1 – Legal Issues:
1.1. Legal Issues
Only physicians, dentists, and advanced registered nurse practitioners may “prescribe” medication. Physicians, dentists, and pharmacists are licensed to “dispense” medications.
Nurses are licensed to “administer” medications and may delegate the task to administer oral and topical medications to persons who have completed a course such as this. Only licensed nurses can take verbal or phone orders for medications or treatment from a prescribing physician.
Role of Non-Licensed Personnel in Medication Administration:
Where delegation is required the non-licensed personnel will perform medication administration as a delegated function under nursing supervision.
The following cannot be delegated:
- Conversion or calculation of medication dosage;
- Assessment of an individual’s need for or response to medication;
- Nursing judgment regarding the administration of PRN (medications are given as ordered) medications.
Non-licensed personnel will be permitted to follow a specific physician protocol for PRN medication and document the effectiveness or ineffectiveness of the medication.
Example: if the physician wrote an order for Tylenol 350 mg for fever >100.0 F and the non-licensed personnel administered Tylenol for a fever of 101.0 then documented a decrease in the temperature or no decrease in temperature. The non-licensed staff is simply collecting information and documenting, not using nursing or medical judgment about an action or intervention.
The non-licensed personnel shall not perform a task that involves an individual who is not in a stable condition.
- Assessment for the individual’s need for medication
- Calculation of the dosage of medication
- Conversion of the medication dosage
The non-licensed personnel should NEVER accept a delegation that he/she knows is beyond his/her skill set or knowledge. (example: take orders over the phone). Non-licensed personnel have the right and are encouraged to ask for assistance and/or additional training.
The non-licensed personnel has the responsibility to ALWAYS follow agency policy and procedure to report to the nurse if they have any reason to believe they have made a medication error. This should be reported as soon as possible.
The non-licensed personnel has the responsibility to ALWAYS report (according to agency policy) the following:
- Signs or symptoms that appear life-threatening
- Events that appear health-threatening
- Medication that produces no results or undesired results
This must be clearly identified in the provider agency’s policies
Registered Nurse and Licensed Practical Nurse:
What’s the Difference?
Both the Registered Nurse and the Licensed Practical Nurse
- Must complete education requirements from an accredited program;
- Must pass the National License Exam;
- Must have ongoing education to ensure competence and complete the required number of Continuing Education Credits each year;
The Registered Nurse:
- Must complete a higher degree of educational preparation;
- Has greater responsibilities;
- Works directly under the direction of physicians, dentists, or advance practice nurses;
- The License Practical Nurse;
- Must complete a lesser degree of education preparation;
- Has a lesser degree of responsibilities;
- Works both independently of and performs acts prescribed by the physician, dentists or advance nurse practice nurses AND a Registered Nurse.
The non-licensed personnel must be familiar with agency policies and procedures related to medication administration and know where to find them.
Please, review of your agency-specific policies and procedures related to:
- Storing Medications;
- Medication Keys;
- Disposal of Medications;
- Medication upon admission;
- Medication upon discharge;
- Client medication education;
- Medication Administration Records;
- Client refusal of medications;
- Medication errors;
- Client assessment/Screenings;
- Monitoring effects of medications/adverse drug events.
1.2. Difference between Monitoring, Administering and Client self-administration of medications.
Monitoring medication taken by the client:
1. Regulations do not require successful completion of a QMAP course if staff only “monitors” and does not “administer” medications to the client:
- Reminding a specific individual client to take medication at the time ordered;
- Delivering a container of medication lawfully labeled to a specific client, if needed;
- Observing a specific individual client to make sure s/he took medications;
- Making a written record of each medication, with the note “monitored”;
2. Administering medication to a client:
- Assisting a client in the ingestion, application, inhalation, or Insertion of a rectal or vaginal medication according to written directions of an authorized practitioner;
- Handing staff-prepared medications to a client;
- Making a written record of each medication administered, including both prescription and over the counter drugs.
3. Self-administration of medication by a client:
- “Self-administration” means the ability of a person to take medication independently without any assistance from another person. It is okay to make a general “reminder” to self-administering clients;
- The client is completely responsible for taking his/her own medications. Staff is not involved other than to ensure safety of other clients and encourage notification of updated information;
- There is no requirement for daily documentation of self-administered medication;
- There should be a note on the plan of care at least once yearly, updated as appropriate, documenting the facility’s knowledge of medications being self-administered;
- If a facility administers some medications and a client self-administers some medications the facility must have written physician approval for each self-administered medication.
