Medications: Non-Oral Administration

Script

ContentsSegment 1 Ointments and creams...........................................................................................................................................1

Segment 2 Eye, Ear, Nasal drops and Sprays and Ear Drops.....................................................................................................3

Segment 3 Spacers and Inhalers...............................................................................................................................................6

Segment 4 Transdermal Patches..............................................................................................................................................9

Segment 5 Suppositories, enemas and pessaries...................................................................................................................12

Segment 6 Insulin Administration..........................................................................................................................................13

Note: this script may vary slightly from the recording

Segment 1 Ointments and creamsSlide 1

Now we will discuss how to apply ointment, creams and lotions

Slide 2

All your residents or clients should have their skin moisturised daily and after each shower. As people get older, their skin becomes very dry so in order to keep it well moisturised you should apply this at least after every shower but better to be done each day. However from time to time you will also have to apply special ointments, creams or lotions for a specific reason or condition. Sometimes they will be prescribed by the doctor and others your registered nurse my put on their plan of care to apply. So if a person is prescribed to have an ointment, cream or lotion applied you will need to check the care plan or the prescribing sheet to see what needs to applied and when.

You then gather all your equipment. Which means the cream, lotion or ointment, a spatula if it is in a jar and gloves. Always put these in a container to take to the bedside and cover the container with a paper towel. You must always check the expiry date at well. This is particularly important if the person has not had it applied for a while – that is a prn application. You must also read the label. Please take care the label does not get covered in the ointment, cream or lotion as it will be difficult to read. If you cannot read the label that the pharmacist has put on it, you should check with the registered nurse before applying it or even get a new tube, jar or bottle and return what you cannot read to the pharmacy.

A note here though; do not discard it in the rubbish. Some of these can be very toxic and dangerous if out in general rubbish. This is another reason why it is important to read the label or check with your registered nurse as

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to any general precautions. For example if you are applying a general moisturising cream, and the skin is intact, you may not need to wear gloves to apply but if it is a prescription you do.

Slide 3

Before you start any procedure you must explain to the person what you are going to do. Some people are really fearful and frightened but apart from that this is a general courtesy that you should apply whenever you are going to do any procedure. Imagine how you would feel if someone comes up to you and just starts lifting up your arm and apply some cream so by saying something like “Hello Mary, the doctor has prescribed this ointment for the rash on your arm to take away the itch. Is it okay if we do this now?” This is being respectful

Then you must wash and dry your hands before applying the cream and put on gloves if appropriate i.e. a prescription treatment you should, a general moisturiser you probably don’t need gloves.

Slide 4

When you can apply the cream, lotion or ointment, be careful not to put too much onto the skin. Often only a small amount is required to be applied to the area. If you put too much on, it will take a lot longer to rub into the skin and it won’t do any better job. When putting face moisturiser on often you are told to use a cream the size of a pee or a 10cent coin so more is not best. Use a small amount only and massage it into the skin to make sure it is absorbed – that means till it disappears and you don’t see any left on the skin.

A tip is to apply it when the skin is warm and it will absorb much quicker. You will really notice then when you apply moisturiser after a shower.

After you have completed applying the cream always wash your hands. If you have had gloves on remember to wash your hands after removing the gloves. Gloves often have tiny pin holes in them that you cannot see so you don’t want your skin to be contaminated

Slide 5

When you have completed the task you must always sign that you have applied the ointment, cream or lotion so the registered nurse knows it has been applied. These are prescribed for a reason. The lesion, rash or even dry skin will not improve or get better if you do not follow the care plan or the doctors’ orders. I have to say it is very embarrassing when conducting a doctors round to find that a prescribed treatment has not been given by the caregiver. The registered nurse cannot be everywhere and do everything so we rely heavily on you to do some things for us and if for any reason the treatment wasn’t carried out we need to know why. Also record if it wasn’t given for some reason. The person may have refused, there was insufficient cream or lotion or had run out, they were out of the premises - whatever the reason, we need to know.

Slide 6

When you are applying creams, lotions and ointments, never share them between residents. Every person should have their own moisturiser container. This is how infection gets transferred from one person to another.

If cream or ointment is in a jar, always use a wooden spatula to get the cream or ointment out. Don’t dig your fingers into it as you could contaminate the rest of the jar.

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Also never use the tubes, jars or bottles in the resident’s rooms. The resident could try to treat themselves and be over medicated or they could go missing. Tubes, jars and bottles have a habit of disappearing from rooms so always take them back to the treatment room and put away in the trolley or cupboard.

Segment 2 Eye, Ear, Nasal drops and Sprays and Ear DropsSlide 1

Instilling eye, ear and nasal drops or sprays.

