Department of Health and Human Services

MAINE Division of Licensing and Certification

CiSiP

September 2005

The Maine Department of Health and Human Services does not discriminate against people on the basis of disability, race, color, creed, gender, age or national origin in admission to, access to, or operations of its programs, services or activities, or its hiring or employment practices. This information is available in alternate format upon request.

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 2 of 177 TABLE OF CONTENTS

Section 1...... 9

CRMA Role...... 9

• Certification Limitations...... 9 • Job Description...... 10 • Other Staff Roles...... 10 • Key Responsibilities...... 10 • Characteristics...... 10

Section 2...... 11

INSTRUCTIONS FOR DOCUMENTATION EXERCISE ...... 11

PHYSICIAN’S ORDERS ...... 12

RESIDENT CARE NOTES...... 13

Medication Administration Record...... 14

Medication Disposal Form...... 16 Medication Error Form...... 17 Medication Sign Out Record Form ...... 18 Missed or Late Medications ...... 19 Over The Counter Medication Form...... 20 Physician’s Order...... 21 CRMA – RECERT Medication Administration Skills Checklist...... 22

Section 3...... 25

MEDICAL ABBREVIATIONS...... 25

Section 4...... 28

MEDICATION MEASUREMENTS...... 28

Systems of Measurement...... 28 • Metric Terms...... 28 • Apothecary System Description ...... 29 • Household System Description...... 29 • Metric System ...... 29 • Weight...... 29

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 3 of 177 • Volume...... 30 • Length ...... 30 Apothecary System...... 30 • Weight -- (Dry) ...... 30 • Volume -- (Wet)...... 30 Household System ...... 31 Equivalent Dry Measurement Units...... 31 Equivalent Liquid Measurement Units...... 32

Section 5...... 33

Review of Drug Classifications...... 33

Medication Classification Terms and Definitions ...... 33

Section 6...... 36

Medication Orders ...... 36

• Obtaining Medication Orders ...... 36 • Prescription ...... 36 • Duly Authorized Licensed Practitioner Order ...... 36 Psychotropic PRN’s...... 37 Calling In Orders...... 37 Appointment for Service/Order Sheet ...... 37 Telephone Orders...... 38

When Must Orders be Written or Re-Written?...... 38

During the Admission Process...... 38 Psychotropic Orders ...... 38 Medical Orders ...... 39 Upon Discharge from a Hospitalization...... 39 New Orders...... 39 Changed Orders...... 40 Discontinued or Stop Orders...... 41

Section 7...... 42

Medication Ordering...... 42

SECTION 8...... 43

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 4 of 177 Documentation...... 43

• Initials ...... 43 • Unusual Circumstances...... 43 • Refusal ...... 43

Medication Administration Record (MAR)...... 44

General Information ...... 44 Medication Name(s), Dose, Frequency, and Route...... 45 Order Date...... 45 Provider ...... 45 Times of Administration ...... 45 PRN’s ...... 45 Change in Dose...... 46 Change in Start Dates...... 46 MAR Review ...... 46 Missing Initials on the MAR...... 47 Resident Refuses to Take Medication: ...... 47 Life Span For Drugs ...... 48

SECTION 9...... 49

Medication Administration ...... 49

Seven (7) Rights of Safe Medication Administration...... 49

REMEMBER:...... 50

Routes of Administration...... 51

Oral ...... 51 • Oral Administration Equipment...... 51 • Oral Administration Process...... 52 Rectal...... 53 • Administration Technique...... 53 Vaginal...... 54 • Administration Technique...... 54 Topical ...... 55 • Administration Technique...... 55 • Equipment...... 55 • Technique...... 55 • Nitroglycerin Ointment Guidelines...... 56

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 5 of 177 • Transdermal ...... 57 • Patches ...... 57 • Nitro-paste...... 57 • Administration Techniques...... 57 Eye Drops...... 58 • Administration Technique...... 58 • Equipment...... 58 • Technique...... 58 Nose Drops ...... 59 • Administration Technique...... 59 • Equipment...... 59 • Technique...... 59 Ear Drops ...... 60 • Administration Technique...... 60 • Technique...... 60 Inhalants ...... 61 • Administration Technique...... 61 Injectable ...... 62 Crushing Medications ...... 63 • What Can and Can’t Be Crushed? ...... 63 • When in DOUBT, Call the Pharmacist...... 63 When Not To Give Medication ...... 64

Medication Administration Procedures...... 64

Designated Times...... 64 Dosage...... 64 Guidelines ...... 65 Charting (Documenting) Guidelines ...... 67

Medication Storage...... 68

Disposing of Medications...... 70

Section 10...... 71

Emergency Situations...... 71

The Maine Poison Control: ...... 72

Section 11...... 73

Review of Common Errors and how to prevent them...... 73

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 6 of 177 • Type of Errors...... 73 • Documentation...... 73 • Omission ...... 73 • Refusal ...... 73 • Transcription...... 73 • Wrong Dosage ...... 74 • Wrong Medication ...... 74 • Wrong Person...... 74 • Wrong Time...... 74 • Contamination...... 74 Pharmacy Package/Label error...... 74 Other...... 74

Incident Reports ...... 75

Tips for Error Prevention ...... 75

APPENDIX A...... 76

Medications/body systems charts...... 76 Medications Used in Treating Muscular and Skeletal System Disorders...... 77 • Medications Used in Treating Muscular and Skeletal System Disorders continued...... 79 • Cardiovascular Disorders...... 80 • Respiratory Disorders ...... 88 • Nervous System and Psychiatric Disorders ...... 92 • Endocrine Disorders...... 101 • Gastrointestinal Disorders (Digestive) Disorders ...... 105 • Genitourinary Disorders...... 111 • Ear, Eye and Skin Disorders ...... 113 • Infectious Disorders...... 117

APPENDIX B ...... 122

INFECTION CONTROL ...... 123 Infection Control Practices...... 123 Bloodborne Diseases...... 125 Workplace Transmission ...... 126 Means of Transmission ...... 126 Contaminated Surfaces...... 127 Hepatitis Viruses (HV) ...... 128

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 7 of 177 • Hepatitis A...... 128 • Hepatitis B...... 129 • Hepatitis C...... 131 Human Immunodeficiency Virus (HIV) ...... 132 Exposure Control Plan...... 133 Standard Precautions ...... 133 Reducing Your Exposure Risk...... 134 • Engineering Controls...... 134 • Employee Work Practices...... 134 • Environmental Practices...... 135 Personal Hygiene...... 136 Personal Protective Equipment (PPE)...... 136 • Exception to the PPE Rule...... 136 • Resuscitation Devices...... 137 • Gloves ...... 137 Hand Washing...... 138 • Hand Washing Technique...... 139 BioHazardous Materials...... 140

APPENDIX C...... 141

FOOD AND DRUG INTERACTIONS ...... 141

APPENDIX D...... 167

STATE REGULATIONS FOR LEVEL IV ...... 167 Section 5...... 168 • Resident Rights ...... 168 Section 7...... 172 • Medications And Treatments...... 172 Section 8...... 177 • Verification of Credentials...... 177

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 8 of 177 Section 1

CRMA Role

• Certification Limitations

It is important that you understand that your certification allows you to administer medication in Maine and only in facilities covered under the regulations that provided the authorization for your training. Even though your employer may have sponsored your training, you have earned the certification for yourself. If you leave your current employer and find employment elsewhere, your certification is part of the qualifications that you possess. It is not restricted only to the agency you are currently working with. You can serve as a CRMA in more than one agency at a time so long as you have met the requirements of each agency that expects you to perform as a CRMA.

Be sure that you understand your responsibility in relation to any medication policy within your facility. You need to be sure that policies are in place that clearly state what is expected of you, how you are to document your actions, and who is responsible for supervising your role as a CRMA.

It is important that a CRMA always remember that s/he

A. Must understand the facility medication policy. B. Must have knowledge of and respect resident rights. C. Must have knowledge of what is necessary to ensure resident safety. D. Must have knowledge of how to approach the resident. E. Must have knowledge of the medications that residents are taking. F. Must administer the drug according to physician's orders. G. Must be able to administer non-injectable medications in a manner that is safe, proper, and accurate. H. Must have knowledge and documented skills training to administer injectable medication and assist a resident in using a breathing apparatus in a manner that is safe and accurate.

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 9 of 177 • Job Description

You may serve as a CRMA in more than one licensed facility over the duration of your career.

Therefore, be sure that you understand your responsibility in relation to any standard operating procedures by your employer. You need to be sure that policies are in place that clearly state what is expected of you, how you are to document your actions, and who is responsible for supervising your role as a CRMA.

• Other Staff Roles

Since the CRMA may work in a variety of environments, s/he may also report to and/or work with a variety of other staff members. Clearly, each of these positions is important to the successful delivery of Residential Care Services. Typical positions may include:

♦ Administrator ♦ Directors ♦ Care Staff ♦ Facility Staff ♦ Nurse Consultants ♦ Pharmacist

• Key Responsibilities

It is important to recognize and define the “key” or “common” responsibilities performed by the CRMA regardless of the licensed facility these duties are being performed in.

• Characteristics

Equally important to the integrity of the CRMA profession as the job description and the key responsibilities is knowledge of the characteristics and values that are indicative of the “best” CRMA employee.

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 10 of 177

Section 2

INSTRUCTIONS FOR DOCUMENTATION EXERCISE

On the MAR provided:

1. Transcribe the orders on the physician’s order sheet onto the MAR.

2. Donnie is at Bestfacilitynthstate.

3. Donnie’s last name is the last name of the student.

4. He is in room 100-A

5. Donnie’s MOM is being D/C’d on the 18th, please D/C the med appropriately on the MAR.

6. Facility med pass times are as follows:

a. QD 8 am b. BID 8 am 8 pm c. TID 9 am 1 pm 9 pm d. QID 8 am 12 pm 4 pm 8 pm e. All other med times as specified by physician’s orders.

7. Donnie refused his Lasix on the 12th because he was going out shopping. Document the refusal.

8. Document the administration of medications for 5 days, (beginning on the 4th).

9. Know that all additional orders/Rx have been signed and dated by Dr. Getchafeelinbetter, M.D.

10. Donnie does not self administer.

11. Donnie has NKA and NKFDA.

Dr. Soursik Getchafeelinbetter, M.D. Dr. Soursik Getchafeelinbetter, M.D. 1367 Healthy Way 1367 Healthy Way No-oneseversick, USA 3390990 No-oneseversick, USA 3390990 DEA# 2774747899900488000 DEA# 2774747899900488000

Current month/18/current year Current month/06/current year

Donnie (Last name of Student) Donnie (Last name of Student)

D/C Milk of Magnesia 30 cc’s p.o. qd prn for Ampicillin 500 mgs., P.O., Q 6 H, for 14 days constipation. (pneumonia). Dr. Getchafeelinbetter, M.D. Dr. Getchafeelinbetter, M.D. Dr. Getchafellinbetter, MD (dated) Dr. Getchafellinbetter, MD (dated)

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PHYSICIAN’S ORDERS

DATE ORDERS Current month/04/and year. Lasix 20 mgs. P.O., QD @ 6 am (CHF) Digoxin 0.125 mgs. P.O., QD, hold if pulse ↓ 58 Beats/min. (CHF) Depakote Spansules, 250 mgs., P.O. , B.I.D. (Seizure Disorder) Risperdal 0.5 mgs., P.O., Q D (Behavioral Seizures) Xanax, 0.25 mgs., P.O., Q 4 H, PRN for anxiety attacks, (restlessness, palpitations, pacing, Repetitive remarks, self injurious behaviors) Blood pressure daily MOM 30 cc’s P.O., QD, PRN for constipation Tylenol 650mgs. P.O. q 4 h, PRN for ↑ temp., or pain Dr. Getchafeelinbetter, M.D.

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RESIDENT CARE NOTES

DATE NOTES

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 13 of 177

Bestfacilitynthstate Medication Administration Record Medications Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Nurse’s Orders, Medication Notes, and Instructions on Reverse Side Charting For Through Physician Telephone No. Medical Record No. Alt. Physician Alt. Telephone Allergies

Diagnosis

Medicaid Number Medicare Number Complete Entries Checked: By: Resident Resident Room No. Bed Facility Code Code Initials Nurse’s Signature Initials Nurse’s Signature Initials Nurse’s Signature

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Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date Temp/ Temp/ Pulse Pulse Blood Blood Pressure Pressure

NURSE’S MEDICATION NOTES Date/Hour Medication/Dosage Reason Results/Response Hour Initials

Patch Site/Injection Site Codes:

1 – Right Dorsal Gluteus 5 – Right Lateral Thigh 9 – Right Upper Arm 13 – Upper Back Left 17 – To Right and Above Umbilicus 2 – Left Dorsal Gluteus 6 – Left Lateral Thigh 10 – Left Upper Arm 14 – Upper Back Right 18 – To Left and Above Level of Umbilicus 3 – Right Ventral Gluteus 7 – Right Deltoid 11 – Right Anterior Thigh 15 – Upper Chest Left 19 – To Right and Below Level of Umbilicus 4 – Left Ventral Gluteus 8 – left Deltoid 12 – Left Anterior Thigh 16 – Upper Chest Right 20 – To Left and Below Level of Umbilicus

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Medication Disposal Form Bestfacilitynthstate

Medication Disposal Form

Individual’s Name:______

Date and Name/Dose of RX # Pharmacy # To Be Reason for Signature Signature Time Medication Name Disposed Disposal of Of Med.

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Medication Error Form Bestfacilitynthstate

Medication Error Discipline Report Form

STAFF______

TYPE OF DISCIPLINE

VERBAL WARNING WRITTEN WARNING WRITTEN WARNING AND 30 DAY PROBATION TERMINATION AND NOTIFICATION OF C.R.M.A. REGISTRY DATE______

DISCIPLINE DATE______REASON______

PLAN OF ACTION______

______Jody Smith, R.N. EMPLOYEE SIGNATURE

______TEAM LEADER

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Medication Sign Out Record Form Bestfacilitynthstate Medication Sign Out Record (Release of Prescribed Medications)

Name of Individual:______

Pharmacy RX Medication Prescribed By: Amount Amount Orders Number Name Released Returned Attached Yes / No

Special Instructions:______

Name of person completing this form:______(Please Print)

Signature:______Title:______

Date:______Witness signature (optional)______Date:______

I hereby certify that I have received the above-listed medications and instructions for continuing my care. I assume responsibility for the listed medications.

Signature______Date:______(To Be Completed Upon Return To Anywhere Programs of Maine)

No ٱ Yes ٱ ?Does medication appear to be in good condition

Signature of Person returning the Medication(s):______

Signature of Staff receiving the Medication(s):______

Does it appear that the medication(s) were given according to physicians’ order(s)? No ٱ Yes ٱ If No, please explain:______CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 18 of 177

Missed or Late Medications Bestfacilitynthstate Nursing Orders For Missed or Late Medications

Name:______Initial Date:______

Residence:______

Phone Number:______

Medication:______Medication:______Omit if outside ½ hour window ٱ Omit if outside ½ hour window ٱ May give up to 2 hours later ٱ May give up to 2 hours later ٱ May give up to 4 hours later ٱ May give up to 4 hours later ٱ Omit the next dose ٱ Omit the next dose ٱ May combine with the next dose ٱ May combine with the next dose ٱ May give late, but space succeeding doses ٱ May give late, but space succeeding doses ٱ ______hours apart ______hours apart May give any time in 24 hours ٱ May give any time in 24 hours ٱ Special Notes:______Special Notes:______Date:______Date:______

Medication:______Medication:______Omit if outside ½ hour window ٱ Omit if outside ½ hour window ٱ May give up to 2 hours later ٱ May give up to 2 hours later ٱ May give up to 4 hours later ٱ May give up to 4 hours later ٱ Omit the next dose ٱ Omit the next dose ٱ May combine with the next dose ٱ May combine with the next dose ٱ May give late, but space succeeding doses ٱ May give late, but space succeeding doses ٱ ______hours apart ______hours apart May give any time in 24 hours ٱ May give any time in 24 hours ٱ Special Notes:______Special Notes:______Date:______Date:______

.(Keep a record of missed or late medications for review at the next appointment. (Incident Report Form ٱ

Provider’s Signature: ______Date:______

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Over The Counter Medication Form Bestfacilitynthstate

Dear Dr.______

Your resident______, is served by Anywhere Programs of Maine. In compliance with state regulations for licensing, the following assistance from you is needed.

To have on hand a supply of approved stock medications for common ailments to be used for the client, please indicate by checking the space provided, if your resident may use these medications with supervision of the RN/CRMA staff.

May May Not Drug/Product Use Use Directions for Use Acetaminophen 325mg take two (2) tablets by mouth every 4 to six hours as needed for pain or elevated temperature above 101F Acetaminophen 500mg tablet: take two (2) tablets by mouth every 4 to 6 hours as needed for pain, inflammation, or temperature above 101F Acetaminophen Liquid 1000mg/30ml 4 to 6 hours as needed for pain or elevated temperature above 101 F Ibuprofen 200 mg. Tablet: take 2 tablets by mouth every 4 to 6 hours as needed for pain, inflammation, or fever over 101F May use above x 3 consecutive days – Then notify R.N. if resident requests on fourth consecutive day. Sudafed Pseudophedrine: 30 mg. tablet, take 2 tablets by mouth every 4 to 6 hours as needed for sinus congestion Alka-Seltzer Plus Dissolve one tablet in water and take by mouth every 4 to 6 hour as needed for pain or fever above 101F Antacid/Antiflatulent Alamag: take 15 ml. by mouth every 4 hours as needed for indigestion, stomach upset, excess gas Tums 500mg Tablet: take two (2) tablets by mouth qid/prn heartburn/indigestion Do not use antacid within 1 hour of administering psychotropic medications. Allergy Capsules Diphenhydramine HCL: 25 mg 2 capsules by mouth every 4 to 6 hours as needed for runny/itchy nose, sneezing, scratchy throat, itchy/watery eyes Anti-diarrhea Kaopectate Suspension: take 4 tablespoons (60ml) by mouth after each loose bowel movement Cough syrup Robitussin Expectorant: take 10ml by mouth every 4 to 6 hours as needed for cough and/or congestion Cough syrup Robitussin PE (expectorant/decongestant) take 10 ml by mouth every 4 to 6 hours as needed for cough and/or congestion Cough syrup Robitussin DM (cough suppressant) take 10 ml by mouth every 4 to 6 hours as needed for cough Cough drops Halls regular: take 1 drop q 15min. prn/cough NTE 12 drops in 24 hours. Cough drops Halls sugar free: take 1 drop q 15min. prn/cough NTE 12 drops in 24 hours. Ipecac Syrup One Tablespoon followed by a half a cup to a cup of water. If vomiting does not occur in 20 mins., repeat dosage Milk of Magnesia Take 15ml by mouth at bedtime for constipation, if no bowel movement for 2 days Bactine Spray Apply a small amount on the area one to three times daily Calamine Lotion Apply to itchy or rashy areas three times daily as needed for irritation Ivy-dry Apply liberal amount to skin for poison ivy, poison oak, and poison sumac as often as needed Benadryl Cream Apply to affected area not more than three to four times daily. Do not use on broken skin. Desenex Powder Clean the affected area and dry thoroughly. Apply a thin layer over the affected area twice daily. Noxema (sunburn) Apply to the skin 3 times daily as needed for irritation. Peroxide/H2O ½ strength solution, wash cuts thoroughly, pat dry Triple Antibiotic Apply to the irritated, cut or infected area 3 times daily and cover with a dry sterile bandage if needed Ointment or Bacitracin After cleansing with ½ strength peroxide solution. Notify R.N. for redness, swelling, heat, or exudate. Warm/Cold Packs Apply to affected/painful areas as needed Act Fluoride Rinse Rinse 10cc between teeth for 30 seconds qhs after brushing then spit out. Other:

Physician’s Signature______Date______

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Physician’s Order Bestfacilitynthstate Physician’s Orders

Resident’s Name:______

Date: Orders:

Date: Orders:

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CRMA – RECERT Medication Administration Skills Checklist

Date: ______Participant: ______RN Evaluator: ______

= Completed

Directions: The RN Evaluator will observe the Participant perform each of the following tasks and place a checkmark, and comments in the appropriate column. Both the Participant and the Instructor will sign and date this checklist to verify completion. *All areas not covered in Mock Medication Administration MUST be part of the WRITTEN portion of the Mock Medication Pass.

Tasks Performed/Comments Tasks Performed/Comments A. Verify Medication F. Record, Count, and Sign for Controlled Substances* 1. Compare MAR with Physician’s Order 1. Write Schedule III, IV, and V’s on Control Count Sheet 2. Identify type of order (stat, give now, prn, time 2. Write in Schedule II on Control Count Sheet limited) and in Bound Book 3. Determine Completeness of Order (name, time, 3. Write in Individual Count Record date, route, frequency, dosage) B. Check for Special Considerations G. Store Medications

1. Verify instructions on label 1. Separation – Internal and External

2. Review parameters 2. Locked

3. Check for contraindications 3. Double Locked

4. Check for food, drug, or latex allergies 4. Refrigeration

5. Check for food and/or drug interactions 5. Temperature

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Task Performed/Comments Task Performed/Comments

C. Transcribe order to Medication Administration Record (MAR) D. Order and Reorder Medications*

E. Receive and Count Medications*

H. Administer Medications and Associated Treatment Procedures

1. Wash or sanitize hands 5. Utilize seven (7) right to Pass Medication 2. Wear gloves when indicated a. Right resident

3. Compare label with MAR – Three b. Right medication Checks a. Before pouring c. Right Dose

b. Immediately after pouring d. Right Route

c. Before administering e. Right Time

4. Prepare Medications f. Right to Know

a. Count g. Right to Refuse

b. Pour 6. Document Medication Administration c. Crush a. Document routine and prn medication use d. Mix b. Transcribe initial use of standing orders e. Measure c. Process new and change orders

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 23 of 177

f. d. Document the refusal of a medication

7. Document Medication Errors 8. Demonstrate Medication Administration a. Define medication error a. Oral

b. Document on MAR b. Ear Drops

c. Complete Incident/Medication Error c. Eye Drops Report

9. VITAL SIGNS (Actual Demonstration d. Nose Sprays/Drops is required.) e. Rectal Temperature f. Vaginal Pulses (at least Radial and Apical) g. Liquids Respirations h. Inhaler Blood Pressure OVERALL COMMENTS:

INSTRUCTOR’S INITIALS: ______

______Participant’s Signature Date RN Evaluator’s Signature Date CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 24 of 177

Section 3

MEDICAL ABBREVIATIONS

COMMON MEDICAL ABBREVIATIONS/SYMBOLS

Abbreviation/ Meaning Abbreviation/ Meaning Symbol Symbol BP Blood Pressure N & V Nausea & Vomiting BM Bowel Movement noc* Night BR Bathroom NPO Nothing by Mouth BRP Bathroom Privileges OTC Over the Counter C Centigrade PER By or With With PO or p By Mouth CBC Complete Blood Count PR Per Rectal CHF Congestive Heart qs Quantity Failure Sufficient CNS Central Nervous System R Rectal or Respiration Dr. Doctor (R) Right DSD Dry Sterile Dressing RBC Red Blood Count Dx Diagnosis ROM Range of Motion EENT Ear, Eye, Nose, Throat Rx Treatment F Fahrenheit Without GI Gastrointestinal Spec Specimen GU Genitourinary SS Soap Suds Hct Hematocrit TPR Temperature, Pulse & Respiration Hgb Hemoglobin UV Ultraviolet Hx History VS Vital Signs I & O Intake & Output (L) Left WBC White Blood Count LAB Laboratory W/C Wheel Chair MAR Medication Wgt Weight Administration Record

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 25 of 177

May see these abbreviations a “line” over them.

DRUG ADMINISTRATION ABBREVIATIONS/SYMBOLS Abbreviation/ Abbreviation/ Meaning Meaning Symbol Symbol @ At a* Before p* After aa Of each pc* After Meals ac* Before Meals prn As Needed ad Right Ear q Every as Left Ear qd Once a Day au Both Ears qh Every Hour ad lib As Patient Desires q2H, q4H, q8H Every 2, 4 8 Hours bid Two Times Per Day qhs Every Night at Bedtime cap Capsule qid Four Times a Day cc Cubic Centimeter qod Every Other Day c/o Complaint Of d/c Discontinue sc or suq Subcutaneous dr Dram SL Sublingual Gm Gram sol Solution gr grain ss One Half gtt A Drop stat At Once HS Hour of Sleep supp or Sp Suppository IM Intramuscularly susp Suspension IV Intravenous tab Tablet Kg Kilogram tid Three Times a Day LLQ Lower Left Quadrant tinct or tr Tincture L Liter T or Tbs Tablespoon mg Milligrams od Right Eye t or tsp Teaspoon os Left Eye U Unit ou Both Eyes ung Ointment oz Ounce ↑ Increase, Upper, Elevate(d) ∆ Change ↓ Decrease, Lower ______1 tab, 2 tabs, 3 tabs, etc. (May also I, II, III, IV, V ** be used for tsps or ozs.

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*May see these abbreviations a “line” over them. **May see these abbreviations with dots over them as well as the line.

COMMON CHEMICAL AND DRUG ABBREVIATIONS

Abbreviation Meaning

ASA Aspirin (Acetylsalicylic Acid) Ca Calcium Cl Chloride CPZ Thorazine DSS Colace (Dioctyl Sodium Silfosuccinate) FeSO4 Ferrous Sulfate H2O Water H2O2 Hydrogen Peroxide I Iodine K Potassium KI Potassium Iodine KCL Potassium Chloride LiCO3 Lithium Carbonate Mg Magnesium MOM Milk of Magnesia MS Morphine Sulfate Na Sodium NaCL Sodium Chloride NS Normal Saline NTG Nitroglycerine O2 Oxygen SSKI Saturated Solution of Potassium Iodine

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 27 of 177

Section 4

MEDICATION MEASUREMENTS

Medication administration involves calculating the proper dose, and it may be measured in volume or weight. The other unit of measure that is sometimes used is length.

Systems of Measurement

Three systems of measurement are common in medication administration and include:

• Metric Terms

1. The international language of measurement. a. Symbols are identical the world over and in all languages. b. Terms used are meters, grams and liter. (1) Meter is the basic unit of length. (2) Gram is basic unit of weight. (3) Liter is basic unit of volume. c. Prefixes are added to distinguish the various amounts. (1) Kilo - one thousand (2) Milli - one thousandth (3) Centi - one hundredth (4) Deci - one-tenth

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 28 of 177

• Apothecary System Description

1. Not used as much as it used to be, but should be learned. 2. Some measurements are the same as household measures. 3. Examples: a. Grain, dram, ounce, pound

• Household System Description

1. Used primarily in the home. 2. Examples: a. Teaspoon, cup, pint, and quart

• Metric System

The metric system is used extensively in the practice and is the international language of measurement with common symbols in all languages.

In the metric system the basic unit of length is the meter, for weight, it’s the gram; and for volume it’s the liter. The prefix kilo = one thousand, milli = one-thousandth, centi = one hundredth, and deci = one tenth.

• Weight

1 kilogram (kg) = 1000 grams (G) 1 gram (GM or G) = 1000 milligrams (mg) 1 milligram (mg) = 1000 micrograms (mcg)

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 29 of 177

• Volume

1 kiloliter (kl) = 1000 liters (L) 1 liter (L) = 1000 milliliters (ml) or 1000 cubic centimeters (cc)

1 milliliter (ml) = 1 cubic centimeter (cc)

• Length

1 kilometer (km) = 1000 meters (m) 1 meter (m) = 1000 millimeters (mm)

Apothecary System

• Weight -- (Dry)

60 grains (gr) = 1 dram (dr) = (15 g) 480 grains (gr) = 1 ounce (oz) = (30 g) = 30cc or 30ml 8 drams (dr) = 1 ounce (oz) = (30 g) = 30cc or 30ml 12 ounces (oz) = 1 pound (lb) = (360g)

• Volume -- (Wet)

60 minims (m) = 1 fluid dram (fl dr) 480 minims (m) = 1 fluid ounce (fl oz) = 30 cc or 30 ml 8 fluid drams (fl dr) = 1 fluid ounce (fl oz) = 30cc or 30ml 16 fluid ounces (fl oz) = 1 pint (pt) 500 ml 32 fluid ounces (fl oz) = 1 quart (qt) = 11 = 1000 ml 4 quarts (qt) = 1 gallon (gal) = 41 = 4000 ml

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Some of the units of measure in the apothecaries’ system are also common to the household system. This system also calculates 12 ounces as equal to a pound. The system is frequently used in medication orders, and your calculations need to be accurate.