1.3. The seven rights of medication administration.
- Right client;
- Right time – ½ hour before scheduled dose to ½ hour after; if a specific time is stated on the order;
- Right medication;
- Right dose;
- Right route;
- Right documentation;
- Right to refuse.
(Medications that are ordered to be given “am” or “pm” do not have a time requirement set by the prescribing authority; however, the facility may designate a timeframe in their policies and procedures or use “am” and “pm” for medications to be given).
1.4. The 4 “routes” of giving medications
a) Oral tablets, capsules or liquids;
b) Lozenges (in the mouth, not swallowed);
c) Sublingual tablets (under the tongue, not swallowed) Note: QMAPs are allowed to utilize the barrel of a syringe to administer oral medications.
a) Skin ointments, gels, lotions, liniments;
b) Skin sprays or aerosols;
c) Throat gargles;
d) Transdermal skin patches;
e) Eye ointment or drops;
f) Ear drops;
g) Nose drops or nasal sprays.
a) Rectal suppositories;
b) Vaginal suppositories or creams.
Glossary of terms.
- · Oral – taken by the mouth and swallowed;
- · Buccal – placed between cheek and gum;
- · Sublingual – placed under the tongue;
- · Eye – placed in the pocket of the eye created when the lower eyelid is gently pulled down;
- · Ear – placed in the ear canal created when the external ear is pulled up and back;
- · Nasal – placed in the nostril;
- · Inhalant – inhaled into the lungs;
- · Transdermal – placed and affixed to the skin;
- · Topical – applied to the skin or hair;
- · Vaginal – inserted into the vagina;
- · Rectal – inserted into the rectum;
- · Subcutaneous– injected into the fat with a syringe).
QMAPs do not allow administering medication through IV ports, G- Tubes, NG-Tubes or for injections into the blood stream or skin including insulin pens.
QMAPs do not allow injecting insulin, drawing up or dialing an insulin pen for injections.
Completion of this course does not qualify a student to perform finger sticks or blood glucose testing.
Additional documented training must be given by a licensed professional at the facility.
A qualified medication administration person shall not administer epinephrine injections unless the QMAP:
(A) Has been directed to do so by a 911 emergency call operator as an urgent first-aid measure,
(B) Has completed an anaphylaxis training program conducted by a nationally recognized organization and is authorized to use an epinephrine injector pursuant to section 25-47-103, C.R.S.
- ALWAYS measure using the metric system.
- ALWAYS use an oral measuring syringe for small amounts of liquid medication.
- ALWAYS place cup on a solid surface at eye level. If the label says to measure in mls, ALWAYS use a measuring device that is marked in mls.
- If the label says to measure in mgs, ALWAYS use a measuring device that is marked in mgs for that medication.
- ALWAYS consult your pharmacist when you have a question about measuring.
- NEVER use household spoons.
- NEVER switch the special droppers that come with some liquid medications.
- NEVER use cups that are not marked with the amount they hold.
- NEVER measure mls with a measuring device that is marked in mgs.
- NEVER measure mgs with measuring devices that are marked in mls.
- NEVER leave air bubbles mixed with the liquid in an oral measuring syringe.
1.5. Client/Resident’s rights to refuse medications
It is the client’s right to refuse medications. Individuals should understand the symptoms that medications are prescribed for, and also should be made aware of any common side effects. He/she should also be able to verbalize understanding that these medications are considered a part of treatment and that the Licensed Practitioner will be notified should he/she refuse the medication
1. When the client refuses medication:
- The client always has the right to refuse medications.
- Clients refuse to take medications for many reasons. Some of the reasons are;
- The effects and/or side effects are unpleasant or unwanted;
- The medication tastes bad;
- The client has difficulty swallowing;
- Religious, cultural, or ethnic beliefs;
- Depression or loss of will to live;
- Delusional belief that staff is intending to harm (“poison”) him/her.
2. B. Types of refusal
- Actual refusal is when a person directly refuses to take the medication;
- Passive refusal is less direct and requires closer observation.
The client takes the medication but later spits the medication out; he/she may or may not attempt to hide the medication.
3. C. Questions to ask to try to determine the reason for refusal:
- Does the client experience any unpleasant effect from the medication?
