Nursing care
Topical and Transdermal Medications: the nurse's role, start to finish
Written and reviewed by Dana Whitfield, RN, MSN · 6 min read · Updated September 2026
Short answer
Topical and transdermal medications are applied to the skin for local effect or absorbed through it into the bloodstream for a systemic one, most often via patches that release drug over 24 to 96 hours. The nurse always removes the old patch before placing a new one, gloves before handling any patch, and rotates application sites to prevent skin breakdown. Skipping the old-patch removal or gloving step risks overdose in the patient and accidental exposure in the nurse.
Indications and contraindications
Topical agents treat the skin itself — corticosteroids for dermatitis, antifungals for tinea, local anaesthetics before a procedure. Transdermal systems are different in intent: fentanyl, nicotine, clonidine, nitroglycerin, and hormone patches use the skin as a route into systemic circulation, avoiding first-pass liver metabolism and giving a steady drug level over days rather than hours.
Avoid transdermal opioids in opioid-naïve patients or those with acute, unstable pain, since the slow onset and long half-life make dose titration difficult and the risk of accumulation real. Broken, inflamed, irradiated, or excessively hairy skin is a poor application site for any patch, and fever or an external heat source such as a heating pad increases absorption rate unpredictably, which matters most with fentanyl.
Getting the patient ready
Check the site before application: it should be clean, dry, intact, and free of hair (clip rather than shave, since shaving nicks the skin and alters absorption). Wash the area with water alone — soap, alcohol, or lotion can change how the drug penetrates the skin, and residual lotion is a common reason a patch fails to adhere.
Confirm the order against the five rights as with any medication, but pay particular attention to strength and duration for patches, since a fentanyl patch ordered in micrograms per hour is easy to misread against an oral morphine dose the patient may already be on. Ask about any existing patches on the patient's body — patients sometimes forget a patch is still in place under clothing or hair, which is how accidental double-dosing happens.
Technique and safety checks
Put on gloves before touching either the old or the new patch. Fentanyl and similarly potent transdermal drugs absorb through intact skin on contact, and a nurse who applies or removes a patch bare-handed can develop sedation, nausea, or respiratory depression from that exposure alone — this has caused documented staff injuries and is not a theoretical risk.
Remove the old patch first, fold it in half with the adhesive sides together, and dispose of it according to your facility's controlled substance waste policy before applying the new one. Never apply a new patch over or near an existing one, and never cut a patch to adjust the dose — cutting breaches the release membrane and can dump the full reservoir of drug at once.
Press the new patch firmly against clean, dry skin for the full time stated in the manufacturer instructions, commonly 30 seconds, and rotate the site from the last application by several centimetres to let the previous area recover. Document the application site, date, and time on the patch itself and in the record so the next nurse can find and remove it without searching.
What can go wrong
The most serious risk with transdermal opioids is respiratory depression from delayed absorption, heat exposure, or a second patch applied before the first is removed. Because onset is slow, symptoms can appear hours after application and may be missed if the nurse is watching for the rapid changes seen with IV opioids instead.
Local skin reactions — erythema, itching, or contact dermatitis at the application site — are common with adhesive patches and usually mild, but a patch that will not stay adherent risks partial dosing that is hard to quantify. Staff and family exposure from handling used or new patches without gloves, and paediatric or pet exposure from a discarded patch retrieved from a bin, are underrecognised but real safety events.
Ongoing care
Reassess the application site at every shift for adherence, skin irritation, and whether the patch is still the one you applied — patches can be dislodged by sweating, bathing, or clothing friction. Track and rotate sites methodically, using a body diagram if your facility provides one, so the same patch of skin is not reused within the recommended interval.
Monitor for the systemic effect the drug is meant to have, not just the local skin condition: sedation and respiratory rate for opioid patches, heart rate and blood pressure for clonidine or nitroglycerin. Confirm at handover exactly which patches are currently on the patient and where, since a missed or forgotten patch is one of the more common medication errors on units that use them regularly.
Common exam questions
Expect scenario items that test whether you remove the old patch before applying a new one, and whether you glove before touching either — a stem describing a nurse applying a fentanyl patch bare-handed is testing recognition of a safety violation, not a trick question. Questions may also ask you to identify an inappropriate transdermal candidate, such as an opioid-naïve patient prescribed a fentanyl patch for acute post-operative pain.
Other recurring themes include the effect of heat on absorption (a heating pad over a fentanyl patch is a classic wrong-answer distractor to catch), the correct disposal method for a controlled substance patch, and the instruction never to cut a patch to reduce the dose.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our pharmacology practice questions are the closest set to what this page covers.
One question from the pharmacology set
A client with heart failure is started on furosemide 40 mg PO daily. Which findings should the nurse report to the provider before administering the next dose? Select all that apply.
Rationale
Furosemide is a loop diuretic, so the two things you are watching are potassium and kidney function. A potassium of 2.9 mEq/L is below the 3.5–5.0 reference range and puts the client at risk for dysrhythmia — hold and report. Muscle cramps with palpitations are the clinical face of that same hypokalemia, so they are reported together, not separately. A creatinine that doubles signals the diuresis has outrun renal perfusion. A blood pressure of 132/78 and a 1 kg loss are the expected response to the drug working, not reasons to hold it.
Answer: A, D, E
Common questions
Do I need to remove an old transdermal patch before applying a new one?
Yes, always. Applying a new patch without removing the old one, or applying it to a site that still has residual drug in the skin, can cause accidental overdose. Check the patient's whole body if there's any doubt a previous patch was removed, since patches are easy to forget under clothing or hair.
Why do I need to wear gloves to apply or remove a fentanyl patch?
Fentanyl and other potent transdermal drugs absorb through intact skin on contact, not just through a needle stick or broken skin. A nurse handling a patch bare-handed can absorb enough drug to become sedated or short of breath, so gloves are required for both application and removal, and hands should be washed after gloves come off.
Can I cut a transdermal patch to give a smaller dose?
No. Most transdermal patches release drug through a controlled membrane or matrix, and cutting the patch breaches that mechanism, potentially releasing the full reservoir of drug at once. If a smaller dose is needed, the prescriber should order a lower-strength patch.
How do I dispose of a used fentanyl patch?
Fold the patch in half with the adhesive surfaces sticking together so no drug-containing surface is exposed, then dispose of it per your facility's controlled substance waste policy, which typically means witnessed disposal in a sharps or pharmaceutical waste container rather than a regular bin. Never place a used opioid patch in household or general ward rubbish, where it can be retrieved by a child, pet, or another person.
Why does a heating pad matter for a patient wearing a fentanyl patch?
Heat increases blood flow to the skin and speeds drug release from the patch, which can push the patient into an unintentional overdose. Advise patients to avoid heating pads, electric blankets, saunas, and hot tubs directly over or near a transdermal opioid patch, and to report fever, which has the same effect.
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