NMHCA PRECEPTOR TRAINING CMA PROGRAM Sept 2005 Susan

NMHCA PRECEPTOR TRAINING CMA PROGRAM Sept. 2005 Susan C. Peyerl BSN, NHA © NEW MEXICO HEALTH CARE ASSOCIATION 2005

OVERVIEW OF PROGRAM o o o Introductions Hours Lunch/breaks

TOPICS COVERED TODAY o Topics n n n Pilot BON regs Functions of CMA’s Preceptor responsibilities - 1: 1 or 1: 2 NF regs – time windows for med pass, etc.

TOPICS COVERED TODAY n n n Principles of adult education and how they learn Rules of Med administration – 6 rights How to structure med passes – 10 -15/hr Time management Organization skills – only a week Managing distractions in med pass

TOPICS COVERED TODAY n n Documentation of medications Use of Skills checklist, Clinical Evaluation Tool Curriculum review Review parameters for med administration – pulse, B/P, etc.

TOPICS COVERED TODAY n n Procedure student taught for notifying nurse – refusals, condition change, errors, etc. Reporting process to BON for med errors

REQUIREMENTS FOR CMA CERTIFICATION o o Students pass class and clinical Meet BON requirements

BOARD OF NURSING REGULATIONS n n BON Regs - handout Functions of CMA’s Preceptor responsibilities - 1: 1 or 1: 2 Please discuss curriculum and duties of CMA with Administrator and DON evaluation

BOARD OF NURSING REGULATIONS n NF regs o 1 hour before/1 hour after o Consultant pharmacist – monthly o Review records – every pass o Nurse orders, receives meds

PRINCIPLES OF ADULT LEARNING n Adult learners want the teacher to: o o o o Be knowledgeable Show concern for learning Present material clearly Motivate Be enthusiastic To emphasize relevance of class material Create comfortable learning atmosphere Variety

PRINCIPLES OF ADULT LEARNING n n n Integration of new knowledge and skill take time. Small steps Rewards go far Be consistent Do not embarrass Must know the skills!

CURRICULUM REVIEW o See BON regulations

RULES OF MEDICATION ADMINISTRATION n n n You pour, you give Pour, document, pass Contact nurse every time, every PRN 1 hr. follow up for PRN’s Initial all meds as poured. Circle for any reason not given. Document on reverse MAR – what happened and what action taken. Dropped pills – baggie, label, store, pour, circle initial, document reverse

RULES OF MEDICATION ADMINISTRATION n 6 rights o o o n n Resident Time Medication Dose Route Documentation Notify nurse for all med errors Notify nurse if MAR doesn’t match the bottle or bubble pack

RULES OF MEDICATION ADMINISTRATION n n n They will know top 100 NF meds and general use of each. OK if you do not. Ask them questions and have them use their book to research answer. Give them 10 or more meds to look up in between med passes. Use meds residents are taking. Student will come to nurse for any math calculations other than simple math or for questions.

HOW TO STRUCTURE MED PASSES n n Nervous at start Give 3 -4 residents at first and then increase. Need to successfully administer to 10 -15 residents per hour – 20 -30 total. Take over and have them watch you as time line is approaching. Do process right. Pour, document, pass. Let student critique you.

HOW TO STRUCTURE MED PASSES n n Minimize distractions during med pass. 1: 1 – 1: 2 supervision. Can’t be on phone, doing other things. Must be at side to observe, correct and praise. Do not correct in front of resident Stop process if any of 6 rights are not being met. Correct and then proceed.

HOW TO STRUCTURE MED PASSES n n n Time management – watch two hour time frame. Organization skills – only a week Managing distractions in med pass

DOCUMENTATION OF MEDS n POUR, INITIAL, PASS o o Refused meds – lock up, try different approach 10 -15 min later, no success, circle initials, reverse MAR and write “refused X two and list meds, and nurse notified” Nurse is to call MD. Dropped – glove, pick up, label, lock up, re pour, circle initial, reverse MAR “dropped, saved for pharmacist, new pill given”.

DOCUMENTATION OF MEDS n POUR, INITIAL, PASS o o Expired med –initial, circle initials, reverse MAR and write “med expired. Nurse notified, med not given”. Nurse is to call pharmacy and reorder. No med –initial, circle initials, reverse MAR and write “no med to give. Nurse notified”. Nurse is to call pharmacy and reorder.

DOCUMENTATION OF MEDS n POUR, INITIAL, PASS o o No resident –initial, circle initials, reverse MAR and write “resident in hospital, out of facility, etc. , med not given”. May have to notify nurse to give med upon return. No blanks on the MAR

DOCUMENTATION OF MEDS o PRN’s – notify nurse, get permission, pour med, initial, write time below, pass, nurse initial below time, 1 hr follow up, reverse MAR and chart resident words if possible. Notify nurse of results.

