Administering Anti TB Medications Barbarah Martinez, RN, BSN September 13, 2017 TB Nurse Case Management September 12 14, 2017 EXCELLENCE EXPERTISE INNOVATION Barbarah Martinez, RN, BSN has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1
Administering Anti TB Medications Barbarah Martinez RN, BSN Houston Health Department Identify tools to aid in DOT visit DOT kit Objectives List strategies for successful DOT Incentives and Enablers Education Barriers to treatment How to overcome barriers 2
Incidentals Water/snack Preparing/Mixing Patient record Itinerary Respiratory Protection DOT Tool Kit Most important Tool YOU 3
Incidentals ID Pen Paper Blank Envelopes CHARGED cellphone Cash For the Patients Something to drink A light snack 4
For Yourself Something to drink A light snack Preparing/Mixing Tools Pill cutter Pill crusher Medicine dispenser Oral syringe Cherry Syrup or Jelly Poly towel Hand Sanitizer 5
Patients Record/DOT Log Patients record or DOT Log Patients prescription Progress note File storage for records Easily accessible Itinerary Have an itinerary Be sure to leave a copy with someone in the office Help keep you on track with your visits Keep track of your mileage Stick it on a clipboard 6
Respiratory Protection Be sure to have a supply of N95 Masks that are fit for your face. Masks can be reused as long as they are stored in a paper bag, NEVER PLASTIC, and are not wet or dirty. Bring extra surgical masks incase the patient has run out and needs more. Our Patients Little ones Big ones 7
Providing DOT/DOPT to Children Partnership with parent(s) 0 2 years old 3 6 years old 7 12 years old 13 years and older Overcoming challenges Partnering with Parents Have a plan in place that was developed with the support and input of the parents. Identify common terms that will be used by both you and the parents to identify symptoms. Discuss potential incentives for the patient. Discuss concerns in private, away from the child. 8
Partnering with Parents Involve parents in problem solving Provide the nurse case manager s phone number and advise family to call if child experiences any problems. Instruct caregiver when to seek medical evaluation or immediate medical attention Discuss directly observed therapy (DOT) plan. Be a team, show a united front between you and the parent. Methods to Deliver TB Medications Liquids: INH suspension is available commercially in sorbitol The syrup form of isoniazid is unlikely to be tolerated in amounts greater than 10 ml to 15 ml (i.e., doses in excess of 100 150 mg) Pills and capsules taken intact or in halves: Tip the head back to swallow pills and tip the head forward to swallow capsules Tablets SINK, Capsules FLOAT Pills fragmented (with a knife or commercial pill cutter) or crushed (by commercial pill crusher, mortar and pestle, spoon against spoon or bowl); capsules can be opened 9
Delivery Method Syringe Medicine dropper with larger tip Catheter tip syringe Baby bottle (may need to make hole larger) Special Rx MediBottle with internal sleeve for syringe Medicine delivering pacifier (may need to make hole larger) Medications can be crushed and mixed with formula or breastmilk Medications can be crushed and mixed with food or juice Medication can be formulated into a liquid Pediatric tools 0 2 Years Old 10
Use Caution Children learn from and adapt to their situations. When presented with something they do not want to do, they may cry or act out. If this works in their favor, they will repeat this behavior. When prescribed twice weekly dosage, they may act out in hopes of not having to take medication. If this works and they succeed in sending you away for days, they will repeat this behavior every time you visit. 11
Medications can be crushed and mixed with food or juice Medication can be formulated into a liquid 3 6 Years Old Talk to the child at the child's level of understanding Offer options not directives Offer incentives 12
The Problem Child 4 Year old king of the castle Refused Window Prophylaxis treatment But then converted his skin test Mother enabled bad behavior Spit Kicked Cried Bribery in this case did not work Removed the mother from the situation New scary DOT worker Medications can be scored Medications can be crushed if necessary Offer options not directives Discuss symptoms Provide education Provide encouragement Provide praise 7 12 Years Old 13
13 Years and Older Medications can be taken whole Make them a part of the treatment plan Similar to adults Provide education Provide encouragement Provide praise 14
Detecting Problems We cannot predict who will take their TB medications correctly! You should notify your program manager, nurse case manager, or the designated point of contact as soon as you suspect issues. Determine why the patient is not willing to take medications and begin strategies that will help the patient finish treatment before legal measures are taken. 15
Potential Barriers to Treatment Social Drug addictions The importance is placed on illicit drug use and not treatment. Employment DOT may interfere with employment either because the patient has no time or the employment site is a challenge to coordinate (Truck Driver) Mental illness Depending on the illness a patient may feel like they are being poisoned. Denial There's Always Something Additional Barriers Competing priorities Patient no longer feels sick Lack of motivation Poor relationship with healthcare worker(s) Control issues Ensuring Treatment Success Assessment of needs and development of a treatment plan Providing appropriate education to the patient Keep appointments Effective monitoring and management of adverse drug reactions 16
