Post on 28-Aug-2018
transcript
INTRODUCTION:
MEDICATION ADMINISTRATION1
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INTRODUCTION
Implementing a safe medication administration system is an essential responsibility of the AFH licensee:
Administering medications involves more than giving residents their medications including:
Obtaining and managing medical orders;
Understanding each residents medications;
Proper storage;
Proper disposal.
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INTRODUCTION CONTINUED
Medications treat a wide variety of chronic conditions and diseases allowing people to live longer, healthier and more independently than in the past. Medications not used properly can have serious consequences including:
Significant injury to major organs, such as kidneys and liver; or
Death.
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INTRODUCTION CONTINUED
The AFH rules require licensees and their caregivers to:Know the reason the medication is taken;
Understand how the medication is expected to work;
Know the side effects of each medication;
Understand any client or resident specific instructions.
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ALERT
All substitute caregivers must have training on how to administer
medications properly and knowledge of each residents
medications BEFORE they administer any medication.
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AGE-RELATED CHANGES6
Normal aging alters medication absorption and elimination, which means the action of many medications in the elderly is less predictable than in younger adults:Each person reacts differently to medication
therapy;
Age-related changes can cause changes in how the person reacts to the medication in part due to:
Natural decline in kidney and liver function; or
Damage to kidney or liver function due to disease or other causes.
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AGE-RELATED CHANGES CONTINUED7
Age-related changes affecting the action of medications include:
Decrease in volume of blood and water in the body. Result:
Medication is distributed throughout the body in a more concentrated form.
Decrease in liver and kidney function. Result:
The organs are slower in breaking down and eliminating medication. medications remain active in the body longer and may build to toxic levels.
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AGE-RELATED CHANGES CONTINUED8
Decline in gastrointestinal function. Result:
Medication absorption is delayed.
More body fat than muscle. Result:
Because fatty tissue stores some medications, unpredictable and delayed medication action may occur.
Lower body weight in older adults. Result:
Normal adult dosage may cause overdose. Fewer medications are required with low body weight.
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ADMINISTRATION SYSTEM
A medication administration system includes:
Obtaining medical orders;
Transcribing medication orders on to the medication administration record (MAR);
Verifying medical orders against the MAR;
Administering medications;
Infection control practices;
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ADMINISTRATION SYSTEM
Monitoring and documenting;
Storage;
Disposing of discontinued, unused, contaminated or expired medication;
Disposing of sharps;
Disposing of contaminated supplies used when administering medications; and
Re-ordering medications.
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You and your staff must understand the resident’s orders and be able to perform the tasks required to administer the medications:
All caregivers must get training before giving medications;
Tasks such as taking a pulse may need to be performed before giving a medication;
Checking a pulse, blood pressure (BP) or blood sugar (CBG) before giving a medication is common in AFH.
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When dispensing medications all caregivers must use infection control procedures:
Proper hand washing techniques:
Wash hands before and after administering medications for each resident;
Wear gloves when appropriate administering:
Topical medications;
CBG testing;
Subcutaneous injections.
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MEDICAL ORDERS
The resident’s healthcare provider or specialist (prescriber) is responsible for approving all medications and treatments:
A written order or prescription for all medications;
Treatments, therapies and any special diet requirements; and
Written approval for over-the-counter (OTC), supplements and herbal treatments requested by the resident.
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WHO CAN PRESCRIBE?
Prescribing authority in Oregon includes:
Medical doctor (M.D.);
Doctor of osteopathic medicine (D.O.);
Doctor of podiatric medicine (D.P.M.);
Physician’s assistant (P.A.);
Nurse practitioner (N.P.);
Clinical nurse specialist (C.N.S.); or
Dentist (D.M.D. or D.D.S.).
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WHAT ARE MEDICATIONS?
Medications are any chemical treatment, medication or remedy used to:
Maintain health;
Treat disease or illness; and
Prevent or treat a symptom, including but not limited to:
Aches that are not related to disease (headaches, sprains, etc.); or
Difficulty sleeping.
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WHAT ARE MEDICATIONS?
Medications include:
Prescription medications — prescribed by a medical professional and dispensed through a pharmacy;
Over-the-counter medications (OTC) — can be purchased without a prescription including:
Cold remedies, aspirin etc.;
Alternative medications — herbal remedies such as Saint John’s Wart, nutritional supplements such as Ensure, and vitamins;
Home remedies.
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ALERT
No matter the type of medication, the risk for a medication
interaction increases with each additional medication the person
takes.
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THERAPEUTIC EFFECT
All medications have a therapeutic effect known as desired effects. Examples include:
Pain relief from pain medication;
Reduced high blood pressure from blood pressure medication;
Maintenance of appropriate blood sugar levels in diabetes; and
Reduced psychotic symptoms in psychiatric conditions.
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SIDE EFFECTS
Side effects may be desirable or undesirable. Examples of undesirable effects (not intended):
An antihistamine (allergy medication) may stop you from sneezing and having a runny nose, but it may also make you sleepy.
An antacid may relieve stomach irritation and discomfort, but may cause:
Constipation; and
Interfere with the effectiveness of other medications.
