Download supporting the use of medication in care settings

SUPPORTING
THE USE OF
MEDICATION IN
CARE SETTINGS
carer edition
CONTENTS
Chapter 1
medication
law
04
04
04
05
05
05
The Medicines Act
L
egal classification of medicines
Controlled Drugs
Common Controlled Drugs
Data Protection Act
Best Practice
Chapter 2
SERVICE USER
PRESCRIPTIONS
06
06
06
07
07
07
Acute prescriptions
Repeat prescriptions
Ordering repeat prescriptions
W
ho orders the prescriptions?
Medication Reviews
Managed repeats
Chapter 4
Administering
Medication Safely
12 Safe working practice
13 Basics of administering medication
14 Pharmacy labels
Chapter 5
When patients
decline medication
18 Recording declined medication
18 Putting back medication in the pack
19 Covert administration
Chapter 6
Information
about medicines
21 Drug interactions
Chapter 3
SAFE STORAGE &
HANDLING OF MEDICATION
08
09
10
10
11
Temperature/light/moisture
Fridge items
Use of gloves
‘When required’ medicines
Monitored Dose System
Chapter 7
Administering solid
oral medicines
Chapter 10
Administering
inhaled medicines
Swallowing difficulties
Crushing tablets and opening capsules
Enteric coating
What if patients chew medication?
W
hat if patients vomit after
taking medication?
25 Lozenges and pastilles
25 Sublingual tablets
26 Buccal tablets
36
36
38
38
38
39
40
22
23
23
24
25
Chapter 8
Administering
oral liquids
27 Medicines spoon
27 Measuring cups
28 Oral syringes
Chapter 9
Applying topical
medication
30
30
31
32
32
33
33
34
34
35
Creams/lotions/ointments/gels
Medicated and non-medicated topicals
W
earing gloves
Applying barrier creams
Applying moisturisers
Soap substitutes
Applying non-medicated ointments
Bath oils
Applying medicated topicals
Applying medicated patches
Relievers
Preventers
Combination inhalers
COPD
Models of inhaler
Spacer devices
Administering an inhaler
with a spacer device
Chapter 11
Administering medication
to the eye, ear & nose
42 Eye drops
43 Administering eye ointments
43 Patients who find it hard to
keep their eye open
43 If a second drop is needed afterwards
44 Administering eye drops
44 Administering nasal drops
45 Administering ear drops
Chapter 12
Important medications
often taken by the elderly
& how to administer
46 Alendronic Acid
46 Calcium supplements
47 references
Chapter 1
MEDICATION
LAW
The Medicines Act 1988
Controlled drugs
+ Anyone can administer a prescribed
+ CDs are ordered on prescription in
medicine to another person but must
follow instructions from prescriber – i.e. what is on the label
+ Prescription medicines must only be
administered to the person they are
prescribed for, they remain the property of the patient and must not be shared
with others
the same way as all other medicines
+ Care professionals are allowed to collect
CDs from the dispensary but you must
provide some form of identification – you
will be asked to provide your name and
sign to say you’ve received the CDs.
+ If you are receiving a delivery of CDs from
the dispensary then you are normally
asked to sign something to say you have received them.
+ Generic name = Name of the drug
e.g. ibuprofen
+ Brand name = Name each manufacturer
gives that drug e.g. ibuprofen comes
as Nurofen
Legal classification
of medicines
GSL: General Sales List
Can be bought without prescription from any shop/supermarket.
P: Pharmacy Only Medicine
Can only be bought in pharmacies under pharmacist supervision,
often kept behind counter.
CD: Controlled Drug
Has the potential to be abused/stolen. Stored in a metal cabinet, recorded in CD register and with a witness present.
POM: Prescription Only Medicine
Can only be obtained with a prescription and only for the patient stated.
04
Common controlled drugs
generic name
uses
brand names/formulations
Temazepam
Sleeping tablet
Generic tablets, oral solution
Morphine
Pain killer
Oramorph liquid, MST tablets, MXL capsules, Zomorph capsules
Diamorphine
Pain killer
Generic tablets, syrup, injection
Dipipanone
Pain killer
Diconal tablets
Fentanyl
Pain killer
Abstral tablets, Effentora tablets, Instanyl nasal
spray, Actiq lozenges, Durogesic DTrans patches
Hydromorphone
Pain killer
Palladone capsules
Methadone
Pain killer
Physeptone liquid and capsules
Oxycodone
Pain killer
Oxynorm capsules, Oxycontin tablets
Pethidine
Pain killer
Generic tablets and injections
Buprenorphine
Pain killer
Temgesic tablets
Pentazocin
Pain killer
Fortral tablets
Methylphenidate
ADHD
Ritalin tablets, Concerta XL tablets
Data Protection Act
Best practice
+ Describes the information you can share
+ Means the current best way of working
about patients e.g. medication details,
health problems etc.
+ Ensures patient confidentiality and privacy.
+ The act states that you should only share
sensitive information about patients with
people who need to know if it’s in the
patient’s best interest. For example with
colleagues, doctors, nurses, pharmacists,
social workers etc.
+ You should not disclose details about
patients to friends, family or anyone else
who doesn’t need to know.
to get the best results
+ For medicines – guidance is issued by
Royal Pharmaceutical Society of Great
Britain who published ‘The Handling of
Medicines in Social Care’ in 2007.
05
Chapter 2
SERVICE USER
PRESCRIPTIONS
Two types of prescription produced by the
surgery: acute and repeat.
Acute prescription
+ For acute illnesses that occur suddenly
over a short period of time e.g. cough,
cold, athletes foot, infection. An acute
prescription is a one off prescription for
a short course of medication – once it is
finished there’s usually no need to order
any more unless the illness hasn’t cleared
up. In this case the doctor will need to
be contacted and may want to see the
patient again.
Repeat prescription
+ Repeat prescriptions are for chronic
illnesses which are long lasting and can’t
normally be cured. Examples include:
asthma, high blood pressure and arthritis.
If a patient needs to take a particular
medication for a long time the doctor can
issue a repeat prescription. There is no
need to make an appointment to see the
doctor each time they need more of that
particular medication.
+ Repeat prescriptions are usually for 28
days worth of medication, however the
patient can ask the doctor for more than
28 days worth if need be.
06
Ordering repeat
prescriptions
+ Each repeat prescription comes with
a white tear-off repeat slip attached to
it. This is a form used to order another
prescription. Each item of medication
that the person can have is listed on the
repeat slip – to order more of an item
the box needs to be ticked and the slip
dropped into the box in the surgery
+ To order a repeat prescription, the
dispensary needs a written request.
+ In person: simply drop your repeat slip
into the practice. If you have lost this, ask
and we will print you off another one.
+ By fax: fax your repeat slip to the practice
+ By email: go onto the practice website
and follow the link on the front page that
says ‘prescriptions’
+ By post: send your repeat slip to the
practice.
Allow a minimum of two working days
for a prescription to be sent to the
chemist. Please note we do not take
requests over the phone due to the risk
of errors occurring and overloading an
already busy phone line.
Who orders the
prescriptions?
Medication reviews
+ It needs to be clear who is responsible
for ordering the medication and should
be recorded in the care plan. It may be
a family member or a carer. If there are a
number of different carers going in to see
the patient everyone needs to be clear
about who will be doing the ordering.
+ Don’t just re-order the same items each
month – always check to see which items
are needed. Medicines taken on a ‘when
required’ basis are not always taken every
day, therefore there may be enough left
over from last month.
+ If the patient has run out of medication ask
for ‘urgent’ to be written on the repeat slip
and it will be put towards the top of the
pile – the medication will possibly be ready
for collection the same day.
+ Medication reviews are required to ensure
the patient’s medication is correct and up
to date. These may be at a clinic (LTMC),
with a GP/nurse/pharmacist and may be
conducted via a phone call appointment.
Managed repeat medication
for dispensary
+ We offer a managed repeat service where
you can order what you need for next
month when collecting your prescription.