Slide 2

Now we will talk about instilling eye drops and ointments. You may well be asked to do this whether it be with liquid tears, in people eyes. Sometimes there is an imbalance in the tear flow system a natural process of aging especially menopause. Some drugs can give side effects that cause dry eyes for example antihistamines and birth control pills. Also there are some diseases that affect the ability for to make tears, such as Sjogren's Syndrome, rheumatoid arthritis, and collagen vascular diseases. There may also be structural problems with the eyelids that don't allow them to close properly so instilling eyedrops is really important to keep the eye moist.

Glaucoma is another condition where it is imperative an eyedrops are as if the fluid builds up in the eye and doesn’t drain away then the person can go bling. Eye infection also may require eye drops or sometime ointment and if they have attended eye clinic they may be required to have drops or ointment. So you need to know how to give eye drops or apply eye ointment

Firstly check the medication notes to see what has been prescribed and when.

Next you need to assemble your equipment. Always put this in a kidney dish or plastic container and cover it with a paper towel to take to the person.

When you get out the eye drops or ointment there are two dates you need to check. One is the expiry date of the medication the other is the use by date which will be hand written on the outside of the box. The reason it is handwritten is eye drops only have a life of 1 month after being opened. Some eye drops also have be kept in the fridge so you need to get them from the fridge and return them to the fridge after use.

Slide 3

So before you give the eye drops or ointment you have to make sure your wash your hands. Gloves are not necessary unless the person has an eye infection where it may be prudent to take the extra precaution.

You then get the person to lie down flat on the bed or tip their head back but many older people or people with disabilities are not able to tip their head back, so lying down may be easier for everyone.

To instil the drop, you gently pull the eyelid down from the bottom of the eye. If you are unsure, there is a video on how to instil eye drops in the resources section that will help you. However your registered nurse should train you first.

Slide 4

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Now if you are instilling an eye drop, you put one drop in the eye and instruct the person to avoid blinking if possible but they may not be able to do that but if they can keep their eye closed. If you are putting in ointment, then you hold the eye lid down and gently squeeze the ointment along the bottom of the eyelid. If you have to give more than one eyedrop, then wait a while before you put the other drop in. About 5 minutes is the best time.

Slide 5

As I said before, get the person to keep their eye closed and apply gentle pressure to the tear duct which is on the nose side of the eye. This will enable to drop to work and prevent any loss of the medication through the tear duct or to slide out of the eye. Next replace the dropper or the cap of the bottle or tube and make sure they are secure. You do not want any drops or ointment to leak out.

Slide 6

Wipe any excess tears or ointment away from the face with a clean soft tissue or a gauze swab and discard. Wash your hands and before you leave the person make sure they are comfortable or return them to the day room. They may want to lie down on their bed for a while but this is up to them.

Slide 7

Next you return the bottle to the trolley, cupboard or fridge and wipe clean or discard the receptacle you took the eye drop or ointment to the person in. Then sign that they were given, or not given or refused on the signing sheet. If they were refused or not given, then tell the registered nurse and record the reasons in the person notes and any other observations you may have made like the eyes watered excessively, complained of excessively stinging eyes or the amount of pus or exudate in the eye. Is it getting less? These are all significant and important things the registered nurse or the doctor should know.

Slide 8

Now there are some don’ts around eye drops and ointments. Firstly never use past either their expiry date or use by date or they will not be effective

Never share drops or ointment. They will be prescribed for the person and can only be used for that person. Apart from being only for the person, it is very easy to transfer infections from one person to the other. And don’t leave the bottles or tubes in the person’s room. As I mentioned earlier, they have a habit of disappearing and could also be misused or over used.

Slide 9

Don’t let the dropper, bottle or end of the tube of ointment touch the mucous membrane of the eye lid. This ensures that bacteria cannot grow on the tip of the dropper, bottle or tube so you are less likely to transmit infection to the eye.

Don’t wash or wipe the dropper, end of bottle or tube before you replace the cap so be careful when instilling ointment that you do not squeeze too much ointment out

Eye drops and ointments are commonly stored in the fridge especially once they are opened so make sure you store and replace them as per manufacturer’s instructions.

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Remember if you are ever in doubt, you can ask the registered nurse or refer to policies and procedure. When do such treatments a registered nurse should always train you first?

Slide 10

Now let’s talk about giving nasal drops or sprays. It is not often that drops are given these days, but I have included drops in this presentation in case you have to do this. Nor am I talking about inhalers. I will talk about them after this.

