Medicine Management Policy

Transcription

1 INDEX Structure of the Medicine Management Program Page 2 Risk Management Structure Page 3 Types of Medicines Page 4 Prescribing Page 5 Ordering Page 5 Dispensing Page 6 Telephone Orders Page 7 Safe Storage of Medicines Page 7 Restocking Page 8 Safe Administration Page 9 Administration of Controlled Drugs Page 10 Controlled Drug Register - example Page 11 Problems & Errors Page 12 Minimising Risk Page 13 Self Administration Page 14 Medication Changes Page 15 Standing Orders Page 16 Medication Review Page 16 Disposal of Medication Page 17 Administration of Insulin Page 18 Administration of Warfarin Page 20 Pain Management Page 22 Analgesic Agents Page 24 Use of Morphine Page 25 Appendix 1: Pain Assessment Tool Appendix 2: Posters Diabetes Awareness Appendix 3: Posters Safe Medication Risk Pyramids Issue Number: 02 Issue Date: Page 1 of 27

2 Safe Medicine Management POLICY: Residents / residents will receive medication in a safe and timely manner according to current standards and best practice guidelines. Medications are for best possible health outcomes for residents. Errors / problems with medications will be detected and managed with the focus upon prevention. Medicines must be reconciled [against prescription and counted according to guideline] at all stages of Medicine Management. REFERENCES: NZS 8134: 2004 Part 5.3 & NZS 8134: 2007 Safe Management of Medicines: A Guide for Managers of Old People's Homes and Residential Care Facilities; Douglas Medication Systems; NZNO Organisation Guidelines for Safe Administration Medicines; Medicines Act 1981, Medicines Regulations 1984, Misuse of Drugs Act 1975; Misuse of Drugs Regulations 1977, New Ethicals. Medicine Management Standard NZS 8134 STRUCTURE: MOH Benchmarking Stats Program DHB GP Support External Consultant Support Statistics & Data Team Leader Manager or RN Laboratory & Pharmacy Douglas Pharmaceuticals Team Current Health & Safety Representatives Keeping safe Staff Service Users / Residents & their families Visitors Issue Number: 02 Issue Date: Page 2 of 27

3 RISK MANAGEMENT STRUCTURE Ministry of Health Benchmarking Stats Program Compares with other providers Accesses Best Practice Guidelines District Health Boards Printouts How do we compare? Information for staff Information for residents Surveillance & Data Collection Medication Error / Problem Forms Quality Review Medicine Management by External Consultant /s Manager RN Team Leader H&S Reps Laboratory Reporting Notifiable Diseases Share Information Education Program Inductions ALL EMPLOYEES Manager / RN Training Staff Training Assessing educators Assessing understanding Learning sessions in response to surveys Learning sessions in response to incidents Doctors Share information Agree guidelines Business Risk Management Known Risks Assessed / Rated / Controlled / Minimised Issue Number: 02 Issue Date: Page 3 of 27

4 RIGHTS & RESPONSIBILITIES: The fundamental principal, according to the NZNO Guidelines for the Safe Administration of Medicines: Residents /clients should not be treated without their consent People have the Right to Refuse - Refusal needs to be discussed to find out the reason for it. - We need to consider if the refusal is likely to affect the person s wellness, or other medicines that are being taken. - Refusals need to be reported - Document well [use Medication Problem Form] NB: People are sensible to refuse medicines they no longer need NB: RN s need to be able to recognise when a refusal can result in a poorer medical condition. E.g. High blood sugar or blood pressure. Consent needs to fully inform Our resident or client needs to be able to understand TYPES OF MEDICINES: 1. Prescription Medicines Can only be supplied by a doctor, dentist, and registered midwife or endorsed Nurse Practitioner. 2. Pharmacist only or Restricted Medicines Medicine supplied by a pharmacist 3. Pharmacy only Medicines Medicine sold at a pharmacy or hospital or isolated shop with special license 4. General Sale Medicines Medicine supplied from any retail outlet 5. Controlled Drugs Stronger medications [that can have more serious side effects]. These are counted when they arrive and signed out as they are used, or returned. Issue Number: 02 Issue Date: Page 4 of 27

