s upporting t he use of m edication in c are...
TRANSCRIPT
SUPPORTING THE USE OF MEDICATION IN CARE SETTINGS carer edition
CONTENTS
Chapter 1MEDICATION lAw
04 The Medicines Act04 ���Legal classification of medicines 04 Controlled Drugs05 Common Controlled Drugs05 Data Protection Act05 Best Practice
Chapter 2SERVICE USER PRESCRIPTIONS
06 Acute prescriptions06 Repeat prescriptions 06 Ordering repeat prescriptions07 ���Who orders the prescriptions?07 Medication Reviews07 Managed repeats
Chapter 3SAFE STORAGE & HANDlING OF MEDICATION
08 Temperature/light/moisture 09 Fridge items 10 Use of gloves10 ‘When required’ medicines 11 Monitored Dose System
Chapter 4ADMINISTERING MEDICATION SAFEly
12 Safe working practice 13 Basics of administering medication14 Pharmacy labels
Chapter 5wHEN PATIENTS DEClINE MEDICATION
18 Recording declined medication 18 Putting back medication in the pack19 ���Covert administration
Chapter 6INFORMATION AbOUT MEDICINES
21 Drug interactions
Chapter 7ADMINISTERING SOlID ORAl MEDICINES
22 Swallowing difficulties23 Crushing tablets and opening capsules23 Enteric coating24 What if patients chew medication? 25 What if patients vomit after
taking medication?25 Lozenges and pastilles25 Sublingual tablets 26 Buccal tablets
Chapter 8ADMINISTERING ORAl lIqUIDS
27 Medicines spoon27 Measuring cups 28 Oral syringes
Chapter 9APPlyING TOPICAl MEDICATION
30 Creams/lotions/ointments/gels30 Medicated and non-medicated topicals31 ���Wearing gloves 32 Applying barrier creams 32 Applying moisturisers33 Soap substitutes 33 Applying non-medicated ointments34 Bath oils34 Applying medicated topicals35 Applying medicated patches
Chapter 10ADMINISTERING INHAlED MEDICINES
36 Relievers36 Preventers 38 Combination inhalers38 COPD 38 ���Models of inhaler 39 ���Spacer devices 40 ���Administering an inhaler
with a spacer device
Chapter 11ADMINISTERING MEDICATION TO THE EyE, EAR & NOSE
42 ���Eye drops43 Administering eye ointments43 ���Patients who find it hard to
keep their eye open43 If a second drop is needed afterwards44 Administering eye drops 44 Administering nasal drops45 Administering ear drops
Chapter 12IMPORTANT MEDICATIONS OFTEN TAkEN by THE ElDERly & HOw TO ADMINISTER
46 Alendronic Acid46 Calcium supplements
47 references
04
MEDICATION lAw
Chapter 1
THE MEDICINES ACT 1988
+���Anyone�can�administer�a�prescribed�medicine�to�another�person�but�must�follow�instructions�from�prescriber�–��i.e.�what�is�on�the�label�
+���Prescription�medicines�must�only�be�administered�to�the�person�they�are�prescribed�for,�they�remain�the�property��of�the�patient�and�must�not�be�shared�with�others
CONTROllED DRUGS
+���CDs�are�ordered�on�prescription�in�the�same�way�as�all�other�medicines
+���Care�professionals�are�allowed�to�collect�CDs�from�the�dispensary�but�you�must�provide�some�form�of�identification�–�you�will�be�asked�to�provide�your�name�and�sign�to�say�you’ve�received�the�CDs.
+���If�you�are�receiving�a�delivery�of�CDs�from�the�dispensary�then�you�are�normally�asked�to�sign�something��to�say�you�have�received�them.
+���Generic�name�=�Name�of�the�drug�e.g.�ibuprofen
+����Brand�name�=�Name�each�manufacturer�gives�that�drug�e.g.�ibuprofen comes�as�Nurofen
lEGAl ClASSIFICATION OF MEDICINES
GSl: General Sales list Can�be�bought�without�prescription�from�any�shop/supermarket.
P: Pharmacy Only Medicine Can�only�be�bought�in�pharmacies�under�pharmacist�supervision,�often�kept�behind�counter.
CD: Controlled Drug Has�the�potential�to�be�abused/stolen.�Stored�in�a�metal�cabinet,��recorded�in�CD�register�and�with�a�witness�present.
POM: Prescription Only Medicine Can�only�be�obtained�with�a�prescription�and�only�for�the�patient�stated.
DATA PROTECTION ACT
+���Describes�the�information�you�can�share�about�patients�e.g.�medication�details,�health�problems�etc.
+���Ensures�patient�confidentiality�and�privacy.�+���The�act�states�that�you�should�only�share�
sensitive�information�about�patients�with�people�who�need�to�know�if�it’s�in�the�patient’s�best�interest.�For�example�with�colleagues,�doctors,�nurses,�pharmacists,�social�workers�etc.
+���You�should�not�disclose�details�about�patients�to�friends,�family�or�anyone�else�who�doesn’t�need�to�know.
bEST PRACTICE
+���Means�the�current�best�way�of�working�to�get�the�best�results
+���For�medicines�–�guidance�is�issued�by�Royal�Pharmaceutical�Society�of�Great�Britain�who�published�‘The�Handling�of�Medicines�in�Social�Care’�in�2007.
GENERIC NAME USES bRAND NAMES/FORMUlATIONS
Temazepam Sleeping�tablet Generic�tablets,�oral�solution
Morphine Pain�killerOramorph�liquid,�MST�tablets,�MXL�capsules,��Zomorph�capsules
Diamorphine Pain�killer Generic�tablets,�syrup,�injection
Dipipanone Pain�killer Diconal�tablets
Fentanyl Pain�killerAbstral�tablets,�Effentora�tablets,�Instanyl�nasal�spray,��Actiq�lozenges,�Durogesic�DTrans�patches
Hydromorphone Pain�killer Palladone�capsules
Methadone Pain�killer Physeptone�liquid�and�capsules
Oxycodone Pain�killer Oxynorm�capsules,�Oxycontin�tablets
Pethidine Pain�killer Generic�tablets�and�injections
Buprenorphine Pain�killer Temgesic�tablets
Pentazocin Pain�killer Fortral�tablets
Methylphenidate ADHD Ritalin�tablets,�Concerta�XL�tablets
COMMON CONTROllED DRUGS
05
SERVICE USER PRESCRIPTIONS
Chapter 2
Two�types�of�prescription�produced�by�the�surgery:�acute�and�repeat.
ACUTE PRESCRIPTION
+���For�acute�illnesses�that�occur�suddenly�over�a�short�period�of�time�e.g.�cough,�cold,�athletes�foot,�infection.�An�acute�prescription�is�a�one�off�prescription�for�a�short�course�of�medication�–�once�it�is�finished�there’s�usually�no�need�to�order�any�more�unless�the�illness�hasn’t�cleared�up.�In�this�case�the�doctor�will�need�to�be�contacted�and�may�want�to�see�the�patient�again.
REPEAT PRESCRIPTION
+���Repeat�prescriptions�are�for�chronic�illnesses�which�are�long�lasting�and�can’t�normally�be�cured.�Examples�include:�asthma,�high�blood�pressure�and�arthritis.�If�a�patient�needs�to�take�a�particular�medication�for�a�long�time�the�doctor�can�issue�a�repeat�prescription.�There�is�no�need�to�make�an�appointment�to�see�the�doctor�each�time�they�need�more�of�that�particular�medication.�
+���Repeat�prescriptions�are�usually�for�28�days�worth�of�medication,�however�the�patient�can�ask�the�doctor�for�more�than�28�days�worth�if�need�be.
ORDERING REPEAT PRESCRIPTIONS
+����Each�repeat�prescription�comes�with�a�white�tear-off�repeat�slip�attached�to�it.�This�is�a�form�used�to�order�another�prescription.�Each�item�of�medication�that�the�person�can�have�is�listed�on�the�repeat�slip�–�to�order�more�of�an�item�the�box�needs�to�be�ticked�and�the�slip�dropped�into�the�box�in�the�surgery
+�����To�order�a�repeat�prescription,�the�dispensary�needs�a�written�request.�
+�����In person:�simply�drop�your�repeat�slip�into�the�practice.�If�you�have�lost�this,�ask�and�we�will�print�you�off�another�one.
+����by fax:�fax�your�repeat�slip�to�the�practice+����by email:�go�onto�the�practice�website�
and�follow�the�link�on�the�front�page�that�says�‘prescriptions’�
+����by post:�send�your�repeat�slip�to�the�practice.�
Allow a minimum of two working days for a prescription to be sent to the chemist. Please note we do not take requests over the phone due to the risk of errors occurring and overloading an already busy phone line.
06
wHO ORDERS THE PRESCRIPTIONS?
+�����It�needs�to�be�clear�who�is�responsible�for�ordering�the�medication�and�should�be�recorded�in�the�care�plan.�It�may�be�a�family�member�or�a�carer.�If�there�are�a�number�of�different�carers�going�in�to�see�the�patient�everyone�needs�to�be�clear�about�who�will�be�doing�the�ordering.�
+����Don’t�just�re-order�the�same�items�each�month�–�always�check�to�see�which�items�are�needed.�Medicines�taken�on�a�‘when�required’�basis�are�not�always�taken�every�day,�therefore�there�may�be�enough�left�over�from�last�month.�
+�����If�the�patient�has�run�out�of�medication�ask�for�‘urgent’�to�be�written�on�the�repeat�slip�and�it�will�be�put�towards�the�top�of�the�pile�–�the�medication�will�possibly�be�ready�for�collection�the�same�day.
MEDICATION REVIEwS
+�����Medication�reviews�are�required�to�ensure�the�patient’s�medication�is�correct�and�up�to�date.�These�may�be�at�a�clinic�(LTMC),�with�a�GP/nurse/pharmacist�and�may�be�conducted�via�a�phone�call�appointment.�
MANAGED REPEAT MEDICATION FOR DISPENSARy
+����We�offer�a�managed�repeat�service�where�you�can�order�what�you�need�for�next�month�when�collecting�your�prescription.�This�makes�ordering�easier�as�it�is�one�less�trip�to�make�and�helps�you�to�only�order�what�you�need.�Please�enquire�at�the�Stowhealth�complementary�shop�regarding�this�service.
This�half�is�your��prescription�to�obtain��
your�medication.
This�half�is�your�repeat��list�which�you�should��keep�to�enable�you�to��
order�more.
REVIEW�DATE�-�your�medication�needs�reviewing�by�this�date.��
See�“Review�Dates”.
Tick�the�box�if�you�need�more��of�this�item.�If�you�don’t�need��
any,�leave�it�blank
GUIDANCE
Filling�in�a�repeat�prescription
07
SAFE STORAGE & HANDlING OF MEDICATION
Chapter 3
Medicines�are�affected�by�the�environment�in�which�they�are�kept�and�can�be�affected�by:
TEMPERATURE
+�����Most�medicines�need�to�be�stored�at�room�temperature�(below�25°C)
+�����Too�hot�=�the�active�ingredient�can�degrade�(go�off)�or�liquid�medicines�can�grow�microbes.�Some�medicines�are�so�sensitive�to�heat�that�they�need�to�be�refrigerated
+�����Too�cold�=�medicines�can�also�degrade�especially�if�they�are�allowed�to�freeze�or�drop�below�a�certain�temperature
lIGHT
+����Light�can�also�cause�medicines�to�degrade.�This�is�why�bottles�that�pharmacies�dispense�into�are�made�of�brown�plastic�in�order�to�reduce�the�amount�of�light�that�gets�in.
