Medication Medication AdministrationAdministration

and Assistance with Self-Administration of and Assistance with Self-Administration of MedicationMedication

Florida Administrative Rule 65G-7Florida Administrative Rule 65G-7

Agency for Persons with Disabilities State CurriculumJanuary 2009

Florida Administrative Rule 65G-7Florida Administrative Rule 65G-7

Medication Administration Rule◦Allows unlicensed staff who are working with

clients of the Agency for Persons with Disabilities to Administer medication or Supervise the self administration of medication

◦Gives specific training/validation guidelines◦ Discusses the do’s and don’t of the Medication

Assistant Provider (MAP)◦Explains the documentation process

Direct AuthorityDirect Authority

Florida Statutes 393.506

◦Section (5) “ The agency shall establish by rule standards and

procedures that a direct service provider must follow when supervising the self-administration of medication by a client and when administering medication to a client”

Outcome of Training Course Outcome of Training Course

Will understand both training and validation requirements Will demonstrate ability to complete and maintain all required forms Will understand how to document and communicate determination of need Will state the six rights of medication administration Will understand the difference between fully capable of self administration,

supervision of self administration and administration of medication Will understand the importance of information on symptoms of adverse

reactions and side effects of prescribed or over the counter medications, and how to locate it

Will understand health care practitioner orders, prescriptions and prescription labels

Will understand how to complete a Medication Administration Record (MAR) Will be able to discuss safe handling of medications and sanitary conditions Will understand the allowed routes of medication administration Will have knowledge of proper preparation and positioning of the client Will have knowledge of medication errors, disposal of medication and safe

storage Will understand steps that need to be taken when medication is taken off-site

When can I give medications?When can I give medications?

After attending a minimum 4 hour class and passing the exam with 80% or above Once you have completed

this course and pass the course exam, you will be issued a certificate of successful completion

After on-site Validation with 100% competency by a RN, ARNP, or MD (APD form 65G7-04) You will receive a Validation

Certificate, with each route you are validated for signed off on the back.

Once you receive a client assignment you will need to make sure the next 2 items are in place:

Authorization for Medication Administration signed by client’s MD, PA, or ARNP (APD form 65G7-01)

Informed Consent for Medication Administration form, signed by client or their legal representative (APD form 65G7-02)

On-site validation by routeOn-site validation by route

Must be done on-site, with real clientMust be done by a RN, ARNP, or MDMust validate with 100% competencyEach Route of medication administration

must be individually validated (signed on back of form)

Revalidation must occur yearlyEmployer, if any, must also keep a copy

available for review

What are “routes?”What are “routes?”

The ways that medications can be delivered to the body

◦ MAP’s can administer medication for only approved routes of delivery.

◦ MAP’s can only administer medication via a route that they have been validated for

ApprovedRoutes ofDelivery:

Oral Topical Transdermal Ophthalmic Otic Rectal Inhaled Enteral

Client/guardian Informed ConsentClient/guardian Informed Consent

Informed Consent ◦ (APD form 65G7-02)

Signed by client or client’s authorized representative

May be filled out with the agency (ie: abc group home) or individual MAP’s name in the provider space

Kept in client record readily accessible for review

Authorization for Medication Authorization for Medication Administration 65G-7.01Administration 65G-7.01

The Authorization Form

Three levels of “ABILITY”

Must be completed by an MD, PA, or ARNP for clients annually or with any changes to health status or ability

Keep with clients record, easily accessible for review

Fully capable of self administering own medication without supervision

Requires supervision while administering own medication

Requires medication administration

““Fully capable of Self Fully capable of Self Administration” Administration” What does this mean?What does this mean?

These clients may take their own medications by themselves, without supervision

A MAR is not kept (document only what you do)

The client may need a little help with reminding, reordering or getting medication from the pharmacy

Not required to lock up medication in own home

Storage:◦ May use pill minder◦ Keep in locked container if

client lives in GH or multi-person SL

◦ Under certain circumstances medication may need to be centrally stored Medication threatens

health, welfare or safety of the client or others

Client does not keep medication in locked place

Physical arrangements or habits of other clients makes it unsafe

Client or their authorized representative asks for the medication to be centrally stored

Supervision of self administrationSupervision of self administration

Will need properly trained and validated MAP complete this task

Tasks will not be the same for every client◦MAP may complete the following duties

Prompt and observe client taking medication Confirm the client is taking dosage as prescribed Assist clients when there is something they can’t

do Document on MAR Medication must be centrally stored

Supervision of Self AdministrationSupervision of Self Administration

Supervision of Self Administration of medication includes instructions or any other assistance necessary to ensure the correct self administration of medication.

• Client may be able to take oral medications – but cannot give themselves eye drops, or insert a rectal suppository• Client may be able to identify the medications needed, and the route…but may be unable to remove the medication from the container, or put the medication in their mouth without help

MAP must assist with every scheduled medication delivery

MAP documents on MAR that they observed the client appropriately received the scheduled medication

• Client may be able to self administer a topical medication in an easy to reach area, but need the MAP to apply it on a less easy to reach area

Administration of MedicationAdministration of Medication

Clients are not yet able to safely give their own medications

MAP must prepare and give medications

MAP must document immediately on a Medication Administration Record (MAR)

Medication must be centrally stored

Goal is IndependenceGoal is Independence

Training and encouragement for clients to become independent is central to the views of this agency.