- Does the client have difficulty swallowing?
- Is the client afraid for some reason?
- Is the client refusing other medical treatment?
4. D. Examples of Strategies for dealing with client’s refusal:
- If the client refuses and gives no reason, wait a few minutes and then offer the medication again. If the client refuses again, try again in another few minutes before considering a final refusal. This is particularly important for clients who have a diagnosis of dementia.
NOTE For clients with cognitive impairment such as dementia, it is important to know when the client designee, such as a responsible party or guardian, wants to be notified if the client refuses medication. The client designee may be able to encourage the client to take the medication.
- Notify the prescribing practitioner or supervisor when a client refuses medication;
- Document refusal;
- Observe the client and report any effect which may result from refusal;
- If there is swallowing difficulty, report to your supervisor and/or client’s physician;
- Consider changing the time of administration if taking the drug interferes with an activity or with sleep. (Example: diuretics may limit a client’s ability to participate in an outing because of the need to go to the bathroom frequently.);
- If there is a suspicion of passive refusal such as “cheeking” medication, follow the recommendations for action on the client’s Individualized Care Plan;
- If the refusals continue, explore other options with the client’s physician.
NOTE: Passive refusal is not uncommon in clients with diagnoses of mental illness. It is important that the client or client designee, facility staff, nurse, pharmacist, and physician collaborate to develop and follow a plan to assist the client with adherence to his/her drug regimen.
1.6. Guidelines for communicating with the cognitively impaired client
How to communicate with impaired clients or/and elders? As a caregiver you may provide care to a client who has physical disabilities or impairments that may interfere with communication. The following are some techniques to use in those situations.
Blind or Visually Impaired
- Get the person attention before talking;
- Identify yourself when entering the room;
- Say their name;
- Use common sounds, such as ringing a bell, whistling, etc.;
- Explain what you are doing as you do it;
- Ask for feedback to check for understanding;
- Make sure eyeglasses have up-to-date prescriptions and are clean;
- Print in big, bold letters when necessary.
Deaf or Hearing Impaired
- Make sure you face the client who reads lips;
- Use visual actions to communicate;
- Get their attention before talking to them;
- Face them when you are talking. Maintain eye contact; avoid turning or looking away while you are talking;
- Talk at a normal pace;
- Raise your voice some and lower your tone. DON’T yell. Speak to the side where hearing is best;
- If necessary, use paper and pencil to write messages;
- Get rid of other noises – TV, radio, etc.;
- Make sure hearing aides are working and are properly inserted;
- Write down messages;
- Ask for feedback to determine understanding.
Speech Impaired, Aphasic (Aphasia-Trouble speaking or understanding, often result of a stroke)
- Ø Address the person by name;
- Ø Keep communication simple and clear. Speak slowly and use simple words;
- Ø Ask questions that can be answered with yes or no;
- Ø Make message clear, emphasizing key words, limiting details;
- Ø Eliminate unnecessary background noises (to help the client concentrate on what is being said);
- Ø Be patient. Give the client enough time to respond to you. At least 10 seconds is the recommendation. (Time yourself for 10 seconds so you can see how long it is. You’ll be surprised!);
- Ø Use visual devices like a message board, pictures, or gestures;
- Ø Be supportive and positive, avoiding criticism/corrections;
- Ø Pay attention to body language;
- Ø Ask the person to repeat if necessary, rather than pretending you understand.
Cognitive impairment refers to difficulty in processing information. There are numerous diseases that cause cognitive impairment, such as Alzheimer’s, Parkinson’s, Multi-Infarct Dementia, and AIDS. All of these diseases affect the brain in different ways to cause the impairment. Care recipients with any of these conditions will require unique caregiving in order to deal with some of the problems present. The symptoms presented will vary from person to person and will depend on the stage of the disease. Some of the common symptoms associated with dementia are as follows, with some examples:
- Gradual memory loss;
- Inability to perform routine tasks–dressing, cooking, cleaning;
- Disorientation in time and space – don’t know what day it is or where they are;
- Personality changes;
- Unable to learn new information;
- Judgment is impaired – doesn’t know if something is safe or is unable to make choices;
- Loss of language skills – can’t remember words, etc.