5 PRESCRIBING: Doctor / Other Prescriber Responsibility [SEE PRESCRIBING POSTER APPENDIX THIS POLICY] Prescriptions must: 1. Be dated 2. Be reviewed within the past month [past three months at doctor discretion] 3. [Doctor Responsibility] Meet Section 41 Medicines Act 1982 for prescribing i.e. Signed [with clear signatures] Be legibly and indelibly printed. No transcribing. Contain adequate instructions including the number of times the drug may be given / length of course and the date. Clearly indicate: name of the recipient, strength & dosage of the medicine and the route & time for administration. 4. The doctor signs medications as discontinued and crossed them out on the prescription. [Unused medications are returned to pharmacy]. 5. Allergies are clearly marked in red or by yellow highlighter so that anyone looking at the file is instantly alerted to this potential risk. NB: Residents [according to DHB contract] are to be seen by a GP at least monthly, including a medication review. This may be changed to 3 monthly at doctor discretion. The manager or RN may also determine a greater frequency of visit at any time. ORDERING: Shared Manager / Team Leader responsibility: 1. Medicines scripts are signed by the resident s doctor or specialist. 2. The prescription is faxed delivered to the pharmacy. A copy is kept in the Resident Medication Profile. 3. The pharmacy dispenses the prescribed medication, to that individual resident. Medicines are collected by the Service By Medicines are delivered to the Service. By... Issue Number: 02 Issue Date: Page 5 of 27

6 DISPENSING: Pharmacy responsibility Medications are blister packed. Blister packs show: Header Labels show Resident name & prescription & any special requirements [e.g. Take with food or storage requirements] Administration time. Backing sheets describe the tablets & capsules they contain. Liquid Medications are labeled to show Resident name & prescription & any special requirements. Tubes of Medicine are labeled similarly. 4. All medicines are checked into the facility. The RN / Team Leader, or their delegate, confirms the medicines against the Residents Medication Order Sheet as they are unpacked. Form, amount, strength, dosage, time & route of administration are compared. Any discrepancies must be clarified with the prescribing doctor and pharmacy. After Hours Service We hold emergency stock Contact the pharmacist on this out-of-hours number: A starter supply may be supplied by the attending doctor Deciding who can Administer Medication Nurses Organisation Guide: a) We need to recognise that situations vary widely [high care levels to minimal assistance needed] b) It is vital that there is assessment of response to the medicine [is it working, is it working well enough? Are their any problems? Have an understanding of when medicines should not be given. c) The person who leads the administration needs to fully understand their own accountability. Issue Number: 02 Issue Date: Page 6 of 27

7 Registered Nurses Regulated by Nursing Council [current practicing certificate] Enrolled Nurses Regulated by the Nursing Council [current practicing certificate] Care Givers Unregulated: Must not give medicines in acute care setting [like A&E] Must not give medicines to very ill residents [e.g. assessed as Hospital Care]. It may help to take medicine from a monitored dosage system [such as Douglas Pharmaceuticals' Medico Packs]. 5. Policy on Telephone Instructions: Telephone orders initiated by the Doctor must be written up within 72 hours. Telephone orders are not supported by the policy of the Home. [Repeat prescriptions may be initiated by telephone where part of the prescription is still held by the pharmacy. It is the pharmacy s responsibility to label the medications clearly showing when prescriptions need to be renewed]. SAFE STORAGE OF MEDICATIONS [Key Carrier / Management Responsibility] 1. Storage area is restricted to approved staff. 2. Medicines are stored in a designated locked room or locked cupboard, which is free from heat, moisture and light. A list of key carriers signatures & initials [staff who are endorsed as competent to give out medications] is kept inside the Medication Cupboards. The most senior person on duty responsible for medication administration usually holds the keys. 3. Medicines are stored in their original Blister Packs. 4. Medicine bottles & containers / packs must keep their original labels. 5. Medicines stay in their original containers until immediately prior to administration. No medicine is transferred into another container. 6. Some medicines [especially liquid medicines] require refrigeration. Please select best option below We have a dedicated medication fridge. An air tight container in the fridge separates medication from food to avoid contamination. Issue Number: 02 Issue Date: Page 7 of 27

8 Temperatures are recorded daily. Acceptable temperature range = Temperatures outside this range are reported to the Manager, RN or Team Leader immediately. An Incident Form is filled in so that Management can track this safety aspect of medication administration. Incorrect temperatures may represent a risk. EXPIRED AND DISCONTINUED MEDICATIONS 1. Expiry date has been reached 2. Course of medication has been discontinued 3. Medication from a deceased resident 4. Any unlabelled medication 5. Medication that is no longer required Flag blister packs with a marker pen [ X across the backing sheet] and lock up awaiting return to pharmacy. These are stored separate from in-use medications to AVOID RE-USE. Safe Storage of Controlled Drugs Manager Responsibility Controlled Drugs are kept in a locked container attached firmly to the inside of the locked cupboard, accessible only to senior staff. Copies of original prescriptions are kept by the Home Administration is recorded in a Controlled Drug Register [a dedicated book], in ink, which logs the amount of medication on hand. Nominated staff members must sign all entries in the Register, with their name AND designation e.g. Care giver or Manager or Team Leader. It is not acceptable: To amend previous entries on behalf of another person or To use twink. Restocking When the last dose from each of the blister packs has been administered [e.g. a Sunday night], empty packs are removed from the medicine cupboard and replaced by an entire batch of new packs. All redundant packs are returned to pharmacy. Empty packs may be disposed of, so long as resident identification / information is removed. Otherwise return empties to pharmacy for disposal. Issue Number: 02 Issue Date: Page 8 of 27