Your input can be very helpful to health care practitioners when deciding on the client’s capabilities. ◦Reviews must be done annually and/or upon

health status change

Does Administrative Rule Does Administrative Rule 65G-7 Apply to 65G-7 Apply to

EVERYONE?EVERYONE?

NO, it does not.

Who is exempt?Who is exempt?

Health care practitioners whose licenses include medication administration-LPN’s RN’,s, etc.

A client’s family members or friends who provide assistance with medication with out compensation

Providers employed by or under contract to: Intermediate Care Facilities for the developmentally disabled, home health agencies, hospices, health care service pools, or assisted living facilities.

Clients who are authorized to self administer their

medications without supervision.

Six Rights of Medication Six Rights of Medication AdministrationAdministration

What rights do clients have?What rights do clients have?

Safely give medication by practicing the Six Rights of Medication Administration ◦Right Client◦Right Medication◦Right Dosage◦Right Time◦Right Route◦Right Documentation

Prescription is ordered for your client What happens next?

Tracking and DocumentationTracking and Documentation

Health care practitioner writes the prescriptionMAP makes copy of the prescription for the client

record and takes original to pharmacy◦ Current copies in the MAR for reference◦ Archive discontinued prescription orders

Write prescription order on the client MARWhen medication is picked up or delivered from

pharmacy◦ Compare label with copy of prescription and with MAR

All information must matchMedication should be started in a reasonable time

frame (within 24 hours)Medication is given as prescribedDocument on MAR

Who can write a medication Who can write a medication order?order?

Medical Physician or Psychiatrist (MD)Osteopathic Physician (DO)Advanced Registered Nurse Practitioner

(ARNP)Physician Assistant (PA)Dentist (DDS or DMD)Optometrist (OD)Podiatrist (DPM)

Pharmacist dutiesPharmacist duties

DispensesLabelsPackages

Only pharmacist can change a label Only pharmacist can write on a labelOnly pharmacist can transfer from one

container to another

What is on a prescription label?What is on a prescription label?

Label Example (PRN)

Name Strength Route Amount Time Reason for use Condition to notify MD Maximum number of

doses

Tylenol 325mg By mouth 2 tablets (650mg) Every 4 hours Fever> 101F Fever> 102F 3 days

Manufactures Labels for OTC Manufactures Labels for OTC medicationsmedications

Will contain◦ Name of medication◦ Strength of medication◦ Purpose of medication◦ Amount of medication included in container◦ Directions for use◦ Active and inert ingredients◦ Possible side effects◦ Warning- possible drug interactions, maximum dosage◦ Storage conditions◦ Name and address of the manufacturer◦ Expiration Date◦ Lot number

What you need to know!What you need to know!

All medication must be properly labeled◦Sample Medication:

Must be accompanied by a prescription Maintained in original container Labeled by dispensing healthcare practitioner

◦Clients name◦Practitioners name◦Directions for administering the medications

The MAP must initial the label and add the date the medication was opened

You can not change a prescription You can not change a prescription label.label.

The physician may ◦Change the dose or time of medication

All changes must be in writing on a prescription and taken to the pharmacy to dispense the appropriate medication with the appropriate label

◦Write “as directed” on the prescription You will need to get more specific directions in

writing before medication can be given◦Try to give you verbal order

You must ask the physician to fax the order since all orders must be in writing.

PRN medicationPRN medication

◦Healthcare Practitioner must provide written directions that include: Then name of the medication The prescription number, if applicable The prescription dosage Specific directions for use, including medical

reason for the medication, the time intervals for administration, the maximum number of doses, the maximum number of days that the medication should be administered and conditions under which the health care practitioner should be notified

Controlled MedicationsControlled Medications

Medication that is regulated under the jurisdiction of the Controlled Substance Act of 1970

Abuse is the highest with schedule I drugsFive groups (scheduled I thru V)

◦Example: Schedule II:

◦Ritalin, Codeine, Demerol, Duragesic patch, Percocet Schedule IV:

◦Phenobarbital, Valium, Ativan

Documentation of Controlled Documentation of Controlled DrugsDrugs

When do I document?◦Pharmacy provided form stamped with “C”◦On the MAR immediately after administration◦Control Medication Count Sheet (APD form

65G7.07) To verify count accuracy Must be signed by two providers Your responsibility to count and document as

directed by rule Must report any medication discrepancies to

supervisor

How to store controlled drugsHow to store controlled drugs

Stored separately from other prescriptions or OTC drugs

Double Locked◦A locked container◦A locked enclosure

Forms of PackagingForms of Packaging

Labeled BottlesBubble packs or

bingo cardsColor coding on

packaging for different time periods (only developed by the Pharmacy)

Unit dose dispensing systems

AbbreviationsAbbreviations

po by mouthp.c. after mealsprn as neededQD every dayQOD every other

dayTab tabletQ3h every 3

hoursQID or qid four times

per daysig labelTID or tid three times

per dayU units

a.c. before meals

ad lib as directed BID twice a day cap capsule d/c or D/C discontinue gtt drop H.S. or h.s hour of

sleep mg milligram ml milliliter od right eye os left eye ou both eyes

Abbreviations - continued

When writing on a MAR it is best NOT to use the abbreviations. While many health care practitioners use them, abbreviations have been identified as the main cause of many medication errors.