This makes ordering easier as it is one
less trip to make and helps you to only
order what you need. Please enquire at
the Stowhealth complementary shop
regarding this service.
GUIDANCE
Filling in a repeat prescription
This half is your prescription to obtain your medication.
This half is your repeat list which you should keep to enable you to order more.
Tick the box if you need more of this item. If you don’t need any, leave it blank
REVIEW DATE - your medication
needs reviewing by this date. See “Review Dates”.
07
Chapter 3
Safe storage
& handling of
medication
Medicines are affected by the environment in
which they are kept and can be affected by:
Temperature
+ Most medicines need to be stored at
room temperature (below 25°C)
+ Too hot = the active ingredient can degrade
(go off) or liquid medicines can grow
microbes. Some medicines are so sensitive
to heat that they need to be refrigerated
+ Too cold = medicines can also degrade
especially if they are allowed to freeze or
drop below a certain temperature
Light
+ Light can also cause medicines to
degrade. This is why bottles that
pharmacies dispense into are made
of brown plastic in order to reduce the
amount of light that gets in.
08
Moisture
+ Moisture can reduce a tablet’s ability to
dissolve or even break down the active
ingredient. Sodium valproate tablets (an
epilepsy drug) are sensitive to moisture.
+ Places to avoid storing medicines include
the cupboard above a kettle – heat
and steam could damage them, on a
window sill – sunlight and heat could
again damage them. Dressings, food
supplements, urine bags and catheters
should not be stored directly on the floor
as any spillages can get them wet.
+ There are occasions when a selfmedicating patient may place themselves
at risk by taking too much of their
medication. If this happens often a risk
assessment can be carried out to decide
if it is safe for them to carry on selfmedicating. If not, it may be safer to store the medication directly away from
the patient.
+ Medications should be ideally be kept in
the patient’s locked medicine cabinet.
+ If there is a risk that the patient will still
gain access to their medicines then
it is acceptable to store them in the
manager’s office or somewhere else away
from the patient. However this must be an
exception rather than the norm and a risk
assessment must have concluded that
this way is in the patient’s best interest.
Staff must ensure that medicines are
kept securely, at the correct temperature,
with keys that are held securely and that
fridges are monitored.
Items that need to be stored
in a fridge
+ You would know that a medicine needs to
be stored in the fridge by the presence of
a bag label saying ‘fridge’, on the label or
in the patient information leaflet.
+ Some items which are normally kept in
the fridge are stable at room temperature
for short periods of time and can be
kept out of the fridge for the time they’re
being used. For example, some types of
eye drops such as Xalatan and Xalacom
(used for glaucoma) are usually stored
in the fridge but can be stored at room
temperature for four weeks.
+ Always write the date you first open the
eye drops on the bottle and box.
+ Avoid placing medicines at the back of
the fridge as they can get pushed against
the back plate of the fridge and freeze
which can damage medicines.
09
Use of gloves
No need to wear gloves for the following:
+ Coated tablets and capsules: most
tablets are coated in a film/sugar coating
so you don’t touch the drug inside.
Capsules are coated in plastic so there
is no risk of absorbing any medication
through your own skin.
Wear gloves for the following:
+ Topical creams, ointments etc: Wear
gloves or wash hands after application
of medicated topical to prevent any
medication absorbing through your own skin
+ Uncoated tablets (if you are allergic or
pregnant): Unlikely that any medication
would absorb through your own skin but
a small theoretical risk – only problematic
if you were allergic to that particular drug
+ Oral liquids (if you think spillage onto
your own skin could occur): If you spilled
liquid medication onto your skin and
failed to wash it off you could get a small
amount showing up in your blood stream.
10
+ Drugs that cause rashes and
cytotoxics: Chlorpromazine (used in
mental health) can sometimes cause
rashes in people who frequently handle
the uncoated tablet or spill the liquid
on them. It is a COSHH requirement to
wear gloves in the handling of uncoated
methotrexate (used in treatment of
arthritis and psoriasis).
Medicines prescribed as
‘when required’
+ Also known as PRN and are medicines
that are only taken when needed.
Examples include pain killers, laxatives,
indigestion treatments etc.
+ PRN medicines should be offered to the
patient – if they do not want or need them
then you do not have to let the doctor or
supervisor know. They are not refusing
them; they just don’t need any at that
particular time.
Monitored Dose System
+ Also known as MDS, blister packs or
NOMAD trays and contain a whole week’s
worth of medication
+ Always check you have the current week’s
pack and check the patient’s name
carefully
+ You cannot give medicines from MDS
packs that have been filled by friends or
family as there would be no pharmacy
labels attached. As well as labels there
should also be a written description of the
tablets/capsules
Examples of medication that is unsuitable
for MDS packs:
+ Some types of tablet and capsule are
not stable enough to be placed in MDS
packs as moisture can enter and cause
the active ingredient to degrade. Also the
tops of the packs are clear – allowing light
in which can damage certain medicines.
Medicines in MDS packs are only stable
for eight weeks.
+ Soluble tablets, dispersible tablets or
sublingual tablets (under the tongue) or
anything that cannot be swallowed whole.
+ PRN medicines – if they are placed in
an MDS pack they tend to be given to
patients regularly instead of only being
given when they are needed.
exampleS
Medicines that need to be refrigerated
MDS pack
Dosette box
11
Chapter 4
Administering
medication –
safe working
practices
Safe working practices
are to provide:
The right medication to the right patient at the
right dose in the right way at the right time
right
medication
AT THE
right
TIME
TO THE
right
PATIENT
Safe working
practice
IN THE
right
WAY
12
AT THE
right
DOSE
GUIDANCE
Basics of Administering medication
1 If unfamiliar with the patient read the care plan to find out which tasks you need to
carry out and any personal preferences they have
2 Check you have the current medicines chart and any other paperwork needed
3 Wash your hands or wear gloves if needed
4 C
heck if the patient has already taken or been given any doses check the
medicines chart or check with patient
5 F
or PRN medication check any when required protocols or ask the patient
if they need the item
6 If you are giving from MDS packs check that you have the correct weeks pack for the
right patient. Check the medicines chart to see how many items are due. Check the
MDS pack and make sure the blister you are about to pop out has the right number of
items in. Check for any items listed on the medicine chart not in the MDS pack
7 If
you are giving any medicines not in an MDS pack, compare the pharmacy label
with the entry on the medicines chart. Make sure the following details agree: 1 Drug name 2 Drug strength 3 Form of the drug 4 Directions 5 Patient’s name 6 Expiry date
8 R
ead any warning/cautionary and advisory labels on the pharmacy label e.g.
take with food and act on them
9 Administer each item according to ‘best practice’
10 Observe the patient take each item
11 E
nter the correct code/your initials on the medicine chart only when you
personally have seen the patient take or use the item or decline it
13
PHARMACY LABELS
GUIDANCE
Typical pharmacy label
1 Name
2 Strength
3 Form
Asprin 75mg dispersible tablets 28
4 Direction
5 Patient’s
name
6 Quantity
Take ONE tablet Daily
Dissolve or mix with water before taking Take with or after food
Contains aspirin
7C
autionary and
advisory labels
Mr John Greene
8D
ate of
dispensing
23 March 2012
1 Name of the drug
2 Strength
The same drug can have two names the
generic (e.g. diclofenac) and the brand name
(e.g. Voltarol). Make sure the name on the
label matches the name on the medicines
chart. If the medicines chart has the
brand name and the label has the generic
name (or vice versa) it may still be okay to
administer the medicine (you can check with
a pharmacist for clarification).
The same medicine can come in many
different strengths, so check you’ve got the
correct one. Strengths are written in various
ways for example:
14
+ Grams (g)
+ Milligrams (mg) there are 1000
milligrams in one gram
+ Micrograms (mcg) there are 1000
micrograms in one milligram
For example:
4 Directions
+ Warfarin 0.5mg tablets
+ Warfarin 1mg tablets
+ Warfarin 3mg tablets
+ Warfarin 5g tablets
+ Digoxin 62.5mcg tablets
+ Digoxin 125mcg tablets
+ Digoxin 250mcg tablets
Sometimes directions are written as ‘Take
ONCE daily’ on the label, but state ‘Take
ONCE in the morning’ on the medicines
chart (or vice versa). This is okay as
long as the two sets of directions don’t
contradict each other. Directions such as
‘take as directed’ (or similar wording) are
not acceptable for you to work from. The
dispensary/pharmacy should be asked to
seek directions from the prescriber and add
them to the label.