9 ADMINISTRATION FROM BLISTER PACKS / PILL SACHETS: Staff Responsibility NB: Medicines must only be given to the person they were prescribed for. 1. Wash your hands well may wear Medication Round ID Apron [avoid interruption]. 2. RIGHT PERSON RIGHT TIME / RIGHT MEDICATION Resident COMPARE WITH Resident Photo Medication Order Sheet [full name] Blister Pack / PILL sachet [full name] 3. RIGHT AMOUNT. Count that the number in the Blister Pack matches the number prescribed. [Look on the back of the blister pack]. 4. The blister / pill sachet is taken to the resident. Explain to the resident that you have their medication. Medication is removed as described by the Medication System [e.g. the backing sheet is punctured]. Give the medicines to the resident directly from their blister pack / pill sachet. 5. Make sure the resident has fluids to take with the medicine, and fill special instructions [e.g. take with milk or take before a meal]. 6. Observe the resident taking their medication. Be careful! A commonly made medication error occurs where a tablet is left behind in a bubble pack. Some residents cannot hold tablets in their hands. Use of a teaspoon is a widely accepted practicable solution, but tablets must be administered directly. It is NOT acceptable to transfer medicines from blisters into other containers to be taken later! Medicine must not be left for the resident to take later. 7. Sign the Medication Administration Record. This shows: - Time of administration - Initial of person making entry [NB: Initials match names on Key Carrier List]. Sign for PRN [as required medication] including lotions & liquid meds. Note any doses withheld, refused or extra doses given. Issue Number: 02 Issue Date: Page 9 of 27

10 Special provisions for the ADMINISTRATION OF CONTROLLED DRUGS: Controlled Drugs are entered into the Controlled Drug Register as they are received from the Pharmacy, signed in by senior key holder and pharmacist. Controlled Drugs are stored in a dedicated locked cabinet or safe i.e. double locked with the second locked container secured within the first. Similarly, controlled drugs that are returned are signed out as returned to the Pharmacy. It is NOT acceptable to sign them out as destroyed. Administration of Controlled Drugs is recorded in the Controlled Drug Register as well as on the Administration Signing Record. Doctors Medications Order Forms are checked against the name on the label AND observed to be taken by the resident by TWO staff members, one of the staff being the most senior key carrier on duty. If an RN is on duty, then this senior is the RN rather than a Care Giver who is unregulated [see page 7]. A physical count of the medicine is recorded, with the entry signed and dated. This is countersigned by another staff member. Each person receiving a Controlled Drug has their own dedicated page in the Register. A Weekly Stock take of Controlled Drugs is conducted by a Senior Manager, rather than the RN, and another person. Only stock on hand needs to be counted An audit of Controlled Drugs is carried out by the Pharmacist & senior staff at least six monthly. This is NOT necessary where the number of Controlled Drugs in use = zero. Keys to the medicines and Controlled Drugs rooms or cupboards are held by one senior staff member responsible for drug administration on each duty. Errors writing up medication counts in the Controlled Drug register should be crossed out and re written. Also write error & sign. These do NOT comprise a medication error in our stats. Issue Number: 02 Issue Date: Page 10 of 27

11 Name of Resident: Janette Little. Medicine Management Policy Example Register of Controlled Drugs Name and form of drug: M-Eslon 10 mg Prescribing doctor: Dr Warrick Tolks MD [GP Number] Date Time Name of resident / service user, or received from information or stocktaking In Out Amount of medication stored. Name & designation of staff giving the medication Signature of checking staff Date Time From Pharmacy Mary Hard Worker RN Pharmacist Sig Date 0800 am M-Eslon 1 9 Mary Hard Worker RN Selwyn Slacker C/G Date 8 pm M-Eslon 1 8 Jane Lee RN Pauline White C/G NB: One kind and one strength of medication or only one person s medication recorded per page. Issue Number: 02 Issue Date: Page 11 of 27

12 MEDICATION PROBLEMS OR ERRORS Drug incorrect resident given & takes the wrong kind of medication Dosage Incorrect given the wrong amount [too much or too little] Medication given to wrong resident [takes someone else s meds] Missed medication [forgotten or not returned from leave] Administration error [e.g. tablet dropped on floor]. Resident refused / unable to take medication Adverse reaction to medication diarrhea, ringing in ears, nausea, vomiting, skin rash, allergic reaction where tong may swell / feel strange. Dispensing error (pharmacy) wrong pills or wrong amount packed. Medication not signed for may have been given but not signed for. Medication Problem Guideline: for errors that are more than trivial. 1. STOP 2. Do not give any more meds. 3. CALL FOR SUPPORT! If the team leader is there, tell them straight away. It is the Team Leader responsibility to SUPPORT YOU! 4. If the team leader is not there contact the person on call, or if they cannot be reached, the doctor. They will instruct you from there. 5. Record error on the Medication Problem Form. These are INVESTIGATED AND CAREFULLY EXAMINED at Service Review Meetings. 6. Recognise errors that require urgent attention: - TOO MUCH INSULIN - TOO MUCH MORPHINE - NOT ENOUGH PAIN KILLERS [MISSED] - REACTIONS WHERE THE RESIDENT IS NOT THEMSELVES [You are concerned] o Confused o Unable to talk properly any more or looks unwell CALL FOR HELP RN / TEAM LEADER OR GP Accident / Incident Investigation Reporting a near hit / near miss may PREVENT a future error. Investigation must focus on finding out WHY this happened then present ways to PREVENT it from happening again. Best prevention looks at Robust Systems. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 12 of 26