Firstly you must check the instructions on the medication chart. Then gather the equipment you need. It may be that all you need is the nasal spray or drops. Check the expiry date on the bottle as again if it is past the expiry date it will not be as effective. However unlike eye drops, they generally will last longer than a month once opened and will not need to be kept in the fridge. You then need to wash your hands. It will not be necessary to wear gloves for this procedure however again, if the person has a dripping nose then you may prefer to wear them

Slide 11

When you get to the person, you would first ask them to blow their nose gently first. This is to ensure the medicine will get to the mucous membrane of the nose so it can work. You don’t want the medicine to get mixed with the exudate from the nose so it will drip straight back out.

If you are using drops it will be better for the person to lie on the end of the bed and tip their head back so you can instil the drops. You can see this in the video in the resources section. Now if you are using nasal sprays it is the opposite. The person needs to tilt their head forward so that when you squeeze the medicine into the nose it will spray up. Now it is important that when putting the spray in that you press gently on the nostril that is not getting the spray otherwise the spray will just go up one nostril and out the other. So don’t forget to so this.

Slide 12

You then have put the drops in the nose, or spray the spray up the nostril. Don’t forget if you are using a spray you will need to shake it before you administer the spray. Once the spray or drops have been administered, ask the person to sniff gently, make sure they are comfortable before you leave them then put the dropper back into the bottle and recap the spray.

Slide 13

You then return the bottle or spray back to the trolley or cupboard for storage, sign the medication chart or record anything you noticed or it wasn’t given or the person refused. Recording is really important.

Now if you didn’t understand any parts of instilling nasal sprays or drops make sure you go to the videos in the resources section, ask your registered nurse to show you or read up on your policies and procedures.

Slide 14

Instilling ear drops. The first thing you must do is read the instructions on the medication chart and retrieve the ear drops from the medication trolley or cupboard. Then wash your hands. It is not necessary to wear gloves for this procedure however if the ear is oozing, which I hope it isn’t, then it would be a wise precaution

Slide 15

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Before you instil the ear drops, warm them in your hands to get them to body temperature. This will make them more comfortable for the person when you instil them. However DO NOT put these in hot water as this could alter or affect the components in the ear drops.

Next you ask the resident to turn their head to the side with the ear you are going to put the drops into. It will be much easier for both you and the resident if the person is lying on their bed. It will also ensure the drops actually get into the ear canal. When putting the ear drop or drops in, gently grasp the ear lobe and pull it upward toward the head, and then back. You want to make sure the ear canal is straight.

Slide 16

Then you instil the required number of drops. Be careful not to let the end of the bottle or dropper touch the actual ear. It is easy to drop them in without doing that. Now keep the ear tilted upwards for 5-10 seconds. You will need to keep holding onto the ear. This is to ensure the drops actually get into the right place to do the job and prevent it from coming directly back out of the ear.

Slide 17

After the 5-10 seconds release the ear and if there is still some seepage than put a small amount of cotton wood gently into the canal. The resident can then get up. If you have to do the other ear, then the same procedure applies.

Recap the bottle or put the dropper back in the bottle and secure

Wash your hands at the end of the procedure

Slide 18

Return the bottle to the medicine trolley or cupboard and sign the medication sheet that they have been given. If the person refused the drops or the person wasn’t in the facility to get them or for any other reason, record this in the person’s notes. Also report anything you noticed like did the person complain of pain, was the ear seeping, did they say it was less painful. Anything you observed. Always check the policies and procedures of the facility and if you are in doubt of what to do, ask the registered nurse for help. You may find it really helpful to see the videos in the resources section on instilling ear drops.

Segment 3 Spacers and Inhalers

Slide 1

In this section I will look at spacers and inhalers. It is really important that you know how to use these properly for if you don’t, the person will not get the medicine which helps them to breath.

Segment 2

Now inhalers are sometime called puffers. So if you hear it referred to as a puffer, then it is the same as an inhaler

Inhalers deliver medicine direct to the lung so a person can breathe properly. They work much quicker than a tablet so a person can get relief from symptoms really quickly or they may need to have one that enables them to

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breathe properly all the time. So there are what is called reliever inhalers which a person only takes when they have symptoms of asthma and there are preventer inhalers that need to be used all the time to maintain healthy breathing. You need to know the difference between the two as some people will have both. One that keeps them stable and the other if for some reason they get worse. You will see they are often different colours so it will be easy to distinguish one from the other. If you are unsure, then ask your registered nurse to explain it to you.

Slide 3

These devices are called metre dose inhalers or MDI for short. This is because when the canister is pushed down a measured dose in puffed into the lung. Each time you push it down it will give the appropriate measured dose to either maintain breathing as in a preventer or as reliever to relieve symptoms or poor breathing. The medicine is in the canister or in what is called dry powder devices. They both do the same job but they may look different.