Household System

60 drops (gtts) = 1 teaspoon (tsp) 1 dash = less than 1/8 teaspoon 3 teaspoons (tsp) = 1 tablespoon (Tbsp) 2 tablespoons (Tbsp)= 1 ounce (oz) 4 ounces (fl oz) = 1 juice glass 6 ounces (fl oz) = 1 teacup 8 ounces (fl oz) = 1 glass 16 tablespoons (Tbsp)= 8 ounces (oz) or 1 measuring cup (c) 2 cups (c) = 1 pint (pt) 2 pints (pt) = 1 quart (qt) 4 quarts (qt) = 1 gallon (gal)

Equivalent Dry Measurement Units

Household Metric (dry) Apothecary

1/8 teaspoon 0.6 grams or 60 milligrams 1 grain ¼ teaspoon .5 grams 7.5 grains 1 teaspoon 1 gram 15 grains 1 tablespoon 4 grams or 1 dram 60 grains 2 tablespoons 30 grams 1 ounce

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Equivalent Liquid Measurement Units

Household Metric (liquid) Apothecary 1 drop (gtt) .06 milliliters 1 minim 15 drops 1 milliliter 15 minims 1 teaspoon (5ml) 4 milliliters 1 fluid dram 1 dessert spoon 8 milliliters 2 fluid drams 6 teaspoons or 2 tablespoons 30 milliliters 1 fluid ounce

1 juice glass 120 milliliters 4 fluid ounces 2 cups 500 milliliters 1 pint 4 measuring cups 1000 milliliters 1 quart or 2 pints

You should be very familiar with each of the measuring devices available at the facility where you are responsible for administering medications. Some devices will have one, two, and sometimes three different scales for you to select from. Some medications will be supplied with their own medication cup, dropper, or measuring device. If that is the case, the medication should be given only from that device to avoid any medication errors.

Some medication administration measuring devices will have markings that indicate an “adult dose” or “read the label directions.” It is best to follow the directions that are on the label rather than to calculate the units of measure to be used with another device. This is particularly true with some over the counter liquid cold medications. The cup that is supplied is mainly for convenience, and the markings may not be accurate volume measurements.

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Section 5

Review of Drug Classifications

Medication Classification Terms and Definitions

Amphetamine - Cerebral stimulant.

Analgesic - Pain reliever.

Antacid - Prevents or relieves gastric distress.

AntiAnxiety (Benzodiazepines) - Prevents or relieves anxiety.

AntiArrhythmic (Heart Rhythm Regulators) - Prevents or relieves irregular heartbeat.

AntiAsthmatic (Bronchodilator) - Prevents or relieves respiratory distress.

AntiBiotic - Resolves infection.

AntiCoagulant - Prevents blood clotting.

AntiConvulsant (Antiepileptics) - Prevents or controls seizures.

AntiDepressant, Mood Elevator, Tricyclics - Prevent or relieve depression.

AntiDiabetic (Hypoglycemic) - Controls diabetes, decreases blood sugar.

Antidiarrheal - Controls diarrhea.

AntiEmetic (Antinausea) - Controls nausea and vomiting.

AntiFungal - Resolves fungus infection.

AntiHistamine - Relieves allergic symptoms.

AntiHypertensive - Controls high blood pressure.

AntiInflammatory (Antiarthritic): Steroid or NSAID - Decreases inflammation, swelling, pain.

Steroid - Naturally occurring hormone. CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 33 of 177

NSAID - (Non Steroidal Anti-Inflammatory Drug) - A synthetic anti-inflammatory drug.

AntiOvulant (Birth Control) - Prevents ovulation, birth control medication.

AntiParkinson - Controls tremors which are symptoms of Parkinson’s disease.

AntiPruritic (Anti-Itching) - Relieves itching.

AntiPsychotic (Tranquilizers, Strong) - Controls symptoms of psychotic diseases such as schizophrenia.

AntiPyretic (Fever Reducing) - Reduces fever.

AntiSpasmodic - Prevents muscle spasms.

AntiTussive, Cough Suppressant - Relieves cough.

Barbituate - Sedative, causes sleep.

Cardiac Drug, Cardiac Glycoside, Beta Blocker, Nitrates, Calcium Channel Blocker - Drugs which slow and regulate the heartbeat.

Coagulant Drug - Causes blood to clot.

Cortisone-Like Drugs - A hormone, which reduces inflammation.

Decongestant - Relieves congestion.

Diuretic - Relieves fluid retention.

Electrolyte Supplement - Replaces depleted body chemicals.

Emetic - Causes vomiting.

Enzyme - A protein substance, which digests tissue.

Expectorant - Loosens secretions so they can be coughed up.

Hormone - A regulating substance produced in the body.

Hypnotic (Sleep Inducer) - Sedative, causes sleep.

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Laxative, Cathartic - Causes bowel movement.

Miotic - Causes constriction of the pupil of the eye.

Muscle Relaxant - Relaxes skeletal muscle.

Potassium Supplement - Replaces potassium in the body.

Psychotropic - Any mind altering drug, i.e., antipsychotic, antidepressant, antianxiety, hypnotics.

Sedative - Causes Sleep.

Stool Softener - Adds water to feces.

Sulfa Drug (Sulfonamides) - Primarily relieves urinary tract infection.

Urinary Antiseptic (Antiinfectives, Nonantibiotic) - Prevents urinary tract infection.

Vaccine - Prevents disease.

Vasodilator - Relaxes and dilates blood vessels.

Vitamin Supplement - Replaces vitamins.

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Section 6

Medication Orders

• Obtaining Medication Orders

No person may administer medications without a valid order on file. Order may be written on a variety of forms, as long as the order contains all of the required elements. Required elements are:

• Prescription A prescription is usually a 3x5-sized piece of paper that is one leaf of a pad.

Prescription forms usually have the authorized provider’s name, address, phone number, and DEA number (a unique number denoting their ability to write prescriptions for controlled substances).

The authorized person writes the order using the required elements. The pharmacist dispenses the medication and keeps the prescription on file. The program may retain a copy of the prescription so as to have a valid order on file.

• Duly Authorized Licensed Practitioner Order A medication order must contain all of the following information:

1. Resident’s name 2. Resident’s date of birth 3. Name of medication 4. Dosage 5. Time to be administered 6. Check label on bottle against order 7. Check for Practitioner’s signature 8. Directions for administration 9. Date order was written 10. Check for expiration 11. Check for other considerations, (allergies, sensitivities, etc.). 12. Check for self-administration order

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Psychotropic PRN’s

These orders must be very detailed as well and include the following:

a. Resident’s name b. Resident’s date of birth c. Name of medication d. Time to be administered e. Directions for administration f. Exact dosage g. Exact time frames between dosages h. Maximum dosage to be given in a 24-hour period i. Renewal of time period if other than every 3 months

Calling In Orders

Physician’s often ‘call in’ or fax prescriptions to the pharmacy where the individual usually obtains his/her medications.

When that happens the program overseeing the medications may not receive a prescription or order. In that case, the program must request an order or a copy of the signed order maintained at the physician’s office or clinic.

Appointment for Service/Order Sheet The program may maintain specific order sheets that can be used to exchange information to the provider (pursuant to an authorized release of information).

If an individual of services is learning the skills necessary to independently manage his/her illness(es) and the medications prescribed for that illness, the program may wish to encourage the person to make a written list of his/her needs in lieu of an official form. In that case, a prescription or order written on the originating agency form is acceptable.

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Telephone Orders

From time to time it may be necessary to receive an order to clarify a written order when the clinic and offices are closed. In that case a Registered Nurse may discuss the need with an authorized provider over the telephone and write the provider’s verbal direction.

Individual’s may also require emergency orders given over the telephone by the provider to the Registered Nurse, Licensed Nurse or Pharmacist.

The provider and the nurse are encouraged to make use of alternate technology such as faxes so as to provide a written copy (when possible). The originating provider must sign telephone orders within five working days of the receipt of the order. Direct care staff may not use a pharmacist telephone order. The order must be a direct line from Doctor to Nurse to Direct Care Staff.

Fax(ed) orders are legal acceptable orders if signed and dated by the duly authorized licensed practitioner and may be received by the CRMA.

When Must Orders be Written or Re-Written?

As with most professions, the medical field has not arrived at a “paperless” environment even with all of the technology advancements. In fact, paperwork is critical to the record keeping process, which means there is a lot of paperwork the CRMA must know and be responsible for.

During the Admission Process When individuals begin transition visits their provider must furnish orders to the program for any medications that will be administered during the visit.

Psychotropic Orders Orders for psychotropic medications may not exceed three months unless otherwise indicated in writing by the duly authorized practitioner. It is preferable that orders be re-written by providers so an error might not be carried through over time.

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Medical Orders

Orders written by primary providers, effective for a year, do not have to be renewed prior to that time, unless by so doing confusion about proper medications may be averted. The same rules apply for re-writing orders.

Upon Discharge from a Hospitalization

Upon admission and during discharge planning, program staff should review the person’s complete medication orders with hospital staff. Once Admitted to the Hospital, all orders at the facility for the Resident are on hold until reordered by the resident’s primary physician/practitioner upon their return. The MAR and medications will be removed from active use.

Medications will need to be re-ordered by a physician or other authorized provider at time of discharge, and agreed to by the resident’s primary attending practitioner responsible for their care in the facility.

Transcribe Orders Whenever a resident returns from a physician visit or is visited by the physician at the facility, the resident’s record must be reviewed for new orders.

New Orders

If there is a new order, be sure to read it carefully before proceeding.

If there are any questions about the order, ask for clarification before going any further.

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Clarification may come from contacting the physician, the pharmacy via fax, or the licensed staff person at your facility.

Carry out every aspect of the order once there has been clarification. For example:

♦ Receive order. ♦ Read order and determine completeness of order and that you understand the order. ♦ Contact the pharmacy with new prescription (telephone or fax). ♦ Write the medication order on the MAR, using blue or black ink. Any special instructions should be in red ink with the alternate name of the drug in green or another color. (This brings attention to the special instructions and the alternate name of the drug.) ♦ Indicate date and time to begin medication. (A yellow highlighter may be used to block out the days prior to the start of the medication. ♦ Indicate time/times medication is to be given. ♦ Indicate date and time to stop medication, if appropriate, (in red ink). ♦ Notify staff members who will have responsibility to administer medication. ♦ Bracket the order in red, write “Noted” and sign your full name, title and the date and time. ♦ Request another staff person review your steps to assure accuracy. ♦ Have the other staff person bracket and write “Second √, sign there full name, title, and the date and time in an alternate colored ink, (i.e., green). This signifies that a second check has been performed.

Changed Orders Yes, change happens in a resident facility! Some steps to follow include:

♦ Follow the process for New Orders. ♦ Review and note the order. ♦ Transcribe the new order in the MAR. ♦ Yellow out the old order. (Remaining days only. Do not highlight the complete order across the page. This may be misconstrued as an order that was continued after the date of discontinuance.) ♦ Document in the remaining space – “See New Order.” This is also where you would document the amount/number of remaining medication removed for destruction or return, accompanied by 2 signatures. (This should be done in red ink.) ♦ Date and initial what you have done on the MAR. ♦ Fax changes to the Pharmacy – alert them if you will need the med or not. ♦ Flag the medication container by placing a sticker on it and document – “Change in Order.” If the correct dosage of medication for the new order can be provided from the container.

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♦ All unopened containers should be removed for return to the pharmacy for re-labeling or credit. ♦ Note the med change in “Change-of-Shift Report”, if applicable.

Discontinued or Stop Orders Finally, there are times a medication order will be “discontinued” or “stopped.” Some steps to follow for this process include:

♦ Follow the process for New Orders. ♦ Review and note the Order. ♦ Find the ordered medication on the MAR. ♦ Yellow out the Order. (Remaining days only. Do not highlight the complete order across the page. This may be misconstrued as an order that was continued after the date of discontinuance.) ♦ Document in the remaining space – “Order d/c’d” and the date, in red ink. Document number (#) of tabs/pills to be returned on the MAR – documentation on the MAR must have 2 signatures. ♦ Date and initial your work on the MAR. ♦ Fax the Order to the Pharmacy. ♦ Remove the bubble pack and any backup supply from the med cart and the med room. ♦ Document the # returned to the Pharmacy (attach a communication slip). ♦ Document the # transferred to administration for destruction (attach Control Sheet to med). ♦ Place the d/c’d meds in Pharmacy bag for return to the Pharmacy unless it is a controlled med. The controlled meds will be destroyed in the facility by authorized individuals ONLY and must have the signatures of both individuals. ♦ If the medication is a Scheduled II, there needs to be an accounting of the # of meds remaining in the following:

Bound Book MAR Control Accountability Sheet

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Section 7

Medication Ordering

It is the responsibility of everyone passing medications to assure that medications ordered by the duly authorized licensed practitioner, are available in the facility for the resident.

All CRMA’s should be checking medication amounts to assure that there is at least a 5 day supply of the medication for the resident. It is not at all appropriate to omit a medication because it was not reordered. This is a medication error and should be treated as such.

Persons responsible for passing medications are also responsible to assure that there is at least a 5 day supply of medication on hand and should be reordering the medication, if appropriate, when there is only a 5 day supply left. This includes liquid medications and treatments.

Liquid medications should be reordered when there is only a quarter of the bottle left. Medications in tubes, (creams, ointments, etc.) should be reordered when there is only a quarter of the container left.

Remember, liquid medications often contain extra of the medication. If there is liquid medication left after the d/c date, dispose of it accordingly.

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SECTION 8

Documentation

The cardinal rule of Medication Administration is “If it is not documented, it did not happen!” Therefore, documenting all aspects of the medication administration process is critical to the CRMA. The following section discusses typical documentation issues and procedures. However, it is imperative that the CRMA know and abide by all facility-specific medication administration documentation policies and procedures.

• Initials

After a medication has been administered, an entry is made on the MAR in the corresponding date and time block in black or blue ink only, or according to facility policy.

Documentation consists of the initials (at least the first initial of the first and last names) of the administering staff. Additionally, on the bottom of the reverse side of the MAR form, an entry is made by noting one’s initials and full signature with credential upon first administering medications in a given month.

• Unusual Circumstances

If unusual circumstances around medication administration need to be documented, the CRMA must ensure that there is written documentation on the reverse of the MAR by placing a circle around his/her initials signifying that interested staff should look for further documentation.

• Refusal

Administering staff shall document refusals by initialing the block as usual, circling the initials (using the same color ink), and making a note on the back of the form, or the refused medication summary prepared for the authorized person.

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Medication Administration Record (MAR)

An individual computerized, personalized Medication Administration Record (MAR) shall be kept of all treatments, drugs, and medications ordered and administered.

Medication Administration Records (MAR’s) provide a monthly record of medication orders and administration.

MAR’s are checked against valid orders:

1. At the time orders are transcribed. 2. When the order is double-checked by staff. 3. At the beginning of each month by a CRMA or other staff designated by the facility and at the end of the month, and reviewed by a Registered Nurse as mandated by regulation.

Staff members certified to administer medications and trained in the use of computer programs may be assigned to prepare monthly MAR’s. The following describes the information that is required on the MAR.

General Information

Enter the person’s name, the month and year at the bottom of the form. Enter the number of the page for that month on the top bar. Example: If the person has three sheets in use for that month, the transcriber writes 1 of 3 on the first page, 2 of 3 on the second page, and 3 of 3 on the third page.

If more pages are added during the month, the count must be adjusted by lining out the summary number on each page and entering the correct new number: From 1 of 3 to 1 of 4.

Document allergies and sensitivities in red ink in the lower left corner.

Note the provider’s name and phone number above the allergies section.

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Medication Name(s), Dose, Frequency, and Route

It is best practice to have generic names entered in each box followed by the brand name.

Note the available strength of the medication and calculate the number of units of medication needed to provide the total dose and enter, e.g. 10 mg. x 4 tablets = 40 mg.

If the same medication is given in different dosages during the day use a different box for each dose.

Order Date

Note the most recent valid order date in the lower left-hand corner of the box.

Provider

Note the Provider’s name in the lower left-hand corner of the box.

Times of Administration

If possible, group medications in the same timeframes on the same sheet. For example, 8 a.m.

PRN’s

All prn medications should be grouped on a separate sheet. The word PRN should be written in Red ink or Underlined in Red ink.

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Change in Dose

A change in dosage requires an entry. The old order shall be crossed over with yellow highlighter and a note to that effect, in red ink, written on the bar below the medication box. The transcriber shall also indicate the page where the new order will be found.

Change in Start Dates

When a medication has been reordered without change, the transcribing staff person should line out the old date and indicate the new date to the right and initial.

MAR Review

Each facility will more than likely have specific procedures for reviewing MAR’s that will include some of the following steps:

First Check:

1. Start at date of annual physical OR physician order. 2. Review those orders with new MAR. 3. Place a check (√) on side of medication. (In red ink.) 4. Place an “0” if unable to locate med order with current physician order. 5. Review all physician orders since last renewal – place a red (√) when order is located. 6. If order has been d/c’d, yellow out the order/date when it was d/c’d and initial.

Second Check:

♦ Read each medication and the instructions. ♦ Place a line through the check (√) when the order reads the Same. This line should be in green ink or other alternate color as per facility policy. . red

green

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♦ Transcribe any new order that has been added to the MAR since the first check was completed.

Missing Initials on the MAR

If a staff member has not written his/her initials onto the MAR and the medication time has passed, the person who identifies the blank block shall notify the person responsible for the missing documentation and determine if the medication itself was not administered.

The person who found the empty block in either circumstance should initiate an incident report as an error in documentation.

If the medication was administered, the block should remain empty until the staff that administered the medication can return before the end of his/her shift to sign off on the MAR, if the occurrence was due to an emergency.

If the CRMA whose initials were missing is not located to initial the MAR before the end of his/her shift, this incident becomes a “medication error” and an Incident Report must be filled out

Remember, there is a 1 hour window before and after the scheduled time for administration.

If the facility uses “bubble packs,” the staff person’s initials and date will be on the pack to validate that the medication was passed.

Resident Refuses to Take Medication:

♦ Explain to the resident why it is important to take the medication as prescribed by the physician.

♦ Encourage the resident to cooperate and offer the medication at fifteen (15) minute intervals not to exceed one hour before or after the scheduled dosage time. ♦ If resident still refuses, do not force.

♦ Circle initials for refusal on MAR - write reason on reverse side and note in resident’s chart.

♦ Fill out a refusal of care form.

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♦ Call Administrator on call for direction.

♦ Also you may refer to the regulations covering this topic.

♦ Continued refusal requires you to notify the physician for possible changes in the resident’s condition and new orders.

Life Span For Drugs

• Nonprescription medicines must be dated when they are opened, and discarded when they have expired.

• Any medication in a bottle must be dated when the bottle is opened.

• Expiration dated on medications in bottles or other containers should be circled and checked by the person administering medications prior to administration.

• Insulin must be dated when opened and expire after 30 days.

• Nitroglycerin tablets must be dated when opened and expire 90 days after the bottle has been opened.

• Vaccines must be dated when opened and disposed of after 30 days or the expiration date of the lot specified by the manufacturer.

• Calcitonin nasal spray must be dated when opened and expires 30 days after opening if not refrigerated.

• Check with the pharmacy if no expiration date is apparent on any medication or treatment.

• In general, most medications have an expiration date listed on the label. However, if changes in composition of the drug are noted before that date, immediately alert the consulting pharmacist. The drug should be discarded or returned for credit.

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SECTION 9

Medication Administration

Seven (7) Rights of Safe Medication Administration

1. The RIGHT resident –

Each time you administer a medication, you must ensure you are giving it to the person for whom the order was written. If a doubt arises, you must stop, and get clarification as to whom you are to be medicating.

2. The RIGHT medication –

Each time you administer a medication, you must ensure you are giving the right drug. This is done in three steps:

1. Check the medication label before taking medication from cabinet/cart. You should be comparing it to the MAR and/or the medication card. 2. Before removing the medication from the medication container, compare the label with the MAR and/or medication card again. 3. When returning the medication container to the cabinet/cart, compare the label and the MAR and/or the medication card once again.

This may seem overwhelming at first, but if you do it enough it becomes a habit that ensure the safety of the person who is receiving the medication from you.

3. The RIGHT dose –

Each time you administer a medication, you must ensure you are giving the right dose. Check the dosage ordered against the specified drug ranges in a drug reference book. Once this has been done, follow the three steps to assure you are giving the dose ordered.

4. The RIGHT time –

Each time you administer a medication, you must ensure that it is the right time for this medication. Again, by following the above steps (2. a, b, c), the correct time will be assured. It is also important to keep in mind therapeutic blood levels, diagnostic testing, facility’s standardized times and the use of PRN medication.

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5. The RIGHT route –

Dependent upon the specific order written by the physician, there must be no variation to this order utilizing the above steps (2., a, b, c) to ensure the right route.

6. The RIGHT to know –

Each individual has the right to know what medications they are receiving, the expected effects and side effects, and why they are receiving this medication. If the resident is unable to comprehend the instructions for the use of breathing apparatus, or other medication instructions, documentation of this shall be recorded in the Resident Care Notes.

7. The RIGHT to refuse –

Individuals have the legal right to refuse taking their medication. This is supported by the 14th Amendment to The Constitution of the United States and State Laws. This being so, it is the providers responsibility to educate the person to the benefits of the medication but to be supportive to the individual’s choice. If the individual continual refusal of the medication(s) creates a behavior infringing upon the rights of others, follow facility policy or DHHS regulation.

8. The RIGHT documentation –

Although not part of the “7 rights,” it is extremely important that the RIGHT documentation also be performed as part of the medication administration process. This is an important medico-legal responsibility. Prompt recording of pertinent medication administration information and adverse reactions is important. Initialing the MAR means that you have given the person the medication and that they have taken it. (Refer to the “Documentation” section of this unit for more information.)

REMEMBER:

WHEN GIVING MEDICATIONS THE PROPER STEPS ARE:

1. POUR

2. PASS

3. DOCUMENT

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Routes of Administration

Medications may be administered utilizing a variety of methods. This section will discuss oral, rectal, vaginal, topical, eye drops, eardrops, nose drops and inhalants.

Oral Requires an alert, cooperative resident with an intact swallowing reflex.

• Oral Administration Equipment

1. Unit dose or Single Dose – Provides a single dose in one package ready for dispensing. 2. Soufflé Cup – Used to transport solid medication in order to prevent contamination in large bottles of medication to be used. 3. Medicine Cup – a plastic cup that has three sides for measurement of liquid medication. (apothecary, metric, household). 4. Medicine Dropper – a plastic barrel with a plastic bulb. Calibrations are on the side. 5. Teaspoon – Different from household teaspoon. It is a standard 5 ml. 6. Tablespoon – Different from household tablespoon. It is a standard 14 ml. 7. Oral Syringe – Very similar to an injectable syringe, except measured in milliliters, and a needle is unable to fit the tip.

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• Oral Administration Process

• Give most important medications first. This may be difficult to determine in some cases due to the complexity of the medications. Know your facility’s procedures regarding this issue.

• Allow person to drink a small amount of fluid first

• Have person place medication on the back of the tongue

• Give the person liquid to swallow the medication

• Drink a full glass of fluid, if possible, to assist medication getting to the stomach and to begin digestion

• Remain with the person while they are taking the medication

• Never dilute a liquid medication unless specifically ordered to do so

• Remember the EIGHT RIGHTS OF MEDICATION ADMINISTRATION

• ALWAYS pour liquid medications away from the label, keeping the med. cup on a flat surface at eye level. (Palm the label.)

• POUR, PASS, DOCUMENT

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Rectal Usually includes a solid glycerin suppository form or a liquid enema form. This route is limited to medications that do not irritate the delicate tissue of the rectum. Absorption is altered by fecal content of the rectum, erratic blood flow to the tissue and expulsion of the medication.

• Administration Technique

1. Equipment – Disposable gloves, water-soluble lubricant.

2. Technique –

a. Wash hands. b. Remember the SEVEN RIGHTS. c. Explain the procedure to the person. d. Ensure privacy. e. Assist resident to lie on the left side. f. Provide for the person’s privacy. g. Put on gloves. h. Ask person to bend uppermost leg toward the waist. i. Unwrap suppository and apply a liberal amount of water-soluble lubricant to tip. (DO NOT USE VASELINE or other non-water soluble substances). j. Place suppository at the rectal entrance. Gently insert suppository into rectum about one inch beyond the opening using a single finger. k. Remove finger. l. Ask the person to lie on their side for 15-20 minutes. m. Discard used materials and wash hands thoroughly. n. Document, document, document! o. POUR, PASS, DOCUMENT

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Vaginal Creams, jellies, tablets, foams, suppositories, ointments, or douches are generally the form of medications administered via this route.

• Administration Technique

1. Equipment – Prescribed medication, vaginal applicator (if applicable), perineal pads, water-soluble lubricant (for suppository and/or applicator), gloves, and paper towels.

2. Technique –

a. Wash hands and gather equipment needed. b. Remember the SEVEN RIGHTS. c. Explain the procedure to the person. d. Ensure privacy. e. Have the person void for comfort. f. Put on gloves. g. Prepare prescribed medication; h. Ask the person to lie down on their back, with their hips on a pillow with legs separated. Ensure respect while the person is getting into this position. i. Lubricate the medication and/or applicator generously, unless otherwise specified by physician order, with a water-soluble lubricant. j. Separate labia with a non-dominant hand to expose vagina. k. Insert medication approximately 2 inches upward and backward into the vagina. l. Remove equipment and assist the person to a position of comfort. m. Discard used materials and wash hands thoroughly. n. Document, document, document! o. POUR, PASS, DOCUMENT

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Topical Some of the typical topical (dermatological) applications may include patches petroleum-based ointments, water-based creams or powders.

• Administration Technique

• Equipment a. Prescribed medication b. 2x2 gauze, sponges, cotton tipped applicators. c. Tongue depressor. d. Gloves

• Technique

e. Wash hands and assemble equipment. f. Remember the SEVEN RIGHTS. g. Provide for the person/s privacy and explain the procedure. h. Ask the person to place the affected area in a position of comfort in order to apply topical medication. i. Don gloves. j. Cleanse the area prior to application of medication. k. Maintain cleanliness of medication. Apply medication directly on dressing, then, apply to affected areas. l. Clean area and all equipment used. Ensure that the person is comfortable. m. Wash hands thoroughly. n. POUR, PASS, DOCUMENT

NOTE: Fever enhances the release and uptake of the drug and the resident may experience a local skin reaction.

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• Nitroglycerin Ointment Guidelines

• Don gloves.

• Remove old patch and cleanse area. Remove gloves.

• Select a new site for application.

• Lay measuring paper on clean surface so you can read measures.

• Don clean gloves.

• Squeeze a ribbon of ointment of proper length onto applicator paper.

• Place paper on skin, ointment side down. (DO NOT RUB INTO SKIN).

• Tape in place. (Place your initials and the date on the tape.)

• Wash hands after procedure.

• POUR, PASS, DOCUMENT

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• Transdermal

“Trans dermal” means “through the skin” and medications that the CRMA may administer in this category include the following:

• Patches

Fever enhances the release and uptake of the drug. May have local skin reactions.

• Nitro-paste

• Administration Techniques

• Don gloves. • Remove old patch and cleanse area. Remove gloves. • Select a new site for application. • Obtain new patch. • Date and initial patch. • Don clean gloves. • Apply patch to new site. • Remember to rotate sites. • Wash hands after procedure. • POUR, PASS, DOCUMENT

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Eye Drops Includes drops or ointments intended for use in the eyes.

• Administration Technique

1. Dosage Forms: a. Ocular solutions – sterile, easily administered and usually do not interfere with vision. b. Ointments – Longer duration of action than solutions. Do cause alterations in visual acuity.

• Equipment c. Gloves d. Prescribed medication. e. Manufacturer’s droppers. f. Paper, tissues or cotton balls. g. Sterile eye dressing pads as needed. h. Normal saline solution as ordered by the physician for cleansing of the eye prior to administration of the medication.

• Technique i. Wash hands and assemble ophthalmic medication. j. Remember the SEVEN RIGHTS. k. Provide for the person’s privacy and explain the procedure. l. Put on gloves. Clean eye(s) as necessary. Ensure the wiping of the eye from the innermost corner to the outermost corner. m. Ask the person to position their head so their face is pointing upward. n. Pull gently on the lower lid to make a cup of the lower lid. o. Have the person look upward. Drop the specified number of drops into the cup without touching the applicator to the eye surface. p. Instruct the person to close the eye gently and to rotate eye. q. Ask the person to hold eye closed for a minute. r. Clean area and wash hands thoroughly. s. POUR, PASS, DOCUMENT

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Nose Drops Typical medications for the nose will include drops used to treat temporary disorders affecting the nasal mucous membrane or sprays that are absorbed by the nasal mucous membrane.