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SIDE EFFECTS CONTINUED
Side effects may be:
Minor and may not interfere with the individual’s quality of life; or
Can be enough of a problem that it interferes with the person’s quality of life:
AFH provider is expected to document all side effects and work with the resident’s healthcare provider if side effects negatively impact the resident.
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ALERT
Do not minimize an individual’s complaints regarding side effects. What may seem insignificant to
you can be a significant to someone else. Side effects are frequently the
reason people stop taking their medications.
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ADVERSE MEDICATION REACTION
An adverse medication (drug) reaction (ADR) is a less common or unexpected effect that generally means a medication is not right for that person:
Severity can range from moderate to extremely serious;
An ADR can occur soon after beginning a medication, or it can take weeks or months to appear.
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ADR CONTINUED
ADR must be:
Reported to the prescriber immediately; and
Documented in the resident’s record.
Examples of ADRs:
Sedation/insomnia (sleepiness);
Confusion;
Unsteady gait;
Blurred vision;
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ADR CONTINUED
Movement disorders;
Memory loss;
Rash;
Agitation, anxiety;
Seizures;
Stomach ulcers or bleeding;
Incontinence;
Hallucinations.
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SIDE EFFECTS|ADRs
Side effects and adverse medication reactions (ADRs) can be subtle and hard to identify. For example:
A red, bumpy rash from head to toe would be a clear indication of an adverse medication reaction.
It would be harder to identify an ADR if the same person stopped reading the newspaper due to blurred vision.
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SIDE EFFECTS|ADRs CONTINUED
Side effects and ADRs often go unnoticed or are misdiagnosed in seniors:
Physical reactions such as fatigue, falling or weight loss that may be mistaken as “normal” aging;
Symptoms may be mistaken for decline of an existing health condition or a new health condition;
May mimic diseases such as the confusion associated with dementia or Alzheimer’s disease.
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ALERT
Consider any sudden change in an older adult’s physical ability or
personality, especially after beginning a new medication, to be
an adverse medication reaction until proven otherwise.
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MEDICATION INTERACTIONS
A medication interaction is when one medication changes or alters the function of another medication. This includes:
Pharmacy-dispensed medications;
Medications purchased over-the-counter;
Alternative medications and supplements;
Home remedies; and
Foods and beverages can also interact with medications.
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MEDICATION INTERACTIONS CONTINUED
Medication interactions include:
Medication to medication:
Calcium supplement can reduce the effectiveness of medications used to treat low thyroid levels; or
Two different medications that cause drowsiness can significantly increase the risk of injury or falls.
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MEDICATION INTERACTIONS CONTINUED
Medication to food or beverage:
Grapefruit juice and fresh grapefruit can increase the amount of active ingredient for certain medications leading to increased adverse medication reactions.
Medication to disease:
An existing medical condition can make certain medications potentially harmful. For example someone with liver damage may have to restrict or avoid acetaminophen or other medications that can be harmful to the liver.
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MEDICATION INTERACTIONS CONTINUED
Seniors, persons with chronic health conditions or developmental or physical disabilities are at higher risk for medication-related problems:
Taking several medications increases the risk for an adverse reaction;
One or more chronic conditions — such as heart disease, high blood pressure, diabetes and arthritis — can affect how a medication works in the body.
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ACCESS TO INFORMATION
Caregivers must have immediate availability to medication references:
Online resources:medications.com
Current medication reference:Updated medication reference books are
generally available annually in October/November.
Current product inserts or medication summary:Must replace each time a refill is picked up;
AND
Each time an OTC is purchased.
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MEDICATION ERRORS
Medications are used to treat disease and ease discomfort or pain. When medication errors occur it may cause harm:
Medication errors are a common problem resulting in ER visits, hospitalizations and even death;
It is estimated that 98,000 individuals die each year due to medication errors:
Taking too much
Not taking; or
Taking inappropriately.
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All medication errors have the potential to be serious and cause harm:
Negative effects of a medication error may not be visible for years;
Overuse or overdose can cause damage to major organs such as kidneys and liver:
Overdose can even occur when a medication ordered multiple times a day is given too close together.
Medication errors may lead to corrective action and/or a finding of abuse.
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Common medication errors include but not limited to:
Giving a medication at the wrong time;
Not giving a scheduled medication;
Not giving a PRN medication when indicated;
Giving a medication using the wrong route;
Giving an incorrect dose;
Not rotating subcutaneous injections or transdermal patches;
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Giving the wrong medication;
Giving a discontinued medication;
Giving an expired medication;
Giving a medication to wrong resident;
Improperly stored medication;
Missing or incomplete documentation;
Improper disposal.
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37 HOW TO READ LABELS PRESCIPTION
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38 HOW TO READ LABELS OVER-THE-COUNTER
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39 HOW TO READ LABELS SUPPLEMENTS
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40 HOW TO READ LABELS HERBAL TEAS
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Herbal tea remedies can interfere with other medications or certain conditions. It is critical to read all labels even for herbal teas:Chamomile:
Negatively interacts with estrogen, tamoxifen and coumadin; and
Isn’t recommended for individuals with allergies to ragweed.