Slide 4

So why are spacers used sometimes instead of just using the puffer directly into the mouth? Well it is recommended that a spacer is used because a person will get 50% more medicine into the lungs.

It is also much easier for people to coordinate and therefore can be used more effectively for children or older people so they get the full measured dose, not just half of it. This is why a spacer should be used

Slide 5

Before you use a device you must make sure it is primed first and then every 4 weeks after that. By priming halers ensures that the correct metred dose will be given. To prime an inhaler you press down the canister with the index finger to release the medication. You must hold the inhaler away from your face to prevent medication from getting into your eyes. Then press the canister down again 3 times more before you administer the metered dose and don’t forget to replace the cap.

Slide 6

After the inhaler has been primed, you can now use it for person. So must check their medication chart of to see what has been charted. Then wash your hands and read the label and follow the instructions.

Slide 7

Now we are going to talk about giving an inhaler with a spacer. Firstly you explain to the person what you are about to do. It is more than likely they will know what you are going to do but that does not excuse you from explaining to them each time you are going to administer the medication. Saying something like, “Mrs Moore, it is time for you to have you inhaler now. I am just going to help you.” Now some people may want to do it themselves especially if they have been using inhalers for a long time. However some people may have memory loss and have completely forgotten that they need an inhaler, So you need to look at each person as an individual.

Next make sure the person is sitting up straight or are standing. If they are all hunched over the medicine will not be able to get into the lungs and therefore will not be able to work. Next you remove the cap. It is important that the inhaler always has the cap on it to prevent foreign objects, like insects, or dust getting into the medicine. Some people keep these devices in handbag or pocket and all sorts of dust and matter can be floating around in their bags or pockets so please make sure that the inhalers always has the cap on it.

Slide 8

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Next you shake the inhaler well. You do this even if you have only just primed it. Then you insert the inhaler mouth piece into the spacer device

Ask the person to then place their lips over the mouth piece of the spacer and make sure that it is well sealed.

Slide 9

Next fire the canister once into the spacer and then instruct the person to breath in and out normally 4-5 times. You may like to count for them so they know when they have finished. Remove the spacer from the person’s mouth. Now if they are to have a second puff as sometimes the doctor will order two puffs, you must wait 30 seconds before putting it into the spacer and doing the process all over again. Two puffs does not mean two puffs at the same time. They must be separate.

Slide 10

Now we are going to talk about giving a metre dose inhaler without using a spacer. The first part of the process is actually the same as for using a spacer except you are not using the spacer this time. Just putting the inhaler directly on to the person’s mouth. You may know friends who use an inhaler this way or you may even use one yourself. Like with everything you must explain to the person what you are going to do before you start and also wash your hands. Sit the person up or you can do this while they are standing. Remove the cap from the mouth piece and shake the inhaler well.

Slide 11

Now this is where it differs from using a spacer. Firstly ask the person to take a few deep breaths and then breathe out completely. Insert the inhaler into the person’s mouth and ensure the lips forma good seal around the mouth piece. Then ask the person to start breathing in slowly and deeply.

Slide 12

Now you press the canister once to release the medication after the breath in has started. This is really important as if you don’t, they will not get the correct meter dose. Now make sure that the person continues to breathe in as deeply as possible and then to hold their breaths for 5-10 seconds. You can count the time by putting up one finger per second so they know when to breathe out or breathe normally. Again if a second puff is required, wait 30 seconds before you go through the process again. You don’t give two puffs at the same time. You start the process over again for the second puff.

Slide 13

Now we need to talk about cleaning the inhaler. You do this by removing the canister insert and washing the mouth piece and drying it thoroughly. Then you replace the canister into the inhaler and put it back into the medicine trolley or cupboard.

Slide 14

Cleaning spacer too is very important. Now you have to prime the spacer before the first use and then every 4 weeks so you are going to have to record it so you know when to do it. It may be that the process is that it is primed the 1st of every month or you may have another system. Don’t rely on remembering a date. If it is something like the 1st day of each month it will be easier but you also need to record it has been cleaned or primed.

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Now to prime the spacer you have to wash it in warm soapy water. This is dishwashing liquid, not any other type of soap and then you allow it to air dry, which means you turn it upside down on a paper towel and let it dry naturally.

Slide 15

Never wipe the inside of the spacer or rinse it or put it in the dishwasher. Spacers are plastic and hold a lot of static and dishwashing liquid does is provide a coating on the inside of the spacer and has been proven to lower the static in them. Static in the spacer means that the full medicine does may not be received by the person as some of the medicine may stick to the sides of the spacer. By washing it in dish washing liquid will make sure this does not happen.

