NUR 113 – SKILL 21-3:

1. NUR 113 – SKILL 21-3: APPLYING TOPICAL MEDICATION TO THE SKIN

2. Applying Topical Medications to the Skin - Introduction • Topical administration of medication involves applying drugs locally to the skin, mucous membranes, or tissues. • Topical drugs such as lotions, patches, pastes, and ointments primarily produce local effects; but they can create systemic effects if absorbed through the skin. • Systemic effects are more likely to occur if the skin is thin, drug concentration is high, contact with the skin is prolonged, or the drug is applied to skin that is not intact.

3. Applying Topical Medications to the Skin – Cont’d • To protect from accidental exposure, apply topical drugs using gloves and applicators. • Skin encrustations and dead tissue harbor microorganisms and block contact of medications with the affected tissue or membrane. • Applying new medication over a previously applied medication does little to prevent infection or provide therapeutic benefit to a patient.

4. Applying Topical Medications to the Skin – Cont’d • Always clean the skin or wound thoroughly before applying a new does of topical medication. • Apply each type of medication, whether an ointment, lotion, powder, or patch, in a specific way to ensure proper penetration and absorption.

5. HOW TO PASS THE SKILL • I am going to summarize the information for you that was taken from your book, Clinical Nursing Skills & Techniques, 8th Edition. • While I encourage you to review this power point presentation, as well as review what is written in your book, you need to practice this skill in the skills lab, along with any other skill that you wish to pass. • These power point presentations were meant to help you, but remember you still need to practice and also, have your fellow students quiz you, whenever possible. • I was in your shoes once, and believe me, you can make it!

6. ASSESSMENT • 1. Check accuracy and completeness of each medication administration record (MAR) with health care provider’s medication order. Check patient’s name, drug name and dosage, route of administration, and time for administration. Clarify incomplete or unclear orders with health care provider before administration. • 2. Review pertinent information related to medication, including action, purpose, normal dose and route, side effects, time of onset and peak action, and nursing implications.

7. ASSESSMENT – CONT’D • 3. Assess condition of skin or membrane where medication is to be applied (see Chapter 6). If there is an open wound, perform hand hygiene and apply clean gloves. First wash site thoroughly with mild, nondrying soap and warm water, rinse and dry. Be sure to remove any previously applied medication or debris. Also remove any blood, body fluids, secretions, or excretions. Assess for symptoms of skin irritation such as pruritus or burning. Remove gloves when finished. • 4. Assess patient’s medical history, history of allergies (including latex and topical agent), and medication history. Ask if patient has had reaction to a cream or lotion applied to skin. • Allergic contact dermatitis is relatively common and can worsen dermatologic (skin) condition. In addition, some patients may be allergic to preservatives or fragrances in topical medications. Latex allergy requires use of non-latex gloves.

8. ASSESSMENT – CONT’D • 5. Determine amount of topical agent required for application by assessing skin site, reviewing health care provider’s order, and reading application directions carefully (a thin, even layer is usually adequate). • An excessive amount of topical agent can chemically irritate skin, negate effectiveness of drug, and/or cause adverse systemic effects such as decreased white blood cell (WBC) counts. • 6. Assess patient’s knowledge of action and purpose of medication being given, application schedule, and willingness to adhere to drug regiment. • 7. Determine if patient or family caregiver is physically able to apply medication by assessing grasp, hand strength, reach, and coordination. • Necessary if patient is to self-administer drug at home.

9. PLANNING • Expected outcomes following completion of procedure: • Patient is able to identify drug and describe action, purpose, does, side effects, and schedule of medication. • Patient is able to apply medication without assistance on prescribed schedule. • With repeated applications, skin becomes clear, without inflammation or drainage from lesions. • Existing lesions heal and/or disappear as result of therapeutic action of medication.

10. IMPLEMENTATION • 1. Prepare medications for application. Check label of medication against MAR 2 times (see Skill 22-1). Preparation usually involves taking bottle of tube of lotion, cream, ointment, or patch out of storage and to patient room. Check expiration date on container. • 2. Take medication (s) to patient at correct time (see agency policy). • 3. Perform hand hygiene. Help patient to comfortable position. • 4. Identify patient using two identifiers. (i.e., name and birthday or name and account number) according to agency policy. Compare identifiers in MAR/ medical record with information on patient’s identification bracelet and/or ask patient to state name.

11. IMPLEMENTATION – CONT’D • 5. At patient’s bedside again compare MAR or computer printout with names of medications on medication labels and patient name. Ask patient if he or she has any allergies. • 6. Discuss purpose of each medication, action, and possible adverse effects. Allow patient to ask any questions about the drugs. • 7. If skin is broken, apply sterile gloves. Otherwise apply clean gloves.

