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Medication Transcription, Verifying Medication Orders

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Title: Medication Transcription, Verifying Medication Orders


1
Medication Transcription, Verifying Medication
Orders Administration
  • By
  • Evelyn W. Stone RN.,BSN.,M.Ed.
  • www.qprofessionalmentalhealthservice.com

2
Types of Drug Orders
  • Written
  • Verbal
  • PRN
  • Discontinued
  • STAT

3
Written Order
  • Prescriber may write order on order form.
  • Prescriber may call order in to pharmacy.
  • Carefully check medication label to be sure it
    agrees with the order you have received.
  • FAXED orders are legal and acceptable.

4
Verbal Order
  • May be received in person or on the phone (only
    by nurses or pharmacists).
  • The person receiving it must prepare a written
    copy of the order for the prescribers signature.

5
PRN Order
  • Medication/treatment may be used as needed
  • Include what the medication is.
  • Include what the treatment is.
  • The problem being treated.
  • Frequency of administration.

6
Discontinue Order
  • Medication/treatment is to be stopped
  • Discontinued medications should be immediately
    removed
  • D/Cd meds can be -
  • returned to the pharmacy
  • flushed down a drain
  • Document name of med, amount, method and date of
    disposal on med disposal form

7
STAT Orders
  • Do it now
  • Get the med and give to client
  • Document in designated section on the MAR
  • Report to oncoming nurse of the STAT order and
    that it was carried out

8
STAT (Continued)
  • Use highlighter and yellow out the section of the
    MAR where you initialed or signed that the stat
    med was given.
  • Document in the progress notes that the
    medication was given.

9
Physician Orders
  • All orders, whether written or verbal, must
    include
  • Client name
  • Medication to be given
  • Strength of medication
  • Dose to be given
  • Frequency to be given
  • Route
  • Length of time to be given

10
Medical Alerts/Allergies
  • Physician must be made aware of
  • Allergies
  • Conditions
  • All other meds client is taking
  • which might contraindicate a specific
  • medication.
  • Be prepared to give complete, correct
    information about a clients diagnoses,
    allergies, and all current meds to physician.

11
Factors that Influence Medication Dosage
  • Age
  • Weight
  • Time
  • Rate Excreted
  • Route
  • Drug Combinations/Interactions
  • Condition of the client

12
Age
  • Pediatric and the Elderly excrete meds at
    different rates

13
Weight
  • Some medication dosages are calculated by the
    physician based on body weight.

14
Time
  • The time is specified if it is to be given once a
    day.
  • If unsure of the time in which the med is to be
    given, call the pharmacist.
  • Call the Administrator, Director or Qualified
    Professional

15
Route
  • How medications are taken and absorbed by the
    body may affect the dosage.

16
Drug Combinations/Interactions
  • Two drugs given together may react differently
    than the same drugs given separately.

17
Condition of the Client
  • Behavior
  • Seizures
  • Diabetes
  • Vital Signs (history of high BP, fast irregular
    heart rate)
  • Acceptance of food, fluids
  • Mobility
  • Others

18
Basic Rules for Administering Medications
  • Be sure medications are being taken as
    prescribed. Be alert to changes in clients
    behavior, and physical well-being. Report changes
    to the Administrator Nurse.
  • Correct transcription of orders
  • Knowledge of drugs being given
  • Special administration instructions
  • Knowledge of clients physical condition
  • Knowledge of clients emotional status
  • Climate conducive to concentration
  • Communication of information to others
  • Resources for medication information

19
Correct Transcription of Orders
  • Read every word on the script.
  • Fax the script to the pharmacy.
  • When the medication is received from the
    pharmacy, check to make sure that it is the
    correct medication.
  • Write each word on the MAR that is on the
    medication label.
  • Recheck your transcription word for word to make
    sure that it was transcribed correctly.

20
Knowledge of Drugs Being Given
  • Name of Medication and dosage
  • Why it was ordered
  • What benefit should be expected
  • Side-effects to be expected
  • Special monitoring needed
  • Vital signs
  • Stool records c. seizure records
  • Special administration instructions
  • 1. crushed or chewed
  • 2. given in food
  • 3. need to be given on empty stomach
  • 4. given with any liquid

21
Knowledge of Clients physical condition
  • Medical alert Seizures, Diabetes, HIV etc.
  • Physical limitations Spinabifeda, amputee etc.

