Medication Administration and Assistance with Self-Administration of Medication Florida Administrative Rule 65G-7

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Medication Administrationand Assistance with
Self-Administration of MedicationFlorida
Administrative Rule 65G-7

• Agency for Persons with Disabilities State
  Curriculum
• January 2009

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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

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Direct 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

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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

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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)

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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

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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

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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

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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

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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

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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

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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 routebut may be unable to remove
  the medication from the container, or put the
  medication in their mouth without help

• 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

• MAP must assist with every scheduled medication
  delivery
• MAP documents on MAR that they observed the
  client appropriately received the scheduled
  medication

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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

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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

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Does Administrative Rule 65G-7 Apply to EVERYONE?

• NO, it does not.

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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.

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Six Rights of Medication Administration
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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

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Prescription is ordered for your client

• What happens next?

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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

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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)

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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

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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
• Fevergt 101F
• Fevergt 102F
• 3 days

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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

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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

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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.

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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

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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

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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

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How to store controlled drugs

• Stored separately from other prescriptions or OTC
  drugs
• Double Locked
• A locked container
• A locked enclosure

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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

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Abbreviations

• po by mouth
• p.c. after meals
• prn as needed
• QD every day
• QOD every other day
• Tab tablet
• Q3h every 3 hours
• QID or qid four times per day
• sig label
• TID or tid three times per day
• U 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

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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?

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Procedures for Routes of Medication Administration

• How to give medications

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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.

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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.

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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.

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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.

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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)

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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.

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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.

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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 11-18 for inhalers, above.
• Document on the MAR.
• Have the client use any inhalers first and then
• take oral medications.

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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

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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

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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.

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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.

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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.

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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).

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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.

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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.

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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.

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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.

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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

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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

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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.

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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.

57
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

58
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.

59
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.

60
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.

61
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.

62
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.

63
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.

64
Importance of positioning

• For Medication Administration

65
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.

66
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

67
Documentation on a MAR

• Prescription, OTC, PRN

68
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

69
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

70
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)

71
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
• Home visit
• ADT/School/Work
• ER/Hospitalization
• Refused/Chose not to
• Medication not available
• Held per MD order/NPO
• Other
• 5, 6, and 7 must be accompanied with an
  explanation on the back of the MAR

72
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

73
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)

74
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)

75
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

76
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.

77
Cardiovascular System Medications

• VasodilatorsNitroglycerin, Isosorbide
• DiureticsLasix, HCTZ, Aldactone many others
• AntihypertensivesLopressor, Calan,
  Captoprilmany!
• AntiarrhythmicsDigoxin, Lanoxin, Quinora, many
  more
• AnticoagulantsWarfarin, 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.

78
Respiratory system medications

• Antitussives cough suppressants like Codeine,
  Dimetapp-DM, and many others.
• Expectorants break up thick mucus. Examples are
  Robitussin, Mucinex, many others.
• Decongestantsreduce 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

79
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.

80
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
  presentFlomax, Proscar, Uroxatral are some.
• Diuretics increase urine flow for persons with
  kidney disorders Lasix (furosemide), Dyazide
  (triamterine), HCTZ

81
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)

82
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.

83
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

84
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

85
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

86
PSYCHIATRIC MEDICATIONS
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
87
PSYCHIATRIC MEDICATIONS
BRAND NAME GENERIC NAME
Ativan Lorazepam
Klonopin Clonazepam
Librium Chlordiazpoxide
Serax Oxazepam
Tranxene Clorazepate
Valium Diazepam
Xanax Alprazolam
Buspar Buspirone
ANTI-ANXIETY
88
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
89
PSYCHIATRIC MEDICATIONS
BRAND NAME GENERIC NAME
Lithium Lithobid, Lithium
Eskalith Lithium
Tegretol Carbamazepine
Depakote Depakene, Valproic Acid
MOOD STABILIZING MEDICATIONS
90
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.

91
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

92
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

93
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

94
Medication Errors
95
Medication 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

96
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

97
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

98
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

99
Medication RefusalNot 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

100
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

101
Medication Destruction RecordAPD Form 65G7-06

• What medication needs to be destroyed?
• Discontinued
• Expired
• Two way to dispose
• Return to pharmacy in a sealed container or
  bubble pack
• Consult with your pharmacy as to safe destruction
  practice. You will need two people to destroy,
  witness and document on form

102
Off-Site Medication

• 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

• 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

103
Questions?