13 Minimising Risk of Medication Incident: Help Line: Care staff need to have a senior person they can turn to if unsure, or if something goes wrong. Registered Nurse / On Call phone number available in the Office. YES NO Staff Training: - In-house training has a theoretical and practical component - Each is followed by an assessment of knowledge. - Work Based First Aid Training includes action to take in emergency situations and recognising resident distress. - Douglas Pharmaceuticals provide training with their Medico Pack System. - Medication Resource Folder available for self training. - Actions and side effects of medicines taken by residents / service users. - Up-to-date online resource at (online) - Medication reactions / adverse events should be reported to the NZ Pharmacovigilance Centre [ Management Support Following Incident - Supported & monitored - Retrained - Competency reassessed - Given other duties instead if insufficiently confident [or competent]. Staff supporting Management: - By not interrupting those giving out meds [flagged by Meds Round Apron] - By attending training. - By being very familiar with the correct way to administer medications. - Following established steps in medication administration recognising that shortcuts invite risk. - By seeking help when unsure about anything. - Through assessments of knowledge. - Telling Management / H&S Reps about good ideas for improvement. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 13 of 26

14 Lotions & Creams Lotions & creams are usually prescribed. Some residents prefer topical applications of medicines like cortico steroids such as Voltarin Emugel rather than the medicine in tablet form. These should be noted in Care Planning. No lotions, or creams are shared. Follow administration according to instruction on the tube or bottle & sign appropriately. SELF ADMINISTRATION Risk of error must be weighed against the positive aspect of encouraging resident independence. Residents are assessed on admission, by all appropriate stake holders about self administration. The final decision must rest with the service for reasons of Health & Safety responsibility. For the risk to be adequately managed the resident s level of knowledge must be assessed and further education provided as necessary. Medications must be kept safe [locked & secure] at all times accessed only by resident and staff. It is the resident s responsibility to inform staff when medications have been taken, refused or mislaid. Failure to tell staff must inspire reassessment [by the doctor] Staff must check at least every week to ensure no problems have arisen. Doctor responsibility includes assessing our resident s ability to take the medicine. This review is needed at least every 3 months. The doctor signs and dates each review on the resident s prescription chart. RESPITE RESIDENTS treated as though long stay. Respite residents need their medication blister packed. This should be done prior to arrival, and is a condition of entry. If a new respite resident arrives with medication in bottles [and packets] it is the responsibility of the senior person on duty to have this medication taken to the pharmacy and blister packed. This is because of the increased likelihood of error where medication is not blister packed. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 14 of 26

15 MEDICATION CHANGES Changes to medication made by visiting doctors are made on the Medication Order Form. The form is faxed to the Pharmacy who then sends an amended Blister Pack / Pill sachet. When the new pack arrives it must be EXCHANGED for the old pack. Remove & quarantine the old pack. [Place in safe returns box] Exchange must be done between doses. BEWARE OF ERROR WHERE OLD PACK IS NOT REMOVED double dose error BEWARE OF ERROR WHERE OLD PACK IS NOT REPLACED missed medication Doctors should direct medication changes directly to pharmacy from their surgeries. Changes received from the doctor need to be immediately redirected to the Pharmacy. Changed Packs should contain a Cautionary Change Label to provide care staff with full details of the change. This is signed [authorized] by the doctor at their next visit. BEWARE THIS IS A COMMON PLACE FOR MIX UPS AND ERRORS TO OCCUR They can be avoided by: - Ensuring the resident has good knowledge and will check their pills themselves if appropriate - Verbally telling the next shift at hand over - Writing in the communication book - Flagging the change of medication with a red marker clipped into the resident Medication Profile or other similar method. HOUSE HOLD REMEDIES Household remedies are General Sale Medications, such as cough syrup available in grocery stores and dairies. The list of Household Remedies held on site is agreed and reviewed at the Quality Review of Medicine Management [annually or more frequently if indicated]. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 15 of 26

