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Administering Medicines

 

Administering medications by enema

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The administration of substances into the bloodstream. This may be done in situations where it is undesirable or impossible to deliver a medication by mouth, such as antiemetics given to reduce nausea (though not many antiemetics are delivered by enema). Additionally, several anti-angiogenic agents, which work better without digestion, can be safely administered via a gentle enema. Medicines for cancer, for arthritis, and for age-related macular degeneration are often given via enema in order to avoid the normally-functioning digestive tract. Interestingly, some water-based enemas are also used as a relieving agent for irritable bowel syndrome, using cayenne pepper to squelch irritation in the colon and rectal area. Finally, an enema may also be used for hydration purposes.

Emergency blood expansion. Emergency pre-hospital treatment of haemorrhage requires immediate fluid replacement therapy. In mass casualty, remote or rural settings, the lack of sterile fluids, intravenous equipment or the knowledge to use them might limit the treatment options available. In such situations proctoclysis remains an easy and effective way to provide fluid replacement. It does not require sterile fluids, special equipment or complex training, and it is useful when alternative routes are not readily available.

The topical administration of medications into the rectum, such as corticosteroids and mesalazine used in the treatment of inflammatory bowel disease. Administration by enema avoids having the medication pass through the entire gastrointestinal tract, therefore simplifying the delivery of the medication to the affected area and limiting the amount that is absorbed into the bloodstream.

General anesthetic agents for surgical purposes are sometimes administered by way of an enema. Occasionally, anesthetic agents are used rectally to reduce medically-induced vomiting during and after surgical procedures, in an attempt to avoid aspiration of stomach contents.


Administering a suppository

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A suppository is a drug delivery system that is inserted into the rectum (rectal suppository), vagina (vaginal suppository) or urethra (urethral suppository), where it dissolves or melts.

They are used to deliver both systemically-acting and locally-acting medications.

The alternative term for delivery of medicine via such routes is pharmaceutical pessary.

The general principle is that the suppository is inserted as a solid, and will dissolve or melt inside the body to deliver the medicine pseudo received by the many blood vessels that follow the larger intestine.

Rectal suppositories are commonly used for:

laxative purposes, with chemicals such as glycerin or bisacodyl treatment of hemorrhoids by delivering a moisturizer or vasoconstrictor delivery of many other systemically-acting medications, such as promethazine or aspirin

General medical administration purposes: the substance crosses the rectal mucosa into the bloodstream; examples include paracetamol (acetaminophen), diclofenac, opiates, and eucalyptol suppositories.

Mode of insertion

In 1991, Abd-El-Maeboud and his colleagues published a study in The Lancet, based upon their investigation into whether there was some hidden and forgotten knowledge behind the traditional shape of a rectal suppository.

Their research very clearly demonstrated that there was, indeed, a very good reason for the traditional torpedo shape; namely, that the shape had a strong influence on the extent to which the rectal suppository traveled internally — and, thus, upon its increased efficiency.

They (counter-intuitively) found that the ideal mode of insertion was to insert suppositories blunt end first, rather than the generally used mode of inserting the tapered end first. This conclusion was based on the greater distance of internal travel of the suppository once inserted, which was entirely a mechanical consequence of the natural actions of the bowel's muscular structure and the rectal configuration.

As a consequence, and in order to guarantee the maximum optimal efficiency, they recommended that all rectal suppositories be inserted blunt end first. The findings of this single study have been challenged as insufficient evidence on which to base clinical practice.

Non-laxative rectal suppositories

Four 500 mg paracetamol suppositories

Non-laxative rectal suppositories are to be used after defecation, so as not to be expelled before they are fully dissolved and the substance is absorbed. The use of an examination glove or a finger cot can ease insertion by protecting the rectal wall from fingernail(s).

Vaginal suppositories

Vaginal suppositories are meant for introduction into the vagina. These are generally conical, rod shaped or wedge shaped and are larger than Rectal suppositories (4-8 g). Commonly used for local actions in the treatment of gynecological ailments, including vaginal infections such as candidiasis.

Urethral suppositories

Alprostadil pellets are urethral suppositories used for the treatment of severe erectile dysfunction. They are marketed under the name Muse in the United States. Its use has diminished since the development of oral impotence medications.

