Long-Term Care Nursing: Medication Pass

Long-term nursing is not an easy field, but it comes with many rewards as well as challenges. Long-term care nurses care for patients in need of extended care, including geriatric, wound care, chronic diseases, and disabilities. Nurses must be dedicated to patient care because the same patients are seen day in and day out. Although most residents are elderly, many are younger.

A long-term care nurse must have a passion for working with special residents in a long- term care facility. The work can be difficult at times but can be so rewarding. Let's explore the duties of a long-term care nurse.

Long-term care nurses focus on providing care to patients in need of extended care. This care may entail routine care, wound care, dementia, including Alzheimer's disease, cancer, and aftercare following surgery or strokes. The main focus is assessing and monitoring the residents' functional status and maintaining or restoring physical health. Due to physiological changes, particularly in hepatic metabolism and renal elimination, dosing in the elderly population can be challenging. The elderly may experience an increase in side effects or toxicity more easily. Awareness of side effects in the elderly is particularly important as most elderly patients are on more than one drug. Great care should be taken when combining drugs.

Routine care involves nursing assessments, medication administration, wound care, and collaboration with the team including physicians, families, pharmacy, and therapy. Also included would be daily care with Activities of Daily Living (A.D.L.s) as needed and proper documentation.

Responsibilities may include:

• Consults and coordinates with healthcare team members to assess, plan, implement, and evaluate patient care plans.
• Prepares, administers, and records given prescribed medications. Reports adverse reactions to medications or treatments.
• Records residents' medical information and vital signs.
• Assesses resident's ability to perform routine A.D.L.s.
• Assists residents with basic needs such as dressing, eating, and bathing and encourages patients to do things for themselves to retain feelings of independence and self-worth.
• Recognizes and manages geriatric syndromes common to older adults, including cardiovascular, respiratory, gastrointestinal, urinary, musculoskeletal, neurological, integumentary, sensory, and pain problems.
• Prepares equipment and assists the physician during examination and treatment of a patient.
• Facilitates older adults' active participation in all aspects of their healthcare.
• Involves, educates, and, when appropriate, supervises family/significant others in implementing best practices for older adults.

These responsibilities sound overwhelming, especially for a new nurse, but it does become easier with time and experience. A solid orientation is of the utmost importance and the nurse must feel comfortable asking questions.

First and foremost, nurses must remember the 10 Rights of Medication Pass:

Right Patient:

• Use two identifiers. The room number is not an identifier. Ask the patient to identify themself, check the name on the order, and the patient. If available, use technology such as barcoding. For patients not wearing I.D. bands or those who cannot identify themselves, extra caution is necessary. A system should be in place to identify patients without name bands or who are incompetent.

Right Drug:

• Every drug administered must have an order from the provider. Compare the order with the medication administration record (M.A.R.) for accuracy. Compare the label on the drug to the information on the M.A.R. three times:
  1. Before removing the container from the drawer
  2. As the drug is removed from the container and
  3. At the bedside before administering it to the patient
• Do not prepare unmarked drug containers or illegible containers. Be sure to verify drugs at the patient's bedside with the M.A.R. and two patient identifiers (Potter et al., 2017).

Right Dose:

• Have a second nurse check any calculations that need to be done. Use standard measuring devices such as syringes, graduated cups, or scaled droppers. See if the pharmacists can split any required pills for safety (Potter et al., 2017).
• If drugs need to be crushed, be sure to clean the devices used before and after. Nurses should access information on therapeutic doses, therapeutic serum levels if applicable, and laboratory results when needed. If there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering.

Right Route:

• Drug errors involving the wrong route of drug administration are common. Be sure to verify if there is any question as to the drug route. The nurse must know the appropriate route for the drug. Giving drugs via the wrong route can cause serious harm to patients. If possible, when using a syringe or other device, label the appropriate route so that there is no confusion.

Right Time:

• Nurses need to understand why drugs are given at certain times. Although some drugs require clinical judgment as to when to administer, such as an as-needed sleeping drug, other drugs are labeled time-critical (Vaismoradi et al., 2018). Studies show that giving drugs at incorrect times results in 30-40% of all drug errors (Tariq & Scherbak, 2019; Gorgich et al., 2016). Giving drugs at an incorrect time can impact the bioavailability and efficacy of the drug. Doing this results in the drug not working for the patient as it should. Likewise, drugs should not be prepared or mixed in advance for the same reason.

Right Documentation:

• Write down the drug after you give the dose. Note injection sites.

Right Patient Education:

• Educate the patient on what to expect regarding side effects, benefits, reactions, and when to seek medical help.

Right to Refuse:

• Patients have a right to refuse any drug. Document refusal of the drug.

Right Assessment:

• Assess the patient. Note the patient's history and any perimeters around drug administration.

Right Evaluation:

• Check for drug allergies and interactions.