• Administration Technique

• Equipment a. Gloves b. Prescribed medication, drops or spray. c. Manufacturer’s dropper d. Tissue.

• Technique

e. Wash hands and assemble equipment. f. Remember the SEVEN RIGHTS. g. Provide for the person’s privacy and explain the procedure. h. Have the person gently blow his/her nose. i. Don gloves. j. For: DROPS – have the person position his/her head upward at a 450 angle. Do not hyperextend the neck as this will enable medications to enter the throat. Draw prescribed amount and instill number of drops prescribed. Do not touch the dropper to the nose. Have the person remain in this position for 2-3 minutes.

SPRAY – Have the person sit upright and block one nostril. Shake the solution, if directed and immediately insert tip into nostril. Ask the person to inhale through nose and then squeeze spray at the same time. Offer the resident a tissue to wipe away excess medication or nasal drainage.

k. Clean area and wash hands. l. POUR, PASS, DOCUMENT

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Ear Drops This medication includes drops to treat localized infection of the ear.

• Administration Technique

1. Equipment: a. Gloves. b. Prescribed otic solution. c. Manufacturer’s dropper.

• Technique d. Wash hands and assemble equipment. e. Remember the SEVEN RIGHTS. f. Provide for the person’s privacy and explain the procedure. g. Ask the person to position their head so that the affected ear is directed upwards. Put on gloves. h. Allow medication to warm to room temperature. Shake well, as directed and draw into dropper. i. Pull their ear upward and back, if an adult and downward and back, if a child. Instill the prescribed number of drops. Do not touch the dropper to the ear. j. Insert cotton as directed. 2. Clean the area and wash hands. 3. POUR, PASS, DOCUMENT

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Inhalants This is the most difficult means of administration – especially for the elderly and children.

• Administration Technique

1. Equipment: IMPORTANT a. Disposable gloves. b. Prescribed medication. Do not use this method if the

person is not 2. Technique: able to breathe in appropriately. a. Wash hands. b. Remember the SEVEN RIGHTS. c. Provide privacy and explain the procedure to the person. d. Ask the person to get comfortable and put on gloves. e. Shake the container to mix medication, if required. f. Have the person take several deep breaths through the mouth. Place mouthpiece into mouth and ask the person to purse lips tightly around it. g. Administer one puff as the person inhales deeply. h. Ask the person to hold their breath 5-10 seconds. i. If a second dose is needed, allow the person to take several deep breaths in between doses, and administer the second dose according to pharmacy instruction, package insert or other drug reference. (Should be 5 minutes with Steroids and 1 to 2 minutes with all other inhalers unless otherwise specified.) j. Clean mouthpiece of inhaler with warm water and dry. k. Wash hands. l. Have person rinse mouth after medication is administered, if indicated to do so. m. Cleanse any other equipment according to specific directions given by the supplier.

• Review this procedure with the person before attempting to administer inhaler.

• POUR, PASS, DOCUMENT

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Injectable

Maine’s revised regulations address the issue of injectable medications as follows:

7.1.2 No injectable medications may be administered by an unlicensed person, with the exception of bee sting kits and insulin. 7.1.3 Before using a bee sting kit, unlicensed persons (CRMAs), must be trained by a Registered Professional Nurse in regard to the safe and proper use of kit. Documentation of training shall be included in the employee record. 7.1.4 If a resident has Diabetes, unlicensed persons must be trained by a Registered Professional Nurse in regard to the management of persons with Diabetes. The Registered Professional Nurse must provide in-service training and documentation to include:

7.1.4.1 Dietary requirements; 7.1.4.2 Anti-Diabetic Oral medications – inclusive of adverse reactions and interventions, hyper and hypo glycemic reactions; 7.1.4.3 Insulin mixing including insulin action; 7.1.4.4 Insulin storage; 7.1.4.5 Injection techniques and site rotation; 7.1.4.6 Treatment and prevention of insulin reaction including signs/symptoms; 7.1.4.7 Foot care; 7.1.4.8 Lab testing, urine testing and blood glucose monitoring; and 7.1.4.9 Standard Precautions.

Documentation of training shall be included in the employee record.

7.16 Whenever a Registered Nurse teaches or provides in-service training to unlicensed personnel on medical issues, treatments and/or medical equipment not specifically outlined in these Regulations, there must be documentation in the Employee File.

(I.E., other subcutaneous injections.)

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Crushing Medications

Some residents are unable to swallow solid oral medications, but not all medications can be crushed. Crushing medications may produce unwanted pharmacological effects in the resident and may be tantamount to administering doses of the medication, other than as prescribed. Crushing any medication should be avoided unless a liquid dosage form or substitute in liquid form is not available.

• What Can and Can’t Be Crushed?

Sublingual tablets should not be crushed.

Delayed-release or time-released medications can not be crushed.

Coated tablets, in general, should not be crushed.

Some Coated tablets should never be crushed if:

The active medication is surrounded by an enteric or protective coating. The medication is formulated to provide slow release or extended release. The medication has a bitter or poor taste. The medication may cause discoloration of the mouth and teeth or may cause chemical burning of the mouth or throat. If the medication is in a capsule that is not permanently sealed, and you have the pharmacist’s OK to open it, you may open it and mix it with applesauce, but do not crush the contents.

• When in DOUBT, Call the Pharmacist.

When crushing meds:

♦ Use a clean mortar and pestle or a tablet crusher or other acceptable means. Place tablet between two (2) soufflé cups when crushing or other appropriate pill crushing equipment used by the facility.

♦ Mix the medication with a small volume of appropriate soft food immediately before administration. Be sure that you inform the resident that the food contains medication.

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When Not To Give Medication

If one or more of the following required items is missing, do not give medications:

♦ No physician’s order. Never give a medication without a physician’s order. ♦ No MAR. Where is it? ♦ The pharmacy label is not legible. Note: This does not mean you just don’t give the medication. You must take care of this situation if the resident is supposed to receive a particular medication. The point is not to give a medication if you’re not sure what it is.

Resident exhibits a dramatic change in status: If the resident is showing signs of seizures, unconsciousness, difficulty breathing or any other change which appears to be health- threatening, do not administer the medication. Follow the instructions given for reporting an emergency health-threatening situation. Call 911 or an ambulance and the doctor.

If you have any doubt that you have the right resident, right drug, right dosage, right time or right route, get assistance from another staff member or call the administrator on-call.

Medication Administration Procedures

Designated Times

♦ Watch that medications ordered “A.C.”, “P.C.”, and “with food” are given at appropriate times. ♦ Give antispasmodics (Bentyl, Donnatal, Reglan, Propulsid, etc.) thirty minutes before meals. ♦ Give long-acting drugs (time released, sustained released) at equal intervals - every 6 hours rather than QID, etc. ♦ All medication must be passed within one hour on either side of the designated time. ♦ All new med orders must be started after the next regular medication delivery unless ordered “Now” or “Stat” per pharmacy Policy and Procedures.

Dosage

♦ Give exact number of tablets/capsules ordered. Have the transcriber “use red ink or underline in red ink” any variation from usual dosage per facility policy. ♦ Do not “estimate” liquid doses. Do measure at eye level, on a flat surface, using an oral syringe for odd amounts (i.e. 7ml, 3.4ml). ♦ Do not calculate any drug doses. The pharmacy label must include this information, or the Registered Nurse may calculate and transcribe this onto the MAR. CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 64 of 177

♦ Do not accept instructions from the pharmacy to give amounts which are unusual to measure, such as “3.33 cc”, have the order changed to an even number such as “3.4 cc”. ♦ Remember that ONLY scored tablets may be split.

Guidelines

♦ Wash hands – gloves are not a substitute for this step. ♦ Do not pre-pour any medication, or open unit dose packages until administration of medication. This includes: o the pouring and storing of medications prior to administration in the medication cart/cabinet. o Pouring medications for multiple residents at the same time. o Pouring medications prior to the 1 hour window on either side of the administration time. ♦ Do not touch any tablets or capsules with fingers. Maintain sanitary techniques during medication administration. ♦ Identify individual before administering medications. ♦ All medications given must be labeled for that individual or are from facility approved house stock. ♦ Do not leave the individual until all pills and liquids are swallowed. You may ask the resident to see if they have swallowed the medication. ♦ Wash hands (with soap and water or waterless hand cleaners) after each medication administration. ♦ Do not touch the inside or rim of the medication cup. ♦ Wear single use gloves. ♦ Before and after administering eye drops, wash hands with soap and water. ♦ Watch for expired and discontinued medications. ♦ Do not give a PRN drug every day if the resident does not request them. Individual’s medication therapy should be evaluated. The resident may need to be seen by the physician or the order may need to be changed to a routine order, when appropriate. ♦ The individual’s privacy must be maintained during all treatments. Treatments include the administration or application of eye medications, patches and injections. ♦ Orders to hold drugs when pulse/BP is low should be documented on the MAR in red ink. ♦ Observe all pharmacy warning labels such as “give with water,” “do not give with antacids”, etc. ♦ Apply nitropaste exactly as instructed by manufacturer. Rotate and record site. ♦ Avoid giving antacid with orange juice. ♦ Metamucil must be dissolved in 6-8 oz. of water. ♦ All KCL liquids must be diluted before administering. ♦ Liquid concentrates (e.g. Mellaril, Thorazine, etc.) should be diluted in liquid before administration. Check manufacturer’s labeling for correct dilution.

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♦ Lanoxin must not be given with antacid, Ascriptin or Bufferin. Separate doses by one hour or more. ♦ Do not crush sustained release, enteric coated drugs, drugs containing iron (Theragram Hemetinic, Ferro Folic-500, Iberet Folic, Feosol) or any other medications so labeled. ♦ Do not give non-steriods (NSAID) to a resident allergic to aspirin (ASA). ♦ Do not transfer anything into a different container with an improvised label. No person(s), other than Pharmacists, are allowed to affix a new label or change a prescription label. ♦ If using a stock item for a treatment, measure the required amount into a medication cup immediately prior to doing the treatment. Take this cup into the resident’s room, but do not carry the stock container into resident rooms. ♦ Know what you are giving and why. If you don’t know, LOOK IT UP or call the PHARMACY prior to administration.

♦ POUR, PASS, DOCUMENT

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Charting (Documenting) Guidelines

♦ Chart medication when given. Please keep in mind every medication that is uncharted is considered an error.

♦ Sign out Schedule II medications when given. Use the Bound Book and Individual Narcotic Record/Accountability sheet and the MAR.

♦ Sign out all other Controlled/Scheduled medications as per facility policy.

♦ Chart actual hours, not shift.

♦ Chart all PRN’s on medication record. Chart reason and result on back of medication record.

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Medication Storage

Medications that have been delivered to your facility must be recorded as having been received on appropriate forms containing specific information.

After receiving the medications, they must be placed in appropriate storage. All drugs must be stored in their original containers as they were received from the pharmacy.

The labels must be kept intact on all medications. If a label becomes difficult to read, call the pharmacy and ask that it be replaced with a legible label.

All medications must be stored centrally in a locked cabinet or medication cart with sufficient storage space and adequate lighting. Medications for external use must be kept and labeled in a separate area of the cabinet/cart or a separate locked cabinet/cart.

The key to the locked medication cabinet/cart must be kept by the person responsible for medication. The key and an unlocked cabinet/cart must never be left unattended.

• Medications should not be handled with fingers.

• In order to prevent mishaps with ingestion of medications topical medications must be stored apart from oral medications.

• Medications must be stored according to the manufacturers recommendations as to temperature and light.

• Medications that must be refrigerated should be stored away from food products (a separate firmly closed container is acceptable). All Schedule II medications requiring refrigeration must be under double lock and key.

• A thermometer should be used in refrigeration to ensure proper temperature regulation for each medication. A log of periodic (daily) checks provides appropriate documentation of the temperature of refrigerator. This check will also ensure staff’s ability to adjust temperature as needed to ensure appropriate refrigeration of any medication.

• When a temporary absence from the facility is expected to be greater than seventy-two (72) hours, medications leaving the facility must be in a form packaged and labeled by a pharmacist.

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• For medications leaving the facility for seventy-two (72) hours or less, a responsible party at the appropriate time shall package the correct medication in such a way as to facilitate self- administration or administration.

Properly certified or licensed staff will use acceptable methods and procedures for preparing medications for leaving the facility. Staff will follow the same policies used in the facility for administering medications. The name of the resident and the name and strength of each drug, as well as the directions from the original prescription package, should be conveyed to the resident or their responsible party along with all cautionary information in writing, either directly on an envelope containing the appropriate dose or on a separate instruction sheet. Pills must be counted and documented upon leaving and returning to the facility.

• Residents who self-administer medications and who handle their own medical regime may keep medications in their own room. To ensure the safety of other residents, the resident may be required to keep the medications in a locked area or container. Service Plans must outline the plan to educate the resident for appropriate self administration of medication.

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Disposing of Medications

When a prescription is discontinued or medications are left after a person’s transfer or death, your responsibility is to remove all the drugs from storage. These medications should be returned to the Pharmacist. The number of tabs, capsules, etc. should be listed on the MAR, in the Hi-Lighted area in Red Ink with the signatures of 2 competent persons.

If any drug is accidentally contaminated or not usable, it must be recorded and witnessed by two employees.

• Person’s name • Medication name • Date • Why it is being discarded • Script # • Your signature/witness • Number of pills/capsules, etc. • Schedule II medications must be destroyed in the presence of a representative of the department, a licensed Pharmacist, a representative on the Commission of Pharmacy or a representative of the Drug Enforcement Agency.

You must not dispose of any drug yourself.

Remember, each facility will have its own medication disposal procedures based on State Regulations– be sure to know them!

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Section 10

Emergency Situations

Medication administration is not without risks. Even when you have done everything properly there can be unexpected reactions to medication that result in a true emergency. If this happens, you must have a plan of action and be prepared to implement that plan.

Everyone is concerned about, “When should I call the ambulance?” For instance, most people would have difficulty stating what the circumstances would have to be before they would make that call for assistance. It may help if you think through the following definition.

An emergency situation may be defined as a “serious, unexpected situation that something can be done about and must be done immediately or the situation will get worse.” Examples of possible emergency situations may include the following:

• Any respiratory condition that the rate, rhythm, and depth of ventilations are too high or too low.

• Any bleeding that cannot be controlled by direct pressure, elevation, ice, and immobilization. If pressure points or a tourniquet is necessary, a physician must evaluate the injury.

• Any seizure activity that is continuous or with short times between seizures.

• Any behavior that is harmful and/or dangerous to the resident, other residents, or staff.

• Ingestion of anything that may be harmful even if no symptoms are present.

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The Maine Poison Control:

In Maine, Poison Control can be reached toll free by dialing:

1-800-442-6305

Be prepared to describe the following:

• What was taken. • How much was taken. • How long ago it was taken. • Any symptoms that you may be observing.

If you have any doubt, call 911 first; then call Poison Control.

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Section 11

Review of Common Errors and how to prevent them.

• Type of Errors Although extensive policies and procedures are in place to eliminate errors from the medication administration process, sometimes errors do occur. Some of the types of errors may include the following:

• Documentation

An error that occurs when a medication is administered but the signature is not present or a PRN med is administered but no results are documented.

• Omission

Medications have not been given, or the individual was not present at the time of medication administration.

• Refusal

In the event of a refusal, administering staff will explain the risks and benefits of refusing medications to the person, document the refusal on the Incident Report, and report the refusal to senior staff on call for any additional direction.

The provider must be notified. If the individual continues to refuse the medication and the provider does not wish to discontinue the medication, the provider may request that a log of refusals be kept until the next appointment.

• Transcription

A medication order, dosage, or administration route was improperly transcribed.

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• Wrong Dosage

The wrong dose of the medication was administered.

• Wrong Medication

The wrong medication was administered.

• Wrong Person

The medication was administered to the incorrect person.

• Wrong Time

A medication was administered at a time other than when it was ordered to be administered.

• Contamination

Medications show some evidence of tampering, deterioration, or damage. The medication in question shall be destroyed and its destruction documented on the medication inventory sheet that notes the number, type, appearance, and prescription number.

If a question as to the status of a whole vial of medications exists, it must be withdrawn from use and reported to the issuing pharmacy at the earliest possible time.

If a med is dropped on the floor, it must be destroyed and documented on the MAR.

Pharmacy Package/Label error

The medication has been improperly labeled, or the label does not correspond to the order.

Other

Yes, this is the catchall category and includes any other circumstances that do not fit in any of the aforementioned categories.

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Incident Reports

In the event of a medication error, staff must complete a Medication Incident Form.

Tips for Error Prevention

• If administering medications is part of your assignment, review new information in the log or on the MAR prior to administering any medications.

• Review the times and medications that have to be administered prior to starting.

• Review the medications you have administered before leaving to make sure you have given and documented all medications.

• Review any new orders or other information with the staff member who relieves you.

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APPENDIX A

Medications/body systems charts

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Medications Used in Treating Muscular and Skeletal System Disorders

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Analgesic (non-narcotic) Acetaminophen (or Tylenol, Panadol, Relieves pain, reduces fever Allergic reaction - rash, fever, or 1. Do not exceed the recommended APAP) Tempra,etc. difficulty breathing dosage. Yellow eyes or skin Over dosage can 2. Check the labels of all prescription & cause liver damage nonprescription medication the person takes. If any contain acetaminophen, check with the person's health care pro- fessional. (Taking them together with This medication may cause an overdose.) 1. Relieves pain - used for Aspirin Anacin, Bufferin, headache, Stomach ulcers - signs include: bloody 1. Take with food or after meals & take with other names include Ecotrin, Zorprin, muscle ache, etc. or black, tarry stools; throwing up blood a full glass of water. ASA or ECASA (If Alka-Seltzer, etc. 2. Reduces inflammation - used for or material that looks like coffee grounds; 2. Do not use if a strong vinegar-like odor enteric-coated) arthritis & other inflammatory stomach pain is present. 3. Reduces fever Easy bruising/bleeding 3. Do not crush enteric-coated aspirin. 4. Decreases ability of blood to clot - Allergic reaction - shortness of breath; 4. Do not place or dissolve directly on an used to prevent heart attacks and wheezing, itching, inflammation inside aching tooth, canker sore, or cold sore. A strokes the nose, swelling of eyelids, face & lips serious inflammatory reaction could occur. Stomach Upset - (nausea, indigestion, 5. Aspirin should not be used if the heartburn) person takes blood thinners (Coumadin). Ringing in ears, hearing loss Check with physician. Dizziness, weakness, confusion Nonsteroidal Anti-inflammatory Drugs (NSAIDs) 1. Relieves pain - used for Ibuprofen Advil, Motrin, headache, Stomach ulcers - signs include: bloody 1. Take with food or after meals & take with Nuprin, etc. muscle ache, etc. or black, tarry stools; throwing up blood a full glass of water. The person should Also, used to treat the symptoms of or material that looks like coffee grounds; avoid lying down for at least 30 minutes PMS and menstrual cramps. stomach pain after taking the medicine. 2. Reduces inflammation - used for Stomach Upset - (nausea, indigestion, 2. May cause sensitivity to sunlight. Use arthritis & other inflammatory heartburn) sunscreen and wear protective clothing. 3. Reduces fever Ringing in ears, hearing loss Allergic reaction (see aspirin above) Fluid retention/weight gain Dizziness, weakness, headache, vision changes.

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• Medications Used in Treating Muscular and Skeletal System Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Nonsteroidal Anti-inflammatory Drugs (NSAIDs) continued Naproxen Naprosyn, See Ibuprofen See Ibuprofen See Ibuprofen Anaprox, Aleve Indomethacin Indocin Relieves pain & reduces inflammation (also: headache is the most common used for arthritis, gout, & other side effect of indomethacin) inflammatory diseases Sulindac Clinoril Relieves pain & reduces inflammation used for arthritis, gout, & other inflammatory diseases Diclofenac Voltaren Relieves pain; reduces inflammation used for arthritis & other inflammatory diseases. Fenpprofen Nalfon Relieves pain; reduces inflammation used for arthritis & other inflammatory diseases. Narcotic Analgesics Morphine MS Contin, MSIR, Relief of moderate to severe pain nausea; vomiting; constipation; dry 1. Narcotic analgesics will add to the effects RMS suppositories, mouth; drowsiness; hallucinations; cold, of alcohol & other CNS depressants (drugs etc. clammy skin; itching; rash; flushed face; that slow down the nervous system, possibly Codeine Tylenol with Relief of mild to moderate pain; also increased sweating; slowed or troubled causing drowsiness). Person should not codeine*, suppresses cough breathing; low blood pressure; drink alcohol. Overdosage of narcotics can Robitussin AC, etc. decreased urination, seizures lead to unconsciousness & death. Hydrcodone Lortab*, Vicodin*, Relief of mild to moderate pain; also (especially with meperidine) 2. Take with food if stomach upset occurs. Tussionex (with suppresses cough chlorpheniramine), etc. Oxycodone Percocet*, Relief of moderate to severe pain Roxicet*, Tylox*, Oxycontin. Etc. Hydrmorphone Dilaudid Relief of moderate to severe pain Meperidine Demerol, Relief of moderate to severe pain Mepergan Fortis (with Phenergan)

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• Medications Used in Treating Muscular and Skeletal System Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Narcotic Analgesics continued Propoxyphene Darvocet*, Darvon Relief of mild to moderate pain *contains (also: propoxyphene can cause dark acetaminophen urine and yellow skin & eyes) Steroids (oral) Prednisone Deltasone Used to decrease inflammation See "Medications Used in Treating Enodocrine Disorders" Prednisolone Prelone; Delta- associated with arthritis, chronic Cortef respiratory problems, allergic Methylprednisolone Medrol reactions, and other inflammatory Dexamethasone Decadron diseases Hydrocortisone Cortef Triamcinolone Aristacort Muscle Relaxants Methocarbamol Robaxin Treatment of muscle sprains, drowsiness, dizziness, flushing of 1. All muscle relaxants will add to the effects strains, or spasms face, nausea, vomiting, rash, of alcohol & other CNS depressants (drugs nasal congestion that slow down the nervous system). People Cyclobenzaprine Flexeril Treatment of acute muscle sprains, drowsiness, dizziness,; dry mouth; taking these drugs should not drink strains, or spasms swelling of face/lips; difficulty in alcohol. urinating; weakness; ringing in the 2. Methocarbamol may cause the person's ears urine to turn black, brown, or green. Diazepam Valium Treatment of muscle spasticity drowsiness; dizziness; low blood 3. Diazepam - withdrawal symptoms could pressure; dry mouth; slowed breathing; occur if long-term or high-dose therapy is slurred speech suddenly stopped. Baclofen Lioresal Treatment of muscle spasticity drowsiness; dizziness; slurred speech; 4. Baclofen - hallucinations or seizures can difficulty sleeping; weakness; occur if therapy is suddenly stopped. frequent or difficult urination; 5. Dantrolene - can make skin more constipation; nausea sensitive to the sun. Avoid long exposure Dantrolene Dantrium Treatment of muscle spasticity drowsiness; dizziness; weakness; to sun, use sunscreen, and wear protective difficulty sleeping; diarrhea; stomach clothing. cramps; nausea; slowed breathing

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• Cardiovascular Disorders

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) General Considerations: 1. People on these medications should not take any over-the-counter medication unless it had been prescribed by the doctor. 2. It is very important that these medications be given as scheduled. 3. Salt in-take and fluid intake/output should be monitored as directed by the doctor. 4. Routine blood pressure monitoring is important for people on these drugs. Antihypertensive Drugs (drugs that lower blood pressure) Atenolol Tenormin This group of medicines is known as tiredness, dizziness, depression, 1. These medicines should not be stopped Metoprolol Lopressor "beta blockers". These medicines are confusion, weakness, slow heart rate, suddenly (can cause withdrawal symptoms Propranolol Inderal used to treat high blood pressure & wheezing or shortness of breath, such as sweating, pounding heart beat, & abnormal heart rhythms and to stomach upset, diarrhea, dry mouth, headache; could worsen chest pain or cause prevent heart attacks. Propranolol is itching/rash heart attack). also used for some psychiatric 2. In diabetics, these drugs can mask the disorders, migraine headaches, and signs of low blood sugar (such as fast heart tremors. rate) and change blood sugar levels. Nifedipine Procardia, This group of medicines is known as slow heart rate; heart palpitations; 1. Do not crush sustained-release drugs Procardia XL "calcium channel blockers". These swelling of legs or feet; flushing; such as Procardia XL, Cardizem CD, or Diltiazem Cardizem, medicines are used to treat high dizziness; nausea; constipation; muscle Calan SR. Cardizem CD, blood pressure and control chest cramps; overgrowth of gums 2. These medicines should not be stopped Dilacor, etc. pain. suddenly (could cause chest pain) Verapamil Calan, Isoptin, etc. 3. Good dental hygiene is very important to prevent overgrowth of gum tissue. Amlodipine Norvasc 4. If the person is taking Procardia XL, an empty tablet may be seen in the stool; this is no cause for concern. Lisinopril Prinivil, Zestril This group of medicines is known as cough; dizziness; lightheadedness, or 1. Notify doctor immediately if person has "ACE inhibitors". These medicines Benazepril Lotensin are fainting, especially when rising too swelling of face, lips, or tongue or has Fosinopril Monopril used to treat high blood pressure quickly from a seated or lying position; difficulty breathing. Quinapril Accupril and heart failure rash; headache; stomach upset; diarrhea; 2. Do not use salt substitutes (potassium) high potassium level (signs: confusion, without the doctor's advice. tingling or numbness of hands or feet, weakness, irregular heartbeat, shortness of breath) Prazosin Minipress This group of medicines is known as dizziness, lightheadedness, or fainting Dizziness or fainting is more likely to occur

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• Cardiovascular Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) General Considerations: 1. People on these medications should not take any over-the-counter medication unless it had been prescribed by the doctor. 2. It is very important that these medications be given as scheduled. 3. Salt in-take and fluid intake/output should be monitored as directed by the doctor. 4. Routine blood pressure monitoring is important for people on these drugs. Antihypertensive Drugs (drugs that lower blood pressure) continued Terazosin Hytrin "alpha blockers" & is used to treat when rising too quickly from a seated or after the first dose. The first dose is usually high blood pressure. These lying position; drowsiness; weakness; given at bedtime to prevent problems. medicines are used to treat men with headache; swelling of feet or lower legs; However, dizziness can occur after any dose, enlarged prostates. irregular of pounding heart beat so the person should get up slowly. Labetalol Normodyne Used to treat high blood pressure dizziness, lightheadedness, or fainting 1. Dizziness or fainting is more likely to occur when rising too quickly from a seated or after the first dose or after dosage increases. lying position; swelling of legs/feet; upset The person should get up slowly from a stomach; wheezing or trouble breathing; seated pr lying position. tiredness; dizziness; headache; rash 2. In diabetics, labetolol can mask the signs of low blood sugar (such as fast heart rate) and change blood sugar levels. 3. Labetalol should not be stopped suddenly. Used to treat high blood pressure; Clonidine Catapres has dizziness, lightheadedness, or fainting 1. Clonidine should not be stopped abruptly. also been used for some psychiatric when rising too quickly from a seated or This can cause a rapid increase in blood disorders such as Attention Deficit lying position; drowsiness; confusion; pressure. Disorder and Tourette's Syndrome. depression; headache; weakness; 2. If the person is using Catapres swelling of feet or legs; dry mouth; Transdermal patch, apply it to hairless area of constipation; nausea skin on upper arm or chest. Every 7 days, the old patch is removed and a new patch is applied-use a different skin site from the previous application. The patch should stay in place even during showering, bathing, or swimming. If the patch becomes loose, cover it with the adhesive overlay that is provided. For additional information, see package insert. Hydralazine Apresoline Used to treat high blood pressure & heart palpitation; redness of flushing of May cause dizziness, lightheadedness, or heart failure face; fast heart rate; headache; nausea/ fainting when rising too quickly from a vomiting; constipation; muscle or joint seated pr lying position. aches; rash; numbness or tingling in the hands or feet

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• Cardiovascular Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) General Considerations: 1. People on these medications should not take any over-the-counter medication unless it had been prescribed by the doctor. 2. It is very important that these medications be given as scheduled. 3. Salt in-take and fluid intake/output should be monitored as directed by the doctor. 4. Routine blood pressure monitoring is important for people on these drugs. Antihypertensive Drugs (drugs that lower blood pressure) continued Methyldopa Aldomet Used to treat high blood pressure dizziness, lightheadedness, or fainting 1. May cause urine to become dark. When rising too quickly from a seated or 2. Notify doctor if person has prolonged lying position; swelling of legs/feet; fever or tiredness, or if their skin yellows. Drowsiness; depression; tiredness; headache; fever; dry mouth; upset stomach; trouble breathing; swelling of breasts Diuretics also known as “water pills” Furosemide Lasix Used to treat high blood pressure by dizziness, lightheadedness, or fainting 1. Furosemide can make the skin more causing increased elimination of water when rising too quickly from a seated sensitive to sunlight (causing rash, sunburn, and sodium; also used to decrease or lying position; low potassium level itching). Person should stay out of direct sun- fluid retention due to heart, liver, or (symptoms: mental changes, muscle light, wear sun block (SPF 15 or higher), wear kidney disease. Cramps, weakness, nausea, irregular protective clothing, & wear sun block lip balm. Heartbeat); increased thirst; rash 2. May affect blood sugar level in diabetics. 3. Increases urination, so dose should be scheduled early in the day to avoid disruption of sleep. Hydrochlorothiazide Hydrodiuril Used for high blood pressure & fluid See Furosemide See Furosemide (HCTZ) retention in heart and kidney disease. Triamterene & Dyazide, Maxide Used for high blood pressure & fluid nausea; stomach cramps; diarrhea; See Furosemide. Also, avoid salt Hydrochlorothiazide retention in heart and kidney disease. Increased thirst; high potassium level substitutes & large amounts of (signs: confusion, tingling or numbness potassium rich food. Of hands feet, weakness, irregular heartbeat, shortness of breath); rash

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• Cardiovascular Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) General Considerations: 1. People on these medications should not take any over-the-counter medication unless it had been prescribed by the doctor. 2. It is very important that these medications be given as scheduled. 3. Salt in-take and fluid intake/output should be monitored as directed by the doctor. 4. Routine blood pressure monitoring is important for people on these drugs. Diuretics also known as “water pills” continued Spironolactone Aldactone Used for high blood pressure & fluid high potassium level (signs: confusion, 1. Take with food to prevent stomach upset. retention in liver disease. tingling or numbness of hands or feet, 2. Avoid salt substitutes & large amounts weakness, irregular heartbeat, shortness of potassium-rich food. of breath); dizziness; breast tenderness & increased hair growth in females; breast enlargement in males; increased thirst; diarrhea; nausea; sweating Cardiotonics Digoxin Lanoxin Used to treat heart failure & some Signs of high digoxin level: nausea; 1. Notify doctor immediately if person shows abnormal heart rhythms. vomiting; visual disturbances (see halos, signs of a high digoxin level. yellow or green spots, flashing lights), 2. The person should take his medicine at weakness; dizziness; headache; generally the same time each day, usually drowsiness; disorientation; in the morning. hallucinations; irregular heartbeat. 3. A pulse, preferably apical, should be taken prior to receiving or administration of this med. It should be documented on MAR by staff with every med pass. Antiarrhythmics Disopyramide Norpace Used to treat abnormal heart rhythms difficulty urinating; dry eyes,nose,mouth; 1. Do not break or chew sustained-release constipation; nausea; weakness; products. dizziness or fainting when rising too 2. This medicine should not be stopped quickly from a seated position; swelling suddenly; this could cause a serious change of feet or legs; chest pain in heart function. 3. This drug may cause low blood sugar in some people; watch for signs: chills, unsteady walk, cold sweats, confusion, shakiness, anxiety.

