Medication Administration and Documentation. A NC Approved CE Class offered by

Transcription

1 Medication Administration and Documentation A NC Approved CE Class offered by

2 Common Medical Abbreviations - Doses gm = gram gtt = drop mg = milligram ss = 1/2 mcg = microgram oz = ounce cc = cubic centimeter meq = milliequivalent ml = milliliter tsp = teaspoonful tbsp = tablespoonful

3 Common Medical Abbreviations - Routes po = by mouth AD = right ear pr = per rectum AS = left ear OD = right eye AU = both ears OS = left eye OU = both eyes per GT = gastrostomy tube SQ - subcutaneous (under the skin) SL - sublingual

4 Common Medical Abbreviations - Frequency/Times QD = every day TID = three times a day QID = four times a day q_h = every _ hours Qhs = at bedtime AC = before meals PC = after meals QOD = every other day PRN = as needed stat = immediately AC/HS = before meals and at bedtime PC/HS = after meals and at bedtime

5 Common Medical Abbreviations - Other MAR = Medication Administration Record emar = Electronic Medication Administration Record OTC = over the counter SIG = Label or directions MD = Medical Doctor NP = Nurse Practitioner PA = Physicians Assistant DAW = Dispense as written

6 Common Dosage Forms Tablet - Hard, compressed medication in round, oval or square shape. Some have enteric coating or other types of coatings, which delay the release of the drug and can not be crushed or chewed. Capsule - Medication in a gelatin container. The capsule may be hard or soft and dissolves quickly in the stomach. Liquid - There are different types of liquid medications: A. Solution B. Suspension C. Syrup D. Elixir

7 Common Dosage Forms Cont d Suppository - small solid medicated mass, usually cone-shaped. They melt at body temperature. May be administered by rectum or vagina. Refrigerate as directed by manufacturer. Inhalant - medication carried into the respiratory tract through vehicles of air, oxygen, or steam. There are inhalants used orally and nasally. Topical - applied directly to the skin surface. Topical medications include the following: A. Ointment F. Patches (Transdermal) B. Lotion G. Powder C. Paste H. Aeroso sprays D. Cream E. Shampoo

8 6 Rights of Medication Administration 1. RIGHT Resident 2. RIGHT Medication 3. RIGHT Dose 4. RIGHT Route 5. RIGHT Time 6. RIGHT Documentation

9 What s a Medication Error Definition: when a medication is not administered as prescribed. Any of the 6 Rights done incorrectly. Action: know the facilities medication error policy and procedure: where to find it, who to report to, and/or forms to complete. Correction: The quicker the error can be corrected, the more likely more serious problems are prevented.

10 Resident s Rights (regarding medications) Respect: How the resident is addressed. Resident should not be interrupted from eating for administration of medications like oral inhalers or eye drops. Resident shouldn t be awakened to administer a medication that could be scheduled at different times. Explain what is about to happen and answer questions resident may have. Refusal: Resident has a right to refuse medications. Should never be forced to take. Facility should have a policy & procedure to follow to address, which should include notifying the physician. Privacy: Knock on closed doors before entering. Do not administer medications when resident is receiving personal care in the bathroom. Administering injectables, treatments requiring removal of clothing, or vaginal/rectal medications outside the resident s room in not acceptable. Chemical Restraint: Medications, especially psychotropics, are not to be administered for staff convenience.

11 What s a Medication Allergy? Definition: A reaction occurring as the result of an unusual sensitivity to a medication or other substance. Presentation: May be mild or life-threatening. May be include rashes, swelling, itching, significant discomfort or an undesirable change in mental status. Life-Threatening: Such as breathing difficulties, require immediate emergency care. Reporting: All should be reported to a physician and the pharmacy. This information is recorded in the resident s record. No known allergies should also documented

12 Medication Resources & References All employees should be familiar with the location of resources & references. Resources & Reference s include: *Facility Policy & Procedure Manual *Pharmacy Policy & Procedure Manual *Pharmacy Information Sheets *Nursing Drug Handbook *Online sources *Medical References, such as Physician Desk Reference (PDR)

13 Medication Orders Components of a complete order: 1. Medication Name 2. Strength of Medication 3. Dosage of medication to administer 4. Route of Administration 5. Specific directions for use, including frequency (how often) of administration 6. PRN or as needed orders must state reason for use

14 PRN (as needed) Medications Recommended to have a maximum dosage to be administered in a 24 hour period. Especially with Psychotropic medications. Example: Ativan 0.5mg PO Q4HR PRN for anxiety, not to exceed more than 4 doses in a 24hr period.

15 Transcription of Orders to MAR 1. Use proper abbreviations or not at all is best 2. Calculate stop dates correctly (i.e. Antibiotics) 3. Transcribe PRN orders correctly 4. Copy orders completely and legibly 5. Discontinue orders properly- No refills doesn t mean D/C 6. Initial and date transcription 7. Double check entry with pharmacy label

16 Telephone Orders *Only accepted by a licensed healthcare professional acting within the scope of their profession or an individual who has successfully completed a training program. *Telephone orders must be signed and dated by person receiving order and MD within 15 days of when the order is received

17 New/Re-Admission vs FL-2 Form *FL-2 form is required for admission *FL-2 from must be reviewed for accuracy *Readmission must have FL-2 or discharge summary from hospital *FL-2 renewal annually *Medication orders must be reviewed and signed by the physician at least every 6 months * Continue previous medications or same medications are not complete medications orders and are not to be accepted for medication orders *Difference between an order and a prescription; facility needs an order to administer a medication, prescription is needed for pharmacy to fill

