Assistance with Self-Administration: Medication Savvy for Nursing Assistants

Certified Nursing Assistants (CNAs) are permitted to assist with medications in the home setting and in Assisted Living Facilities. It is a huge responsibility, and there are specific Florida laws to address these positions. Assisting with medications has serious considerations to keep in mind. Learning about the different classes of drugs and their most common side effects is an awesome responsibility. Keeping narcotics safe is another part of assisting with medications.

Understanding what types of medications your residents are taking is another part of assisting with self-administration of medications.

Florida State Statute (Chapter 465.003) states that "administration means the obtaining and giving of a single dose of medicinal drugs by a legally authorized person to a patient for her or his consumption" (Florida State Statute, 2004). The laws are very specific about how CNAs can assist with medications. Assisting with medications is NOT giving medications, but just helping the person to take their own medicines. According to the Florida Statutes, assistance with self-administered medications means taking the medication from a previously dispensed, properly labeled container.

"Informed consent" means advising the patient or the patient's surrogate, guardian, or attorney that the patient may be receiving assistance with self-administration of medication from an unlicensed person (Nursing Assistant Education, 2009).

In addition, CNAs can not prepare injections. If the patient asks you to fill their Insulin needle, you must say “No.”. Rectal medications can not be given by unlicensed personnel. Nebulizer treatments must be given by a licensed nurse.

So, now let us look at what a CNA can do! Topically means putting creams, lotions, and ointments on the skin. If you see an open area, do not use the cream/ointment until you have spoken with your nurse or the doctor. Otic (ear) means assisting with eardrops. Nasal means assisting with nose sprays. You may hand the resident the ear drops or the nasal spray. CNAs can assist with oral medications, but keep in mind that you can only open the containers that the medications are in. You can also assist with narcotics, but again, only open the container the medication is in. With narcotics, keeping good records is very important. You must have the correct amount of the narcotic at the end of every shift.

Inhalers are used to help with breathing problems. You may assist with the metered dose inhalers, but not with a nebulizer.
You are also allowed to assist with “Transdermal” medications. This means that the medicine is given through the skin by a patch.

The seven rights of medication administration is the backbone of giving medications safely.

1. Right patient: always ask the person’s name, and if in a facility, check armband or photo identification.  
2. Right medicine: always look at the container the medicine is in, and read the label!   
3. Right dose: Again, read the label. After checking the Doctor’s order, read the label again the make sure the dose is correct.   
4. Right time: Make sure you are giving the medicine at the time the doctor wants it given. Many medications can only be given at a specific time of day.   
5. Right route: This is very important! You will be assisting with all types of medications.   
6. Right form: You are only permitted to assist with oral, topical, ear and nasal medications. You will not be involved in any other form.   
7. Right documentation: You will be asked to document which medications you assisted with, what, if any, reactions are noted, and you will note which controlled medications were given.

A doctor or another person, like a nurse practitioner, must write a complete and legible order for a medicine before it is given or taken.

A complete order must have the:

• date of the order,
• the time of the order,
• name of the medicine,
• dose,
• route,
• form,
• time or frequency that it should be taken, and
• signature of the MD or nurse practitioner

(Nursing Assistant Education, 2009)

Sample Prescription

This prescription tells you that Lasix is to be given by mouth daily. Disp. #30 means that 30 pills are to be dispensed from the pharmacy. There are only 2 refills.

Although it is easier to use abbreviations, they can cause medication errors, so be very careful! The most common abbreviations are:

• Q.D.- every day(daily)
• Q.O.D.-every other day
• B.I.D.- twice daily
• T.I.D- three times daily
• Q.I.D.-four times daily
• P.R.N.- when necessary
• P.O.-by mouth

To avoid making a mistake, it is wise to write out words instead of using abbreviations. If, for some reason, you do not understand a label or doctor’s order or have any doubt about a medication, call your supervisor for clarification. If the medication label and the care plan do not agree on any of the “7 Rights”, call your supervisor (Alvare, Fuzy & Rymer, 2009).