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• Cardiovascular Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) General Considerations: 1. People on these medications should not take any over-the-counter medication unless it had been prescribed by the doctor. 2. It is very important that these medications be given as scheduled. 3. Salt in-take and fluid intake/output should be monitored as directed by the doctor. 4. Routine blood pressure monitoring is important for people on these drugs. Antiarrhythmics continued Procainamide Pronestyl, nausea; diarrhea; dizziness; fainting; 1. See numbers 1 & 2 above. Procanbid fever; chills; joint pain or swelling; rash 2. Extended-release tablet may be seen in the stool. This is normal & no cause for concern. 3. Notify doctor if person has sore mouth, gums or throat or if they have symptoms of a respiratory tract infection. Propafenone Rythmol dizziness; drowsiness; headache; 1. This medicine should not be stopped constipation; stomach upset; abnormal suddenly; this could cause a serious change taste; heart palpitations; chest pain in heart function. 2. Notify doctor of sore throat, unusual bleeding or bruising, or extreme tiredness. Quinidine Quinaglute, diarrhea; nausea; stomach cramps; 1. Do not break or chew sustained-release Quinidex bitter taste; headache; dizziness; products. fainting; ringing in the ears; rash 2. Take with food. 3. This medicine should not be stopped suddenly; this could cause a serious change in heart function. 4. Notify doctor of rash, unusual bleeding or bruising, ringing in ears, or fainting. Nitrates (Nitroglycerin) Nitroglycerin Nitro, NitroDur, Used to prevent or treat chest pain dizziness, lightheadedness, or fainting, 1. Take the oral form on an empty stomach. NitroBid, (called "angina"). especially when rising too quickly from Do not crush or chew extended-release Nitrostat, etc. a seated or lying position; headaches; dosage forms. blurred vision; dry mouth; flushing 2. Do not chew or swallow sublingual tablets. 3. Topical ointment-Use the dose measuring papers to measure the length of ointment to the skin. Apply to a non-hairy area of chest or back. Do not rub or massage the ointment into the skin; just spread a thin, even layer.

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• Cardiovascular Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) General Considerations: 1. People on these medications should not take any over-the-counter medication unless it had been prescribed by the doctor. 2. It is very important that these medications be given as scheduled. 3. Salt in-take and fluid intake/output should be monitored as directed by the doctor. 4. Routine blood pressure monitoring is important for people on these drugs. Nitrates (Nitroglycerin) continued Nitroglycerin continued See package insert for further information. 4. Patch-apply it to hairless area of skin on upper arm or chest; remove the old patch before applying a new one; change at least daily (usually left on 12-14 hours & then taken off); follow doctor's instructions and package insert. 5. The patch (both new & used) is extremely toxic if ingested. After removing a used patch, fold it in half with the sticky sides together. Dispose of it where no one can get it. The patch form should generally be avoided in people with Pica (consuming inedible Anticoagulants (also known as "blood thinners") Warfarin Coumadin Used to prevent blood clots; also Signs of bleeding inside the body: 1. Notify doctor immediately if person shows used to prevent strokes and heart black, tarry stools; blood in the stool; pink any signs of bleeding or experiences falls, attacks or red urine; vomiting blood; vomit that injuries, or blows to the head or body. looks like coffee grounds; abdominal 2. Foods high in Vitamin K can decrease the pain; severe headache; joint pain; effectiveness if warfarin. A balanced diet with fainting; dizziness; shortness of breath. a consistent intake of Vitamin K is essential; Can also see: bleeding gums; excessive avoid large amounts of liver and leafy green menstrual bleeding; nosebleeds; vegetables (turnip greens, broccoli, spinach, bruising. asparagus etc.). Do not change diet once Other adverse effects:nausea; stable on warfarin therapy. vomiting; diarrhea; hair loss; purple dis- 3. Routine lab testing is extremely important. coloration of toes; purple/black areas or 4. Use special care in toothbrushing & skin breakdown on buttocks, thighs, shaving. Use a soft toothbrush. Use an breasts or stomach. electric razor rather than a blade, if possible. 5. Be prepared for multiple dosages as the dose us driven by blood tests.

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• Cardiovascular Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) General Considerations: 1. People on these medications should not take any over-the-counter medication unless it had been prescribed by the doctor. 2. It is very important that these medications be given as scheduled. 3. Salt in-take and fluid intake/output should be monitored as directed by the doctor. 4. Routine blood pressure monitoring is important for people on these drugs. Anticoagulants (also known as "blood thinners") continued Warfarin continued 6. Avoid alcohol and aspirin. Warfarin has many other drug interactions. Check with the doctor who monitors the warfarin therapy before starting or stopping any medication See "Medications Used in Treating Muscular and Skeletal System Aspirin Anacin, Ecotrin etc. Disorders" Antihyperlipidemic Drugs (Cholesterol-Lowering Drugs) These drugs are most effective when used with a diet that is low in cholesterol and fat. Follow the diet that the doctor prescribes Cholestyramine Questran Used to lower cholesterol; also used constipation; nausea; vomiting; 1. This medicine should never be taken in its for some gastrointestinal conditions. indigestion; gas; stomach pain; black, dry form, since it could cause the person to It binds to certain substances in the tarry stools; burnt smell to urine choke. Mix the powder with 4-6 ounces of gut. Since cholestyramine is not water or juice. The powder may also be mixed absorbed, these substances also pass with milk in breakfast cereals, with thin soups, out of the body without being or with pulpy fruit (such as applesauce). Absorbed. 2. The person should drink plenty of fluid throughout the day to prevent constipation. 3. This drug may interfere with the absorption of other medicines. Generally take other medications either 1 hour before or 4-6 hours after the cholestyramine. Fluvastatin Lescol Lowers cholesterol by blocking an indigestion; nausea; diarrhea; stomach 1. Notify the doctor of unexplained muscle Lovastatin Mevacor enzyme that is needed by the body pain; gas; headache; back pain; pain, tenderness, or weakness, especailly Pravastatin Pravachol to make cholesterol. Muscle pain; joint pain if accompanied by fever or general discomfort Simvastatin Zocor 2. Dose is usually given in the evening. Gemfibrozil Lopid Used to lower cholesterol & indigestion; stomach pain; diarrhea; 1. Notify the doctor of unexplained muscle triglycerides. Nausea; tiredness; dizziness pain, tenderness, or weakness, especailly if accompanied by fever or general discomfort

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• Cardiovascular Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) General Considerations: 1. People on these medications should not take any over-the-counter medication unless it had been prescribed by the doctor. 2. It is very important that these medications be given as scheduled. 3. Salt in-take and fluid intake/output should be monitored as directed by the doctor. 4. Routine blood pressure monitoring is important for people on these drugs. Naicin Nicobid, Nicolar Niacin is a vitamin supplement that nausea; bloating; gas; headache; 1. Person may experience skin flushing & a flushing; tingling or arms/legs; is also used to decrease dizziness sensation of warmth, especially of the face, cholesterol. Or fainting, especially when getting up neck & ears. Itching, tingling, or headache from a lying or sitting position; fast heart may also occur. These effects are temporary rate; rash; yellowing of skin or eyes. And will gradually decrease with continued therapy 2. Niacin may cause stomach upset. Take with food. 3. Do not crush or chew extended-release capsules or tablets.

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• Respiratory Disorders

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Bronchodilators fast heart rate; heart palpitations; Albuterol Ventolin, Proventil, These medicines make breathing flushing 1. Aerosol: Shake well before each use. Do not Proventil Repetabs easier by widening the breathing of face; nausea; stomach upset; dry spray in eyes. If the dose requires more than Pirbuterol Maxair passages of the lungs. Used for the mouth; coughing; nervousness; hyper- 1 inhalation (puff), wait at least 1 minute Terbutaline Brethaire, Brethine treatment of asthma, chronic activity; headache; difficulty sleeping; between inhalations. Follow specific bronchitis & other lung diseases. dizziness; tremor; sweating; difficulty instructions that accompany the inhaler. Salmeterol Serevent Short-acting drugs in this class, urinating; mental status changes 2. Tablets: Do not crush extended-release usually albuterol, are also used for tablets or Repetabs. The tablet form of sudden breathing problems (acute albuterol is more likely to cause side effects attacks). than the aerosol. 3. Serevent is used for long-term treatment of asthma, not for acute attacks. The person should have an albuterol or other short- acting bronchodilator inhaler for sudden breathing problems. Salmeterol 4. If the person has also been prescribed a steroid or ipratropium inhaler, the bronchodilator should be used first. This will help the steroid or ipratropium to reach the air passages. 5. Contact the doctor if the person does not get the usual relief from their normal dose. Theophylline TheoDur, Theo-24, Bronchodilator used for long-term High levels can cause: nausea/vomiting; 1. Avoid large amounts of caffeine-containing Uniphyl, etc. treatment of asthma, chronic diarrhea; stomach pain; tremor; food (chocolate) or beverages (tea, coffee, bronchitis & other lung diseases. nervousness; headache; agitation; cola). These may increase the side effects difficulty sleeping; fast heart rate and of theophylline. seizures 2. Don not crush or chew extended-release tablets. Sprinkle capsules may be opened and the contents (beads) sprinkled on a

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• Respiratory Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Bronchodilators continued Theophylline continued small amount of food (such as applesauce); do not chew the beads. 3. Notify the doctor if the person shows symptoms of high levels. Observe the person carefully for these symptoms when starting new medications or stopping old medications (theophylline interacts with many drugs). Anticholinergic Agents dry mouth; nausea; stomach upset; Ipratropium Atrovent Ipratropium makes breathing easier cough; 1. Ipratropium can cause blurred vision if it is by widening the breathing passages nervousness; dizziness; headache; sprayed in the eye. The person should close of the lungs. Used for the long-term blurred vision; difficulty sleeping; their eyes while the treatment is being given. treatment if chronic bronchitis and trembling; difficulty urinating; heart 2. Shake the canister well before use. Follow other lung diseases. It is not used palpitations the specific instructions that accompany for emergencies. the inhaler. Anti-Inflammatory Agents Oral: creamy, white, curd-like patches Beclomethasone Vanceril, Beclovent, These medicines decrease in 1. Oral: shake well before each use. Follow the (oral inhalers); inflammation. Uses: the mouth or throat &/or pain when specific instructions that accompany the Beconase AQ; Oral inhalation: long-term eating or swallowing (sign of infection); inhaler. The person should rinse their mouth Vancenase AQ treatment of asthma (not used for cough; hoarseness; dry mouth; nausea; with water (& spit it out) after using the (nasal aerosol) asthma attacks) headache. inhaler. This helps prevent infections and Beclomethasone continued Nasal aerosol: treatment of allergy Nasal: burning or stinging inside the throat irritation.

nose; nosebleeds, sores inside nose; Triamcinolone Azmacort (oral); symptoms including itching, runny dry 2. Nasal: shake well before each use. The Nasacort AQ (nasal) nose, nasal congestion & sneezing. nose; sore throat; white patches in person should blow their nose before using nose/throat; sneezing. the aerosol. Follow the specific instructions

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• Respiratory Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Anti-Inflammatory Agents continued Flunisolide AeroBid (oral); that accompany the aerosol. Nasalide (nasal) 3. Oral or Nasal: Notify the doctor if the person has sores or white patches in the nose or mouth. Cromolyn Intal (oral) Cromolyn is used to prevent Oral: unpleasant taste; coughing; 1. Oral: shake well before each use. Follow the Nasalcrom (nasal) asthma (oral inhaler) or allergy hoarseness; dry mouth; throat specific instructions that accompany the irritation' allergic reaction (swelling of symptoms (nasal aerosol); it is not lips, inhaler. used to treat asthma attacks. eyelids, or face; wheezing; trouble 2. Nasal: shake well before each use. The swallowing). person should blow their nose before using Nasal: sneezing; nose irritation/burning; the aerosol. Follow the specific instructions nosebleeds; allergic reaction. that accompany the aerosol. Antihistamines Diphenhydramine Benadryl, Nytol, Used for allergies, allergic reactions, drowsiness; dizziness; thickening of These drugs will add to the effects of alcohol etc. and cold symptoms (sneezing, bronchial secretions; headache; blurred & other CNS depressants (drugs that slow Chlorpheniramine Chlor-Trimeton watery eyes, runny nose, etc). vision; nervousness; stomach upset; down the nervous system, possibly causing dry mouth; constipation; difficult Cyproheptadine Periactin Diphenhydramine is also used to urination; drowsiness). Person should not drink treat the symptoms of Parkinson's dizziness; lightheadedness or fainting alcohol. Disease, the side effects of anti- when rising too quickly from a seated psychotic drugs & as a nighttime or lying position. sleep aid. Cyproheptadine is also used as an appetite stimulant. Loratadine Claritan Used for the relief of seasonal drowsiness; headache; dry mouth; These medications cause less drowsiness allergy symptoms. stomach upset; anxiety; fast heart rate than older antihistamines (see above). Fexofenadine Allegra drowsiness; stomach upset; menstrual However, they could add to the effect of cramps alcohol & other CNS depressants. Cough/Cold Drugs nausea; vomiting; drowsiness; Guaifensin Robitussin Thins respiratory tract mucus so that headache; Drink a glass of water or other fluid with each it can be coughed up. rash dose. Good fluid intake helps to thin respiratory tract mucus.

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• Respiratory Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Cough/Cold Drugs continued Dextromethorphan Benylin DM, Dextromethorphan is used to drowsiness; dizziness; stomach upset; Dextromethorphan may interact with some Robitussin DM* suppress nonproductive cough (no constipation drugs (such as anti-depressants & meperidine) mucus production) associated with to cause confusion, tremor, agitation, cold or allergy. unsteadiness, fever, sweating, & diarrhea. Notify the doctor if these adverse effects occur. fast heart rate; heart palpitations; Pseudoephedrine Sudafed Relieves nasal congestion due to increased 1. Do not crush sustained-release product. colds, allergies, or sinus infections blood pressure; nervousness; dizziness; 2. Usually used for short-term treatment headache; difficulty sleeping; sweating; (3 - 5 days). difficult urination burning or stinging in the nose; dry Phenylephrine Neo-Synephrine These are nasal sprays that relieve nose; These drugs should not be used for longer

sneezing; rebound nasal congestion Oxymetazoline Afrin nasal congestion due to colds, with than 3- 5 days. Long-term use can cause prolonged use; tremor; heart allergies or sinus infections. palpitations; rebound congestion to occur when the dose nervousness wears off.

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• Nervous System and Psychiatric Disorders

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antiepileptic/Anticonvulsant Agents Note: abrupt withdrawal of any of these medications could cause seizures. Carbamazepine Tegretol Treatment of epilepsy (seizures). sedation, dizziness, unsteadiness, Do not crush Tegretol XR (other tablets may (Caramazepine, Valproic Acid, and confusion, blurred vision, nausea, be crushed). The suspension should be Clonazepam are also used for some vomiting, diarrhea, rash, easy bruising shaken well (immediately before each use). mental illnesses, such as manic- or bleeding, difficult urination depression.) Phenytoin Dilantin unsteadiness & decreases mental 1. The suspension should be shaken well activity are related to elevated (immediately before each use). levels of the drug; Others include: 2. If the person is receiving feeding and dizziness, rash, drowsiness, headache, medication through a tube into their stomach, difficulty sleeping, delirium, slurred the tube feeding should be stopped for at speech, nausea, vomiting, overgrowth least 1 hour before and after the dose of of gums, lack of appetite, constipation, phenytoin is given. (The tube feeding can Phenytoin continued weight loss decrease the absorption of the phenytoin.) 3. Good dental hygiene is very important to prevent overgrowth of gum tissue. 1. Valproic Acid 1. Depakene nausea, vomiting, weight gain, Available in syrup, sprinkle capsules, and 2. Divalproex 2. Depakote stomach cramps, drowsiness, enteric-coated tablets. Sprinkle capsules may unsteadiness, confusion, tremor, hair be opened and the contents sprinkled on a loss, easy bruising/bleeding, rash, small amount of food (such as applesauce). changes in menstrual cycle Do not crush the sprinkles or the enteric- coated tablets. Clonazepam Klonopin drowsiness, confusion, dizziness, Clonazepam will add to the effects of alcohol & unsteadiness, difficulty sleeping, other CNS depressants (drugs that slow down depression, headache, blurred vision, the nervous system). People taking this drug nausea, vomiting, dry mouth, diarrhea, should not drink alcohol. constipation, rash, increased heart rate, low blood pressure, fainting, slurred speech, tremor

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• Nervous System and Psychiatric Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antiepileptic/Anticonvulsant Agents comtinued Note: abrupt withdrawal of any of these medications could cause seizures. Phenobarbital No Brand Name drowsiness, confusion, dizziness, Phenobarbital will add to the effects of alcohol difficulty sleeping, depression, & other CNS depressants (drugs that slow headache, nausea, vomiting, down the nervous system). People taking this constipation, slowed breathing, low drug should not drink alcohol. Blood pressure Primidone Mysoline See Carbamazepine same as phenobarbital same as henobarbital; Also, the suspension should be shaken well (immediately before each use). Gabapentin Neurontin drowsiness; dizziness; unsteadiness Give Neurontin at least 2 hours after antacids, such as Maalox-antacids decrease absorption Lamotrigine Lamictal rash; nausea; dizziness; drowsiness; unsteadiness Topiramate Topamax weight loss; kidney stones (painful urination, back pain); drowsiness; speech or language problems; confusion; difficulty with concentration; mood changes Tiagabine Gabitril dizziness; drowsiness; nausea; nervousness; lack of energy Antiparkinsonian Agents Benztropine Cogentin Used in combination with other dry skin; dry mouth; constipation; 1. This medicine can reduce the ability to drugs to treat symptoms of increased heart rate; difficulty sweat (sweating prevents overheating). Avoid Parkinson’s Disease. Also used to swallowing; confusion; hallucinations; excessive exercise and sun exposure. Treat some of the side effects of difficulty urinating; increased 2. Drinking fluids, sucking on hard candy (if anti-psychotic drugs. Sensitivity to light appropriate) and good dental hygiene Trihexyphenidyl Artane can relieve dry mouth. Diphenhydramine Benadryl See “Medications Used in Treating Respiratory Disorders” for information

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• Nervous System and Psychiatric Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antiparkinsonian Agents continued Amantadine Symmetrel Used in combination with other dry mouth; nausea; constipation; 1. May cause seizures, especially in people drugs to treat the symptoms of difficulty sleeping; depression; swelling with epilepsy. Parkinson’s Disease. Also used to of legs/feet; dizziness; fainting; 2. Person should not get up quickly after treat some of the side effects of anti- headache; difficulty urinating sitting or lying down; this may cause fainting psychotic drugs and to treat the flu. Or dizziness. Carbidopa nausea; vomiting; loss of appetite; sitting or lying down; this may cause fainting constipation; involuntary movements; or dizziness.

Levadopa/ Sinemet Treatment of Parkinson’s Disease dizziness; confusion; nightmares; 1. Person should not get up quickly after difficulty urinating; darkened urine & 2. Can take with food to prevent stomach upset sweat (not harmful) 3. Do not take levadopa with vitamin Levadopa Larodopa, Dopar supplements that contain Vitamin B6 (pyridoxine). This does not apply to products containing carbidopa, such as Sinemet. Antipsychotic Agents (also known as Neuroleptics Acetophenazine Tindal These drugs are mainly used to EPS (Extra Pyramidal Symptoms) 1. Antipsychotics can make the skin more Chlorpromazine Thorazine treat psychotic disorders, such as Early stages: decreased appetite, sensitive to sunlight (causing sunburn, rash, Chlorprothixene Taractan schizophrenia. They are also used insomnia, elevated blood pressure, itching). Person should stay out of direct Clozapine Clorazil to treat other psychiatric diseases. Elevated pulse, slight agitation, change sunlight, wear sun block (SPF 15 or higher), Fluphenazine Prolixin in hygiene care, restlessness and wear protective clothing & wear sun block lip Haloperidol Haldol increased activity, decreased attention balm. Loxapine Loxitane span, increased confusion/disorientation 2. Antipsychotics can make the person sweat Mesoridazine Serentil Middle stages: fine tremors in hands, less. Use extra care to not become overheated Molindone Moban feet, lips & tongue, stiffness in arms, during exercise or hot weather. Olanzapine Zyprexa back & neck, slight drooling, occasional 3. Antipsychotics will add to the effects of Perphenazine Trilafon rolling of eyes upward, garbled speech, alcohol & other CNS depressants (drugs that

Pimozide Orap irritability, isolates self slow down the nervous system, possibly Promazine Sparine Late stages: excessive drooling, severe causing drowsiness). Person should not muscle rigidity, severe tremors of Quetiapine Seroquel hands, drink alcohol. Risperidone Risperdal feet, lips & tongue, eyes roll upward & 4. Many of these drugs are available as a Thioridazine Mellaril remain (no control), slurred speech, concentrated oral liquid & come in a dropper

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• Nervous System and Psychiatric Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antipsychotic Agents (also known as Neuroleptics continued Thiothixene Navane treading in place. bottle. Measure each dose with the dropper Trifluoperazine Stelazine Neuroleptic Malignant Syndrome - provided and dilute it in at least 1/2 glass fever, dark urine, paleness, sweating, (4 ounces) of water of juice. See package muscle stiffness, decreased level of information for specific guidelines. **Clozapine & consciousness, increased heart rate 6. Clozapine can cause a decrease in Carbenzepine Tardive Dyskinesia - abnormal, the number of certain blood cells that should not be used involuntary movements that occur after fight infection. Regular lab tests will together unless all long-term use of antipsychotics; mainly be necessary to monitor for this affect the facial muscles, tongue, other like drug mouth, adverse effect. Watch for fever, chills, combinations have hands & feet; movements include; sore throat, weakness, flu-like been utilized and chewing, lip-smacking, puffing of symptoms & other signs of infection. proven inneffective. cheeks, grimacing, rapid blinking, etc. Report these to the doctor as soon as Other: dry mouth; drowsiness; This combination has confusion possible. been proven lethal constipation; difficulty with urination; 7. Notify the doctor of any signs of tardive in past years. dizziness; lightheadedness, or fainting dyskinesia. can occur when rising too quickly from sitting or lying; sore throat; fever; weakness; skin discoloration; weight gain Antidepressants Tricyclic/Tetracyclic Antidepressants Amitriptyline Elavil Usually used to treat depression & dry mouth; constipation; blurred vision; 1. These drugs can make the skin more difficult urination; drowsiness; Amoxapine Asendin other mood disorders; they may also weakness; sensitive to sunlight (causing rash, sunburn, Clomipramine Anafranil be used for other psychiatric restlessness; tremor; fast heart rate; itching). Person should stay out of direct Desipramine Norpramin disorders. Clomipramine is used to weight gain; dizziness; lightheadedness sunlight, wear sun block (SPF 15 or higher), Dozepin Sinequan, Adepin treat obsessive-compulsive disorder. or fainting can occur when getting up wear protective clothing, & wear sun block Imipramine Tofranil Imipramine is also used to treat too fast from a lying or sitting position; lip balm. Maprotiline Ludiomil bed-wetting. seizures. 2. These drugs will add to the effects of Nortriptyline Pamelor, Aventyl Amoxapine may also cause tardive alcohol & other CNS depressants (drugs that Protriptyline Vivactil dyskinesia (see Anti-psychotic agents) slow down the nervous system, possibly

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• Nervous System and Psychiatric Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antidepressants continued Trimipramine Surmontil causing drowsiness). Person should not drink alcohol. 3. Drinking fluids, sucking on hard candy (if appropriate), and good dental hygiene can relieve dry mouth. Monamine Oxidase Inhibitors (MAO's) Hypertensive Crisis (sudden increase Phenelzine Nardil Treatment of depression in 1. If person has signs of hypertensive crisis, blood pressure): severe headache, Tranylcypromine Parnate neck call doctor immediately! This is a serious stiffness or soreness, nausea, vomiting, adverse effect. sweating, clammy skin, chest pain, 2. Several foods & drinks may interact with heart palpitations MAO's to cause hypertensive crisis. Other: dizziness; lightheadedness or These foods must be avoided: fainting when rising too quickly from a (check with dietician for full list of foods): seated or lying position; blurred vision; a. cheeses, yogurt, sour cream drowsiness; fast heart rate; trembling; b. smoked or pickled meats, bologna, constipation; dry mouth; yellowing of pepperoni, salami, summer sausage skin/eyes; weight gain c. alcoholic beverages and no-alcoholic beer d. caffeine containing products (cola, coffee, tea, chocolate) e. certain fruits/vegetables (sauerkraut, cava beans, bananas, overripe fruit, raisins) 3. The person should not take other any medicine unless prescribed by the doctor (this include over the counter medicines) Selective Seratonin Reuptake Inhibitors (SSRI's) Fluoxetine Prozac Used to treat depression, obsessive- headache, nervousness, difficulty 1. If medicine causes upset stomach, it may Fluvoxamine Luvox compulsive disorder, manic- sleeping, drowsiness, dizziness, dry be taken with food. mouth, nausea, diarrhea, itching, Paroxetine Paxil depression, panic disorders & rash, 2. These drugs will add to the effects of

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• Nervous System and Psychiatric Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antidepressants continued Sertraline Zoloft eating disorders sweating alcohol & other CNS depressants (drugs that slow down the nervous system, possibly causing drowsiness). Person should not drink alcohol. 3. Drinking fluids, sucking on hard candy (if appropriate and good dental hygiene can relieve dry mouth. Other Antidepressants agitation; difficulty sleeping; Bupropion Wellbutrin Treatment of depression headache; 1. Do not discontinue abruptly. restlessness; confusion; blurred vision; 2. Will add to the effect of alcohol & CNS tremor; nausea; vomiting; dry mouth; depressants (See #2 above). constipations; rash; seizures headache; drowsiness; difficulty Nefazodone Serzone Treatment of depression sleeping; 1. Will add to the effect of alcohol & CNS agitation; dizziness; confusion; dry mouth; depressants (See #2 under SSRI special nausea; constipation; tremor; lightheaded- considerations-above). ness or fainting when rising too 2. May cause prolonged or painful erections. quickly from a seated or lying position Contact doctor if this occurs. drowsiness; headache; confusion; Trazodone Desyrel Treatment of depression; may also tremor; 1. Will add to the effect of alcohol & CNS help in treating anxiety and weakness; blurred vision; dry mouth; depressants (See #2 under SSRI special nausea; dizziness; lightheadedness schizophrenia or considerations-above). fainting when rising too quickly from a 2. May cause prolonged or painful erections. seated or lying position Contact doctor if this occurs. 3. Take shortly after a meal or light snack; often prescribed to be given at bedtime due to drowsiness.

