Topical drugs are applied directly to the skin surface. They include lotions, pastes, ointments, creams, powders, shampoos, patches, and aerosol sprays. Topical medications are absorbed through the epidermal layer into the dermis. The extent of absorption depends on the vascularity of the region.
Nitroglycerin, fentanyl, nicotine, and certain supplemental hormone replacements are used for systemic effects. Most other topical medications are used for local effects. Ointments have a fatty base, which is an ideal vehicle for drugs such as antimicrobials and antiseptics. Typically, topical medications should be applied two or three times per day to achieve their therapeutic effect.
Equipment
Patient's medication record and chart • prescribed medication • gloves • sterile tongue blades • 4″ × 4″ sterile gauze pads • transparent semipermeable dressing • adhesive tape • solvent (such as cottonseed oil).
Implementation
Verify the order on the patient's medication record by checking it against the physician's order on the chart.
Make sure the label on the medication agrees with the medication order. Read the label again before you open the container and as you remove the medication from the container. Check the expiration date.
Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Provide privacy.
Explain the procedure thoroughly to the patient because he may have to apply the medication by himself after discharge.
Wash your hands to prevent cross-contamination, and glove your dominant hand. Use gloves on both hands if exposure to body fluids is likely.
Help the patient assume a comfortable position that provides access to the area to be treated.
Expose the area to be treated. Make sure the skin or mucous membrane is intact (unless the medication has been ordered to treat a skin lesion, such as an ulcer).Applying medication to broken or abraded skin may cause unwanted systemic absorption and result in further irritation.
If necessary, clean the skin of debris, including crusts, epidermal scales, and old medication. You may have to change the glove if it becomes soiled.
Applying paste, cream, or ointment
Open the container. Place the lid or cap upside down to prevent contamination of the inside surface.
Remove a tongue blade from its sterile wrapper, and cover one end with medication from the tube or jar. Then transfer the medication from the tongue blade to your gloved hand.
Apply the medication to the affected area with long, smooth strokes that follow the direction of hair growth. This technique avoids forcing medication into hair follicles, which can cause irritation and lead to folliculitis. Avoid excessive pressure when applying the medication because it could abrade the skin.
To prevent contamination of the medication, use a new tongue blade each time you remove medication from the container.
Removing ointment
Wash your hands and apply gloves. Then rub solvent on them and apply it liberally to the ointment-treated area in the direction of hair growth. Alternatively, saturate a sterile gauze pad with the solvent and use the pad to gently remove the ointment. Remove excess oil by gently wiping the area with a sterile gauze pad. Don't rub too hard to remove the medication because you could irritate the skin.
Applying other topical medications
To apply shampoos, follow package directions. (See Using medicated shampoos.)
To apply aerosol sprays, shake the container, if indicated, to completely mix the medication. Hold the container 6″ to 12″ (15 to 30 cm) from the skin, or follow the manufacturer's recommendation. Spray a thin film of the medication evenly over the treatment area.
To apply powders, dry the skin surface, making sure to spread skin folds where moisture collects. Then apply a thin layer of powder over the treatment area.
To protect applied medications and prevent them from soiling the patient's clothes, tape an appropriate amount of sterile gauze pad or a transparent semipermeable dressing over the treated area. With certain medications (such as topical steroids), semipermeable dressings may be contraindicated. Check medication information and cautions. If you're applying a topical medication to the patient's hands or feet, cover the site with white cotton gloves for the hands or terry cloth scuffs for the feet.
PEDIATRIC ALERT In children, topical medications (such as steroids) should be covered only loosely with a diaper. Don't use plastic pants.
Assess the patient's skin for signs of irritation, allergic reaction, or breakdown.
Special considerations
Never apply medication without first removing previous applications to prevent skin irritation from an accumulation of medication.
Be sure to wear gloves to prevent absorption by your own skin. If the patient has an infectious skin condition, use sterile gloves and dispose of old dressings according to your facility's policy.
Don't apply ointments to mucous membranes as liberally as you would to skinbecause mucous membranes are usually moist and absorb ointment more quickly than skin does. Also, don't apply too much ointment to any skin area because it might cause irritation and discomfort, stain clothing and bedding, and make removal difficult.
Never apply ointment to the eyelids or ear canal unless ordered. The ointment might congeal and occlude the tear duct or ear canal.
Inspect the treated area frequently for adverse effects, such as signs of an allergic reaction.
Complications
Skin irritation, a rash, or an allergic reaction may occur.
Documentation
Record the medication applied; time, date, and site of application; and condition of the patient's skin at the time of application. Note the patient's tolerance and subsequent effects of the medication, if any.