Presentation on theme: "Agency for Persons with Disabilities State Curriculum January 2009"— Presentation transcript:
1Agency for Persons with Disabilities State Curriculum January 2009 Medication Administration and Assistance with Self-Administration of Medication Florida Administrative Rule 65G-7Agency for Persons with Disabilities State CurriculumJanuary 2009
2Florida Administrative Rule 65G-7 Medication Administration RuleAllows unlicensed staff who are working with clients of the Agency for Persons with Disabilities toAdminister medication orSupervise the self administration of medicationGives specific training/validation guidelinesDiscusses the do’s and don’t of the Medication Assistant Provider (MAP)Explains the documentation processFlorida Administrative Rule 65G-7
3Direct 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”This statute is what gives the APD the authority to write and enforce the Medication Administration Rule.Direct Authority
4Outcome of Training Course Will understand both training and validation requirementsWill demonstrate ability to complete and maintain all required formsWill understand how to document and communicate determination of needWill state the six rights of medication administrationWill understand the difference between fully capable of self administration, supervision of self administration and administration of medicationWill understand the importance of information on symptoms of adverse reactions and side effects of prescribed or over the counter medications, and how to locate itWill understand health care practitioner orders, prescriptions and prescription labelsWill understand how to complete a Medication Administration Record (MAR)Will be able to discuss safe handling of medications and sanitary conditionsWill understand the allowed routes of medication administrationWill have knowledge of proper preparation and positioning of the clientWill have knowledge of medication errors, disposal of medication and safe storageWill understand steps that need to be taken when medication is taken off-siteOutcome of Training Course
5When can I give medications? After attending a minimum 4 hour class and passing the exam with 80% or aboveOnce you have completed this course and pass the course exam, you will be issued a certificate of successful completionAfter 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)This class is longer than 4 hours!When can I give medications?
6On-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 reviewDO ACTIVITY ONE IS SMALL GROUPS, THEN DISCUSS AS A CLASS.Emphasize that the MAP keeps their original copy of the validation certificate and the certificate from this class… NOT the employer. The employer gets a copy for their files.On-site validation by route
7What are “routes?” Approved The ways that medications can be delivered to the bodyMAP’s can administer medication for only approved routes of delivery.MAP’s can only administer medication via a route that they have been validated forApprovedRoutes ofDelivery:OralTopicalTransdermalOphthalmicOticRectalInhaledEnteralWhat are “routes?”
8Client/guardian Informed Consent (APD form 65G7-02)Signed by client or client’s authorized representativeMay be filled out with the agency (ie: abc group home) or individual MAP’s name in the provider spaceKept in client record readily accessible for reviewClient/guardian Informed Consent
9Authorization for Medication Administration 65G-7.01 The Authorization FormThree levels of “ABILITY”Must be completed by an MD, PA, or ARNP for clients annually or with any changes to health status or abilityKeep with clients record, easily accessible for reviewFully capable of self administering own medication without supervisionRequires supervision while administering own medicationRequires medication administrationAuthorization for Medication Administration 65G-7.01
10“Fully capable of Self Administration” What does this mean? These clients may take their own medications by themselves, without supervisionA MAR is not kept (document only what you do)The client may need a little help with reminding, reordering or getting medication from the pharmacyNot required to lock up medication in own homeStorage:May use pill minderKeep in locked container if client lives in GH or multi- person SLUnder certain circumstances medication may need to be centrally storedMedication threatens health, welfare or safety of the client or othersClient does not keep medication in locked placePhysical arrangements or habits of other clients makes it unsafeClient or their authorized representative asks for the medication to be centrally stored“Fully capable of Self Administration” What does this mean?
11Supervision of self administration Will need properly trained and validated MAP complete this taskTasks will not be the same for every clientMAP may complete the following dutiesPrompt and observe client taking medicationConfirm the client is taking dosage as prescribedAssist clients when there is something they can’t doDocument on MARMedication must be centrally storedSupervision of self administration
12Supervision 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 suppositoryClient 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 helpClient 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 areaMAP must assist with every scheduled medication deliveryMAP documents on MAR that they observed the client appropriately received the scheduled medicationSupervision of Self Administration
13Administration of Medication Clients are not yet able to safely give their own medicationsMAP must prepare and give medicationsMAP must document immediately on a Medication Administration Record (MAR)Medication must be centrally storedAdministration of Medication
14Training 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 changeDO ACTIVITY TWO IN SMALL GROUPS – EACH GROUP GETS ONE QUESTION. HAVE EACH GROUP PRESENT THEIR QUESTION.Goal is Independence
15Does Administrative Rule 65G-7 Apply to EVERYONE? NO, it does not.
