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Medication Medication AdministrationAdministration
and Assistance with Self-Administration of and Assistance with Self-Administration of MedicationMedication
Florida Administrative Rule 65G-7Florida Administrative Rule 65G-7
Agency for Persons with Disabilities State CurriculumJanuary 2009
Florida Administrative Rule 65G-7Florida Administrative Rule 65G-7
Medication Administration Rule◦Allows unlicensed staff who are working with
clients of the Agency for Persons with Disabilities to Administer medication or Supervise the self administration of medication
◦Gives specific training/validation guidelines◦ Discusses the do’s and don’t of the Medication
Assistant Provider (MAP)◦Explains the documentation process
Direct AuthorityDirect Authority
Florida Statutes 393.506
◦Section (5) “ The agency shall establish by rule standards and
procedures that a direct service provider must follow when supervising the self-administration of medication by a client and when administering medication to a client”
Outcome of Training Course Outcome of Training Course
Will understand both training and validation requirements Will demonstrate ability to complete and maintain all required forms Will understand how to document and communicate determination of need Will state the six rights of medication administration Will understand the difference between fully capable of self administration,
supervision of self administration and administration of medication Will understand the importance of information on symptoms of adverse
reactions and side effects of prescribed or over the counter medications, and how to locate it
Will understand health care practitioner orders, prescriptions and prescription labels
Will understand how to complete a Medication Administration Record (MAR) Will be able to discuss safe handling of medications and sanitary conditions Will understand the allowed routes of medication administration Will have knowledge of proper preparation and positioning of the client Will have knowledge of medication errors, disposal of medication and safe
storage Will understand steps that need to be taken when medication is taken off-site
When can I give medications?When can I give medications?
After attending a minimum 4 hour class and passing the exam with 80% or above Once you have completed
this course and pass the course exam, you will be issued a certificate of successful completion
After on-site Validation with 100% competency by a RN, ARNP, or MD (APD form 65G7-04) You will receive a Validation
Certificate, with each route you are validated for signed off on the back.
Once you receive a client assignment you will need to make sure the next 2 items are in place:
Authorization for Medication Administration signed by client’s MD, PA, or ARNP (APD form 65G7-01)
Informed Consent for Medication Administration form, signed by client or their legal representative (APD form 65G7-02)
On-site validation by routeOn-site validation by route
Must be done on-site, with real clientMust be done by a RN, ARNP, or MDMust validate with 100% competencyEach Route of medication administration
must be individually validated (signed on back of form)
Revalidation must occur yearlyEmployer, if any, must also keep a copy
available for review
What are “routes?”What are “routes?”
The ways that medications can be delivered to the body
◦ MAP’s can administer medication for only approved routes of delivery.
◦ MAP’s can only administer medication via a route that they have been validated for
ApprovedRoutes ofDelivery:
Oral Topical Transdermal Ophthalmic Otic Rectal Inhaled Enteral
Client/guardian Informed ConsentClient/guardian Informed Consent
Informed Consent ◦ (APD form 65G7-02)
Signed by client or client’s authorized representative
May be filled out with the agency (ie: abc group home) or individual MAP’s name in the provider space
Kept in client record readily accessible for review
Authorization for Medication Authorization for Medication Administration 65G-7.01Administration 65G-7.01
The Authorization Form
Three levels of “ABILITY”
Must be completed by an MD, PA, or ARNP for clients annually or with any changes to health status or ability
Keep with clients record, easily accessible for review
Fully capable of self administering own medication without supervision
Requires supervision while administering own medication
Requires medication administration
““Fully capable of Self Fully capable of Self Administration” Administration” What does this mean?What does this mean?
These clients may take their own medications by themselves, without supervision
A MAR is not kept (document only what you do)
The client may need a little help with reminding, reordering or getting medication from the pharmacy
Not required to lock up medication in own home
Storage:◦ May use pill minder◦ Keep in locked container if
client lives in GH or multi-person SL
◦ Under certain circumstances medication may need to be centrally stored Medication threatens
health, welfare or safety of the client or others
Client does not keep medication in locked place
Physical arrangements or habits of other clients makes it unsafe
Client or their authorized representative asks for the medication to be centrally stored
Supervision of self administrationSupervision of self administration
Will need properly trained and validated MAP complete this task
Tasks will not be the same for every client◦MAP may complete the following duties
Prompt and observe client taking medication Confirm the client is taking dosage as prescribed Assist clients when there is something they can’t
do Document on MAR Medication must be centrally stored
Supervision of Self AdministrationSupervision of Self Administration
Supervision of Self Administration of medication includes instructions or any other assistance necessary to ensure the correct self administration of medication.
• Client may be able to take oral medications – but cannot give themselves eye drops, or insert a rectal suppository• Client may be able to identify the medications needed, and the route…but may be unable to remove the medication from the container, or put the medication in their mouth without help
MAP must assist with every scheduled medication delivery
MAP documents on MAR that they observed the client appropriately received the scheduled medication
• Client may be able to self administer a topical medication in an easy to reach area, but need the MAP to apply it on a less easy to reach area
Administration of MedicationAdministration of Medication
Clients are not yet able to safely give their own medications
MAP must prepare and give medications
MAP must document immediately on a Medication Administration Record (MAR)
Medication must be centrally stored
Goal is IndependenceGoal is Independence
Training and encouragement for clients to become independent is central to the views of this agency.