VERY CONFUSING

QD, QID, QOD (look similar)PO, pc, pr, prn (look similar)

CAN YOU SEE WHY IT IS BEST NOT TO USE ABBREVIATIONS?

Procedures for Routes of Procedures for Routes of Medication Medication

AdministrationAdministrationHow to give medications

Medication Administration for Oral Medication Administration for Oral RouteRoute

Wash your hands. Gather equipment – medication spoon or syringe, medicine

cup, pill cutters or crushers, paper towels, glass of water or other liquid with which to take or follow medication.

Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one client’s

medication at a time. Select the needed medications, making sure to compare the

label to the order or prescription to the MAR and check expiration dates.

Make sure you follow any special instructions, for instance “take on empty stomach,” “take with food,” “check pulse and hold for pulse less than 60,” “do not give if client is having diarrhea.”

Oral MedicationOral Medication

• Place a dot on the MAR. Pop or pour the medication into a medication cup –

remember to pour a pill from the container into the lid, then into the medication cup. If you pour too many into the lid, you can pour them back into the bottle and try again. Do not touch with fingers.

For liquid medications, shake bottle before pouring (as directed by label), make sure that the cup is on a level surface for accurate measuring, pour away from the label. Wipe the lid and neck of the bottle with a dampened paper towel before returning to storage. Read the amount of medication at the bottom of the curve of the liquid in the medication cup at eye level.

Crush medications if directed to do so, and mix with applesauce, pudding, or ordered substance.

Compare the label on the medication to the directions on the MAR again.

Oral Medications - continued

Return the medication to the storage area and lock. Hand the medication cup to the client, followed by glass of

liquid with which to swallow the pills. Verify that the client swallows the medication. Give pills first, liquids last. If giving a medication for cough, it should be given last to coat the throat.

Again check the label against the MAR. Sign the MAR and blister pack, if used.

Wash your hands. Document on the MAR. Controlled substances requires

additional documentation on the Controlled Drug Count Form (see attached)

Check on client and assist to comfortable position, if needed. Check client for response to medication, especially if PRN

medication.

Buccal or SublingualBuccal or Sublingual

Wash your hands. Gather equipment-medication cup, gloves, glass of water or other

liquid with which to take or follow medication. Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one client’s

medication at a time. Select the needed medications, making sure to compare the label to

the order or prescription to the MAR and check expiration date. Make sure you follow any special instructions, for instance “take on

empty stomach.” “take with food,” “check pulse and hold for pulse less than 60,” “do not give if client is having diarrhea.”

Place a dot on the MAR. Pop or pour the medication into a medication cup-remember to pour

a pill from the container into the lid, then into the medication cup. If you pour too many into the lid, you can pour them back into the bottle and try again. Do not touch with fingers.

Compare the label on the medication to the directions on the MAR again.

Buccal or Sublingual - continued

Return the medication to the storage area and lock. Hand the medication cup to the client and instruct them to place the

medication under their tongue if sublingual, or between cheek and gum if buccal. If the client is unable to do this, carefully place the medication in the appropriate spot yourself.

Instruct the client not to drink liquids until the medication has dissolved and been absorbed.

Tell the client not to swallow the pill, and to let it dissolve Again check the label against the MAR. Initial the MAR and blister pack, if used.

Wash your hands. Document on the MAR. Controlled substances require additional

documentation on the Controlled Drug Count Form (see attached). Check on client and assist to comfortable position, if needed. Check client for response to medication, especially if PRN medication.

(if PRN medication document response on back of MAR)

Inhaled (such as albuterol)Inhaled (such as albuterol)

Wash hands. Gather equipment – spacers, glass of water, tissue, Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one client’s

medication at a time. Select the needed medications, making sure to compare the label

to the order or prescription to the MAR. Place a dot on the MAR. Remove the cap from the inhaler and ensure that mouthpiece is

clean; shake if indicated. Ask the client to exhale and then place the mouthpiece, tilted

slightly upward, into his/her mouth. Instruct the client to close lips around mouthpiece.

Use a spacer attached to the mouthpiece as instructed if the client is unable to close lips around mouthpiece.

Ask the client to inhale slowly as you push the cylinder of the medication down against the mouthpiece one time.

Inhaled - continuedInhaled - continued

Ask the client to hold his/her breath for several seconds. Remove the mouthpiece from the client’s mouth. Ask the client to exhale slowly through pursed lips. If a second puff is required, wait at least one minute between

each puff, and then repeat above instructions. Ask the client to rinse out his/her mouth. Rinse the mouthpiece with warm water, dry with a paper towel,

and recap. Wash hands. Store medication in proper locked area. Document on the MAR. Have the client use any inhalers first and then take oral

medications.

Dry powder inhalers (such as Dry powder inhalers (such as Advair)Advair)

Follow the steps above for inhalers through step 6. Pull back the dose lever until it clicks into place. Do not tilt

the inhaler, and ask the client not to breath into the inhaler.

Ask the client to exhale. Place the mouthpiece into the client’s mouth, and instruct

the client to close his/her lips around it. Instruct the client to inhale forcefully and deeply. Continue with steps 11-18 for inhalers, above. Document on the MAR. Have the client use any inhalers first and then take oral medications.