MOISTURE
+����Moisture�can�reduce�a�tablet’s�ability�to�dissolve�or�even�break�down�the�active�ingredient.�Sodium�valproate�tablets�(an�epilepsy�drug)�are�sensitive�to�moisture.
+����Places�to�avoid�storing�medicines�include�the�cupboard�above�a�kettle�–�heat�and�steam�could�damage�them,�on�a�window�sill�–�sunlight�and�heat�could�again�damage�them.�Dressings,�food�supplements,�urine�bags�and�catheters�should�not�be�stored�directly�on�the�floor�as�any�spillages�can�get�them�wet.�
+�����There�are�occasions�when�a�self-medicating�patient�may�place�themselves�at�risk�by�taking�too�much�of�their�medication.�If�this�happens�often�a�risk�assessment�can�be�carried�out�to�decide�if�it�is�safe�for�them�to�carry�on�self-medicating.�If�not,�it�may�be�safer�to��store�the�medication�directly�away�from�the�patient.�
+�����Medications�should�be�ideally�be�kept�in�the�patient’s�locked�medicine�cabinet.
+�����If�there�is�a�risk�that�the�patient�will�still�gain�access�to�their�medicines�then�it�is�acceptable�to�store�them�in�the�manager’s�office�or�somewhere�else�away�from�the�patient.�However�this�must�be�an�exception�rather�than�the�norm�and�a�risk�assessment�must�have�concluded�that�this�way�is�in�the�patient’s�best�interest.�Staff�must�ensure�that�medicines�are�kept�securely,�at�the�correct�temperature,�with�keys�that�are�held�securely�and�that�fridges�are�monitored.�
08
09
ITEMS THAT NEED TO bE STORED IN A FRIDGE
+����You�would�know�that�a�medicine�needs�to�be�stored�in�the�fridge�by�the�presence�of�a�bag�label�saying�‘fridge’,�on�the�label�or�in�the�patient�information�leaflet.
+����Some�items�which�are�normally�kept�in�the�fridge�are�stable�at�room�temperature�for�short�periods�of�time�and�can�be�kept�out�of�the�fridge�for�the�time�they’re�being�used.�For�example,�some�types�of�eye�drops�such�as�Xalatan�and�Xalacom�(used�for�glaucoma)�are�usually�stored�in�the�fridge�but�can�be�stored�at�room�temperature�for�four�weeks.
+����Always�write�the�date�you�first�open�the�eye�drops�on�the�bottle�and�box.
+�����Avoid�placing�medicines�at�the�back�of�the�fridge�as�they�can�get�pushed�against�the�back�plate�of�the�fridge�and�freeze�which�can�damage�medicines.�
+����Drugs that cause rashes and cytotoxics: Chlorpromazine�(used�in�mental�health)�can�sometimes�cause�rashes�in�people�who�frequently�handle�the�uncoated�tablet�or�spill�the�liquid�on�them.�It�is�a�COSHH�requirement�to�wear�gloves�in�the�handling�of�uncoated�methotrexate�(used�in�treatment�of�arthritis�and�psoriasis).
MEDICINES PRESCRIbED AS ‘wHEN REqUIRED’
+����Also�known�as�PRN�and�are�medicines�that�are�only�taken�when�needed.�Examples�include�pain�killers,�laxatives,�indigestion�treatments�etc.�
+����PRN�medicines�should�be�offered�to�the�patient�–�if�they�do�not�want�or�need�them�then�you�do�not�have�to�let�the�doctor�or�supervisor�know.�They�are�not�refusing�them;�they�just�don’t�need�any�at�that�particular�time.�
10
USE OF GlOVES
No need to wear gloves for the following:
+����Coated tablets and capsules:�most�tablets�are�coated�in�a�film/sugar�coating�so�you�don’t�touch�the�drug�inside.�Capsules�are�coated�in�plastic�so�there�is�no�risk�of�absorbing�any�medication�through�your�own�skin.
wear gloves for the following:
+����Topical creams, ointments etc: Wear�gloves�or�wash�hands�after�application�of�medicated�topical�to�prevent�any�medication�absorbing�through�your��own�skin
+�����Uncoated tablets (if you are allergic or pregnant): Unlikely�that�any�medication�would�absorb�through�your�own�skin�but�a�small�theoretical�risk�–�only�problematic�if�you�were�allergic�to�that�particular�drug
+����Oral liquids (if you think spillage onto your own skin could occur): If�you�spilled�liquid�medication�onto�your�skin�and�failed�to�wash�it�off�you�could�get�a�small�amount�showing�up�in�your�blood�stream.
MONITORED DOSE SySTEM
+����Also�known�as�MDS,�blister�packs�or�NOMAD�trays�and�contain�a�whole�week’s�worth�of�medication�
+����Always�check�you�have�the�current�week’s�pack�and�check�the�patient’s�name�carefully
+����You�cannot�give�medicines�from�MDS�packs�that�have�been�filled�by�friends�or�family�as�there�would�be�no�pharmacy�labels�attached.�As�well�as�labels�there�should�also�be�a�written�description�of�the�tablets/capsules
MDS�pack Dosette�box
11
ExAMPlES
Medicines�that�need�to�be�refrigerated�
Examples of medication that is unsuitable for MDS packs:
+����Some�types�of�tablet�and�capsule�are�not�stable�enough�to�be�placed�in�MDS�packs�as�moisture�can�enter�and�cause�the�active�ingredient�to�degrade.�Also�the�tops�of�the�packs�are�clear�–�allowing�light�in�which�can�damage�certain�medicines.�Medicines�in�MDS�packs�are�only�stable�for�eight�weeks.�
+����Soluble�tablets,�dispersible�tablets�or�sublingual�tablets�(under�the�tongue)�or�anything�that�cannot�be�swallowed�whole.
+����PRN�medicines�–�if�they�are�placed�in�an�MDS�pack�they�tend�to�be�given�to�patients�regularly�instead�of�only�being�given�when�they�are�needed.�
12
ADMINISTERING MEDICATION – SAFE wORkING PRACTICES
Chapter 4
SAFE wORkING PRACTICE
RIGHT MEDICATION
TO THE RIGHT PATIENT
AT THE RIGHT DOSE
AT THE RIGHT
TIME
IN THE RIGHT
wAy
SAFE wORkING PRACTICES ARE TO PROVIDE:
The�right�medication�to�the�right�patient�at�the�right�dose�in�the�right�way�at�the�right�time
1 If�unfamiliar�with�the�patient�read�the�care�plan�to�find�out�which�tasks�you�need�to�carry�out�and�any�personal�preferences�they�have
2 Check�you�have�the�current�medicines�chart�and�any�other�paperwork�needed
3 Wash�your�hands�or�wear�gloves�if�needed
4 Check�if�the�patient�has�already�taken�or�been�given�any�doses�check�the�medicines�chart�or�check�with�patient
5 For�PRN�medication�check�any�when�required�protocols�or�ask�the�patient�if�they�need�the�item
6 If�you�are�giving�from�MDS�packs�check�that�you�have�the�correct�weeks�pack�for�the�right�patient.�Check�the�medicines�chart�to�see�how�many�items�are�due.�Check�the�MDS�pack�and�make�sure�the�blister�you�are�about�to�pop�out�has�the�right�number�of�items�in.�Check�for�any�items�listed�on�the�medicine�chart�not�in�the�MDS�pack
8 Read�any�warning/cautionary�and�advisory�labels�on�the�pharmacy�label�e.g.�take�with�food�and�act�on�them
9 Administer�each�item�according�to�‘best�practice’
10 Observe�the�patient�take�each�item
11 Enter�the�correct�code/your�initials�on�the�medicine�chart�only�when�you�personally�have�seen�the�patient�take�or�use�the�item�or�decline�it
bASICS OF ADMINISTERING MEDICATION
GUIDANCE
7 If�you�are�giving�any�medicines�not�in�an�MDS�pack,�compare�the�pharmacy�label�with�the�entry�on�the�medicines�chart.�Make�sure�the�following�details�agree:��1�Drug�name��2�Drug�strength��3�Form�of�the�drug��4�Directions��5�Patient’s�name��6�Expiry�date
13
1 NAME OF THE DRUG
The�same�drug�can�have�two�names�the�generic�(e.g.�diclofenac)�and�the�brand�name�(e.g.�Voltarol).�Make�sure�the�name�on�the�label�matches�the�name�on�the�medicines�chart.�If�the�medicines�chart�has�the�brand�name�and�the�label�has�the�generic�name�(or�vice�versa)�it�may�still�be�okay�to�administer�the�medicine�(you�can�check�with�a�pharmacist�for�clarification).