Your input can be very helpful to health care practitioners when deciding on the client’s capabilities. ◦Reviews must be done annually and/or upon
health status change
Does Administrative Rule Does Administrative Rule 65G-7 Apply to 65G-7 Apply to
EVERYONE?EVERYONE?
NO, it does not.
Who is exempt?Who is exempt?
Health care practitioners whose licenses include medication administration-LPN’s RN’,s, etc.
A client’s family members or friends who provide assistance with medication with out compensation
Providers employed by or under contract to: Intermediate Care Facilities for the developmentally disabled, home health agencies, hospices, health care service pools, or assisted living facilities.
Clients who are authorized to self administer their
medications without supervision.
Six Rights of Medication Six Rights of Medication AdministrationAdministration
What rights do clients have?What rights do clients have?
Safely give medication by practicing the Six Rights of Medication Administration ◦Right Client◦Right Medication◦Right Dosage◦Right Time◦Right Route◦Right Documentation
Prescription is ordered for your client What happens next?
Tracking and DocumentationTracking and Documentation
Health care practitioner writes the prescriptionMAP makes copy of the prescription for the client
record and takes original to pharmacy◦ Current copies in the MAR for reference◦ Archive discontinued prescription orders
Write prescription order on the client MARWhen medication is picked up or delivered from
pharmacy◦ Compare label with copy of prescription and with MAR
All information must matchMedication should be started in a reasonable time
frame (within 24 hours)Medication is given as prescribedDocument on MAR
Who can write a medication Who can write a medication order?order?
Medical Physician or Psychiatrist (MD)Osteopathic Physician (DO)Advanced Registered Nurse Practitioner
(ARNP)Physician Assistant (PA)Dentist (DDS or DMD)Optometrist (OD)Podiatrist (DPM)
Pharmacist dutiesPharmacist duties
DispensesLabelsPackages
Only pharmacist can change a label Only pharmacist can write on a labelOnly pharmacist can transfer from one
container to another
What is on a prescription label?What is on a prescription label?
Label Example (PRN)
Name Strength Route Amount Time Reason for use Condition to notify MD Maximum number of
doses
Tylenol 325mg By mouth 2 tablets (650mg) Every 4 hours Fever> 101F Fever> 102F 3 days
Manufactures Labels for OTC Manufactures Labels for OTC medicationsmedications
Will contain◦ Name of medication◦ Strength of medication◦ Purpose of medication◦ Amount of medication included in container◦ Directions for use◦ Active and inert ingredients◦ Possible side effects◦ Warning- possible drug interactions, maximum dosage◦ Storage conditions◦ Name and address of the manufacturer◦ Expiration Date◦ Lot number
What you need to know!What you need to know!
All medication must be properly labeled◦Sample Medication:
Must be accompanied by a prescription Maintained in original container Labeled by dispensing healthcare practitioner
◦Clients name◦Practitioners name◦Directions for administering the medications
The MAP must initial the label and add the date the medication was opened
You can not change a prescription You can not change a prescription label.label.
The physician may ◦Change the dose or time of medication
All changes must be in writing on a prescription and taken to the pharmacy to dispense the appropriate medication with the appropriate label
◦Write “as directed” on the prescription You will need to get more specific directions in
writing before medication can be given◦Try to give you verbal order
You must ask the physician to fax the order since all orders must be in writing.
PRN medicationPRN medication
◦Healthcare Practitioner must provide written directions that include: Then name of the medication The prescription number, if applicable The prescription dosage Specific directions for use, including medical
reason for the medication, the time intervals for administration, the maximum number of doses, the maximum number of days that the medication should be administered and conditions under which the health care practitioner should be notified
Controlled MedicationsControlled Medications
Medication that is regulated under the jurisdiction of the Controlled Substance Act of 1970
Abuse is the highest with schedule I drugsFive groups (scheduled I thru V)
◦Example: Schedule II:
◦Ritalin, Codeine, Demerol, Duragesic patch, Percocet Schedule IV:
◦Phenobarbital, Valium, Ativan
Documentation of Controlled Documentation of Controlled DrugsDrugs
When do I document?◦Pharmacy provided form stamped with “C”◦On the MAR immediately after administration◦Control Medication Count Sheet (APD form
65G7.07) To verify count accuracy Must be signed by two providers Your responsibility to count and document as
directed by rule Must report any medication discrepancies to
supervisor
How to store controlled drugsHow to store controlled drugs
Stored separately from other prescriptions or OTC drugs
Double Locked◦A locked container◦A locked enclosure
Forms of PackagingForms of Packaging
Labeled BottlesBubble packs or
bingo cardsColor coding on
packaging for different time periods (only developed by the Pharmacy)
Unit dose dispensing systems
AbbreviationsAbbreviations
po by mouthp.c. after mealsprn as neededQD every dayQOD every other
dayTab tabletQ3h every 3
hoursQID or qid four times
per daysig labelTID or tid three times
per dayU units
a.c. before meals
ad lib as directed BID twice a day cap capsule d/c or D/C discontinue gtt drop H.S. or h.s hour of
sleep mg milligram ml milliliter od right eye os left eye ou both eyes
Abbreviations - continued
When writing on a MAR it is best NOT to use the abbreviations. While many health care practitioners use them, abbreviations have been identified as the main cause of many medication errors.