Nose sprayNose spray

• Wash hands• Gather paper towels or tissues and gloves• Verify the first five Rights of Medication Administration• Unlock the medication storage area – remove one client’s medication at a time • Select the needed medications, making sure to compare the label to the order or prescription to the MAR• Place a dot on the MAR• Put on gloves• Ask the client to blow his/her nose gently to clear the nasal passages• Ask the client to tilt his/her head backwards, making sure the neck is supported• Elevate the nostrils slightly by pressing the thumb against the tip of the nose

Nose spray - continued

Hold the spray just above the client’s nostril, without touching it.

Use spray as directed by the prescription or orderAsk the client to inhale slowly and deeply through the nose,

hold breath for several seconds and then exhale slowly. Client may blot nose with tissue, but ask client not to blow

nose for several minutes following instillationRinse the tip of the spray bottle with hot water or wipe with an

alcohol pad and dry with tissue before recappingRemove gloves and dispose of properlyPlace medication back in locked storage areaWash handsDocument on the MAR

Nose dropsNose drops

Follow the directions for nasal sprays above, making sure to use the correct number of drops.

Do not touch the nostrils with the dropper.Document on the MAR.

Transdermal – self adhesive Transdermal – self adhesive patchespatches

Wash hands. Gather equipment – gloves, washcloth and towel. Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one

client’s medication at a time. Select the needed medications, making sure to compare

the label to the order or prescription to the MAR. Place a dot on the MAR. Provide for privacy for client. Wear gloves; check client for latex allergies if using latex

gloves. Remove old patch and dispose of appropriately.

Transdermal patches - continued

Make sure site for new patch is clean and dry. If needed, clean area with soap and warm water and then pat area dry. Do not apply over a bony prominence such as the collarbone or shoulder blade. Do not apply the patch over a pacemaker site. Apply in a hairless area. Apply the patch to a different site with each new patch application. Avoid areas of increased warmth (such as the back if bed-ridden) which would promote faster absorption. Do not apply to areas with redness, rash, or broken skin. Report these areas to your supervisor.

Open the package and remove the patch. Date and initial the patch. Remove the backing from the patch. Apply the patch to the chosen spot, pressing firmly around the edges

to adhere. Apply, and cover patch, if applicable, making sure it is dated and

initialed. Remove gloves and dispose of properly Place medication back in locked storage area. Wash hands. Document on the MAR.

Topical (ointments, lotions, creams, sprays)Topical (ointments, lotions, creams, sprays)

Wash hands. Gather equipment – gloves, applicators, wash cloth and towel, water. Verify first five Rights of Medication Administration, making sure you

understand where on the client’s body the medication is to be applied. Unlock the medication storage area and remove one client’s medication at

a time. Select the needed medications, making sure to compare the label to the

order or prescription to the MAR. Place a dot on the MAR. Provide for privacy for client. Wear gloves: check client for latex allergies if using latex gloves. Make sure site for medication is clean and dry. If not, cleanse gently with

soap and warm water and pat dry, unless the prescription directions say otherwise. Previous medications are usually removed before applying additional medication, except for lotions which are used for soothing the skin).

Topical - continued

Squeeze a small amount of medication (if a cream, ointment, or lotion) onto the applicator. Always shake lotions to activate ingredients. If applying to a large surface area, warm lotions/creams in hands before use so the client does not chill. Keep powder away from the nose and mouth to keep the client from inhaling it. If applied to the face, apply while the client exhales. If applying nitroglycerin ointment, measure in centimeters or inches on special provided paper or applicator. Do not apply to areas with redness, rash, or broken skin unless you are treating that area (rash).

Apply gently to correct site. If a spray, hold the can about 6” away from site and spray. Discard applicator. Gently lay dressing over site, if applicable, and secure. MAP may only apply simple

dressings which are intended to cover and protect, such as Band-Aids, Telfa or gauze pads.

Discard gloves and dispose of properly. Place medication back in locked storage area. Wash hands. Document on the MAR.

Eye medications (ointments and drops)Eye medications (ointments and drops)

Wash hands. Gather equipment – gloves, cotton balls or gauze, tissues, wash cloth,

towel, warm water, simple dressing, if ordered. Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one client’s medication

at a time. Select the needed medications, making sure to compare the label to the

order or prescription to the MAR. Check number of drops and eye (right, left, both).

Place a dot on the MAR. Wear gloves: check client for latex allergies if using latex gloves. Assist the client to a comfortable position either sitting or lying down

with head tilted back. May turn the head slightly toward the affected side to prevent medication or tears from flowing toward the opposite eye. If using both drops and ointment, administer the drops first and wait 5 minutes before applying the ointment.

Eye medications - continued

Give client a tissue to remove solution/tears that may spill from eye during the procedure.

Clean eye area if discharge or crusting is present. Use cotton balls moistened with warm water (unless ordered otherwise). Use each cotton ball for only one stroke, starting at the inner eye corner and working outward away from the nose. If using wash cloth instead of cotton balls, rotate to new area of wash cloth with each stroke.

After removing the lid to the medication, place on a clean tissue, on its side.

Gently pull down on the lower eyelid. Ask the client to look upward. Approach the eye from the side and drop medication into the

center of the lower lid. Do not touch the eye with the dropper, or drop medication directly onto the surface of the eye.