16 STANDING ORDERS These are medication that an RN can initiate endorsed by the doctor. Examples: Panadol Tinea treatments Cough mixtures Hay fever tablets Medication to reduce flu symptoms Vitamin supplements [make separate list]. Homeopathic remedies [e.g. arnica tablets] Standing Orders for Registered Nurses Standing orders need to be signed by prescribing doctors. A registered nurse may initiate standing orders The doctor MUST sign the standing order at their next visit. MEDICATION REVIEW Level 1 Medications are reviewed at an individual level When the resident looks unwell. When the RN or Team Leader believes they can be optimised [more or less or a change may improve the resident s condition]. Monthly by the doctor. Or, 3 monthly by the doctor if they sign that this is sufficient. NB: The RN is responsible for monitoring & evaluating the appropriateness of any PRN medication that has been administered, so the doctor may then adjust the prescription as sensible. Care staff can contact the on call RN for advice. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 16 of 26

17 Level 2 Medication problems are recorded on a Medication Problem Form See also the Exception Reporting Policy. Errors are inputted in the Online Benchmarking Stats Program where error rates are compared to other similar facilities. Level 3 Our statistics from the Benchmarking Program are discussed at 3 monthly Service Review Meetings To try and ensure that the error NEVER happens again To assess if staff need more support / training To see if the Medicine Management System can be made safer. Level 4 Quality Review of Medicine Management Includes: Compliance with policy Correct Prescribing Storage of ordinary & Controlled Drugs Safe administration [looks at error trends] Reporting Systems [are staff reporting all errors fully] Investigation systems [assessing the robustness & documentation of errors] Appropriate response to adverse reactions and errors Adequacy of the training program DISPOSAL OF MEDICATION BLISTER PACS / MEDICO PACKS: All packs containing medication need to be safely quarantined [where they cannot be confused with in use medication. Please select below The pharmacy takes unused medicine when it delivers The Home takes its returns to the pharmacy monthly, or as appropriate. Empty packs should only be disposed of in a way that removes resident identification / information or returned to pharmacy. Safely disposing of Controlled Drugs is the Managers Responsibility. These must be signed out of the Controlled Drug Register when returned to the Pharmacy. This must be done at first opportunity and within. days. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 17 of 26

18 They are stored as Controlled Drugs meantime. Weekly stock take is a good time to check and see that medicines no longer in use are returned. Packs belonging to deceased residents need to be quarantined and held separately until the death certificate is signed in case they are needed at inquest. As soon as decision against inquest is made, return as for any other unused pack. Diabetics & Insulin: Self administration is encouraged. If residents cannot inject themselves then a trained staff member needs to help. Staff undergo training, then fill out a theoretical assessment of knowledge. After competent theoretical assessment, staff undergo a practical assessment by a person Management decide is a competent trainer e.g. Team Leader or RN. These are signed off on the staff member s Induction & Ongoing Training Record. Only signed off staff may administer insulin. If an RN is on duty, they should administer the insulin [checking the pen against the prescription with a second person]. Otherwise this task should belong to the next most competent person. It is important that staff understand the risk of giving insulin to someone with a low blood sugar. There is also risk where insulin is given and the resident fails to eat afterwards. Staff need to understand what actions to take. Work Instructions to guide these actions are readily available on laminated posters in the nurses station. Insulin: Rapid Acting Act Rapid Short Acting Intermediate Acting Long Acting Ultra Lente Check the Medication Profile: - Name of resident - Type of Insulin - Amount of Insulin - Time of Administration Storage: Insulin needs to be kept refrigerated [86 degrees Farenheight] Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 18 of 26

19 Safe Insulin Administration: 1. Wash Hands 2. Get Supplies - Insulin Pen & needle [insulin is delivered by Insulin Pen in the Home]. - Alcohol Wipe - Sharps container - Gloves 3. Two people verify dose in the pen with the Medication Order Sheet one being the MOST SENIOR PERSON on duty who is an assessed key carrier. NB: People on insulin will have their own pens. 4. Ensure adequate privacy for the resident 5. Explain to the resident 6. Choose site Upper arms, lateral aspect of thighs, abdomen or buttocks 7. Clean skin with alcohol wipe 8. Screw on Pen Needle 9. Hold upright & remove air by pressing the plunger. Repeat prime until insulin shows at the end of the needle. 10. Prime: dial appropriate number of units 11. Pinch up the skin & push needle in at 90 degrees. Release the pinch and push the plunger in. Pause for a few seconds [count to 5]. Remove needle. 12. Dispose of Pen Needle directly into sharps container 13. Remove gloves and wash hands. 14. Sign the Medication Administration Record time, dose, site, blood glucose value [BM]. Monitoring: The site for leakage For effectiveness [repeat BM s if requested] Food intake: giving insulin when someone is not eating is a serious risk for LOW blood sugar. Effectiveness & general well being Please print out and laminate the Safe Medication Administration Posters appendixes to this policy. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 19 of 26