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• Nervous System and Psychiatric Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antidepressants continued Venlafaxine Effexor Treatment of depression; has also headache; drowsiness; dizziness; 1. Take with food. been used for obsessive-compulsive weakness; nausea; constipation; dry 2. Extended release capsules-do not crush, disorder. mouth; difficulty swallowing; sweating; chew or dissolve in water. Swallow whole heart palpitations; fast heart rate; weight with adequate amount of fluid. loss; increased blood pressure 3. Will add to the effect of alcohol & CNS depressants (See #2 under SSRI special considerations-above). Antianxiety Drugs/Sedatives/Hypnotics slowed or difficult breathing; Alprazolam Xanax These drugs belong to a class called drowsiness; 1. These drugs will add to the effects of incoordination; dizziness; slurred Anafranil Clomipramine benzodiazepines. They are used for: speech; alcohol & other CNS depressants (drugs lightheadedness; confusion; dry Chlordiazepoxide Librium 1. Anxiety disorders; (e.g., post mouth that slow down the nervous system, change in appetite; nausea; Clonazepam Klonopin traumatic stress disorder, obsessive constipation; possibly causing drowsiness). Person fainting; low blood pressure; change Diazepam Valium compulsive disorder) in should not drink alcohol. Lorazepam Ativan 2. Short-term relief of anxiety: (e.g., weight; itching; rash; sweating 2. Withdrawal symptoms could occur if long- Oxazepam Serax before surgery) term or high-dose therapy is suddenly Temazepam Restoril 3. Sedation & relief of anxiety before stopped. medical procedures (lorazepam most commonly used) 4. Insomnia (inability to sleep) 5. Schizophrenia (with antipsychotics) 6. Epilepsy (diazepam, lorazepam, & clonazepam) 7. Spasticity (diazepam) drowsiness; dizziness; Buspirone BuSpar Used for the treatment of anxiety lightheadedness; The full effect of Buspirone may not be seen disorders. headache; restlessness; difficulty until after 3 - 4 weeks of treatment. sleeping; nausea

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• Nervous System and Psychiatric Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antianxiety Drugs/Sedatives/Hypnotics continued Chloral Hydrate Noctec Usually used as a sedative prior to stomach irritation; nausea; vomiting; 1. Take capsule with a full glass of water. The EEG evaluations, dental procedures, diarrhea; drowsiness; hallucinations; capsule should not be crushed or chewed. If or other diagnostic procedures. It is dizziness; incoordination; "hangover" using the syrup, dilute the dose in at least a also used for the short-term (less than effect; rash; itching half glass of water, ginger ale or fruit juice. 2 weeks) treatment of insomnia 2. This drug will add to the effects of alcohol & other CNS depressants (drugs that slow down the nervous system, possibly causing drowsiness). Person should not drink alcohol. Diphenhydramine Benadryl, Nytol, etc. Diphenhydramine is an antihistamine See under "Medications Used in Treating Respiratory Disorders" that is often used as a nighttime sleep aid. It is also used to treat the symptoms of Parkinson's Disease., the side effects of anti-psychotic drugs & allergies Hydroxyzine Vistaril, Atarax Hydroxyzine is an antihistamine that drowsiness; dizziness; thickening of Hydroxyzine will add to the effects of alcohol is also used to treat anxiety bronchial secretions; headache & other CNS depressants (drugs that slow Zolpidem Ambien Used for the short-term treatment of drowsiness; dizziness; headache; down the nervous system, possibly causing confusion; stomach upset; muscle insomnia ache drowsiness). Should not drink alcohol Antimania Drugs Lithium Lithobid, Eskalith, Used to treat mania, depression & Signs of lithium overdose/toxicity: 1. Take after meals. Lithonate, etc. psychotic disorders. Intention Tremor; Double or 2. Drink 8 to 12 glasses of water or other fluids blurred vision; confusion; severe per day, and use a normal amount of salt drowsiness; loss of appetite; vomiting; in food. muscle twitching; slurred speech, 3. Use extra care in hot water and when walking, seizures, coma exercising. The loss of too much water and Other adverse effects: increased salt from the body can lead to serious side thirst; increased urination; nausea; effects. stomach upset; bloating; weight gain; 4. Notify the doctor if the person has an fine hand tremor; weakness; impaired infection of illness that causes vomiting,

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• Nervous System and Psychiatric Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antimania Drugs continued Lithium continued memory; difficulty concentrating; rash; diarrhea or heavy sweating. These could acne; hair loss lead to the loss of too much water & salt. 5. Do not open, crush or chew extended- release capsules or tablets. 6. Contact the physician as soon as possible if the person shows the signs of lithium toxicity. 7. Lithium levels must be drawn a minimum of 12 hours after the last dose with no significant change in fluid intake of output. Carbamazepine Tegretol See under "Medications Used in Treating Nervous System Disorders" Valproic Acid Depakote, Depakene See under "Medications Used in Treating Nervous System Disorders"

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• Endocrine Disorders

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Androgens Testosterone Delatestryl, This is a male hormone used to acne; pain at injection site; flushing; 1. The doctor should be notified if the person Depo- treat testosterone deficiency. It is fluid retention; increased hair growth; has painful, prolonged erections. nausea; aggressive behavior; Testosterone sometimes used in women for headache; 2. Injections are given every 2 - 4 weeks. breast cancer depression; sleeplessness Estrogens Conjugated Premarin This is a female hormone used for swelling of hands, feet or legs; breast Estrogens can contribute to blood clot enlargement or tenderness; Estrogens replacement, usually after menstrual formation. Notify the doctor if the person has hysterectomy or during changes; breast tumors; depression; signs of a blood clot; they include: calf or menopause nausea; headache groin pain (may be accompanied by swelling or warmth); extremity numbness or weakness; chest pain; shortness of breath; severe headache; change in vision or speech; abdominal pain. Progestins Medroxyprogesterone Provera, This is a hormone that is used fluid retention; breakthrough bleeding; 1. Progestins can contribute to blood clot Depo- orally to treat irregular menstrual change in menstrual flow; absence of formation. Notify the doctor if the person has Provera flow & absence of menstrual flow. menstrual flow; depression; signs of a blood clot; they include: calf or weakness; It is also used with estrogens in increased breast tenderness; pain at groin pain (may be accompanied by injection site; suicide ideation; hormone replacement therapy. The changes swelling or warmth); extremity numbness or injection is usually used to prevent in mental status weakness; chest pain; shortness of breath; pregnancy. severe headache; change in vision or speech; abdominal pain. 2. This drug can make the skin more sensitive to sunlight (causing rash, sunburn, itching). Person should stay out of direct sunlight, wear sun block (SPF 15 or higher), wear protective clothing, & wear sun block lip balm.

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• Endocrine Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Progestins continued Medroxyprogesterone continued 3. The oral tablets may be prescribed for only 5 - 10 days out of the month or they may be prescribed for daily use. Pay close attention to the doctor's directions for use. 4. The injection is usually given every 3 months. Oral Contraceptives Ethinyl Estradiol & Brevicon, Ortho- Used to prevent pregnancy, to treat swelling of hands, feet, or legs; breast 1. Contraceptives can contribute to blood clot Norethindrone Novum, Tri-Norinyl excessive or painful menstrual enlargement or tenderness; nausea; formation. Notify the doctor if the person has Levlen, Tri-Levlen bleeding or to treat endometriosis diarrhea; bloating; headache signs of a blood clot; they include: calf or Ethinyl Estradiol & groin pain (may be accompanied by Levonorgestrel swelling or warmth); extremity numbness or weakness; chest pain; shortness of breath; severe headache; change in vision or speech; abdominal pain. 2. If oral contraceptives are taken to prevent pregnancy, additional protection should be used when taking anti-epileptic drugs and antibiotics. These drugs can decrease the effectiveness of oral contraceptives. 3. Check with the doctor to determine how to handle a missed dose. If oral contraceptives are being used to prevent pregnancy, additional protection should be used during the rest of the month. 4. This drug can make the skin more sensitive to sunlight (causing rash, sunburn, itching). Person should stay out of direct sunlight, wear sun block (SPF 15 or higher), wear protective clothing, & wear sun block lip balm.

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• Endocrine Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Thyroid Hormone Levothyroxine Synthroid, Used to treat hypothyroidism (low Signs of too much thyroid hormone: 1. Dose should be taken at the same time Levoxyl thyroid hormone secretion) nervousness' heart palpitation; hand each day, usually before breakfast. tremor; sleeplessness; unsteadiness; 2. Notify the doctor if the person has signs of weight loss; hair loss; changes in too much thyroid hormone. menstrual cycle; sweating Antidiabetic Agents Insulin Humulin A hormone used to treat diabetes that Signs of low blood sugar: anxious 1. Administer of insulin & management of feeling; behavior change similar to is injected to lower blood sugar levels, being diabetes requires extensive education by a It is used in people that cannot control drunk; blurred vision; coldsweats; trained health professional. their sugar levels with diet, exercise, or confusion; cool pale skin; difficulty in 2. Symptoms of low blood sugar must be concentrating; headache; nausea; oral medicine. rapid recognized & treated immediately before they heartbeat; shakiness; weakness lead to unconsciousness (passing out) Fruit Signs of high blood sugar: blurred There are several types of insulin that vision; juice, non-diet soft drinks, glucose tablets, act for different periods of time. drowsiness; dry mouth; increased candy (not chocolate), or table sugar should Regular insulin (Humulin R) is short- urination; unusual thirst; tiredness; always be available to give to the person if they nausea; change in appetite; acting. NPH (Humulin N) & Lente sleepiness show signs of low blood sugar. (Humulin L) are intermediate-acting. Other: thickening of the skin or 3. It is extremely important for the person to eat Ultra-lente (Humulin U) is long-acting. depressed skin at the injection site. meals as scheduled and to follow their meal A mixture of regular and NPH insulin plan. Missing meals or scheduled snacks is also available (Humulin 70/30) could cause low blood sugar. High blood sugar could result from not following dietary instructions. 4. If signs of severe high blood sugar are present, the person requires immediate hospitalization These include: flushed, dry skin; fruit-like breath odor; troubled breathing ( rapid & deep) passing out 5. Person should not drink alcohol (can cause low blood sugar). 6.Insulin should be stored in the refrigerator.

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• Endocrine Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antidiabetic Agents Monitor for low or high blood sugar Glyburide Diabeta, These medicines stimulate the (See 1. See items #2, 3 & 4 above. Glynase secretion of insulin from the above under insulin). Other adverse 2. Person should not drink alcohol because Glipizide Glucotrol pancreas. They are used to treat effects include: rash; itching; nausea; it can cause flushing, headache, nausea, Tolazamide Tolinase diabetes that does not require constipation; increased amount or vomiting, fast heart rate & sweating (in Tolbutamide Orinase insulin. frequency of urination; diarrhea; addition to low blood sugar). Chlorpropropamide Diabinese unusual bruising or bleeding Steroids (oral) Prednisone Deltasone Used to decrease inflammation nausea; vomiting; black, tarry stools; 1. May cause stomach upset. Take medicine Prednisolone Prelone; associated with arthritis, chronic vomiting blood; indigestion; stomach with food. Delta-Cortef respiratory problems, allergic pain; weight gain; swelling of the feet 2. Steroids may lower resistance to infection. or legs; menstrual irregularities or Methylprednisolone Medrol reactions and other inflammatory pain; Check with the doctor as soon as possible if mental depression; confusion; puffy Dexamethasone Decadron diseases. face; the person has signs of infection such as sore Hydrocortisone Cortef increase in psychosis throat, fever, coughing, etc. Triamcinolone Aristacort 3. Steroids should not be stopped abruptly if the person has been taking them for a long time or in high doses. This can cause nausea, vomiting, diarrhea, weight loss, lack of appetite, weakness and dizziness. Other Endocrine Agents Calcitonin (salmon) Calcimar, Used to treat osteoporosis & other facial flushing; nausea; diarrhea; 1. Calcitonin is available as an injection & as a increased urination; swelling at Miacalcin bone diseases injection nasal spray. A nurse must give the injection. site; nasal irritation (nasal spray only) The nasal spray should be administered according to the package insert. 2. Both the injection & the nasal spray should be stored in the refrigerator. Store the nasal spray in an upright position (do not allow it to lay on its side) Etidronate Didronel Used to treat osteoporosis & other fever; bone pain; nausea; diarrhea; Take with a full glass of water at least 2 hours metallic taste; rash; difficulty bone diseases breathing before meals.

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• Gastrointestinal Disorders (Digestive) Disorders

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antacids Aluminum Amphogel Used to treat stomach upset due to constipation; diarrhea; nausea; loss of 1. Shake liquid antacids before each use. Hydroxide excess acid, such as heartburn or appetite; muscle weakness; difficult or 2. Do not take antacids within 1 - 2 hours of Aluminum & Mylanta, Maalox indigestion. May also be used to painful urination; mood or mental taking other medications (antacids may keep Magnesium treat the symptoms of stomach changes. Aluminum hydroxide causes other medicines from being absorbed). more constipation. Magnesium Hydroxide ulcers. hydroxide 3. Notify doctor if the person vomits coffee- causes more diarrhea. ground looking material or has black, tarry stools (may indicate bleeding stomach or intestine). Antidiarrheal Agents Attapulgite Kaopectate Used to treat diarrhea. constipation; fecal impaction 1. Notify the doctor if diarrhea is not controlled within 48 hours. 2. Do not used if the person has a fever or blood/mucus in their stool. Contact the doctor. 3. Shake well before each use. 4. Take other medicines at least 2 hours after attapulgite. Taking them at the same time could decrease the absorption of the other medicines. Antidiarrheal Agents continued Bismuth Pepto-Bismol Used to treat diarrhea, nausea, and darkening of the tongue; gray-black 1. Notify the doctor if diarrhea is not controlled stools; constipation; nausea; Subsalicylate indigestion headache; within 48 hours or if the person has a high fever. confusion; ringing in the ears; weakness; 2. Do not use if the person is allergic to aspirin allergic reaction (difficulty breathing, or cannot take aspirin for some other reason. rash) 3. Shake liquid well before each use. Tablets should be chewed. Diphenoxylate Lomotil Used to treat diarrhea. drowsiness; dry mouth; constipation; 1. Notify the doctor if diarrhea is not controlled with Atropine difficult urination; blurred vision; within 48 hours or if the person has a high fever. headache; confusion; difficulty 2. Do not use more than the prescribed dose. breathing; fast heart rate; itching 3. This drug will add to the effects of alcohol &

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• Gastrointestinal Disorders (Digestive) Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antidiarrheal Agents continued Diphenoxylate other CNS depressants (drugs that slow down with Atropine continued the nervous system, possibly causing drowsiness). Person should not drink alcohol. Loperamide Imodium Used to treat acute and chronic drowsiness; dizziness; dry mouth; 1. Notify the doctor if diarrhea is not controlled nausea; constipation; stomach diarrhea. cramps; within 48 hours or if the person has a high fever. rash 2. Do not use more that 8 capsules or 80 ml in a 24 hour period. Antiemetics Promethazine Phenergan Used to control nausea and vomiting. drowsiness; dry mouth; thickening of 1. This drug can make the skin more sensitive bronchial secretions; headache; Also used for motion sickness. dizziness; to sunlight (causing rash, sunburn, itching). restlessness; involuntary movements; Person should stay out of direct sunlight, wear easy bruising or bleeding; muscle ache; sun block (SPF 15 or higher), wear protective sore throat clothing & wear sun block lip balm. 2. This drug will add to the effects of alcohol & other CNS depressants (drugs that slow down the nervous system, possibly causing drowsiness). Person should not drink alcohol. 3. Store suppositories in the refrigerator. Antiulcer Agents dizziness; agitation; headache; Cimetidine Tagamet This is a class of drugs known as confusion; 1. Do not take directly with antacids; separate Famotidine Pepcid "blockers" & they decrease the constipation; diarrhea; nausea; rash; doses by at least one hour. Nizatidine Axid amount of acid produced by the drowsiness 2. Notify the doctor of any symptoms that stomach. They are used to treat Ranitidine Zantac ulcers, suggest a bleeding ulcer, such as: black, heartburn, and other conditions tarry stools; blood in the stool; vomiting blood; caused by too much stomach acid vomit that looks like coffee grounds; severe stomach pain; fainting; dizziness; shortness of breath. 3. Cimetidine has many drug interactions. Monitor the person for side effects from their other medications when cimetidine is start/stop.

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• Gastrointestinal Disorders (Digestive) Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Antiulcer Agents headache; dizziness; nausea; Lansoprazole Prevacid This is a class of drugs known as diarrhea; 1. Take before eating. Omeprazole Prilosec "proton-pump inhibitors" & they stomach pain; constipation; rash; 2. Generally, these drugs should be swallowed decrease the amount of acid muscle or joint pain whole. However, the capsule can be opened produced by the stomach. They and the pellets mixed wit hone tablespoon are used to treat ulcers & of applesauce or with a small amount of gastroesophageal reflux disease (a cranberry or orange juice. The mixture should condition in which the acid in the be swallowed immediately. The pellets should stomach washes back up into the not be chewed or crushed. esophagus). 3. Notify the doctor of any symptoms that suggest a bleeding ulcer, such as: black, tarry stools; blood in the stool; vomiting blood; vomit that looks like coffee grounds; severe stomach pain; fainting; dizziness; shortness of breath. Laxatives Note: A proper diet containing roughage (whole grain breads and cereals, bran, fruit, and green leafy vegetables), with 6 to 8 full glasses of liquids each day, and daily exercise are most important in maintaining healthy bowel function. Bisacodyl Dulcolax These are stimulant laxatives that stomach cramps; nausea; vomiting; 1. Do not crush biscodyl tablets. Senna Senokot used for the short-term treatment of diarrhea; dizziness; rectal bleeding 2. Laxative effect will be seen in 6 - 10 hours. constipation & to clean out the bowel 3. Long-term use of stimulant laxatives can before bowel exams or surgery. result in laxative dependence or in imbalance in fluid & electrolyte levels (symptoms-muscle cramps, weakness, dizziness). 4. Red-brown, pink-red, or red-violet discoloration of the urine may occur with Senna. Docusate Colace Used to soften the stool so the diarrhea; stomach cramping; throat 1. Do not crush capsules. The liquid can be person can have a bowel movement irritation (liquid form) given in milk or fruit juice to mask the bitter without straining. taste. 2. Do not use in the presence of abdominal pain, nausea or vomiting.

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• Gastrointestinal Disorders (Digestive) Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Laxatives continued Glycerin Babylax, Used for the treatment of irritation or bleeding in the rectal area; 1. Insert one suppository high in the rectum & Suppositories Sani-Supp constipation. Glycerin draws fluid bowel cramps; nausea; diarrhea retain for 15 minutes. Effects usually occur into the bowel & stimulates in 30 minutes. evacuation. 2. Do not use in the presence of abdominal pain, nausea or vomiting. 3. Store suppositories at room temperature. Lactulose Chronulac Used for the treatment of gas; diarrhea; stomach pain; nausea 1. Lactulose may be given "as is" or diluted constipation. It works by drawing with water, fruit juice or milk. fluid into the bowel. 2. Laxative results may not occur for 24 - 48 hrs

Magnesium Milk of Magnesia Used for the treatment of diarrhea; stomach cramping 1. Shake well before each use. Hydroxide constipation. It works by drawing 2. Take with plenty of water. fluid into the bowel. 3. Do not take at the same time as warfarin, digoxin, or certain antibiotics (cipro, tetracycline, etc.) 4. Notify doctor if symptoms of electrolyte imbalance occur (muscle cramps or pain, weakness, drowsiness, slowed breathing). 5. Laxative effects will be seen in 4 - 6 hours. Magnesium Citroma Used for the short-term treatment of diarrhea; gas; stomach cramps 1. Take with a glass of water or fruit juice. Chill Citrate constipation or for evacuation of the before using to improve taste. bowel for surgical or diagnostic 2. Effects will occur in 30 minutes to 3 hours. procedures. It works by drawing fluid 3. Notify doctor if symptoms of electrolyte into the bowel. imbalance occur (muscle cramps or pain, weakness, drowsiness, slowed breathing). Psyllium Metamucil A bulk-forming laxative used for the stomach pain; bowel obstruction; gas; 1. To allow psylium to work properly & to prevent treatment of constipation. It may also constipation; diarrhea intestinal blockage, it is necessary to drink be used for the treatment of plenty of fluids during it use. Each dose diarrhea and high cholesterol. should be mixed in a full glass (8 ounces) of water or juice. Giving a second glass of water or juice will help avoid side effects. 2. Full effects may take 2 - 3 days.

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• Gastrointestinal Disorders (Digestive) Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Other Gastrointestinal Drugs Cisapride Propulsid Cisapride increases the movements headache; stomach cramps; diarrhea; 1. This drug is usually taken at least 15 minutes or contractions of the stomach & gas; dry mouth; stuffy nose; difficulty before meals & at bedtime. intestines. Used for the treatment of sleeping; anxiety; rash 2. Cisapride can cause fainting, dizziness, & gastroesophageal reflux disease (a irregular heartbeats when given with certain condition in which the acid in the medications. Cisapride should not be given stomach washes back up into the with erythromycin, clarithromycin (Biaxin), esophagus). ketoconazole (Nizoral), itraconazole(Sporanox), fluconazole (Diflucan), indinavir (Crixivan) or ritonavir (Norvir). Check with the doctor if any of these are prescribed for the person. 3. Shake the suspension well before each use. Metoclopramide Reglan It increase the movements or drowsiness; diarrhea; weakness; 1. Metoclopramide is usually taken 30 minutes contractions of the stomach & involuntary movements of the face, before meals & at bedtime. intestines. Used for the treatment of mouth, or limbs; trembling; confusion; 2. Notify doctor if involuntary movements occur gastroesophageal reflux disease (a restlessness; difficulty sleeping; (such as chewing, lip-smacking, puffing of condition in which the acid in the depression; dry mouth; seizures cheeks, grimacing, rapid blinking, etc.) stomach washes back up into the 3. This drug will add to the effects of alcohol esophagus). & other CNS depressants (drugs that slow down the nervous system, possibly causing drowsiness). Person should not drink alcohol. headache; stomach pain; cramps; Mesalamine Asacol, Pentasa Used to treat ulcerative colitis gas; Do not crush or chew sustained-release hair loss; rash; diarrhea capsules or tablets. dizziness; headache; diarrhea; Sulfasalazine Azulfidine Used to treat ulcerative colitis nausea; 1. Take after meals. Do not take with antacids. vomiting; itching; rash; yellowing of the 2. May cause orange-yellow discoloration of skin the urine. 3. This drug can make the skin more sensitive to sunlight (causing rash, sunburn, itching). Person should stay out of direct sunlight, wear sun block (SPF 15 or higher), wear protective clothing & wear sun block lip balm.

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• Gastrointestinal Disorders (Digestive) Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Other Gastrointestinal Drugs Simethicone Gas-X, Phazyme Used to relieve the painful symptoms No common or important side effects Shake drops well before each use. Tablets & pressure of excess gas in the should be chewed thoroughly before stomach swallowing.

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• Genitourinary Disorders

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Urinary Muscle Relaxants Oxybutynin Ditropan Used to decrease muscle spasms of drowsiness; dry mouth; constipation; 1. This drug will add to the effects of alcohol &

Oxybutynin continued the bladder and the frequent urge fast hear rate; dizziness; weakness; other CNS depressants (drugs that slow down to urinate caused by these spasms. sleeplessness; decreased urination the nervous system, possibly causing drowsiness). Person should not drink alcohol. 2. Use caution in hot weather. This drug can cause fever & heatstroke due to decreased sweating. Cholinergic Agents Bethanechol Urecholine Helps to cause urination and emptying stomach cramps; diarrhea; nausea; Should be taken 1 hour before or 2 hours increased watering of mouth; of the bladder. sweating; after meals to avoid nausea and vomiting flushed skin; difficulty breathing; dizziness, lightheadedness or fainting when rising too quickly from a seated or lying position Urinary Tract Analgesics headache; dizziness; stomach Phenazopyridine Pyridium Used for short-term (2 day) relief of cramps; 1. Take with food or after meals pain, burning, & frequent urination rash 2. May cause urine to turn reddish-orange. associated with urinary tract infections May stain bedding or underwear. Urinary Anti-infectives rash; stomach upset; vomiting; Nitrofurantoin Macrodantin Used for the prevention and treatment diarrhea; 1. Take with food or milk. loss of appetite; drowsiness; of urinary tract infections caused by headache; 2. Antacids may decrease the absorption of dizziness; weakness; certain bacteria tingling/numbness nitrofurantoin. Do not give them at the same of hands or feet; muscle ache; difficulty time. breathing; chest pain 3. May turn urine dark yellow or brown.

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• Genitourinary Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Vaginal Products Clindamycin Cleocin Used to treat certain vaginal bacterial rash; itching; local pain; vaginal yeast 1. Follow the administration directions & use infection (thick, white vaginal infections discharge); the disposable applicators included in the diarrhea; stomach upset package. 2. Use at bedtime. This will help keep the medicine in the vagina & reduce leaking. Wearing a sanitary napkin or mini-pad may prevent staining of clothing. Do not use tampons Clotrimazole Mycelex, Gyne- Used to treat vaginal yeast infections local pain/burning; itching; rash; See special considerations for Lotrimin stomach cramps Clindamycin (above) Miconazole Monistat

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• Ear, Eye and Skin Disorders

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Otic (Ear) Drugs burning; itching; swelling or redness Bensocaine/ Auralgan This product is used to relieve pain of 1. The ear drops may be warmed by holding Antipyrine associated with ear infections. It is the ear; rash the bottle in the hand for a few minutes. Do not used to treat the infection itself. not use other methods to heat the eardrops. Neomycin/Polymixin Cortisporin, Otocort, This is a combination product This could cause injury. Hydrocortisone Pediotic, etc. containing antibiotics & a steroid. It is 2. Do not allow the dropper to touch any used to treat some ear infections & surface (including the ear). This is to keep relieve the swelling associated with the germs from getting into the ear drops. infection. Carbamide Debrox Used to loosen & remove ear wax. rash; itching; redness 1. See # 1 & 2 above. Peroxide 2. Notify the doctor if the person has dizziness or has ear pain, discharge/ drainage, rash or redness. Triethanolamine Cerumenex 3. Triethanolamine only-the usual administration is to fill the ear canal, insert a cotton plug, allow the medicine to remain in the ear for 15 - 30 minutes, then flush the ear with lukewarm water. Ophthalmic (Eye) Drugs Note: Wash hands before administration. Do not touch the applicator tip to any surface (including the eye). Replace the cap after using. White Petrolatum Lacrilube A lubricant used to prevent irritation No common or important side effects. Notify the doctor if the person has eye pain, & relieve dryness of the eye changes in vision, continued redness or irritation or if the condition worsens stinging or burning when applied; Sulfacetamide Bleph-10, Sulamyd An antibiotic used to treat eye itching; 1. Wait at least 10 minutes before using any redness; swelling or other signs of infections. It belongs to a class of eye other eye preparation. irritation; allergic reaction (rash, drugs know as "sulfa drugs". difficulty 2. Notify the doctor if the person has an allergic breathing, or swelling of the face) reaction, develops a rash, or if the condition does not improve in 3 - 4 days.