PHARMACy lAbElS
2 STRENGTH
The�same�medicine�can�come�in�many�different�strengths,�so�check�you’ve�got�the�correct�one.�Strengths�are�written�in�various�ways�for�example:�
+��Grams�(g)+���Milligrams�(mg)�there are 1000
milligrams in one gram+���Micrograms�(mcg)�there are 1000
micrograms in one milligram
Typical�pharmacy�label
Asprin��������75mg��������dispersible�tablets������28
Take�ONE�tablet�Daily
Dissolve�or�mix�with�water�before�taking��Take�with�or�after�food�Contains�aspirin
Mr John Greene 23 March 2012
1 Name 2 Strength
4 Direction
5 Patient’s name
6 quantity
7 Cautionary and advisory labels
8 Date of dispensing
14
GUIDANCE
3 Form
15
For�example:�
+��Warfarin�0.5mg�tablets+��Warfarin�1mg�tablets+��Warfarin�3mg�tablets+��Warfarin�5g�tablets+��Digoxin�62.5mcg�tablets+��Digoxin�125mcg�tablets+��Digoxin�250mcg�tablets
The�strengths�of�liquids�and�creams�are�sometimes�written�as�a�percentage,��for�example:
+��Hydrocortisone�0.5%�cream+��Hydrocortisone�1%�cream
Some�medicines�are�only�available�in�one�strength�(e.g.�lactulose)�in�which�case�the�strength�isn’t�always�written�on�the�label�or�medicines�chart.��
3 FORM
Form�means�formulation.�Medicines�come��in�various�formulations,�for�example:+��Diclofenac�dispersible�tablets+���Diclofenac�gel+���Diclofenac�suppositories+��Diclofenac�injection+��Diclofenac�tablets+���Diclofenac�slow�release�tablets+��Diclofenac�capsules
4 DIRECTIONS
Sometimes�directions�are�written�as�‘Take�ONCE�daily’�on�the�label,�but�state�‘Take�ONCE�in�the�morning’�on�the�medicines�chart�(or�vice�versa).�This�is�okay�as�long�as�the�two�sets�of�directions�don’t�contradict�each�other.�Directions�such�as�‘take�as�directed’�(or�similar�wording)�are�not�acceptable�for�you�to�work�from.�The�dispensary/pharmacy�should�be�asked�to�seek�directions�from�the�prescriber�and�add�them�to�the�label.�
There�are�exceptions�for�this�rule:�drugs�whose�doses�vary�frequently�such�as�warfarin�or�insulin�can�be�labelled�‘Take�as�directed’.�However�there�should�be�a�way�of�finding�out�what�the�dose�is.�With�warfarin�you�should�always�check�the�laboratory�test�results�(INR�results)�before�you�give�the�dose.�These�INR�results�will�tell�you�how�many�milligrams�of�warfarin�to�give�the�patient.�Don’t�just�give�the�same�dose�of�warfarin�as�yesterday�without�checking�the�results�first�as�the�dose�may�have�changed.�
5 PATIENT’S NAME
Make�sure�the�patient’s�name�on�the�label�matches�the�patient’s�name�on�the�medicines�chart.�
6 qUANTITy
The�amount�of�medication�in�the�pack
7 CAUTIONARy AND ADVISORy lAbElS
These�warnings�are�put�on�the�label�automatically�by�the�dispensary’s�computer�system.�They�contain�important�information�such�as�whether�the�drug�needs�to�be�given�with�food�or�on�an�empty�stomach,�or�whether�the�drug�causes�drowsiness�as�well�as�other�important�information.�These�warnings�are�not�always�printed�on�the�medicines�chart�and�so�you’ll�need�to�check�these�on�the�label�before�administering�the�item�to�the�patient.�
8 THE DATE OF DISPENSING
Not�the�expiry�date,�the�date�when�the�item�was�dispensed,�i.e.�on�the�23rd�March�2012.�
16
ExPIRy DATES (MEDICINES OFTEN HAVE TwO)
+���The�expiry�date�before�the�pack�is�opened:�medicines�supplied�in�the�manufacturer’s�original�packaging�will�have�an�expiry�date�printed�on�the�pack�or�on�any�foil�strips.�Unfortunately�if�the�dispensary�repacks�the�item�into�another�container,�then�this�expiry�date�is�sometimes�lost.�When�this�happens�the�advice�from�the�regulators�is�to�assume�medicines�are�still�in�date�6�months�after�the�date�of�dispensing.�
+���The�expiry�date�once�the�product�has�been�opened:�most�medicines�contain�preservatives�but�they�don’t�protect�the�product�forever.�Once�you�open�a�pack�of�medication�it�starts�to�‘go�off’�(the�active�ingredient�degrades�and�becomes�less�effective.�Bacteria�can�also�start�to�contaminate�liquid�medicines.)�The�table�below�shows�examples�of�the�shelf�life�on�some�liquids.�
ITEM SHElF lIFE ONCE OPENED
Chlorpromazine�syrup� 6�months
Ditropan�elixir 28�days
Folicare 4�weeks
Frusol�liquid 3�months
Gastrocote�liquid 1�month
Largactil�syrup 1�month
Neoral�oral�solution 2�months
Oramorph�oral�
solution90�days
Phenergan�elixir 1�month
Risperdal�liquid 3�months
Antibiotic�liquids 7-10�days�(needs�to�be�refrigerated)
lIqUID SHElF lIFE
ITEM SHElF lIFE ONCE OPENED
Oral�liquids 6�months
Creams�in�tubes 3�months
Creams�in�jars/pots 1�month
Ointments�in�tubes 6�months
Ointments�in�jars/pots
3�months
Eye�drops 28�days
OTHER ITEMS SHElF lIFE
17
wHEN PATIENTS DEClINE THEIR MEDICATION
Chapter 5
+����We�all�have�the�right�to�refuse�medication��and�you�should�never�pressure�a�patient�into�taking�their�medicines�but�gentle�encouragement�is�okay
+����If�you�have�more�time�to�spend�with�the�patient�you�could�leave�their�medicines�chart�blank,�walk�away�and�try�again�later.�Patients�with�dementia�often�forget�they�declined�medication�so�you�may�be�able�to�offer�them�the�item�again
+����It�would�be�helpful�to�spend�some�time�talking�with�the�patient�to�find�out�why�they�don’t�want�their�medication�e.g.�they�find�tablets�hard�to�swallow�–�a�pharmacist�could�recommend�another�formulation.�They�also�may�not�know�why�they�take�the�item�-�in�cases�like�this�a�MUR�(medication�usage�review)�may�be�helpful.�If�you�have�a�patient�who�is�hiding�medication�from�you�instead�of�taking�it,�remind�them�that�they�have�the�right�to�refuse�medication.�They�don’t�need�to�pretend�that�they’ve�taken�doses�they�don’t�want.�
RECORDING wHEN MEDICINES ARE DEClINED
+����There�comes�a�point�when�you�have�to�code�the�medicines�chart�that�the�dose�was�declined�–�check�and�see�what�code�to�use.�Also�check�what�your�policy�is�on�declined�medication�–�some�people�contact�the�prescriber�straight�away,�some�contact�them�after�the�patient�has�refused�for�more�than�24�hours,�some�wait�longer.�It�also�depends�on�the�drug�declined.�The�time�period�can�be�agreed�with�prescribers.�
CAN I PUT A TAblET OR CAPSUlE bACk IN THE PACk?
+����If�a�tablet/capsule�has�come�from�a�blister�strip�or�MDS�then�you�won’t�be�able�to�put�it�back.�Don’t�be�tempted�to�try�and�re-seal�it�with�tape.�However�if�it�has�come�from�a�bottle�it�may�be�okay�to�put�it�back�although�take�great�care�to�check�you�are�putting�the�same�tablet/capsule�back.�
+����Check�that�the�patient�will�take�the�item�of�medication�before�you�remove�it�from�the�pack�so�you�won’t�have�to�deal�with�any�doses�you�have�taken�out.�
18
COVERT ADMINISTRATION+����If�the�patient�has�adequate�mental�
capacity�then�they�have�the�right�to�decline�their�medicines,�but�what�about�patients�with�limited�mental�capacity?�Laws�and�guidance�state�that�if�a�person’s�mental�capacity�is�under�doubt�than�an�assessment�of�their�mental�capacity�may�be�needed.�
+����In�cases�where�patients�lack�the�mental�capacity�to�take�and�understand�their�medications�there�are�certain�situations�when�we�can�hide�medicines�in�food�and�drink,�i.e.�give�a�person�their�medication�without�them�realising�it�(covert�administration).�However�one�of�the�difficulties�with�this�is�that�you�need�to�ensure�the�patient�swallows�the�entire�drink�or�meal�to�get�the�full�dose.�If�the�patient�shares�the�living�space�with�others�you�need�to�think�about�how�you’d�prevent�someone�else�finishing�their�meal�or�drink�and�inadvertently�swallowing�their�medicine.�
19
+����Don’t�confuse�covert�administration�with�putting�medicines�in�food/drink�to�help�someone�swallow.�If�the�patient�understands�that�their�medication�is�mixed�with�a�drink�or�food�then�this�is��not�covert�administration.�
+����The�doctor,�a�social�work�team,�family�members�and�a�pharmacist�would�all�have�to�be�consulted�before�covert�administration�could�take�place.�
20
INFORMATION AbOUT MEDICINES
Chapter 6
+����The�amount�of�knowledge�you�are�expected�to�have�about�the�medicines�you�administer�depends�on�how�many�different�types�you�encounter�on�a�day-to�day�basis.
+����It’s�very�important�you�have�the�right�forms�in�place�e.g.�care�plans,�medicines�charts,�PRN�protocols�etc.�These�forms�should�contain�all�the�information�you�need�to�give�medicines�safely�and�appropriately.�
THE lATEST AND bEST INFORMATION SOURCES THAT ARE AVAIlAblE TO yOU INClUDE:
+����Patient information leaflets:�pharmacies�are�required�to�supply�a�patient�information�leaflet�with�each�medicine�they�dispense�–�it�should�contain�all�the�information�you�and�the�patient�need.�Make�sure�the�leaflet�you�are�reading�is�up�to�date�as�information�about�medicines�sometimes�changes.�Patient�information�leaflets�should�be�made�available�for�the�patient�to�read�–�you�may�have�to�help�patients�with�limited�mental�capacity�understand�the�leaflets�by�reading�them�out�and�explaining�them�using�more�simple�language.
+����bNF: the�British�National�Formulary�is�designed�to�be�used�by�pharmacists/nurses/doctors�and�therefore�contains�quite�a�lot�of�medical�jargon�and�terminology.�However�it�contains�a�lot�of�detailed�information�on�medicines.�
+����www.bnf.org�the�British�National�Formulary�is�also�available�online�
+����New Guide to Medicines & Drugs book: The�British�Medical�Association�produces�a�useful�book�aimed�at�the�general�public�and�has�advice�about�what�to�do�if�a�particular�medicine�is�given�late.�
+����www.medicines.org/guides the�Electronic�Medicines�Compendium�(EMC)�provides�up-to-date,�reliable�and�understandable�information�about�medicines.�It�also�allows�you�to�download�patient�information�leaflets�for�many�different�drugs�simple�language.
BNF New�Guide�to�Medicine�&�Drugs
ExAMPlES
21
DRUG INTERACTIONS
+����Multiple�items�of�medication�can�interact�in�other�ways�to�produce�a�range�of�side�effects.�Some�examples�are:�some�cough/cold�treatments�contain�paracetamol�which�when�given�with�co-codamol�could�cause�a�paracetamol�overdose.�Ibuprofen�can�interact�with�a�number�of�medicines�such�as�lithium�with�sometimes�quite�serious�consequences.�
+����It’s�best�to�advise�any�patient�where�there’s�a�risk�that�medication�bought�over�the�counter�can�interact�with�their�prescribed�medications�or�hide�symptoms�that�might�need�investigating.�It’s�best�to�check�with�a�pharmacist�or�the�patient’s�GP�to�see�if�they�can�be�taken�together�safely.�
+����Some�policies�state�that�you�are�only�to�assist�with�medication�that�has�been�prescribed.�This�is�because�prescribed�items�will�already�have�been�checked�by�a�doctor�and�pharmacist�and�so�shouldn’t�interact�with�each�other.�If�you�are�giving�patients�items�of�over�the�counter�medication�then�these�should�be�added�to�their�medicines�chart.