16Health 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 compensationProviders 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.Who is exempt?
18What rights do clients have? Safely give medication by practicing the Six Rights of Medication AdministrationRight ClientRight MedicationRight DosageRight TimeRight RouteRight DocumentationWhat rights do clients have?
19Prescription is ordered for your client What happens next?
20Tracking and Documentation Health care practitioner writes the prescriptionMAP makes copy of the prescription for the client record and takes original to pharmacyCurrent copies in the MAR for referenceArchive discontinued prescription ordersWrite prescription order on the client MARWhen medication is picked up or delivered from pharmacyCompare label with copy of prescription and with MARAll information must matchMedication should be started in a reasonable time frame (within 24 hours)Medication is given as prescribedDocument on MARTracking and Documentation
21Who can write a medication 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)Who can write a medication order?
22Pharmacist duties Dispenses Labels Packages Only pharmacist can change a labelOnly pharmacist can write on a labelOnly pharmacist can transfer from one container to anotherPharmacist duties
23What is on a prescription label? Example (PRN)NameStrengthRouteAmountTimeReason for useCondition to notify MDMaximum number of dosesTylenol325mgBy mouth2 tablets (650mg)Every 4 hoursFever> 101FFever> 102F3 daysWhat is on a prescription label?
24Manufactures Labels for OTC medications Will containName of medicationStrength of medicationPurpose of medicationAmount of medication included in containerDirections for useActive and inert ingredientsPossible side effectsWarning- possible drug interactions, maximum dosageStorage conditionsName and address of the manufacturerExpiration DateLot numberManufactures Labels for OTC medications
25What you need to know! All medication must be properly labeled Sample Medication:Must be accompanied by a prescriptionMaintained in original containerLabeled by dispensing healthcare practitionerClients namePractitioners nameDirections for administering the medicationsThe MAP must initial the label and add the date the medication was openedWhat you need to know!
26You can not change a prescription label. The physician mayChange the dose or time of medicationAll changes must be in writing on a prescription and taken to the pharmacy to dispense the appropriate medication with the appropriate labelWrite “as directed” on the prescriptionYou will need to get more specific directions in writing before medication can be givenTry to give you verbal orderYou must ask the physician to fax the order since all orders must be in writing.You can not change a prescription label.
27Healthcare Practitioner must provide written directions that include: Then name of the medicationThe prescription number, if applicableThe prescription dosageSpecific 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 notifiedPRN medication
28Controlled Medications Medication that is regulated under the jurisdiction of the Controlled Substance Act of 1970Abuse is the highest with schedule I drugsFive groups (scheduled I thru V)Example:Schedule II:Ritalin, Codeine, Demerol, Duragesic patch, PercocetSchedule IV:Phenobarbital, Valium, AtivanControlled Medications
29Documentation of Controlled Drugs When do I document?Pharmacy provided form stamped with “C”On the MAR immediately after administrationControl Medication Count Sheet (APD form 65G7.07)To verify count accuracyMust be signed by two providersYour responsibility to count and document as directed by ruleMust report any medication discrepancies to supervisorDocumentation of Controlled Drugs
30How to store controlled drugs Stored separately from other prescriptions or OTC drugsDouble LockedA locked containerA locked enclosureHow to store controlled drugs
31Forms of Packaging Labeled Bottles Bubble packs or bingo cards Color coding on packaging for different time periods (only developed by the Pharmacy)Unit dose dispensing systemsShow different forms of packaging you have brought with youForms of Packaging
32Abbreviations po by mouth a.c. before meals p.c. after meals prn as neededQD every dayQOD every other dayTab tabletQ3h every 3 hoursQID or qid four times per daysig labelTID or tid three times per dayU unitsa.c. before mealsad lib as directedBID twice a daycap capsuled/c or D/C discontinuegtt dropH.S. or h.s hour of sleepmg milligramml milliliterod right eyeos left eyeou both eyesAbbreviations
33Abbreviations - 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 CONFUSINGQD, QID, QOD (look similar)PO, pc, pr, prn (look similar)CAN YOU SEE WHY IT IS BEST NOT TO USE ABBREVIATIONS?Abbreviations - continued
34Procedures for Routes of Medication Administration How to give medicationsYou may demonstrate/practice each route as they are covered, or at the end of this section. There is a class activity to be done at that time, as well.