SKILL CHECKLISTS AND EVALUATION TOOLS n n n Review each of the 12 skills and comments at end of skill Instruct on responsibilities of clinical preceptor and evaluating skills Use of skill cover sheet Use of Clinical Evaluation Tool Certificate for student

MEDICATION ADMINISTRATION PARAMETERS n n Pulse – Digoxin – below 60, don’t give. B/P – taken before antihypertensive meds? Fosamax – upright, 30 min before meal, 6 -8 oz water, upright Others:

PROCEDURE FOR NOTIFYING NURSE n n Direct supervision 1: 1 – 1: 2 Notify nurse for anything from refusal, no med, expired med, change in resident condition, missing controlled med, etc.

BON MONTHLY REPORTING n n Fill out med error sheet for any errors One page sheet Take offline and complete monthly Send to BON - Timely

ORIENTATION TO FEDERAL, STATE REGULATIONS o Nurse Role RN/LPN n n Oversee CMA, s and clinical training, direct supervision LPN/RN – direct supervision during clinical Reports to Administrator of program and NF administrator monthly Arranges for staffing

ORIENTATION TO FEDERAL, STATE REGULATIONS o Med Aide Role n n n Report to class and clinical every day Pass class and clinical training Report to preceptor nurse – any resident change in condition or problem with medication Administer and document all routine and PRN medications except – IV, IM, SQ, or NG Pass BON exam 8 CE’s every year. Can overlap with CNA CE’s

ORIENTATION TO FEDERAL, STATE REGULATIONS o State Board of Pharmacy n n Custodial Drug Permit Oversee all Medication Administration Monthly Site Visits Rules of Medication Administration o o o o o No pre-pour MD order, in writing for all meds Meds stored separately One hour lee way time frame No sharing of medicines Controlled medications, counted each shift You pour, you give All meds locked at all times Refrigerator temp 35 -45 degrees Do not crush pills without order

ORIENTATION TO FEDERAL, STATE REGULATIONS o State Board of Nursing n n Approved this Program Issues Certification Exam Periodic Site Visits Evaluates Program

GENERAL ORIENTATION TO NF o Philosophy and Objectives n n Home for residents Residents are # 1 priority Improve or maintain quality of life With CMA’s – More nurse time with residents for assessment, intervention, treatment

ORIENTATION TO THE MEDICATION AIDE POSITION o Expectations and Responsibilities n n n n Come to work on time, when scheduled, good mood Administer routine and PRN meds as ordered Administer medications during allotted time period Report any changes in resident condition to nurse Ask nurse any question about any medication issue Report all medication errors to nurse and DON Complete medication error reports when medication error made

ON A TREADMILL AND CAN’T GET OFF?

ORIENTATION TO THE RESIDENT POPULATION o Other Challenges n n n Number of residents Number of medications per resident Changes in medications Changes in residents, nurses and orders Time guidelines

LEGAL ASPECTS AND RESPONSIBILITIES OF MEDICATION ADMINISTRATION o Facility Policies n n You pour the medication, you give the medication Do not destroy any medication for any reason Always call the nurse for any questions with medications Never give a medication if the MAR does not match the medication container

LEGAL ASPECTS AND RESPONSIBILITIES OF MEDICATION ADMINISTRATION o Facility Policies n n n Find out at your facility which shift gives meds given around change of shift times. Find out what times qd’s, bid’s, q 12 h, etc. are given. Be to work early enough to be on time for administering meds. Remember leeway time frame is 1 hour only

LEGAL ASPECTS AND RESPONSIBILITIES OF MEDICATION ADMINISTRATION o Legal/Ethical Issues of Charting and Record Keeping n n How to correct a charting mistake – one line through the error, your initials and then continue writing Late entry – In column, write “late entry for___” (date, shift), current date and then write note and sign name with title

LEGAL ASPECTS AND RESPONSIBILITIES OF MEDICATION ADMINISTRATION o Ethical Aspects of Medication Administration n Discuss end of life issues Discuss polypharmacy – the taking of many different medications Staff are not in NF to promote personal beliefs on aging and medications

LEGAL ASPECTS AND RESPONSIBILITIES OF MEDICATION ADMINISTRATION o Medication Errors n Identification o Ask yourself if you gave medication n n n o To the right resident At the right time In the right dose Using the right medication By the right route And documented it correctly “No” to any of the above and you made a medication error. Discuss examples.