ADMINISTERING SOlID ORAl MEDICINES
Chapter 7
SwAllOwING DIFFICUlTIES
+����Many�people�find�swallowing�tablets�and�capsules�difficult
+����The�wider�the�cup�the�better�as�the�patient�won’t�need�to�tip�their�head�back�to�get�to�the�liquid�-�makes�swallowing�more�difficult
+����Make�sure�you�have�filled�the�cup�to�the�top�with�liquid�otherwise�they’ll�need�to�tip�their�head�back
+����Some�people�find�it�easier�to�swallow�if�they�suck�the�liquid�up�with�a�straw
+����Swallowing�problems�can�also�occur�if�patients�suffer�from�a�dry�mouth�–�you�could�give�them�a�drink�to��wet�their�mouth�with�before�they�put�the�tablets�in�their�mouth.�
+����Many�people�find�it�easier�to�swallow�capsules,�sugar�coated�tablets,�or�a�liquid�formulation.�Talk�to�the�dispensary�to�see�if�they�can�change�the�formulation��if�necessary.�
+����Most�people�need�a�drink�in�order�to�swallow�tablets/capsules.�You�can�always�add�some�cordial�if�the�patient�prefers.�
+����Milk�can�affect�certain�types�of�medication�by�reducing�the�amount�of�drug�that�gets�absorbed.�Check�the�cautionary�and�advisory�warnings�on�the�label�if�it�says�‘do�not�take�with�milk’�then�you’ll�need�to�advise�the�patient�about�this.�
+����Most�types�of�fruit�juice�are�okay�however�grapefruit�juice�can�interact�with�nifedipine,�simvastatin�and�carbamazepine.�Cranberry�juice�can�also�be�a�problem�in�some�patients�taking�warfarin�–�there�should�be�a�warning�on�the�label�or�within�the�patient�information�leaflet.�
+�����The�caffeine�in�tea�and�coffee�can�interact�with�theophylline.�Another�problem�with�hot�drinks�is�that�patients�cannot�take�a�big�enough�‘gulp’�to�make�sure�the�tablet�is�swallowed�properly.�There�have�also�been�cases�where�soft�gelatine�capsules�have�melted�in�the�mouth�when�taken�with�a�hot�drink,�releasing�the�drug�into�the�mouth�which�can�taste�quite�bitter.�If�the�patient�has�milk�with�their�tea�or�coffee�check�the�label�to�see�if�it�says�‘do�not�take�with�milk’.�
+����Alendronic�acid�should�only�be�given�with�water�(no�cordial�and�not�mineral�water).�There�are�multiple�warnings�such�as�‘take�on�an�empty�stomach’��surrounding�alendronic�acid�which�can�be�found�in�the�patient�information�leaflet
22
CRUSHING TAblETS AND OPENING CAPSUlES
+����Some�tablets�are�designed�to�be�chewed�e.g.�Natecal
+����Some�tablets�are�designed�to�be�crushed�e.g.�Epilim�crushable�tablets�
+����You�could�find�this�information�by�reading�the�patient�information�leaflet.�However�if�the�tablets�you�are�administering�have�not�been�designed�to�be�crushed/chewed�then�don’t�crush�them�unless�you’ve�had�permission�from�the�pharmacist�and�doctor.�Permission�should�be�recorded�in�care�notes.��
+������Some�capsules�are�designed�to�be�opened�up�e.g.�Zomorph.�However�unless�it�states�in�the�patient�information�leaflet�that�you�can�do�this,�don’t�open�up�any�capsules�unless�you’ve�had�permission�from�a�pharmacist�and�doctor.�
You�have�to�be�cautious�when�determining�whether�tablets�can�be�crushed/chewed�for�the�following�reasons:
+����Some tablets are coated as�there�are�some�drugs�that�can�be�damaged�by�acid�in�the�stomach.�To�protect�them�they�are�coated�in�a�film�that�doesn’t�dissolve�in�acid�known�as�an�enteric�coating.�This�coat�will�dissolve�to�release�the�drug�in�a�more�neutral�or�alkaline�environment�once�it�passes�through�the�stomach�into�the�intestines.�Some�drugs�also�have�an�enteric�coat�to�stop�the�drug�in�them�irritating�the�stomach�lining.�
+����With�enteric�coated�tablets�and�capsules�there�is�always�a�warning�on�the�label�saying�‘swallow�whole,�do�not�crush��or�chew’.�
+������Some�tablets�have�a�sugar�(or�film)�coating�which�is�not�the�same�as�an�enteric�coat.�The�sugar�(or�film)�coating�is�just�there�to�make�the�tablet�easier�to�swallow.�These�coatings�will�dissolve�in�the�stomach�along�with�the�tablet.�The�pharmacist�might�give�you�permission�for�you�to�crush�sugar�or�film�coated�tablets.�
+����Some tablets and capsules are slow release which�is�a�mechanism�designed�to�release�the�drug�inside�slowly�throughout�the�day�(or�night).�This�means�that�instead�of�having�to�give�the�medicine�a�number�of�times�throughout�the�day,�the�tablet�or�capsule�can�be�given�less�frequently,�i.e.�only�once�or�twice�a�day.�By�crushing�slow�release�tablets/capsules�you�may�end�up�giving�the�person�an�overdose�as�the�entire�day’s�dose�is�released�in�one�go.�
23
+����With�slow�release�tablets�and�capsules�there�is�always�a�warning�on�the�label�saying�‘swallow�whole,�do�not�crush��or�chew’.
+����You�cannot�crush�tablets�or�open�up�capsules�that�are�not�coated�or�slow�release�unless�you�have�had�permission�from�a�pharmacist�and�the�doctor.�Giving�medicines�in�a�way�that�the�manufacturer�didn’t�intend�them�to�be�given�is�called�a�drug�‘off�licence’�or�giving�it�as�an�un-licensed�drug.�The�prescriber�has�to�be�asked�permission�if�any�drug�is�to�be�given�in�an�unlicensed�way.�
+�����It�is�okay�to�break�tablets�in�half�if�they�have�a�‘score�line’�on�them.�You�don’t�need�permission�from�the�pharmacist/doctor�because�the�manufacturer�has�designed�scored�tablets�to�be�broken�in�half�if�need�be.
wHAT IF THE PATIENT CHEwS THEIR TAblETS OR CAPSUlES?
+����Can�sometimes�occur�in�patients�with�dementia�where�swallowing�difficulties�can�occur.�It’s�only�enteric�coated�or�slow�release�tablets/capsules�that�you�need�to�worry�about.�This�is�important�because�if�a�patient�chews�a�slow�release�tablet,�they�could�end�up�having�an�entire�day’s�dose�in�one�go�which�could�be�dangerous.�Chewing�enteric�coated�tablets�might�stop�them�working�or�cause�stomach�irritation.�
+����If�any�of�the�medicines�patients�are�chewing�have�these�warnings�on�them�(swallow�whole,�do�not�crush�or�chew)�you’d�need�to�warn�the�patient�of�the�risks�and�let�the�pharmacist/doctor�or�another�health�professional�know�as�soon�as�possible.�
+�����If�the�tablets�that�they�are�chewing�are�not�slow�release/enteric�coated�then�there�will�be�no�warning�on�the�label,�however�you�could�still�contact�the�pharmacist��as�they�may�be�able�to�change�the�item�to�a�liquid�or�something�that�is�easier�to�swallow.�The�patient�would�not�be�putting�themselves�in�immediate�harm�by�chewing�tablets�that�are�not�slow�release�though.
24
Breaking�scored�tablets�
GUIDANCE
wHAT IF THE PATIENT VOMITS AFTER TAkING ANy ORAl MEDICATION?
�Unlikely�but�if�this�does�happen�then�contact��a�health�professional�(such�as�a�pharmacist)��they�may�advise�you�to�give�another�dose�if�you�can�see�the�intact�tablet/capsule�in�the�vomit�but�do�not�do�this�unless�you�have�checked�with�a�health�professional.�
lOzENGES AND PASTIllES
+����Occasionally�prescribed�by�doctors,�lozenges�and�pastilles�are�designed�to�be�sucked�and�should�be�held�in�the�mouth�for�as�long�as�possible�and�allowed�to�slowly�dissolve.�
+����Patients�taking�any�medication�that�needs�to�be�sucked�or�chewed�should�avoid�eating�or�drinking�anything�until�the�pastille�or�lozenge�has�fully�dissolved.�
SUblINGUAl TAblETS
+����Sublingual�tablets�are�designed�to�be�placed�under�the�tongue�instead�of�swallowed.�From�there�the�drug�absorbs�directly�into�the�bloodstream�and�so�it�is�able�to�work�more�quickly.�One�example�of�a�sublingual�tablet�is�glyceryl�trinitrate�(GTN)�used�to�treat�angina.
+����Once�used,�GTN�should�ease�chest�pain�within�1-5�minutes.�If�needed,�the���patient�can�have�another�GTN�tablet�after�5�minutes.�If�they�have�taken�3�doses�within�15�minutes�and�the�chest�pain�is�either�no�better�or�worse�then�you�should�call�a�doctor,�or�dial�999�as�the�patient�may�be�having�a�heart�attack.�GTN�can�sometimes�cause�a�headache�–�a�recognised�side�effect�and�although�uncomfortable�is�nothing�to�worry�about.
+����GTN�tablets�expire�8�weeks�after�opening�the�bottle�so�it’s�important�to�keep�them�in�their�original�container,�as�a�metal�seal�in�the�lid�and�the�glass�bottle�is�designed�to�protect�the�tablets.�Any�tablets�remaining�after�8�weeks�need�discarding�and�a�fresh�supply�is�required.�
25
26
Administering�buccal�tablets�
+����GTN�also�comes�as�a�spray�for�under�the�tongue.�The�spray�does�not�expire�after�8�weeks�and�may�be�used�until�its�empty�or�has�reached�its�expiry�date.�When�patients�feel�chest�pain,�they�should�spray�one�or�two�puffs�under�their�tongue.�It’s�important�that�the�canister�is�held�upright�when�spraying.�After�spraying,�the�patient�should�close�their�mouth;�otherwise�the�spray�can�evaporate�out�of�the�mouth.�GTN�tablets�and�spray�can�tingle�or�burn�under�the�tongue,�which�is�normal.�
Sublingual�tablets
bUCCAl TAblETS
+����Designed�to�be�placed�between�the�upper�cheek�(or�lip)�and�the�top�gum�where�they�sit�and�dissolve.�The�drug�then�gets�absorbed�directly�into�the�bloodstream�and�therefore�works�very�quickly.