Eye medications - continued

If using ointment, gently apply the prescribed length of ointment in a thin line along inner edge of the lower lid moving from the inner corner to the outer corner. Do not touch the eye with the end of the tube. If the client blinks, closes eye, or if drops/ointment lands on the outer lid margin, repeat the procedure

Release the lower lid after the eye drops or ointment is administered. If drops, ask the client to close eyes slowly, but not to squeeze or rub

them. Apply gentle pressure over inner corner of eye to prevent eye drops from flowing into tear duct. If ointments, ask the client to close eye and rub lid gently in circular motion, if rubbing is not contraindicated.

Client may open eyes after 30 seconds and gently wipe off excess medication or tears with a tissue.

If multiple medications are needed for the same eye, you must wait at least 5 minutes between medications.

Remove gloves and dispose of properly. Place medication back in locked storage area. Wash hands. Document on MAR.

Ear (Otic) MedicationsEar (Otic) Medications

• Wash hands• Gather equipment – gloves, tissues, clean wash cloth, warm water• Verify the first five Rights of Medication Administration• Unlock the medication storage area and remove one client’s medication at a time• Select the needed medications, making sure to compare the label to the order or prescription to the MAR• Place a dot on the MAR• Put on gloves• Assist the client to a comfortable position either sitting with the head tilted to the side or lying down so that the ear needing drops is up• Warm the medication to body temperature (hold in your hand or place in a cup of warm water for a few minutes) to minimize discomfort to the client• Place drops in the ear according to the prescription, letting the drops fall on the side of the ear canal and not directly on the eardrum. Take care not to touch the ear with the dropper

Ear Medications - continued

Release the ear and have the client hold the head position for at least 2-5 minutes

Allow the client to wipe ear with a tissue Instill drops in the other ear, if prescribed, using the same

procedure MAP may insert or remove cotton portion (wick) into or from outer

part of canal if ordered Remove gloves and dispose of properly Place medication back in locked storage area Wash hands Document on MAR

Rectal SuppositoriesRectal Suppositories

Wash hands. Gather equipment – gloves, tissues, water soluble lubricant

(K-Y jelly) Verify first five Rights of Medication Administration. Unlock the medication storage area and remove one

client’s medication at a time. Select the needed medications, making sure to compare

the label to the order or prescription to the MAR. Place a dot on the MAR. Return the medication to the storage area and lock. Explain to the client what you are about to do, and provide

for privacy.

Rectal suppositories - continued

Place the client in a side lying position, preferably on the left, with the right leg bent at the knee and drawn up towards the stomach. Keep client covered as much as possible. Place waterproof pad or other absorbent material beneath client’s hips and buttocks.

Remove wrapper and lubricate the suppository rounded end or remove cap and lubricate tip (if applicable) and finger tips with a water soluble gel (K-Y jelly).

Separate the buttocks and then have client relax by breathing slow, deep breaths through the mouth while the suppository is gently inserted through the anus about 4 inches for adults and 2 inches for children and infants. Do not attempt to push the suppository through stool. Instead try to place it along the side of the rectal space.

Rectal suppositories - continued

Hold the buttocks together, or press lightly against the anus with a tissue until the urge to push the suppository out has passed. Ask client to remain on side or flat for at least 5 minutes.

Remove gloves and disposes of properly. Assist client to rearrange clothing, etc. Be sure that client

understands that he/she is to retain the suppository, usually for 30-45 minutes after insertion. Have some way (bell) for client to alert staff of urgency if the suppository was a laxative or stool softener.

Wash hands Document on MAR.

Observe and record effects of suppository in comments section of MAR

Enemas (such as Fleet’s)

Follow steps 1-9 for suppositories Remove cap and gently insert lubricated enema tip slowly

into rectum until the entire tip is in the rectum (3-4 inches). If the tip is not lubricated use a water soluble gel (such as K-Y) to lubricate. It is best to guide along the rectal wall, and not try to push it through any stool that may be present.

Gently squeeze the enema bottle slowly (to prevent cramping) to expel the contents into the rectum and colon.

Enemas - continued

If the client begins to cramp, stop squeezing until the cramp eases and then resume squeezing slowly. Encourage the client to hold the enema for as long as possible until the urge to have a bowel movement occurs (at least 2-5 minutes).

Assist the client to the toilet, bedside commode, or bedpan, if necessary. Attend to any cleaning of the client that is needed.

Remove gloves and dispose of properly Wash hands Document on MAR. Also document results of enema per

your company policy and in the comments section of the MAR.

Enteral (G tube)Enteral (G tube)

For clients receiving continuous feeding through their tube, make sure to turn the feeding off at least 30 minutes before giving medication. Get a written order for when to pause pump and for when to resume feeding.

It is extremely important that you understand how to use the type of tube a particular client has. If at any time you are asked to give medication through a tube or device with which you are unfamiliar, you must ask for help. You may need to be validated by a RN or MD if the device is unfamiliar to you. Check with your supervisor.

Remember◦ These are general instructions for giving medications through a

feeding tube. Check with the prescribing health care practitioner about specific instructions for the client you are assisting.