LEGAL ASPECTS AND RESPONSIBILITIES OF MEDICATION ADMINISTRATION o Reporting n n Tell nurse and DON Fill out Medication Error Report or Incident Report per facility policy Document as directed by DON Learn from error

ANATOMY, PHYSIOLOGY AND PATHOPHYSIOLOGY o Common Health Problems of Residents n n n n n Osteoarthritis Impaired Eyesight Impaired Hearing CHF, CAD, ASHD Hypothyroidism Parkinson’s Disease Diabetes S/P CVA RA, Osteoarthritis n n n Chronic Pain Insomnia Dementia, Alzheimers Asthma COPD, Emphysema Hypertension Constipation Pneumonia Osteoporosis MS Macular Degeneration

FUNDAMENTALS OF PHARMACOLOGY o Definitions – n n MAR – Medication Administration Record Routes of Administration the CMA will do: o o o o Oral – by mouth Sublingual, under the tongue Buccal – in the cheek Ophthalmic – by eye Otic – by ear Topical – on the skin Nasal – by nose Rectal – by rectum

FUNDAMENTALS OF PHARMACOLOGY o Abbreviations –

FUNDAMENTALS OF PHARMACOLOGY o PRN ( as often as needed) Medications n n n Resident must ask for the medication or communicate need CMA is not to assess resident for need for PRN’s CMA always gets permission from nurse before administering any PRN medications. Every time, every resident, every PRN.

FUNDAMENTALS OF PHARMACOLOGY o PRN ( as often as needed) Medications n Documentation o o o On MAR with initials and time. On reverse of MAR with med, use, nurse name Nurse initials front of MAR under time CMA writes follow up entry with results of use of med in 1 hr. after administration Notifies nurse

FUNDAMENTALS OF PHARMACOLOGY o Response to Medications n n Desired Effect Side Effect Adverse Reactions Allergic Response

FUNDAMENTALS OF PHARMACOLOGY o Allergic Response n 5 most common allergic responses – o o o Nausea Vomiting Itching Rash Difficulty breathing – could lead to anaphylactic shock and death

FUNDAMENTALS OF PHARMACOLOGY o Anaphylactic Shock – from medication n n n Difficulty breathing Trachea swelling Decreased B/P Increased respirations and pulse Hives – sometimes Loss of consciousness Death

DRUG/ALCOHOL ABUSE

FUNDAMENTALS OF PHARMACOLOGY o Alcohol/Drug Abuse n Discuss medication dependence o o Misuse – Drug abuse is part of this larger problem which is the overuse or careless use of any drug, including alcohol. OTC’s, etc. Abuse – taking an excessive amount of a medication resulting in physical and/or psychological dependence. Taking of the medication interferes with daily living.

FUNDAMENTALS OF PHARMACOLOGY o Sources of Medication Information n n n n Supervising Nurse Physician Pharmacist Resident/Family Physician Orders Poison Control Reference Books Care Plan Internet

FUNDAMENTALS OF PHARMACOLOGY o Methods of Medication Distribution n Unit Dose – bubble pack, single dose in a package Bulk – laxatives, antacids, big containers in med room or on cart that facility purchases Multiple Dose –All of one residents meds for a specific day and time are in one package

SYSTEMS, FUNCTIONS, MEDICATIONS o Circulatory – Common medications n Cardiac Glycosides –digoxin (lanoxin) o o o Use -increases force of contraction of heart, slows down the heart rate, making more effective beats Used for CHF and AF Normal dosage – 0. 125 -0. 5 mg Side effects -Fatigue, anorexia, nausea, vomiting Contraindications - for certain heart arrhythmias. Geriatrics are sensitive to toxicity

SYSTEMS, FUNCTIONS, MEDICATIONS o Respiratory – Common Medications n Oxygen o A medication o On MAR o Initial each shift o Do not adjust liter flow without MD order and nurse. o Do not remove oxygen for bathroom or dining room without MD order. Chart accordingly. o Very flammable – no smoking

SYSTEMS, FUNCTIONS, MEDICATIONS o Nervous – Most Common Medications n Psychotropic Medications – a large grouping of medications that work in various ways to alter behavior, feelings, and other functions of the mind to increase the residents feeling of well being. o o Tranquilizers/Antianxiety Sedatives/Hypnotics Antidepressants Antipsychotics

ADMINISTRATION OF MEDICATIONS o Measurements n n Review conversion sheet in handout 2 Must know how to measure liquids and that o o o 1 tsp = 5 cc or 5 ml 2 tsp = 10 cc or 10 ml 3 tsp = 1 tbsp = 15 cc or 15 ml 1 oz = 30 cc or 30 ml 8 oz = 1 cup = 240 cc or 240 ml Measure at eye level

ADMINISTRATION OF MEDICATIONS o Measurements n Oral medications – must know simple math. Example: o o Dilantin 100 mg, give 300 mg q AM. How many capsules are you going to give? Digoxin. 125 mg, give. 25 mg q AM. How many pills are you going to give? How much is 50%, 25%, 10% of the total? Review Roman numerals – What is I, III, IV, VIII, XII?