35Medication Administration for Oral Route 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.”Medication Administration for Oral Route
36Oral 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 Medication
37Oral 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.Oral Medications - continued
38Buccal 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
39Buccal 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)Buccal or Sublingual - continued
40Inhaled (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 (such as albuterol)
41Ask 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.Inhaled - continued
42Dry powder inhalers (such as 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 for inhalers, above.Document on the MAR.Have the client use any inhalers first and thentake oral medications.Dry powder inhalers (such as Advair)
43Nose spray Gather paper towels or tissues and gloves Wash handsGather paper towels or tissues and glovesVerify the first five Rights of Medication AdministrationUnlock the medication storage area – remove one client’smedication at a timeSelect the needed medications, making sure to compare the labelto the order or prescription to the MARPlace a dot on the MARPut on glovesAsk the client to blow his/her nose gently to clear the nasalpassagesAsk the client to tilt his/her head backwards, making sure the neckis supportedElevate the nostrils slightly by pressing the thumb against the tipof the noseNose spray
44Hold 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 MARNose spray - continued
45Follow 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.Nose drops
46Transdermal – self adhesive patches 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 – self adhesive patches
47Transdermal 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 properlyPlace medication back in locked storage area.Wash hands.Document on the MAR.Transdermal patches - continued
48Topical (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 (ointments, lotions, creams, sprays)
49Squeeze 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.Topical - continued
50Eye 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 (ointments and drops)
51Eye 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
52Eye 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 procedureRelease 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.Eye medications - continued
53Ear (Otic) Medications Wash handsGather equipment – gloves, tissues, clean wash cloth, warm waterVerify the first five Rights of Medication AdministrationUnlock the medication storage area and remove one client’smedication at a timeSelect the needed medications, making sure to compare the labelto the order or prescription to the MARPlace a dot on the MARPut on glovesAssist the client to a comfortable position either sitting with thehead tilted to the side or lying down so that the ear needing drops isupWarm the medication to body temperature (hold in your hand orplace in a cup of warm water for a few minutes) to minimizediscomfort to the clientPlace drops in the ear according to the prescription, letting thedrops fall on the side of the ear canal and not directly on theeardrum. Take care not to touch the ear with the dropperEar (Otic) Medications
54Ear Medications - continued Release the ear and have the client hold the head position for at least 2-5 minutesAllow the client to wipe ear with a tissueInstill drops in the other ear, if prescribed, using the same procedureMAP may insert or remove cotton portion (wick) into or from outer part of canal if orderedRemove gloves and dispose of properlyPlace medication back in locked storage areaWash handsDocument on MAREar Medications - continued
55Rectal 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
56Rectal 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
57Rectal 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 minutes after insertion. Have some way (bell) for client to alert staff of urgency if the suppository was a laxative or stool softener.Wash handsDocument on MAR.Observe and record effects of suppository in comments section of MARRectal suppositories - continued
58Enemas (such as Fleet’s) Follow steps 1-9 for suppositoriesRemove 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 (such as Fleet’s)
59If 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 properlyWash handsDocument on MAR. Also document results of enema per your company policy and in the comments section of the MAR.Enemas - continued
60For 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.RememberThese 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 (G tube)
61Enteral medications - continued Wash handsGather 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 MARPrepare 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
62Enteral 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
63Enteral 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.Enteral medications - continued
64Importance of positioning For Medication Administration
65Positioning for Medication Administration PO – by mouthOphthalmic – eyeOtic – earTopical medicationsSitting uprightSitting upright with head tilted back and supported – OR lying on back with head tilted back over a pillowLying on the opposite side medication is given. May turn to the other side after 5 minutes if medication ordered for both earsNo specific positioning is needed. If possible, keep the client off of the body part being treated for a few minutes.Positioning for Medication Administration
66Positioning - continued Transdermal PatchesNasal drops and spraysInhalersRectalEnteral – G-TubeNo specific positioningSitting with the head tilted back and supported OR lying in bed with the head tilted backSitting upright in chair or in bed with head of bed at a 45 degree angleSide lying – preferably on left side with right knee bent with knee pulled up towards stomachLying in bed with head of bed at a 45 degree angle or higher OR sitting upright in a chairDO ACTIVITY 3. PLACE SCENARIOS PROVIDED ON INDEX CARDS OR SLIPS OF PAPER. PAIR UP STUDENTS AND ROLE PLAY IN FRONT OF CLASS, WITH ONE PERSON ACTING AS THE MAP AND THE OTHER AS THE CLIENT. HAVE THEM FILL OUT MOCK MARS TO THE BEST OF THEIR ABILITY, AND HAVE LABELED MEDICATION CONTAINERS AND SUPPLIES AVAILABLE FOR USE.Positioning - continued
68What 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 backMAP initials and signature for identificationHand out MAR hereWhat is a MAR?