+�����If�the�patient�has�a�dry�mouth,�you�can�moisten�the�inside�of�it�with�some�wet�cotton�wool.�If�you�have�a�patient�who�needs�this�type�of�tablet�regularly,�it’s�best�to�vary�the�place�where�the�tablet�goes�a�little�(to�stop�irritation).�Some�types�of�GTN�tablet�come�as�buccal�tablets.�Some�tablets�used�to�treat�nausea�and�sickness�are�also�available�in�this�form.�
GUIDANCE
ExAMPlES
27
ADMINISTERING ORAl lIqUIDS
Chapter 8
When�measuring�out�oral�liquids,�you�have�three�choices�of�what�to�use:
MEDICINES SPOON
Only�a�5ml�medicines�spoon�is�designed�to�accurately�hold�5mls�of�liquid�–�not�a�metal�teaspoon�or�any�other�type�of�spoon.�However,�most�people�tend�to�pour�out�less�than�5ml�–�only�3�or�4ml.�Whilst�this�may�be�less�important�if�measuring�out�items�such�as�cough�medicines�or�treatments�for�indigestion,�this�could�lead�to�more�serious�under-dosing�if�you�are�measuring�out�items�such�as�antiepileptics,�treatments�for�the�heart,�or�antibiotics�etc.�
To�pour�out�5ml�you�need�to�pour�a�heaped�spoonful�of�liquid.�
Although�spoons�are�not�good�for�measuring�out�liquids,�they�can�be�easy�to�administer�from.�If�the�patient�finds�it�hard�to�swallow�from�a�measuring�cup�or�oral�syringe,�you�can�always�transfer�the�medicine�to�a�spoon�after�measuring�it�out�accurately�using�another�device.�
MEASURING CUPS
Many�care�professionals�use�graduated�medicines�cups�to�measure�out�liquids.�If�you�are�using�these,�it’s�important�to�place�them�on�a�level�surface�to�check�you�have�the�right�dose.�If�you�hold�the�cup�up�to�eye�level,�you�can�end�up�holding�it�at�an�angle�resulting�in�you�measuring�out�the�wrong�dose.�
Medicines�cups�are�more�accurate�than�spoons,�but�many�people�tend�to�pour�too�much�into�them�(sometimes�6�or�7ml�when�aiming�for�5ml).�Also,�thick�medicines�can�be�left�behind�in�the�measuring�cup.�
Measuring�cups�are�better�for�larger�volumes�of�liquid,�e.g.�15�or�20ml.�This�is�because�over�measuring�by�1ml�when�aiming�for�20ml�gives�you�a�5%�error,�whereas�over�measuring�by�1ml�when�aiming�for�5ml�gives�you�a�20%�error.�
Generally�speaking,�most�people�manage�to�swallow�liquids�okay�from�measuring�cups.�However,�you�often�have�to�tip�your�head�back�to�get�the�last�of�the�medicine�from�the�cup.�Tipping�your�head�back�and�looking�up�can�make�swallowing�difficult.�This�might�be�a�problem�if�the�patient�has�a�swallowing�difficulty,�in�which�case�spoons�might�be�easier�(after�using�a�syringe�to�measure�out�the�dose�accurately).�
ORAl SyRINGES
Oral�syringes�are�the�most�accurate�method�of�measuring�out�liquids.�They�come�with�a�plastic�adaptor�which�you�push�into�the�bottle.�You�then�push�the�syringe�into�the�adaptor�and�turn�the�bottle�upside�down.�You�need�to�get�rid�of�the�air�gap�that�you�get�when�you�first�draw�the�liquid�up.�Push�this�air�gap�back�into�the�bottle.�A�few�small�air�bubbles�are�okay,�but�not�an�air�gap.�
If�you�are�holding�the�syringe�pointing�upwards,�make�sure�it’s�the�top�edge�of�the�black�ring�that’s�just�touching�the�underside�of�the�correct�mark.�
If�possible,�it’s�best�to�let�the�patient�use�the�oral�syringe�themselves.�This�way�they�have�control�over�how�quickly�they�push�the�liquid�into�their�mouth�and�it’s�also�more�dignified.�If�the�patient�can’t�do�this�on�their�own,�then�you�may�have�to�do�it�for�them.�Take�care,�as�choking�incidents�have�occurred�when�staff�have�pushed�liquid�in�too�quickly.�
It’s�good�if�you�have�found�a�technique�that�works�for�you�and�the�patient.�As�long�as�medication�does�not�dribble�out�of�their�mouth�and�they�find�the�technique�comfortable,�then�you�can�use�whichever�technique�suits�you�both.�However�the�technique�does�need�to�minimise�the�risk�of�choking.��
Rather�than�pushing�the�whole�of�the�syringe�into�the�mouth,�place�just�the�tip�of�the�syringe�between�the�front�lips�(which�remain�closed)�in�front�of�the�teeth.�If�you�push�the�syringe�in�between�their�teeth,�the�patient�won’t�be�able�to�clench�their�teeth�to�swallow.�
Some�people�place�the�whole�syringe�in�the�side�of�the�cheek,�between�the�teeth�and�the�inside�cheek.�Although�the�patient�can�clench�their�teeth�to�swallow,�they�can’t�form�a�seal�around�the�syringe,�and�liquid�can�leak�out.�Also,�you�can’t�see�how�much�liquid�you�are�squirting�in�at�a�time.�This�is�also�not�the�most�dignified�way�to�treat�the�patient�–�hence�just�place�the�tip�between�the�front�lips.
Not�all�patients�can�take�5ml�in�one�go.�If�this�is�the�case,�squirt�about�2.5ml�in�at�a�time�then�allow�them�to�swallow�this.�Once�they�have�swallowed�it,�push�another�2.5ml�in.�In�time,�you�may�find�that�the�patient�is�able�to�take�a�whole�syringe-worth�of�medication�in�one�go,�however�just�be�cautious�to�begin�with.�If�you�find�that�the�patient�doesn’t�get�on�with�syringes,�you�can�always�squirt�the�medicine�bit-by-bit�from�the�syringe�onto�the�spoon�and�give�it�that�way.�
28
Medicines�spoon� Measuring�cups
Oral�syringes
ClEANING ORAl SyRINGES
Clean�the�syringe�after�each�use�with�fresh,�warm�soapy�water.�Draw�the�plunger�in�and�out�several�times�until�the�inside�of�the�syringe�is�clean.�Separate�the�barrel�and�plunger�and�wash�both�in�soapy�water.�Do�the�same�to�the�adapter.�Rinse�under�cold�water�and�leave�un-assembled�to�dry.�
You�can�use�a�dishwasher,�but�that�doesn’t�clean�the�medicine�out�of�the�tip.�If�you�use�a�dishwasher,�flush�the�medicine�out�first�with�fresh�water.�If�you�are�administering�into�the�mouth,�oral�syringes�need�to�be�clean,�but�not�necessarily�sterile.�
Carry�on�using�the�oral�syringes�until�the�markings�fade.�
29
ExAMPlES
APPlyING TOPICAl MEDICATION
Chapter 9
Topical�products�are�products�applied�to�the�skin.�In�general�terms�this�means�creams,�lotions,�ointments�and�gels.�
+����Creams are�a�combination�of�oil�and�water.�They�also�contain�extra�ingredients�such�as�emulsifying�agents�which�allow�the�oil�and�water�to�mix,�and�preservatives�to�stop�microbes�growing�in�the�water�that�creams�contain.�Medical�creams�don’t�tend�to�contain�colours�or�perfumes�as�these�can�sometimes�irritate�the�skin.�
+�����lotions are�like�creams�but�are�designed�to�be�applied�over�larger�areas�of�skin.�For�this�reason�they�are�often�thinner�and�contain�more�water.�
+����Ointments are�mostly�made�of�oil�or�grease.�They�contain�either�no�water,�or�just�very�small�amounts.�Since�most�ointments�contain�no�water,�they�do�not�need�emulsifying�agents�added�or�even�much�in�the�way�of�preservatives.�Therefore�they�contain�fewer�ingredients,�which�means�they�are�much�less�likely�to�cause�skin�irritation.�Because�they�contain�more�oil,�they�moisturise�the�skin�for�longer,�This�is�because�the�oil�seals�the�water�in�the�skin,�preventing�the�skin�from�drying�out.�Some�patients�don’t�like�the�greasy�feel�of�them�although�they�do�make�excellent�moisturisers.�
+����Gels are�a�much�more�recent�invention�and�can�be�made�of�almost�99%�water�or�any�combination�of�oil�and�water.They�remain�fairly�solid�whilst�they�are�in�their�container,�but�become�softer�when�applied�to�the�skin.�
All of the above can have drugs added to them which would make them ‘medicated’ or they can be used as they are i.e. left as ‘unmedicated’ in which case they are often used as moisturisers.
+����Non-medicated�creams,�ointments,�gels�and�lotions�are�most�often�used�as�moisturisers.�An�example�is�aqueous�cream.�Moisturising�creams�are�normally�applied�quite�thickly.�With�moisturising�ointments,�less�is�needed�as�they�contain�more�oil.
+����Barrier�creams�and�ointments�are�in�a�class�of�their�own.�Examples�include�Sudocrem,�Conotrane�and�Cavilon�cream.�They�contain�a�type�of�silicon�which�sits�on�the�skin�and�acts�as�a�repellent,�keeping�irritants�such�as�sweat,�saliva,�urine�and�faeces�off�the�skin.�The�silicon�doesn’t�get�absorbed,�so�they�aren’t�really�‘medicated’�topicals,�but�because�some�of�them�also�contain�mild�antiseptics�they�aren’t�really�non-medicated�either.�
30
wEAR GlOVES wHEN APPlyING TOPICAl MEDICINES
It’s�best�to�wear�gloves�when�applying�any�medicated�cream/ointment/lotion/gel.�This�prevents�the�drug�absorbing�through�your�own�skin.�There�is�only�a�small�risk�of�this�happening,�especially�as�you’d�wash�your�hands�afterwards,�but�it�is�possible.�
It’s�best�to�spread�topical�products�(medicated,�non-medicated�and�barriers)�onto�the�skin,�rather�than�trying�to�rub�them�in.�Spread�them�down�the�limb�using�a�sweeping�motion�in�the�direction�of�hair�growth�(always�down,�away�from�the�body).�This�is�important�if�the�patient�has�hairy�skin�as�otherwise�you�end�up�brushing�the�hairs�the�wrong�way�which�can�be�uncomfortable�for�them.