Constituents

Some suppositories are made from a greasy base, such as cocoa butter, in which the active ingredient and other excipients are dissolved; this grease will melt at body temperature (this may be a source of discomfort for the patient, as the melted grease may pass through the anus during flatulences). Other suppositories are made from a water soluble base, such as polyethylene glycol. Suppositories made from polyethylene glycol are commonly used in vaginal and urethral suppositories. Glycerin suppositories are made of glycerol and gelatin.

Indications

Suppositories may be used for patients in the event it may be easier to administer than tablets or syrups.

Suppositories may also be used when a patient has a vomiting tendency, as oral medication can be vomited out.

Drugs which often cause stomach upset, for example diclofenac sodium (Voltaren) are better tolerated in suppository form.

Liquid suppository

Liquid suppository involves injecting a liquid, typically a laxative, with a small syringe, into the rectum.


 

Administering an intramuscular injection

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An injection is a method of putting liquid into the body with a hollow needle and a syringe which is pierced through the skin to a sufficient depth for the material to be forced into the body. An injection follows a parenteral route of injection, that is, its effect is not necessarily local to the area in which the injection is administered; it is systemic.

There are several types of injections or infusions, including, subcutaneous, intramuscular, and intravenous infusions.

Intramuscular Injections

The gluteus medius muscle, which is also known as the ventrogluteal site, is the third commonly used site for IM injections. The correct area for injection can be determined in the following manner. Place the heel of the hand of the greater trochanter of the femur with fingers pointing towards the patient's head. The left hand is used for the right hip and vice versa. While keeping the palm of the hand over the greater trochanter and placing the index finger on the anterior superior iliac spine, stretch the middle finger dorsally palpating for the iliac crest and then press lightly below this point. The triangle formed by the iliac crest, the third finger and index finger forms the area suitable for intramuscular injection.

Intramuscular injection is the injection of a substance directly into a muscle. In medicine, it is one of several alternative methods for the administration of medications (see Route of administration). It is used for particular forms of medication that are administered in small amounts. Depending on the chemical properties of the drug, the medication may either be absorbed fairly quickly or more gradually. Intramuscular injections are often given in the deltoid, vastus lateralis, ventrogluteal and dorsogluteal muscles. When the gluteal muscles are used, injections should be made on the upper, outer quadrant of the buttock to avoid damaging the sciatic nerve. Injection fibrosis is a complication that may occur if the injections are delivered with great frequency or with improper technique.

Thrombocytopenia (low platelet counts) and coagulopathy (bleeding tendency) are contraindications for intramuscular injections, as they may lead to hematomas.

Examples of medications that are sometimes administered intramuscularly are:

* codeine

* methotrexate

* metoclopramide

* olanzapine

* Streptomycin

* diazepam

* prednisone

* Interferon beta-1a

* sex hormones, such as testosterone, estradiol valerate, and Depo Provera

* dimercaprol

* ketamine

* naloxone

* quinine in its gluconate form

In addition, some vaccines are administered intramuscularly:

* Gardasil

* hepatitis A vaccine

Subcutaneous Injections

A subcutaneous injection is administered as a bolus into the subcutis, the layer of skin directly below the dermis and epidermis, collectively referred to as the cutis. Subcutaneous injections are highly effective in administering vaccines and such medications as insulin.

Intravenous Injections

Intravenous is a term that means within the vein. An injection is something that is introduced into something else. An intravenous injection is the introduction of a substance into the veins using a needle. This may be necessary for medical reasons. It may also be done for illicit purposes.

An intravenous injection can involve one or more single doses of a substance administered through a needle. The substance to be administered is usually stored in a syringe, which is attached to the needle. Once the needle is inserted into a vein, the raised portion of the syringe may be depressed, forcing the substance into the vein.

Intravenous injection can be a means of therapy in some other medical cases. Sometimes, such as in cases of dehydration, a person is given fluids intravenously over an extended period, which could be hours or days. Instead of syringes, the substance to be injected is often stored in bags hung above the patient. The substance flows through tubes to the needle. Gravity is the force that is generally used to make this possible. The flow is generally controlled by clips that can be connected to the tube that runs to the needle.

Doing this is a means to quickly replace fluids the body needs. This method of treatment may be referred to as a drip or an IV. Blood transfusions and intravenous feeding may also be administered in this way.