VERY CONFUSING
QD, QID, QOD (look similar)PO, pc, pr, prn (look similar)
CAN YOU SEE WHY IT IS BEST NOT TO USE ABBREVIATIONS?
Procedures for Routes of Procedures for Routes of Medication Medication
AdministrationAdministrationHow to give medications
Medication Administration for Oral Medication Administration for Oral RouteRoute
Wash your hands. Gather equipment – medication spoon or syringe, medicine
cup, pill cutters or crushers, paper towels, glass of water or other liquid with which to take or follow medication.
Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one client’s
medication at a time. Select the needed medications, making sure to compare the
label to the order or prescription to the MAR and check expiration dates.
Make sure you follow any special instructions, for instance “take on empty stomach,” “take with food,” “check pulse and hold for pulse less than 60,” “do not give if client is having diarrhea.”
Oral MedicationOral Medication
• Place a dot on the MAR. Pop or pour the medication into a medication cup –
remember to pour a pill from the container into the lid, then into the medication cup. If you pour too many into the lid, you can pour them back into the bottle and try again. Do not touch with fingers.
For liquid medications, shake bottle before pouring (as directed by label), make sure that the cup is on a level surface for accurate measuring, pour away from the label. Wipe the lid and neck of the bottle with a dampened paper towel before returning to storage. Read the amount of medication at the bottom of the curve of the liquid in the medication cup at eye level.
Crush medications if directed to do so, and mix with applesauce, pudding, or ordered substance.
Compare the label on the medication to the directions on the MAR again.
Oral Medications - continued
Return the medication to the storage area and lock. Hand the medication cup to the client, followed by glass of
liquid with which to swallow the pills. Verify that the client swallows the medication. Give pills first, liquids last. If giving a medication for cough, it should be given last to coat the throat.
Again check the label against the MAR. Sign the MAR and blister pack, if used.
Wash your hands. Document on the MAR. Controlled substances requires
additional documentation on the Controlled Drug Count Form (see attached)
Check on client and assist to comfortable position, if needed. Check client for response to medication, especially if PRN
medication.
Buccal or SublingualBuccal or Sublingual
Wash your hands. Gather equipment-medication cup, gloves, glass of water or other
liquid with which to take or follow medication. Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one client’s
medication at a time. Select the needed medications, making sure to compare the label to
the order or prescription to the MAR and check expiration date. Make sure you follow any special instructions, for instance “take on
empty stomach.” “take with food,” “check pulse and hold for pulse less than 60,” “do not give if client is having diarrhea.”
Place a dot on the MAR. Pop or pour the medication into a medication cup-remember to pour
a pill from the container into the lid, then into the medication cup. If you pour too many into the lid, you can pour them back into the bottle and try again. Do not touch with fingers.
Compare the label on the medication to the directions on the MAR again.
Buccal or Sublingual - continued
Return the medication to the storage area and lock. Hand the medication cup to the client and instruct them to place the
medication under their tongue if sublingual, or between cheek and gum if buccal. If the client is unable to do this, carefully place the medication in the appropriate spot yourself.
Instruct the client not to drink liquids until the medication has dissolved and been absorbed.
Tell the client not to swallow the pill, and to let it dissolve Again check the label against the MAR. Initial the MAR and blister pack, if used.
Wash your hands. Document on the MAR. Controlled substances require additional
documentation on the Controlled Drug Count Form (see attached). Check on client and assist to comfortable position, if needed. Check client for response to medication, especially if PRN medication.
(if PRN medication document response on back of MAR)
Inhaled (such as albuterol)Inhaled (such as albuterol)
Wash hands. Gather equipment – spacers, glass of water, tissue, Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one client’s
medication at a time. Select the needed medications, making sure to compare the label
to the order or prescription to the MAR. Place a dot on the MAR. Remove the cap from the inhaler and ensure that mouthpiece is
clean; shake if indicated. Ask the client to exhale and then place the mouthpiece, tilted
slightly upward, into his/her mouth. Instruct the client to close lips around mouthpiece.
Use a spacer attached to the mouthpiece as instructed if the client is unable to close lips around mouthpiece.
Ask the client to inhale slowly as you push the cylinder of the medication down against the mouthpiece one time.
Inhaled - continuedInhaled - continued
Ask the client to hold his/her breath for several seconds. Remove the mouthpiece from the client’s mouth. Ask the client to exhale slowly through pursed lips. If a second puff is required, wait at least one minute between
each puff, and then repeat above instructions. Ask the client to rinse out his/her mouth. Rinse the mouthpiece with warm water, dry with a paper towel,
and recap. Wash hands. Store medication in proper locked area. Document on the MAR. Have the client use any inhalers first and then take oral
medications.
Dry powder inhalers (such as Dry powder inhalers (such as Advair)Advair)
Follow the steps above for inhalers through step 6. Pull back the dose lever until it clicks into place. Do not tilt
the inhaler, and ask the client not to breath into the inhaler.
Ask the client to exhale. Place the mouthpiece into the client’s mouth, and instruct
the client to close his/her lips around it. Instruct the client to inhale forcefully and deeply. Continue with steps 11-18 for inhalers, above. Document on the MAR. Have the client use any inhalers first and then take oral medications.