Licorice has a major interactions with coumadin and negatively interacts with digoxin, estrogen and Lasix;
Ginger can increase the risk of bleeding
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42 MEDICATION ROUTES
Medications can be introduced into the body through many routes. The prescriber will write what route the medication must be given:
If medications are not given as ordered it may result in:
Medication not working properly; or
Harm.
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MEDICATION ROUTES
G-tube/j-tube1;
Subcutaneous injections1;
Intramuscular (IM) injection2;
Inhalation into lungs;
Nasal (drops or inhalers);
Ophthalmic (eye);
Oral (taken by mouth);
Otic (ear);
Rectal;
Sublingual;
Transdermal (via skin);
Vaginal.
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1An RN must delegate a task of nursing before you can perform the task.
Common tasks of nursing include but are not limited to:
Subcutaneous injections, for example insulin;
Food, fluid or medication administration through a gastrointestinal (g-tube) or jejunostomy tube (j-tube);
Peritoneal dialysis;
Other tasks as determined by the RN.
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1The delegation process requires the RN to:
Evaluate the resident and caregiver(s);
Provide training to the caregiver(s);
Observe the caregiver(s) perform the task on the resident;
Leave step-by-step instructions on the task; and
Provide on-going supervision for the task that has been delegated.
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Each delegation is for one specific resident and cannot be transferred to other residents;
The delegated caregiver cannot teach other caregivers to do the task.
For additional information on your responsibility for delegated tasks take the self-study course: RN Delegation for Lay Caregivers at – http://tinyurl.com/DHS-AFHTraining
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MEDICATION ROUTES CONTINUED
Intramuscular2 (IM) injections cannot be delegated. Arrangements must be made with a licensed practitioner to administer. Options available:Request a referral for home health or, if the
resident is on hospice, make arrangements with hospice;
Contract with a nurse to perform the task; or
Make arrangements with the resident’s primary health care practitioner.
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2Intramuscular (IM) injections are allowed for anticipatory emergency medications. Giving IM injections is taught and cannot be delegated:
Epinephrine:
Allergic reaction emergencies;
Glucagon:
Severe low blood sugar emergencies.
June 2012
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2Caregivers must be trained by an approved trainer following the
training curriculum outlined by the Health Division’s Anticipatory
Emergency rules.
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MEDICAL ABBREVIATIONS
While gathering information and medical orders you may encounter medical abbreviations. If you do not understand, ask for clarification from an appropriate medical professional:The abbreviations listed on the following tables
identified with an asterisk (* ) should not be used:
This recommendation is based on high frequency of errors. The abbreviations were included since some individuals may still be using them.
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MEDICAL ABBREVIATIONS CONTINUED
Common Medical Abbreviations
Abbreviations are case-specific. Abbreviations with an asterisk * should not be used or is recommended not to use.
@ At ad lib As desired
< less than AMT Morning> more than AMT/amt amount
a Before APAP Acetaminophen
ac Before meals AS* Left ear
AC* Acetaminophen ASA* Aspirin
Acetam* Acetaminophen ASAP As soon as possible
Acetamin* Acetaminophen AU* Both ears
AD* Right ear BID Twice (2 times) a day
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MEDICAL ABBREVIATIONS CONTINUED
Common Medical Abbreviations
Abbreviations are case-specific. Abbreviations with an asterisk * should not be used or is recommended not to use.
BM Bowel movement drsg Dressing
BP Blood pressure FBS Fasting blood sugar
caps Capsules g-tube Gastrostomy tubecath Catheter hr Hour
c With HS/hs Hour of sleep
CBG Capillary blood glucose H/A Headache
C/O or c/o Complaint of HTN Hypertension
CP Chest pain Hx History
D/C Discontinue I&O Intake & output
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MEDICAL ABBREVIATIONS CONTINUED
Common Medical Abbreviations
Abbreviations are case-specific. Abbreviations with an asterisk * should not be used or is recommended not to use.
IM Intramuscular mid noc Midnight
IV Intravenous min Minute
j-tube Jejunostomy tube mg Milligram
l liter ml Milliliter
L* left MOM Milk of magnesium
liq Liquid N/V Nausea/vomiting
lb Pound N/V/D Nausea/vomiting/diarrhea
mcg Microgram(s) NC Nasal cannula
meds Medications NKDA No known allergies
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MEDICAL ABBREVIATIONS CONTINUED
Common Medical Abbreviations
Abbreviations are case-specific. Abbreviations with an asterisk * should not be used or is recommended not to use.
noc Night pm Afternoon
NPO Nothing by mouth PO By mouth or orally
O2 Oxygen PRN As necessary or needed
OTC Over-the-counter Q/q Everyoz Ounce Q2H/q2h Every 2 hours
p After Q3H/q3h Every 3 hours
pc/ pc after meals Q4H/q4h Every 4 hours
PCN Penicillin Q6H/q6h Every 6 hours
per By or through Q12H/q12h Every 12 hours
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MEDICAL ABBREVIATIONS CONTINUED
Common Medical Abbreviations
Abbreviations are case-specific. Abbreviations with an asterisk * should not be used or is recommended not to use.