The strengths of liquids and creams are
sometimes written as a percentage, for example:
+ Hydrocortisone 0.5% cream
+ Hydrocortisone 1% cream
Some medicines are only available in one
strength (e.g. lactulose) in which case the
strength isn’t always written on the label or
medicines chart. 3 Form
Form means formulation. Medicines come in various formulations, for example:
+ Diclofenac dispersible tablets
+ Diclofenac gel
+ Diclofenac suppositories
+ Diclofenac injection
+ Diclofenac tablets
+ Diclofenac slow release tablets
+ Diclofenac capsules
There are exceptions for this rule: drugs
whose doses vary frequently such as
warfarin or insulin can be labelled ‘Take as
directed’. However there should be a way of
finding out what the dose is. With warfarin
you should always check the laboratory
test results (INR results) before you give
the dose. These INR results will tell you
how many milligrams of warfarin to give the
patient. Don’t just give the same dose of
warfarin as yesterday without checking the
results first as the dose may have changed.
15
5 Patient’s name
Make sure the patient’s name on the
label matches the patient’s name on the
medicines chart.
6 Quantity
The amount of medication in the pack
7 Cautionary and
advisory labels
These warnings are put on the label
automatically by the dispensary’s computer
system. They contain important information
such as whether the drug needs to be
given with food or on an empty stomach,
or whether the drug causes drowsiness as
well as other important information. These
warnings are not always printed on the
medicines chart and so you’ll need to check
these on the label before administering the
item to the patient.
8 The date of dispensing
Not the expiry date, the date when the item
was dispensed, i.e. on the 23rd March 2012.
16
Expiry dates
(medicines often have two)
+ The expiry date before the pack is
opened: medicines supplied in the
manufacturer’s original packaging will
have an expiry date printed on the pack
or on any foil strips. Unfortunately if
the dispensary repacks the item into
another container, then this expiry date is
sometimes lost. When this happens the
advice from the regulators is to assume
medicines are still in date 6 months after
the date of dispensing.
+ The expiry date once the product has
been opened: most medicines contain
preservatives but they don’t protect the
product forever. Once you open a pack
of medication it starts to ‘go off’ (the
active ingredient degrades and becomes
less effective. Bacteria can also start to
contaminate liquid medicines.) The table
below shows examples of the shelf life on
some liquids.
LIQUID SHELF LIFE
OTHER ITEMS SHELF LIFE
ITEM
SHELF life
once opened
ITEM
SHELF life
once opened
Chlorpromazine
syrup
6 months
Oral liquids
6 months
Ditropan elixir
28 days
Creams in tubes
3 months
Folicare
4 weeks
Creams in jars/pots
1 month
Frusol liquid
3 months
Ointments in tubes
6 months
Gastrocote liquid
1 month
Ointments in jars/
pots
3 months
Largactil syrup
1 month
Eye drops
28 days
Neoral oral solution
2 months
Oramorph oral
solution
90 days
Phenergan elixir
1 month
Risperdal liquid
3 months
Antibiotic liquids
7-10 days (needs
to be refrigerated)
17
Chapter 5
When patients
decline their
medication
+ We all have the right to refuse medication Recording when medicines
and you should never pressure a patient
into taking their medicines but gentle
encouragement is okay
+ If you have more time to spend with the
patient you could leave their medicines
chart blank, walk away and try again later.
Patients with dementia often forget they
declined medication so you may be able
to offer them the item again
+ It would be helpful to spend some time
talking with the patient to find out why
they don’t want their medication e.g.
they find tablets hard to swallow – a
pharmacist could recommend another
formulation. They also may not know why
they take the item - in cases like this a
MUR (medication usage review) may be
helpful. If you have a patient who is hiding
medication from you instead of taking it,
remind them that they have the right to
refuse medication. They don’t need to
pretend that they’ve taken doses they
don’t want.
18
are declined
+ There comes a point when you have to
code the medicines chart that the dose
was declined – check and see what code
to use. Also check what your policy is
on declined medication – some people
contact the prescriber straight away,
some contact them after the patient has
refused for more than 24 hours, some
wait longer. It also depends on the drug
declined. The time period can be agreed
with prescribers.
Can I put a tablet or capsule
back in the pack?
+ If a tablet/capsule has come from a blister
strip or MDS then you won’t be able to
put it back. Don’t be tempted to try and
re-seal it with tape. However if it has come
from a bottle it may be okay to put it back
although take great care to check you are
putting the same tablet/capsule back.
+ Check that the patient will take the item
of medication before you remove it from
the pack so you won’t have to deal with
any doses you have taken out.
Covert administration
+ If the patient has adequate mental
capacity then they have the right to
decline their medicines, but what about
patients with limited mental capacity?
Laws and guidance state that if a
person’s mental capacity is under doubt
than an assessment of their mental
capacity may be needed.
+ In cases where patients lack the mental
capacity to take and understand their
medications there are certain situations
when we can hide medicines in food
and drink, i.e. give a person their
medication without them realising it
(covert administration). However one
of the difficulties with this is that you
need to ensure the patient swallows the
entire drink or meal to get the full dose.
If the patient shares the living space with
others you need to think about how you’d
prevent someone else finishing their meal
or drink and inadvertently swallowing
their medicine.
+ Don’t confuse covert administration
with putting medicines in food/drink to
help someone swallow. If the patient
understands that their medication is
mixed with a drink or food then this is not covert administration.
+ The doctor, a social work team, family
members and a pharmacist would all
have to be consulted before covert
administration could take place.
19
Chapter 6
Information
about medicines
+ The amount of knowledge you are
expected to have about the medicines
you administer depends on how many
different types you encounter on a dayto day basis.
+ It’s very important you have the
right forms in place e.g. care plans,
medicines charts, PRN protocols etc.
These forms should contain all the
information you need to give medicines
safely and appropriately.
The latest and best
information sources that
are available to you include:
+ Patient information leaflets:
pharmacies are required to supply a
patient information leaflet with each
medicine they dispense – it should
contain all the information you and the
patient need. Make sure the leaflet you
are reading is up to date as information
about medicines sometimes changes.
Patient information leaflets should be
made available for the patient to read
– you may have to help patients with
limited mental capacity understand
the leaflets by reading them out and
explaining them using more simple
language.
20
+ BNF: the British National Formulary is
designed to be used by pharmacists/
nurses/doctors and therefore contains
quite a lot of medical jargon and
terminology. However it contains a lot of
detailed information on medicines.
+ www.bnf.org the British National
Formulary is also available online
+ New Guide to Medicines & Drugs book:
The British Medical Association produces
a useful book aimed at the general public
and has advice about what to do if a
particular medicine is given late.
+ www.medicines.org/guides the
Electronic Medicines Compendium
(EMC) provides up-to-date, reliable
and understandable information about
medicines. It also allows you to download
patient information leaflets for many
different drugs simple language.
exampleS
BNF
New Guide to Medicine & Drugs
Drug interactions
+ Multiple items of medication can interact
in other ways to produce a range of
side effects. Some examples are:
some cough/cold treatments contain
paracetamol which when given with
co-codamol could cause a paracetamol
overdose. Ibuprofen can interact
with a number of medicines such as
lithium with sometimes quite serious
consequences.
+ It’s best to advise any patient where
there’s a risk that medication bought
over the counter can interact with
their prescribed medications or hide
symptoms that might need investigating.
It’s best to check with a pharmacist or
the patient’s GP to see if they can be
taken together safely.
+ Some policies state that you are only
to assist with medication that has been
prescribed. This is because prescribed
items will already have been checked
by a doctor and pharmacist and so
shouldn’t interact with each other. If
you are giving patients items of over the
counter medication then these should
be added to their medicines chart.