Enteral medications - continued

Wash hands Gather equipment – gloves, extension tubing, cup, warm water,

pill crusher, 30-60cc oral, enteral, or catheter tipped syringe. Verify the first five Rights of Medication Administration. Unlock the medication storage area and remove one clients

medication at a time. Select the needed medications, making sure to compare the label

to the order or prescription to the MAR Prepare the medications as appropriate for administration

through the tube – remember that you need an order to crush, dissolve, or dilute any medications. Mix each crushed medication with 10-30cc warm water to dissolve. Remember that each medication must be mixed and administered separately from others.

Enteral medications - continued

Place a dot on the MAR. Position the client appropriately. If in bed, the head of the

bed must be elevated at least 45 degrees in the position that is specific to that individual. Explain to the client what your are going to do.

Put on gloves. Connect the extension tubing, if necessary. Flush the tube with at least 30cc of warm water, or the

amount ordered by the health care practitioner. Do not force a flush if the tube is not flowing easily. Contact your supervisor.

Enteral medications - continued

Pour the medication into the syringe, and allow to flow slowly by gravity.

Flush with at least 5cc water via gravity after each medication.

Repeat the above two steps with each medication until all medications are given. It is a good idea to give liquid medicines first, medicines that need to be dissolved second, and thick medications last.

Once all medications are administered, flush the tube with at least 30cc warm water via gravity, or the amount ordered by the health care practitioner.

Importance of positioningFor Medication Administration

Positioning for Medication Administration

PO – by mouthOphthalmic – eye

• Otic – ear

• Topical medications

Sitting upright Sitting upright with head

tilted back and supported – OR lying on back with head tilted back over a pillow

Lying on the opposite side medication is given. May turn to the other side after 5 minutes if medication ordered for both ears

No specific positioning is needed. If possible, keep the client off of the body part being treated for a few minutes.

Positioning - continued

Transdermal PatchesNasal drops and

sprays

• Inhalers

• Rectal

• Enteral – G-Tube

No specific positioning Sitting with the head tilted

back and supported OR lying in bed with the head tilted back

Sitting upright in chair or in bed with head of bed at a 45 degree angle

Side lying – preferably on left side with right knee bent with knee pulled up towards stomach

Lying in bed with head of bed at a 45 degree angle or higher OR sitting upright in a chair

Documentation on a MARPrescription, OTC, PRN

What is a MAR?What is a MAR?

Medication Administration Record◦Legal Document

◦Document after medication has been swallowed, applied, inhaled, inserted, etc.

◦Cannot change any entries (even errors) Clarifications made in note section on back

◦MAP initials and signature for identification

What form do I have to use?What form do I have to use?

Pharmacy generated MAR APD approved form (65G7.00) Facility generated with required information

◦ Client’s name◦ Allergies to food or medication or other substances◦ Name of each medication the client takes

Strength Date ordered Date changed or discontinued Prescribed dosage –for instance 10mg or 10mg tab, give two

tabs Time Route Instructions for crushing, mixing or diluting (if applicable) Dates each medication to be given

MAR? What is my role?MAR? What is my role?

Check to make sure the HCP order, the printed section on the MAR and the label all read the same (no abbreviations)

Initial the MAR immediately after successful administration (be sure your full signature is also in the space provided)

Missed medication!Missed medication!What do I do?What do I do?

How to Document◦Determine the reason

◦Place your initials in the space provided on front of MAR and circle initials

◦On the back of the MAR explain reason for missed medication (using the code and explanation when necessary)

Code established by Rule1. Home visit2. ADT/School/Work3. ER/Hospitalization4. Refused/Chose not to5. Medication not available6. Held per MD order/NPO7. Other

◦ # 5, 6, and 7 must be accompanied with an explanation on the back of the MAR

YOU MUST!YOU MUST!

Identify the right client◦ One client at a time

Give medication at the correct time◦ Only medication properly ordered, labeled, dispensed◦ Be sure medications are filled on time

Make sure medication has been swallowed◦ Understand how to operate equipment (if applicable)◦ Check for all special instructions

Report all problems◦ Be sure to document

Educate ◦ Be kind and friendly and assist as needed

Observe ◦ At least for 20 min

Is there anything I cannot do?Is there anything I cannot do?

Prepare syringes for injectionsVaginal or tracheotomy medicationsMix or pour medication administered through

a positive pressure breathing machine Irrigation or debridement of skinMedications that require judgmentMedications prepared by othersMedication that has to be cut (may break a

scored tablet, if necessary)

How do I document PRN’s?How do I document PRN’s?

Use either the APD approved form, pharmacy generated MAR or facility generated form◦Documentation required

Client’s name and allergies Name of prescribing HCP Date medication ordered Name, dose, route, directions for use and when

HCP needs to be notified Date, time and MAP initials each time used (do not

forget the MAP signature at bottom of page)

Where are documents kept?Where are documents kept?

MARAll current

• Prescriptions Controlled medication form Authorization form Medication Administration Current Informed Consent Current Drug Information Sheet

Remember to Archive all old information

Common Medications and Their Side Effects

The next slides are examples of classes of drugs and the most common medications in each. Refer to your handouts for more complete lists.