69What form do I have to use? Pharmacy generated MARAPD approved form (65G7.00)Facility generated with required informationClient’s nameAllergies to food or medication or other substancesName of each medication the client takesStrengthDate orderedDate changed or discontinuedPrescribed dosage –for instance 10mg or 10mg tab, give two tabsTimeRouteInstructions for crushing, mixing or diluting (if applicable)Dates each medication to be givenWhat form do I have to use?
70Check 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)To ensure safety: here are some tipsa updated picture of the client should be in the MAR (best practice –not required)develop system to check the prescription label with the MAR at the beginning of the month or with medication changes (to ensure accuracy)at each administration check prescription label with MAR documentation and client name (place dot in box if all match)put initials in box once medication has successfully been administered (use the code system in rule for medication not administered as prescribed)MAR? What is my role?
71Missed medication! What do I do? How to DocumentDetermine the reasonPlace your initials in the space provided on front of MAR and circle initialsOn the back of the MAR explain reason for missed medication (using the code and explanation when necessary)Code established by RuleHome visitADT/School/WorkER/HospitalizationRefused/Chose not toMedication not availableHeld per MD order/NPOOther# 5, 6, and 7 must be accompanied with an explanation on the back of the MARMake sure you notify the designated person for your facilityMissed medication! What do I do?
72YOU MUST! Identify the right client One client at a time Give medication at the correct timeOnly medication properly ordered, labeled, dispensedBe sure medications are filled on timeMake sure medication has been swallowedUnderstand how to operate equipment (if applicable)Check for all special instructionsReport all problemsBe sure to documentEducateBe kind and friendly and assist as neededObserveAt least for 20 minThe person who prepares the medication must administer the medication to the right client. To identify the correct client you may call the client by name, ask the client to tell you his/her name (if possible), use a photo ID, if present in MAR, or ask another staff member to identify clientYou may give the medication up to one hour before or after the designated time and always make sure the client swallows the medication before documenting it as given. If you are having problems, for any reason, notify your supervisor per agency policy. Also notify your supervisor if medication is not refilled timely. The goal is to educate the client and to encourage independence. Be sure to listen to your client. For the clients who need more support you must observe for adverse reaction or side effects. Twenty minuets is recommended but please be aware that time frame of reaction may vary per client. Always check for doctor ordered special instructions that are critical to the medication that is being administered.YOU MUST!
73Is there anything I cannot do? Prepare syringes for injectionsVaginal or tracheotomy medicationsMix or pour medication administered through a positive pressure breathing machineIrrigation or debridement of skinMedications that require judgmentMedications prepared by othersMedication that has to be cut (may break a scored tablet, if necessary)MAPs may not administer or supervise the administration of an injection, vaginal medication or any medication that would be administered through a tracheotomy tube. MAP’s may assist or supervise clients with medication through a positive pressure breathing machine if the MAP is properly trained on the equipment by a certified equipment technician, respiratory therapist, or registered nurse. Remember a certificate of training must be issued and kept in client file. The MAP may not do any dressing changes. The MAP may reinforce dressings to keep body fluids from contaminating clothing, etc. (such as band aids, telfa pads or gauze dressings) MAPs may not change or apply dressings to decubitus ulcer (bedsores) or surgical wounds that require packing, or irrigation. In doubt- ASK a SUPERVISOR.Always ensure ALL SIX RIGHTS HAVE BEEN MET!Is there anything I cannot do?
74Use either the APD approved form, pharmacy generated MAR or facility generated form Documentation requiredClient’s name and allergiesName of prescribing HCPDate medication orderedName, dose, route, directions for use and when HCP needs to be notifiedDate, time and MAP initials each time used (do not forget the MAP signature at bottom of page)DO ACTIVITY FOUR HERE. MAKE SURE ALL PARTICIPANTS HAVE A BLANK MAR. PRACTICE TRANSCRIBING THE SCENARIOS ONTO THE MARS.Points for discussion include: Does the prescription or order give enough information? Which MAR should be used? Are missed medications properly documented?How do I document PRN’s?