21
Chapter 7
Administering
solid oral
medicines
Swallowing difficulties
+ Many people find swallowing tablets and
capsules difficult
+ The wider the cup the better as the
patient won’t need to tip their head back
to get to the liquid - makes swallowing
more difficult
+ Make sure you have filled the cup to the
top with liquid otherwise they’ll need to
tip their head back
+ Some people find it easier to swallow if
they suck the liquid up with a straw
+ Swallowing problems can also occur if
patients suffer from a dry mouth – you
could give them a drink to wet their mouth with before they put the
tablets in their mouth.
+ Many people find it easier to swallow
capsules, sugar coated tablets, or a liquid
formulation. Talk to the dispensary to see
if they can change the formulation if necessary.
+ Most people need a drink in order to
swallow tablets/capsules. You can always
add some cordial if the patient prefers.
+ Milk can affect certain types of medication
by reducing the amount of drug that gets
absorbed. Check the cautionary and
advisory warnings on the label if it says
‘do not take with milk’ then you’ll need to
advise the patient about this.
22
+ Most types of fruit juice are okay however
grapefruit juice can interact with nifedipine,
simvastatin and carbamazepine. Cranberry
juice can also be a problem in some
patients taking warfarin – there should be
a warning on the label or within the patient
information leaflet.
+ The caffeine in tea and coffee can interact
with theophylline. Another problem with
hot drinks is that patients cannot take a
big enough ‘gulp’ to make sure the tablet
is swallowed properly. There have also
been cases where soft gelatine capsules
have melted in the mouth when taken
with a hot drink, releasing the drug into
the mouth which can taste quite bitter.
If the patient has milk with their tea or
coffee check the label to see if it says ‘do
not take with milk’.
+ Alendronic acid should only be given with
water (no cordial and not mineral water).
There are multiple warnings such as
‘take on an empty stomach’ surrounding
alendronic acid which can be found in the
patient information leaflet
Crushing tablets
and opening capsules
+ Some tablets are designed to be chewed
e.g. Natecal
+ Some tablets are designed to be crushed
e.g. Epilim crushable tablets
+ You could find this information by reading
the patient information leaflet. However
if the tablets you are administering have
not been designed to be crushed/chewed
then don’t crush them unless you’ve
had permission from the pharmacist and
doctor. Permission should be recorded in
care notes.
+ Some capsules are designed to be
opened up e.g. Zomorph. However unless
it states in the patient information leaflet
that you can do this, don’t open up any
capsules unless you’ve had permission
from a pharmacist and doctor.
You have to be cautious when determining
whether tablets can be crushed/chewed for
the following reasons:
+ Some tablets are coated as there are
+ With enteric coated tablets and capsules
there is always a warning on the label
saying ‘swallow whole, do not crush or chew’.
+ Some tablets have a sugar (or film)
coating which is not the same as an
enteric coat. The sugar (or film) coating
is just there to make the tablet easier to
swallow. These coatings will dissolve in
the stomach along with the tablet. The
pharmacist might give you permission for
you to crush sugar or film coated tablets.
+ Some tablets and capsules are
slow release which is a mechanism
designed to release the drug inside
slowly throughout the day (or night). This
means that instead of having to give the
medicine a number of times throughout
the day, the tablet or capsule can be
given less frequently, i.e. only once or
twice a day. By crushing slow release
tablets/capsules you may end up giving
the person an overdose as the entire
day’s dose is released in one go.
some drugs that can be damaged by acid
in the stomach. To protect them they are
coated in a film that doesn’t dissolve in
acid known as an enteric coating. This
coat will dissolve to release the drug in
a more neutral or alkaline environment
once it passes through the stomach into
the intestines. Some drugs also have
an enteric coat to stop the drug in them
irritating the stomach lining.
23
+ With slow release tablets and capsules
there is always a warning on the label
saying ‘swallow whole, do not crush or chew’.
+ You cannot crush tablets or open up
capsules that are not coated or slow
release unless you have had permission
from a pharmacist and the doctor. Giving
medicines in a way that the manufacturer
didn’t intend them to be given is called a
drug ‘off licence’ or giving it as an unlicensed drug. The prescriber has to be
asked permission if any drug is to be
given in an unlicensed way.
+ It is okay to break tablets in half if they
have a ‘score line’ on them. You don’t
need permission from the pharmacist/
doctor because the manufacturer has
designed scored tablets to be broken in
half if need be.
GUIDANCE
Breaking scored tablets
24
What if the patient chews
their tablets or capsules?
+ Can sometimes occur in patients with
dementia where swallowing difficulties
can occur. It’s only enteric coated or
slow release tablets/capsules that you
need to worry about. This is important
because if a patient chews a slow release
tablet, they could end up having an
entire day’s dose in one go which could
be dangerous. Chewing enteric coated
tablets might stop them working or cause
stomach irritation.
+ If any of the medicines patients are
chewing have these warnings on them
(swallow whole, do not crush or chew)
you’d need to warn the patient of the
risks and let the pharmacist/doctor or
another health professional know as soon
as possible.
+ If the tablets that they are chewing are not
slow release/enteric coated then there will
be no warning on the label, however you
could still contact the pharmacist as they
may be able to change the item to a liquid
or something that is easier to swallow. The
patient would not be putting themselves
in immediate harm by chewing tablets that
are not slow release though.
What if the patient vomits
after taking any oral
medication?
Unlikely but if this does happen then
contact a health professional (such as a
pharmacist) they may advise you to give
another dose if you can see the intact
tablet/capsule in the vomit but do not
do this unless you have checked with a
health professional.
Lozenges and pastilles
+ Occasionally prescribed by doctors,
lozenges and pastilles are designed to be
sucked and should be held in the mouth
for as long as possible and allowed to
slowly dissolve.
+ Patients taking any medication that
needs to be sucked or chewed should
avoid eating or drinking anything until the
pastille or lozenge has fully dissolved.
Sublingual tablets
+ Sublingual tablets are designed to be
placed under the tongue instead of
swallowed. From there the drug absorbs
directly into the bloodstream and so it is
able to work more quickly. One example
of a sublingual tablet is glyceryl trinitrate
(GTN) used to treat angina.
+ Once used, GTN should ease chest pain
within 1-5 minutes. If needed, the patient
can have another GTN tablet after 5
minutes. If they have taken 3 doses within
15 minutes and the chest pain is either
no better or worse then you should call a
doctor, or dial 999 as the patient may be
having a heart attack. GTN can sometimes
cause a headache – a recognised side
effect and although uncomfortable is
nothing to worry about.
+ GTN tablets expire 8 weeks after opening
the bottle so it’s important to keep them in
their original container, as a metal seal in
the lid and the glass bottle is designed to
protect the tablets. Any tablets remaining
after 8 weeks need discarding and a fresh
supply is required.
25
+ GTN also comes as a spray for under the
tongue. The spray does not expire after 8
weeks and may be used until its empty or
has reached its expiry date. When patients
feel chest pain, they should spray one or
two puffs under their tongue. It’s important
that the canister is held upright when
spraying. After spraying, the patient should
close their mouth; otherwise the spray can
evaporate out of the mouth. GTN tablets
and spray can tingle or burn under the
tongue, which is normal.
exampleS
Sublingual tablets
Buccal tablets
+ Designed to be placed between the upper
cheek (or lip) and the top gum where
they sit and dissolve. The drug then gets
absorbed directly into the bloodstream
and therefore works very quickly.
+ If the patient has a dry mouth, you can
moisten the inside of it with some wet
cotton wool. If you have a patient who
needs this type of tablet regularly, it’s best
to vary the place where the tablet goes
a little (to stop irritation). Some types of
GTN tablet come as buccal tablets. Some
tablets used to treat nausea and sickness
are also available in this form.