Scenario 1:

You are in a hurry because your shift is almost over, and you have been “behind” all day. Mr. Smith has been hard to find, but you finally spot him in the hallway. After picking up a medicine bottle, and because you are in a hurry, you do not look at the label. After giving Mr. Smith the medicine you realize that it was a mistake. You had given him pain medicine (which was another patient’s medication) instead of his blood pressure pill. So, let us see, you have the right patient and the right form. BUT, you did not have the right dose, the right medicine or the right time. You now need to call the doctor, explain to the charge nurse that you gave the wrong medication because you were in a hurry, and monitor the patient for side effects. A medication error report must be filed as well as an incident report.

All of this could have been prevented if you had taken the time to read the medicine bottle label.

Scenario 2:

Here is another scenario to think about:

The physician writes an order for Lasix 20 mg PO QD. The C.N.A. can not read the entire order, thinking that QD means every other day. Instead of asking for clarification, the patient gets Lasix every other day. Lasix is a diuretic, and is important to take every day when in Congestive Heart Failure (CHF), and for other serious conditions. Now the patient is getting edema (swelling) in both legs. How does this get reported? A medication error has just occurred, and this must be reported to the supervisor and the physician. Who gets hurt? The patient. If you do not understand an order, you are required to get clarification.

There are many different forms of medications. To be even more confusing, many medications come in more than one form. The following table shows which form you may or may not assist with:

Some medications that come in both pill and liquid form include: diuretics, seizure medications and antibiotics. There are some medications that come in the patch form. READ the label to make sure you are assisting the resident to take the correct medication in the correct dose and in the correct form.

Some Do’s and Don’ts:

• Do read the label
• Do provide water or juice to take pills
• Do NOT assist to give a medication if the label has been removed
• Do NOT touch medication with your hands
• Document the times the resident took the medication
• Do NOT insert suppositories
• Do NOT put in eye drops
• Do NOT give vaginal medications
• Do NOT attempt bladder irrigation

Analgesics: Drugs that help relieve pain; narcotic and non-narcotic
Analgesics are important medications. These help relieve pain, which can affect every aspect of a resident’s daily life. It is imperative that you follow instructions carefully and document them precisely. One of the most common but potentially serious side effects is sedation. If the resident becomes too sleepy, your observation is very important. Always make sure that you give the pain medication at the correct time. Given too early the patient may become too lethargic; given too late, the pain may be hard to control.

Antacids: Helps to reduce indigestion and heartburn: most antacids include Maalox, Zantac, and Tums. These drugs slow down the rate of the stomach emptying and neutralize acids in the stomach.

Antibiotics: Helps to control infections: There are many types of antibiotics, and most have specific targets. Infections can be deadly if not treated quickly and effectively. These medicines must be given exactly as the physician writes the order. If the order is to be given four times a day for seven days, that is exactly what you do. Another infection may occur if the medicine is stopped before the correct doses are given. Or, even worse, a “super” infection may result. The superinfections are very hard to stop once they begin. They are resistant to antibiotics.

Anticoagulants: Helps to thin the blood, slowing clotting. The most common anticoagulant is Coumadin. This drug helps to prevent blood clots. It must be given exactly as ordered. In addition, side effects must be monitored closely. So, as a medication assistant, you must look for new bruises or actual bleeding.

Anticonvulsants: Controls seizures: When anticonvulsants are given routinely, the chance of seizures is less. These medications should be given on schedule and at the same time every day. If seizures increase, the physician must be notified.

Antidepressants: Many older people take these drugs because depression is a common diagnosis. Antidepressants are not happy pills. They can only be prescribed by a physician and come with many risks and benefits (Croft, H., 2010).

• Antihypertensive- for controlling blood pressure. Blood pressure should be monitored for highs and lows. If blood pressure is too high or low, call the physician immediately. The physician will set the limits.
• Diuretics-helping the body to get rid of excess fluids through the urine. Try to give these medications as early in the day as possible because otherwise, the resident will not feel comfortable going out for activities. If given late in the day, the resident may lose sleep because of the need to urinate at night.
• Antihyperliperdemics- to help reduce the excess fat content in the blood (high cholesterol). These medications should be given at 5 P.M. unless the physician orders a specific time.
• Hypoglycemics- (Oral only!)- Drugs that lower the level of glucose in the blood (FDA, 2009). You may never give Insulin. The residents must pull up the Insulin into the needle by themselves. If a blood sugar is too low, the resident may become hard to wake up. Always check the blood glucose level, and if too low, give something sweet (if the resident can swallow).
• Antipsychotics- Medications are used to treat the symptoms of mental disorders such as schizophrenia, depression, bipolar disorder (sometimes called manic-depressive illness), anxiety disorders, and attention deficit-hyperactivity disorder, also known as ADHD (NIMH, 2008). Side effects from these medications are usually severe, so close monitoring is imperative. If a resident is noted to start shuffling while walking, and it is a new behavior, it has to be reported to the physician. If a resident begins to drool, and it is a new behavior, call the physician. Never be afraid to call for help. The residents’ well-being is of the utmost concern.

