Nur 113: skill 21-2: ADMINISTERING ORAL MEDICATIONS

1. Nur 113: skill 21-2: ADMINISTERING ORAL MEDICATIONS

2. ASSESSMENT • 1. Check accuracy and completeness of each medication administration record (MAR), with health care provider’s medication order. Check patient’s name and drug name, dosage and route and time of administration. Clarify incomplete or unclear orders with health care provider before administration. • 2. Review pertinent information related to medication, including action, purpose, normal dose and route, side effects, time of onset and peak action, and nursing implications. • 3. Assess for any contraindications to patient receiving oral medication, including being NPO status, inability to swallow, nausea / vomiting, bowel inflammation, reduced peristalsis, recent gastrointestinal (GI) surgery, gastric suction, and decreased level of consciousness (LOC). Notify health care provider if any contraindications are present. • 4. Assess risk for aspiration using a dysphagia screening tool if available. Protect patient from aspiration by assessing swallowing ability.

3. ASSESSMENT – CONT’D • 5. Assess patient’s medical history, history of allergies, medication history, and diet history. List any drug allergies on each page of the MAR and prominently display on patient’s medical record. When allergies are present, patient should wear an allergy bracelet. • 6. Gather and review physical assessment findings and laboratory data that influence drug administration such as vital signs and results of renal and liver function studies. • 7. Assess patient’s knowledge regarding health and medication use, medication schedule, and ability to prepare medications. • 8. Assess patient’s preference for fluids and determine if medications can be given with these fluids. Maintain fluid restrictions as prescribed.

4. PROTECTING THE PATIENT FROM ASPIRATION

5. PROTECTING THE PATIENT FROM ASPIRATION – CONT’D

6. PLANNING • 1. Expected outcomes following completion of the procedure: • Patient responds appropriately to desired medication effect. • Patient denies any GI discomfort or symptoms of alterations. • Patient explains purpose of medication and drug dosage schedule • 2. Explain procedure to the patient. Be specific if patient wishes to self-administer medications • This makes patient a participant in care, which minimizes anxiety. • Begins patient teaching regarding medications. • Enables patient to self-administer drug, which increases feelings of independence.

7. IMPLEMENTATION • 1. PREPARING MEDICATIONS: • A. Perform hand hygiene. • B. Plan medication administration to avoid interruptions, keep door to medication room closed, do not take phone calls, limit conversation with colleagues for only essential information; follow agency “No Interruption Zone” policy. • C. Arrange medication tray and cups in medication preparation area or move medication cart to position outside patient’s room. • D. Access automated dispensing system (ADS) or unlock medicine drawer or cart.

8. Implementation – cont’d • PREPARING MEDICATIONS – CONT’D • E. Prepare medications for one patient at a time. Follow the six rights of medication administration. Keep all pages of MARs or computer printouts for one patient together or look at only one patient’s medication administration computer screen. • F. Select correct medication from ADS, unit-dose drawer, or stock supply. Compare name of medication on label with MAR or computer printout. Exit ADS after removing drug (s). • G. Check or calculate drug dose as necessary. Double-check any calculation. Check expiration date on all medications and return outdated medication to pharmacy • Double-checking pharmacy calculations reduces the risk for error. • Agency policy may require you to check calculations of certain medications such as insulin with another nurse. • Expired medications may be inactive or harmful to the patient.

9. Implementation – cont’d • PREPARING MEDICATIONS – CONT’D • H. If preparing a controlled substance, check record for previous medication count and compare current count with supply available. Controlled drugs may be stored in computerized lock cart. • I. Prepare solid forms of oral medications. • 1. To prepare unit-dose tablets or capsules, place packaged tablet or capsule directly into medication cup without removing the wrapper. Administer medications only from containers with labels that are clearly marked. • 2. When using a blister pack, “pop” medications through foil or paper backing into a medication cup.

10. Implementation – cont’d • PREPARING SOLID FORMS OF ORAL MEDICATION – CONT’D • 3. If it necessary to give half the dose of medication, pharmacy should split, label, package, and send medication to the unit. If you must split medication, use clean, gloved hand to cut with clean pill-cutting device. Only cut tablets that are pre-scored by the manufacturer (line transverses the center of the tablet). • 4. Place all tablets or capsules that patient will receive in one medicine cup, except for those requiring pre-administration assessments (e.g., pulse rate or blood pressure). Place in separate additional cup with wrapper intact.

11. Implementation – cont’d • PREPARING SOLID FORMS OF ORAL MEDICATION – CONT’D • 5. If patient has difficulty swallowing and liquid medications are not an option, use a pill-crushing device. Clean the device before using it. Place medicine in between two cups, and grind and crush. Mix ground tablet in small amount (teaspoon) of soft food (custard or applesauce).

12. Implementation – cont’d • J. Preparing liquids: • 1. Thoroughly mix by shaking gently before administration. If drug is in unit-dose container with correct volume, shaking is not needed. If drug is in multi-dose bottle, remove bottle cap from container and place cap upside down on work surface. • 2. Hold bottle with label against palm of hand while pouring. • 3. Place medication cup at eye level on countertop and fill to desired level on scale. Scale should be even with fluid level at its surface or base of meniscus, not edges. – This ensures accuracy of the measurement. • 3. Discard any excess liquid into the sink or a place specially designated for wasting of medications. Wipe lip of bottle with paper towel and recap.

13. Implementation – cont’d • Preparing liquids (Cont’d) • 5. If giving less than 10 mL of liquid, prepare medication in oral syringe. Do not use hypodermic syringe or syringe with needle or syringe cap. • 6. Administer liquid medication packaged in single-dose cup. Do not pour into a medicine cup. • Clinical Decision Point: Only use syringes specifically designed for oral use when administering liquid medications. If using hypodermic syringes, the medication may be accidentally administered parenterally; or the syringe cap or needle, if not removed from the syringe before administration, may become dislodged and accidentally aspirated during administration of oral medications.