GUIDANCE
Administering buccal tablets
26
Chapter 8
Administering
oral liquids
When measuring out oral liquids, you have
three choices of what to use:
medicines spOON
Only a 5ml medicines spoon is designed
to accurately hold 5mls of liquid – not a
metal teaspoon or any other type of spoon.
However, most people tend to pour out less
than 5ml – only 3 or 4ml. Whilst this may
be less important if measuring out items
such as cough medicines or treatments for
indigestion, this could lead to more serious
under-dosing if you are measuring out items
such as antiepileptics, treatments for the
heart, or antibiotics etc.
To pour out 5ml you need to pour a heaped
spoonful of liquid.
Although spoons are not good for measuring
out liquids, they can be easy to administer
from. If the patient finds it hard to swallow
from a measuring cup or oral syringe, you
can always transfer the medicine to a spoon
after measuring it out accurately using
another device.
Measuring cupS
Many care professionals use graduated
medicines cups to measure out liquids. If you
are using these, it’s important to place them
on a level surface to check you have the right
dose. If you hold the cup up to eye level, you
can end up holding it at an angle resulting in
you measuring out the wrong dose.
Medicines cups are more accurate than
spoons, but many people tend to pour too
much into them (sometimes 6 or 7ml when
aiming for 5ml). Also, thick medicines can be
left behind in the measuring cup.
Measuring cups are better for larger volumes
of liquid, e.g. 15 or 20ml. This is because
over measuring by 1ml when aiming for
20ml gives you a 5% error, whereas over
measuring by 1ml when aiming for 5ml gives
you a 20% error.
Generally speaking, most people manage to
swallow liquids okay from measuring cups.
However, you often have to tip your head
back to get the last of the medicine from the
cup. Tipping your head back and looking up
can make swallowing difficult. This might
be a problem if the patient has a swallowing
difficulty, in which case spoons might be
easier (after using a syringe to measure out
the dose accurately).
27
Oral syringES
Oral syringes are the most accurate method
of measuring out liquids. They come with
a plastic adaptor which you push into the
bottle. You then push the syringe into the
adaptor and turn the bottle upside down.
You need to get rid of the air gap that you
get when you first draw the liquid up. Push
this air gap back into the bottle. A few small
air bubbles are okay, but not an air gap.
If you are holding the syringe pointing
upwards, make sure it’s the top edge of the
black ring that’s just touching the underside
of the correct mark.
If possible, it’s best to let the patient use the
oral syringe themselves. This way they have
control over how quickly they push the liquid
into their mouth and it’s also more dignified.
If the patient can’t do this on their own, then
you may have to do it for them. Take care, as
choking incidents have occurred when staff
have pushed liquid in too quickly.
It’s good if you have found a technique that
works for you and the patient. As long as
medication does not dribble out of their mouth
and they find the technique comfortable, then
you can use whichever technique suits you
both. However the technique does need to
minimise the risk of choking. 28
Rather than pushing the whole of the syringe
into the mouth, place just the tip of the syringe
between the front lips (which remain closed)
in front of the teeth. If you push the syringe in
between their teeth, the patient won’t be able
to clench their teeth to swallow.
Some people place the whole syringe in the
side of the cheek, between the teeth and
the inside cheek. Although the patient can
clench their teeth to swallow, they can’t
form a seal around the syringe, and liquid
can leak out. Also, you can’t see how much
liquid you are squirting in at a time. This is
also not the most dignified way to treat the
patient – hence just place the tip between
the front lips.
Not all patients can take 5ml in one go. If this
is the case, squirt about 2.5ml in at a time
then allow them to swallow this. Once they
have swallowed it, push another 2.5ml in. In
time, you may find that the patient is able to
take a whole syringe-worth of medication in
one go, however just be cautious to begin
with. If you find that the patient doesn’t get
on with syringes, you can always squirt the
medicine bit-by-bit from the syringe onto the
spoon and give it that way.
Cleaning oral syringes
Clean the syringe after each use with fresh,
warm soapy water. Draw the plunger in
and out several times until the inside of the
syringe is clean. Separate the barrel and
plunger and wash both in soapy water. Do
the same to the adapter. Rinse under cold
water and leave un-assembled to dry.
You can use a dishwasher, but that doesn’t
clean the medicine out of the tip. If you use
a dishwasher, flush the medicine out first
with fresh water. If you are administering into
the mouth, oral syringes need to be clean,
but not necessarily sterile.
exampleS
Medicines spoon
Measuring cups
Oral syringes
Carry on using the oral syringes until the
markings fade.
29
Chapter 9
Applying topical
medication
Topical products are products applied to the
skin. In general terms this means creams,
lotions, ointments and gels.
+ Creams are a combination of oil and
water. They also contain extra ingredients
such as emulsifying agents which allow
the oil and water to mix, and preservatives
to stop microbes growing in the water
that creams contain. Medical creams
don’t tend to contain colours or perfumes
as these can sometimes irritate the skin.
+ Lotions are like creams but are designed
to be applied over larger areas of skin.
For this reason they are often thinner and
contain more water.
+ Ointments are mostly made of oil or
grease. They contain either no water,
or just very small amounts. Since most
ointments contain no water, they do
not need emulsifying agents added or
even much in the way of preservatives.
Therefore they contain fewer ingredients,
which means they are much less likely
to cause skin irritation. Because they
contain more oil, they moisturise the skin
for longer, This is because the oil seals
the water in the skin, preventing the skin
from drying out. Some patients don’t like
the greasy feel of them although they do
make excellent moisturisers.
+ Gels are a much more recent invention
and can be made of almost 99% water
or any combination of oil and water.
They remain fairly solid whilst they are in
their container, but become softer when
applied to the skin.
30
All of the above can have drugs added
to them which would make them
‘medicated’ or they can be used as they
are i.e. left as ‘unmedicated’ in which
case they are often used as moisturisers.
+ Non-medicated creams, ointments,
gels and lotions are most often used as
moisturisers. An example is aqueous
cream. Moisturising creams are normally
applied quite thickly. With moisturising
ointments, less is needed as they contain
more oil.
+ Barrier creams and ointments are in a
class of their own. Examples include
Sudocrem, Conotrane and Cavilon cream.
They contain a type of silicon which
sits on the skin and acts as a repellent,
keeping irritants such as sweat, saliva,
urine and faeces off the skin. The silicon
doesn’t get absorbed, so they aren’t really
‘medicated’ topicals, but because some
of them also contain mild antiseptics they
aren’t really non-medicated either.
Wear gloves when applying
topical medicines
exampleS
Non-medicated cream
Medicated cream
It’s best to wear gloves when applying any
medicated cream/ointment/lotion/gel. This
prevents the drug absorbing through your
own skin. There is only a small risk of this
happening, especially as you’d wash your
hands afterwards, but it is possible.
It’s best to spread topical products
(medicated, non-medicated and barriers)
onto the skin, rather than trying to rub
them in. Spread them down the limb using
a sweeping motion in the direction of hair
growth (always down, away from the body).
This is important if the patient has hairy skin
as otherwise you end up brushing the hairs
the wrong way which can be uncomfortable
for them.
Barrier cream
Don’t try and rub topical products in
vigorously, as this can irritate the skin and
will take a long time. Skin is a barrier and it
can take a while for things to soak through
(depending on what is applied). As far as
creams are concerned, they are mostly
made of water. Most of this water dries into
the air, rather than soaking through the skin.
The active ingredient is then left behind on
the skin to soak in. Rubbing creams around
the skin just heats up the skin and causes
the water to evaporate more quickly.
31
Therefore the advice is to stroke topical
products across the skin and leave them
there to soak in. However, although it is
usually pointless trying to rub the cream in,
some patients enjoy the massaging action
when creams are applied. If massaging the
skin is not causing any irritation and the
patient enjoys it then carry on. It won’t cause
the product to soak in more quickly but it
might help the patient to relax.
Applying barrier creams
Many people apply barrier creams too thickly.
You should stroke a small amount thinly
across the skin, but still be able to see the
skin through the cream. If the skin is very
white, then you’ve applied too much. This can
be difficult to wash off and the patient can
end up with layer upon layer of barrier cream
building up. The result is that their skin never
gets cleaned underneath which can cause skin irritation.
