cheek and the gums. Both mucous membrane areas are rich in blood vessels. The medication is absorbed rapidly into the bloodstream. Special administration techniques may be required for SL and buccal medications. These may include the following:

• Do not eat or smoke prior to taking SL and buccal medications.
• Do not chew or swallow SL or buccal medications.
• Water can be taken prior to the medication to wet the mouth. No liquids can be taken until the medication has dissolved.
• Alternate cheeks used for buccal medication to avoid mucosal irritation.

Transdermal route

Transdermal medications are placed on the skin and absorbed into the bloodstream. Transdermal medications are different from topical medications, which provide a local action. Transdermal medications provide a systemic action. The transdermal drug delivery system uses patches that adhere to the skin. Medication in the patch is slowly absorbed through the skin. Depending on the medication, the patch may be worn for a part of a day to many days.

When replacing a patch or teaching a patient to use transdermal patches, follow these steps:

1. Write the date and time on the new patch.
2. Wear gloves if changing a patch on another person.
3. Remove the old patch. Fold the sticky sides together and discard. If the old patch is not removed, the person may be at risk for an overdose.
4. Remove any residual medication from the skin using a tissue.
5. Decide where to apply the new patch. Select a different location. Depending on the medication, it may be on the shoulder, back, upper arm, lower abdomen, or hip. Clean and dry the new site.
6. Remove the protective liner on the patch. Do not use torn patches. Do not touch the sticky side of the patch.
7. Place the patch’s sticky side on the skin. Press down on the patch to ensure it adheres to the skin. Make sure the patch is smooth, without folds.

Inhalation route

Medications for the nose, throat, and lungs can be inhaled. The small particles of medication are aerosolized in a fine mist. The medication is inhaled and reaches the mucous membrane or alveoli in the lungs, where it is absorbed. Metered-dose inhalers (MDIs) and nebulizers are common devices for inhaled drugs. Many nebulized medications come in a premixed solution. If the medication is not premixed, normal saline is usually recommended to dilute the medication.

Topical route

Applying a drug to a mucous membrane or the skin is considered use of the topical route. Absorption through the mucous membrane is usually faster than through the skin. Topical medications provide a local effect.

Many times, when a drug is ordered to be applied “topically,” it means that it should be applied to the skin. Topical drugs may also be administered by other routes. The provider will indicate a more specific route, such as rectal, vaginal, ophthalmic, nasal, or optic, for these medications.

When the medical assistant applies a topical medication to a patient’s skin, it is important to do the following:

• Wear gloves.
• Use a sterile applicator (tongue blade or swab) to remove medication from the container. A new sterile applicator must be used each time to keep the container sterile.
• Rub creams gently into the skin, pat lotions onto the skin, and apply ointment using a sterile applicator.
• Liniments must be rubbed into the skin.
• For topical aerosol sprays, hold the bottle 3 to 6 inches from the skin and spray.

Vaginal route

The vaginal route is used to insert suppositories, tablets, creams, and foams into the vagina. Typically, vaginal medications are used to treat local infections. Most medications can be inserted using the accompanying applicator. If no applicator is available, the patient should insert medications as is done with suppositories, using a finger. Usually, the medication must be inserted about 3 to 4 inches.

Vaginal instillation is most effective if the patient remains lying down after administration to prevent leakage. Many medications are intended to be used at bedtime. The patient may need to wear a pad to absorb drainage.

Rectal route

Rectal medications are inserted into the rectum. Suppositories and enemas are the most common forms of rectal medications. The medication is absorbed slowly and irregularly through the rectal mucous membrane. This route is useful when a patient cannot tolerate oral medications or if the patient is constipated. It is important for the medical assistant to remind patients to give both the enema and suppository time to work before using the bathroom.

Sometimes a medical assistant needs to teach a patient about inserting suppositories. It is helpful for the patient to know what supplies are needed and where the supplies can be purchased. Supplies required include the suppository, gloves, and water-soluble jelly (KY jelly). Encourage the patient to review the storage directions for the suppositories. The following tips are helpful for inserting a suppository:

• Remove the wrapping from the suppository.
• Lubricate the pointed part of the suppository with water-soluble jelly.
• Be in the side-lying position, with the knee drawn up toward the chest.
• Carefully insert the suppository pointed side first.
• For adults and older children: Use the gloved index finger to push the medication in. Both vaginal and rectal suppositories should be inserted about 3 to 4 inches. Have the person slowly breathe to help with the discomfort.
• For small children: Use the gloved little finger to insert the medication. Rectal suppositories should be advanced about 2 inches.

Nasal route

Drugs given via the nasal route are breathed in through the nose. The medication is absorbed through the nasal mucous membrane. The medication can have local or systemic effects. If the medical assistant is administering the nasal medication, it is important to wear gloves. Patients should blow their noses prior to receiving the medication. They should sit in an upright position. The patient should sniff when the medication is given. Intranasal medications should be charted as “intranasal.”

Ocular route

Medication may be instilled (poured drop by drop) into the eye to treat an infection, soothe irritation, anesthetize the eye, or dilate the pupils before examination or treatment. Ophthalmic medications are available in different forms. Liquid drops usually are supplied in small squeeze bottles. The tip allows one drop at a time to be administered. Other bottles may have a dropper that is used to administer the medication. Eye ointments come in small, metal or plastic tubes. The tip allows a small ribbon of ointment to be administered along the inner lower eyelid margin.

When instilling eye medications, avoid injuring the eye. Do not touch the eye with the tip or applicator. Always keep the tip or applicator sterile. If it gets contaminated, discard the container.

Otic route

Ear conditions can cause pain and make hearing difficult. Medication may be instilled into the ear to treat infection or inflammation or to soften cerumen. It is important to ensure that the ear drops get into the external canal.

Irrigation route

Irrigation is also a route of administration. Irrigation means to bathe or flush open wounds or body cavities. Irrigation can be used to remove foreign bodies or debris. It can also be used to bathe the area with medication. Wound, eye, and ear irrigations are commonly seen in ambulatory care settings.

Eye irrigation is done to remove foreign bodies or to flush irritants (e.g., chemicals) from the eye. Irrigation of the external auditory canal will do the following:

• Remove excessive or impacted cerumen
• Remove a foreign body (contraindicated if the item will absorb fluid [e.g., bean, pea, or corn kernel])
• Treat the inflamed ear with an antiseptic solution

Parenteral route

The parenteral route involves administration by infusion, injection, or implantation. In the ambulatory care environment, injections and infusions are common. Vaccine administration in primary care settings (e.g., family practice and internal medicine) is a frequent duty of medical assistants. Types of injections performed by medical assistants include the following:

• Intramuscular (IM): Administration within a muscle
• Subcutaneous (SUBQ): Administration beneath the skin
• Intradermal (ID): Administration within the dermis

The rest of the chapter will focus on the parenteral route. The following topics are discussed: injection supplies, medication preparation, site location, and medication administration. An intravenous infusion means fluid and medications are administered into a vein. This type of administration would be out of the Scope of Practice with a medical assistant however.