QD or qd Each day or daily SL Sublingual
QH or qh Every hour SOB Shortness of breath
QHS/qhs* at bedtime SQ or sq subcutaneous
QID or qid* Four times a day Sx Symptom
QOD/qod* Every other day tab tablet
R Right TID or tid Three times a day
ROM Range of motion V/S Vital signs
RxPrescription medication wt Weight
s/s̄ Without
MEDICAL ORDERS56
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The AFH provider is responsible for obtaining all necessary written orders and understanding:
The reason for the medication;
How the medication is expected to work; and
Any special instructions from the prescribing practitioner about the medications.
The AFH provider is responsible for carrying out the written orders.
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MEDICAL ORDERS CONTINUED
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The following must all have a written medical order from a prescribing practitioner:
Prescription medications;
Prescribed over-the-counter (OTC) medications including vitamins and other nutritional supplements;
Prescribed dietary supplements; and
Prescribed treatments and therapies.
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MEDICAL ORDERS CONTINUED
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OTC medications, vitamins, nutritional supplements or home remedies not prescribed, but requested by the resident, must be reviewed by the resident’s primary health care practitioner, approved and documented in the resident’s record.
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MEDICAL ORDERS CONTINUED
Written orders from a hospital, emergency room or nursing home sent with the resident can be used initially ifsigned by a prescriber. These orders are temporary and must be followed up with written orders from the resident’s primary healthcare practitioner immediately.
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Changes to medical orders may not be made without the prescribing practitioner’s approval;
All medical orders must be followed as prescribed unless the resident or their legal guardian refuses:
If a medical order is refused, the prescribing practitioner must be notified immediately by the AFH provider and documented in the resident’s record.
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MEDICAL ORDERS CONTINUED
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Changes to medication or treatment orders obtained by telephone must be followed up with a signed order from the prescribing practitioner, immediately:
Phone orders must be recorded in the resident’s record with the printed name and signature of the person taking the phone order;
Requests for signed orders must be made promptly after receiving any telephone order;
All attempts to request written orders must be documented in the resident’s record.
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MEDICAL ORDERS CONTINUED
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Changes in dose or frequency of an existing medication must be clearly identified:
Changes need to be written on an auxiliary label and affixed to the original medication container.
Be sure to inform the pharmacist of the changes before it is time to refill the order:
DO NOT have the prescription refilled without the pharmacist contacting the prescriber for the correct information.
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MEDICAL ORDERS CONTINUED
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MEDICAL ORDERS CONTINUED
Do not obscure the original order. Attach a label to the side of the bottle with the new orders clearly identified. Use until supply is gone.
New
3/1
6/2
01
1
take
30
mg
(1.5
ta
ble
ts)
by
mo
uth
in
am
KL
MEDICATION ADMINISTRATION RECORD65
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A written medication administration record (MAR) must be kept for each resident:
Frequent changes to the dosage of some medications are common. The MAR must be kept current at all times;
Failure to keep the MAR up-to-date could result in a medical emergency for the resident.
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MAR
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The MAR must identify all medications and treatments ordered including, but not limited to:
Prescription medications;
Over-the-counter medications;
Dietary supplements, including vitamins and minerals;
Treatments;
Vital signs and/or weight; and
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MAR CONTINUED
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The MAR must be legible and clearly indicate:
Name of each medication;
Dose;
Route (how it is to be administered) if other than by mouth;
Day and frequency (i.e. daily, or tid); and
Time the medication must be given.
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MAR CONTINUED
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Immediately after administering a medication or performing a treatment, therapy or procedure, the person doing the task must write his or her initials and the time in the appropriate place and note any information required:
Every set of initials must have a legible signature on the MAR for identification purposes.
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MAR CONTINUED
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If multiple caregivers have the same two initials, decide who will need to add an additional initial to include a middle name.
Make sure there is a printed name with a matching signature for every set of initials on the MAR.
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MAR CONTINUED
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Each new month write the month and year on a new MAR sheet:
Carefully write the medication, dose, route, days and times the medications are to be administered and any specific instructions on each resident’s MAR according to the written medical orders.
If you receive an order to stop a medication during the month, note that on the MAR immediately.
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MAR CONTINUED
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MAR SAMPLE
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MAR INFORMATION
All fields must be filled out:Resident’s full name;Name of resident’s healthcare provider:Recommended to also list phone number.
List of all allergies;Month and year.
Resident: Residents full name
Month/Year: Enter current month and year
Physician: Name of healthcare provider and phone #
Allergies: List all allergies
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MAR INFORMATION CONTINUED
Name of the medication (write exactly as written):
Strength of medication for example 20 mg.;
Write dose if strength and dose are not equal. For example give 10 mg (1/2 tablet);
Frequency, for example BID in AM and PM;
How to administer, for example PO;
Any special instructions such as hold if pulse less than 60 or blood sugar less than 100 etc.; and
Reason for the medication.