Slide 16

Now there are some important notes you must know. Firstly never share a spacer. Each person must have their own spacer with their name on it. Neither do you share inhalers. If a person has run out of medication make sure you tell the registered nurse so they can order more or get a repeat prescription.

When you have given an inhaler dose, make sure you sign it has been given. If they refuse or it is not given for any reason, make sure this is noted on the medication signing sheet and record in their notes the reason why it was not given or refused.

Slide 17

Also make sure you record in their notes anything you noted. Was their breathing different after you had given the inhaler, did they have any difficulty breathing in the medicine. Did they sound wheezy in their chest – just anything you noted and also tell your registered nurse so they are aware of what is going on with the person? If the information is given to them as soon as you notice it, it could prevent the person from going into hospital.

You must also write either on the spacer or somewhere on the chart when the spacer was first used as they do need to be replaced every 6 to 12 months.

Segment 4 Transdermal Patches

Slide 1

Now let’s talk about transdermal patches.

Slide 2

So what are these? Well these are patches that deliver a controlled dose of medication over a period of time. The medication is contained in the patch and has either a porous membrane covering where the medication is stored or embedded in the patch so the release of the medicine will is controlled by the body melting the thin layers where the medication is embedded in the adhesive. This means the medication can be delivered through the skin continuously.

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Unfortunately not all medication can be delivered in this way because the skin is what is known as an effective barrier which can prevent the medication getting through the skin. So for this method of medication administration the molecules of the medication have be small enough to penetrate the skin.

Slide 3

The sorts of medications you may see given this way are Nitroglycerin which is used for people who suffer from angina or heart pain. By using a patch, it maintains a continuous dosage so the person is not crippled by chest pain.

Another one you may be familiar with is nicotine patches. These are used to help people stop smoking. You will have seen them advertised on TV or you may know of someone who has used them.

Analgesic, which are medicines for pain are increasingly being used in patches too. It can offer a sustained release, which means it releases medication over a period of time rather than one single dose of medication so the person can manage their pain better.

Slide 4

Now before we talk about applying a transdermal patch let’s look at some of the precautions or special things you must know about transdermal patches. Firstly never apply the patch to the same area twice. So you don’t take off the patch today and put another one in that same place after you have removed the old one. By this we mean you rotate the patch around the body. Now you will come back to that same part of the body at some time but it will be some days after you removed it. You can see on the diagram on this slide what I mean.

Now if you miss not putting a patch on the day it is supposed to be applied, don’t apply two at once thinking it will give them a catch up dose. It won’t. You are likely to over dose them with medication which could have serious side effects for the person or even an adverse event.

If a person is likely to pull the patch off, put it in a same area where they cannot reach it. If they cannot see it or feel it they are probably unlikely to be able to remove it.

Slide 5

Always apply it to a hairless part of the body as it is less likely to stick to a body that is very hairy. Now if the person has a lot of hair on the body check with your registered nurse to see if the area can be shaved or does it have to be clipped. Some medications cannot be applied to a shaved area so best for the registered nurse to find out from the pharmacist or it may be in patch instructions. The main thing is that it is placed on a part of the body that has little or no hair on it.

If the skin has a rash, is broken or scarred, do not apply the patch to these areas. It could affect the absorption of the medication by either the person not receiving enough medication or too much medication too quickly.

When applying the patch, do not remove the patch from the sticky pouch until you are ready to use it. It could be dropped and wasted or you could get some of it on your body. Rule of thumb – take off the sticky pouch and apply it immediately.

Slide 6

Do not let your skin touch the mediation on the patch as you will get some of the medication too. If this does happen you must wash your hands immediately under running water and dry thoroughly

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If for any reason the patch is torn or broken, do not apply it. Make sure you record that is was destroyed and why by completing and accident incident form or whatever the policy and procedures for your facility or organisation.

Always apply the patch to a flat area of the body so don’t put it on any area that has creases on it like the elbow or knee. It is best to apply it to the chest wall, upper arm or upper back. Check the manufacturer’s instructions on the leaflet so you know exactly the places it can be places and talk to your registered nurse if you are unclear with any instructions.

Slide 7

Never leave a patch on for longer than is prescribed. They have a time limit for a reason so make sure you remove it as instructed and reapply a new one somewhere else on the body if that is what is prescribed.

After applying the patch, wash your hand with clear water. Do not use soap or cleaners. However before you apply the patch to the person, wash your own hands in soap and water to make sure they clean and dry them thoroughly.

Also don’t apply a patch to skin that is oily as it will not stick to the skin. It may also inhibit the affect the absorption of the medication.