Nose sprayNose spray
• Wash hands• Gather paper towels or tissues and gloves• Verify the first five Rights of Medication Administration• Unlock the medication storage area – remove one client’s medication at a time • Select the needed medications, making sure to compare the label to the order or prescription to the MAR• Place a dot on the MAR• Put on gloves• Ask the client to blow his/her nose gently to clear the nasal passages• Ask the client to tilt his/her head backwards, making sure the neck is supported• Elevate the nostrils slightly by pressing the thumb against the tip of the nose
Nose spray - continued
Hold the spray just above the client’s nostril, without touching it.
Use spray as directed by the prescription or orderAsk the client to inhale slowly and deeply through the nose,
hold breath for several seconds and then exhale slowly. Client may blot nose with tissue, but ask client not to blow
nose for several minutes following instillationRinse the tip of the spray bottle with hot water or wipe with an
alcohol pad and dry with tissue before recappingRemove gloves and dispose of properlyPlace medication back in locked storage areaWash handsDocument on the MAR
Nose dropsNose drops
Follow the directions for nasal sprays above, making sure to use the correct number of drops.
Do not touch the nostrils with the dropper.Document on the MAR.
Transdermal – self adhesive Transdermal – self adhesive patchespatches
Wash hands. Gather equipment – gloves, washcloth and towel. Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one
client’s medication at a time. Select the needed medications, making sure to compare
the label to the order or prescription to the MAR. Place a dot on the MAR. Provide for privacy for client. Wear gloves; check client for latex allergies if using latex
gloves. Remove old patch and dispose of appropriately.
Transdermal patches - continued
Make sure site for new patch is clean and dry. If needed, clean area with soap and warm water and then pat area dry. Do not apply over a bony prominence such as the collarbone or shoulder blade. Do not apply the patch over a pacemaker site. Apply in a hairless area. Apply the patch to a different site with each new patch application. Avoid areas of increased warmth (such as the back if bed-ridden) which would promote faster absorption. Do not apply to areas with redness, rash, or broken skin. Report these areas to your supervisor.
Open the package and remove the patch. Date and initial the patch. Remove the backing from the patch. Apply the patch to the chosen spot, pressing firmly around the edges
to adhere. Apply, and cover patch, if applicable, making sure it is dated and
initialed. Remove gloves and dispose of properly Place medication back in locked storage area. Wash hands. Document on the MAR.
Topical (ointments, lotions, creams, sprays)Topical (ointments, lotions, creams, sprays)
Wash hands. Gather equipment – gloves, applicators, wash cloth and towel, water. Verify first five Rights of Medication Administration, making sure you
understand where on the client’s body the medication is to be applied. Unlock the medication storage area and remove one client’s medication at
a time. Select the needed medications, making sure to compare the label to the
order or prescription to the MAR. Place a dot on the MAR. Provide for privacy for client. Wear gloves: check client for latex allergies if using latex gloves. Make sure site for medication is clean and dry. If not, cleanse gently with
soap and warm water and pat dry, unless the prescription directions say otherwise. Previous medications are usually removed before applying additional medication, except for lotions which are used for soothing the skin).
Topical - continued
Squeeze a small amount of medication (if a cream, ointment, or lotion) onto the applicator. Always shake lotions to activate ingredients. If applying to a large surface area, warm lotions/creams in hands before use so the client does not chill. Keep powder away from the nose and mouth to keep the client from inhaling it. If applied to the face, apply while the client exhales. If applying nitroglycerin ointment, measure in centimeters or inches on special provided paper or applicator. Do not apply to areas with redness, rash, or broken skin unless you are treating that area (rash).
Apply gently to correct site. If a spray, hold the can about 6” away from site and spray. Discard applicator. Gently lay dressing over site, if applicable, and secure. MAP may only apply simple
dressings which are intended to cover and protect, such as Band-Aids, Telfa or gauze pads.
Discard gloves and dispose of properly. Place medication back in locked storage area. Wash hands. Document on the MAR.
Eye medications (ointments and drops)Eye medications (ointments and drops)
Wash hands. Gather equipment – gloves, cotton balls or gauze, tissues, wash cloth,
towel, warm water, simple dressing, if ordered. Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one client’s medication
at a time. Select the needed medications, making sure to compare the label to the
order or prescription to the MAR. Check number of drops and eye (right, left, both).
Place a dot on the MAR. Wear gloves: check client for latex allergies if using latex gloves. Assist the client to a comfortable position either sitting or lying down
with head tilted back. May turn the head slightly toward the affected side to prevent medication or tears from flowing toward the opposite eye. If using both drops and ointment, administer the drops first and wait 5 minutes before applying the ointment.
Eye medications - continued
Give client a tissue to remove solution/tears that may spill from eye during the procedure.
Clean eye area if discharge or crusting is present. Use cotton balls moistened with warm water (unless ordered otherwise). Use each cotton ball for only one stroke, starting at the inner eye corner and working outward away from the nose. If using wash cloth instead of cotton balls, rotate to new area of wash cloth with each stroke.
After removing the lid to the medication, place on a clean tissue, on its side.