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MAR INFORMATION CONTINUED
Medication Hour 1 2 3 4 5 6 7 8
Lasix 20 mg, 1 tablet po each AM for CHF
Name of the drug; strength and dose if not equal t the strength; frequency; how to administer (route); any special instructions; and reason for the medication.
Use as many segments on the MAR as necessary.
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MAR INFORMATION CONTINUED
Medication Hour 1 2 3 4 5 6 7 8
Lasix 20 mg, 1 tablet po each AM for CHF
9 AMList the time to be given. You must list an actual hour.
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MAR INFORMATION CONTINUED
Medication Hour 1 2 3 4 5 6 7 8
Lasix 20 mg, 1 tablet po each AM for CHF
9 AM
8:30 AM
BC
Initial and indicate
the actual time give.
Initials: BC Signature - Best Caregiver Best Caregiver
Initials: Signature -
Each set of initials must have a signature and the name
printed on the MAR.
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Some medications, such as those used for pain, are written as “PRN.” This means the medication is given as needed:
All PRN medications must be written on the MAR;
All PRN medications, including over-the-counter medications, must have specific parameters indicating:
What the medication is for; and
Specifically when, how much and how often the medication may be administered.
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MAR PRN MEDICATIONS
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It is best if the prescriber writes the parameters when ordering PRN medications:
Ask your pharmacist to request this information when accepting a prescription order;
If a PRN medication does not include specific written parameters, an RN may be able to write parameters after assessing the resident:
RNs cannot write parameters for any medication including OTCs and supplements that does not have a medical order.
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MAR PRN MEDICATIONS CONTINUED
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The parameters should be recorded on the medication administration record (MAR):
Caregivers dispensing PRN medications must follow the resident-specific written instructions;
If the instructions are confusing or do not make sense seek clarification with the RN, pharmacist or prescribing practitioner before giving.
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MAR PRN MEDICATIONS CONTINUED
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Documenting PRN medications on the MAR must include the:
Time given;
Dose how much was given;
The reason for giving the medication; and
Whether or not it was effective.
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MAR PRN MEDICATIONS CONTINUED
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MAR PRN MEDICATIONS CONTINUED
Documentation:
Medication Hour 1 2 3 4 5 6
Hydroco/AC 5-500 Tab take 1 tablet PO every 4 hours as needed for jaw pain. May take 1 more tablet in 2 hours if no relief after the first dose. Maximum of 8 tablets in 24 hours
DS 5 PM
DS 7:15 PM
Medication Hour 1 2 3 4 5 6
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MAR PRN MEDICATIONS CONTINUED
Documentation example for a verbal resident:
Date Hour Medication Reason Results Hour
4/6/2014 3 PM Hydroco/AC 5-500 mg 1 tab
c/o jaw pain Still in pain 5 PM
4/6/2014 5 PM Hydroco/AC 5-500 mg 1 tab
Still in pain States no pain
7:15 PM
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MAR PRN MEDICATIONS CONTINUED
Documentation example for a non-verbal resident:
Date Hour Medication Reason Results Hour
4/6/2014 3 PM Hydroco/AC 5-500 mg 1 tab
Moaning and holding jaw where tooth was pulled
Still in moaning and appears to be in pain
5 PM
4/6/2014 5 PM Hydroco/AC 5-500 mg 1 tab
Still moaning Appears comfortable and participating in activities
7:15 PM
85
The caregiver giving the PRN medication needs to document in the resident’s record the response to the medication. For example:
01/02/2011 Ms. M.M.A. complained of a headache at 10 am. Gave her two Tylenol tablets at 10:15 a.m. At 11 a.m. Ms. M.M.A. reported that she no longer had a headache.
01/05/2011 Ms. M.M.A. has not had a BM for three days gave 2 tablespoons of milk of magnesia at 8 a.m.
01/06/2011 Ms. M.M.A. had a BM this morning.
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MAR PRN MEDICATIONS CONTINUED
86
Most scheduled medications for the same dose each day however, there are some medications that are not given every day:
For example, a medication used to treat hypothyroid disease frequently is scheduled for only five days a week;
The two days of the week, the medication is not to be given must be clearly marked on the MAR.
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MAR SCHEDULED MEDICATIONS – ALTERNATING DAYS
87
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MAR SCHEDULED MEDICATIONS – ALTERNATING DAYS
Medication Administration/Instruction Record
Resident: Mxxx Lxxxx Physician: Dr. Feelbetter
Month/Year: January 2011 Allergies: Codeine, Sulfa drugs, dairy products
Medication Hour 1 2 3 4 5 6 7 8
L-thyroxine 125 mcg1 tablet every Mon, Tue, Thu, Fri & Sat
7AM BC BC BC IX BC BC
Medication Hour 1 2 3 4 5 6 7 8
Initials: BC Signature - Best Caregiver Best Caregiver
Initials: IX Signature - Ifnx Xmnky Ifnx Xmnky
88
Some medications may be ordered to give dosages on different days:
When different doses of the same medication are given on different days or different times, the medication needs to be listed on the MAR each time the dose is different:
In the following example L-thyroxine is given in two different doses on alternating days.