22
Knowledge of clients emotional status
  • Disoriented
  • Hostile
  • Mute, withdrawn
  • Refusing medications
  • Assaultive behavior

23
Climate Conducive to Concentration
  • Temperature 68-82 degrees
  • Not too hot
  • Not too cold

24
Communication of Information to Others
  • Drug Information
  • Learn the information that comes with the drug.
  • Call the Pharmacist and request medication
    leaflets that are suitable for lay public.
  • Client information Special alerts to staff.
    Staff to give client education each time the meds
    are given to help the client recognize his meds
    and what they are for.

25
Resources for Medication Information
  • Pharmacist
  • Physician/Dentist
  • RN Consultant/RN Qualified Professional
  • Drug Information Sheet
  • Drug Handbook

26
Common Dosage Forms
  • Solids
  • Topical
  • Tablet
  • Capsule
  • Liquids
  • Gases

27
Solids
  • Suppository- small, solid, cone shaped, glycerin
    base, melt at body temperature, administered by
    rectum or vagina.
  • Refrigerate as directed
  • Topical- applied directly to skin, lotion
    (external use), paste (mixture of powders and
    ointments), ointment, cream (suspension of oil
    and water), powder (finely ground drugs), shampoo
    (medication in soap), patches (slowly release
    meds.), Aerosol sprays (suspended in gas, e.g.
    Desenex spray, Cruex spray).
  • Used for local effect

28
Solids (cont.)
  • Tablet- powdered drug compressed into small, hard
    disc
  • Capsule- powdered, liquid, or oil drug form
  • hard or soft
  • dissolves quickly in the mouth

29
Liquids
  • Solution- one or more drugs dissolved in water.
  • Suspension- preparation of a finely divided,
    undissolved drug in a liquid.
  • Syrup- aqueous solution of sugar.
  • Elixir- drug mixed in an alcohol solution,
    sweetened.

30
Gases
  • Inhalant- Medication carried into the respiratory
    tract through air, oxygen, or steam

31
Common Routes of Administering Medications
  • Medications are designed for one or two specific
  • routes of administration. Physicians order the
  • route of administration when ordering the
  • medication.
  • Oral
  • Insertion
  • Instillation
  • Topical
  • Inhalation
  • Parenteral

32
Oral
  • By mouth
  • Buccal between the cheek and gum
  • Sublingual under the tongue

33
Insertion
  • Putting in vaginally or rectally

34
Instillation
  • Putting a drug in liquid or ointment form into
    ears, eyes or nose

35
Topical
  • External application of meds to the skin, nails
    or hair

36
Inhalation
  • Inhaling a drug into the respiratory tract.

37
Parenteral
  • By injection
  • Injections are given by a licensed person.
  • A habilitation tech may be trained by a licensed
    person to give insulin injection.

38
Correct Preparation and Administration
  • General Medication administration procedures
  • Oral Medications
  • Liquid Medications
  • Inserting Medications
  • Instilling Medications
  • Topical Medications
  • Inhalants
  • Nebulizers

39
General Med Administration Procedures
  • Wash hands
  • Verify the order on the MAR by checking it
    against the doctors order.
  • Do the Three Checks
  • a. when selecting from the storage
    area
  • b. before pouring the med
  • c. after pouring and prior to returning med to
    storage area

40
(continued)
  • Confirm the clients identity.
  • Give the med by the route as ordered.
  • Document on MAR IMMEDIATELY after they are
    given to each client before going to the next
    client.
  • Never sign off meds prior to giving it.
  • Complete this process for each client prior to
    going to the next client.

41
Administering Oral Meds
  • Pour the correct number of pills/capsules into
    the medication lid, then into the med cup.
  • Explain to client what meds you are giving and
    the purpose at clients level of understanding.
  • Give with water or other fluid.
  • Stay with client until all meds are swallowed.
  • Sublingual meds are placed under the tongue.

42
Liquid Medications
  • Liquid meds must be measured in a calibrated
    medication cup.
  • Place the med cup on a level surface at eye level
  • Hold the med container so that the medication
    flows from the side opposite the label so it
    doesnt run down the container and stain or
    obscure the label.
  • Check the med cup again to make sure you have
    poured the correct amount.
  • For small amounts less than 5cc, use a calibrated
    syringe to measure the medication.
  • Give the med with the appropriate liquid.
  • Always do the 3 checks before giving the med.