The most common way people take medications is orally (by mouth). Depending on what your doctor has prescribed, your oral medication can be swallowed, chewed or placed under your tongue to dissolve.

Medications that you swallow travel from your stomach or intestine into your bloodstream and then are carried to all parts of your body. This is known as absorption. The speed with which this occurs depends on several factors:

The type of medication you are taking – e.g. liquid or tablet

Whether you take your medication with food, after food or on an empty stomach

The ability of your medication to pass into your bloodstream – some medications have a special coating and dissolve slowly in your stomach

How your medication reacts with the acid conditions in your stomach

Whether your medication interacts with other medications you are taking at the same time

If a quick effect is desired, your doctor may prescribe a medication that will dissolve in your mouth and rapidly enter your bloodstream.

Types of Oral Medications

Tablets and Capsules

In general, you should take tablets and capsules with water. For example, taking certain pills, such as Lipitor (Atorvastatin) and Viagra (Sildenafil), with grapefruit juice can cause potentially dangerous side effects. Additionally, milk can block the absorption of some antibiotics, such as Cipro (Ciprofloxacin).

Your healthcare provider or pharmacist will tell you if you should take your medication on an empty stomach or before or after eating. This is very important since food in your stomach and intestine can interfere with your medication dissolving and passing into your bloodstream. Make sure to follow the directions on your prescription very carefully.

Additionally, do not break, crush, or chew any capsule or tablet before swallowing. Many medications are long-acting or have a special coating and are intended to be swallowed whole. If you are not sure, ask your pharmacist.

If you have trouble swallowing your medication, tell your doctor and pharmacist. They may be able to provide you with a liquid form of the medication or a pill that is smaller and easier to swallow.

Liquids

Liquid medications are good for children and adults (especially older adults) who are not able to swallow tablets or capsules. Many liquid medications, including both prescription drugs and over-the-counter drugs, are made for children and are flavored to mask the taste of the medication.

Before measuring the proper dose of liquid medication, make sure to shake the bottle as some of the medication may have “settled” at the bottom.

Most often, you will be told to measure the medication using a teaspoon. To a doctor and pharmacist, this means 5 ml (milliliters) of medication. Many household teaspoons are different sizes and hold more or less than 5 ml. Therefore, you might get too much or too little medication on your spoon.

Measure your liquid medication carefully! Ask your pharmacist for a spoon, medicine cup, medicine dropper, or a syringe without a needle meant specifically for measuring medications. Your pharmacist can show you how to properly use these. Many over-the-counter liquid medications come with a small medicine cup attached to the top of the bottle.

If the medication has been prescribed for an infant or young child, make sure to speak with your pediatrician about the proper dosage, or amount, of liquid medication for your child.

Sublingual and Buccal Medications

Certain medications are placed under the tongue (sublingual) or between the teeth and the cheek (buccal). These medications are absorbed quickly into the bloodstream through the lining of the mouth and are used to relieve symptoms almost immediately.

Some examples of sublingual medications are Nitrostat and other nitroglycerin preparations used to treat angina (chest pain) and Suboxone (bupronorphine with naloxone) used to treat addiction to heroin and narcotic painkillers.

Other Forms of Oral Medications

Although most oral medications are swallowed, some are released in the mouth by chewing, dissolving slowly or melting on the tongue. Many of these medications are sold over-the-counter.

Chewable tablets should be chewed until they have dissolved completely. They are not meant to be swallowed. Examples of chewable tablets include Tylenol Chewable and many brands of children’s vitamins.

Chewing gum medications have a minimum time that they must be chewed to assure that the entire amount of drug has been released, often up to 30 minutes. Examples of medicated chewing gums include Nicorette Gum (nicotine) and Aspergum (aspirin).

Lozenges are meant to be “sucked” on like hard candy and allowed to dissolve slowly in your mouth. They should not be swallowed. Examples of medicated lozenges include Commit (nicotine) and Cepacol (benzocaine).

Softchew® medications are meant to melt in your mouth or to be chewed. Examples of Softchew® medications are Triaminic Softchew Cold and Allergy Medication (chlorpheniramine and pseudoephedrine) and Rolaids Soft Chew (calcium carbonate).

 

    
       

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