Documentation Medication Administration and A NC Approved ...expresscarerx.net/wp-content/uploads/2014/08/medadmin.pdf · *Medication orders must be reviewed and signed by the physician

Medication Administration and Documentation

A NC Approved CE Class offered by

Common Medical Abbreviations - Doses

gm = gram gtt = dropmg = milligram ss = 1/2mcg = microgram oz = ouncecc = cubic centimeter mEq = milliequivalentml = millilitertsp = teaspoonfultbsp = tablespoonful

Common Medical Abbreviations - Routes

po = by mouth AD = right earpr = per rectum AS = left ear OD = right eye AU = both earsOS = left eyeOU = both eyesper GT = gastrostomy tubeSQ - subcutaneous (under the skin)SL - sublingual

Common Medical Abbreviations - Frequency/Times

QD = every day PRN = as neededTID = three times a day stat = immediatelyQID = four times a day AC/HS = before meals andq_h = every _ hours at bedtimeQhs = at bedtime PC/HS = after meals andAC = before meals at bedtimePC = after mealsQOD = every other day

Common Medical Abbreviations - Other

MAR = Medication Administration RecordeMAR = Electronic Medication Administration RecordOTC = over the counterSIG = Label or directionsMD = Medical DoctorNP = Nurse PractitionerPA = Physicians AssistantDAW = Dispense as written

Common Dosage FormsTablet - 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. SolutionB. SuspensionC. SyrupD. Elixir

Common Dosage Forms Cont’dSuppository - 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. PowderC. Paste H. Aeroso spraysD. CreamE. Shampoo

6 Rights of Medication Administration

1. RIGHT Resident2. RIGHT Medication3. RIGHT Dose4. RIGHT Route5. RIGHT Time6. RIGHT Documentation

What’s a Medication ErrorDefinition: 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.

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.

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

Medication Resources & ReferencesAll 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)

Medication OrdersComponents of a complete order:1. Medication Name2. Strength of Medication3. Dosage of medication to administer4. Route of Administration5. Specific directions for use, including frequency

(how often) of administration6. PRN or “as needed” orders must state reason for use

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.

Transcription of Orders to MAR1. Use proper abbreviations or not at all is best2. Calculate stop dates correctly (i.e. Antibiotics)3. Transcribe PRN orders correctly4. Copy orders completely and legibly 5. Discontinue orders properly- No refills doesn’t mean D/C6. Initial and date transcription7. Double check entry with pharmacy label

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

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

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

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

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 area2. Prior to pouring the medications3. After pouring prior to returning to storage area

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

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

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

Monitoring Resident’s Condition

Side Effects*Change in Behavior*Change in Alertness*Change in Eating/Swallowing*Change in Mobility*Change in Appearance

Universal Precautions*hand washing

1. soap and water2. antiseptic gel

*wearing gloves1.when exposed to bodily fluids2. when administering transdermal products

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

Questions