18 Required Information on the Medication Label *Medication name (Written for and dispensed for) - generic *Medication strength *Quantity dispensed *Dispensing date *Directions for use *Pharmacy name/ph #/address *Prescription # *Expiration date *Prescribing Physician name

19 Medications Prepared in Advance ***Allowable but very discouraged*** *Must be in a capped or sealed *Container must contain resident s name and medications inside the container *Person preparing must use MAR and document medication prepared. *Person administering must also document administration

20 Administration of Medications *Gather appropriate equipment *Identify resident *Utilize MAR when administering medications *Read label 3 times 1. When selecting the medication from the storage area 2. Prior to pouring the medications 3. After pouring prior to returning to storage area

21 Administration of Medications *Use sanitary technique when pouring or preparing medications into the appropriate container - do not touch or handle medications *Offer sufficient fluids with medications even if the medication is administered in a food substance *Observe resident medications have been taken and swallowed

22 Special Administration/Monitoring Techniques *Vital signs - prior to administration -Digoxin & other BP medications -Thyroid treatment *Crush medications - post list (XR,ER,XL,SR,EC) *Blood sugars *Mix with food or liquids

23 Administration at Appropriate Time *2-hour time frame = 1 hour before to 1 hour after scheduled administration time *Before meals = 30 minutes before *After & With meals = after resident starts eating up to 60 minutes after finished eating

24 Monitoring Resident s Condition Side Effects *Change in Behavior *Change in Alertness *Change in Eating/Swallowing *Change in Mobility *Change in Appearance

25 Universal Precautions *hand washing 1. soap and water 2. antiseptic gel *wearing gloves 1.when exposed to bodily fluids 2. when administering transdermal products

26 Documentation *Sign MAR immediately after administration *Equivalent signature with corresponding initials on back of MAR *Refusal, held, or not administered medications *Controlled medications *PRN medications - effectiveness *LOA medications

27 Medication Storage *Refrigerator items (36-46 degrees F) *Separate topicals and orals *Store in a locked area at all times (especially during medication administration times) -safety for resident s -security of medications *Disposed of contaminated or refused medications

28 Appropriate Technique for Administration of Different Dosage Forms Oral Tablets and Capsules -elevate head -offer sufficient fluids -watch do not crush list -more than one may be administered in same cup

29 Appropriate Technique for Administration of Different Dosage Forms Oral Liquids -measure at eye level in calibrate device -shake when appropriate -hold label in hand pouring -do not mix together with other liquids -watch directions: mgs vs mls

30 Appropriate Technique for Administration of Different Dosage Forms Sublingual Medications -place under resident s tongue -do not chew or swallow -do not follow with a liquid - may cause medication to be swallowed -good option for resident s experiencing difficulty swallowing capsules/tablets

31 Appropriate Technique for Administration of Different Dosage Forms Oral Inhalers -Proper technique is vital -Spacing and sequence of multiple inhalers is also vital to effectiveness -Rescue inhaler (Albuterol) always first -Use of a spacer may be indicated -Wait at least 1 minute to puffs -Rinse mouth after steroid inhalers

32 Appropriate Technique for Administration of Different Dosage Forms Eye Drops & Ointments -Wash hands prior to administration or wear gloves -Separate 2 or more eye drops by 3-5 minutes -Do not touch the resident s eyes with dropper

33 Appropriate Technique for Administration of Different Dosage Forms Ear Drops -Wash hands prior to administration or wear gloves -Gently pull on ear to straighten ear canal -Remain in position for 5 minutes to all medication to penetrate

34 Appropriate Technique for Administration of Different Dosage Forms Nose Drops & Nasal Sprays/Inhalers -Wash hands before & after or wear gloves -Have resident clear nasal passage (blow) -Drops: lie on back with head tilted back, remain in position for 2 minutes -Sprays: hold head erect and spray quickly/forcefully, while resident sniffs quickly. -Wipe dropper/spray with tissue after use

35 Appropriate Technique for Administration of Different Dosage Forms Transdermal Medications/Patches -Rotate site to prevent irritation (document) -Document administration & removal -Always wear gloves for administration and removal -Clean area to remove residue

36 Appropriate Technique for Administration of Different Dosage Forms Topicals- creams, ointments, dressing changes -Wear gloves, gauze, or cotton-tipped applicator to apply medications -Privacy should be provided -Avoid using excessive amounts -Discard gloves & applicators

37 Appropriate Technique for Administration of Different Dosage Forms Suppositories - Rectal and Vaginal -Wash hands before and after-wear gloves -Remove foil or wrapper -Lubricate or use fingers to melt for ease of insertion -Privacy is to be provided

38 Appropriate Technique for Administration of Different Dosage Forms Enemas -Wash hands before and after-wear gloves -Have resident lie on side with one leg up -Insert enema, squeeze to inject medication and then remove -Privacy is to be provided

39 Appropriate Technique for Administration of Different Dosage Forms Injections & Other Subcutaneous medications -Syringes are not to be recapped, and disposed in appropriate containers -Wash hands before & after-wear gloves -Rotate sites -Know policies for Insulin administration

40 Self Administration of Medications *Resident may self administer medications, only with a physicians order. *Storage requirements are the same for these residents...locked at all times.

41 Questions