Cardiovascular System Medications

Vasodilators……Nitroglycerin, IsosorbideDiuretics……Lasix, HCTZ, Aldactone… many othersAntihypertensives…Lopressor, Calan, Captopril…many!Antiarrhythmics…Digoxin, Lanoxin, Quinora, many

moreAnticoagulants…Warfarin, Coumadin, Plavix, others

Most side effects come from over dosage. Report headache, nervousness, “pounding pulse,” weakness, flushing of skin, or fainting immediately!

Monitor the use of aspirin with anti-coagulants – both thin the blood, used together, may cause bleeding.

Respiratory system medications

Antitussives… cough suppressants like Codeine, Dimetapp-DM, and many others.

Expectorants… break up thick mucus. Examples are Robitussin, Mucinex, many others.

Decongestants…reduce swelling, dry up mucous membrane. Examples are Neo-Synephrine, Sudafed, Afrin, others. May come as nasal sprays, or oral medications.

Bronchodilators… relax and expand the bronchioles. Usually an inhaler such as albuterol, Advair, theophylline

Medications for the skin

Common ones you are familiar with – Calamine lotion, neosporin, triple antibiotic ointment or lotion, zinc oxide, moisturizers, anti-fungals, hydrocortisone creams, alcohol, betadine. Do you know what each of these is for?

Less common… Parasiticides such as Kwell, or Nix. These kill parasites like scabies or lice.

Skin medications may be sold over-the-counter – but if they are medicated they require a doctor’s order to use.

Urinary system medications

Antibiotics – urinary tract, bladder, and kidney infections. Cipro, Bactrim, Septra, Macrobid are examples

Analgesics – relieve pain from UTI. Pyridium is one. These drugs may stain the urine bright ORANGE. Make sure clients or caregivers know this so they are not alarmed.

Benign prostatic hyperplasia drugs – increase urinary flow when an enlarged prostate is present…Flomax, Proscar, Uroxatral are some.

Diuretics – increase urine flow for persons with kidney disorders… Lasix (furosemide), Dyazide (triamterine), HCTZ

Gastrointestinal System medications

Most chronic gastrointestinal (stomach or digestive system) problems require physical care and oversight by a medical professional, as well as medication.

• Antacids – relieve gastric and ulcer pain… Milk of Magnesia, Maalox, Gelusil, Mylanta are some of these

• Acid Blockers – Block the production of acid by the stomach… examples include Zantac, Prilosec, Axid

• Antiflatulents – relieve gassiness and bloating… Phazyne, Di-Gel, Mylanta, Gas-X and others

• Emetics – cause vomiting in case of poisoning… Ipecac• Anticholenergics/antispasmodics – treat ulcers and

irritable bowel syndrome… Levsin, Bentyl (dicyclomine)

More Gastrointestinal medications

Anti-inflammatory drugs – treat colitis… Medrol and Prednisone

Gastrointestinal stimulant – speeds transit time of food through the bowel, relieves nausea, promotes gastric emptying… Reglan (metoclopramide) Persons on this drug should be observed for jerky movements of the limbs or face (tardive dyskinesia) regularly. If noted inform the person’s doctor immediately.

More gastrointestinal medications

Medications for Constipation – MANY!!!◦ Stimulants… Castor oil, Senokot, Dulcolax, Ex-lax◦ Saline… Milk of Magnesia, Epsom Salts, Saline Enemas◦ Bulk formers… Metamucil, others◦ Emollients and Lubricants (stool softeners)… Colace

(docusate), Peri-Colace, Senokot-S, mineral oil enemas

Endocrine system Medications

Antidiabetic agents – oral – used to control blood sugar levels… Glucotrol (glipizide), Glucophage (metaformin), Micronase Diabeta (glyburide), others

Antidiabetic agents – injectable – used to control blood sugar levels… Humalog, Novolin, Humulin, others

Hormonal drugs – for thyroid, pituitary, and/or adrenal glands, pancreas, ovaries and testes… Synthroid, Pitressin (vasopressin), ACTH (corticotropin), estrogen, Androderm, birth control pills and patches

Seizure Medications

There are many of these… Dilantin (phenytoin), Depakote, Tegretol (carbamazepine), Klonopin (clonazepam), Neurontin (gabapentin), and others

It is VERY important that these medications are taken as ordered, and that doses are not missed! Many clients will be taking more than one medication of this type.

Watch for: slurred speech, dizziness, insomnia, twitching, headache, increased eye movement, confusion

