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Medication Administration and Assistance with Self-Administration of Medication Florida Administrative Rule 65G-7 Agency for Persons with Disabilities.

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Presentation on theme: "Medication Administration and Assistance with Self-Administration of Medication Florida Administrative Rule 65G-7 Agency for Persons with Disabilities."— Presentation transcript:

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2 Medication Administration and Assistance with Self-Administration of Medication Florida Administrative Rule 65G-7 Agency for Persons with Disabilities State Curriculum January 2009

3 Florida 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 dos and dont of the Medication Assistant Provider (MAP) Explains the documentation process

4 Direct Authority Florida Statutes 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

5 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

6 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 clients 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)

7 On-site validation by route Must be done on-site, with real client Must be done by a RN, ARNP, or MD Must validate with 100% competency Each Route of medication administration must be individually validated (signed on back of form) Revalidation must occur yearly Employer, if any, must also keep a copy available for review

8 What are routes? The ways that medications can be delivered to the body MAPs can administer medication for only approved routes of delivery. MAPs can only administer medication via a route that they have been validated for Approved Routes of Delivery: Oral Topical Transdermal Ophthalmic Otic Rectal Inhaled Enteral

9 Client/guardian Informed Consent Informed Consent (APD form 65G7-02) Signed by client or clients authorized representative May be filled out with the agency (ie: abc group home) or individual MAPs name in the provider space Kept in client record readily accessible for review

10 Authorization for Medication Administration 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

11 Fully capable of Self Administration 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

12 Supervision 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 cant do Document on MAR Medication must be centrally stored

13 Supervision 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

14 Administration 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

15 Goal 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 clients capabilities. Reviews must be done annually and/or upon health status change

16 Does Administrative Rule 65G-7 Apply to EVERYONE? NO, it does not.

17 Who is exempt? Health care practitioners whose licenses include medication administration-LPNs RN,s, etc. A clients 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.

18 Six Rights of Medication Administration

19 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

20 Prescription is ordered for your client What happens next?

21 Tracking and Documentation Health care practitioner writes the prescription MAP 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 MAR When medication is picked up or delivered from pharmacy Compare label with copy of prescription and with MAR All information must match Medication should be started in a reasonable time frame (within 24 hours) Medication is given as prescribed Document on MAR

22 Who 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)

23 Pharmacist duties Dispenses Labels Packages Only pharmacist can change a label Only pharmacist can write on a label Only pharmacist can transfer from one container to another

24 What is on a prescription label? LabelExample (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

25 Manufactures Labels for OTC medications 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

26 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

27 You can not change a prescription 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.

28 PRN 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

29 Controlled Medications Medication that is regulated under the jurisdiction of the Controlled Substance Act of 1970 Abuse is the highest with schedule I drugs Five groups (scheduled I thru V) Example: Schedule II: Ritalin, Codeine, Demerol, Duragesic patch, Percocet Schedule IV: Phenobarbital, Valium, Ativan

30 Documentation of Controlled Drugs 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

31 How to store controlled drugs Stored separately from other prescriptions or OTC drugs Double Locked A locked container A locked enclosure

32 Forms 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 systems

33 Abbreviations poby mouth p.c.after meals prnas needed QDevery day QODevery other day Tabtablet Q3hevery 3 hours QID or qidfour times per day siglabel TID or tidthree times per day Uunits a.c.before meals ad libas directed BIDtwice a day cap capsule d/c or D/Cdiscontinue gttdrop H.S. or h.shour of sleep mgmilligram ml milliliter odright eye osleft eye ouboth eyes

34 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?

35 Procedures for Routes of Medication Administration How to give medications

36 Medication 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 clients 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.

37 Oral 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.

38 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.

39 Buccal 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 clients 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.

40 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)

41 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 clients 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.

42 Inhaled - continued Ask the client to hold his/her breath for several seconds. Remove the mouthpiece from the clients 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.

43 Dry 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 clients 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 then take oral medications.

44 Nose 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 clients 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

45 Nose spray - continued Hold the spray just above the clients nostril, without touching it. Use spray as directed by the prescription or order Ask 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 instillation Rinse the tip of the spray bottle with hot water or wipe with an alcohol pad and dry with tissue before recapping Remove gloves and dispose of properly Place medication back in locked storage area Wash hands Document on the MAR

46 Nose 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.

47 Transdermal – 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 clients 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.

48 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.

49 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 clients body the medication is to be applied. 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. 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).

50 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.

51 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 clients 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.

52 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.

53 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.