43
Eye Drops
  • Explain purpose and procedure
  • Have client assume back-lying position
  • Put on gloves
  • Instruct client to look up toward ceiling
  • Hold dropper 1 above eye, install drops into
    pocket of the outer 1/3 of the eye
  • Instruct client to close eye gently and wipe
    excess away
  • Remove and discard gloves
  • Gather and dispose of equipment
  • Wash hands

44
Eye Ointments
  • Follow steps for eye drops
  • Discard first bead of ointment
  • Squeeze small amount of ointment into the lower
    eyelid from the side near the nose to the outer
    eye

45
Ear Drops
  • Draw proper amount of med into dropper
  • Explain purpose of the med
  • Put on gloves
  • Straighten ear canal adult pull up back/child
    pull down back
  • Hold the tip of the ear dropper just over the ear
    canal.
  • Client should remain on side for 5-10 minutes
  • Remove gloves wash hands

46
Nose Drops
  • Explain purpose of med
  • Put on gloves
  • Have client lie on back with head slightly
    hyper-extended
  • Draw up med into dropper
  • Push up the tip of the clients nose slightly
  • Hold dropper just above the nostril and direct
    its tip toward the midline of the nose so the
    drops flow toward the back of the nasal cavity.
  • Instill the number of drops
  • Have client remain in lying position for 5
    minutes and breathe through the mouth
  • Remove the gloves
  • Wash your hands

47
Topical
  • Explain purpose of med
  • Put on gloves
  • Open container and place cap or lid upside down
    to prevent contamination
  • Use a tongue blade, gauze or cotton applicator to
    apply
  • Cover the end of the tongue blade, gauze or
    applicator with med
  • Apply medication to affected area
  • Remove the gloves
  • Wash your hands

48
Aerosol Sprays
  • Explain purpose of medication
  • Shake the container if indicated
  • Hold the container 6-12 inches from the affected
    area
  • Spray evenly

49
Inhalants
  • Explain the purpose of procedure
  • Shake the inhaler
  • Have client exhale completely then place the
    mouth piece in mouth, close lips around it.
  • Have client inhale slowly deeply
  • Repeat the procedure as necessary to give as
    prescribed
  • Client may gargle to remove medication from the
    mouth
  • Clean mouth piece
  • Return to storage place

50
Narcotics Schedule II Drugs
  • Controlled substances
  • Secured under DOUBLE LOCK system
  • Sign out each dose each time a dose is given on
    the medication sign out sheet that came with the
    medication from the pharmacy
  • Always confirm the correct count of all narcotics
    when oncoming and off going.

51
Safety Rules
  • Right Client
  • Right Drug
  • Right Dose
  • Right Time
  • Right route
  • Right Documentation

52
(Continued)
  • No medication should ever be given without a
    doctors order
  • Encourage client to take meds as prescribed
  • Keep an MAR on each client
  • For Each medication, your MAR should include drug
    name, the amount to be given how often the drug
    should be taken

53
(Continued)
  • Medication should always be administered within 1
    hour of the time it is prescribed
  • If a client refuse medication, try find out why
  • You can not force a client to take medication
  • Write R in the block of the date it supposed to
    be given circle it
  • Write on the back of the MAR in the designated
    area about the refusal

54
(Continued)
  • Document in the progress note the refusal and the
    reason
  • Inform the Administrator
  • Notify the physician
  • Notify the team

55
Conclusion
  1. Remember to do the three checks
  2. Remember If there are more than three pills
    recheck the order before administering
  3. Remember 6 checks
  4. Remember Client education must be done each time
    medication is given

56
Other Services
  • Medication Administration
  • Seizure Management
  • Behavior Management
  • Client Abuse
  • Incidents
  • Ten Traits of a Professional
  • Boundaries

57
Other Services
  • Mental Illness
  • Bloodborne Pathogens
  • Autism
  • Developmental Disabilities
  • Develop Procedure Policy Manual

58
To Contact Instructor
  • www.ewsastaffingnetwork.com
  • www.qprofessionalmentalhealtservice.com
  • 1008-F Big Oak Court
  • Knightdale, NC 27545
  • (919) 266-7050
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