20 Warfarin Administration Guideline [Warfarin & Marevan] Description: Warfarin is a drug that thins the blood. It helps afford protection from stroke, deep vein thrombosis and pulmonary embolism. It is important to monitor Warfarin doses carefully: - Too much will create a bleeding problem - Not enough will not be effective as treatment Pill Colours: Marevan 1 mg = Brown Marevan 3 mg = Blue Marevan 5 mg = Bright Pink Coumadin 1 mg = Beige / Tan Coumadin 3 mg = Lavender Coumadin 5 mg = Green Blood tests [every two four weeks] helps determine a therapeutic range [ideal amount in the blood] for best treatment effect. Blood tests reveal clotting time otherwise known as INR. Test INR more frequently if: Resident has been on antibiotics After any medication change If the resident has been seriously ill If the resident is bleeding [request a Bleeding Action Plan from the doctor] NB: People on Warfarin should not stop therapy consult the GP if unable or unwilling to take Warfarin. Warfarin is prescribed on its own dedicated prescription chart. See example below: Warfarin Prescribing & Administration Chart INR Record Resident Name Address Warfarin Commence Date Date INR Medication Dose Doctors Name Doctors Phone Doctors Fax Route Dosage Time to be given Date of next blood test Doctor Sign Sign Douglas supply these with Monitoring Graph on the reverse side. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 20 of 26

21 Warfarin Administration Guideline: 1. Warfarin thins the blood and this helps some people. The RN monitors Warfarin Administration in the Home. 2. INR = Clotting Time - too long [blood too thin & resident prone to bleed] - too short [not thin enough prone to medical problems like clots in arteries] 3. Doctor decides how often blood tests need to be taken - weekly - monthly 4. The lab comes and takes the resident blood in the morning 5. The laboratory phones or faxes the doctor & the Home in the afternoon 6. If there is a change in Warfarin dose the doctor phones the Home 7. This is documented on the Warfarin Administration Form 8. Warfarin is not blister packed: - staff need to select the dose from the bottles it comes in - different doses are different colours - Only staff trained and signed as competent should give Warfarin. - Daily dose is usually at 5 or 6 pm. 9. Remember people on Warfarin are more likely to bleed their blood has been thinned [is slower to clot]. 10. This can be flagged in their notes with an alert page of sticker. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 21 of 26

22 Pain Management Definitions of Pain: Pain is a personal to each person. It can change depending on the amount of physical harm, or medical condition, emotions at the time and personal coping mechanisms. It can be changed by support people [or the lack of them]. Pain cannot be measured like an X-ray or laboratory test. All reports of pain must be regarded as real. Chronic pain For a duration of six months or longer. Craven and Hirnle Fundamentals of Nursing. Pain is whatever the person says it is and occurs whenever the person says it does Elizabeth Kubler Ross. Resident definition of Pain Signs of pain include guarded movements and withdrawal from social contact. Pain behaviours include: moaning, crying, pacing, limping, more. Pain can increase blood pressure, pulse and breathing rate. Or, residents may feel pain but not show it. Signs of chronic pain include: weight change, sleep loss, crabbiness, emotional outbursts and not wanting to socialise. All residents must have a comprehensive pain assessment as part of the RN assessment. This is a quality indicator that we survey to ensure no one misses out. The Nursing Process The best means of preventing pain is to control possible sources. This may be achieved by: Regular change of position Comfortable positioning making use of pillows Use of hot baths, rubs and heat packs as appropriate to help prevent stiffness. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 22 of 26

23 Regular exercise, including passive exercise, to help prevent stiffness and soreness Promoting an environment where residents feel supported and cared for and not alone (pain endured alone often magnifies) Good assessment so that pain is known as it arises. Use Pain Assessment Form [appendix at end of this policy] if residents exhibits ANY Pain Behaviour - Aim for 95% of residents to have been offered a pain assessment within 6 months of admission to meet Best Practice Guidelines. - Staff may use these forms as an efficient way to report Resident Condition - Corrective Actions may be made AFTER the assessment is endorsed by Trained Clinician [Trained Clinician = someone with a Health Qualification] Make surroundings clean and nice Plenty of fluids Kind words and supportive statements Pain Behaviour - Calling out or Moaning - Rocking - Holding or rubbing a sore part - Wearing a bandage - Limping - Frowning - Being grumpy or otherwise looking unhappy - Not Sleeping - Weight Loss - Difficulty Eating - Not socialising - Emotional Outburst Alternate Therapies Rongoa [Maori Medicine]: Topical applications are known to be successful in place of or alongside Modern Medicine. Massage Mirimiri [Maori Medicine involving massage & spiritual support] Suppliments: These need to be shown to the doctor if this resident takes regular medications. Supplements can limit uptake or effectiveness of some medicines. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 23 of 26

