Administration of Medicines Neil Petrie Consultant Pharmacist October

Administration of Medicines Neil Petrie Consultant Pharmacist October 2018

What we will cover Application of patches Bisphonate (Fosamax etc) PRN Medicines Anginine and Nitrolingual spray Cytotoxic medicines Application of creams

Patch’s - What’s on the market Drug Brand Dose Buprenorphine Norspan Weekly Fentanyl Durogesic, Denpax , Dutran, Fenpatch Every 3 -days Nitrate Transiderm Nitro, Nitro-Dur, Minitran Daily with nitrate free period Estraderm and other hormones Climara Weekly Estraderm Every 3 -days Nicorette Daily 16 hours Nicotine Nicabate, Nicotinell, Quit. X Rivastigmine Oxybutynin Daily 24 hours Exelon Daily Oxytrol Twice weekly

Why Use Patch Therapy When resident’s have problems swallowing Lower doses opioid than SR S 8 tablets. less risk of over narcotic effects. "flat" steady state effect no or small peaks / troughs Convenient - apply & go. . .

How to Apply 1. Remove old patch and fold sticky sides together 2. Select a new clean, non-irritated area. – Intact, relatively hairless 3. Clean the site with water and pat dry 4. Remove new patch from sealed packaging 5. Remove clear protective liner 6. Immediately press the patch onto the site with the palm of the hand for 30 seconds – Ensure whole patch and edges are in contact with skin 7. Wash your hands

Tips • Avoid use of soaps, lotions or creams on site where the patch is to be applied. • Clip any hair as close to the skin as possible – Do not shave. • Patches should not be cut • Rotate application sites – To minimise irritation

Disposal of Used Patches How are they disposed Fold together so it sticks to itself Wrap and dispose of in garbage away from children Still 60% of the drug remaining when taken off. Durogesic 12 mcg/hr = 900 mcg over 72 hours Durogesic 12 mcg/hr = Durogesic 2. 1 mg in each patch 1200 mcg left NPS Radar 2006

Issues of Patch Therapy Heat increases absorption from patches No application of excessive heat Hot packs, heat lamps, electric blankets Hot sun, hot shower, sauna If acute fever Skin irritation Forgetting to take the old patch off Slow onset of effect

Norspan Each patch should be numbered to indicate the site of application Do not use same site for 3 -4 weeks

Durogesic Several days should elapse before using same site

Compact Patch Application form

Application of Patches Paper tape may be used around the edge Recording Important to use “Patient Record Patch application” Application sites Apply to clean, dry, non-irritated, non-irradiated, nonhairy skin of torso, upper arm.

For Non-adhering patches Ensure patch is adhered correctly Non-hairy area Non irritated skin Apply with palm and press for 30 seconds First option Apply a paper tape around edges Second option Transparent adhesive film dressing may be used (Not endorsed by manufacturer CMI or PI) Monitor clinically Lack of effect Increased side effects If patch falls off Do not reapply the same patch Apply a new patch to a different area

Tips Record on patch with a permanent marker Time of application Date of application Initials of resident Check and sign daily that the patch is still stuck on.

Nitrate Patches Why are they not on for 24 hours Ensure a nitrate-free period of 10– 12 hours each day with patch to avoid tolerance. Apply Clean, dry skin Chest area or upper arm Be careful with strength between brands Transiderm 25 = 0. 2 mg/hour (4. 8 mg/24 hours) Minitran 5 or Nitro-Dur 5 (5 mg/24 hours) Release rate per hour

Fosamax and Actonel Must be administered half an hour before breakfast. With a full glass of water Resident must remain upright for 30 minutes after taking. Actonel EC can be administered with food.

What does PRN stand for? Pro re nata When necessary Perceive the need Report and Relieve Note the effects

PRN Medicines Can assist in managing conditions or symptoms that are not usually experienced by the resident on an ongoing basis Are prescribed for an individual resident and recorded on the medication chart

Policy and Procedure PRN orders should specify the condition for which the medication is to be used for. Stemetil for dizziness Coloxyl & Senna for constipation There is space available on the chart

Policy & Procedure PRN orders should specify the administration time range if applicable

Policy & Procedure Document on the separate designed PRN section of the Drug Chart and not in the regular administered section. Supplied in a separate white Webster.

Policy & Procedure When administering PRN orders the Date Time Quantity Should be completed in the history detailing the reason and result of the administration Name of RN Div 1 authorising

Policy & Procedure Familiarise yourself with the indication for use of each PRN medication. PRN medicine must be authorised by a RN Div 1 PRN medications are not the same as a nurse initiated medicine where a RN Div 1 initiates a medication that is not ordered for a resident by the residents doctor.

Policy & Procedure Before administration Understand the reason for administration Once administered Ensure you document the correct time of administration Make sure you have signed that it has been given Follow up 30 minutes later note the effect of the medication

Regular PRNs If a resident requests or requires a PRN on a regular basis Document in history An assessment by the treating doctor

Slow Release Products Should not be used for PRN orders Slow onset of effect Panadol Osteo may be used Bilayer tablet with an immediate release component

Anginine Angina pain/Chest pain Refer to Chest Pain Protocol Dissolved under tongue Usual dose ½-1 repeated every 3 -4 minutes until pain is resolved, to a maximum of 2 -3 tablets over 15 minutes. May be used before exercise

Anginine Store in original glass container away from moisture, heat and light. Write the date on the bottle when you open it and discard 3 months later.

Nitrolingual spray Same indication as Anginine Has a longer shelf life that Anginine Dose 1 -2 sprays under tongue Common side effects Headache, flushing, palpitations, hypotension Practice Points Prime the spray before using it for the first time by pressing the nozzle 5 times, spraying it into the air. Prime it with 1 spray if it hasn't been used for 7 days. Prime it with 5 sprays if it hasn't been used for more than 4 months.

Behaviours of concern PRN medications Are not the preferred management strategy for behaviours of concern May be an option when other measures are not effective Effectiveness of benzodiazepines and antipsychotics used in this situation is due to their sedative effects May be considered a chemical restraint.

Cytotoxic Medicines What are cytotoxic drugs Therapeutic agents intended for, but not limited to, the treatment of cancer. These drugs are highly toxic to cells. Many are Carcinogenic Mutagenic Teratogenic They have potential to cause great harm if they are not administered and disposed of safely and correctly

Workplace Health and Safety Exposure may by through Skin contact Inhalation of particles Ingestion Needle stick injuries

What Medicines are included Busulphan Busulfex Chlorambucil Leukeran Cyclophosphamide Cycloblastin Hydroxyurea Hydrea Lomustine (Cee. NU) Mercaptopurine Puri-Nethol Methotrexate Methoblastin Mitomycin (Inj) Procarbazine Natulan Fluorouracil Efudix

Administration Tips These medicines should never be Crushed Halved Capsules should never be opened They should be swallowed whole Not chewed As carers Must use a “no touch” technique Or wear gloves to minimise any risk.

Administration Tips Also consider how Urine/faeces or continence pads are disposed of Keep handling to a minimum If possible, only handled by the resident for whom they are prescribed.

Topical Therapies Creams, Ointments, Lotions Dry skin is a common cause of itch Apply moisturisers liberally after a shower Use mild/unscented soap or soap substitutes Pat skin dry – Do not rub. Lotions are probably better for older people

Finger Tip Units The “fingertip” unit for steroid creams The amount of cream needed to treat an area 1 fingertip unit will treat an area the size of the front & back of ONE adult hand.

Number of Fingertip units needed for different parts of the body

PRN Consulting Website