Don’t�try�and�rub�topical�products�in�vigorously,�as�this�can�irritate�the�skin�and�will�take�a�long�time.�Skin�is�a�barrier�and�it�can�take�a�while�for�things�to�soak�through�(depending�on�what�is�applied).�As�far�as�creams�are�concerned,�they�are�mostly�made�of�water.�Most�of�this�water�dries�into�the�air,�rather�than�soaking�through�the�skin.�The�active�ingredient�is�then�left�behind�on�the�skin�to�soak�in.�Rubbing�creams�around�the�skin�just�heats�up�the�skin�and�causes�the�water�to�evaporate�more�quickly.�
31
Non-medicated�cream Medicated�cream
Barrier�cream
ExAMPlES
32
APPlyING MOISTURISERS
A�good�moisturiser�doesn’t�just�add�water�to�dry�skin,�it��adds�plenty�of�oil�to�it�in�order�to�fill�all�the�gaps�between�skin�cells�and�restore�the�skin’s�natural�barrier�function.�With�moisturising�creams,�the�oil�they�contain�has�been�diluted�with�water.�This�is�why�you�need�to�apply�so�much,�as�shown�below:
Most�patients�will�probably�not�want�you�to�put�this�much�on.�You�could�ask�them�to�try�it�for�a�week�to�see�what�difference�it�makes.�Depending�on�how�dry�the�skin�is,�it�takes�about�10-30�minutes�for�the�water�to�dry�off�(some�of�the�water�soaks�into�the�skin,�most�of�it�evaporates�into�the�air).�After�the�water�has�gone,�you�are�left�with�a�thin�layer�of�oil�on�the�skin.�The�oil�then�soaks�into�the�skin�over�the�next�few�hours.�It�fills�the�gaps�between�the�skin�cells,�which�seals�in�the�water�already�present�in�the�skin.�Once�you�have�applied�all�of�this�moisturising�cream,�the�patient�can�get�dressed�over�the�top�of�it�with�an�old�dressing�gown�or�clothes�which�they�don’t�mind�getting�a�little�greasy.�It�doesn’t�stain�most�clothing�(apart�from�silk)�as�the�oil�normally�remains�in�the�skin�rather�than�soaking�into�the�fabric.�Any�product�will�come�off�the�fabric�in�the�wash.�
Moisturisers�work�even�better�when�applied�to�wet�skin�as�they�lock�the�moisture�in.�It’s�best�to�pat�the�skin�dry�a�little�first�to�avoid�diluting�the�cream�too�much�with�water.�
Therefore�the�advice�is�to�stroke�topical�products�across�the�skin�and�leave�them�there�to�soak�in.�However,�although�it�is�usually�pointless�trying�to�rub�the�cream�in,�some�patients�enjoy�the�massaging�action�when�creams�are�applied.�If�massaging�the�skin�is�not�causing�any�irritation�and�the�patient�enjoys�it�then�carry�on.�It�won’t�cause�the�product�to�soak�in�more�quickly�but�it�might�help�the�patient�to�relax.�
APPlyING bARRIER CREAMS
Many�people�apply�barrier�creams�too�thickly.�You�should�stroke�a�small�amount�thinly�across�the�skin,�but�still�be�able�to�see�the�skin�through�the�cream.�If�the�skin�is�very�white,�then�you’ve�applied�too�much.�This�can�be�difficult�to�wash�off�and�the�patient�can�end�up�with�layer�upon�layer�of�barrier�cream�building�up.�The�result�is�that�their�skin�never�gets�cleaned�underneath�which�can�cause��skin�irritation.�
Therefore�the�advice�is�to�stroke�topical�products�across�the�skin�and�leave�them�there�to�soak�in.�However,�although�it�is�usually�pointless�trying�to�rub�the�cream�in,�some�patients�enjoy�the�massaging�action�when�creams�are�applied.�If�massaging�the�skin�is�not�causing�any�irritation�and�the�patient�enjoys�it�then�carry�on.�It�won’t�cause�the�product�to�soak�in�more�quickly�but�it�might�help�the�patient�to�relax.�
33
Some�patients�may�have�a�limited�understanding�of�why�you�have�to�apply�this�much�(e.g.�patients�with�a�learning�disability�or�dementia).�It�might�be�easier�to�use�moisturising�ointments�with�these�people�as�they�are�less�visible�on�the�skin�and�less�likely�to�get�rubbed�off.�
MOISTURISING CREAMS CAN bE USED AS SOAP SUbSTITUTES
The�water,�oil�and�emulsifying�agents�in�creams�means�they�can�act�as�a�kind�of�soap.�They�can�be�kinder�to�the�skin�than�normal�soaps�which�often�strip�the�skin�of�its�natural�oils.�People�with�dry�skin�or�eczema�tend�to�use�moisturising�creams�(such�as�aqueous�creams)�as�soap�substitutes.�
APPlyING NON-MEDICATED OINTMENTS
Examples�include�Vaseline,�Epaderm�ointment,�Emollient�50,�Diprobase��ointment�etc.�
Moisturising�ointments�don’t�need�to�be�applied�as�thickly�as�moisturising�creams,�as�they�are�made�almost�entirely�of�oil,�so�a�thin�layer�is�fine.�It�wouldn’t�do�any�harm�to�apply�them�too�thickly;�you�just�don’t�need�that�much.�
Unfortunately,�people�don’t�always�like�the�greasy�feel�of�ointments�on�their�skin,�so�although�ointments�are�fantastic�moisturisers,�people�often�prefer�water�based�(and�often�less�effective)�creams�and�lotions.�Because�ointments�contain�less�water,�they�don’t�need�as�many�preservatives�in�them.�Therefore�with�ointments,�there’s�less�chance�that�people�will�experience�the�stinging�sensations�they�can�get�with�creams.�
Applying�moisturisers
GUIDANCE
Moisturising�ointment Bath�oil Medicated�topical
bATH OIlS
Examples�include�Oilatum�and�Balneum��bath�oils.�
These�are�oil�based�products�added�in�small�quantities�to�the�bath�water.�They�float�on�the�surface�of�the�water�and�coat�the�skin�in�oil.�They�don’t�dry�the�skin�like�traditional�bath�soaps�can.�People�often�use�bath�oils�and�moisturising�soap�substitutes�together.�Take�care�when�using�bath�oils�as�they�can�make�the�bath�slippery�which�could�lead�to�a�fall.�A�rubber�bath�can�help�prevent�this.�
APPlyING MEDICATED TOPICAlS
Medicated�topicals�contain�drugs�such�as�antibiotics,�anti-fungals,�and�steroids�etc.�They�come�as�creams,�ointments,�lotions�and�gels.�
They�need�to�be�applied�thinly.�If�you�apply�too�much,�the�patient�could�get�an�overdose�of�the�drug�which�could�cause�side�effects.�Medicated�topicals�are�often�applied�to�a�small�patch�of�skin�–�wherever�the�problem�is.�The�information�leaflet�inside�should�tell�you�exactly�how�much�to�apply.�You’ll�usually�find�a�warning�on�the�label�that�states�‘to�be�spread�thinly’.�A�fingertip’s�worth�of�medicated�topical�covers�two�hand’s�worth�of�skin.�
Fingertip�units�are�there�as�a�guide�and�are�probably�most�useful�for�applying�steroids�(as�they�are�often�applied�over�larger�areas�of�skin).�When�we�say�apply�thinly,�this�means�you�should�be�able�to�see�the�skin�through�the�topical�product.�There�should�be�hardly�any�topical�product�visible�on�the�surface�of�the�skin.
IF yOU NEED TO APPly A NON-MEDICATED TOPICAl AND A MEDICATED TOPICAl TO THE SAME PATCH OF SkIN, wHICH wOUlD yOU APPly FIRST?
The�most�sensible�advice�is�to�apply�the�non-medicated�topical�first,�then�apply�the�medicated�topical�on�top.�This�is�because�if�you�applied�a�lot�of�non-medicated�topical�on�top�of�a�little�patch�of�medicated�topical,�you�could�end�up�washing�the�medicated�topical�off.�
DO I NEED TO ADD TOPICAlS TO THE MEDICINES CHART?
The�care�regulators�recommend�that�all�topicals�(whether�medicated�or�non-medicated)�should�be�added�to�the�medicines�chart�(including�moisturisers�and�bath�oils).�This�is�to�show�that�they�have�been�applied�or�used�regularly.��The�only�exception�to�this�is�moisturising�creams�used�as�soap�substitutes.�
34
ExAMPlES
APPlyING MEDICATED PATCHES
Examples�include�nicotine,�Fentanyl�and��glyceryl�trinitrate�patches.�
Some�medicines�can�be�given�as�a�skin�patch.�These�patches�are�like�large�sticking�plasters,�with�the�drug�contained�inside�them.�The�drug�absorbs�through�the�skin�straight�into�the�bloodstream.�Patches�can�be�applied�to�various�parts�of�the�body.�Exactly�where�depends�on�the�type�of�drug�contained�in�the�patch�(this�will�be�explained�on�the�leaflet�inside�the�box).�Usual�places�include:
4 Back4 Stomach4 Top�of�the�arms4 Thighs
Places�to�avoid�sticking�patches�include:
6 ���Very�hairy�skin6 ���Oily�skin6 ���Sunburned�skin6 ���Scarred�skin6 ���Rough�skin6 ���Damaged�skin6 �����Areas�that�get�sweaty�–�e.g.�underarms6 �����Places�where�the�patch�could�get�rubbed�
off�–�e.g.�under�bra�strap,�on�the�waist6 �����Bony�areas�–�e.g.�shoulders�or�hips
The�area�of�the�skin�where�the�patch�will�be�applied�needs�to�be�clean�and�dry.�You�may�need�to�wash�off�any�moisturiser�or�body�lotion�that�the�patient�has�used,�and�pat�the�area�dry�first�of�all.�
Peel�off�the�backing�paper�and�stick�the�patch�onto�the�skin.�Press�the�patch�on�firmly�so�it�sticks�well,�especially�around�the�edges.�So�long�as�you�are�careful�and�avoid�touching�the�sticky�side,�you�wouldn’t�necessarily�need�to�wear�gloves�when�applying�patches.�
Some�patches�are�only�worn�during�the�day;�some�are�also�worn�at�night.�Some�patches�are�kept�on�for�as�long�as�three�days.�Check�to�see�what�the�instructions�say.�Some�people�write�the�date�when�the�patch�was�applied�onto�the�actual�patch�itself�to�remind�them�when�a�new�one�is�needed.
Remove�the�previous�patch�before�applying�a�new�one.�Fold�the�old�patch�in�half,�sticking�it�to�itself�before�discarding�it.�When�applying�a�new�patch,�stick�it�near�to�where�the�last�one�was,�but�not�directly�over�the�same�patch�of�skin.�This�prevents�the�same�patch�of�skin�getting�irritated.
35
Applying�medicated�patches
GUIDANCE
36
ADMINISTERING INHAlED MEDICINES
Chapter 10
Inhalers�are�given�to�patients�suffering�from�lung�diseases�–�the�two�most�common�ones�you’ll�see�are�asthma�and�COPD�(chronic�obstructive�pulmonary�disease).�Asthma�is�called�a�variable�and�reversible�condition�which�means�the�symptoms�can�come�and�go;�it�is�often�caused�by�allergies.�COPD�is�called�a�‘fixed’�disease�which�means�it�doesn’t�tend�to�get�better.
RElIEVERS
Everyone�with�asthma�should�have�a�reliever�inhaler�(usually�blue).��The�most�common�reliever�drug�is�salbutamol.�Relievers�don’t�reduce�the�inflammation�and�mucus,�they�just�open�the�narrowed�bronchioles�quickly�(within�a�few�minutes)�making�it�easier�to�breathe.�Salbutamol�inhalers�normally�last�about�four�hours.�
With�asthma,�relievers�should�be�used�when�the�patient�either�gets�symptoms�or�expects�them�to�come�(i.e.�before�exercise�or�being�exposed�to�anything�that�triggers�their�asthma).�Side-effects�include�a�slight�tremor�in�the�hands�–�this�isn’t�normally�anything�to�worry�about.�It’s�important�patients�are�able�to�self�medicate�with�their�relievers,�as�you�might�not�be�around�when�they�get�symptoms.�Assuming�the�patient�has�a�good�technique�with�their�reliever�inhaler�but�still�
needs�it�frequently,�the�next�step�is�to�add�a�preventer�inhaler.�If�a�patient�needs�to�use�their�reliever�inhaler�more�than�three�times�a�week,�they�may�need�an�asthma�review.�
PREVENTERS
Preventer�inhalers�contain�steroids�(the�most�common�being�beclometasone).�Steroids�reduce�inflammation�and�mucus,�and�makes�the�lungs�less�sensitive�to�triggers�so�the�patient�is�less�likely�to�suffer�an�asthma�attack.�Preventers�are�brown,�orange�or�burgundy.�Light�brown�inhalers�contain�less�steroid;�darker�brown,�orange�and�burgundy�inhalers�contain�higher�doses.�In�asthma,�preventers�are�added�when�patients: +����Cough,�or�have�chest�tightness�or�
breathing�difficulties�more�than�three�times�a�week
+����Need�to�use�their�reliever�inhaler�more�than�three�times�a�week
+����Get�breathless�because�of�a�chest�infection�or�smoky�atmosphere
It�is�important�patients�use�their�preventers�regularly,�once�or�twice�a�day.�Preventers�take�up�to�14�days�to�work�fully,�hence�they�are�taken�every�day�even�if�the�patient�feels�well.�Forgetting�the�occasional�dose�won’t�usually�bring�symptoms�back�straight�away,�but�forgetting�doses�for�several�days�can�cause�symptoms�to�return�and�make�their�asthma�more�unstable.