Gently pull down on the lower eyelid. Ask the client to look upward. Approach the eye from the side and drop medication into the
center of the lower lid. Do not touch the eye with the dropper, or drop medication directly onto the surface of the eye.
Eye medications - continued
If using ointment, gently apply the prescribed length of ointment in a thin line along inner edge of the lower lid moving from the inner corner to the outer corner. Do not touch the eye with the end of the tube. If the client blinks, closes eye, or if drops/ointment lands on the outer lid margin, repeat the procedure
Release the lower lid after the eye drops or ointment is administered. If drops, ask the client to close eyes slowly, but not to squeeze or rub
them. Apply gentle pressure over inner corner of eye to prevent eye drops from flowing into tear duct. If ointments, ask the client to close eye and rub lid gently in circular motion, if rubbing is not contraindicated.
Client may open eyes after 30 seconds and gently wipe off excess medication or tears with a tissue.
If multiple medications are needed for the same eye, you must wait at least 5 minutes between medications.
Remove gloves and dispose of properly. Place medication back in locked storage area. Wash hands. Document on MAR.
Ear (Otic) MedicationsEar (Otic) Medications
• Wash hands• Gather equipment – gloves, tissues, clean wash cloth, warm water• Verify the first five Rights of Medication Administration• Unlock the medication storage area and remove one client’s medication at a time• Select the needed medications, making sure to compare the label to the order or prescription to the MAR• Place a dot on the MAR• Put on gloves• Assist the client to a comfortable position either sitting with the head tilted to the side or lying down so that the ear needing drops is up• Warm the medication to body temperature (hold in your hand or place in a cup of warm water for a few minutes) to minimize discomfort to the client• Place drops in the ear according to the prescription, letting the drops fall on the side of the ear canal and not directly on the eardrum. Take care not to touch the ear with the dropper
Ear Medications - continued
Release the ear and have the client hold the head position for at least 2-5 minutes
Allow the client to wipe ear with a tissue Instill drops in the other ear, if prescribed, using the same
procedure MAP may insert or remove cotton portion (wick) into or from outer
part of canal if ordered Remove gloves and dispose of properly Place medication back in locked storage area Wash hands Document on MAR
Rectal SuppositoriesRectal Suppositories
Wash hands. Gather equipment – gloves, tissues, water soluble lubricant
(K-Y jelly) Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one
client’s medication at a time. Select the needed medications, making sure to compare
the label to the order or prescription to the MAR. Place a dot on the MAR. Return the medication to the storage area and lock. Explain to the client what you are about to do, and provide
for privacy.
Rectal suppositories - continued
Place the client in a side lying position, preferably on the left, with the right leg bent at the knee and drawn up towards the stomach. Keep client covered as much as possible. Place waterproof pad or other absorbent material beneath client’s hips and buttocks.
Remove wrapper and lubricate the suppository rounded end or remove cap and lubricate tip (if applicable) and finger tips with a water soluble gel (K-Y jelly).
Separate the buttocks and then have client relax by breathing slow, deep breaths through the mouth while the suppository is gently inserted through the anus about 4 inches for adults and 2 inches for children and infants. Do not attempt to push the suppository through stool. Instead try to place it along the side of the rectal space.
Rectal suppositories - continued
Hold the buttocks together, or press lightly against the anus with a tissue until the urge to push the suppository out has passed. Ask client to remain on side or flat for at least 5 minutes.
Remove gloves and disposes of properly. Assist client to rearrange clothing, etc. Be sure that client
understands that he/she is to retain the suppository, usually for 30-45 minutes after insertion. Have some way (bell) for client to alert staff of urgency if the suppository was a laxative or stool softener.
Wash hands Document on MAR.
Observe and record effects of suppository in comments section of MAR
Enemas (such as Fleet’s)
Follow steps 1-9 for suppositories Remove cap and gently insert lubricated enema tip slowly
into rectum until the entire tip is in the rectum (3-4 inches). If the tip is not lubricated use a water soluble gel (such as K-Y) to lubricate. It is best to guide along the rectal wall, and not try to push it through any stool that may be present.
Gently squeeze the enema bottle slowly (to prevent cramping) to expel the contents into the rectum and colon.
Enemas - continued
If the client begins to cramp, stop squeezing until the cramp eases and then resume squeezing slowly. Encourage the client to hold the enema for as long as possible until the urge to have a bowel movement occurs (at least 2-5 minutes).
Assist the client to the toilet, bedside commode, or bedpan, if necessary. Attend to any cleaning of the client that is needed.
Remove gloves and dispose of properly Wash hands Document on MAR. Also document results of enema per
your company policy and in the comments section of the MAR.
Enteral (G tube)Enteral (G tube)
For clients receiving continuous feeding through their tube, make sure to turn the feeding off at least 30 minutes before giving medication. Get a written order for when to pause pump and for when to resume feeding.
It is extremely important that you understand how to use the type of tube a particular client has. If at any time you are asked to give medication through a tube or device with which you are unfamiliar, you must ask for help. You may need to be validated by a RN or MD if the device is unfamiliar to you. Check with your supervisor.
Remember◦ These are general instructions for giving medications through a
feeding tube. Check with the prescribing health care practitioner about specific instructions for the client you are assisting.