12. IMPLEMENTATION – CONT’D • 8. APPLY TOPICAL CREAMS, OINTMENTS, AND OIL-BASED LOTIONS: • A. Expose affected area while keeping unaffected areas covered. • B. Wash, rinse, and dry affected area before applying medication (see Assessment, Step 3). • C. If skin is excessively dry and flaking, apply topical agent while skin is still damp. • D. Remove gloves, perform hand hygiene, and apply new clean or sterile gloves. • E. Place required amount of medication in palm of gloved hand and soften by rubbing briskly between hands. • F. Tell patient that initial application of agent may feel cold. Once medication is softened, spread it evenly over skin surface, using long, even strokes that follow direction of hair growth. Do not vigorously rub skin. Apply to thickness specified by manufacturer instructions. • G. Explain to patient that skin may feel greasy after applications.

13. IMPLEMENTATION – CONT’D • 9. APPLY ANTIANGINAL (NITROGLYCERIN) OINTMENT: • A. Remove previous dose paper. Fold used paper containing any residual medication with used sides together and dispose of it in biohazard trash container. Wipe off residual medication with tissue. • B. Write date, time, and nurse’s initials on new application paper. • C. Anti-anginal(nitroglycerin) ointments are usually ordered in inches and can be measured on small sheets of paper marked off in 1.25 cm (1/2 inch) markings. Unit-dose packages are available. Apply desired number of inches of ointment to paper-measuring guide.

14. IMPLEMENTATION – CONT’D • APPLY ANTIANGINAL (NITROGLYCERIN) OINTMENT – CONT’D • D. Select application site: Apply nitroglycerin to chest area, back, abdomen, or anterior thigh. Do not apply on hairy surfaces or over scar tissue. • E. Be sure to rotate application sites. • F. Apply ointment to skin surface by holding edge or back of paper-measuring guide and placing ointment and wrapper directly on skin. Do not rub or massage ointment into skin. • G. Secure ointment and paper with transparent dressing or strip of tape. Place wrap may be used as occlusive dressing. • Clinical Decision Point: Unit-dose packages are available. NOTE: One package equals 2.5 cm (1 inch); smaller amounts should be measured from this package.

15. IMPLEMENTATION – CONT’D • 10. APPLY TRANSERMAL PATCHES (E.G., ANALGESIC, NICOTINE, NITROGLYCERIN, ESTROGEN). • A. If old patch is present, remove it and clean area. Be sure to check between skinfolds for patch. • Failure to remove old patch can result in overdose. Many patches are small, clear, or flesh colored and can be easily hidden between skinfolds. Cleaning removes traces of previous patch. • B. Dispose of old patch by folding in half with sticky sides together. Some agencies require patch to be cut before disposal (see agency policy). Dispose of it in biohazard trash bag.

16. IMPLEMENTATION – CONT’D • 10. APPLY TRANSERMAL PATCHES (E.G., ANALGESIC, NICOTINE, NITROGLYCERIN, ESTROGEN). – CONT’D • C. Date and initial outer side of new patch before applying it and note time of administration. Use soft-tip or felt-tip pen. • D. Choose a new site that is clean, dry, and free of hair. Some patches have specific instructions for placement locations (e.g., Testoderm patches are placed on scrotum: a scopolamine patch is placed behind the ear; never apply an estrogen patch to breast tissue or waistline). Do not apply patch on skin that is oily, burned, cut, or irritated in any way. • Clinical Decision Point: Never apply heat such as with a heating pad over a transdermal patch because this results in an increased rate of absorption with potentially serious adverse effects.

17. IMPLEMENTATION – CONT’D • 10. APPLY TRANSERMAL PATCHES (E.G., ANALGESIC, NICOTINE, NITROGLYCERIN, ESTROGEN). – CONT’D • Clinical Decision Point: It is recommended to have a daily “patch free” interval of 10 to 12 hours because tolerance develops if patches are used 24 hours a day every day. Apply a new patch each morning, leave in place for 12 to 14 hours, and remove in the evening. • E. Carefully remove patch from its protective covering by pulling off liner. Hold patch by edge without touching adhesive edges. • Touching only edges ensures that patch will adhere and that medication dose has not changed. Removing protective covering allows medication to be absorbed through skin. • F. Apply Patch. Hold palm of one hand firmly over patch for 10 seconds. Make sure that it sticks well, especially around edges. Apply overlay if provided with patch. • Adequate adhesion prevents loss of patch, which results in decreased dose and effectiveness..