Many�people�rely�on�their�relievers�too�much�and�don’t�use�their�preventers�regularly.�This��is�often�because�they�feel�an�immediate�effect�from�their�reliever,�whilst�their�preventer�takes�longer�to�work.�However,�this�isn’t�good�for�their�asthma.�Relievers�don’t�treat�the�underlying�symptoms,�so�their�asthma�can�become�unstable�and�worsen.�If�patients�have�frequent�symptoms�and�aren’t�getting�the�right�treatment,�they�can�end�up�in�hospital�with�a�serious�asthma�attack.�
People�worry�about�side�effects�with�steroids.�However,�preventers�only�have�small�amounts�of�steroid�in�them�and�if�they�are�used�properly,�it’s�unlikely�patients�will�suffer�serious�side�effects.�One�side�effect�with�steroids�is�thrush�(a�yeast�infection)�in�the�mouth.�If�a�patient�using�steroid�preventer�inhalers�has�a�sore�mouth�or�throat,�the�doctor�can�prescribe�something�to�treat�it.�To�reduce�the�risk�of�thrush,�patients�must�rinse�their�mouth�out�with�water�(and�spit�the�water�out)�after�using�their�preventer�inhaler.�Alternatively,�they�can�brush�their�teeth�after�using�their�preventer�inhaler.�A�spacer�device�can�also�reduce�the�build-up�of�steroid�in�the�mouth�to�prevent�thrush�and�other�side�effects.�
Relievers Preventers
37
ExAMPlES
38
HOw DO THE TREATMENTS FOR COPD DIFFER FROM ASTHMA?
Just�like�with�asthma,�everyone�with�COPD�needs�a�short-acting�reliever�inhaler.�However,�the�relievers�are�often�prescribed�on�a�regular�basis�rather�than�‘when�required’.�
Instead�of�adding�a�preventer�next,�prescribers�tend�to�add�a�protector�instead.�If�the�relievers�and�protectors�aren’t�enough,�then�preventers�are�added.�Preventers�are�used�last�because�they�are�less�effective�in�COPD�(as�there�is�less�inflammation�present�than�with�asthma).�
Patients�with�COPD�can�have�another�type�of�inhaler�called�an�‘anticholinergic’.�Examples�include�Atrovent�(contains�ipratropium)�and�Spiriva�(contains�tiotropium).�
THE VARIOUS DIFFERENT MODElS OF INHAlER
There�are�many�different�inhaler�devices�used�to�deliver�the�drugs�we’ve�looked�at.�Asthma�UK�has�produced�an�animated�guide�showing�how�to�use�these�at�www.asthma.org.uk.�The�patient�information�leaflet�should�also�show�the�patient�how��to�use�their�inhaler�device.�
If�the�patient�self�administers�inhalers,�check�that�they�are�using�them�correctly.�If�you�see�mist�coming�from�the�top�of�the�inhaler�or�their�mouth,�they�won’t�be�getting�much�benefit�from�it.�You�could�always�suggest�they�see�a�health�care�professional�who�can�review�their�treatment.�
PROTECTORS
If�reliever�and�preventer�inhalers�are�still�not�controlling�the�asthma,�the�next�step�is�to�add�a�third�inhaler�called�a�protector.�Protector�inhalers�are�usually�green�or�turquoise.�These�are�basically�long-acting�reliever�drugs.�They�act�for�around�12�hours�so�are�usually�prescribed�twice�a�day.�
In�asthma,�it�is�very�important�that�patients�continue�to�use�their�steroid�inhalers�even�if�they�have�also�been�prescribed�a�protector.�If�they�stop�using�their�preventer�and�just�rely�on�the�protector�inhaler,�it�can�make�their�asthma�very�unstable�and�lead�to�a�life-threatening�asthma�attack.�
COMbINATION INHAlERS
Combination�inhalers�contain�a�protector�and�a�preventer.�Combination�inhalers�should�be�taken�regularly:�once�or�twice�daily.�They�are�usually�purple,�red�or�white.�
Protectors Combination�inhaler
ExAMPlES
39
SPACER DEVICES
A�spacer�is�a�plastic�container�that�is�added�to�a�standard�inhaler.�There�are�many�different�designs,�including�smaller�ones�such�as�the�Aerochamber�Plus�or�larger�spacers�such�as�the�Volumatic.�Aerochambers�have�a�soft�rubber�end�so�they�can�fit�different�types�of�inhaler,�whereas�Volumatics�can�only�fit�inhalers��with�a�square�mouthpiece.�
Aerochambers�also�have�a�whistle�on�them�to�let�you�know�if�the�patient�is�breathing�in�too�fast.�It’s�okay�to�hear�a�quiet�whistle,�not�a�loud�one.�If�the�whistle�is�loud,�ask�the�patient�to�try�again�with�a�gentler�in-breath.�It’s�not�a�good�idea�to�change�the�type�of�spacer�without�checking�with�the�prescriber.�
Most�spacer�devices�also�have�a�version�with�a�soft�silicon�face�mask.�Patients�who�are�unable�to�form�a�good�seal�around�the�mouthpiece�(which�can�sometimes�happen�after�a�stroke)�might�benefit�from�a�face�mask.�Patients�who�keep�breathing�through�their�nose�might�also�benefit�from�a�mask.�
With�spacers,�there�are�two�techniques:
1��Taking�in�one�long�breath�from�the�spacer�device�and�holding�it�for�10�seconds�or
2��Taking�5�breaths�in�and�out�from�the�spacer�device�(called�tidal�breathing)
Both�techniques�are�effective�but�patients�often�prefer�the�second�technique�as�some�find�it�difficult�holding�their�breath.
TAkING CARE OF SPACER DEVICES
Spacer�devices�should�be�cleaned�regularly�by�washing�them�in�soapy�water.�After�you�have�given�the�spacer�a�good�clean,�rinse�the�soap�off�the�outside�of�the�spacer,�but�leave�the�soap�bubbles�on�the�inside.�When�the�spacer�is�dry,�the�bubbles�will�have�burst�leaving�an�invisible�coating�of�soap�on�the�inside�of�the�spacer.�This�reduces�static�build�up�so�less�of�the�drug�mist�sticks�to�the�sides�of�the�spacer�and�more�of�the�drug�reaches�the�lungs.�Don’t�dry�the�spacer�with�a�towel�or�tissue,�as�the�rubbing�action�adds�static.�Volumatics�need�to�be�washed�once�a�month�and�Aerochambers�every�1-2�weeks.�If�used�regularly,�spacer�devices�should�be�replaced�every�6-12�months.
Spacer Aerochamber Spacer�with�face�mask
ExAMPlES
1 Remove�the�lid.�Check�there�are�no�foreign�objects�inside�the�mouthpiece
2 Test�the�inhaler.�If�it�hasn’t�been�used�for�7�days�shake�it�and�then�spray�two�puffs�into�the�air;�this�ensures�the�patient�gets�a�full�dose�of�the�drug
3 Insert�the�inhaler�into�the�spacer.�If�you�are�using�an�Aerochamber,�you�might�need�to�twist�the�rubber�end�around�(where�the�inhaler�fits�into�the�spacer)�so�that�the�inhaler�is�pointing�upwards�at�12�o’clock�
4 Shake�the�inhaler�whilst�it�is�in�the�spacer,�4�or�5�times
5 The�patient�should�be�sat�up�straight�or�standing.�Where�possible,�their�chin�should�be�lifted�up�to�open�the�airways.�This�is�the�ideal�position,�but�might�not�be�possi-ble�with�some�patients�with�a�physical�disability
6 Establish�which�technique�the�patient�prefers:�taking�in�one�breath�and�holding�it�for�10�seconds�or�taking�5�breaths�in�and�out.�It’s�a�good�idea�to�record�which�technique�they�prefer�on�the�medicines�chart
7 Put�the�spacer�in�their�mouth�and�check�their�lips�form�a�tight�seal.�Check�that�they�are�breathing�through�the�spacer�device�correctly�before�you�fire�a�puff�in�(if�you�are�using�an�Aerochamber,�you�shouldn’t�hear�a�loud�whistle).�Make�sure�they�are�breathing�through�their�mouth�rather�than�their�nose
ADMINISTERING AN INHAlER wITH A SPACER DEVICE
40
GUIDANCE
8 If�the�patient�cannot�form�a�good�seal�with�their�lips�around�the�spacer,�they�may�need�to�use�a�spacer�with�a�mask�attached�instead.�Make�sure�that�the�spacer�is�level�(hori-zontal)�otherwise�they�might�not�receive�a�full�dose
9 HOlDING bREATH TECHNIqUE:�get�the�patient�to�blow�out�into�the�spacer�device�which�empties�their�lungs.�Tell�them�to�take�a�slow,�deep�breath�in.�As�they�breathe�in,�fire�a�puff�into�the�spacer.�Encourage�them�to�carry�on�breathing�in.�Keep�the�spacer�in�their�mouth�as�they�breathe�in.�Once�they�have�breathed�in�fully,�take�the�spacer�out�and�ask�them�to�hold�their�breath�for�as�long�as�is�comfortable��(10�seconds�if�possible)
9 bREATHS IN AND OUT TECHNIqUE:�as�the�patient�is�breathing�in�and�out,�fire�in�one�puff.�Keep�the�spacer�in�their�mouth�for�5�breaths�in�and�out.�You�can�always�help�the�patient�by�breathing�in�and�out�5�times�with�them.�This�can�help�some�patients�with�dementia�or�learning�disabilities�understand�what�to�do.�When�you�do�this,�the�patient�often�copies�your�own�breathing�pattern.�This�also�means�that�you�can�count�your�own�breaths�rather�than�trying�to�see�if�the�patient��is�breathing�in�and�out�5�times
10 If�a�second�puff�is�needed,�wait�30�seconds�then�repeat�the�whole�procedure.�Don’t�put�more�than�one�puff�into�the�spacer�at�a�time,�as�the�droplets�can�end�up�joining�together�to�form�larger�droplets�which�cannot�get�deep�into�the�lungs,�and�so�reduces�the�amount�of�drug�you�are�helping�to�administer
11 Replace�the�mouthpiece�and�record�on�the�medicines�chart.�If�using�a�preventer,�ensure�the�patient�rinses�their�mouth�out�with�water�(rinse,�gargle�and�spit)�or�cleans�their�teeth�afterwards
41
42
ADMINISTERING MEDICATION TO THE EyE, EAR & NOSE
Chapter 11
Medicines�can�be�applied�to�the�eye,�ear�and�nose�in�the�form�of�drops,�creams,�gels,�ointments�and�sprays.�According�to�the�care�regulators,�care�professionals�can�administer�these�types�of�medicines�after�their�‘basic�medicines�training’�(i.e.�you�don’t�need�to�have�a�registered�health�professional�provide�personalised�training).�However�having�said�this,�some�employers�have�stricter�policies�than�this.�Check�your�medication�policy�to�see�if�your�employer�lets�you�administer�medications�to�the�eye,�ear�or�nose.�
If�patients�have�had�a�recent�eye�operation�(such�as�having�cataracts�removed)�some�employers�will�not�allow�care�workers�to�administer�eye�drops,�insisting�instead�that�nurses�do�this.�This�is�because�there�is�a�higher�risk�of�getting�eye�infections�after�surgery�and�nurses�are�trained�to�pick�up��the�signs�and�symptoms�of�eye�infections.�
EyE DROPS
There�are�many�different�ways�of�administering�eye�drops,�the�most�important�thing�is�to�get�a�drop�into�the�patient’s�eye�in�a�way�that�doesn’t�cause�them�discomfort.�Some�patients�will�sit�patiently�and�let�you�administer�eye�drops�and�are�usually�patients�who�have�had�them�before.�They�may�have�had�conditions�like�glaucoma�or�dry�eyes.�There�will�also�be��those�patients�who�have�not�had�eye�drops�before�and�may�find�it�harder�to�keep�their�eyes�open�as�you�put�drops�in.�
Many�people�stand�above�the�patient�and�let�the�drop�fall�onto�the�eyeball.�If�this�technique�works�for�you�and�the�patient,�carry�on.�However�this�can�be�uncomfortable�for�patients.�It�also�makes�them�more�likely�to�blink,�as�they�see�the�drop�hanging�above�their�eye.�Older�patients�and�those�in�high-backed�wheelchairs�may�also�find�it�difficult�tipping�their�head�back.�
An�alternative�used�by�many�opticians,�is�to�place�the�drop�onto�the�lower�eyelid�whilst�the�patient�looks�away.�By�touching�the�drop�against�the�lower�lid,�it�gets�‘sucked’�into�the�eye.�You�only�need�to�touch�the�drop�on�the�lower�lid,�not�the�bottle�tip.�Some�people�worry�that�bacteria�will�be�transferred�onto�the�tip�of�the�bottle�it�touches�the�lower�lid.�However,�the�drops�are�only�used�for�28�days;�they�contain�preservative�and�are�not�swapped�between�patients�so�this�shouldn’t�be�a�problem.�
ADMINISTERING EyE OINTMENTS
With�eye�ointments�you�can�use�the�same�technique.�You�need�to�squeeze�about�1cm�of�ointment�inside�the�lower�eyelid.�The�ointments�can�make�the�vision�blurred�as�they�can�be�quite�greasy.�
ADMINISTERING EyE DROPS TO PATIENTS wHO FIND IT HARD TO kEEP THEIR EyES OPEN
Despite�your�best�efforts,�some�patients�might�find�it�hard�to�keep�their�eyes�open�as�you�administer�drops.�There�is�another�technique�you�can�use.�
Have�the�patient�lie�on�their�back�and�close�their�eyes.�Gently�place�a�few�drops�(3�or�4)�into�the�eye�socket�near�the�side�of�the�nose.�Make�sure�the�drops�run�along�the�eyelashes.�Next,�ask�the�patient�to�open�their�eye(s),�you�might�need�to�help�them�do�this.�The�drops�will�then�enter�their�eye(s).�Wipe�away�any�excess�drops�with�a�clean�tissue.�Remember,�the�eye�will�only�retain�what�it�needs�(about�one�drop).�The�patient�will�need�to�then�close�their�eyes�for�about�30�seconds�for�the�drop�to�absorb.�
IF A SECOND TyPE OF EyE DROP OR OINTMENT IS NEEDED AFTERwARDS
Some�patients�have�more�than�one�type�of�medication�administered�to�the�same�eye.�Wait�3�or�4�minutes�for�the�first�drop�to�absorb�before�administering�another�eye�drop.�If�you�have�to�administer�an�eye�ointment�and�a�drop�to�the�same�eye,�it’s�best�to�administer�the�drop�first,�wait�3�or�4�minutes,�then�administer�the�ointment�afterwards.�If�you�try�administering�an�eye�drop�after�an�eye�ointment,�the�drop�will�find�it�hard�to�absorb�through�the�greasy�ointment.��
Some�eye�preparations�can�sting�(e.g.pilocarpine).�If�these�are�needed�with�other�drops,�then�administer�the�pilocarpine�afterwards,�because�the�patient�will�find�it�hard�to�keep�their�eyes�open�if�they�sting.�If�an�ointment�is�then�needed,�wait�for�the�stinging�to�stop�before�administering�the�ointment�last�of�all.
Eye�drops Eye�ointmentsLower�eyelid�application
43
ExAMPlESGUIDANCE
ADMINISTERING NASAl DROPS
THE TECHNIqUE OF ADMINISTERING EyE DROPS
PREPARE THE PATIENT:�The�patient�can�be�sat�upright�in�a�chair.�They�do�not�necessarily�need�to�tip�their�head�back�with�this�technique
PREPARE THE RIGHT DOSE OF MEDICATION:�Wash�your�hands,�shake�the�bot-tle,�unscrew�the�lid�and�put�it�somewhere�clean.�Gloves�are�not�always�needed�when�administering�drops
ADMINISTER THE MEDICATION:Push�out�a�drop�and�leave�it�hanging�from�the�tip�of�the�dropper�bottle.�With�your�free�hand,�pull�the�lower�lid�down�gently�away�from�the�eyeball�to�make�a�pocket�in�which�you�can�place�the�drop.
Tell�the�patient�to�look�towards�the�bridge�of�their�nose�and�then�upwards.�Looking�up�takes�the�upper�eyelid�and�lashes�out�of�the�way�and�gives�you�more�room�to�put�the�drop�in.Gently�touch�the�drop�onto�the�lower�lid�to�release�it.�Don’t�worry�if�you�accidently�put�more�than�one�drop�in�the�eye�–�the�eye�can�only�hold�onto�one�drop,�so�any�others�will�flow�away�harmlessly�down�the�cheek�Give�the�patient�a�clean�tissue�to�wipe�away�any�excess.�Once�you’ve�put�in�the�drops,�tell�the�patient�to�close�their�eyes�for�about�30�seconds.�This�spreads�the�drops�over�the�eyeball.�Check�for�any�redness,�pain,�itching�or�swelling�in�the�eye�–�a�little�stinging�and�itching�is�okay�as�long�as�it’s�not�too�uncomfortable
GET READy:�Check�the�drops�haven’t�passed�their�expiry�date.�When�breaking�the�seal�on�new�drops,�write�the�expiry�date�on�the�bottle�(28�days)
GET READy:�Check�the�drops�haven’t�passed�their�expiry�date.�When�breaking�the�seal�on�new�drops,�write�the�expiry�date�on�the�bottle�(28�days)
PREPARE THE PATIENT:�The�patient�can�either�lie,�or�sit�down�with�their�head�tilted�backwards.�If�the�patient�lies�down,�put�a�pillow�under�their�shoulders.�This�way�their�head�tilts�back�a�little,�over�the�edge�of�the�pillow
44
GUIDANCE
PREPARE THE RIGHT DOSE OF MEDICATION:�Wash�your�hands,�shake�the�bottle�and�unscrew�the�lid
GET READy:�Check�the�drops�haven’t�passed�their�expiry�date.�When�breaking�the�seal�on�new�drops,�write�the�expiry�date�on�the�bottle�(28�days)
PREPARE THE PATIENT:�Help�the�patient�lie�down�on�the�bed,�with�the�ear�being�treated�uppermost.�Alternatively,�they�can�sit�with�their�head�tilted�so�that�the�treated�ear�is�upright
PREPARE THE RIGHT DOSE OF MEDICATION:�Wash�your�hands,�shake�the�bottle�and�unscrew�the�lid
ADMINISTER THE MEDICATION:Pull�the�ear�upward�(away�from�the�neck)�and�backwards�a�little�(away�from�the�face).�This�straightens�the�ear�canal�so�that�the�drops�flow�right�down�into�the�ear�where�they�need�to�work.�Gently�squeeze�the�correct�number�of�drops�down�the�side�of�the�ear�canal,�not�straight�down�the�centre�as�they’ll�hit�the�ear�drum�(which�is�loud�and�sometimes�painful).�Try�not�to�let�the�dropper�touch�any�part�of�the�ear�or�ear�canal.��Ask�the�patient�to�stay�lying�or�sitting,�with�their�head�tilted�for�about�5�minutes�after�you�have�instilled�the�medication�(this�allows�the�drops�to�soak�in).Wipe�away�any�drops�that�have�dribbled�down�the�neck�with�a�clean�tissue.If�both�ears�need�drops,�wait�for�about�5�minutes�for�the�first�drop�to�absorb�and�then�get�the�patient�to�turn�over�and�repeat�the�procedure.
ADMINISTERING EAR DROPS
ADMINISTER THE MEDICATION:Hold�the�dropper�just�above�the�patient’s�nostril�and�gently�squeeze�a�drop�down�the�centre�of�the�nostril�(you�can�make�the�nostril�a�little�wider�by�pressing�your�thumb�against�the�tip�of�the�nose,�which�opens�them�up)Ask�the�patient�to�inhale�slowly�and�deeply�through�the�nose,�hold�their�breath�for�several�seconds,�then�breathe�out�slowly.�All�the�while�they�should�stay�with�their�head�back,�or�lying�down�for�one�minute.�This�lets�the�drops�soak�in.�If�you’ve�used�a�dropper,�squirt�out�any�medication�left�in�the�dropper�into�a�clean�tissue�before�putting�the�dropper�back�in�the�bottle.
45
IMPORTANT MEDICINES OFTEN TAkEN by THE ElDERly & HOw TO ADMINISTER
Chapter 12
AlENDRONIC ACID: USED IN TREATMENT OF OSTEOPOROSIS
+����This�drug�is�usually�taken�only�once�a�week�on�the�same�day.�
+�����Taken�about�30�minutes�before�breakfast�(8am)
+����Swallow�whole�do�not�chew+�����Take�with�a�full�glass�of�water+�����Stand�or�sit�upright�for�at�least�30�minutes�
after�swallowing�the�tablet�and�do�not�lie�down�until�after�you�have�eaten�breakfast.
+����If�a�weekly�dose�is�missed�take�the�next�morning�and�continue�as�normal.�
CAlCIUM SUPPlEMENTS
+�����Calcium�is�an�important�element�to�build�&�keep�bones�strong.�It�is�often�taken�in�conjunction�with�Alendronic�acid.
+����If�on�Alendronic�acid�do�not�take�calcium�on�the�same�day�as�taking�this.�
+����Take�calcium�carbonate�supplements�with�meals�to�assure�high�stomach�acid�for�maximum�absorption.�
+����Taking�calcium�supplements�in�divided�doses�throughout�the�day�is�important�if�the�total�daily�dose�of�calcium�is�500g�or�more.
+����Avoid�carbonated�soft�drinks�and�antacids�containing�aluminium�as�they�can�interfere�with�the�absorption�of�calcium.
46
IMPORTANT MEDICINES OFTEN TAkEN by THE ElDERly & HOw TO ADMINISTER
REFERENCES
��The�Royal�Pharmaceutical�Society�of�Great�Britain�‘The�Handling�of�Medicines�in�Social�Care’�2007
��Care�Quality�Commission�Outcome:�Management�of�Medicines
��Commission�for�Social�Care�Inspection�‘Professional�Advice:�The�Administration�of�Medicines�in�Care�Homes’
��Commission�for�Social�Care�Inspection�‘Professional�Advice:�Safe�Management�of�CD’s�in�Care�Homes’�Jan�2008
��Peterborough�Primary�Care�Trust�oral�administration�guidelines�for�good�practice�and�NOMAD�system�operating
�Patient.co.uk:�How�to�use�eye�drops�Asthma.org.uk:�Using�your�inhaler�British�National�Formulary�MIMS
Designed by cobalt id | cobaltid.co.ukCover image by Andrzej Tokarski (fotoila.com)
Violet�Hill�HouseViolet�Hill�RoadStowmarketSuffolk�IP14�1NL
stowhealth
stowhealth.co.uk