Laxatives-Medications that increase the frequency and ease of bowel movements (FDA, 2009). Laxatives come in various forms: pills, liquids, or suppositories. Laxatives may be a prescription or over-the-counter. Many of the elderly take an excess of laxatives. Please be aware that laxatives can deplete the body of important electrolytes and minerals. They can become dehydrated, which can lead to more serious illnesses such as Urinary tract infections.

There are many more drugs, including OTC (Over-the-counter), such as vitamins, aspirin, and drugs for treating colds. Always check with the physician before assisting the resident with over-the-counter medications.

Major Side Effects to watch for are:

• Dizziness/fainting
• Nausea/vomiting
• Rash/hives/itching
• Difficulty breathing
• Headache
• Drowsiness
• Any other unusual sign

(Alvare, Fuzy, Rhymer, 2009)

When watching for side effects, if the resident is having a severe reaction to a medication, call for help immediately. Severe reactions can happen to anyone at any time and include difficulty breathing, tongue swelling, rashes that continue to spread, severe dizziness, nausea, and vomiting. An extremely severe reaction is Anaphylaxis and is a medical emergency that requires immediate attention (Nursing Assistant Education, 2009). If you are alone, call 911 as soon as you observe any of these reactions.

When assisting with pills and capsules, you must pay attention to the labels. Some pills can not be crushed, and capsules can not be opened. If the word “enteric” is on the label, it can not be crushed. Enteric pills are coated to reduce stomach irritation. Certain pain medications are not to be crushed, especially MS Contin. This is a time-released medication, and if crushed, the entire dose is given at once. When using the liquid form, please be sure to measure accurately. Always keep the measuring cup at eye level to ensure the correct amount is being poured. To assist with a patch, please remember to clean the skin and make sure it is dry before applying. Do not forget to wear gloves because you do not want to get the medicine on your skin.

All medications must be stored safely, whether in the home or an assisted living facility. If the medication requires refrigeration, do not forget to put the medicine back in the refrigerator after each use. Never store medicine near heat. This would include storing it on a window shelf or near a stove. If medications are out of date, do not take it upon yourself to throw the medicine away. If you are working in the home setting, please make sure that all medicine containers are out of the reach of children!.

Last, but not least, you must be attentive to the signs of drug misuse. Drug misuse may be accidental or deliberate (Alvare, Fuzy, Rymer, 2009). If you suspect an overdose or if you notice that the patient has been drinking alcohol, notify the physician immediately if your supervisor can not be reached.

Medication savvy is a very important role for the Certified Nursing Assistant. Federal and state laws dictate how to manage your practice. You must be aware of what you can and can not do. And never deviate from these laws. Assisting with medications is an awesome responsibility that can also be scary at times. Remember to call for help in any situation that makes you uncomfortable. This ensures that your resident is safe, and that you are giving the best care possible.

(Alvare S Fuzy J Rymer S 2009 Nursing assistant care)Alvare, S., Fuzy, J., & Rymer, S. (2009). Nursing assistant care. Albuquerque, NM: Hartman Publishing, Inc. (Florida Legislature 2007 Florida State Statutes, Chapter 465.003).

Florida State Statutes (2004). Chapter 465.003 Medication Administration. Retrieved from (Visit Source).

Nursing Assistant Education. (2009). Assisting with medications. Retrieved from (Visit Source).

Croft, H. (2010). Antidepressant medications for depression. Retrieved June 1, 2010, from (Visit Source).

Fda. (2009). Drugs. Retrieved March 14, 2010, from (Visit Source).

National Institutes of Health and Human Services. (2010). Mental health medications. Retrieved June 1, 2010, from (Visit Source).