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Administration of Medicines Ingrid Johnston Consultant Pharmacist LIQUIDS Prepare 1. Identify the desired measurement on the medicine cup. 2. If indicated, shake the medication. 3. Pour the liquid into the cup to the desired level. 4. With the medication cup on a flat surface, check the medication level by bringing your eye to the same level as the cup. 5. Pour any excess into a disposable cup. 6. Recheck the level SHAKE WELL BEFORE USE Meniscus Administer 1. Check medication chart and observe the “x” Rights of Medication Administration 2. Observe resident take the medication 3. Add a small amount of water to the cup and swish around – have resident drink this also 4. Offer a glass of water after the dose 5. Document medication administration 6. Clean and dry medicine cup Practice points • Order on drug chart must specify strength of liquid preparation eg Epilim® 200mg/5mL • Best practice for doses should be expressed in millilitres and milligrams Eg 12.5mLs = 500mg • Avoid dripping medication on label • Do not mix liquid medications together • Do not mix with other drinks or food Some extra tips… Effervescent tablets eg Chlorvescent® - dissolve in at least 125mLs water - ensure FULLY dissolved before administration Sachets eg Movicol® or Gastrolyte® ensure packet directions regarding volume for mixing are followed EYE MEDICATIONS Medications for the eyes • Types of medications for the eyes – Drops – Gels and ointments – Sprays • Used to treat conditions such as: – Dry eyes, redness, allergies, conjunctivitis, glaucoma Sterility of eye preparations • Eye medications are manufactured to be sterile • Preventing contamination – Do not touch any part of the eye with the tip of the dropper/ointment tube – Close cap tightly when finished using eye drops/ointments – Ensure proper storage of eye drops/ointments Storage • Each eye medication may require different storage – All medications should be kept away from humidity – Most require storage at room temperature – Some require storage in the refrigerator – Never store medications in the freezer • Most eye drops have a 30 day expiry • Some lubricant preparations now have a 6 month expiry • Single use products also available Administration • Easiest when resident is sitting or lying down • Check expiry date on bottle – Once eye drops are opened, they should be disposed of after 1 month unless otherwise indicated • Wash hands with soap and water • Remove lid • Hold or place it down carefully so it does not become contaminated • Hold bottle upside down in one hand between thumb and index finger • Using other hand, gently pull down lower eyelid to form a pouch Administration • Have resident tilt head back and look up • Put tip of bottle close to lower eyelid – Do not let it touch the eye • Release one drop into the pouch by gently squeezing the bottle, or squeeze in desired amount of ointment • Instruct resident to close eyes and keep closed (do not blink or rub eye) • While eye is still closed, have resident place index finger against inner corner of the eye and press against the nose for two minutes • This stops the medicine from draining through tear duct to nose/throat Administration • • • • Blot excess solution around the eye with a tissue Seal lid of medication tightly Wash hands again with soap and water After use, wait at least 5 minutes before putting any other eye drops in eye(s) Practice points • Only one drop should be used at a time • A second drop may – wash out the first or – increase the possibility of systemic absorption and toxicity, – it can also often end up on the skin of the eyelids and the patient is then more likely to develop a contact allergy – doubles the cost of the medication (there are 20 drops per ml) • Patients who develop an allergy to the preservative may need to use a formulation without a preservative • Many eye drops are also available in single-use disposable containers Practice points • If the resident is wearing contact lenses, they should be removed before putting the drops in the eye. • The resident should wait at least 15 minutes before replacing the contact lenses. • Be careful not to touch the dropper tip against the eye, eyelid or anything else to avoid contaminating the eye drops. • There are dose administration aids available for residents who self administer eye drops but are having difficulty – speak to the pharmacist Eye Drop Aids Eye sprays 1. Liposomes are sprayed onto the eyelid and gather in the corners 2. Liposomes mix with natural lipids 3. When the eyes open, the new lipid mixture covers the whole tear film More than one eye preparation? 1st: Clear medicated drops 2nd: Cloudy eye preparations (shaken) Eg. Azopt®, FML®, Flarex® 3rd: Lubricant eye drops 4th: Eye gels as they are designed to stay in the eye longer Last: Ointments last as they repel other drops and will stay in the eye the longest Questions 1. Why do you need to block the tear duct after instilling eye drops? 