BRAND NAME GENERIC NAME

Elavil Amitriptyline

Norpramin Desipramine

Tofranil Imipramine

Pamelor Nortriptyline

Sinequan Doxepin

Ludiomil Maprotiline

Paxil Paroxetine

Prozac Fluoxetine

Wellbutrin Bupropion

Zoloft Sertraline

Desyrel Trazodone

ANTI-DEPRESSANTS

PSYCHIATRIC MEDICATIONS

BRAND NAME GENERIC NAME

Ativan Lorazepam

Klonopin Clonazepam

Librium Chlordiazpoxide

Serax Oxazepam

Tranxene Clorazepate

Valium Diazepam

Xanax Alprazolam

Buspar Buspirone

ANTI-ANXIETY

PSYCHIATRIC MEDICATIONS

BRAND NAME GENERIC NAME

Mellaril Thioridazine

Stelazine Trifluoperazine

Thorazine Chlorpromazine

Trilafon Perphenazine

Navane Thiothixene

Loxitane Loxapine

Moban Molindone

Clozaril Lozapine

Risperdal Risperidone

Haldol Haloperidol

Prolixin Fluphenazine

Zyprexa Olanzapine

Seroquel Quetiapine

ANTI-PSYCHOTIC MEDICATIONS

BRAND NAME GENERIC NAME

Lithium Lithobid, Lithium

Eskalith Lithium

Tegretol Carbamazepine

Depakote Depakene, Valproic

Acid

MOOD STABILIZING MEDICATIONS

PSYCHIATRIC MEDICATIONS

UNDERSTANDING SIDE EFFECTS UNDERSTANDING SIDE EFFECTS OF MEDICATIONOF MEDICATION

A side effect is the body’s reaction to a medication, which is different from that which was intended by the health care provider. There are some general side effects that you should be aware of. Some mild side effects can be taken care of by simple techniques. More severe side effects should be reported to the consumer’s healthcare provider immediately (these are commonly called ‘adverse reactions’). Your facility should have clear procedures for responding to changes in a client’s condition. These procedures should describe the type of changes which should be documented in the client’s records, when changes should be reported to the supervisor, nurse, or health care provider, and who should call the health care provider. Before administering a medication, find out what your facility’s procedure is. Remember, you are responsible for safely administering the needed medications and for noticing side effects and responding to them in a timely manner.

COMMON MILD TO MODERATE SIDE EFFECTS

SYMPTOM

Eyes sensitive to light

Dry lips or mouth

Occasional upset stomach

ACTION TO TAKE

Wear sunglasses, hat, avoid prolonged sun exposure

Increase fluid intake, rinse mouth with water, offer ice chips or sugarless gum

Drink small amounts of water, eat dry saltines or toast. Do NOT take over-the-counter medications without an order from the health care provider

COMMON MILD TO MODERATE SIDE EFFECTS - CONTINUED

SYMPTOM

Occasional constipation

Occasional dizziness

Tiredness

ACTION TO TAKE

Increase water intake, physical exercise, eat leafy green vegetables and bran cereal, drink lemon juice in warm water

Get up slowly from a sitting or lying down position

Take a brief rest period during the day

COMMON MILD TO MODERATE SIDE EFFECTS - CONTINUED

SYMPTOM Dryness of skin

Mild restlessness, muscle stiffness, or feeling “slowed down”

Weight gain

Dark or discolored urine

ACTION TO TAKE Mild shampoo and soap,

hand and body lotion after bathing, seasonal protective clothing

Exercise, short walks, stretching, relax to music

Increase exercise, reduce overeating, watch diet

Increase fluid intake

Medication ErrorsMedication Errors

Medication ErrorsMedication Errors

Definition◦The National Coordinating Council for

Medication Error Reporting and Prevention (2005) “any preventable event that may cause or lead to

inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures and systems, including prescribing orders; communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”

What could cause a medication error?

Preparing meds in poor lightingPouring meds for more than one client at a timePre-pouring medicationsDISTRACTIONS!!!

◦ Talking to others◦ Talking on your cell phone, or texting◦ Watching TV or listening to the radio◦ Attending to other tasks while preparing medications

Medication Error (Form 65G7.05)Medication Error (Form 65G7.05)

A medication error is the following action◦ Wrong medication◦ Wrong dose◦ Wrong route◦ Wrong reason◦ Wrong client◦ Wrong time◦ Not documenting immediately or accurately ◦ Not filling or refilling current medication on time◦ Giving improperly labeled medication◦ Failing to conduct accurate medication for controlled

medications

What do I do Next?What do I do Next?

An error could cause serious harm◦Observe (call 911 if applicable)◦Notify your supervisor (according to agency

policy)◦Notify the HCP◦Fill out the medication error report

To facility administrator/supervisor To APD MCM within 24 hours of discovery Keep error report in client file if in SL or FH

Medication RefusalMedication RefusalNot a medication errorNot a medication error

Clients have a right to refuse some or all of their medication.◦What should you do?

Educate and encourage them to take there medication

Notify supervisor and WSC Notify the HCP Document in the client record

◦If the client is incompetent or a minor Notify the Guardian and WSC immediately Document in client record

Medication StorageMedication Storage

All medication locked in a cabinet/cart at normal temperature

Controlled Drugs –Double LockedKept in original containerKept separate from other clients medicationEach route of medication separated by physical

barriers from other routesRefrigerated when necessary (locked)Keys must be stored in safe area which is

inaccessible to clients

Medication Destruction RecordMedication Destruction RecordAPD Form 65G7-06 APD Form 65G7-06

What medication needs to be destroyed?◦Discontinued◦ Expired

◦Two way to dispose 1. Return to pharmacy in a sealed container or

bubble pack2. Consult with your pharmacy as to safe

destruction practice. You will need two people to destroy, witness and document on form

Off-Site Medication Off-Site Medication

When a client is away from a licensed residential facility or supported living home and will need medication assistance by some one other than MAP

Enough medication must be provided for all doses needed while away

Must be sent in original containers

Only client who is authorized to self administer medications without supervision may use a “pill minder”

Meds must be counted when provided, and when returned, using the “Off-Site Medication Form” 65G7-08

MAP must provide the name and contact person, AND the name and telephone number of the client’s HCP

Questions?Questions?