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• Ear, Eye and Skin Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Ophthalmic (Eye) Drugs rash; itching; redness, swelling or Neomycin/ Neosporin This is a combination of 3 antibiotics other Notify the doctor if the person has an allergic Gramicidin/ Ophthalmic Drops & it is used to treat eye infections signs of eye irritation; stinging or reaction, develops a rash, or if the condition Polymixin B burning when applied does not improve in 3 - 4 days. Prednisoine PredForte These drugs are steroids that are used blurred vision; burning, stinging, 1. If using the suspension form, shake well Dexamethasone Decadron, Maxidex to relieve redness, irritation, & watering or redness of the eyes; eye before each use. swelling of the eyes. infection 2. Notify the doctor if the eye condition Fluorometholone FML Forte does not improve after 5 - 7 days or if the condition worsens. Timolol Timoptic These drugs are in a class called Eye: redness of eyes; stinging in eyes 1. The person's eyes may become more or other signs of irritation when "beta-blockers" & lower the pressure applied; sensitive to light. Wearing sunglasses & Betaxolol Betoptic in the eyes. They are used to treat increased sensitivity of eye to light; avoiding bright light may help. glaucoma watery eyes; dry eyes; blurred vision 2. In diabetics, these drugs can mask some of Systemic: slow heart rate; heart the signs of low blood sugar (such as fast palpitations; chest pain; swelling of feet heart rate & trembling) and change blood or lower legs; difficulty breathing; sugar levels. nervousness; dizziness; tiredness; 3. The systemic adverse effects may be a sign headache; itching that the body is absorbing too much drug. If the person experience these effects, notify the doctor. 4. Apply gentle pressure to the inner corner of the eye with your finger for about 1 minute after instilling the eye drops. This decreases the systemic absorption.

Pilocarpine Isopto-Carpine Used to treat glaucoma Eye: blurred vision; decrease in night 1. The systemic adverse effects may be a sign vision; eye irritation; eye pain; browache; that the body is absorbing too much drug. If headache the person experience these effects, notify Systemic: increased sweating; muscle the doctor.

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• Ear, Eye and Skin Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Ophthalmic (Eye) Drugs continued tremors; wheezing or difficulty Pilocarpine continued breathing; 2. Apply gentle pressure to the inner corner of watering of mouth; nausea; vomiting; the eye with your finger for about 1 minute diarrhea after instilling the eye drops. This decreases the systemic absorption. Topical (Skin) Medication - General Information Use gloves when applying topical medications. Apply to clean, dry skin. These products are for external use only. Avoid contact with the eyes. Topical (Skin) Anti-infectives Neomycin/ Neosporin This is a combination of 3 anti- itching; skin rash; redness; swelling 1. Clean the affected area with soap & water and Bacitracin/Polymixin Ointment biotics. The product is used to treat dry thoroughly (or clean the area according & prevent skin infections caused by to the doctor's instructions) before using. bacteria. 2. If the skin problem does not improve after 7 days or it gets worse, notify the doctor. Clotrimazole Lotrium This drug is used to treat fungal rash; hives; burning or stinging upon Clean the affected area with soap & water and application; swelling, itching, redness, infections of the skin. or dry thoroughly (or clean the area according other signs of skin irritation to the doctor's instructions) before using. Topical (Skin) Steroids Hydrocortisone Hytone These drugs are used to relieve the dryness; irritation; burning; rash; skin 1. Apply sparingly & rub in gently. thinning; streaks in skin; acne; Triamcinolone Kenalog redness, itching & swelling impaired 2. Do not bandage or wrap the treated area Betamethasone Diprosone, Valisone associated with rashes and other wound healing unless directed by the doctor. For systemic side effects, see the skin conditions steroid 3. Do not use these drugs more often or for a section of "Drugs Used to Treat longer time than ordered by the doctor. Endocrine Disorders". 4. The systemic adverse effects may be a sign that the body is absorbing too much drug. In this case, notify the doctor. Other Topical (Skin) Drugs Permethrin Elimite Cream, Nix The shampoo is used to treat head itching; redness; rash; burning; 1. Follow the doctor's orders or the directions stinging; numbness or scalp Cream Rinse lice. The cream is used to treat discomfort. that accompany the product. scabies. 2. If treating head lice, all clothing, bedding, towels, & washcloths should be washed in hot

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• Ear, Eye and Skin Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Other Topical (Skin) Drugs continued Permethrin comtinued water & dried using the hot cycle. Clothing or

bedding that cannot be washed should be placed in an airtight plastic bag for 2 weeks. Thoroughly vacuum furniture, rugs & floors. Wash all hairbrushes, combs, & toys in hot soapy water for 5 - 10 minutes 3. Shake the liquid well before using. burning; dryness; itching; irritation; Nystatin/ Mycolog This is an antifungal & steroid rash; 1. Apply sparingly & rub in gently. Triamcinolone combination product. skin thinning; streaks in skin; acne; 2. Do not bandage or wrap the treated area impaired wound healing unless directed by the doctor. 3. Do not use these drugs more often or for a longer time than ordered by the doctor.

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• Infectious Disorders

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Note: Immediate medical attention is required if the person has a severe allergic reaction. Also, notify the doctor as soon as possible if the person develops a rash. Penicillins diarrhea; allergic reaction (rash, Penicillin Pen Vee K These are used to treat infections difficulty 1. Shake the suspension well before each use Amoxicillin Amoxil caused by certain bacteria. They breathing, or swelling of the face); & store in the refrigerator. Ampicillin Principen work by killing the bacteria or nausea; stomach cramps; seizures 2. Take at evenly spaced intervals throughout Dicloxacillin Dynapen preventing their growth. the day. Take with plenty of water. Amoxicillin & Augmentin 3. Notify the doctor if severe diarrhea occurs. Clayulinic Acid This could be a sign of a serious side effect. Cephalosporins diarrhea; allergic reaction (rash, Cephalexin Keflex These are used to treat infections difficulty 1. Shake the suspension well before each use Cefuroxime Ceftin caused by certain bacteria. They breathing, or swelling of the face); & store in the refrigerator. (cefixime does not nausea; stomach cramps; vaginal Cefaclor Ceclor work by killing the bacteria or itching need to be refrigerated). Cefixime Suprax preventing their growth. or discharge 2. Take at evenly spaced intervals throughout the day. Take with plenty of water. 3. Notify the doctor if severe diarrhea occurs. This could be a sign of a serious side effect. Macrolides Azithromycin Zithromax These are used to treat infections diarrhea; stomach cramping; nausea; 1. Shake the suspension well before each use Clarithromycin Biaxin caused by certain bacteria. They vomiting; allergic reaction (rash, & store in the refrigerator. Erythromycin Erythrocin, Ery- work by killing the bacteria or difficulty breathing, or swelling of the 2. May take with food if stomach upset occurs. Tab, E.E.S., etc. preventing their growth. face). Take with plenty of water. 3. Take evenly spaced intervals through the day. 4. Do not crush delayed release products. Erythromycin continued 5. Moderate diarrhea may occur. Notify doctor if it is prolonged or severe. Sulfonamides Trimethoprim & Septra, Used to treat infections caused by allergic reaction (rash, difficulty 1. This drug can make the skin more sensitive Sulfamethoxazole Bactrim certain bacteria. It is also used long- breathing, or swelling of the face); to sunlight (causing rash, sunburn, itching). term to prevent urinary tract infections, nausea; vomiting; loss of appetite; Person should stay out of direct sunlight, pneumonia, & ear infections. dizziness; fever; muscle & joint wear sun block (SPF 15 or higher), wear aching. protective clothing & wear sun block lip balm.

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• Infectious Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Note: Immediate medical attention is required if the person has a severe allergic reaction. Also, notify the doctor as soon as possible if the person develops a rash. Sulfonamides Sulfamethoxazole continued 2. Notify the doctor if the person has redness, blistering, peeling, or loosening of the skin. Also, notify the doctor of severe or prolonged diarrhea. These could be signs of severe adverse reactions. 3. Take with a full glasses (8 ounces) of water & the person should drink plenty of water throughout the day. Fluroquinolones Ciprofloxacin Cipro These are used to treat infections headache; restlessness; dizziness; 1. These drugs should be taken with a full glass Levofloxacin Levoquin caused by certain bacteria. They nausea; diarrhea; stomach pain; (8 ounces) of water & the person should drink Ofloxacin Floxin work by killing the bacteria or allergic reaction (rash, difficulty plenty of water throughout the day. breathing, or swelling of the face); preventing their growth. seizures; 2. These antibiotics should be given at least pain in calves or heels 2 hours before or 2 hours after the following: iron products, calcium supplements, zinc supplements, or multivitamins with minerals. These antibiotics should be given at least 2 hours before or 4 hours after antacids or sucralfate. These drugs can decrease the absorption of the antibiotics. 3. Fluroquinolones can make the skin more Ofloxacin continued sensitive to sunlight (causing rash, sunburn, itching). Person should stay out of direct sun- light, wear sun block (SPF 15 or higher), wear protective clothing & wear sun block lip balm. Tetracyclines Tetracycline Sumycin, These medicines are used to treat stomach cramps; diarrhea; nausea; 1. Should not be given to children less than Achromycin infections and to help control acne. headache; loss of appetite; dizziness; 8 years old. Doxycycline Vibramycin allergic reaction (rash, difficulty 2. All tetracycline should be taken at least 1

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• Infectious Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Note: Immediate medical attention is required if the person has a severe allergic reaction. Also, notify the doctor as soon as possible if the person develops a rash. Tetracyclines Minocycline Minocin breathing, or swelling of the face) hour before or 2 - 3 hours after the following: calcium supplements, milk/dairy products, iron supplements, antacids, magnesium supplements/laxatives, multivitamins with minerals, or zinc supplements. These drugs could decrease the absorption of the antibiotics. 3. Tetracyclines can make the skin more sensitive to sunlight (causing rash, sunburn, itching). Person should stay out of direct sun- light, wear sun block (SPF 15 or higher), wear protective clothing & wear sun block lip balm. 4. Tetracyclines should be taken with a full glass (8 ounces) of water to prevent irritation of the esophagus. The person should not lie down for at least 30 min. after taking medicine. 5. Do not use outdated (old) medicine. This could cause serious side effects. Other Antibiotics Clindamycin Cleocin Used to treat infections caused by diarrhea; nausea; vomiting; allergic 1. Moderate diarrhea may occur. Notify the certain bacteria reaction (rash, difficulty breathing or doctor if it is prolonged or severe. This could be swelling of the face) a sign of severe adverse reaction. 2. Take with a full glass (8 ounces) of water. dizziness; headache; nausea; Metronidazole Flagyl Used to treat infections (usually diarrhea; 1. The person should not drink alcohol because in the abdomen) unsteadiness; seizures; dry mouth; it can cause flushing, headache, nausea, metallic taste; vaginal yeast infection; vomiting, fast heart rate & sweating. numbness or tingling in the arms or 2. May turn the urine dark or reddish-=brown. legs; allergic reaction (rash, difficulty breathing, or swelling of the face). Nitrofurantoin Macrodantin See "Medications Used in Treating Urinary Disorders"

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• Infectious Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Note: Immediate medical attention is required if the person has a severe allergic reaction. Also, notify the doctor as soon as possible if the person develops a rash. Antituberculosis Agents Rifampin Rifadin Used to treat tuberculosis. May also flushing; swelling; headache; nausea; 1. This drug will cause the urine, tears, sweat stomach cramps; diarrhea; be used for some other types of drowsiness; & other body fluids to turn reddish-orange. dizziness; numbness; itching; infections. yellowing 2. Contents of capsules may be mixed with a of skin or eyes; unusual bleeding or small amount of applesauce or jelly. bruising. 3. Women on birth control pills should use additional means of birth control while taking this medication (also see under "Drugs Used to Treat Endocrine Disorders"). 4. The person should not drink alcohol while taking this medication. Isoniazid (also Laniazid Used to treat or prevent tuberculosis dizziness; slurred speech; tiredness; 1. Notify the doctor if the person has yellowing called INH) yellowing of skin or eyes; seizures; of the skin/eyes, dark urine, tiredness, weakness rash; numbness or tingling in arms or nausea, or vomiting. These could be signs of legs. hepatitis. Also report and numbness or tingling in the arms or legs. 2. Do not take antacids within 1 hour of taking isoniazid. 3. May take with food if stomach upset occurs. 4. The doctor may prescribe Vitamin B6 to prevent some of the side effects of isoniazid. It is very important to take this every day. Analgesic (non-narcotic) Acetaminophen (or Tylenol, Panadol, Relieves pain, reduces fever Allergic reaction - rash, fever, or 1. Do not exceed the recommended APAP) Tempra,etc. difficulty breathing dosage. Yellow eyes or skin Overdosage can 2. Check the labels of all prescription & cause liver damage nonprescription medication the person takes. If any contain acetaminophen, check with the person's health care pro- fessional. (Taking them together with this medication may cause an overdose.)

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• Infectious Disorders continued

EXAMPLES: EXAMPLES: INDICATIONS/USE MAJOR SIDE EFFECTS SPECIAL CONSIDERATIONS GENERIC NAME TRADE NAME (Does not include all side effects) Note: Immediate medical attention is required if the person has a severe allergic reaction. Also, notify the doctor as soon as possible if the person develops a rash. Stomach ulcers - signs include: Aspirin Anacin, Bufferin, 1. Relieves pain - used for headache, bloody 1. Take with food or after meals & take with or black, tarry stools; throwing up other names include Ecotrin, Zorprin, muscle ache, etc. blood a full glass of water. or material that looks like coffee ASA or ECASA (If Alka-Seltzer, etc. 2. Reduces inflammation - used for grounds; 2. Do not use if a strong vinegar-like odor enteric-coated) arthritis & other inflammatory stomach pain is present. 3. Reduces fever Easy bruising/bleeding 3. Do not crush enteric-coated aspirin. 4. Decreases ability of blood to clot - Allergic reaction - shortness of breath; 4. Do not place or dissolve directly on an used to prevent heart attacks and wheezing, itching, inflammation inside aching tooth, canker sore, or cold sore. A the nose, swelling of eyelids, face & strokes lips serious inflammatory reaction could occur. Stomach Upset - (nausea, indigestion, 5. Aspirin should not be used if the heartburn) person takes blood thinners (Coumadin). Ringing in ears, hearing loss Check with physician. Dizziness, weakness, confusion Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Stomach ulcers - signs include: Ibuprofen Advil, Motrin, 1. Relieves pain - used for headache, bloody 1. Take with food or after meals & take with or black, tarry stools; throwing up Nuprin, etc. muscle ache, etc. blood a full glass of water. The person should or material that looks like coffee Also, used to treat the symptoms of grounds; avoid lying down for at least 30 minutes PMS and menstrual cramps. stomach pain after taking the medicine. Stomach Upset - (nausea, 2. Reduces inflammation - used for indigestion, 2. May cause sensitivity to sunlight. Use arthritis & other inflammatory heartburn) sunscreen and wear protective clothing. 3. Reduces fever Ringing in ears, hearing loss Allergic reaction (see aspirin above) Fluid retention/weight gain Dizziness, weakness, headache, vision changes

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APPENDIX B

INFECTION CONTROL

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INFECTION CONTROL

Infection Control Practices

Infection Control is taking active measures to prevent illness in people receiving or giving care. There are four links in the infection chain that must be present before infection can be spread. These four links are:

• A germ, such as a Virus, bacterium, fungus, or parasite. • A place for the germ to live and multiply, such as a person, animal, plant, food, soil, or water. • A susceptible host – a person who does not have resistance (immunity) to the germ. • A way for the germ to enter the host. Different germs may require different routes. For example:

Direct contact – when people touch each other, kiss, have sex, etc. Indirect contact – when food, water, feces, bandages, or other substances contaminated by the germ enter the host. Droplets – such as those produced by a sneeze or cough. Other particles in the air.

Removing any one of these links breaks the “chain of infection.” Some important measures to take include the following:

• Good hand washing. • Good housekeeping. • Using protective barriers (gloves, masks, gowns, etc.). • Immunizations. • Store food carefully. • Wash fruits and vegetables. • Use separate cutting boards. • Use hot soapy water to wash dishes. • Not sharing personal items (razor, toothbrush, etc.).

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Signs and symptoms of infection may include the following:

• Inflamed skin (red, hot, swollen or a rash). • Fever or chills. • Pus (green or yellow drainage from a wound). • Nausea or vomiting. • Persistent diarrhea. • Sore throat or a cough. • Painful urination.

Concerns about AIDS can make needle sticks, slips and spills alarming if you work in healthcare. Yet AIDS is not the only blood-borne threat you face. In fact, you are more likely to be infected in the line of duty by the Hepatitis B Virus (HBV), which is just as deadly.

The Occupational Safety and Health Administration (OSHA) has issued a standard that, if followed, is designed to protect you. It details ways that you and your employer can work together to substantially reduce your risk of contracting a blood-borne disease on the job. You are covered by the standard if it is reasonably anticipated that you could be exposed to blood- borne pathogens as a result of performing your job duties.

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Bloodborne Diseases

Blood-borne diseases that you could be exposed to on the job include non-A hepatitis, non-B hepatitis, hepatitis B and delta hepatitis, as well as syphilis, malaria and human immunodeficiency virus (HIV).

The Bloodborne Pathogens Standard contains special requirements for those who work in HIV and HBV research labs and production facilities, however, it is important that you know the following for your own protection:

• If you are exposed, report the incident immediately to your supervisor. • If you consent, your employer will provide you with a confidential medical evaluation, including blood tests, any available post-exposure preventive treatment and follow-up counseling. • Your employer will provide you with a free training program during working hours and annually thereafter • Training will tell you more about bloodborne diseases, how to use personal protective equipment and report an exposure incident. It will also detail your rights and responsibilities as a worker.

Any employee who suspects s/he may have had an occupational exposure to blood or body fluids should IMMEDIATELY REPORT this incident to the supervisor. A blood test is available to detect the disease.

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Workplace Transmission

Bloodborne Pathogens may be present in:

• Body fluids such as saliva, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, and any other body fluids visibly contaminated with blood. • Saliva and blood contacted during dental procedures. • Unfixed tissue or organs other than intact skin from living or dead humans. • Cell or tissue cultures that contain HIV or HBV.

Means of Transmission

Bloodborne pathogens may enter your body and infect you through a variety of means including:

• An accidental injury by a sharp object contaminated with infectious material. Sharps include:

• Needles • Scalpels • Broken glass • Exposed ends of dental wire • Razors

• Anything that can pierce, puncture or cut your skin • Open cuts, nicks and skin abrasions, even dermatitis and acne, as well as the mucous membranes of your mouth, eyes, or nose. • Indirect transmission, such as touching a contaminated object or surface and transferring the infectious material to your mouth, eyes, nose, or open skin.

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These “Means of Transmission” are typically classified into the following three categories:

• Air – sneezing or coughing. • Contact – Razor cut, existing cut or break in the skin, needle sticks, and splashing of blood or body fluids. • Droplet – Someone’s blood getting in your eye, blood getting into your open cut, semen, or vaginal fluid.

Contaminated Surfaces

Contaminated environmental surfaces are a major mode of HBV spread in certain settings, particularly hemodialysis units. HBV can survive on environmental surfaces dried and at room temperatures for a least one week. Substances, such as serum or plasma, without visible signs, can heavily contaminate surfaces and objects.

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Hepatitis Viruses (HV)

Hepatitis means “inflammation of the liver” and the three Hepatitis Viruses are known as Hepatitis A, Hepatitis B, and Hepatitis C.

• Hepatitis A

Hepatitis A infection is most commonly spread:

• Through personal contact. • Through child care centers. • From international travel. • Through contaminated food or water.

Symptoms of Hepatitis A infection can include:

• Fever • Fatigue • Loss of appetite • Nausea • Abdominal discomfort • Dark urine • Jaundice

Infected adults may experience all or some of these symptoms. After becoming infected, people are infectious for one to two weeks before feeling sick. Symptoms of Hepatitis A infection commonly last less than two months, but may last as long as six months. The likelihood of symptoms increases with age.

Children often do not have symptoms. While they may not feel sick, they can still infect family and others with whom they come in contact.

Hepatitis A can be prevented with a pre-exposure vaccination, however, this is not routinely done as the vaccine only provides temporary protection for one to five months at a time requiring frequent boosters and the risk of becoming infected is slim with good hand washing techniques. If an individual does become infected with the Hepatitis A virus, s/he can be administered with a Hepatitis A Immune Globulin.

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• Hepatitis B

Hepatitis B Virus (HBV) is a serious viral infection that causes inflammation of the liver. HBV is transmitted through blood and body fluids, (semen, vaginal fluid, cerebrospinal fluid). Of the adults who acquire acute hepatitis, 5-10% will go on to develop active liver disease (cirrhosis) over several decades.

HBV is the major infectious bloodborne hazard you face on the job. It infects approximately 8,700 healthcare workers a year, resulting in more than 400 hospitalizations and 200 deaths.

Risk factors include:

• History of contact with HBV-positive blood. • Sharing injection drug equipment. • Sharing infected person’s razor, toothbrush or earrings. • Children born to HBV-positive mothers. • Unprotected sexual contact. • Contaminated needles used in tattooing or piercing.

Incubation period for HBV is six weeks to six months. Acute hepatitis usually begins with mild symptoms that may or may not become severe. Contact through mucous membranes and/or breaks in the skin are the most common routes of transmission.

Signs and symptoms include:

• Fever, weakness or headache. • Nausea and vomiting. • Abdominal discomfort in RUQ • Jaundice occurring <25%. • Elevation of liver enzymes.

Workplace controls include:

• Proper hand washing. • Never recap needles. • Proper disposal of sharps containers. • Procedures involving blood or other body fluids are performed in a manner to avoid splashing, spraying, and splattering. • Specimens are obtained, stored, and handled in a safe container and manner.

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Prevention includes:

• Remembering that all human blood and other potentially infected materials are to be treated as if they are infected with HBV. • Obtaining a vaccine that includes a series of three injections over a four- to six-month period. Today’s vaccines are safe and effective. • Those now used in the U.S. are made from yeast and cannot be infected with HIV or other bloodborne pathogens. Over 2 million U.S. healthcare workers have already been vaccinated. • The complete series of HBV vaccinations is 85 to 97 percent effective at protecting you from getting the disease or becoming a carrier for nine years or longer. • You should not be vaccinated if You have already received the complete Hepatitis B vaccination series. Antibody testing reveals you are immune. You should not receive the vaccination for other specific medical reasons.

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• Hepatitis C

Hepatitis C Virus (HCV) is a serious infection of the liver for which there is no preventive treatment. HCV is the most common chronic bloodborne infection in the United States. HCV is transmitted through the blood and body fluids (semen, vaginal fluid, and cerebrospinal fluid).

Risk factors include:

• History of contact with HCV-positive blood. • History of blood or blood component (plasma) transfusion or organ transplant prior to July 1992. • History of long-term renal dialysis. • History of IV Drug use (even one episode). • Children born to HCV-positive mothers. • Unprotected sexual contact.

The infected person may be without symptoms or have mild symptoms. The incubation period following exposure is two to twenty-six weeks. The disease may go undetected for up to ten to twenty years after exposure and show up as a chronic hepatitis or advanced liver failure.

Signs and symptoms include:

• Fatigue • Anorexia • Nausea • Diarrhea • Abdominal discomfort • Jaundice (20-30%) • 60-70% of persons infected may have no symptoms • Chronic liver disease (Cirrhosis – scarring and shrinking of the liver).

Hepatitis C is not spread by the following:

• Sneezing or coughing. • Touching or hugging. • Sharing utensils or drinking glasses. • Food or water. • Casual contact.

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Human Immunodeficiency Virus (HIV)

The human immunodeficiency virus (HIV) attacks the body’s immune system, causing the disease known as AIDS, or Acquired Immune Deficiency Syndrome. Currently, there is no vaccine to prevent infection. A person infected with HIV:

• May carry the virus without developing symptoms for several years. • Will eventually develop AIDS. AIDS is the final stage of infection by a Virus called HIV. AIDS is an abbreviation for the following:

• Acquired – You get it; it is not inherited. • Immuno – The immune system that protects us against viruses. • Deficiency – a problem with the immune system. • Syndrome – a group of diseases.

• May suffer from flu-like symptoms, fever, diarrhea and fatigue. • May develop other AIDS-related illnesses including neurological problems, cancer and other opportunistic infections.

Protection is simple:

• Avoid unprotected sexual intercourse with potentially infected individuals. • Avoid multiple sexual partners. • Do not share needles as an IV Drug User. • Prevent needle sticks in healthcare facilities.

HIV is very small -- as many as 230 million HIV particles can fit on the head of a pin. HIV dies when exposed to heat, water, or air while many other viruses are spread through casual contact since they can live in water or in the air. Since HIV does not live in the heat, water, or air, HIV cannot be spread by:

• A mosquito bite. • A swimming pool. • A toilet. • Sharing food or utensils. • Taking care of someone with AIDS. • Sneezing or coughing. • Sharing make-up. • Hugging, kissing or spitting.

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• Giving blood.

HIV is transmitted primarily through sexual contact, but may also be transmitted through contact with blood and some body fluids.

HIV lives in white blood cells (WBC) and is passed from person to person in blood, semen, and vaginal fluids. Once in the body, HIV is impossible to destroy. The immune system cannot destroy HIV, once the virus enters the body and invades cells. HIV can “hide” in people for years without making them sick.

Exposure Control Plan

The risks of bloodborne diseases in the workplace are quite serious. Yet you can learn effective ways of minimizing them. A good place to start is with your employer’s written Exposure Control Plan. A copy should be made available for you to review at your workplace.

Standard Precautions Standard Precautions are work practices that help prevent contact with blood and certain other body fluids. Everyone in any type of facility that may potentially come in contact with blood or other body fluids of other people should practice Standard Precautions.

Standard Precautions can help prevent illness and save lives. Standard Precautions help prevent infection through the use of the following:

• Protective barriers such as gloves, gowns, masks, and goggles. • Safe work practices such as proper disposal of sharps and utilizing proper hand washing techniques.

You may not be able to tell for sure which residents carry a blood-borne pathogen by taking a medical history or by examination. Both HIV and HBV infect people of all ages, socioeconomic classes, from every state and territory and from rural areas as well as cities.

• Many people carry blood-borne infections without visible symptoms. • Many people carry blood-borne infections without even knowing it.

You cannot identify every resident who may transmit infection. Yet you cannot afford not to since it takes just one exposure to become infected. Standard precautions resolve this uncertainty by requiring you to treat all human blood and certain human body fluids as if they are known to be infected with HIV, HBV or other blood-borne pathogens.

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Reducing Your Exposure Risk

Five major tactics reduce your risk of exposure to bloodborne pathogens on the job:

• Engineering controls • Employee work practices • Environmental Practices • Personal protective equipment • Housekeeping

• Engineering Controls

These are physical or mechanical systems your employer provides to eliminate hazards at their source. Some examples are:

• Self-sheathing needles • Biosafety containers • Autoclaves

Engineering control effectiveness usually depends on you.

• Employee Work Practices

There are specific procedures you must follow on the job (refer to “Exposure Control Plan” section) to reduce your exposure to bloodborne pathogens or infectious materials. The respective facility that you work with will have specific work practices and guidelines that you will need to follow to keep the residents and yourself safe.

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• Environmental Practices

Environmental Practices are carried out when and wherever workers interact with individuals in the course of their work, including the administration of medications. Environmental Practices include:

• No blood products or other potentially infectious materials secured or transported. • Workers assist individuals in maintaining their own supplies for blood testing of glucose. • Eating, drinking, or applying cosmetics is prohibited when there is a reasonable likelihood of occupational exposure. • When administering medications make sure environmental surfaces are clean and dry. Cleanse surfaces between administrations of medications. • Wash hands before and after administering medications. • Pills are not transferred with the fingers, but are gently tapped from the vial into a disposable medicine cup. • Gloves must be worn when counting and verifying numbers of medications brought into a program. • Medications that are dropped on the floor must be discarded.

SAFE TRANSFER OF MEDICATIONS TO PERSONS

1. Use disposable cups 2. Use a tray with a towel on it to minimize the likelihood of pills bouncing out of the cup or onto the floor. 3. One person, either individual or worker performs the action of transferring pills. 4. Take your time!