2. How long should you wait between instilling 2 drops 3. If a resident is prescribed Timolol eye drops and Refresh Plus eye drops what order should they be instilled? 4. What is the expiry date of eye drops? EAR PREPARATIONS Ear medications • Drops • Ointments Drops usually preferred as less likely to cause blockage of the ear canal and drops penetrate further into the ear canal Administration • Remove anything in the ear (hearing aids) • Clean and dry the external ear canal thoroughly, making sure no trace of soap or other cleanser remains. • Lie the patient down with the affected ear upwards. • Warming the bottle in your hand can reduce drop viscosity and increase comfort Administration • Instil the prescribed number of drops or small amount of ointment into the ear canal • Massage the cartilage flap over the opening of the ear canal to aid penetration into the ear canal. • Leave the patient in the prone position for few minutes to allow the preparation to ‘penetrate’. Storage of ear medications • Storage recommendations are specific for each product • All medications should be stored away from humidity • Most should be stored at room temperature • Some should be stored in the refrigerator – Kenacomb (Otocomb®) drops • Should never be stored in the freezer DOSE ADMINISTRATION AIDS Types of DAAs • • • • • • Compartmentalised plastic boxes Blister packs Sachets Automated devices Unit dose pack Multidose pack What can be packed? • Solid oral dose forms • Some medication may require separate packing – PRN medication – cytotoxics – – – – S8 medications antibiotics Short term medications warfarin Medication considerations • Occupational health & safety risks for staff • Space – Interaction – Checking – Physical damage • Stability – – – – Temperature (heat/refrigeration) Moisture Light Air Not suitable for packing Type of tablet Examples Effervescent/dispersible Chlorvescent Sublingual Anginine Chewable Vitamin C Hygroscopic Sodium valproate (Epilim) Light sensitive Tamoxifen Heat sensitive Containing Al hydroxide/Mg trisilicate Gaviscon, hiprex Wafers Risperidone Manufacturer specified Dabigatrin (Pradaxa®) Expiry dates • Manufacturer – Removal from original packaging reduces or invalidates expiry date indicated on the immediate packaging Expiry dates • The Pharmaceutical Society of Australia (PSA) recommends the quantity packed should not exceed the quantity that reasonably could be required during 8 weeks . • Paracetamol tablets have evidence of stability in a Webster‐pak stored for 12 months. Expiry dates • US FDA recommend – an expiry date of 6 months from the date packed into a single unit dose container OR – 25% of the remaining time of manufacturer's original expiry date. DAA labelling Monitor the resident for outcomes and adverse reactions to the medication. Documentation • • • • Recording of administration Dropped or misplaced medication Refused medications Appropriate disposal PEG ADMINISTRATION OF MEDICATION Enteral Feeding Tubes May affect the bioavailability of the medicine – Change in site of delivery – Nutrient interactions Issues to Consider 1. 2. 3. 4. Is the medication still necessary? Change to liquid forms of the medicine Change to alternative routes of administration Medicine must not be added directly to the enteral feed a) May change physical characteristic of feed (clumping or thickening) b) Feed may have an effect on the medicine c) Risk of microbial contamination of sterile pre-packed feed d) Changes in feed rates can increase risk of over or under dosing Special Considerations • Medicines to be given on an empty stomach • Give single daily dose during period where the feed is stopped and the GIT is resting • If enteral tube is in stomach – Stop enteral feed for at least 2-hours before admin – Wait at least 30 minutes after dosing before restarting feed. • If enteral feed is in duodenum or jejunum – Stop feed for 30-60 min before admin – Wait for 30 min after dosing before restarting Special Considerations • If unable to stop the feed a dose adjustment may be needed – consult pharmacist / drug info service • If feed interruption is required – consult with a dietician • Consult individual medicine monographs Special Considerations Buccal or sublingual tablets should not be given via enteral feed – designed to be absorbed in mouth Effervescent tabs dispersed in at least 50 ml of water in a cup – to allow gases to escape Some antacids and sucralfate act locally in the stomach – not suitable for duodenal or jejunal tubes Some medicines may have increased bioavailability when given via jejunal tube References • Appropriate use of dose administration aids Rohan A Elliott, Australian Prescriber, vol.37 : no. 2 : April 2014 • Not Just Pills, Penny Kraemer • Guidelines and Standards for Pharmacists – Dose Administration Aids Service • Guiding Principles for Medication Management in RACFs – October 2012 Aust Gov Dept of Health and Ageing • Webster resources • eMims March 2015