The following are some simple guidelines that should help you in dealing with care recipients who have cognitive impairments:
- Speak slowly;
- Keep conversations short and simple;
- Do NOT argue or reason with the care recipient;
- Write down instructions, keeping them simple and step-by-step;
- Do tasks one-step at a time?
- Provide objects that make things easier, such as slip-on shoes, finger foods, etc.
- Maintain a routine. Change of routine adds confusion;
- Use the memory loss to your advantage to distract the care recipient;
- Provide a safe living environment;
- Label drawers, cupboards, and doors;
- Encourage as much independence as possible;
- Approach the care recipient slowly from the front;
- Limit the choices the care recipient has to decide among;
- Play music since it is therapeutic. Make tapes.
Avoid the following behaviors that are emotional barriers to communication:
- Acting impatient, irritated, or annoyed;
- Ignoring, acting bored;
- Threatening, shouting, or using harsh language;
- Judging or giving advice;
- Changing the subject;
- Being defensive;
1.7. Abuse and neglect
- Physical abuse.
- Sexual abuse.
- Verbal abuse.
- Emotional abuse. (Threats, humiliation).
- Involuntary seclusion.
- Financial abuse.
How do you recognize signs of abuse and neglect?
Unfortunately, we occasionally read about or hear news reports of abuse and neglect Occurring in personal homes or facilities. Clients, client’s family members may abuse one another, staff.
May abuse clients or clients may abuse staff. By law, signs of abuse and neglect are to be reported. Therefore, you must become knowledgeable about this topic. Abuse can be physical or emotional. Some examples of abuse are:
- Pushing, hitting or shaking.
- Pulling hair or ear.
- Tying a client to a bed or chair.
- Locking a client in a room.
- A staff person engaging in any sexual contact with a resident.
- Giving too much medicine on purpose.
- Yelling at or threatening with words.
- Harassing a person.
- Using ethnic slurs.
- Sexual harassment.
- Attempted rape.
- Sexual assault.
- Threatening to make a person leave the home.
Another form of abuse is “financial abuse.” This involves taking property or money from a client or encouraging a client to hand over his/her assets. Clients have the right to protection of their money and property. Neglect is the failure to provide the necessary care that results in harm to the client.
Examples of neglect include:
- Leaving a group of aggressive clients unsupervised;
- A direct care staff person falling asleep while on duty;
- Delaying the normal scheduling of routine medical or dental visits for health maintenance;
- Isolating a client in their room;
- Leaving a client unattended by staff for long periods of time;
- Failing to seek medical help when a client shows symptoms of injury or illness, or if a client complains of pain;
- Delaying assistance with activities of daily living, such as failure to help a client with toileting and causing the client to soil himself/herself.
Neglect and abuse occurrence are reportable.
What should you do if you see abuse or neglect?
You should ask your supervisor what the facility’s procedures are to report suspected abuse or neglect. It is not your responsibility to investigate or confirm the suspected abuse or neglect—only to report what you see. When reporting to your supervisor, it is important to be “objective.” State only what you see or hear, not your interpretation of what you see or what you assume is happening, which is “subjective” information. In other words, just state the facts.
1.8. Quiz 1 (Check yourself).
1. Medication administration is when the care provider is responsible for giving the client’s Medicines.
True or False
2. Self-administered medication is when the client is responsible for taking His/her medicine.
True or False
3. Clients who self-administer medicines must: (Choose all that apply).
a) Keep the medicine in the original container;
b) Keep the medicine in a secure location;
c) Keep the medicine out of reach of other clients;
d) Keep the medicine in the bathroom.
4. It is not necessary to keep medication records on clients who are assisted with medications.
True or False
5. When you assist a client with his medication, you are responsible for being sure the medicine is taken correctly.
True or False
6. List the Seven Rights of providing medication assistance.
The Right: (1) _____, (2) _____, (3) _____, (4) _____, (5) _____, (6) _____, (7) _____ .
7. It is a law, that signs of abuse and neglect are to be reported.
True or False.
8. What are the different routes in administrating medications?
(1) __________, (2) __________, (3) __________, (4) ____________.
9. As a none licensed person, I can take orders over the phone?
True or False.
10. I can give medications that I didn’t set up?
True or False.
Answers module 1: 1.true 2.true 3. a, b, c 4. false 5.true 6. client, time, drug, dose, route, documentation. 7. true. 8. Ingestion, application, inhalation, insertion. 9. false 10. false.