75Where are documents kept? MARAll currentPrescriptionsControlled medication formAuthorization form Medication AdministrationCurrent Informed ConsentCurrent Drug Information SheetRemember to Archive all old informationDepending on where the client lives, there may be a MAR book for the entire facility with all clients included (usually seen in group Homes), or each client may have a separate record that includes the MAR (usually in supported living or family home). Wherever the current MAR is, the information about side effects, adverse reactions, and drug interactions for each medication should be kept in the back of that clients MAR, or in a separate book that is READILY available for consultation. Copies of prescriptions or orders for current medications are kept in the same area of the book or record. It is good to have copies of any lab report or consultations related to these medication also with the MAR.Where are documents kept?
76Common 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.
77Cardiovascular System Medications Vasodilators……Nitroglycerin, IsosorbideDiuretics……Lasix, HCTZ, Aldactone… many othersAntihypertensives…Lopressor, Calan, Captopril…many!Antiarrhythmics…Digoxin, Lanoxin, Quinora, many moreAnticoagulants…Warfarin, Coumadin, Plavix, othersMost 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.Cardiovascular System Medications
78Respiratory 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, theophyllineRespiratory system medications
79Medications 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.Medications for the skin
80Urinary system medications Antibiotics – urinary tract, bladder, and kidney infections. Cipro, Bactrim, Septra, Macrobid are examplesAnalgesics – 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), HCTZUrinary system medications
81Gastrointestinal 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 theseAcid Blockers – Block the production of acid by the stomach… examples include Zantac, Prilosec, AxidAntiflatulents – relieve gassiness and bloating… Phazyne, Di-Gel, Mylanta, Gas-X and othersEmetics – cause vomiting in case of poisoning… IpecacAnticholenergics/antispasmodics – treat ulcers and irritable bowel syndrome… Levsin, Bentyl (dicyclomine)It is important to take GI medications as ordered. Often, the orders will tell you to give these medications “30 minutes before eating” or “on an empty stomach.” Many of them will not work as intended if the directions are not followed.Gastrointestinal System medications
82More Gastrointestinal medications Anti-inflammatory drugs – treat colitis… Medrol and PrednisoneGastrointestinal 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
83More gastrointestinal medications Medications for Constipation – MANY!!!Stimulants… Castor oil, Senokot, Dulcolax, Ex-laxSaline… Milk of Magnesia, Epsom Salts, Saline EnemasBulk formers… Metamucil, othersEmollients and Lubricants (stool softeners)… Colace (docusate), Peri-Colace, Senokot-S, mineral oil enemasThe best laxative of all: plenty of fluids – especially water!Take care that persons taking bulk forming medications like Metamucil drink plenty of fluids. Bulk formers can make constipation worse if enough fluids are not supplied.More gastrointestinal medications
84Endocrine system Medications Antidiabetic agents – oral – used to control blood sugar levels… Glucotrol (glipizide), Glucophage (metaformin), Micronase Diabeta (glyburide), othersAntidiabetic agents – injectable – used to control blood sugar levels… Humalog, Novolin, Humulin, othersHormonal drugs – for thyroid, pituitary, and/or adrenal glands, pancreas, ovaries and testes… Synthroid, Pitressin (vasopressin), ACTH (corticotropin), estrogen, Androderm, birth control pills and patchesEnsure that residents take these medications at their regularly scheduled times. DO NOT MISS DOSAGES. If the resident stops taking this medication, notify the health care providerPlease remember that MAPs are not permitted to assist with injectable medications. If a client is authorized to self administer without supervision, a MAP may remind them that it is time for them to take their medications, and may bring the medications to the client – but they may not fill syringes, inject medications, or supervise a client who is using injectables.Ensure that residents take these medications at their regularly scheduled times. DO NOT MISS DOSAGES. If the resident stops taking this medication, notify the health care provider.Please remember that MAPs are not permitted to assist with injectable medications. If a client is authorized to self administer without supervision, the MAP may remind them that it is time for the medication, and may bring the client the medication – but a MAP may not fill a syringe, inject medications, or supervise a client who is using injectables.It is ok for a MAP to perform a blood glucose check (fingerstick) – as long as the fingerstick is NOT associated with the administration of insulin.Endocrine system Medications
85There are many of these… Dilantin (phenytoin), Depakote, Tegretol (carbamazepine), Klonopin (clonazepam), Neurontin (gabapentin), and othersIt 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, confusionSeizure Medications