Therefore the advice is to stroke topical
products across the skin and leave them there
to soak in. However, although it is usually
pointless trying to rub the cream in, some
patients enjoy the massaging action when
creams are applied. If massaging the skin
is not causing any irritation and the patient
enjoys it then carry on. It won’t cause the
product to soak in more quickly but it might
help the patient to relax.
32
Applying moisturisers
A good moisturiser doesn’t just add water
to dry skin, it adds plenty of oil to it in order
to fill all the gaps between skin cells and
restore the skin’s natural barrier function. With
moisturising creams, the oil they contain has
been diluted with water. This is why you
need to apply so much, as shown below:
Most patients will probably not want you to
put this much on. You could ask them to try
it for a week to see what difference it makes.
Depending on how dry the skin is, it takes
about 10-30 minutes for the water to dry
off (some of the water soaks into the skin,
most of it evaporates into the air). After the
water has gone, you are left with a thin layer
of oil on the skin. The oil then soaks into the
skin over the next few hours. It fills the gaps
between the skin cells, which seals in the
water already present in the skin.
Once you have applied all of this moisturising
cream, the patient can get dressed over the
top of it with an old dressing gown or clothes
which they don’t mind getting a little greasy. It
doesn’t stain most clothing (apart from silk) as
the oil normally remains in the skin rather than
soaking into the fabric. Any product will come
off the fabric in the wash.
Moisturisers work even better when applied
to wet skin as they lock the moisture in. It’s
best to pat the skin dry a little first to avoid
diluting the cream too much with water.
Some patients may have a limited
understanding of why you have to apply this
much (e.g. patients with a learning disability
or dementia). It might be easier to use
moisturising ointments with these people
as they are less visible on the skin and less
likely to get rubbed off.
GUIDANCE
Moisturising creams can be
used as soap substitutes
The water, oil and emulsifying agents in
creams means they can act as a kind of
soap. They can be kinder to the skin than
normal soaps which often strip the skin of its
natural oils. People with dry skin or eczema
tend to use moisturising creams (such as
aqueous creams) as soap substitutes.
Applying moisturisers
Applying non-medicated
ointments
Examples include Vaseline, Epaderm
ointment, Emollient 50, Diprobase ointment etc.
Moisturising ointments don’t need to be
applied as thickly as moisturising creams,
as they are made almost entirely of oil, so a
thin layer is fine. It wouldn’t do any harm to
apply them too thickly; you just don’t need
that much.
Unfortunately, people don’t always like
the greasy feel of ointments on their
skin, so although ointments are fantastic
moisturisers, people often prefer water
based (and often less effective) creams
and lotions. Because ointments contain
less water, they don’t need as many
preservatives in them. Therefore with
ointments, there’s less chance that people
will experience the stinging sensations they
can get with creams.
33
exampleS
Moisturising ointment
Bath oil
Medicated topical
Bath oils
Examples include Oilatum and Balneum bath oils.
These are oil based products added in small
quantities to the bath water. They float on
the surface of the water and coat the skin
in oil. They don’t dry the skin like traditional
bath soaps can. People often use bath oils
and moisturising soap substitutes together.
Take care when using bath oils as they can
make the bath slippery which could lead to a
fall. A rubber bath can help prevent this.
Applying medicated topicals
Medicated topicals contain drugs such as
antibiotics, anti-fungals, and steroids etc.
They come as creams, ointments, lotions
and gels.
They need to be applied thinly. If you apply
too much, the patient could get an overdose
of the drug which could cause side effects.
Medicated topicals are often applied to a
small patch of skin – wherever the problem
is. The information leaflet inside should
tell you exactly how much to apply. You’ll
usually find a warning on the label that
states ‘to be spread thinly’. A fingertip’s
worth of medicated topical covers two
hand’s worth of skin.
34
Fingertip units are there as a guide and are
probably most useful for applying steroids
(as they are often applied over larger areas
of skin). When we say apply thinly, this
means you should be able to see the skin
through the topical product. There should
be hardly any topical product visible on the
surface of the skin.
If you need to apply a nonmedicated topical and a
medicated topical to the
same patch of skin, which
would you apply first?
The most sensible advice is to apply the
non-medicated topical first, then apply the
medicated topical on top. This is because if
you applied a lot of non-medicated topical
on top of a little patch of medicated topical,
you could end up washing the medicated
topical off.
Do I need to add topicals to
the medicines chart?
The care regulators recommend that
all topicals (whether medicated or nonmedicated) should be added to the
medicines chart (including moisturisers and
bath oils). This is to show that they have
been applied or used regularly. The only exception to this is moisturising
creams used as soap substitutes.
GUIDANCE
Applying
medicated
patches
Applying medicated patches
Examples include nicotine, Fentanyl and glyceryl trinitrate patches.
Some medicines can be given as a skin
patch. These patches are like large sticking
plasters, with the drug contained inside them.
The drug absorbs through the skin straight
into the bloodstream. Patches can be applied
to various parts of the body. Exactly where
depends on the type of drug contained in
the patch (this will be explained on the leaflet
inside the box). Usual places include:
4
4
4
4
Back
Stomach
Top of the arms
Thighs
Places to avoid sticking patches include:
6 Very hairy skin
6 Oily skin
6 Sunburned skin
6 Scarred skin
6 Rough skin
6 Damaged skin
6 Areas that get sweaty – e.g. underarms
6 Places where the patch could get rubbed
off – e.g. under bra strap, on the waist
6 Bony areas – e.g. shoulders or hips
The area of the skin where the patch will be
applied needs to be clean and dry. You may
need to wash off any moisturiser or body
lotion that the patient has used, and pat the
area dry first of all.
Peel off the backing paper and stick the
patch onto the skin. Press the patch on
firmly so it sticks well, especially around
the edges. So long as you are careful and
avoid touching the sticky side, you wouldn’t
necessarily need to wear gloves when
applying patches.
Some patches are only worn during the day;
some are also worn at night. Some patches
are kept on for as long as three days. Check
to see what the instructions say. Some
people write the date when the patch was
applied onto the actual patch itself to remind
them when a new one is needed.
Remove the previous patch before applying a
new one. Fold the old patch in half, sticking it
to itself before discarding it. When applying a
new patch, stick it near to where the last one
was, but not directly over the same patch of
skin. This prevents the same patch of skin
getting irritated.
35
chapter 10
Administering
inhaled medicines
Inhalers are given to patients suffering from
lung diseases – the two most common ones
you’ll see are asthma and COPD (chronic
obstructive pulmonary disease). Asthma is
called a variable and reversible condition
which means the symptoms can come and
go; it is often caused by allergies. COPD
is called a ‘fixed’ disease which means it
doesn’t tend to get better.
Relievers
Everyone with asthma should have a reliever
inhaler (usually blue). The most common
reliever drug is salbutamol. Relievers don’t
reduce the inflammation and mucus, they
just open the narrowed bronchioles quickly
(within a few minutes) making it easier to
breathe. Salbutamol inhalers normally last
about four hours.
With asthma, relievers should be used when
the patient either gets symptoms or expects
them to come (i.e. before exercise or being
exposed to anything that triggers their
asthma). Side-effects include a slight tremor
in the hands – this isn’t normally anything
to worry about. It’s important patients are
able to self medicate with their relievers,
as you might not be around when they get
symptoms. Assuming the patient has a good
technique with their reliever inhaler but still
36
needs it frequently, the next step is to add
a preventer inhaler. If a patient needs to use
their reliever inhaler more than three times a
week, they may need an asthma review.