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MAR SCHEDULED MEDICATIONS – ALTERNATING DOSES
89
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MAR SCHEDULED MEDICATIONS - ALTERNATING DOSES
Medication Administration/Instruction Record
Resident: Mxxx Lxxxx Physician: Dr. Feelbetter
Month/Year: January 2011 Allergies: Codeine, Sulfa drugs, dairy products
Medication Hour 1 2 3 4 5 6 7 8
L-thyroxine 125 mcg1 tablet every Mon, Wed & Fri
7AM BC IX BC
L-thyroxine 125 mcg2 tablets every Tue, Thu, Sat & Sun
7AM BC
7:30 AM
IX BC 7:15 AM
IX
BC
Medication Hour 1 2 3 4 5 6 7 8
Initials: BC Signature - Best Caregiver Best Caregiver
Initials: IX Signature - Ifnx Xmnky Ifnx Xmnky
90
Insulin orders require additional information on the MAR:
When CBG testing must occur;
CBG value (blood sugar results);
Where the injection was given (rotation site);
What to do if blood sugar is too high or too low.
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MAR SCHEDULED MEDICATIONS - INSULIN
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MAR SCHEDULED MEDICATIONS - INSULIN
Medication Hour 1 2 3 4 5 6 7 8
Novolog 15 units sq TID 5 minutes before eating meal. Hold if CBG less than 100
7:55* AM
8AM BC
CBG 110
Rotation Site 1
Novolog 15 units sq TID 5 minutes before eating meal. Hold if CBG less than 100
11:55* AM
11:55AM BC
CBG 106
Rotation Site 5
Novolog 15 units sq TID 5 minutes before eating meal. Hold if CBG less than 100
5:55* PM
5:55 PM BC
CBG 125
Rotation Site 9
*Times listed are 5 minutes before meals are served. See Novolog ALERT
92
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MAR SCHEDULED MEDICATIONS - INSULIN
Some rotation charts do not have numbers or letters listed. If they are blank: • Add letters or
numbers;• Keep the chart with
the residents MAR;• List the corresponding
number or letter on the MAR
93
Transdermal patches also require additional information to be written on the MAR:
Where the patch was placed (rotation site);
A time to remove if it is not replaced with a new one at the same time each day. For example Nitroglycerin transdermal patches can only be left in place for 8 – 10 hours depending on the order:
Failure to remove can create significant negative outcomes for the resident.
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MAR SCHEDULED MEDICATIONS – TRANSDERMAL PATCHES
94
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MAR SCHEDULED MEDICATIONS – TRANSDERMAL PATCHES
Medication Hour 1 2 3 4 5 6 7 8
Nitro TD Patch-A 0.1 mg/hrplace one patch daily for 10 hours
9AM 9:30 AMBC
Remove nitro patch 7PM BC
Rotation site L1
95
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MAR SCHEDULED MEDICATIONS – TRANSDERMAL PATCHES
• You may use the provided tracker;
• Instructions on appropriate placement is found in the product information sheet;
• This rotation (tracker) document is specific for Exelon.
L1 R1
96
If the medication dose is changed, draw a line from the last dose given to the end of the month:
In a new line, write the new information regarding the medication, dose, route, day and time; draw a line to the start day.
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MAR DOSE CHANGE
97
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MAR DOSE CHANGE CONTINUED
Medication Administration/Instruction Record
Resident: Mxxx Lxxxx Physician: Dr. Feelbetter
Month/Year: January 2011 Allergies: Codeine, Sulfa drugs, dairy products
Initials: BC Signature - Best Caregiver Best Caregiver
Initials: IX Signature - Ifnx Xmnky Ifnx Xmnky
Medication Hour 1 2 3 4 5 6 7 8
L-thyroxine 125 mcg1 tablet every Mon, Tue, Thu, Fri & Sat
7AM BC IX
L-thyroxine 125 mcg1 tablet daily in the am
7AM 7:15 AMIX
BC
Medication Hour 1 2 3 4 5 6 7 8
Order d/c 7/72011
New order started 7/7/2011
98
If a medication is either missed or if the resident refuses to take it, the caregiver must document this on the MAR circling the caregiver’s initials, and indicate why the medication was missed or refused.
The caregiver also documents in the resident’s record what action was taken (who was notified), as well as any follow-up instructions from the resident’s primary health care practitioner.
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MAR MISSED OR REFUSED MEDICATION
99
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MAR MISSED OR REFUSED MEDICATION CONTINUED
Medication Administration/Instruction Record
Resident: Mxxx Lxxxx Physician: Dr. Feelbetter
Month/Year: January 2011 Allergies: Codeine, Sulfa drugs, dairy products
Medication Hour 1 2 3 4 5 6 7 8
Proventil 90/mcg/spray inhaler – 2 puffs thru mouth every 6 hours while awake
7 AM IX BC BC IX BC BC BC IX
1 PM BC BC BC IX BC BC BC IX
7 PM BC BC BC IX BC IX IX IX
Medication Hour 1 2 3 4 5 6 7 8
Initials: BC Signature - Best Caregiver Best Caregiver
Initials: IX Signature - Ifnx Xmnky Ifnx Xmnky
Date Hour Medication Reason Results Hour
1/3/2011 1 PM Proventil Refused stated didn’t need it
No difficulty breathing 7:15 PM
1/8/2011 1 PM Proventil Out shopping No difficulty breathing 7PM
100
In the case of those residents with written authorization from their primary health care practitioner to self-medicate, you are still responsible for:
Knowing the reason for the medication
What the medication is expected to do; and
If there are any special instructions from the prescribing practitioner about the medications.