86ANTI-DEPRESSANTS PSYCHIATRIC MEDICATIONS BRAND NAME GENERIC NAME ElavilAmitriptylineNorpraminDesipramineTofranilImipraminePamelorNortriptylineSinequanDoxepinLudiomilMaprotilinePaxilParoxetineProzacFluoxetineWellbutrinBupropionZoloftSertralineDesyrelTrazodonePSYCHIATRIC MEDICATIONS are given to decrease the symptoms of mental disorder. Each medication helps a certain set of symptoms.ANTI-DEPRESSANTS are used to decrease symptoms of depression such as troubled concentration, loss of enjoyment, changes in sleeping and eating patterns, or thoughts of wishing to die.ANTI-DEPRESSANTS
87ANTI-ANXIETY PSYCHIATRIC MEDICATIONS BRAND NAME GENERIC NAME Ativan LorazepamKlonopinClonazepamLibriumChlordiazpoxideSeraxOxazepamTranxeneClorazepateValiumDiazepamXanaxAlprazolamBusparBuspironeMedications are given to decrease symptoms of anxiety such as panic, intense fears, repetitious thoughts, stomachaches, fast breathing and heartbeat, and tremors. THESE MEDICATIONS ARE OFTEN HABIT FORMING.ANTI-ANXIETY
88ANTI-PSYCHOTIC MEDICATIONS BRAND NAMEGENERIC NAMEMellarilThioridazineStelazineTrifluoperazineThorazineChlorpromazineTrilafonPerphenazineNavaneThiothixeneLoxitaneLoxapineMobanMolindoneClozarilLozapineRisperdalRisperidoneHaldolHaloperidolProlixinFluphenazineZyprexaOlanzapineSeroquelQuetiapineare given to decrease symptoms of psychosis such as hallucinations, delusions, or disorganized thinking.Some side effects that are associated with anti-psychotic medications are dangerous. Tardive dyskinesia is often seen in persons taking anti-psychotic medications. Untreated the symptoms that are characteristic of this side effect can become permanent. These include involuntary movements such as facial tics; facial grimacing, eye blocking, lip smacking, tongue thrusting, foot tapping, shuffling gait, head nodding, and moving ones head to the back or to the side. If you notice any of these symptoms, notify the health care provider as soon as possible. One of the most serious side effects is a life threatening problem called neuroleptic malignant syndrome (NMS) which is a medical emergency. You would suspect NMS if the client has a high fever, stiff muscles, sweating, fast or irregular heartbeat, change in blood pressure, and confusion.ANTI-PSYCHOTIC MEDICATIONS
89PSYCHIATRIC MEDICATIONS BRAND NAMEGENERIC NAMELithiumLithobid, LithiumEskalithTegretolCarbamazepineDepakoteDepakene, Valproic AcidMOOD STABILIZING MEDICATIONS are used to treat the symptoms of mania such as not sleeping for several nights, frantic highs, and drastic lows.Lithium Toxicity occurs when the body has too much lithium and is a potentially life-threatening side effect. It can also occur due to dehydration. Dehydration results from diarrhea, too much alcohol, a bad sunburn, vomiting or anything that causes the person to lose a lot of body fluids.Some or all of the following symptoms would be present if a person is suffering from lithium toxicity: slurred speech, mental confusion, vomiting, diarrhea, severe muscle tremors, severe drowsiness, poor coordination, and coma. If a resident is showing these signs contact the health care provider immediately or call 911.MOOD STABILIZING MEDICATIONS
90UNDERSTANDING SIDE EFFECTS OF 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.UNDERSTANDING SIDE EFFECTS OF MEDICATION
91COMMON MILD TO MODERATE SIDE EFFECTS SYMPTOMEyes sensitive to lightDry lips or mouthOccasional upset stomachACTION TO TAKEWear sunglasses, hat, avoid prolonged sun exposureIncrease fluid intake, rinse mouth with water, offer ice chips or sugarless gumDrink small amounts of water, eat dry saltines or toast. Do NOT take over- the-counter medications without an order from the health care providerCall the health care provider if no relief is obtained by following these suggestions.COMMON MILD TO MODERATE SIDE EFFECTS
92COMMON MILD TO MODERATE SIDE EFFECTS - CONTINUED SYMPTOMOccasional constipationOccasional dizzinessTirednessACTION TO TAKEIncrease water intake, physical exercise, eat leafy green vegetables and bran cereal, drink lemon juice in warm waterGet up slowly from a sitting or lying down positionTake a brief rest period during the dayCOMMON MILD TO MODERATE SIDE EFFECTS - CONTINUED
93COMMON MILD TO MODERATE SIDE EFFECTS - CONTINUED SYMPTOMDryness of skinMild restlessness, muscle stiffness, or feeling “slowed down”Weight gainDark or discolored urineACTION TO TAKEMild shampoo and soap, hand and body lotion after bathing, seasonal protective clothingExercise, short walks, stretching, relax to musicIncrease exercise, reduce overeating, watch dietIncrease fluid intakeCOMMON MILD TO MODERATE SIDE EFFECTS - CONTINUED
95Medication 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”Medication Errors
96What could cause a medication error? Preparing meds in poor lightingPouring meds for more than one client at a timePre-pouring medicationsDISTRACTIONS!!!Talking to othersTalking on your cell phone, or textingWatching TV or listening to the radioAttending to other tasks while preparing medicationsWhat could cause a medication error?
