Medication Administration Process and Staff Responsibilities Overview

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Detailed information on medication administration process, responsibilities of staff members, and general guidelines for ensuring safe and effective medication management. The process involves prescribing medication, filling prescriptions, monitoring the individual, assistance in administration, and documentation. Staff responsibilities include observation, noting changes, informing physicians, pharmacy visits, and proper documentation. General responsibilities focus on adherence to laws and policies, normalization, independence, safety, and sanitation procedures. Boundaries, verbal orders, and storage requirements are also highlighted in this comprehensive guide.


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  1. Medication Module .06 February 2022 Melody Baker, Staff trainer Kalix Updated September 2023

  2. MEDICATION: A SUBSTANCE OR MIXTURE (OTHER THAN FOOD) THAT IS USED TO: PREVENT DISEASE AID IN DIAGNOSIS TREAT A DISEASE OR REDUCE SYMPTOMS MAINTAIN/RESTORE NORMAL FUNCTION

  3. MEDICATION ADMINISTRATION PROCESS Observation Prescription Administration Documentation

  4. PEOPLE IN MEDICATION ADMINISTRATION PROCESS Physician prescribes medication Pharmacistfills prescription and dispenses medication (A pharmacist is the only one who can dispense medication.) Nurse monitors the person Staff assist in administration

  5. MEDICATION CYCLE physician nurse staff Individual staff pharmacist

  6. STAFF RESPONSIBILITIES observation note __________ CHANGES inform physician of changes take prescription to pharmacy administration the medication as ordered then document

  7. 4 GENERAL RESPONSIBILITIES OF STAFF Know and adhere to laws and agency policy 1. Apply normalization and teach independence 2. Know and observe effects 3. Ensure safety and sanitation procedures 4.

  8. 1. KNOW AND ADHERE TO LAWS AND AGENCY POLICY

  9. BOUNDARIES KNOW YOUR ______________ PERFORM ONLY SKILLS TRAINED IN AT THIS AGENCY FOLLOW AGENCY POLICIES WORK UNDER AGENCY ___________ LICENSE KNOW ____________ REQUIREMENTS STORAGE NURSE S NURSE STAFF RESPONSIBILITIES RESPONSIBILITIES

  10. VERBAL ORDERS IN ND ONLY A LICENSED MEDICAL PERSON (AGENCY NURSE) CAN TAKE VERBAL ORDERS OVER THE _______ PHONE IF PHYSICAN CALLS, STAFF REFER TO THE AGENCY __________ NURSE

  11. CONTROLLED SUBSTANCE CONTROLLED MEDICATION ARE THOSE WHICH ARE LIKELY TO BE ___________ ADDICTIVE WHAT DOES THIS MEAN FOR STAFF? A WARNING LABEL ________ REFILLS USUALLY ONLY ONE MONTH SUPPLY SCHEDULE II - _________________ DOCUMENT NUMBER LIMITED DOUBLE LOCK

  12. 2. APPLY NORMALIZATION AND TEACH INDEPENDENCE

  13. APPLYING NORMALIZATION & TEACHING TOOLS use least restrictive methods let ________ do as much for themselves as possible their interdisciplinary _________ decides what should be taught people TEAM

  14. Ways Active Support can be used to engage people in the med process: use the phone to make appointments arrange _____________ to appts pick up prescription Bring a glass of water to the med room Know the __________ of medication knowing when to take their meds TRANSPORTATION EFFECTS

  15. 3. KNOW AND OBSERVE EFFECTS

  16. WE NEED TO KNOW ACTS how the person looks and _________ what medications they are on and ___________ effects & response time DESIRED what potential _________ effects SIDE

  17. Use all your senses for clues to side effects: visual auditory smell touch

  18. THREE PRIMARY EFFECTS DESIRED 1. ___________ EFFCTS WHAT WE WANT THE MEDICATION TO DO i.e. reduce temperature When the medication is working correctly, the desired effect is produced.

  19. THREE PRIMARY EFFECTS NO APPARENT 2. _______________ EFFECTS NO SIGNS OF AN EFFECT TYLENOL FOR FEVER AND FEVER STILL THE SAME

  20. 3. SIDE EFFECTS (EFFECTS OTHER THAN DESIRED) FATAL MILD SEVERE (POTENTIALLY ______________) EXPECTED or UNEXPECTED

  21. OBSERVE FOR _______________ REACTION. REACTIONS CAN OCCUR ANYTIME BUT MOST OFTEN AFTER THE _____________ FEW DOSES SKIN RASH,DIARRHEA, ITCHING, WATER DISCHARGE FROM NOSE, IRRITABILITY, TIREDNESS, HIVES ALLERGIC FIRST

  22. A severe allergic reaction is ANAPHYLACTIC SHOCK It is a medical ___________________ EMERGENCY

  23. MEDICATION INTERACTIONS POTENTIATION AN ____________ IN THE EFFECT BEER + MUSCLE RELAXANT INCREASE ANTAGONISM DECREASE A _______________ IN THE EFFECTS TETRACYCLINE with MILK UNIQUE EFFECT A NEW & DIFFERENT EFFECT

  24. FOLLOW AGENCY POLICY FOLLOW AGENCY POLICY WHEN NO APPARENT EFFECT AFTER RESPONSE TIME STAFF RESPONSIBILITY IF SUSPECT MEDICATION INTERACTION IS TO: _____________ TO NURSE/SUPERVISOR _____________ SYMPTOMS DOCUMENT REPORT