Slide 8

Do not use soaps, other cleansers, lotions or anything that contain alcohol or oil to the skin as it can interfere with the medication. Use only plain water to ensure the skin is clean and make sure you dry it well before you apply the patch

If the patch becomes loose or turns up at the edges, frame it with some tape around the edges or it may be okay to use a clear film cover but you do need to check with the registered nurse, pharmacist and/or read the manufacturer’s instructions to see if it is okay to do so. Remember, if in doubt ask before you do anything.

Slide 9

So how do you apply a transdermal patch? Well it is pretty simple now that all the precautions are dealt with and you know what to do. First thing you must do is read the instruction on the medication chart and on the box the patch comes in. Then wash your hands and make sure they are dry. Explain to the person what you are going to do.

Slide 10

Make sure the skin is clean and dry then apply the patch to the area. Just clean with plain water. Press down firmly with your hand to ensure it has stuck to the skin and that is it.

Slide 11

Finally sign on the medication sheet that you have applied the patch and record in the notes anything you noticed like the skin was red or had a rash on it after the patch was removed, the person refused to have it on or anything else you noticed or happened during this process. And don’t forget to inform you registered

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Segment 5 Suppositories, enemas and pessaries

Slide 1

Now I will talk about suppositories, enemas and pessaries.

Slide 2

Firstly let’s talk about suppositories and enemas. These are used for relief of constipation or ensuring constipation or preventing a person from having difficulty passing a bowel motion.

They are also used quite commonly for pain relief.

Slide 3

The first thing you must do is check either the medication chart or the care plan for instructions so you know what you are to give. You must make sure you give what is prescribed or instructed.

Then get the suppository or the enema out of the cupboard and take it to the person’s bedside. Now must give these while the person is lying down. You will not be able to get the suppository or enema in correctly if the person sitting on the toilet or standing up. It will just come straight back out again and it will not work. So it is a waste of medication, waste of money and no help what so ever for the person.

Slide 4

Explain to the person what you are going to do and get them to lie on their left side on the bed. Make sure you cover them with a blanket or sheet to preserve their dignity. All that should be exposed is the buttocks which should be as close to the edge of the bed as possible. Wash your hands and apply gloves. You may find it easier to wash your hands before you go to the person.

Slide 5

Insert the suppository or enema as high as possible in the rectum but make sure it touches the rectal wall. Putting it directly into faeces just won’t work. The medicine in the suppositories or enema is designed to work by getting the bowel to contract and expel the faeces. There is one exception here though and that is when you use glycerine suppositories. They are designed to actually soften the faeces,

Now the person will think they want to go to the toilet immediately but you need to get them to hold it in as long as possible to enable the medicine to work usually. This is usually about 20 mins if possible.

Now when you are giving suppositories as a medication for something like pain, they will probably not want to go to the toilet but it needs to be able to dissolve on the wall of the bowel for the medication to work.

Remove your gloves and wash your hands.

Slide 6

You will need to put a plastic sheet or disposable pad or sheet under the person as their bowels may start to move before you get back to the person. You do not want to cause them any embarrassment by making a mess and soiling themselves.

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You also need to make sure they are comfortable before you leave the room. It they are not comfortable they will want to get up off the bed.

Have a commode ready for them to use in case they are unable to make it to the toilet. If the person is at risk of wanting to get off the bed, you may have to sit with them for a while so the medication has time to work. If you do leave them on the bed make sure you return in 15 mins to assist them onto the commode or toilet.

Slide 7

Now here are some tips when using suppositories

If using glycerine suppository which can be a bit slippery, soak them in cold water or place them in the fridge to help make them be a bit firmer. This will not affect the suppository as they are just a jelly like substance that is designed to soften faeces.

Always use lubricating gel when inserting suppositories or enema’s to help them to go in the anus easily. It is also more comfortable for the person. It is a natural reaction for people to want to try and prevent anything from going into the anus and they may clamp down the anal area so you do not want to harm them or cause any unnecessary distress.

With the exception of a glycerine suppository, make sure the medicine in the suppository is able to be absorbed by the tissue in the bowel. Putting it into faeces will not enable it to work.

Slide 8

Pessaries are inserted into the vagina. They are used for two main reasons. One is as a medicine that is inserted to treat something like thrush. This may come as a cream or look like a large tablet. The other common use of a pessary is as a device that is inserted into the vagina for treating a prolapsed cervix.

I am not going to discuss these in any detail. You registered nurse will show you how to use them if you have a person in your care who needs a pessary inserted. However there are some videos in the resources section that will help you understand the use of pessaries.