Preventers
Preventer inhalers contain steroids (the most
common being beclometasone). Steroids
reduce inflammation and mucus, and makes
the lungs less sensitive to triggers so the
patient is less likely to suffer an asthma
attack. Preventers are brown, orange or
burgundy. Light brown inhalers contain less
steroid; darker brown, orange and burgundy
inhalers contain higher doses. In asthma,
preventers are added when patients:
+ Cough, or have chest tightness or
breathing difficulties more than three
times a week
+ Need to use their reliever inhaler more
than three times a week
+ Get breathless because of a chest
infection or smoky atmosphere
It is important patients use their preventers
regularly, once or twice a day. Preventers
take up to 14 days to work fully, hence they
are taken every day even if the patient feels
well. Forgetting the occasional dose won’t
usually bring symptoms back straight away,
but forgetting doses for several days can
cause symptoms to return and make their
asthma more unstable.
Many people rely on their relievers too much
and don’t use their preventers regularly. This is often because they feel an immediate
effect from their reliever, whilst their
preventer takes longer to work. However,
this isn’t good for their asthma. Relievers
don’t treat the underlying symptoms, so their
asthma can become unstable and worsen. If
patients have frequent symptoms and aren’t
getting the right treatment, they can end up
in hospital with a serious asthma attack.
exampleS
Relievers
Preventers
People worry about side effects with
steroids. However, preventers only have
small amounts of steroid in them and if they
are used properly, it’s unlikely patients will
suffer serious side effects. One side effect
with steroids is thrush (a yeast infection)
in the mouth. If a patient using steroid
preventer inhalers has a sore mouth or
throat, the doctor can prescribe something
to treat it. To reduce the risk of thrush,
patients must rinse their mouth out with
water (and spit the water out) after using
their preventer inhaler. Alternatively, they can
brush their teeth after using their preventer
inhaler. A spacer device can also reduce the
build-up of steroid in the mouth to prevent
thrush and other side effects.
37
exampleS
Protectors
Combination inhaler
Protectors
If reliever and preventer inhalers are still
not controlling the asthma, the next step
is to add a third inhaler called a protector.
Protector inhalers are usually green or
turquoise. These are basically long-acting
reliever drugs. They act for around 12 hours
so are usually prescribed twice a day.
In asthma, it is very important that patients
continue to use their steroid inhalers even if
they have also been prescribed a protector.
If they stop using their preventer and just
rely on the protector inhaler, it can make
their asthma very unstable and lead to a lifethreatening asthma attack.
Combination inhalers
Combination inhalers contain a protector
and a preventer. Combination inhalers
should be taken regularly: once or twice
daily. They are usually purple, red or white.
How do the treatments for
COPD differ from asthma?
Just like with asthma, everyone with COPD
needs a short-acting reliever inhaler. However,
the relievers are often prescribed on a regular
basis rather than ‘when required’.
Instead of adding a preventer next,
prescribers tend to add a protector instead.
If the relievers and protectors aren’t enough,
then preventers are added. Preventers are
used last because they are less effective in
COPD (as there is less inflammation present
than with asthma).
Patients with COPD can have another type of
inhaler called an ‘anticholinergic’. Examples
include Atrovent (contains ipratropium) and
Spiriva (contains tiotropium).
The various different
models of inhaler
There are many different inhaler devices
used to deliver the drugs we’ve looked at.
Asthma UK has produced an animated
guide showing how to use these at www.
asthma.org.uk. The patient information
leaflet should also show the patient how to use their inhaler device.
If the patient self administers inhalers, check
that they are using them correctly. If you
see mist coming from the top of the inhaler
or their mouth, they won’t be getting much
benefit from it. You could always suggest
they see a health care professional who can
review their treatment.
38
exampleS
Spacer
Aerochamber
Spacer with face mask
Spacer devices
Taking care of spacer devices
A spacer is a plastic container that is
added to a standard inhaler. There are
many different designs, including smaller
ones such as the Aerochamber Plus or
larger spacers such as the Volumatic.
Aerochambers have a soft rubber end
so they can fit different types of inhaler,
whereas Volumatics can only fit inhalers with a square mouthpiece.
Spacer devices should be cleaned regularly
by washing them in soapy water. After you
have given the spacer a good clean, rinse
the soap off the outside of the spacer, but
leave the soap bubbles on the inside. When
the spacer is dry, the bubbles will have burst
leaving an invisible coating of soap on the
inside of the spacer. This reduces static build
up so less of the drug mist sticks to the sides
of the spacer and more of the drug reaches
the lungs. Don’t dry the spacer with a towel
or tissue, as the rubbing action adds static.
Volumatics need to be washed once a month
and Aerochambers every 1-2 weeks. If used
regularly, spacer devices should be replaced
every 6-12 months.
Aerochambers also have a whistle on them
to let you know if the patient is breathing
in too fast. It’s okay to hear a quiet whistle,
not a loud one. If the whistle is loud, ask the
patient to try again with a gentler in-breath.
It’s not a good idea to change the type of
spacer without checking with the prescriber.
Most spacer devices also have a version
with a soft silicon face mask. Patients who
are unable to form a good seal around the
mouthpiece (which can sometimes happen
after a stroke) might benefit from a face
mask. Patients who keep breathing through
their nose might also benefit from a mask.
With spacers, there are two techniques:
1 Taking in one long breath from the spacer
device and holding it for 10 seconds or
2 Taking 5 breaths in and out from the
spacer device (called tidal breathing)
Both techniques are effective but patients
often prefer the second technique as some
find it difficult holding their breath.
39
GUIDANCE
Administering an inhaler with a spacer deviCE
1 Remove the lid. Check there are no foreign objects inside the mouthpiece
2 T
est the inhaler. If it hasn’t been used for 7 days shake it and then spray two puffs
into the air; this ensures the patient gets a full dose of the drug
3 Insert the inhaler into the spacer. If you are using an Aerochamber, you might need
to twist the rubber end around (where the inhaler fits into the spacer) so that the
inhaler is pointing upwards at 12 o’clock
4 Shake the inhaler whilst it is in the spacer, 4 or 5 times
5 T
he patient should be sat up straight or standing. Where possible, their chin should
be lifted up to open the airways. This is the ideal position, but might not be possible with some patients with a physical disability
6 E
stablish which technique the patient prefers: taking in one breath and holding it for
10 seconds or taking 5 breaths in and out. It’s a good idea to record which technique
they prefer on the medicines chart
7 P
ut the spacer in their mouth and check their lips form a tight seal. Check that they
are breathing through the spacer device correctly before you fire a puff in (if you
are using an Aerochamber, you shouldn’t hear a loud whistle). Make sure they are
breathing through their mouth rather than their nose
40
8 If the patient cannot form a good seal with their lips around the spacer, they may need
to use a spacer with a mask attached instead. Make sure that the spacer is level (horizontal) otherwise they might not receive a full dose
9 H
olding breath technique:
get the patient to blow out into the
spacer device which empties their
lungs. Tell them to take a slow, deep
breath in. As they breathe in, fire a puff
into the spacer. Encourage them to
carry on breathing in. Keep the spacer
in their mouth as they breathe in. Once
they have breathed in fully, take the
spacer out and ask them to hold their
breath for as long as is comfortable (10 seconds if possible)
9 Breaths in and out technique:
as the patient is breathing in and out,
fire in one puff. Keep the spacer in
their mouth for 5 breaths in and out.
You can always help the patient by
breathing in and out 5 times with
them. This can help some patients
with dementia or learning disabilities
understand what to do. When you do
this, the patient often copies your own
breathing pattern. This also means that
you can count your own breaths rather
than trying to see if the patient is breathing in and out 5 times
10 If a second puff is needed, wait 30 seconds then repeat the whole procedure. Don’t
put more than one puff into the spacer at a time, as the droplets can end up joining
together to form larger droplets which cannot get deep into the lungs, and so reduces
the amount of drug you are helping to administer
11 R
eplace the mouthpiece and record on the medicines chart. If using a preventer,
ensure the patient rinses their mouth out with water (rinse, gargle and spit) or
cleans their teeth afterwards
41
Chapter 11
Administering
medication to the
eye, ear & nose
Medicines can be applied to the eye, ear
and nose in the form of drops, creams, gels,
ointments and sprays. According to the care
regulators, care professionals can administer
these types of medicines after their ‘basic
medicines training’ (i.e. you don’t need to
have a registered health professional provide
personalised training). However having said
this, some employers have stricter policies
than this. Check your medication policy to
see if your employer lets you administer
medications to the eye, ear or nose.