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MAR SELF-ADMINISTRATION
101
Resident’s able to self-administer still require an updated MAR:
In order for you and your caregivers to document in the resident record that the resident is taking medications as ordered;
Is necessary in an emergency when information needs to be shared with emergency responders;or
On days the resident is unable to take their medications for example when resident is ill.
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MAR SELF-ADMINISTRATION CONTINUED
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MAR SELF-ADMINISTRATION CONTINUED
Medication Administration/Instruction Record
Resident: Mxxx Lxxxx Physician: Dr. Feelbetter
Month/Year: January 2011 Allergies: Codeine, Sulfa drugs, dairy products
Medication Hour 1 2 3 4 5 6 7 8
MultiVit 1 table every AM 8 AM
L-thyroxine 125 mcg 1 tab every AM 8 AM
Tylenol 325 mg 2 tablets every 6 hours as needed for headache
PRN
Milk of Magnesium 2 TB daily if no BM for 3 days
PRN
Medication Hour 1 2 3 4 5 6 7 8
Resident has order to self-
medicate all medications. See
resident record for documentation.
103
When a resident has a medical appointment with her or his primary health care practitioner and/or specialist:
Take a medical visit report, SDS 0341, listing all medications (including over-the-counter) the resident is currently taking; and
Information regarding any concerns or issues with any medication.
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MEDICAL VISITS
104
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MEDICAL VISITS CONTINUED
105
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PSYCHOTROPIC MEDICATIONS
106
Psychotropic, also known as psychoactive, medications act primarily upon the central nervous system where it affects the brain, changing an individual’s perception, mood, consciousness, cognition and/or behavior:
Psychotropic medications are not intended to be used:
For the convenience of the caregiver or facility;
Instead of implementing non-medication interventions, including redirection; or
To control individual behaviors that do not pose a risk to the individual or others.
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PSYCHOTROPIC MEDICATIONS
107
Psychotropic medications are important tools used to treat:
Anxiety;
Attention Deficit Hyperactivity Disorder (ADHD);
Bipolar disorder;
Depression;
Obsessive-compulsive disorders (OCD);
Post Trauma-Stressor Disorders (PTSD);
Schizophrenia.
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PSYCHOTROPIC MEDICATIONS CONTINUED
108
Psychotropic medications must be used with an abundance of caution in the elderly:
Research has demonstrated that the elderly are more likely to experience serious side effects with the use of these medications; and
Have side effects not typically experienced among younger individuals;
Any psychotropic medication that is not scheduled but prescribed as a PRN medication must have specific written parameters;
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PSYCHOTROPIC MEDICATIONS CONTINUED
109
It is important to be aware of potential side effects and carefully monitor the resident taking these medications;
Sedatives/hypnotics are generally used to aid a resident with sleep. The use of these medications is discouraged for the elderly. The sedation effects can create problems such as:
Falls; and
Daytime sedation.
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PSYCHOTROPIC MEDICATIONS CONTINUED
A psychotropic medication used for the sole purpose of treating a resident’s behavioral symptoms is a form of chemical restraint. The resident’s physician, nurse practitioner, a qualified nurse or mental health practitioner prior to prescribing a psychotropic medications must:Complete a behavioral assessment; and
Try alternative interventions before starting a psychotropic medication.
110 ALERT
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111
Psychotropic medications may mask an underlying problem:
The resident’s healthcare practitioner needs to rule out behavioral problems caused by:
Medication side effects;
Medication interactions; or
Infections.
If the reason for seeking a psychotropic medication is to address behaviors:
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PSYCHOTROPIC MEDICATIONS CONTINUED
112
Alternative measures to any medication to control the behaviors must be tried first:
Should include consultation with a behavioral specialist.
All attempts to use alternative measures must be documented including any results; and
The resident’s healthcare practitioner must be notified of all attempts.
Alternative measures include such things as lowering noise level and environmental confusion, change of provider interactions with the resident and redirection of the resident.
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PSYCHOTROPIC MEDICATIONS CONTINUED
113
Psychotropic medications must not be used to:Discipline the resident; or For the provider’s convenience.
Some inappropriate uses include the following: To decrease the amount of supervision the
resident requires;
To stop a resident from yelling;
To stop the resident from pacing or wandering including trying to leave leaving the AFH.
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PSYCHOTROPIC MEDICATIONS CONTINUED
114
Use of a psychotropic medication to treat behavioral symptoms requires:
Prescribing practitioner’s orders;
A thorough assessment conducted by a qualified health professional; and
Resident’s or the legal representative’s consent.