Segment 6 Insulin Administration

Slide 1

Now we will look at giving insulin. A person with Type 1 diabetes will always be on insulin however more and more Type 2 diabetes people are being given insulin these days so it is likely you will find more people in your care on insulin. To find out more about diabetes though, go to the diabetes topic. In this segment I am only going to be talking about giving insulin. However to give insulin you must be trained by a Registered Nurse first.

Slide 2

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Insulin comes in short, medium and long acting. It is only ever given by sub-cutaneous injection more commonly via a small pen that has a cartridge inserted in it. The vial will usually have a combination of insulin i.e. short, medium or long acting that has been prescribed depending on the person’s requirement. Everyone needs different combinations so you must only give the insulin prescribed to the person. It cannot be taken in tablet form as the acid in the stomach destroys the insulin.

Insulin is always given into subcutaneous fat and never into the muscle. This is because it is absorbed much slower in the fatty tissue. If it is given into the muscle it will not last as long and the risk of becoming hypoglycaemic is greater. Plus it is likely to hurt if given into the muscle.

Slide 3

Spare cartridges or vial of insulin that are not in use must be kept in the refrigerator. This is because insulin is a protein dissolved in water and it can spoil if not kept in the fridge.

However the insulin in current use be it by Penmix cartridge or vials can and should be stored at room temperature. This will not spoil as insulin has preservative in and are designed to last up to 28 days out of the fridge but if it is left out longer than that eventually it will stop working. Bacteria begin to grow in the insulin, and start breaking down the protein.

Many people say injections of insulin are more comfortable when the insulin is not cold too and also, many people find it easier to get rid of air bubbles when the insulin is room temperature.

Before you give insulin you must do a blood sugar measurement and record this. Some people may be on a dose of insulin depending on what their blood sugar is however many are on a standard regular dose that has been found to stabilise their blood sugar.

Slide 4

Insulin is given thirty minutes before the meal is due so you need collect all the equipment in this time frame. You also need to check the medication chart as to how much insulin is to be given. You also collect the blood measuring equipment as you must check this before you give the insulin.

Slide 5

Next you take all the equipment to the person along with the signing chart. Wash your hands before you take the blood sugar measurement. It is also a good idea to wash the person’s hands as well. This is because if they have had something sweet on the area you take the blood sugar measurement from it can make the blood sugar reading appear to be high. Washing their hands before you start will avoid such a thing happening.

Slide 6

Now insulin has to be checked with a second person before you give it. This means you must also get them to check you have the correct insulin charted and also includes checking the expiry date of the vial or Penmix before you draw the insulin up into the syringe or dial it up on the pen.

The Insulin vial or cartridge should always be inverted and rolled in your hands about 10 times before giving the insulin to make sure the long and short acting insulin is mixed

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Dial up the correct amount or draw up the insulin in a syringe.

Slide 7

Get the second person to check the amount is correct.

Next you choose the site you are going to inject into. It is important here that you do not always inject into the same area. You must rotate the sites. You will see the sites you can use in slide 14

Pinch the fatty tissue between your thumb and first finger and then insert the needle into the subcutaneous fat at 90⁰ angle. The fat layer is usually thicker than the needle length which is why insulin is usually given in the stomach. If you do not inject at a 90 degree angle, you may end up with a lump under the skin. This means you may have got between the first two layers of the skin and while the insulin will eventually be absorbed, you may find the blood sugars are a little higher than normal for a while.

While most people have a good deal of fat in their stomach area, if a person is particularly thin the needle may have to be put in at a 45 degree angle. However, your registered nurse will advise you if this is the case. Always remember, if you are unsure ask. This way you will not only keep yourself safe but also the client.

Skin does not need to be wiped with an alcohol swab before insulin is given. Providing basic hygiene is applied and a person has a regular bath or shower, the likely hood of getting an infection is very small so the skin does not need to have any special care before injecting. Alcohol swabs do not sterilise the skin, it only cleans it like soap and water so unless there is some reason why the area you are injecting into have become really dirty then special cleaning of the area is not necessary.

Slide 8

Then press the end of the syringe or pen and administer the insulin.

Once the insulin has been administered, leave the needle in the skin for about 5 seconds to make sure all the insulin has been administered. You need to also make sure there is no airlock or blockage in the needle to ensure the full dose of insulin is administered.

Next you sign that the insulin has been given and record the site you gave it into.

Slide 9

Then return all the equipment to the storage area.

Don’t forget to report any observations you have made to the registered nurse and write them in the notes.

Now in your facility, you may check the insulin out in the medication room and just take it to the resident. This is fine as you must follow the policies and procedures of where you are working.