24 Use of Analgesic Agents All residents admitted on pain medication are maintained on their existing pain management regime until seen and reviewed by the doctor. Analgesic medication is the most common approach to pain management. Analgesics can be broken into three main groups Opioid, Non Opioid and Adjuvant. NB: If resident tells you they hurt: TELL the RN She will tell the DOCTOR Doctor refers to PAIN CLINIC or other specialist help Paracetamol is the first line analgesic and may be ordered 2 QID (2 tablets/four times a day) unless otherwise indicated. If stronger pain relief is required, Panadeine 2 QID may be used. If pain remains uncontrolled Paradex 2 Q8H alternating with Paracetamol 2Q8H may be used example. If pain not controlled Non Steroidal Anti Inflammatory Drugs may be considered depending upon the source of pain. Note the side effect of this medication must be made known to staff administering it i.e. give with food or milk to minimise risk of gastric upset and GI Bleed. If pain continues, Morphine or Kapanol or M-Eslon may be appropriate in place of other analgaesics. Chronic pain should not be treated on a PRN basis. Paradex is used as sparingly as possible and not usually on a PRN basis. Any resident commenced on Paradex is monitored for increased risk in falls and other adverse effects. Chest Pain: GTN Spray [Instructions 2 puffs under tongue wait 5 minutes. If pain continues repeat. Wait 5 minutes. If pain persists, repeat. Then call RN immediately. If pain persists after 3 doses of GTN spray or at any time residents become agitated, pale, clammy or pain increases, call 111 for an ambulance immediately with a view of sending to hospital. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 24 of 26

25 Use of Morphine Some General Principles: The amount of morphine required is the amount needed to control a resident s pain. In other words, there is no upper limit for morphine dosage. Generally speaking, if a quantity of morphine fails to control pain the dose of morphine needs to be increased. MST Continuos is designed to be a 12-hourly dose. Adequate control cannot be achieved on a PRN regimen. Should the resident require more MST Continuos, increase the dose not the frequency. Occasionally a resident may be found to have a fast metabolic rate and will require 8 hourly doses. MST Continuos and Kapanol / M-Eslon should not be crushed, as this medication taken whole provides a sustained release of the medication over time. Crushing delivers the full dose too soon. The required dose of morphine may be assessed using prn elixur, then assessing the amount that achieved control (the Doctor does this). Residents with cancer require review at regular intervals. In most cases this means at least once a day. In this way a resident s pain is kept under optimal control. It is important to distinguish between breakthrough pain and Incident pain. PRN analgesia required for breakthrough pain should be incorporated into the regular daily regiment as soon as possible, while incident pain requires anticipatory dosing about 30 minutes before incident. When residents start a new course of morphine we need to ensure: 1. Resident understanding of possible and likely initial side effects [Dr may need to chart an anti-emetic] and reassurance these will only last a short time. 2. Staff understanding also and the knowledge these side effects will need support and good reporting. 3. Resident buy in [good RN and doctor explanation of side effects like initial sleepiness. 4. Effective monitoring by the RN Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 25 of 26

26 Rectal Morphine: Indications: Obstruction / dysphagia. Persistent vomiting. Administration: Oral = rectal dose. Suppositories require to be given 4-hourly Suppositories may be made in any strength up to 300mg. References A guide to palliative care in NZ 2 nd edition Controlling Breakthrough Pain in Residents with Terminal Illness Breakthrough pain may be due to a worsening of the resident s disease state. The pain usually occurs in the hours before the next dose of MST Continuos / Kapanol is due. Elixur may be prescribed for breakthrough pain. The doctor regularly assessed the prescribed dose in these situations. Record all Morphine Administration according to the Standard for Residential Facilities Controlling Incident Pain: Incident pain, unlike breakthrough pain, is brought about by trauma or by a particular activity, eg. dressing changes. Residents will know which activities precipitate incident pain. Appropriate analgesia, as charted, should be administered where pain is anticipated. Alternative Pain Relief Techniques Many people respond well to alternative therapy such as relaxation massage, Yoga, crystals and oils, acupuncture and acupressure. These options should be available and documented as part of Care Planning. Pain may seem much less when a support person is sending the message that the person in pain IS cared for and WILL be looked after. Although, focusing on pain may make it grow. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Page 26 of 26