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PSYCHOTROPIC MEDICATIONS CONTINUED
115
Normal aging alters medication absorption and elimination, which means the action of many medications in the elderly is less predictable than in younger adults:
Each person reacts differently to medication therapy partly because of age-related changes.
Because of natural decline in kidney function, the body is slower to eliminate the medication.
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PSYCHOTROPIC MEDICATIONS CONTINUED
116
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REFUSING MEDICATIONS
117
Residents may resist taking medications for a variety of reasons:
A resident may not openly object, you must be alert to signs that medication is not being taken;
For example, a resident may pretend to swallow a pill, but actually store it in the mouth and spit it out later.
If a resident refuses to take a medication, ask why:
Try to understand the resident’s point of view.
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MEDICATION REFUSAL
MEDICATION REFUSAL CONTINUED118
It is important that residents take their medications as ordered and on time. Call the prescribing practitioner or their healthcare provider and document what happened, what you did and what instructions you were given, if a resident:
Refuses to take medication;
Vomits medication within 20 minutes of taking the medication;
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MEDICATION REFUSAL CONTINUED119
Does not want to or avoids taking medications due to nausea, vomiting or diarrhea;
Reports observing (or you observe) parts of coated tablets in stool;
Shows sudden changes in mental status or behavior;
Shows sudden changes in eating, sleeping or elimination (for example, constipation or diarrhea) patterns.
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The resident has a right to refuse; you cannot force the resident to take a medication. It is inappropriate and a violation of a resident’s rights to put medication in a resident’s food or beverage in order to trick or bully the resident into taking their medication.
120 ALERT
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121
Common reasons for a person refusing to take medications and suggestions for responding are presented in the next slide:
Do not hesitate to contact the resident’s primary care practitioner or the RN consultant when a resident refuses or discards needed medications.
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MEDICATION REFUSAL CONTINUED
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MEDICATION REFUSAL CONTINUED
Common reasons for refusal to take medications
Reason (Complaint) Suggestion
Unpleasant Taste Use an ice cube to numb the taste buds for a few minutes before taking. Provide crackers, apple or juices afterward to help cover up the taste.
Unpleasant side effects Report to their healthcare practitioner. Sometimes changing when or how the medication is given helps with unwanted side effects.
Lack of understanding Provide simple reminders, e.g., “This pill helps lower your high blood pressure.” Use language the resident understands.
Denial of need for medication Discuss need, but do not argue or engage in a power struggle.
123
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MEDICATION STORAGE & DISPOSAL
Medications for each resident must be:Stored in a separate box with the residents
name clearly marked; AND
Locked.
Medications requiring refrigeration must be:Stored in a separate box and locked; AND
If there are any refrigerated medications for the AFH family they also must be locked:
Small dorm refrigerator with a lock on the outside is useful for multiple resident with refrigerated medications.
124 MEDICATION STORAGE
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Refrigerated medications require monitoring:
To ensure proper temperature use a refrigerator thermometer:
Keep a daily temperature log:
If there is a power outage it will assist the pharmacist determining if the medication is still safe.
125 MEDICATION STORAGE CONTINUED
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Medication and associated supplies must be disposed of properly:Sharps OAR 411-050-0650 (5) Safety – use
approved sharps containers:Rigid plastic container with a lid that can be
secured;
Store in a safe secured area;
Must replace when full – do not overfill;
DO NOT dispose of in garbage:Contact your local pharmacy or waste disposal
company for instructions.
126 MEDICATION DISPOSAL
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Contaminated supplies such as bandages etc.:
Dispose of in a plastic bag within a covered garbage container.
Transdermal patches:
Follow manufacturer’s instructions.
Outdated or discontinued medication:
Dispose of immediately:
Follow local regulations.
127 MEDICATION DISPOSAL CONTINUED
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128
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INFECTION CONTROL
Wash hands:
Before setting up a resident’s medication; and
After administering the medications:
If no sink, place hand sanitizer in:
Every room resident care is given; and
In the area where medications are set-up.
Use gloves when appropriate -SQ injections, gels etc.:
Must wash hands before putting gloves on and wash again after removing gloves.
129 INFECTION CONTROL
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Pill boxes, pill cutters/crushers, CBG monitors, Lancet holders,
etc.
Are personal items and MUST NOT be shared. Personal items must be
labeled with the resident’s name.
130 ALERT
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131
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TRAINING
OAR 411-050-0625:
Requires 12 hours of training annually for the:
Licensee;
Caregivers; and
Resident managers, floating resident managers.
Requires all providers (licensees, resident managers, floating resident managers and shift caregivers) to take a Department-approved Six Rights of Safe Medications Administration within the first 12 months from date of licensure or approval.
132 ADDITIONAL TRAINING
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Don’t wait to take the mandatory Six Rights training:
The information provided in the Six Rights training contains critical information needed once you have admitted residents with medications. It is recommended:
You take it within the first month of admitting a resident; and
Your caregivers take the course too.
133 ALERT
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Additional resources on a wide range of medication topics can be found on DHS’s Safe Medication Administration website:www.tinyurl.com/DHS-SafeMeds
134 RESOURCES
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QUESTIONS135
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Where do
you find?
What?
?