Enteral medications - continued
Wash hands Gather equipment – gloves, extension tubing, cup, warm water,
pill crusher, 30-60cc oral, enteral, or catheter tipped syringe. Verify the first five Rights of Medication Administration. Unlock the medication storage area and remove one clients
medication at a time. Select the needed medications, making sure to compare the label
to the order or prescription to the MAR Prepare the medications as appropriate for administration
through the tube – remember that you need an order to crush, dissolve, or dilute any medications. Mix each crushed medication with 10-30cc warm water to dissolve. Remember that each medication must be mixed and administered separately from others.
Enteral medications - continued
Place a dot on the MAR. Position the client appropriately. If in bed, the head of the
bed must be elevated at least 45 degrees in the position that is specific to that individual. Explain to the client what your are going to do.
Put on gloves. Connect the extension tubing, if necessary. Flush the tube with at least 30cc of warm water, or the
amount ordered by the health care practitioner. Do not force a flush if the tube is not flowing easily. Contact your supervisor.
Enteral medications - continued
Pour the medication into the syringe, and allow to flow slowly by gravity.
Flush with at least 5cc water via gravity after each medication.
Repeat the above two steps with each medication until all medications are given. It is a good idea to give liquid medicines first, medicines that need to be dissolved second, and thick medications last.
Once all medications are administered, flush the tube with at least 30cc warm water via gravity, or the amount ordered by the health care practitioner.
Importance of positioningFor Medication Administration
Positioning for Medication Administration
PO – by mouthOphthalmic – eye
• Otic – ear
• Topical medications
Sitting upright Sitting upright with head
tilted back and supported – OR lying on back with head tilted back over a pillow
Lying on the opposite side medication is given. May turn to the other side after 5 minutes if medication ordered for both ears
No specific positioning is needed. If possible, keep the client off of the body part being treated for a few minutes.
Positioning - continued
Transdermal PatchesNasal drops and
sprays
• Inhalers
• Rectal
• Enteral – G-Tube
No specific positioning Sitting with the head tilted
back and supported OR lying in bed with the head tilted back
Sitting upright in chair or in bed with head of bed at a 45 degree angle
Side lying – preferably on left side with right knee bent with knee pulled up towards stomach
Lying in bed with head of bed at a 45 degree angle or higher OR sitting upright in a chair
Documentation on a MARPrescription, OTC, PRN
What is a MAR?What is a MAR?
Medication Administration Record◦Legal Document
◦Document after medication has been swallowed, applied, inhaled, inserted, etc.
◦Cannot change any entries (even errors) Clarifications made in note section on back
◦MAP initials and signature for identification
What form do I have to use?What form do I have to use?
Pharmacy generated MAR APD approved form (65G7.00) Facility generated with required information
◦ Client’s name◦ Allergies to food or medication or other substances◦ Name of each medication the client takes
Strength Date ordered Date changed or discontinued Prescribed dosage –for instance 10mg or 10mg tab, give two
tabs Time Route Instructions for crushing, mixing or diluting (if applicable) Dates each medication to be given
MAR? What is my role?MAR? What is my role?
Check to make sure the HCP order, the printed section on the MAR and the label all read the same (no abbreviations)
Initial the MAR immediately after successful administration (be sure your full signature is also in the space provided)
Missed medication!Missed medication!What do I do?What do I do?
How to Document◦Determine the reason
◦Place your initials in the space provided on front of MAR and circle initials
◦On the back of the MAR explain reason for missed medication (using the code and explanation when necessary)
Code established by Rule1. Home visit2. ADT/School/Work3. ER/Hospitalization4. Refused/Chose not to5. Medication not available6. Held per MD order/NPO7. Other
◦ # 5, 6, and 7 must be accompanied with an explanation on the back of the MAR
YOU MUST!YOU MUST!
Identify the right client◦ One client at a time
Give medication at the correct time◦ Only medication properly ordered, labeled, dispensed◦ Be sure medications are filled on time
Make sure medication has been swallowed◦ Understand how to operate equipment (if applicable)◦ Check for all special instructions
Report all problems◦ Be sure to document
Educate ◦ Be kind and friendly and assist as needed
Observe ◦ At least for 20 min
Is there anything I cannot do?Is there anything I cannot do?
Prepare syringes for injectionsVaginal or tracheotomy medicationsMix or pour medication administered through
a positive pressure breathing machine Irrigation or debridement of skinMedications that require judgmentMedications prepared by othersMedication that has to be cut (may break a
scored tablet, if necessary)
How do I document PRN’s?How do I document PRN’s?
Use either the APD approved form, pharmacy generated MAR or facility generated form◦Documentation required
Client’s name and allergies Name of prescribing HCP Date medication ordered Name, dose, route, directions for use and when
HCP needs to be notified Date, time and MAP initials each time used (do not
forget the MAP signature at bottom of page)
Where are documents kept?Where are documents kept?
MARAll current
• Prescriptions Controlled medication form Authorization form Medication Administration Current Informed Consent Current Drug Information Sheet
Remember to Archive all old information
Common Medications and Their Side Effects
The next slides are examples of classes of drugs and the most common medications in each. Refer to your handouts for more complete lists.