Slide 10

There are some precautions you should take when giving insulin. One is to be careful you do not prick yourself with the needle. While ordinarily you would never recap a needle, insulin pens needles can be used for up to a week. Here lies the dilemma. The needle must be recapped and placed in the protective pouch that the manufacturer

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provides. So I would suggest that you get the person to recap their own needle if they can or refer to the policies and procedures of your organisation and check with your registered nurse what you should do.

Slide 11

A word about blood sugar levels. These must always be taken and recorded before you give insulin. If it is below 4 do not give the insulin and report this to the registered nurse or doctor and they will tell you what to do.

Slide 12

So let’s now have a look at what an insulin pen might look like. You can see in this picture that it just looks like a pen. It has a very fine and small needle at one end and it has a button at the other end. In the middle you will see an insulin vial that has graduated numbers on it. Inside the pen is a rubber bung. You dial up the insulin to the number on the dial as per the amount to be given on the medication chart. Now when you push the button down on the pen when you are giving the insulin, it will gradually push the plunger down and over a number of days, use up all the insulin in the vial. You will then need to replace it with a new vial.

A Penmix needle can be reused for up to a week although the manufacturers recommend it as a single use only. It is the only time a needle is ever recapped. Where possible get the client to inject their own insulin. They will have been specifically trained to do this. It is safe for them to recap their own needle.

If you have to recap the needle, I suggest you do not hold the needle cap between your fingers rather you place the needle cap on a flat surface and slide the needle into the cap. Once it is in the cap, you can then secure the cap with your fingers.

You must at all times keep yourself safe and if by any chance you do sustain needle stick injury make sure you fill out an Accident Incident Form and notify your Registered Nurse immediately. They will advise you what to do.

Slide 13 – Insulin Sites

These are the sites used for administering insulin. It is more commonly given in the stomach area as the absorption rate is quicker however it can be given in the legs, arms or buttocks as shown on the diagram but it takes longer to be absorbed by the body. Always rotate the sites in which insulin is given in a circular motion if possible. It is a good idea to record the site you use each time you give insulin to prevent it being giving in the same site all the time. Some people have a site grid that they use to make sure a different site is used each time. If you use the same spot repeatedly, your body reacts by creating changes in the fatty tissue just under the skin. It can either cause the fat tissue to deteriorate, and create a pit under the skin or it can grow a little extra fat tissue there, and create a lump just under the skin. Either one of these will change the absorption time of insulin. Slides 15-17 will show you what these complications look like.

Slide 14

Now let’s look at what can go wrong if you do not rotate the sites. One condition is Lipoatrophy which is where there is a loss of subcutaneous or the fatty layer under the skin where the insulin is injected into. You will recognise it by a pitting appearance of the skin. While these are rare immune reaction, you need to know that if it occurs it has to be reported immediately. It can be prevented by changing to a highly purified insulin preparation. As you can see it is easy to recognize.

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Slide 15

Another condition is Lipohypertrophy. This is where the fatty tissue or subcutaneous layer becomes thickened and hard. Essentially it is a lump of fatty tissue that develops under the skin when insulin is injected into the same site repeatedly. You can see it on this slide what it looks like. However rotation of sites reduces the risk of this complication occurring.

Slide 17

Some people can get a generalized skin rash as you see in this image. While this is also rare, you need to be able recognize any problems that may occur and report them.

So it is really important for you to report any skin problems around the injection site that you observe immediately.

Slide 18

Now some final notes on Insulin administration.

Always wash your hands before drawing it up the insulin or administering it. This is basic infection control principles that you should know.

It is always better for the person to give their own insulin where possible. While you may have to draw up the insulin or dial up the right amount for them to give it if they have poor eyesight or some other cognitive problem they probably can still be able to give it themselves.

Do not give insulin unless you have been properly trained and are comfortable with giving it. You do not need to put yourself or the client in your care at risk.

Slide 18

If a client is not eating, do not give the insulin. Report this to the registered nurse or doctor and await instructions and record these instructions in the client notes. If do give insulin and they are already hypoglycaemic this could actually kill them.

You must always check the blood sugar measurement before you give insulin.

Slide 19

If the blood sugar level is below 4 withhold the insulin and check with your Registered Nurse or Medical Practitioner for instructions and always write down the instructions you were given. This way you are less likely to make any errors and you are covering yourself if anything goes wrong.

Once a person has been given insulin they must have food within 30 mins so don’t just give it because it is the right time on the chart or it fits in with your work schedule. Make sure that the meal is ready for them so they can eat within the required time.

Remember always check with your Registered Nurse or Medical Practitioner if you have any doubts.

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