If patients have had a recent eye operation
(such as having cataracts removed) some
employers will not allow care workers to
administer eye drops, insisting instead that
nurses do this. This is because there is a
higher risk of getting eye infections after
surgery and nurses are trained to pick up the signs and symptoms of eye infections.
Eye drops
There are many different ways of
administering eye drops, the most important
thing is to get a drop into the patient’s eye in
a way that doesn’t cause them discomfort.
Some patients will sit patiently and let
you administer eye drops and are usually
patients who have had them before. They
may have had conditions like glaucoma or
dry eyes. There will also be those patients
who have not had eye drops before and may
find it harder to keep their eyes open as you
put drops in.
42
Many people stand above the patient and
let the drop fall onto the eyeball. If this
technique works for you and the patient,
carry on. However this can be uncomfortable
for patients. It also makes them more likely
to blink, as they see the drop hanging above
their eye. Older patients and those in highbacked wheelchairs may also find it difficult
tipping their head back.
An alternative used by many opticians, is to
place the drop onto the lower eyelid whilst
the patient looks away. By touching the drop
against the lower lid, it gets ‘sucked’ into
the eye. You only need to touch the drop on
the lower lid, not the bottle tip. Some people
worry that bacteria will be transferred onto
the tip of the bottle it touches the lower lid.
However, the drops are only used for 28
days; they contain preservative and are not
swapped between patients so this shouldn’t
be a problem.
GUIDANCE
Lower eyelid application
Administering eye ointments
With eye ointments you can use the same
technique. You need to squeeze about 1cm
of ointment inside the lower eyelid. The
ointments can make the vision blurred as
they can be quite greasy.
Administering eye drops to
patients who find it hard to
keep their eyes open
Despite your best efforts, some patients
might find it hard to keep their eyes open
as you administer drops. There is another
technique you can use.
Have the patient lie on their back and close
their eyes. Gently place a few drops (3 or
4) into the eye socket near the side of the
nose. Make sure the drops run along the
eyelashes. Next, ask the patient to open
their eye(s), you might need to help them do
this. The drops will then enter their eye(s).
Wipe away any excess drops with a clean
tissue. Remember, the eye will only retain
what it needs (about one drop). The patient
will need to then close their eyes for about
30 seconds for the drop to absorb.
exampleS
Eye drops
Eye ointments
If a second type of eye drop
or ointment is needed
afterwards
Some patients have more than one type of
medication administered to the same eye.
Wait 3 or 4 minutes for the first drop to absorb
before administering another eye drop. If you
have to administer an eye ointment and a
drop to the same eye, it’s best to administer
the drop first, wait 3 or 4 minutes, then
administer the ointment afterwards. If you
try administering an eye drop after an eye
ointment, the drop will find it hard to absorb
through the greasy ointment. Some eye preparations can sting
(e.g.pilocarpine). If these are needed with
other drops, then administer the pilocarpine
afterwards, because the patient will find it
hard to keep their eyes open if they sting.
If an ointment is then needed, wait for the
stinging to stop before administering the
ointment last of all.
43
GUIDANCE
The technique of administering eye drops
Get ready: Check the drops haven’t passed their expiry date.
When breaking the seal on new drops, write the expiry date on the bottle (28 days)
Prepare the patient: The patient can be sat upright in a chair.
They do not necessarily need to tip their head back with this technique
Prepare the right dose of medication: Wash your hands, shake the bottle, unscrew the lid and put it somewhere clean. Gloves are not always needed when
administering drops
Administer the medication:
Push out a drop and leave it hanging from the tip of the dropper bottle. With your free
hand, pull the lower lid down gently away from the eyeball to make a pocket in which
you can place the drop.
Tell the patient to look towards the bridge of their nose and then upwards. Looking
up takes the upper eyelid and lashes out of the way and gives you more room to
put the drop in.
Gently touch the drop onto the lower lid to release it. Don’t worry if you accidently put
more than one drop in the eye – the eye can only hold onto one drop, so any others
will flow away harmlessly down the cheek
Give the patient a clean tissue to wipe away any excess. Once you’ve put in the
drops, tell the patient to close their eyes for about 30 seconds. This spreads the drops
over the eyeball. Check for any redness, pain, itching or swelling in the eye – a little
stinging and itching is okay as long as it’s not too uncomfortable
administering nasal drops
Get ready: Check the drops haven’t passed their expiry date.
When breaking the seal on new drops, write the expiry date on the bottle (28 days)
Prepare the patient: The patient can either lie, or sit down with their head tilted
backwards. If the patient lies down, put a pillow under their shoulders. This way their
head tilts back a little, over the edge of the pillow
44
Prepare the right dose of medication: Wash your hands, shake the bottle
and unscrew the lid
Administer the medication:
Hold the dropper just above the patient’s nostril and gently squeeze a drop down
the centre of the nostril (you can make the nostril a little wider by pressing your
thumb against the tip of the nose, which opens them up)
Ask the patient to inhale slowly and deeply through the nose, hold their breath for
several seconds, then breathe out slowly. All the while they should stay with their head
back, or lying down for one minute. This lets the drops soak in.
If you’ve used a dropper, squirt out any medication left in the dropper into a clean
tissue before putting the dropper back in the bottle.
Administering ear drops
Get ready: Check the drops haven’t passed their expiry date.
When breaking the seal on new drops, write the expiry date on the bottle (28 days)
Prepare the patient: Help the patient lie down on the bed, with the ear being
treated uppermost. Alternatively, they can sit with their head tilted so that the treated
ear is upright
Prepare the right dose of medication: Wash your hands, shake the bottle
and unscrew the lid
Administer the medication:
Pull the ear upward (away from the neck) and backwards a little (away from the
face). This straightens the ear canal so that the drops flow right down into the ear
where they need to work.
Gently squeeze the correct number of drops down the side of the ear canal, not straight
down the centre as they’ll hit the ear drum (which is loud and sometimes painful). Try
not to let the dropper touch any part of the ear or ear canal. Ask the patient to stay lying or sitting, with their head tilted for about 5 minutes after
you have instilled the medication (this allows the drops to soak in).
Wipe away any drops that have dribbled down the neck with a clean tissue.
If both ears need drops, wait for about 5 minutes for the first drop to absorb and then
get the patient to turn over and repeat the procedure.
45
Chapter 12
Important medicines
often taken by the
elderly & how to
administer
Alendronic acid: used in
treatment of osteoporosis
Calcium supplements
+ This drug is usually taken only once a
& keep bones strong. It is often taken in
conjunction with Alendronic acid.
+ If on Alendronic acid do not take calcium
on the same day as taking this.
+ Take calcium carbonate supplements with
meals to assure high stomach acid for
maximum absorption.
+ Taking calcium supplements in divided
doses throughout the day is important if the
total daily dose of calcium is 500g or more.
+ Avoid carbonated soft drinks and antacids
containing aluminium as they can interfere
with the absorption of calcium.
week on the same day.
+ Taken about 30 minutes before
breakfast (8am)
+ Swallow whole do not chew
+ Take with a full glass of water
+ Stand or sit upright for at least 30 minutes
after swallowing the tablet and do not lie
down until after you have eaten breakfast.
+ If a weekly dose is missed take the next
morning and continue as normal.
46
+ Calcium is an important element to build
References
The Royal Pharmaceutical Society of Great Britain
‘The Handling of Medicines in Social Care’ 2007
Care Quality Commission Outcome: Management
of Medicines
Commission for Social Care Inspection
‘Professional Advice: The Administration of
Medicines in Care Homes’
Commission for Social Care Inspection
‘Professional Advice: Safe Management of CD’s in
Care Homes’ Jan 2008
Peterborough Primary Care Trust oral
administration guidelines for good practice and
NOMAD system operating
Patient.co.uk: How to use eye drops
Asthma.org.uk: Using your inhaler
British National Formulary
MIMS
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