  25. Medication response can be influenced by: Illness or disease Body weight Age Gender Medication response

  26. CHARACTERISTICS TO KNOW ABOUT PEOPLE:

  27. 5) PHYSICAL CONDITION OF SKIN 1) GENERAL APPEARANCE 2)BODY ________________ POSTURE 6) PHYSICAL CONDITION OF _______ AND SCALP HAIR 3) GENERAL STATE OF HEALTH 7) PHYSICAL CONDITION OF SENSES 4) PHYSICAL ACTIVITY LEVEL 8) __________________________ SPEECH

  28. Mouth 9)____________, GUMS AND TEETH 13) BOWEL AND BLADDER 14) APPETITE AND EATING HABITS 10) FACIAL EXPRESSIONS 15) GENERAL ____________ STATE EMOTIONAL 11) VITAL SIGNS 16) STATE OF AWARENESS 12) _____________ WEIGHT

  29. 4. ENSURE SAFETY AND SANITATION PROCEDURES

  30. Wash hands before and after administering any medication

  31. Safety Never recap a needle Use gloves when taking blood sugar Protective barriers- Gloves protective eye wear protective clothing

  32. 6 RIGHTS OF MEDICATION ADMINISTRATION RIGHT PERSON RIGHTROUTE RIGHT MEDICATION RIGHTDOSE RIGHT DOCUMENTATION RIGHTTIME

  33. RIGHT PERSON IDENTIFY THE PERSON __________ GIVING MEDICATION BEFORE KNOW THE PERSON ONE ONLY GIVE MEDICATIONS TO _______ PERSON AT A TIME

  34. RIGHT MEDICATION MATCH __________ AND __________ LABEL MAR 2 WAY CHECK REPORT FOLLOW AGENCY POLICY TO ________ DISCREPANCIES (DIFFERENCES)

  35. WHAT THESE MEDICATIONS ARE FOR: SEIZURES ANTICONVULSANT -CONTROL ______________ ANTIBIOTICS - TREAT INFECTIONS ANTIDEPRESSANTS RELIEVE DEPRESSION INSULIN - TREATS ___________________ STEROIDS REDUCE INFLAMATION ANTACIDS - RELIEVE ______________________ LAXATIVE - RELIEVE _________________ CONSTIPATION DIABETES UPSET STOMACH

  36. RIGHT DOSE

  37. RIGHT DOSE Therapeutic ______________ RANGE: A RANGE OF DOSES THAT CAN PRODUCE DESIRED EFFECTS WITH MINIMUM SIDE EFFECTS

  38. RIGHT DOSE MAKE SURE TO ____________________ NUMBER OF TABLETS or CAPSULES READ AND COUNT

  39. Right Time TAKING THE MEDS AT THE SAME TIME EVERY DAY KEEPS CONSISTENT LEVELS ONE HOUR BEFORE TO ONE HOUR AFTER (FOLLOW AGENCY POLICY) CONTACT NURSE IF OUTSIDE OF MED TIME

  40. Right Time MEDS TAKEN ON AN_______________ STOMACH ENTER SYSTEM QUICKER (Medications required to be taken before eating means the medication should be taken on an empty stomach) EMPTY MEDS TAKEN ON A_____________ STOMACH AVOIDS IRRITATION FULL

  41. TIME ABBREVIATIONS PRN as needed

  42. RIGHT ROUTE BODY THE PART OF THE ______________ TO WHICH THE MEDICATION IS ADMINISTERED INTERNAL TAKEN BY MOUTH AND __________________ EXTERNAL APPLIED TO THE _____________ OF THE BODY CREAMS EYE DROPS EAR DROPS (otic ) INTERNAL AND EXTERNAL STORED _______________ SWALLOWED OUTSIDE SEPARATELY

  43. ABBREVIATIONS p.o. ____ by mouth Opth- pertaining to the eye ________ pertaining to the ear I.V. intravenous injection _______ sublingual(under the tongue) otic SL

  44. Right documentation Documentation is done immediately after the medication is given. Only the person who gives the medication can initial the MAR

  45. Procedure for Medication administration

  46. MEDICATION ADMINISTRATION CORRECT ________ TIME WASH HANDS ________ MEDICATION STORAGE UNLOCK CHECK _______ & ________ (2 times) MAR LABEL TEACH THROUGHOUT PROCESS

  47. MEDICATION ADMINISTRATION PROCEDURES: 1. REMOVE RIGHT DOSE SWALLOW 2. OBSERVE THE PERSON ______________ 3. REPLACE MEDICATION IN LOCKED STORAGE 4. _______ THE MEDICATION CHART 5. _________ FOR DESIRED/SIDE EFFECTS OBSERVE

  48. LIQUID MEDICATION ADMINISTRATION SHAKE 1. __________ BEFORE POURING 2. POUR AWAY FROM LABEL SIDE 3. POUR AT ________ LEVEL 4. POUR JUST BEFORE GIVING 5. DO NOT _______ MEDICATIONS 6. OBSERVE SWALLOWING EYE MIX

  49. MEDICATION ADMINISTRATION RECORD MAR Medication can only be given when ordered by a physician. _____________ orders are used for medications for headaches or a cold or something that the person doesn t need every day. That could be an over-the- counter (OTC) medication prescribed for specific reasons. STANDING

  50. MEDICATION ADMINISTRATION RECORD MAR MEDICATIONS GIVEN ARE RECORDED ON THE MAR DOCUMENT: ________ GIVEN _________ STAFF INITIALS TIME DOSE

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