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Personal Hygiene Additional self-protective controls should be followed to protect you:

• Cover any broken skin with a bandage or dressing before going on duty. If you have a weeping skin rash or sore with a discharge, you may be required to refrain from certain duties unless you wear gloves and/or other PPE. • When performing procedures involving blood or other potentially infectious materials, minimize splashing, spraying, spattering and generation of droplets. • Do not eat, drink, smoke or apply cosmetics or lip balms, or handle contact lenses where you may be exposed to blood or other potentially infectious materials. • Avoid petroleum-based lubricants that may eat through latex gloves. Applying hand cream is OK if you thoroughly wash your hands first. • Never mouth pipette or suction blood or other potentially infectious materials. • Don’t keep food and drinks in refrigerators, freezers, and cabinets or on shelves, countertops or bench tops where blood or other potentially infectious materials may be present.

Personal Protective Equipment (PPE) Equipment that protects you from contact with potentially infectious materials may include gloves, masks, gowns, aprons, lab coats, face shields, protective eye wear, mouthpieces, resuscitation bags or other ventilation devices.

• If, when wearing equipment, blood or other potentially infectious materials penetrate it, remove it as soon as feasible. • Before leaving the work area, remove all protective equipment and place it in the designated area or container for washing, decontamination or disposal.

• Exception to the PPE Rule

If you believe using protective equipment would prevent proper delivery of healthcare or jeopardize your safety or a co-worker’s, you may temporarily and briefly abandon its use in an emergency. After the incident, your employer must investigate the circumstances to determine if such a situation could be prevented in the future.

In all other circumstances, wearing appropriate personal protective equipment is not only your best option – it’s your only option.

WEAR IT!

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• Resuscitation Devices

Mechanical emergency respiratory devices and pocket masks are types of personal protective equipment designed to isolate you from contact with a victim’s saliva during resuscitation. Avoid unprotected mouth-to-mouth resuscitation. The resident may expel saliva, blood or other fluids during resuscitation.

• Gloves

Gloves are the most widely used form of personal protective equipment. They act as a primary barrier between your hands and bloodborne pathogens. Latex or vinyl gloves are used for medical, dental or laboratory procedures. Heavy-duty gloves may be used for housekeeping duties.

Here’s how to use them:

• You must wear gloves when you anticipate hand contact with blood, potentially infectious materials, mucous membranes or non-intact skin. • If you are allergic to latex or vinyl gloves, your employer will provide hypoallergenic gloves, glove liners, powder-less gloves or another alternative. • Since gloves can be torn or punctured by sharps, bandage any cuts before being gloved. • Replace disposable single-use gloves, such as surgical or examination gloves, as soon as possible if contaminated, torn, punctured or damaged in any way. Never wash or decontaminate for reuse. • Utility gloves may be decontaminated and reused unless they are cracked, peeling, torn, punctured, or no longer provide barrier protection.

Never Reuse Gloves!

Glove removal:

You must follow a safe procedure for glove removal being careful that no substances from the soiled gloves contact your hands.

• With both hands gloved, peel one glove off from top to bottom and hold it in the gloved hand. • With the exposed hand, peel the second glove from the inside, tucking the first glove inside the second. • Dispose of the entire bundle promptly.

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• Remove gloves when they become contaminated, damaged or before leaving the work area. • Wash your hands thoroughly.

Hand Washing If infectious material gets on your hands, the sooner you wash it off, the less chance you have of becoming infected.

• Hand washing keeps you from transferring contamination from your hands to other areas of your body or other surfaces you may contact later. • Every time you remove your gloves you must wash your hands with non-abrasive soap and running water as soon as you possibly can. • If skin or mucus membranes come in direct contact with blood, wash or flush with water as soon as possible. • When hand-washing facilities are not available, such as an emergency medical van, your employer will provide an antiseptic hand cleanser or antiseptic towelettes. Use these as a temporary measure only. You must still wash your hands with soap and running water as soon as you can.

Wash your hands when you

• Arrive at work. • Leave work to go home. • Give resident care. • Work in the kitchen. • Cough, sneeze, etc. • Eat meals – before and after. • Use the restroom. • Wear gloves – before and after. • Feel you may have come in contact with a resident’s personal belongings, which may potentially be contaminated with any body fluids (e.g., sweat, urine, feces, semen, etc.). • Make or change a resident’s bed, touch his/her laundry, etc.

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• Hand Washing Technique

Hand washing is the single most important procedure for preventing infections. Body secretions, surfaces, and hands of all healthcare workers can carry bacteria, viruses, and fungi that are potentially infectious to themselves and others, including you!

Hand washing is recommended when there is contact with a resident. Wash your hands before and after wearing gloves. Gloves are not a substitute for hand washing!

There is more to hand washing than you think! By rubbing your hands vigorously with soapy water, you pull the dirt plus the oily soils free from your skin. The soap lather suspends both the dirt and germs trapped inside and are then quickly washed away.

Have participants wash hands following the “Hand Washing Technique.”

Follow these simple steps to keeping hands clean:

• Wet your hands with warm running water. • Add soap, and then rub your hands together, making a soapy lather. • Do this away from the running water for at least 10 seconds, being careful not to wash the lather away. Wash the front and back of your hands, as well as between your fingers and under your nails. • Rinse your hands well under warm running water. Let the water run back into the sink, not down to your elbows (do not shake, flick or tap your hands to remove excess water). • Dry hands thoroughly with a clean towel. • Turn off the sink with a dry paper towel and dispose of towel in a proper receptacle. • Any type of soap may be used. However, bar soap should be kept in a self draining holder that is cleaned thoroughly before new bars are put out and liquid soap containers (which must be used in day care centers) should be used until empty and cleaned before refilling. • To prevent chapping use a mild soap with warm water; pat rather than rub hands dry; and apply lotion liberally and frequently.

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BioHazardous Materials READ THE LABEL!

Those warning signs protect you from bloodborne hazards:

• Bags or containers bearing the biohazard sign tell you when the containers hold blood or other potentially infectious materials. Warning labels are also used to designate contaminated equipment. • A fluorescent orange-red biohazard sign on a door indicates that HIV or HBV research or production takes place within. The sign lists special requirements for entering the facility

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APPENDIX C

FOOD AND DRUG INTERACTIONS

THIS SECTION IS TO ASSIST THE CRMA IN CHOOSING APPROPRIATE FOODS TO MIX MEDICATIONS WITH WHEN NEEDED, AND TO HELP THEM RECOGNIZE WHAT MAJOR FOODS INTERACT WITH THE MAJOR CLASSIFICATIONS OF DRUGS UTILIZED IN THE RESIDENTIAL CARE SETTING.

Remember that whenever you add a medication to a soft food and the food or medication change, or begin to change color, a chemical reaction is occurring that may affect the therapeutic action of the drug.

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DRUG/FOOD CAUTIONS

Inside this flyer is a list of some common medications. Following each medication is a number(s) that indicates a specific interaction. These numbers corresponds to the following drug/food cautions:

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1.Avoid drastic changes in dietary habit. 2.Consult your doctor before taking large amounts of Vitamin K (Green leafy vegetables). 3.Avoid alcohol. 4.Avoid sugar and sugary food. 5.Avoid bran and high fiber foods within 2 hours of taking this medication. 6.Take 30-60 minutes before meals. 7.Avoid excess salt/sodium unless otherwise instructed by your physician. 8.Avoid salt substitutes containing potassium. 9.Avoid milk, calcium containing dairy products, iron, antacids, or aluminum salts 2 hours before or 6 hours after using antacids while on this medication. 10.No iron within 4 hours of taking this medication. 11.Avoid aged foods (cheese, red wine), pickled foods, cured foods (bacon/ham), chocolate, fava beans, beer, unless approved by your physician. 12.Take with food. 13.Do not change your salt intake from day to day without telling your doctor. 14.Take on empty stomach: 1 hour before or 2 hours after meals. 15.Increase potassium intake; add a banana or orange juice; unless instructed otherwise. 16.Take this medication either consistently with or without food as instructed by your doctor. 17.Take with a full glass of water 18.Avoid dairy products, eggs, cereals and whole grains within 2 hours of taking this medication. 19.Avoid excessive quantities of coffee or tea (Caffeine). 20.Take this medication with a high fat meal. 21.Take this medication 30 minutes before meals. 22.Avoid taking with grapefruit juice. 23.To avoid constipation: increase your daily intake of fiber (beans, whole grains, vegetables). 24.No iron, zinc or fluoride within 2 hours of taking this medication. May take Vitamin D. 25.Do not take supplements containing Vitamin A. 26.Avoid natural licorice. 27.Do not take Aluminum or magnesium antacids or supplements while on this medication. 28.Do not take calcium, aluminum, magnesium or Iron supplements within 2 hours of taking this medication. 29.Absorption may be decreased with foods high in oxalate (spinach, sweet potatoes, beans, nuts) and phytate (unleavened bread and grains). 30.Take with low fat meal. 31.Do not take with milk. 32.Take 30-60 minutes before breakfast. 33.Take after a full meal. 34.Increase dietary intake of magnesium, folate, vitamin B6, B12, and/or consider taking a multivitamin. 35.Avoid iodine supplements. 36.Avoid St. John’s Wort. 37.Dissolve under the tongue. 38.Take at the same time everyday. 39.Limit garlic, ginger, gingko, and horse chestnut. Avoid avocado.

______

Please note that certain dietary supplements including herbal products may negatively interact with your medications. Consult your physician before using any of these products. ______If you would like more information about food and drug interactions or have other questions about your medications, please ask your HUHS physician or pharmacist.

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Food and Drug Interactions

Harvard University Health Services 12/03December 2003 Acetaminophen (Tylenol)………………………………………………3 Approved by PFEC 12/03 Acetazolamide (Diamox)……………………………………………….12 Alendronate (Fosamax)………………………………………………..17,32 Allopurinol (Zyloprim)…………………………………………………..17 Alprazolam (Xanax)……………………………………………………..3,12,19,22 Amantadine (Symmetrel)…………………………………………….3 Amiloride (Midamor)…………………………………………………….1,8,12,26 Amitriptyline (Elavil) ……………………………………………………3,12,19,36 Amlodipine (Norvasc)…………………………………………………..22,26 Aspirin…………………………………………………………………………..1,2,3,12,17 Atenolol (Tenormin)…….……………………………………………….2,6 Atorvastatin (Lipitor)…………………………………………………….1,3,22,30 Azithromycin (Zithromax)….…………………………………………14,27 Bethanecol (Urecholine)…….………………………………………..14 Bromocriptine (Parlodel)……………………………………………..3,12 Bupropion (Wellbutrin)………………………………………………..3,36 Buspirone (Buspar)…………………………………………………..…3,12,22 Butalbital w/ Caffeine + Acetaminophen (Fioricet).…….3 Butabital w/ Caffeine + Aspirin (Fiorinal)…………….……..3,12 Calcium Carbonate(Tums)………………………………..……….3,12,17,19,24,29 Captopril (Capoten)…….……………………………………………….3,8,14,26,28 Carbamazepine (Tegretol)…………………………………………..3,12,22 Carvedilol (Coreg)……………………………………………………….12 Cephalexin (Keflex)…………………………………………………….14 Cetirizine (Zyrtec)……………………………………………………….3 Choline Magnesium Salicylate (Trilisate)……………….…..12,17 Ciprofloxacin (Cipro)……….…………………………………………..9,17,19 Citalopram (Celexa)…………………………………………………….3,36 Clonazepam (Klonopin)……….………………………………………3,12,19 Codeine (Tylenol#3)…………………………………………………...3,12,23 Conjugated Estrogen (Premarin, Estrace)…………………. 3,12,19 Cyclobenzaprine (Flexaril)…………………………………………..3 Cyclosporine (Neoral)………………………………………………….8,22,38 Desipramine (Norpramin)…………………………………………..3 Dexamethasone (Decadron)……………………………………….3,12,22 Diazepam (Valium)……………………………………………………..3,12,19,22 Dichloralphenazone/Isometheptene/Acetaminophen (Midrin)…3 Dicyclomine (Bentyl)…….……………………………………………..3,21 Didanosine, DDI (Videx)…………………………………………..…3,14 Digoxin (Lanoxin)………………………………………………………..5,7,8,9,39 Diltiazem (Cardizem CD)…………………………………………….21,26 Dimenhydrinate (Dramamine)……………………………….…..3,12 Diphenhydramine HCL (Benadryl)……………………………...3,12 Diphenoxylate/Atropine (Lomotil)……………………………….3,12 Donepezil (Aricept)………………………………………………………3 Doxazosin (Cardura)…………………………………………………..3,26 Doxepin (Sinequan)…………………………………………………...3,12,19,36 Doxycycline (Vibramycin)……………………………………………3,9,17,28 Ergotamine w/ Caffeine (Cafergot)…………………………….3,19,22 Erythromycin (EryTab,EES,Emycin)…………………………..3,14,17,22 Ferrous Sulfate (Iron)………………………………………………..3,5,9,14,17,18 Fludrocortisone (Florinef)……………………………………………7 CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 144 of 177

Fluphenazine (Prolixin)……………………………………………….3,12 Fosinopril (Monopril)…………………………………………………..3,8,26,28 Furosemide (Lasix)….……………………………………………..….3,7,15 Glipizide (Glucotrol)…………………………………………….3,4,32 Glyburide (Micronase)….……………………………………..3,4,32 Griseofulvin (Fulvacin)…………………………………………20 Guaifenesin (Robitussin)……………………………………..17 Guaifenesin + Codeine.……………….……………………….3,12,17 Hydrochlorothiazide (Hydrodiuril)…….……………….…3,7,12,15,26,28 Hydrocodone/Acetaminophen (Vicodin).…..…………3,12,23 Hydroxychloroquine Sulfate (Plaquenil)….…………..12 Hydroxyzine (Atarax)…………………………………………..3 Ibuprofen (Motrin, Advil)…….……………….………………3,12 Imipramine (Tofranil)……………………………….………….3,12,19,36 Indinavir (Crixivan)…..…………………………………….….14,17,22 Indomethacin (Indocin)…..………………………………….3,12 Isoniazid…….…………………………………………………………3,11,14,17,28,34 Isotretinoin (Accutane)……………………………..…………3,12,17,25 Itraconazole (Sporanox)….……………………………….…9,12,22,33 Ketoconazole (Nizoral)………………………………………..3,9,12 Lansoprazole (Prevacid)………………………………………3,6 Levothyroxine (Levoxyl,Synthroid)……………………..10,32 Lisinopril (Zestril, Prinivil)…………..……………………….3,7,8,26 Lithium (LithoTab, Eskalith)…………………………………3,12,13,19,35 Loratadine (Claritin)…………………………………………….14 Lorazepam (Ativan)……………………………………….……3,12,19 Lovastatin (Mevacor)………………….………………………1,3,12,22 Mebendazole (Vermox)……………………………………….12 Medroxyprogesterone (Provera)…………………………12 Mefloquine (Lariam)……………………..…………………...3,12,17 Megestrol (Megace)…………………………………………...12 Metformin (Glucophage)…………………………………...3,12 Methocarbamol (Robaxin)………………………………….3 Methyldopa (Aldomet)…………………………………….…3,24,26,34 Methylphenidate (Ritalin)…………………………………..3,14,19 Metoprolol (Lopressor,Toprol XL).……………………..3,12,26 Metronidazole (Flagyl)……………………………………….3,12 Minocycline (Minocin)…………………………………………12,27 Morphine (MS-IR, MS-Contin)…………………………..3,12,23 Mycophenolate (Cellcept)………………………………….14,28 Nabumetone (Relafen)……………………………………..3,12 Nadolol (Corgard)……………………………………………..3,26 Naproxen (Naprosyn, Aleve)…………………………….3,12,17 Nefazodone (Serzone)………………………………………3,16,39 Nelfinvir (Viracept)…………………………………………….12 Niacin (Vitamin B3)…………………………………………..3,12 Nifedipine (Procardia XL, Adalat)………………………3,22,26,30 Nitrofurantoin (Macrodantin)…………………………….12 Nitroglycerine (Nitrostat)………………………………….3,14,37 Nizatidine (Axid)……………………………………………….3,19,24,27 Nortriptyline (Pamelor)…………………………………….3,12,19 Olanzapine (Zyprexa)………………………………………3 Omeprazole (Prilosec)……………………………………..3,6 Oral Contraceptives………………………………………….3,12,19,34,38 Oxazepam (Serax)…………………………………………..3,12,19 Oxybutynin (Ditropan, XL)……………………………….3,12 Percocet (Roxicet)………………………………………….…3,12,23 Perphenazine (Trilafon)……………………………………3,12,28 Phenazopyridine (Pyridium)………………………….12 Phenelzine (Nardil)………..………………………………3,11,19,36 Phenobarbital…………………………………………………3,19,34 Phenytoin (Dilantin)……………………………………….3,12,28 Potassium Chloride (K-Dur)…………………………..17,33 Pravastatin (Pravachol)………………………………….1,3 Prazosin (Minipress)……………………………………….3,26 Prednisone (Deltasone)………………………………….3,12,22 Prochlorperazine (Compazine)…….…………………3,12,17,19 Promethazine w/ Codeine (Phenergan)………….3,12,23 Propranolol (Inderal)…………………………………….…3,12,26 Propylthiouracil (PTU)………………………………………38 Psyllium (Metamucil)………………………………………..17 Raloxifene (Evista)………………………………………….…3

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Ranitidine (Zantac)……………………………………………3,9,19 Rifampin (Rifadin)……………………………………………..3,14,17 Ritonavir (Norvir)…………………………………………..…12,36 Saquinavir (Invirase)…………………………………………33 Sertraline (Zoloft)……………………………………….…...3,12,22,36 Sildenafil (Viagra)……………………………………….…….14 Simethicone (Mylicon)………………………………….……33 Simvastatin (Zocor)……………………………………….….1,3.22 Spironolactone (Aldactone)……………………………...3,8,12 Spironolactone + HCTZ (Aldactazide)……..……...3,8,12,26,28 Sucralfate (Carafate)………………………..………………3,14,17,28 Sulfamethoxazole/Trimethoprim (Bactrim)………14,17,28 This listing is meant only as a guide. Information Sulfasalazine (Azulfidine)………………………………….12,17,24 about medications is constantly changing so new Temazepam (Restoril)………………………………………3,19,40 and updated material will be made available on a Tetracycline (Sumycin)…………………………………….9,14,17 time-to-time basis. Please consult with your health Theophylline (Theodur)…………………………………….3,12,19 Thyroid Desiccated……………………………………………10,32 clinician when taking any medication. Tolterodine (Detrol)……….…………………………………12 12/03 Tranylcypromine (Parnate)……….……………………..3,11,19,36 Trazodone (Desyrel)……………….………………………..3,12,36 Typhoid Vaccine (Vivotif Berna)…..…………………..14,17 Ursodiol (Actigall)……………………………………………..12 Valproic Acid (Depakote)….………………………………3,12,31 Venlafaxine (Effexor, XR)….……………………………..3,12,36 Verapamil (Calan)……………………………………………..3,12,19,22,26 Warfarin (Coumadin)………………………………………..1,2,3,36,39 Zafirlukast (Accolate)……………………………..………..14 Zalcitabine (Hivid)………………………….…………………14,28 Zolpidem (Ambien)…………………………………………..3,32

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Food & Drug Interactions

Medicines can treat and cure many health problems. However, they must be taken properly to ensure that they are safe and effective. Many medicines have powerful ingredients that interact with the human body in different ways, and diet and lifestyle can sometimes have a significant impact on a drug.s ability to work in the body. Certain foods, beverages, alcohol, caffeine, and even cigarettes can interact with medicines. This may make them less effective or may cause dangerous side effects or other problems. When you take medicine, be sure to follow your doctor.s instructions carefully to obtain the maximum benefit with the least risk. Changes in a medicine.s effect due to an interaction with food, alcohol or caffeine can be significant; however, there are many individual factors that influence the potential for such variations, like dose, age, weight, sex, and overall health. This brochure has information about possible interactions between many common prescription and nonprescription (over-thecounter) medications with food, alcohol and

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 147 of 177 caffeine. But this brochure should not replace the advice from your physician, pharmacist, or other health care professional. If you have any questions or concerns about possible drug interactions, consult your health care professional. Make sure your doctor and pharmacist know about every drug you are taking, including nonprescription drugs and any dietary supplements such as vitamins, minerals and herbals. If you have problems or experience side effects related to medication, call your health care provider right away. It is also important to remember that many drugs interact with other drugs and may cause serious medical conditions. In this brochure, the generic (nonproprietary) name for each drug is stated first. Brand names are in full capital letters and represent only some examples of those medications.

ALLERGIES Antihistamines are used to relieve or prevent the symptoms of colds, hay fever, and allergies. They limit or block histamine, which is released by the body when we are exposed to substances that cause allergic reactions. Antihistamines are available with and without a prescription (overthe- counter). These products vary in their ability to cause drowsiness and sleepiness. ANTIHISTAMINES Some examples are: Over the Counter: brompheniramine / DIMETANE, BROMPHEN chlorpheniramine / CHLOR-TRIMETON diphenhydramine / BENADRYL clemastine/TAVIST Prescription: fexofenadine / ALLEGRA loratadine / CLARITIN cetirizine / ZYRTEC astemizole/HISMANAL Interaction Food: It is best to take prescription antihistamines on an empty stomach to increase their effectiveness. Alcohol: Some antihistamines may increase drowsiness and slow mental and motor performance. Use caution when operating machinery or driving.

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ARTHRITIS AND PAIN ANALGESIC/ANTIPYRETIC They treat mild to moderate pain and fever. An example is: acetaminophen/TYLENOL, TEMPRA Interactions Food: For rapid relief, take on an empty stomach because food may slow the body.s absorption of acetaminophen. Alcohol: Avoid or limit the use of alcohol because chronic alcohol use can increase your risk of liver damage or stomach bleeding. If you consume three or more alcoholic drinks per day talk to your doctor or pharmacist before taking these medications. NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) NSAIDs reduce pain, fever, and inflammation. Some examples are: aspirin/BAYER, ECOTRIN ibuprofen/MOTRIN, ADVIL naproxen/ANAPROX, ALEVE, NAPROSYN ketoprofen/ORUDIS nabumetone/RELAFEN Interaction Food: Because these medications can irritate the stomach, it is best to take them with food or milk. Alcohol: Avoid or limit the use of alcohol because chronic alcohol use can increase your risk of liver damage or stomach bleeding. If you consume three or more alcoholic drinks per day talk to your doctor or pharmacist before taking these medications. Buffered aspirin or enteric coated aspirin may be preferable to regular aspirin to decrease stomach bleeding. CORTICOSTEROIDS They are used to provide relief to inflamed areas of the body. Corticosteroids reduce swelling and itching, and help relieve allergic, rheumatoid, and other conditions. Some examples are: methylprednisolone/MEDROL prednisone/DELTASONE prednisolone/PEDIAPRED, PRELONE cortisone acetate/CORTEF Interaction Food: Take with food or milk to decrease stomach upset. NARCOTIC ANALGESICS Narcotic analgesics are available only with a prescription. They provide relief for moderate to severe pain. Codeine can also be used to CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 149 of 177 suppress cough. Some of these medications can be found in combination with non-narcotic drugs such as acetaminophen, aspirin, or cough syrups. Use caution when taking these medications: take them only as directed by a doctor or pharmacist because they may be habit forming and can cause serious side effects when used improperly. Some examples are: codeine combined with acetaminophen/ TYLENOL #2,#3,& #4 morphine/ROXANOL, MS CONTIN oxycodone combined with acetaminophen/ PERCOCET, ROXICET meperidine/DEMEROL hydrocodone with acetaminophen/ VICODIN, LORCET Interaction Alcohol: Avoid alcohol because it increases the sedative effects of the medications. Use caution when motor skills are required, including operating machinery and driving.

ASTHMA BRONCHODILATORS Bronchodilators are used to treat the symptoms of bronchial asthma, chronic bronchitis and emphysema. These medicines open air passages to the lungs to relieve wheezing, shortness of breath and troubled breathing. Some examples are: theophylline / SLO-BID, THEO-DUR, THEO-DUR 24, UNIPHYL, albuterol / VENTOLIN, PROVENTIL, COMBIVENT epinephrine/PRIMATENE MIST Interactions Food: The effect of food on theophylline medications can vary widely. High-fat meals may increase the amount of theophylline in the body, while high-carbohydrate meals may decrease it. It is important to check with your pharmacist about which form you are taking because food can have different effects depending on the dose form (e.g., regular release, sustained release or sprinkles) For example, food has little effect on Theo-Dur and Slo-Bid, but food increases the absorption of Theo-24 and Uniphyl which can result in side effects of nausea, vomiting, headache and irritability. Food can also decrease absorption of products like Theo-Dur Sprinkles for children. Caffeine: Avoid eating or drinking large amounts

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 150 of 177 of foods and beverages that contain caffeine (e.g., chocolate, colas, coffee, tea) because both oral bronchodilators and caffeine stimulate the central nervous system. Alcohol: Avoid alcohol if you.re taking theophylline medications because it can increase the risk of side effects such as nausea, vomiting, headache and irritability.

CARDIOVASCULAR DISORDERS There are numerous medications used to treat cardiovascular disorders such as high blood pressure, angina, irregular heart beat, and high cholesterol. These drugs are often used in combination to enhance their effectiveness. Some classes of drugs can treat several conditions. For example, beta blockers can be used to treat high blood pressure, angina, and irregular heart beats. Check with your doctor or pharmacist if you have questions on any of your medications. Some of the major cardiovascular drug classes are: DIURETICS Sometimes called “water pills,” diuretics help eliminate water, sodium, and chloride from the body. There are different types of diuretics. Some examples are: furosemide/LASIX triamterene/hydrochlorothiazide/ DYAZIDE, MAXZIDE hydrochlorothiazide/HYDRODIURIL triamterene/DYRENIUM bumetamide/BUMEX metolazone/ZAROXOLYN Interaction Food: Diuretics vary in their interactions with food and specific nutrients. Some diuretics cause loss of potassium, calcium, and magnesium. Triamterene, on the other hand, is known as a “potassium-sparing” diuretic. It blocks the kidneys’ excretion of potassium, which can cause hyperkalemia (increased potassium). Excess potassium may result in irregular heartbeat and heart palpitations. When taking triamterene, avoid eating large amounts of potassium-rich foods such as bananas, oranges and green leafy vegetables, or salt substitutes that contain potassium. BETA BLOCKERS Beta blockers decrease the nerve impulses to the heart and blood vessels. This decreases the heart rate and the work load of the heart.

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Some examples are: atenolol/TENORMIN metoprolol/LOPRESSOR propranolol/INDERAL nadolol/CORGARD Interaction Alcohol: Avoid drinking alcohol with propranolol/INDERAL because the combination lowers blood pressure too much. NITRATES Nitrates relax blood vessels and lower the demand for oxygen by the heart. Some examples are: isosorbide dinitrate/ISORDIL, SORBITRATE nitroglycerin/NITRO, NITRO-DUR, TRANSDERM-NITRO Interaction Alcohol: Avoid alcohol because it may add to the blood vessel-relaxing effect of nitrates and result in dangerously low blood pressure. ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS ACE inhibitors relax blood vessels by preventing angiotensin II, a vasoconstrictor, from being formed. Some examples are: captopril/CAPOTEN enalapril/VASOTEC lisinopril/PRINIVIL, ZESTRIL quinapril/ACCUPRIL moexipril/UNIVASC Interactions Food: Food can decrease the absorption of captopril and moexipril. So take captopril and moexipril one hour before or two hours after meals. ACE inhibitors may increase the amount of potassium in your body. Too much potassium can be harmful. Make sure to tell your doctor if you are taking potassium supplements or diuretics (water pills) that may increase the amount of potassium in your body. Avoid eating large amounts of foods high in potassium such as bananas, green-leafy vegetables, and oranges. HMG-COA REDUCTASE INHIBITORS Otherwise known as “statins,” these medications are used to lower cholesterol. They work to reduce the rate of production of LDL (bad cholesterol). Some of these drugs also lower triglycerides. Recent studies have shown that pravastatin can reduce the risk of heart attack, stroke, or miniature stroke in certain patient populations. CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 152 of 177

Some examples are: atorvastatin/LIPITOR cerivastatin/BAYCOL fluvastatin/LESCOL lovastatin/MEVACOR pravastatin/PRAVACHOL simvastatin/ZOCOR Interaction Alcohol: Avoid drinking large amounts of alcohol because it may increase the risk of liver damage. Food: Lovastatin (Mevacor) should be taken with the evening meal to enhance absorption. ANTICOAGULANTS Anticoagulants help to prevent the formation of blood clots. An example is: warfarin/COUMADIN Interactions Food: Vitamin K produces blood-clotting substances and may reduce the effectiveness of anticoagulants. So limit the amount of foods high in vitamin K (such as broccoli, spinach, kale, turnip greens, cauliflower, and brussel sprouts). High doses of vitamin E (400 IU or more ) may prolong clotting time and increase the risk of bleeding. Talk to your doctor before taking vitamin E supplements.