DOT succeeds for one pivotal reason DOT makes the health care system, not the patient, responsible for achieving a cure WHO REPORT ON THE TUBERCULOSIS EPIDEMIC 1997 An INCENTIVE is something that is offered to the patient to encourage and promote adherence and is specific to the patient. Coloring pages Stickers Stamps Kids meal toys Movie passes Incentives 17
Incentives My Best Friend 4 year old Treatment for TB disease Proclaimed that we were best friends! Mother was fantastic Loved Grape jam Loved Dora the Explorer Incentive used Dora stamp Dora coloring page Conversation 18
Sticker Chart! Sunday Monday Tuesday Wednesday Thursday Friday Saturday 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Current month Positive Reinforcement Positive reinforcement Gummy bears Sticker calendar Silly rituals Small Prizes Try to avoid a battle of the wills The child needs to feel in control Developmental needs of the child There is no standard approach Remember to praise the caregiver for a job well done too! Be flexible when possible to accommodate the families needs Work with the family s schedule Introduce a back up staff member before the need arises 19
Overcoming Challenges : Patient s distrust of a stranger Gain trust Parents AND patient Individualized family education regarding TB and TB medications Have a conversation about TB Provide written information Keep explanations simple and focused Have the parents introduce you to the patient Remind them that the doctor has sent you. Do not be aggressive Overcoming Challenges : This is Taking Too Long 130 doses takes a long, long time Both the child and the parents get tired of daily DOT Difficult to keep up a routine with the appearance of no symptoms, and no visible benefit Health Department staff can also get fatigued 20
Overcoming Challenges : TB Medications are Yucky! Crush and mix Put a thin layer of soft food onto a spoon. Place the pill fragments or powder on top of the food layer and top with more yummy food. Give the child the dose of medication in this sandwich. Teach them to swallow it without chewing by practicing without the medication in place first. Recipe for Success Food Choices: Chocolate sauce Pudding Fudge sauce Ice cream Jelly or marmalade Apple sauce or berrysauce Marshmallow cream Nutella or peanut butter Oreo cookie filling Drink Choices: Kool aid Orange juice Apple juice Sprite 21
Mixing When Mixing Never Ever Ever Premix at the clinic Medications when mixed with food begin to lose their efficacy, so it is important to mix and immediately administer the prescribed dosage. 22
Important Reminders Crushed or opened medication should be mixed with food or liquid immediately before administration. Suspend in a SMALL AMOUNT of food or liquid The crushed pills have a strong flavor; small fragments of the pill taste better If the medication is not administered within 30 minutes after mixing, it should be discarded and a new dose prepared. Attempt to have regularity Same nurse or DOT worker Same time of day Same location Teaching Points Attempt to make interactions positive Use praise Use positive reinforcement Always end the visit on a happy (positive) note Anticipate problems Research ahead of the visit Learn from each visit Have new ideas ready to go Try something new if what you are doing is not working ask for help! 23
Things to Consider: What is a good time for the child? What is their daily schedule? When will they be hungry? When will they be more cooperative (well rested)? Unexpected interruption in their lives. FAQ s What if the child spits out the meds, should I redose? NO! You do not know how much has been absorbed. Make a notation in your DOT log that the child spit out the dosage and be sure to communicate with the nurse. 24
First Visit: What If Patient has Already Self Medicated? Given a prescription upon discharge from the hospital. Primary care physician wrote a prescription that was filled. The patient has taken daily meds that day DOT provision cannot be initiated for 24 hours. If patient took biweekly or triweekly meds that day, DOT cannot be initiated for 48 hours. Self meds should be picked up and returned to the office after an explanation is given to the patient. Tip: When working with the parent/guardian in selecting a food that will work best for the child, be sure to stress to the parent that this will work best if they refrain from giving the food to the child any time other than during the DOT visit. Ex: Mixing meds with chocolate syrup, do not allow the child to have chocolate any other time. 25
Tip: Use a bib to prevent clothing stains from rifampin and rifabutin. Take an extra set of clothes Plan medication delivery to coincide with performance of daily habits or rituals Elicit the support of family and friends Things to Be Aware of Some tricks: cheeking or hiding pill under tongue, keeping pill in hands, hiding in furniture, promising to take later, answering the phone, picking up a child. If you have a strong suspicion patient isn t swallowing medication consider asking the patient to open his/her mouth. 26
Why is it important to check to make sure all meds are taken Risk of treatment failure/relapse Acquired resistance Why are you the most important tool Accompany the patient through treatment Support Educate Persist Celebrate 27
Thanks Jackie Maldonado RN, MSN for sharing your slides with me! I loved not having to re invent the wheel! https://www.youtube.com/watch?v=rjgagn8v ci&feature=youtu.be https://www.youtube.com/watch?v=qenj8_hn 5U&feature=youtu.be https://www.youtube.com/watch?v=hmzboeldjf4&feature=you tu.be https://www.youtube.com/watch?v=5ihwztni30c&feature=you tu.be&t=56s 28