Cardiovascular System Medications
Vasodilators……Nitroglycerin, IsosorbideDiuretics……Lasix, HCTZ, Aldactone… many othersAntihypertensives…Lopressor, Calan, Captopril…many!Antiarrhythmics…Digoxin, Lanoxin, Quinora, many
moreAnticoagulants…Warfarin, Coumadin, Plavix, others
Most side effects come from over dosage. Report headache, nervousness, “pounding pulse,” weakness, flushing of skin, or fainting immediately!
Monitor the use of aspirin with anti-coagulants – both thin the blood, used together, may cause bleeding.
Respiratory system medications
Antitussives… cough suppressants like Codeine, Dimetapp-DM, and many others.
Expectorants… break up thick mucus. Examples are Robitussin, Mucinex, many others.
Decongestants…reduce swelling, dry up mucous membrane. Examples are Neo-Synephrine, Sudafed, Afrin, others. May come as nasal sprays, or oral medications.
Bronchodilators… relax and expand the bronchioles. Usually an inhaler such as albuterol, Advair, theophylline
Medications for the skin
Common ones you are familiar with – Calamine lotion, neosporin, triple antibiotic ointment or lotion, zinc oxide, moisturizers, anti-fungals, hydrocortisone creams, alcohol, betadine. Do you know what each of these is for?
Less common… Parasiticides such as Kwell, or Nix. These kill parasites like scabies or lice.
Skin medications may be sold over-the-counter – but if they are medicated they require a doctor’s order to use.
Urinary system medications
Antibiotics – urinary tract, bladder, and kidney infections. Cipro, Bactrim, Septra, Macrobid are examples
Analgesics – relieve pain from UTI. Pyridium is one. These drugs may stain the urine bright ORANGE. Make sure clients or caregivers know this so they are not alarmed.
Benign prostatic hyperplasia drugs – increase urinary flow when an enlarged prostate is present…Flomax, Proscar, Uroxatral are some.
Diuretics – increase urine flow for persons with kidney disorders… Lasix (furosemide), Dyazide (triamterine), HCTZ
Gastrointestinal System medications
Most chronic gastrointestinal (stomach or digestive system) problems require physical care and oversight by a medical professional, as well as medication.
• Antacids – relieve gastric and ulcer pain… Milk of Magnesia, Maalox, Gelusil, Mylanta are some of these
• Acid Blockers – Block the production of acid by the stomach… examples include Zantac, Prilosec, Axid
• Antiflatulents – relieve gassiness and bloating… Phazyne, Di-Gel, Mylanta, Gas-X and others
• Emetics – cause vomiting in case of poisoning… Ipecac• Anticholenergics/antispasmodics – treat ulcers and
irritable bowel syndrome… Levsin, Bentyl (dicyclomine)
More Gastrointestinal medications
Anti-inflammatory drugs – treat colitis… Medrol and Prednisone
Gastrointestinal stimulant – speeds transit time of food through the bowel, relieves nausea, promotes gastric emptying… Reglan (metoclopramide) Persons on this drug should be observed for jerky movements of the limbs or face (tardive dyskinesia) regularly. If noted inform the person’s doctor immediately.
More gastrointestinal medications
Medications for Constipation – MANY!!!◦ Stimulants… Castor oil, Senokot, Dulcolax, Ex-lax◦ Saline… Milk of Magnesia, Epsom Salts, Saline Enemas◦ Bulk formers… Metamucil, others◦ Emollients and Lubricants (stool softeners)… Colace
(docusate), Peri-Colace, Senokot-S, mineral oil enemas
Endocrine system Medications
Antidiabetic agents – oral – used to control blood sugar levels… Glucotrol (glipizide), Glucophage (metaformin), Micronase Diabeta (glyburide), others
Antidiabetic agents – injectable – used to control blood sugar levels… Humalog, Novolin, Humulin, others
Hormonal drugs – for thyroid, pituitary, and/or adrenal glands, pancreas, ovaries and testes… Synthroid, Pitressin (vasopressin), ACTH (corticotropin), estrogen, Androderm, birth control pills and patches
Seizure Medications
There are many of these… Dilantin (phenytoin), Depakote, Tegretol (carbamazepine), Klonopin (clonazepam), Neurontin (gabapentin), and others
It is VERY important that these medications are taken as ordered, and that doses are not missed! Many clients will be taking more than one medication of this type.