18. IMPLEMENTATION – CONT’D • 10. APPLY TRANSERMAL PATCHES (E.G., ANALGESIC, NICOTINE, NITROGLYCERIN, ESTROGEN). – CONT’D • G. Do not apply patch to previously used sites for at least 1 week. • H. Instruct patient that transdermal patches are never to be cut in half; a change in dose would require prescription for new strength of transdermal medication. • Cutting transdermal patch in half would alter intended medication delivery of transdermal system, resulting in inadequate or altered drug levels. • I. Instruct patient to always remove old patch before applying new one. Patients should not use alternative forms of medication when using patches. For example, patients should not apply nitroglycerin ointment in addition to patch unless specifically ordered to do so by their health care provider. • Use of patch with additional or alternative drug preparation can result in toxicity or other side effects.

19. IMPLEMENTATION – CONT’D • 11. ADMINISTER AEROSOL SPRAY (E.G., LOCAL ANASTHETIC SPRAYS). • A. Shake container vigorously. Read container label for distance recommended to hold spray away from area, usually 15 to 30 cm (6 to 12 inches). • B. Ask patient to turn face away from spray or briefly cover face with towel while spraying neck or chest. • C. Spray medication evenly over affected site (in some cases, time the spray for a period of seconds). 12. APPLY SUSPENSION-BASED LOTION. A. Shake container vigorously. B. Apply small amount of lotion to small gauze dressing or pad and apply to skin by stroking evenly in direction of hair growth. C. Explain to patient that area will feel cool and dry.

20. IMPLEMENTATION – CONT’D • 13. APPLY POWDER: • A. Be sure that skin surface is thoroughly dry. With your non-dominant hand, fully spread apart any skinfolds such as between toes or under axilla and dry with towel. • Minimizes caking and crusting of powder. Fully exposes skin surface for application. • B. If area of application is near face, ask patient to turn face away from powder or briefly cover face with towel. • Prevents inhalation of powder. • C. Dust skin site lightly with dispenser so area is covered with fine, thin layer of powder. • Option: Cover skin area with dressing if ordered by health care provider.

21. IMPLEMENTATION – CONT’D • 14. Help patient to comfortable position, reapply gown, and cover with bed linen as desired. • Provides for patient’s sense of well-being. • 15. Dispose of soiled supplies in receptacle especially designated for such articles, remove and dispose of gloves, and perform hand hygiene. • Keeps patient’s environment neat and reduces spread of infection and residual medication to others.

22. EVALUATION • 1. Ask patient or family caregiver to name the medication and its action, purpose, dose, schedule, and side effects. • Evaluates learning. • 2. Have patient keep diary of doses taken. • Confirms adherence to prescribed therapy. • 3. Observe patient or family caregiver apply topical medication. • Return demonstration measures learning. • 4. Inspect condition of skin between applications. • Determines if skin condition improves.

23. UNEXPECTED OUTCOME • 1. Skin site appears inflamed and edematous with blistering and oozing of fluid from lesions. These signs indicate sub-acute inflammation or eczema that can develop if skin lesions are getting worse. • Hold Medication • Notify health care provider; alternative therapies may be needed. • 2. Patient is unable to explain information about drug or does not administer as prescribed. • Identify possible reasons for noncompliance and explore alternative approaches or options.

24. RECORDING AND REPORTING • 1. Record actual time each drug that was administered, type of agent applied, strength, and site of application in nurses’ notes / EHR and on MAR immediately after administration, not before. Include initials or signature. Record patient teaching and validation of understanding in nurses’ notes. If you withhold a drug, record reason in nurses’ notes and follow agency policy for noting withheld doses. • Describe condition of skin before each application in nurses’ notes and EHR. • Report adverse effects/patient response and/or withheld drugs to nurse in charge or health care provider. Depending on medication, immediate health care provider notification may be required.

25. SPECIAL CONSIDERATIONS - TEACHING • 1. If skin is inflamed, instruct patients to use only warm water rinse without soap for cleaning. • 2. Teach patient how to manage a transdermal patch that begins to peel off before the next dose is due. Rather than tape the patch or cover it, instruct patient to remove it, clean the skin, and apply a new patch to a different area.

26. SPECIAL TEACHING - GERONTOLOGIC • Gerontologic: • Changes in the skin of an older adult patient include increased wrinkling, dryness, flaking, and an increased tendency to bruise. • Be aware of these changes when applying topical medications to ensure proper application. • Older skin is often more fragile and must be handles gently when applying topical medications.

27. END OF SKILL • This is the end of your skill. • Your book has provided a video for this skill and the link is as follows: • VIDEO: • http://bookstie.Elsevier.com/Perry-Potter/ClinicalSkills/video24.php • Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques, 8e – 21.3, Administering Skin Applications