14. IMPLEMENTATION – CONT’D • K. Before going to patient’s room, compare patient’s name and name of medication on label of prepared drugs with MAR. • L. Return stock containers or unused unit-dose medications to shelf or drawer. Label medication cups and poured medications with patient’s name before leaving medication preparation area. Do not leave drugs unattended. • 2. Administer Medications: • A. Take medication(s) to patient at correct time (see agency policy). Medications that require exact timing include stat, first-time or loading doses, and one time doses. Give time-critical scheduled medications (e.g., antibiotics, anticoagulants, insulin, anticonvulsants, immunosuppressive agents) at exact time ordered (no later than 30 minutes before or after schedule dose). Given non-time-critical scheduled medications within a range of 1 or 2 hours of scheduled dose. During administration, apply six rights of medication administration. • B. Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. Compare identifiers in MAR /medical record with information on patient’s identification bracelet and/or ask patient to state their name.

15. IMPLEMENTATION – CONT’D • C. At patient’s bedside again compare MAR or computer printout with names of medications on medication labels and patient name. Ask patient if they have any allergies. • D. Perform necessary pre-administration assessment (e.g., blood pressure, pulse) for specific medications. Ask patient if they have any allergies. • E. Discuss purpose of each medication, action, and possible adverse effects. Allow patient to ask any questions about drugs – as the patient has the right to be informed, and patient’s understanding of purpose of each medication improves adherence to drug therapy.

16. IMPLEMENTATION – CONT’D • F. Help patient to sitting or Fowler’s position. Use side-lying position if they are unable to sit. Have patient stay in this position for 30 minutes after administration. • G. For tablets: patient may wish to hold solid medication in hand or cup before placing in mouth. Offer water or preferred liquid to help patient swallow medications. • H. For orally disintegrating formulations (tablets or strips): Remove medication from packet just before use. Do not push tablet through foil. Place medication on top of patient’s tongue. Caution against chewing it. • I. For sublingually administered medications; Have patient place medication under tongue and allow it to dissolve completely. Caution patient against swallowing table or saliva.

17. IMPLEMENTATION – CONT’D • J. For buccal administered medications: Have patient place medication in mouth against mucous membranes of cheek and gums until it dissolves. • Clinical Decision Point: Avoid administering anything by mouth until orally disintegrating buccal or sublingual medication is completely dissolved. • K. For powdered medications: Mix with liquids at bedside and give to patient to drink. • L. For crushed medications mixed with food: Give each medication separately in teaspoon of food.

18. IMPLEMENTATION – CONT’D • M. Caution patient against chewing or swallowing lozenges. • N. Give effervescent powders and tablets immediately after dissolving. • O. If patient is unable to hold medications, place medication cup to lips and gently introduce each drug into mouth one at a time. A spoon can also be used to place pill in patient’s mouth. Do not rush or force medications. • P. Stay until patient swallows each medication completely or takes it by the prescribed route. Ask patient to open mouth if uncertain whether medication has been swallowed.

19. IMPLEMENTATION – CONT’D • Q. For highly acidic medications (e.g., aspirin), offer patient nonfat snack (e.g., crackers) if not contraindicated by their condition. • R. Help patient return to position of comfort. • S. Dispose of soiled supplies and perform hand hygiene. Return cart to medication room if used. Clean work area. • Clinical Decision Points: Avoid administering anything by mouth until orally disintegrating buccal or sublingual medications is completely dissolved. • If tablet or capsule falls to the floor, discard it and repeat preparation. Drug is contaminated.

20. evaluation • 1. Return within an appropriate time to evaluate the patient’s response to the medications, including therapeutic effects, side effects or allergy; and adverse reactions. • This evaluates therapeutic benefit of drug and helps to detect onset of side effects or allergic reactions. Sublingual medications act in 15 minutes; most oral medications act in 30 to 60 minutes. • 2. Ask patient or family caregiver to identify drug name and explain purpose, action, dose schedule, and potential side effects.

21. UNEXPECTED OUTCOMES • 1. Patient exhibits adverse effects (e.g., side effect, toxic effect, allergic reaction). • Withhold further doses. • Assess vital signs. • Notify health care provider and pharmacy. • Symptoms such as urticarial, rash, pruritus, rhinitis, and wheezing may indicate an allergic reaction and need for emergency medications. • Add allergy information to patient’s medical record. • 2. Patient is unable to explain drug information. • Further assess patient’s or family caregiver’s knowledge of medications and guidelines for drug safety. • Further instruction or different approach to instruction is necessary. • 3. Patient refuses the medication. • Assess why patient is refusing medication • Do not force patient to take medications. • Notify health care provider • Record refused medication and patient’s stated reason.

22. Recording & reporting • Record drug, dose route, and time administered on patient’s MAR immediately after administration, not before. • Include initials or signature. Record patient teaching and validation of understanding in nurses’ notes and electronic health record (EHR). • If drug is withheld, record reason in nurses’ notes and EHR and follow agency policy for noting withheld doses. • Report adverse effects / patient response and / or withheld drugs to nurse in charge or health care provider. Depending on medication, immediate health care provider notification may be required.

23. End of skill • This is the end of the skill. • Your book has provided a video for this and the link is as follows: • http://booksite.Elsevier.com/Perry-Potter/ClinicalSkills/video23.php • Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques, 8e-21.1: Administering oral medications • While this power point presentation, as well as the video provided may be helpful, you will need to go into the skills lab to practice, in order to pass this skill!