54 Ear (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 clients 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

55 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

56 Rectal 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 clients 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.

57 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 clients 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.

58 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 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

59 Enemas (such as Fleets) 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.

60 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.

61 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.

62 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.

63 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.

64 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.

65 Importance of positioning For Medication Administration

66 Positioning for Medication Administration PO – by mouth Ophthalmic – 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.

67 Positioning - continued Transdermal Patches Nasal 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

68 Documentation on a MAR Prescription, OTC, PRN

69 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

70 What form do I have to use? Pharmacy generated MAR APD approved form (65G7.00) Facility generated with required information Clients 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

71 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)

72 Missed medication! 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 Rule 1.Home visit 2.ADT/School/Work 3.ER/Hospitalization 4.Refused/Chose not to 5.Medication not available 6.Held per MD order/NPO 7.Other # 5, 6, and 7 must be accompanied with an explanation on the back of the MAR

73 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

74 Is there anything I cannot do? Prepare syringes for injections Vaginal or tracheotomy medications Mix or pour medication administered through a positive pressure breathing machine Irrigation or debridement of skin Medications that require judgment Medications prepared by others Medication that has to be cut (may break a scored tablet, if necessary)

75 How do I document PRNs? Use either the APD approved form, pharmacy generated MAR or facility generated form Documentation required Clients 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)

76 Where are documents kept? MAR All current Prescriptions Controlled medication form Authorization form Medication Administration Current Informed Consent Current Drug Information Sheet Remember to Archive all old information

77 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.

78 Cardiovascular System Medications Vasodilators…… Nitroglycerin, Isosorbide Diuretics…… Lasix, HCTZ, Aldactone… many others Antihypertensives… Lopressor, Calan, Captopril…many! Antiarrhythmics… Digoxin, Lanoxin, Quinora, many more Anticoagulants… 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.

79 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

80 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 doctors order to use.

81 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

82 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)

83 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 persons doctor immediately.

84 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

85 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

86 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

87 BRAND NAMEGENERIC NAME ElavilAmitriptyline NorpraminDesipramine TofranilImipramine PamelorNortriptyline SinequanDoxepin LudiomilMaprotiline PaxilParoxetine ProzacFluoxetine WellbutrinBupropion ZoloftSertraline DesyrelTrazodone ANTI-DEPRESSANTS PSYCHIATRIC MEDICATIONS

88 BRAND NAMEGENERIC NAME AtivanLorazepam KlonopinClonazepam LibriumChlordiazpoxide SeraxOxazepam TranxeneClorazepate ValiumDiazepam XanaxAlprazolam BusparBuspirone ANTI-ANXIETY PSYCHIATRIC MEDICATIONS

89 BRAND NAMEGENERIC NAME MellarilThioridazine StelazineTrifluoperazine ThorazineChlorpromazine TrilafonPerphenazine NavaneThiothixene LoxitaneLoxapine MobanMolindone ClozarilLozapine RisperdalRisperidone HaldolHaloperidol ProlixinFluphenazine ZyprexaOlanzapine SeroquelQuetiapine ANTI-PSYCHOTIC MEDICATIONS

90 BRAND NAMEGENERIC NAME LithiumLithobid, Lithium EskalithLithium TegretolCarbamazepine DepakoteDepakene, Valproic Acid MOOD STABILIZING MEDICATIONS PSYCHIATRIC MEDICATIONS

91 UNDERSTANDING SIDE EFFECTS OF MEDICATION A side effect is the bodys 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 consumers healthcare provider immediately (these are commonly called adverse reactions). Your facility should have clear procedures for responding to changes in a clients condition. These procedures should describe the type of changes which should be documented in the clients 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 facilitys 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.

92 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

93 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

94 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

95 Medication Errors

96 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

97 What could cause a medication error? Preparing meds in poor lighting Pouring meds for more than one client at a time Pre-pouring medications DISTRACTIONS!!! Talking to others Talking on your cell phone, or texting Watching TV or listening to the radio Attending to other tasks while preparing medications

98 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

99 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

100 Medication 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 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

101 Medication Storage All medication locked in a cabinet/cart at normal temperature Controlled Drugs –Double Locked Kept in original container Kept separate from other clients medication Each route of medication separated by physical barriers from other routes Refrigerated when necessary (locked) Keys must be stored in safe area which is inaccessible to clients

102 Medication Destruction Record 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 pack 2.Consult with your pharmacy as to safe destruction practice. You will need two people to destroy, witness and document on form

103 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 clients HCP

104 Questions?


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