27 Resident/ Client Name: Date: Pain Assessments: Pain is what ever a person says it is Time: [24hr] Resident / Client Self Report of Pain Date Score Sign Wong Baker Pain Assessment Tool Remember pain is worse if you are alone, grieving, in conflict, have not slept, without your usual support people, frightened. Pain Behaviour can be observed Abbey Pain Scale Absent = 0 Mild = 1 Moderate = 2 Severe = 3 For observations 1 6 below please rate a score Score 1. Vocalisation [what they are saying] Examples: whimpering / moaning / crying 2. Facial Expression Looking tense / frowning / facial grimacing / looking frightened 3. Body Language or change in body language Fidgeting / rocking / guarding part of the body / acting withdrawn 4. Behavioural Change Increased confusion / refusing to eat / alteration in usual patterns 5. Physiological Change TPR or Bp outside normal limits / perspiring / flushing or pallor 6. Physical Skin tears / ulcers / arthritis / contractures KEY 0 2 No Pain 3 7 Mild Pain 8 13 Moderate Pain 14 + Severe Acute Chronic Acute episode on chronic Reviews: Date Score Sign & designation Total Score Care Planning Comment: Please write here notes on actions required arising out of this assessment. Issue Number: 02 Policy provided by HH.NET LTD Issue Date: Appendix 1

28 Medicines Act 1981 Prescriptions may be written by doctors, dentists, and registered midwives REGULATION 41 Prescriptions must be: Signed Legible and indelibly printed No Transcribing Contain: - adequate instructions - number of times drug may be given Clearly indicate: - name of the recipient - strength & dosage - route & when to give

29 HYPO and HYPER Glycaemia high and low blood sugar HYPER 11 + When pills or Insulin is missed NORMAL 4-7 Feeling fine HYPO < 4 Can be caused by too many diabetic pills or by insulin Millimoles per litre

30 HYPO Low blood sugar HYPER GLYCAEMIA High blood sugar HYPO HYPER PULSE Rapid Normal SKIN Moist & Pale Flushed & Dry BEHAVIOUR Excited or Nervous Drowsy BREATHING Rapid & Shallow Deep & Laboured BREATH Normal Fruity Odour VOMITING Absent Present TONGUE Moist / Numb Dry HUNGER Present Absent THIRST Absent Present PAIN Headache Abdominal

31 YES! HYPOGLYCAEMIA is identified by the symptoms below: LOW BLOOD SUGAR = LOW BM HYPOGLYCAEMIA PULSE Rapid ACTION SKIN BEHAVIOUS BREATHING BREATH VOMITING TONGUE HUNGER THIRST PAIN Moist & Pale Excited or Nervous Rapid & Shallow Normal Absent Moist / Numb Present Absent Headache This person requires: GLUCOSE

32 Diabetic emergency: Very low blood sugar Practical suggestions for low blood sugar treatment. Also, notify doctor and take BM s. 3 4 Vita or glucose tabs 2-3 tea spoons sugar in a glass of water ½ glass of cordial or fruit juice Hands shaking Blurred Vision Pins and needles lips and tongue Head Ache Confused Thumping Heart Hungry Knees weak and trembling Skin pale and sweaty If not improved give more Vita / glucose. Excited / nervous After 10 mins give 1 slice bread or glass milk or two plain biscuits. If close to meal time, have meal.

33 Healthcare Help Guidelines It is best if the person needing the insulin can give it to themselves. Train ALL people who administer insulin. Assess their knowledge include practical assessments. NO ONE ELSE SHOULD GIVE INSULIN! If you are a health provider and have an Registered Nurse at work, this person should administer the insulin if the client cannot administer it themselves. This Registered Nurse carries the responsibility for Care Staff who might have been delegated this task. DO have good INSTRUCTIONS & help lines available. When giving insulin: Always assess the risk [following the guidelines reduces risk]. If in doubt DO SEEK HELP BEFORE you carry on. Always seek to increase your own knowledge! These posters were developed to help nurses and care staff / support workers give out medication safely. The FREE online digital learning program is on the Healthcare Help website. [ ]. Enjoy! THE END

34 The right patient Best practice is at the TOP of the pyramid Least Risk Client is personally known to me Client lucidly self - identifies ID Wrist band RN personally knows client Caregiver personally knows client Photo ID Name on door or bed Highest Risk Risk Pyramid

35 The right drug Best practice is at the TOP voltarin of the pyramid antibiotic warfarin Panadol Least Risk Drug well known Aware of effect and side effects Knowledge of adverse reactions Usual doses known respiradone Night Administration times / specifics known sedation Unknown drug / First administration Insulin Controlled Drugs Highest Risk Risk Pyramid

36 Controlled Drug Policy Best Practice Procedure for Controlled Drugs This Register is used to count [control] the following drugs. MST, M-eslon, LA Morph [Morphine Elixur], Morphine Injections, Sevredol, Ritalin & Ruvifen. These will be dispensed to individual residents. All controlled drugs arriving at the Home MUST be signed in by the pharmacy delivery person & the most senior person on duty. When a controlled drug is no longer needed it is returned to the pharmacy by the end of the next working day. NB This register MUST be signed with the ZERO balance by the pharmacy & either the RN, the Manager or the Owner! The Controlled Drug Coordinator is:. Weekly stock take day is: Accepted by pharmacy: Pharmacist Note: Information from monthly & quarterly reviews of Medicine Management are shared with the pharmacy & doctors, as appropriate. Healthcare Help