Watch for: slurred speech, dizziness, insomnia, twitching, headache, increased eye movement, confusion
BRAND NAME GENERIC NAME
Elavil Amitriptyline
Norpramin Desipramine
Tofranil Imipramine
Pamelor Nortriptyline
Sinequan Doxepin
Ludiomil Maprotiline
Paxil Paroxetine
Prozac Fluoxetine
Wellbutrin Bupropion
Zoloft Sertraline
Desyrel Trazodone
ANTI-DEPRESSANTS
PSYCHIATRIC MEDICATIONS
BRAND NAME GENERIC NAME
Ativan Lorazepam
Klonopin Clonazepam
Librium Chlordiazpoxide
Serax Oxazepam
Tranxene Clorazepate
Valium Diazepam
Xanax Alprazolam
Buspar Buspirone
ANTI-ANXIETY
PSYCHIATRIC MEDICATIONS
BRAND NAME GENERIC NAME
Mellaril Thioridazine
Stelazine Trifluoperazine
Thorazine Chlorpromazine
Trilafon Perphenazine
Navane Thiothixene
Loxitane Loxapine
Moban Molindone
Clozaril Lozapine
Risperdal Risperidone
Haldol Haloperidol
Prolixin Fluphenazine
Zyprexa Olanzapine
Seroquel Quetiapine
ANTI-PSYCHOTIC MEDICATIONS
BRAND NAME GENERIC NAME
Lithium Lithobid, Lithium
Eskalith Lithium
Tegretol Carbamazepine
Depakote Depakene, Valproic
Acid
MOOD STABILIZING MEDICATIONS
PSYCHIATRIC MEDICATIONS
UNDERSTANDING SIDE EFFECTS UNDERSTANDING SIDE EFFECTS OF MEDICATIONOF MEDICATION
A side effect is the body’s reaction to a medication, which is different from that which was intended by the health care provider. There are some general side effects that you should be aware of. Some mild side effects can be taken care of by simple techniques. More severe side effects should be reported to the consumer’s healthcare provider immediately (these are commonly called ‘adverse reactions’). Your facility should have clear procedures for responding to changes in a client’s condition. These procedures should describe the type of changes which should be documented in the client’s records, when changes should be reported to the supervisor, nurse, or health care provider, and who should call the health care provider. Before administering a medication, find out what your facility’s procedure is. Remember, you are responsible for safely administering the needed medications and for noticing side effects and responding to them in a timely manner.
COMMON MILD TO MODERATE SIDE EFFECTS
SYMPTOM
Eyes sensitive to light
Dry lips or mouth
Occasional upset stomach
ACTION TO TAKE
Wear sunglasses, hat, avoid prolonged sun exposure
Increase fluid intake, rinse mouth with water, offer ice chips or sugarless gum
Drink small amounts of water, eat dry saltines or toast. Do NOT take over-the-counter medications without an order from the health care provider
COMMON MILD TO MODERATE SIDE EFFECTS - CONTINUED
SYMPTOM
Occasional constipation
Occasional dizziness
Tiredness
ACTION TO TAKE
Increase water intake, physical exercise, eat leafy green vegetables and bran cereal, drink lemon juice in warm water
Get up slowly from a sitting or lying down position
Take a brief rest period during the day
COMMON MILD TO MODERATE SIDE EFFECTS - CONTINUED
SYMPTOM Dryness of skin
Mild restlessness, muscle stiffness, or feeling “slowed down”
Weight gain
Dark or discolored urine
ACTION TO TAKE Mild shampoo and soap,
hand and body lotion after bathing, seasonal protective clothing
Exercise, short walks, stretching, relax to music
Increase exercise, reduce overeating, watch diet
Increase fluid intake
Medication ErrorsMedication Errors
Medication ErrorsMedication Errors
Definition◦The National Coordinating Council for
Medication Error Reporting and Prevention (2005) “any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures and systems, including prescribing orders; communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”
What could cause a medication error?
Preparing meds in poor lightingPouring meds for more than one client at a timePre-pouring medicationsDISTRACTIONS!!!
◦ Talking to others◦ Talking on your cell phone, or texting◦ Watching TV or listening to the radio◦ Attending to other tasks while preparing medications
Medication Error (Form 65G7.05)Medication Error (Form 65G7.05)
A medication error is the following action◦ Wrong medication◦ Wrong dose◦ Wrong route◦ Wrong reason◦ Wrong client◦ Wrong time◦ Not documenting immediately or accurately ◦ Not filling or refilling current medication on time◦ Giving improperly labeled medication◦ Failing to conduct accurate medication for controlled
medications
What do I do Next?What do I do Next?
An error could cause serious harm◦Observe (call 911 if applicable)◦Notify your supervisor (according to agency
policy)◦Notify the HCP◦Fill out the medication error report
To facility administrator/supervisor To APD MCM within 24 hours of discovery Keep error report in client file if in SL or FH
Medication RefusalMedication RefusalNot a medication errorNot a medication error
Clients have a right to refuse some or all of their medication.◦What should you do?
Educate and encourage them to take there medication
Notify supervisor and WSC Notify the HCP Document in the client record
◦If the client is incompetent or a minor Notify the Guardian and WSC immediately Document in client record
Medication StorageMedication Storage
All medication locked in a cabinet/cart at normal temperature
Controlled Drugs –Double LockedKept in original containerKept separate from other clients medicationEach route of medication separated by physical
barriers from other routesRefrigerated when necessary (locked)Keys must be stored in safe area which is
inaccessible to clients
Medication Destruction RecordMedication Destruction RecordAPD Form 65G7-06 APD Form 65G7-06
What medication needs to be destroyed?◦Discontinued◦ Expired
◦Two way to dispose 1. Return to pharmacy in a sealed container or
bubble pack2. Consult with your pharmacy as to safe
destruction practice. You will need two people to destroy, witness and document on form
Off-Site Medication Off-Site Medication
When a client is away from a licensed residential facility or supported living home and will need medication assistance by some one other than MAP
Enough medication must be provided for all doses needed while away
Must be sent in original containers
Only client who is authorized to self administer medications without supervision may use a “pill minder”
Meds must be counted when provided, and when returned, using the “Off-Site Medication Form” 65G7-08
MAP must provide the name and contact person, AND the name and telephone number of the client’s HCP
Questions?Questions?