Some of the abbreviations we use for medication passes are not utilized anymore, as they can cause confusion and increase the risk of medication errors. Per The Joint Commission (T.J.C.) (2020), here is the most recent list of abbreviations to avoid:

The rules regarding not using these abbreviations apply to all orders and medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.

*Exception: A "trailing zero" may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation (T.J.C., 2020). Because there are many medication errors involving Morphine Sulfate, it is very important to never use the abbreviation!

• Wash your hands with soap and water before and after med pass.
• Ensure the med cart is locked when not in use.
• Make sure that the med room is always locked.
• Keep your cart clean and organized without any personal items.
• Make sure any applesauce and/or ice cream that you will be using to mix medications in, as well as the clean water pitcher, are dated.
• It is permissible to use alcohol-based hand sanitizer between patients if hands are not visibly soiled.
• Make sure to wash hands again after three uses of hand sanitizer.
• Monitor and record vital signs that are required prior to medication administration.
• Use apical pulse for certain medications such as Digoxin and antihypertensive drugs.
• Check and make sure the order is correct.
• Always check the resident's name, drug, dosage, strength, and route using the MAR for reference.
• Enter the resident's room after knocking and identify yourself.
• Make sure the resident is sitting up before giving the medications.
• Administer the medications via the correct route.
• Document the administration of the medications.

• Never leave the room until you are sure the resident has taken medications.
• Never leave the meds in the room for the resident to take later.
• If there ever is a difference between the MAR and the medication, STOP!
  • Take Action:
    • Review the order in the chart.
    • Check with your supervisor.
    • Call the pharmacy if needed.
    • Do not give the medication until you know the order is correct and the order has been corrected on the MAR.

• Anticoagulants:
  • Heparin is the most common anticoagulant used in long-term care. Monitor for bleeding, chest pain, rapid breathing, and fast heart rate. Vital signs are taken before administration. Vitamin K is to be given for critical level International Normalized Ratio (INR) per physician's orders.
• Hypoglycemics:
  • These are used to control blood sugar. Perform blood sugar tests before giving Insulin or if you suspect low blood sugar. The most common signs/symptoms of low blood sugar include sweating, confusion, weakness, headache, and dizziness. Always have a tube of Glucagon on your cart to help reverse these symptoms.
• Opioids:
  • The drug that nurses have trouble with is liquid morphine. Be sure to check and recheck the concentration. All forms of opioids are considered high-risk. Pay attention to the frequencies and dose. Be sure to watch the resident swallow the narcotic, and if it is timed release, ensure the resident does not chew the pill.
• Digoxin:
  • Vital signs must be taken before dose, pay attention to the pulse! If the pulse is below 60 or above 100, do not give and document findings.
• Chemotherapy Agents:
  • Chemotherapy is only given in oral doses in long-term care. Follow instructions carefully and do not touch the drug.

When preparing oral doses, be sure to follow facility guidelines as well as CMS and pharmacy guidelines:

• If you must touch a pill, use gloves.
• Always pop pills from the bubble pack over the cart.
• If you drop a pill, throw it away. If it is a narcotic, have another nurse waste it with you. You always need a witness when wasting narcotics.
• Be sure to split only pills that are allowed to be split, no pills that are not scored!
• Not all medications that are scored can be crushed [e.g., Toprol XL (metoprolol succinate)].
• If you have an order to crush medications, use a pill crusher or mortar and pestle. Crush the medications into a fine powder and mix in applesauce or other items (water for enteral tubes).
• Be certain to shake liquids before pouring, pour at eye level, wipe any drips from the bottle afterward, and ensure the resident swallows the entire dose.

• Metered-Dose Inhalers (MDIs):
  • They are used to treat asthma and chronic obstructive pulmonary disease (COPD).
  • Wait one minute between puffs.
  • Have resident rinse their mouth after doses are administered.
• Fentanyl Patches:
  • Used for severe pain and is time-released.
  • CMS has determined that some drugs remain on the pad after removal and can lead to potential diversion and abuse.
  • Be sure to document the time the patch is removed and waste with another nurse (depending on the rules of your facility). To properly dispose of it, fold it in half with the sticky sides touching and flush it down the toilet (U.S. Food & Drug Administration [FDA], 2018). Do not place it in a garbage can where others might become exposed upon touching it (FDA, 2018).
• Medication Administration via Feeding Tube: Most time-consuming! Always check placement before administering the drug, give each medication separately, and flush the tube between each medication (American Association of Post-Acute Care Nursing [AAPACN], 2021).

Always use a tissue, put on gloves, and ask the resident to look up. Do not touch the eye with the dropper. Count the drops being administered. Have the resident close their eyes to help wash the medication drop over the entire eye. Wait at least five minutes before administering another drop.

Always use gloves when administering ear drops. Have the resident lie down with the affected ear up, pull up and back on the ear lobe, and instill drops without touching the dropper to the skin, ear lobe, etc.