ADMINISTRATION OF MEDICATIONS o Measurements n Oral medications – must know simple math. Example: o Ratios are X: Y. May have to give something that says give a ratio of Cascara to MOM of 1: 2. So you would give 1 unit of Cascara to 2 units of MOM. Not used often as chance for med errors increase with this approach. Consult with nurse before doing any ratios.

ADMINISTRATION OF MEDICATIONS o Measurements n Oral medications – must know simple math. Example: o o Fractions – May be asked to give ½ of a pill. Any further fraction decisions are to be brought to the nurse. Complete worksheet now.

ADMINISTRATION OF MEDICATIONS o Proper Storage of Medications n Everything locked o o n Med cart Controlled substance drawer Medication room Medication refrigerator – not usually because in a locked room Everything separated o Internals from externals – what does that mean?

ADMINISTRATION OF MEDICATIONS o Ordering, Receiving and Disposing of Medications n n n Review all of the forms again for ordering, receiving and returning medications. Accurate paper trail is imperative Never are you to o Order a new medication o Return a medication to its container if not taken o Destroy a medication

ADMINISTRATION OF MEDICATIONS o Observations n The process o o Wash hands Identify resident – MAR, photo, names on meds Identify time – MAR Identify medications – start at top of first page, one at a time

ADMINISTRATION OF MEDICATIONS o Observations n The process o Read MAR and match with medication label – no match, no give. Get nurse o Read expiration date and warning labels o Pour correct dose into med cup o Chart initial on MAR for correct time, date and medication

ADMINISTRATION OF MEDICATIONS o Observations n The process o o Repeat steps above for all medications to be given for that time. Chart controlled substances on appropriate sheets as you go. Count number of initials on MAR for medications poured Count number of medications in med cup – should match Lock up all meds except those in med cup

ADMINISTRATION OF MEDICATIONS o Observations n The process o o o Close MAR Bring water and med cup into resident Knock on door, introduce self, tell resident you have meds, watch resident swallow Return to med cart Wash hands

ADMINISTRATION OF MEDICATIONS o Observations n The process o o Any refused meds – lock in med cart and retry in 10 -15 minutes – new approach Open MAR and go to next resident

ANY NEW MEDS? o o o o Antidepressants Laxatives Statins BP Diuretics Hypnotics Alzheimers Others

SKILLS – 1 -15 n n n n Handwashing Oral Opthalmic Otic Nasal Vaginal Rectal Penile n n n n Topical Metered dose Transdermal PRN’s Gastrostomy Jejunostomy Nebulizer

SKILL # 1 o Handwashing n n n At least 10 sec washing Between fingers, wrists Downward

SKILL # 2 o Oral – pills, tablets, capsules, powders, liquids n n n Never touch Watch swallow Liquids – eye level

SKILL # 3 o Opthalmic – eye n n Gloves Never touch tip of medicine to anything 5 min between meds Pocket lower lid

SKILL # 4 o Otic - ear n n Gloves Never touch tip of medicine to anything 5 min between meds On side in bed or tilted head in chair

SKILL # 5 o Nasal – dropper or spray n n n Gloves 5 min between meds On side in bed or tilted head in chair

SKILL # 6 o Vaginal - suppositories and creams n n n Gloves Keep covered Keep lying down for 20 minutes

SKILL # 7 o Rectal - suppositories n n n Gloves Keep covered On side in bed Lubricate Wall of rectum and not in feces

SKILL # 8 o Penile - cream n n n Gloves Keep covered On back Wash if needed Foreskin

SKILL # 9 o Topical – cream, ointment, liniment, lotion n n Gloves Privacy Wash off old if visible Thin coat

SKILL # 10 o Metered dose inhalers n n n Gloves Rotate not shake Hand to resident Report to nurse if resident can not coordinate inhalation with depression of inhaler Powders Give water after

SKILL # 11 Transdermal patches n n n n Gloves Remove old patch. Clean and dry area for new patch. Rotate sites. Place patch on and hold in place for about 1 minute. Chart where placed, initial, date, time. Discard used patch in sharps container.

SKILL # 12 o PRN’s n n n Resident communication Nurse approval and initials – every time Follow up 1 hr later and document reverse of MAR

SKILL # 13 o Vital Signs Temperature – 97 -98. 6 n Pulse – 60 -90 n Respirations – 12 -16 n Blood Pressure – 100/60 -120/80’s Know resident “normal” vital signs Do not need nurse or doctor order to take VS n Take VS for any incident and give to nurse n

THE END o o o o Follow six rights – resident, time, med, dose, route, documentation Avoid distractions Never pre pour You pour, you give Leeway time frame – 1 hr. before – 1 hr. after If in doubt, do not give and get nurse Have fun!!!!! Good luck in clinical. Use time wisely!