97Medication Error (Form 65G7.05) A medication error is the following actionWrong medicationWrong doseWrong routeWrong reasonWrong clientWrong timeNot documenting immediately or accuratelyNot filling or refilling current medication on timeGiving improperly labeled medicationFailing to conduct accurate medication for controlled medicationsMedication errors could be classified as high risk events and low risk events. All errors are to be taken seriously. All errors need to be documented, reviewed and analyzed. All efforts to recognize and prevent medication errors should be built into the providers system to ensure health and safety.Medication Error (Form 65G7.05)
98What do I do Next? An error could cause serious harm Observe (call 911 if applicable)Notify your supervisor (according to agency policy)Notify the HCPFill out the medication error reportTo facility administrator/supervisorTo APD MCM within 24 hours of discoveryKeep error report in client file if in SL or FHIf the medication error was the wrong medication or a wrong dosage, you must watch the client closely for at least 20 minuets or longer. You must immediately report any observed changes in the clients condition. It is best to report the prescribing HCP or call 911 to request emergency service if the client exhibits respiratory difficulty or other life-threatening symptoms. Be sure to document what happened, who you notified and the outcome of the event. If the MAP notices a discrepancy in the accounting of controlled substances they must report by 5PM of the next business day following the discovery of the error to the APD office. You will also need to notify your supervisor.What do I do Next?
99Medication Refusal Not 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 medicationNotify supervisor and WSCNotify the HCPDocument in the client recordIf the client is incompetent or a minorNotify the Guardian and WSC immediatelyDocument in client recordMedication Refusal Not a medication error
100All 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 clientsTo ensure the health and safety of the clients you must maintain these strict rules for storage in a facility. If you leave the facility with the keys you must return them immediately. An extra key could be maintained by the supervisor per written policy of the facility.Medication Storage
101Medication Destruction Record APD Form 65G7-06 What medication needs to be destroyed?DiscontinuedExpiredTwo way to disposeReturn to pharmacy in a sealed container or bubble packConsult with your pharmacy as to safe destruction practice. You will need two people to destroy, witness and document on formMedications that are contaminated or refused may be destroyed at the facility using procedure #2. Do not forget to document on back of MAR the reason medication was destroyed.Medication Destruction Record APD Form 65G7-06
102Enough medication must be provided for all doses needed while away Must be sent in original containersOnly 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” 65G7-08MAP must provide the name and contact person, AND the name and telephone number of the client’s HCPWhen a client is away from a licensed residential facility or supported living home and will need medication assistance by some one other than MAPMedication may not be transferred to weekly pill minders. This would be consider a dispensing act which can only be done by a pharmacist. If the client is fully capable of self administration, then he/she could put their own medications in pill minder. A family member or legal guardian could also assist with the filling of a pill minder. Once the client and his her medication is returned to the facility and you discover discrepancies such as medications that may not have been given, you would notify your supervisor. This is not considered to be a medication error, however all family errors should be documented in the client record. If a pattern of errors is noted, the health care practitioner must be contacted, as well as, your APD Area Medical Case manager for consultation and assistance.Off-Site Medication
103DO ACTIVITY 5 AS A CLASS. DISCUSS THE SCENARIO AND PICK OUT AREAS OF CONCERN. Questions?