INFECTIONS ANTIBIOTICS AND ANTIFUNGALS Many different types of drugs are used to treat infections caused by bacteria and fungi. Some general advice to follow when taking any such product is: . Tell your doctor about any skin rashes you may have had with antibiotics or that you get while taking this medication. A rash can be a symptom of an allergic reaction, and allergic reactions can be very serious. . Tell your doctor if you experience diarrhea. . If you are using birth control, consult with your health care provider because some methods may not work when taken with antibiotics. . Be sure to finish all your medication even if you are feeling better. . Take with plenty of water. ANTIBACTERIALS PENICILLIN Some examples are: penicillin V / VEETIDS CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 153 of 177 amoxicillin / TRIMOX, AMOXIL ampicillin / PRINCIPEN, OMNIPEN Interaction Food: Take on an empty stomach, but if it upsets your stomach, take it with food. QUINOLONES Some examples are: ciprofloxacin / CIPRO levofloxacin / LEVAQUIN ofloxacin / FLOXIN trovafloxacin / TROVAN Interactions Food: Take on an empty stomach one hour before or two hours after meals. If your stomach gets upset, take it with food. However, avoid calcium-containing products like milk, yogurt, vitamins or minerals containing iron, and antacids because they significantly decrease drug concentration. Caffeine: Taking these medications with caffeinecontaining products (e.g., coffee, colas, tea, and chocolate) may increase caffeine levels, leading to excitability and nervousness. CEPHALOSPORINS Some example are: cefaclor / CECLOR, CECLOR CD cefadroxil / DURICEF cefixime / SUPRAX cefprozil / CEFZIL cephalexin / KEFLEX, KEFTAB Interaction Food: Take on an empty stomach one hour before or two hours after meals. If your stomach gets upset, take with food. MACROLIDES Some examples are: azithromycin / ZITHROMAX clarithromycin / BIAXIN erythromycin / E-MYCIN, ERY-TAB, ERYC erythromycin + sulfisoxazole /PEDIAZOLE Interaction Food: Take on an empty stomach one hour before or two hours after meals. If your stomach gets upset, take with food. SULFONAMIDES An example is: sulfamethoxazole + trimethoprim / BACTRIM, SEPTRA Interaction Food: Take on an empty stomach one hour before or two hours after meals. If your stomach gets upset, take with food.

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TETRACYCLINES Some examples are: tetracycline / ACHROMYCIN, SUMYCIN doxycycline / VIBRAMYCIN minocycline / MINOCIN Interaction Food: Take on an empty stomach one hour before or two hours after meals. If your stomach gets upset, take with food. However, it is important to avoid taking tetracycline/ ACHROMYCIN, SUMYCIN with dairy products, antacids and vitamins containing iron because these can interfere with the medication.s effectiveness. NITROIMIDAZOLE An example is: metronidazole / FLAGYL Interaction Alcohol: Avoid drinking alcohol or using medications that contain alcohol or eating foods prepared with alcohol while you are taking metronidazole and for at least three days after you finish the medication. Alcohol may cause nausea, abdominal cramps, vomiting, headaches, and flushing. ANTIFUNGALS Some examples are: fluconazole / DIFLUCAN griseofulvin / GRIFULVIN ketoconazole / NIZORAL itraconazole / SPORANOX Interaction Food: It is important to avoid taking these medications with dairy products (milk, cheeses, yogurt, ice cream), or antacids. Alcohol: Avoid drinking alcohol, using medications that contain alcohol, or eating foods prepared with alcohol while you are taking ketoconazole/NIZORAL and for at least three days after you finish the medication. Alcohol may cause nausea, abdominal cramps, vomiting, headaches and flushing.

MOOD DISORDERS Depression, Emotional, and Anxiety Disorders Depression, panic disorder and anxiety are a few examples of mood disorders -- complex medical conditions with varying degrees of severity. When using medications to treat mood disorders it is important to follow your doctor.s instructions. Remember to take your dose as CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 155 of 177 directed even if you are feeling better, and do not stop unless you consult your doctor. In some cases it may take several weeks to see an improvement in symptoms. MONOAMINE OXIDASE (MAO) INHIBITORS Some examples are: phenelzine/NARDIL tranylcypromine/PARNATE Interactions MAO Inhibitors have many dietary restrictions, and people taking them need to follow the dietary guidelines and physician.s instructions very carefully. A rapid, potentially fatal increase in blood pressure can occur if foods or alcoholic beverages containing tyramine are consumed while taking MAO Inhibitors. Alcohol: Do not drink beer, red wine, other alcoholic beverages, non-alcoholic and reduced alcohol-beer and red-wine products. Food: Foods high in tyramine that should be avoided include: . American processed, cheddar, blue, brie, mozzarella and Parmesan cheese; yogurt, sour cream. . Beef or chicken liver; cured meats such as sausage and salami; game meat; caviar; dried fish. . Avocados, bananas, yeast extracts, raisins, sauerkraut, soy sauce, miso soup. . Broad (fava) beans, ginseng, caffeine-containing products (colas, chocolate, coffee and tea). ANTI-ANXIETY DRUGS Some examples are: lorazepam/ATIVAN diazepam/VALIUM alprazolam/XANAX Interactions Alcohol: May impair mental and motor performance (e.g., driving, operating machinery). Caffeine: May cause excitability, nervousness, and hyperactivity and lessen the anti-anxiety effects of the drugs. ANTIDEPRESSANT DRUGS Some examples are: paroxetine/PAXIL sertraline/ZOLOFT fluoxetine/PROZAC Interactions Alcohol: Although alcohol may not significantly interact with these drugs to affect mental or motor skills, people who are depressed should

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 156 of 177 not drink alcohol. Food: These medications can be taken with or without food.

STOMACH CONDITIONS Conditions like acid reflux, heartburn, acid indigestion, sour stomach, and gas are very common ailments. The goal of treatment is to relieve pain, promote healing and prevent the irritation from returning. This is achieved by either reducing the acid the body creates or protecting the stomach from the acid. Lifestyle and dietary habits can play a large role in the symptoms of these conditions. For example, smoking cigarettes and consuming products that contain caffeine may make symptoms return. HISTAMINE BLOCKERS Some examples are: cimetidine / TAGAMET or TAGAMET HB famotidine / PEPCID or PEPCID AC ranitidine / ZANTAC or ZANTAC 75 nizatadine / AXID OR AXID AR Interactions Alcohol: Avoid alcohol while taking these products. Alcohol may irritate the stomach and make it more difficult for the stomach to heal. Food: Can be taken with or without regard to meals. Caffeine: Caffeine products (e.g., cola, chocolate, tea and coffee) may irritate the stomach.

DRUG-TO-DRUG INTERACTIONS Not only can drugs interact with food and alcohol, they can also interact with each other. Some drugs are given together on purpose for an added effect, like codeine and acetaminophen for pain relief. But other drug-to-drug interactions may be unintended and harmful. Prescription drugs can interact with each other or with over-the-counter (OTC) drugs, such as acetaminophen, aspirin, and cold medicine. Likewise, OTC drugs can interact with each other. Sometimes the effect of one drug may be increased or decreased. For example, tricyclic antidepressants such as amitriptyline (ELAVIL), or nortriptyline (PAMELOR) can decrease the ability of clonidine (CATAPRES) to lower blood pressure. In other cases, the effects of a drug can increase the risk of serious side effects. For example, some antifungal medications such as

CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 157 of 177 itraconazole (SPORANOX) and ketoconazole (NIZORAL) can interfere with the way some cholesterol-lowering medications are broken down by the body. This can increase the risk of a serious side effect. Doctors can often prescribe other medications to reduce the risk of drug-drug interactions. For example, two cholesterollowering drugs.pravastatin(PRAVACHOL) and fluvastatin (LESCOL), are less likely to interact with antifungal medications. Be sure to tell your doctor about all medications. prescription and OTC. that you are taking. This brochure was produced in cooperation with the U.S. Food and Drug Administration. National Consumers League 1701 K Street, NW, Suite 1200 Washington, DC 20006 202-835-3323 Fax: 202-835-0747 www.nclnet.org

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FOOD AND DRUG INTERACTIONS

The following list describes potential interactions that may occur between certain medications and foods.

To find the your medication by drug class see list below.

Drug Class: ACE INHIBITORS

Medications: Potential Interactions:

Can increase the amount of potassium in the Benazepril (Lotensin®) body. Limited foods high in potassium such as Captopril (Capoten®) avocado, banana, cantaloupe, grapefruit, Enalapril (Vasotec®) honeydew melon, sweet potatoes, orange, kiwi, Fosinopril (Monopril®) mango, nectarines, prunes, and raisins. Report Lisinopril (Zestril®, Prinivil®) any signs of high potassium, including confusion, Quinapril (Accupril®) irregular heartbeat, heaviness of legs, weakness, Trandolapril (Mavik®) or shortness of breath. Ramipril (Altace®) Moexipril (Univasc®) Perindopril (Aceon®) Drug Class: ANALGESICS Medications: Potential Interactions:

Narcotics: May cause drowsiness, so avoid alcohol and do not drive or perform tasks requiring concentration. Tylenol with codeine Take with food to decrease stomach upset. Lortab® Vicodin®

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Relief of mild to moderate pain. Aspirin has a mild Aspirin Derivatives: anticoagulant (blood thinning) effect, so avoid gingko biloba. To ensure no stomach upset, take with food. Avoid excessive alcohol as this may aggravate stomach Aspirin (Anacin®, Ascriptin®) irritation.

Nonsteroidal antianti---infinfinflammatorylammatory drugs (NSAIDs): Used to relieve pain, inflammation, swelling, and stiffness caused by certain types of arthritis, injuries, and other medical conditions. Should be taken with Ibuprofen (Motrin®, Advil®) food to reduce stomach upset. Report to physician any indigestion, stomach pain, diarrhea, or black or bloody Indomethacin (Indocin®) stools. May cause drowsiness in some people. Can Naproxen (Naprosyn®, Anaprox®) increase blood pressure in people with high blood pressure. Diclofenac (Voltaren®) Sulindac (Clinoril®) Nabumetone (Relafen®) Etodolac (Lodine®) Drug Class: ANTACIDS Medications: Potential Interactions: Mylanta Take on empty stomach -- before meals or 30-60 Maalox minutes after meals -- for the greatest effect. Do Di-Gel not take with other medications (allow at least one Tums hour between doses) since antacids bind some Rolaids drugs and reduce their effectiveness. Riopan

Drug Class: ANTIBIOTICS

Medications: Potential Interactions:

Amoxicillin/clavulanate (Augmentin®) Taking with food decreases the stomach upset, which occurs in some individuals. May also cause diarrhea or rash.

Azithromycin Try to take capsule on empty stomach (1 hour before or two hours after meals) because food reduces absorption (Zithromycin®, Z-pack®) by 50%. Tablet may be taken with meals to decrease Ciprofloxacin stomach upset. Do not take with antacids. (Cipro®)

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Dicloxacillin May be taken with or without food and with full glass of water. However, avoid taking with foods high in (Dycill®, Pathocil®) calcium such as milk, yogurt, or cheese. Do not take with laxatives, oral multivitamins, or mineral supplements.

Doxycycline Take on empty stomach (at least one hour before or two hours after meals). May cause stomach upset, diarrhea, (Vibra-Tabs®, Vibramycin®) or rash.

Take with food to decrease stomach upset. Avoid the Erythromycin following products at least one hour before and two (E-mycin®) hours after taking your medication: dairy products, antacids, excessive alcohol, and multivitamins as these may decrease absorption. Avoid excessive sun exposure. Isoniazid (Nydrazid®) Take with food to decrease stomach upset.

Metronidazole Should be taken one hour before or two hours after meals or on an empty stomach. Avoid alcohol due to (Flagyl®) increased risk of liver damage.

Minocycline May take on empty stomach. Take with food if stomach upset occurs. Avoid alcohol during therapy (Mincoin®) and for two days after therapy completed. May cause metallic taste in mouth and/or dark or reddish-brown discoloration of urine. Do not take within 2 hours of iron-containing products. Nitrofurantoin Take with food to increase absorption and decreased (Macrodantin®, Macrobid®) stomach upset. May discolor urine to a dark yellow or brown color. Avoid alcohol. Penicillin Take on empty stomach one hour before or two hours after meals. Report allergic symptoms -- including (Veetids®) rash, itching, breathing difficulty, swelling of lips or tongue.

Take with a full glass of water on empty stomach one hour before or two hours after meals. Avoid taking Tetracycline within 2 hours of dairy products (milk, yogurt, cheese), antacids, laxatives, or iron products. Avoid excessive sun exposure.

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Take with full glass of water on an empty stomach (1 hour before or two hours after meals). Avoid Trimethoprim/sulfamethoxazole excessive sun exposure. (Septra®, Bactrim®)

Drug Class: ANTICONVULSANTS

Medications: Potential Interactions:

Phenytoin Take with food. Can cause folic acid deficiency (Dilantin®) and decreased calcium levels. Avoid excessive Phenobarbital alcohol.

Drug Class: ANTIDEPRESSANTS

Medications: Potential Interactions:

Tricyclics: Amitriptyline (Elavil®) Avoid alcohol, grapefruit juice, Valerian, St. John's Imipramine (Tofranil®) Wort, and Kava Kava Clomipramine (Anafranil®) Nortriptyline (Pamelor®)

Paxil, Luvox, Prozac, and Celexa may be taken with or without food. Food increases absorption of SSRIs: Zoloft, so you should take Zoloft consistently

(either always with food or always on empty Paroxetine (Paxil®) stomach) to reduce variations in absorption. Avoid Fluoxetine (Prozac®) alcohol, grapefruit juice, Valerian, St. John's Wort, Sertraline (Zoloft®) and Kava Kava. Citalopram (Celexa®)

Fluvoxamine (Luvox®)

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Drug Class: BENZODIAZEPINES

Medications: Potential Interactions:

Alprazolam (Xanax®) Lorazepam (Ativan®) Temazepam (Restoril®) Avoid alcohol, grapefruit juice, Valerian, St. John's Triazolam (Halcion®) Wort, Kava Kava. Diazepam (Valium®) Clonazepam (Klonopin®) Chlordiazepoxide (Librium®) Flurazepam (Dalmane®)

Drug Class: DIURETICS

Medications: Potential Interactions:

Used to reduce blood pressure and increase water Hydrochlorothiazide excretion. Take before 6:00 PM to decreased HCTZ (Diural®) frequency of urination at night. May be taken with Hydrochlorothiazide and Triamterene food. May be associated with low levels of sodium (Diazide®, Maxzide®) or potassium. Report any signs of confusion, weakness, muscle cramps.

Used to reduce blood pressure and increase water excretion. Take before 6:00 PM to decreased Spironolactone frequency of urination at night. May be associated (Aldactone®, Aldactazide®) with elevated levels of potassium. Avoid Triamterene excessive consumption of foods high in potassium (Dyrenium®) such as avocado, banana, cantaloupe, grapefruit, honeydew melon, sweet potatoes, orange, kiwi, mango, nectarines, prunes, and raisins.

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Drug Class: DIABETIC MEDICATIONS These drugs lower blood sugar and can sometimes lower it more than is desirable. Low blood sugar is called hypoglycemia and is manifested by sweating, hunger, fast heart rate, confusion, chills, nausea and vomiting, and headache that won't go away. Usually, orange juice, glucose tablets, or other ready sources of sugar can be taken. Medications: Potential Interactions:

Glyburide Take with breakfast or the first meal of the day (Diabeta®, Micronase®, Glynase®)

Take immediate release tablets (Glucotrol) 30 minutes before a meal. Do not break, crush, or to extended- release tablets (Glucotrol XL). Swallow them whole. Glipizide You may notice a tablet in your stool. There is nothing to worry about because the drug has been adsorbed (Glucotrol®, Glucotrol XL®) from the tablet shell.

Take with morning and/or evening meals to avoid stomach upset. Notify your physician if signs of lactic Metformin acidosis appear: unusual muscle or stomach pain, slow (Glucophage®) or unsteady heartbeat, feeling week, tired, dizzy, or cold. Acarbose Delays absorption of carbohydrates. Take at the (Precose®) start of your main meals (with the first bite).

OTHER MEDICATIONS

Take on an empty stomach at least two hours before any food. Avoid alcohol, caffeine, dairy products, orange juice, and antacids within 2 hours of taking a Alendronate (Fosamax®) dose. Do NOT lie down for at least 30 minutes after taking the dose. Take with PLAIN WATER -- no fruit Risidronate (Actonel®) juices, colas, milk, or coffee.

Avoid foods high in purines, which include spinach, legumes, poultry, sardines, kale, and organ meats such as liver and kidney. Excess vitamin C should be Allopurinol avoided to decrease the possibility of kidney stone formation. Maintain adequate fluid intake. (Zyloprim®, Aloprim®)

Do not take large amounts of bran fiber, which can decrease absorption. Maintain adequate amounts of potassium in diet. Foods high in potassium include avocado, banana, cantaloupe, grapefruit, honeydew

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Digoxin melon, sweet potatoes, orange, kiwi, mango, nectarines, prunes, and raisins. (Lanoxin®)

Theophylline Avoid excessive intake of caffeine. Should be taken with water, 1 hour before or two hours after meals. (Theo-Dur®, Theo-24®, Slo-bid®)

Take at a regular times daily as directed. Do not eat excessive amounts of food high in the vitamin K. These foods include broccoli, Brussels sprouts, Warfarin cabbage, cauliflower, spinach, green onions, kale, (Coumadin®) collard greens, mustard greens, Swiss chard, seaweed, and liver. Avoid excessive alcohol intake. Report any signs of bruising or bleeding or any dark stools.

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GRAPEFRUIT JUICE INTERACTIONS

Grapefruit juice can increase the quantities of some medications in your body, leading to adverse effects. AVOID GRAPEFRUIT JUICE IF YOU TAKE THE FOLLOWING MEDICATIONS, unless otherwise instructed.

Amiodarone (Cordarone®) Carbamazepine (Tegretol®) Alprazolam (Xanax®) Carvedilol (Coreg®) Diazepam (Valium®) Cyclosporine (Neoral®, Sandimmune®) Triazolam (Halcion®) Fexofenadine (Allegra®) Buspirone (BuSpar®) Atorvastatin (Lipitor®) Amlodipine (Norvasc®) Lovastatin (Mevacor®) Diltiazem (Cardizem®) Simvastatin (Zocor®) Felodipine (Plendil®) Itraconazole (Sporanox®) Nicardipine (Cardene®) Losartan (Cozaar®) Nifedipine (Procardia®, Adalat®) Quinidine Verapamil (Calan®, Verelan®) Sertraline (Zoloft®) Tacrolimus (Prograf®)

*This list was compiled by the Pharmacy Department at Scripps Hospital.

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APPENDIX D

SECTIONS 5, 7 AND 8 OF THE STATE REGULATIONS FOR LEVEL IV PNMI’s

(PLEASE BE SURE TO USE APPROPRIATE REGULATIONS IF THESE ARE NOT THE ONES THAT GOVERN THE LICENSING AND FUNCTIONING OF YOUR FACILITY)

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Section 5

• Resident Rights

5.1 Resident rights. The assisted housing program shall promote and encourage residents to exercise their rights, to age in place and make informed choices. [Class IV]

5.2 Freedom of choice of provider. For services and supplies not provided by the licensee , each resident has the right to select the provider of his/her choice. [Class IV]

5.3 Rights regarding transfer and discharge. Each resident has the right to continued residence whenever a valid contract for services is in force. The facility must show documented evidence of strategies used to prevent involuntary transfers or discharges. A resident shall not be transferred or discharged involuntarily, except for the following reasons:

5.3.1 When there is documented evidence that a resident has violated the admission contract obligations, despite reasonable attempts at problem resolution; [Class IV]

5.3.2 A resident’s continued tenancy constitutes a direct threat to the health or safety of others; [Class IV]

5.3.3 A resident’s intentional behavior has resulted in substantial physical damage to the property of the assisted housing program or others residing in or working there; [Class IV]

5.3.4 A resident has not paid for his/her residential services in accordance with the contract between the assisted housing program and the resident; [Class IV]

5.3.5 When there is documented evidence that the facility cannot meet the needs of the resident as the program is fundamentally designed; [Class IV] or

5.3.6 The license has been revoked, not renewed, or voluntarily surrendered. [Class IV]

5.4 Transfer or discharge. When a resident is transferred or discharged in a non-emergency situation, the resident or his/her guardian shall be provided with at least fifteen (15) days advance written notice to ensure adequate time to find an alternative placement that is safe and appropriate. The provider has an affirmative responsibility to assist in the transfer or discharge process and to produce a safe and orderly discharge plan. If no discharge plan is possible, then no involuntary non-emergency discharge shall occur until a safe discharge plan is in place. Appropriate information, including copies of pertinent records, shall be transferred with a resident to a new placement. [Class IV] Each notice must be written and include the following:

5.4.1 The reason for the transfer or discharge, including events which are the basis for such action; [Class IV]

5.4.2 The effective date of the transfer or discharge; [Class IV]

5.4.3 Notice of the resident’s right to appeal the transfer or discharge as set forth in Section 5.28; [Class IV]

5.4.4 The mailing address and toll-free telephone number of the Long Term Care Ombudsman Program; [Class IV]

5.4.5 In the case of residents with developmental disabilities or mental illness, the mailing address and telephone number of the Office of Advocacy, Department of Behavioral and Developmental Services; [Class IV]

5.4.6 The resident’s right to be represented by himself/herself or by legal counsel, a relative, friend or other spokesperson. [Class IV]

5.5 Emergency transfer or discharge. When an emergency situation exists, no written notice is required, but such notice as is practical under the circumstance shall be given to the resident and/or resident’s representative. The facility shall assist the resident and authorized representatives in locating an appropriate placement. Transfer to an acute hospital is not considered a placement and the obligation in regard to such assistance does not necessarily terminate. [Class IV]

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5.6 Leaves of absence. When a resident is away, and continues to pay for services in accordance with the contract, the resident shall be permitted to return unless any of the reasons set forth in Section 5.4 are present and the resident or resident’s legal representative has been given notice as may be required in these regulations. [Class IV]

5.7 Assistance in finding alternative placement. Residents who choose to relocate shall be offered assistance in doing so.

5.7.1 Residents of assisted living programs, residential care facilities or private non-medical institutions shall not be required to give advance notice. [Class IV]

5.8 Right to communicate grievances and recommend changes. The facility/program shall assist and encourage residents to exercise their rights as residents and citizens. Residents may freely communicate grievances and recommend changes in policies and services to the assisted housing program and to outside representatives of their choice, without restraint, interference, coercion, discrimination or reprisal. All grievances shall be documented. Assisted housing programs shall establish and implement a procedure for the timely review and disposition of grievances. The procedure shall include a written response to the grievant describing disposition of the complaint. These documents shall be maintained and available for review upon request by the Department. [Class IV]

5.9 Right to manage financial affairs. Residents shall manage their own financial affairs, unless there is a representative payee, other legal representative appointed or other person designated by the resident. [Class IV]

5.10 Right to freedom from abuse, neglect or exploitation. Residents shall be free from mental, verbal, physical and/or sexual abuse, neglect and exploitation. [Class I, II, III, IV]

5.11 Rights regarding restraints and aversive conditioning. There shall be no use of physical, chemical, psychological or mechanical restraints or aversive conditioning, except in accordance with this section. [Class I, II, III, IV]

5.11.1 Full-length bedrails on both sides of the bed are considered restraints and shall not be attached to the bed. Half- length bedrails attached to the top half of the bed are permissible. One full-length bed rail and one half-length bed rail may be used if the full-length rail is on the side against the wall. [Class I, II, III, IV]

5.11.2 In the case of a person with mental retardation, the provider must comply with the requirements of the Regulations Governing the Use of Behavioral Procedures in Maine Programs Serving Persons with Mental Retardation and the Regulations Governing the Use of Restraints in Community Settings. These regulations are promulgated and enforced by the Department of Behavioral and Developmental Services. [Class I, II, III, IV]

5.11.3 For any resident who is a client of the Department of Behavioral and Development Services due to his/her mental illness, the facility/program shall comply with the Rights of Recipients of Mental Health Services, promulgated and enforced by the Department of Behavioral and Development Services. [Class I, II, III, IV]

5.12 Right to confidentiality. Residents’ records and information pertaining to their personal, medical and mental health status is confidential. Residents and their legal representatives shall have access to all records pertaining to the resident at reasonable times, in the presence of the provider or his/her representative, within one (1) business day of the request. Residents and their legal representatives are entitled to have copies made of their record within one (1) business day of the request. The licensee and employees shall have access to confidential information about each resident only to the extent needed to carry out the requirements of the licensing regulations or as authorized by any other applicable state of federal law. The written consent of the resident or his/her legal representative shall be required for release of information to any other person except authorized representatives of the Department or the Long Term Care Ombudsman Program. The Department shall have access to these records for determining compliance with these regulations. Records shall not be removed from the facility, except as may be necessary to carry out these regulations. Upon admission, each resident shall sign and date a written consent which lists individuals, groups, or categories with whom the program may share information (e.g., sons, daughters, family members or duly authorized licensed practitioners, etc.). A written consent to release of information shall be renewed and time dated every thirty (30) months, pursuant to 22 M.R.S.A. §1711-C (4). Consent may be withdrawn at any time. [Class IV]

5.13 Right to refuse to perform services for the facility. Residents may refuse to perform services for the facility. [Class IV]

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5.14 Right to privacy and consideration. Residents shall be treated with respect. Residents shall also be treated with respect and consideration with regard to their individual need for privacy when receiving personal care or treatment, preferred mode of language and communication. [Class IV]

5.15 Right to communicate privately with persons of choice. Residents may associate and communicate privately with persons of their choice at any time, unless to do so would infringe on the rights of others. They may receive personal mail, unopened, and shall be assisted when necessary with writing and mailing letters and making phone calls. Residents shall have privacy when having telephone conversations. [Class IV]

5.16 Right to participate in activities of choice. Residents may participate in social, political, religious and community activities, unless to do so would infringe on the rights of others. [Class IV]

5.17 Right to personal clothing and possessions. Residents may retain and use their personal clothing and possessions as space permits, unless to do so would infringe upon the rights of other residents or impair the provider’s ability to meet the purpose of these rules. [Class IV]

5.18 Couples. A couple residing in an assisted housing program has the right to share a room. [Class IV]

5.19 Right to be informed of services provided by the facility/program. Residents shall be fully informed of items or services which are included in the rate they pay. This rate shall include the cost of repair or replacement of items damaged by normal wear and tear. [Class IV]

5.20 Right to refuse treatment or services. Residents may choose to refuse medications, treatments or services. If the resident refuses necessary care or treatment, the provider shall make reasonable efforts to consult the resident’s duly authorized licensed practitioner, caseworker or other appropriate individuals in order to encourage residents to receive necessary services. No person without legal authority to do so shall order treatment, which has not been consented to by a competent resident. [Class IV]

5.21 Right to be free from discrimination. A resident shall be provided services without regard to race, age, national origin, religion, disability, gender or sexual orientation. [Class IV]

5.22 Right to information regarding deficiencies. Residents have the right to be fully informed of findings of the most recent survey conducted by the Department. The provider shall inform residents or their legal representatives that the survey results are public information and are available in a common area of the facility. Residents and their legal representatives shall be notified by the provider, in writing, of any actions proposed or taken against the license of the facility/program by the Department, including but not limited to, decisions to issue a Directed Plan of Correction, decisions to issue a Conditional license, refusal to renew a license, appointment of a receiver or decisions to impose fines or other sanctions. This notification shall take place within fifteen (15) working days from receipt of notice of action. [Class IV]

5.23 Notification of rights. The provider shall inform each resident and legal representative prior to or at admission or within thirty (30) calendar days of any changes to Section 5 of these rights and shall provide them with a copy thereof. The provider must accommodate for any communication barriers that may exist, to ensure that each resident is fully informed of his/her rights. [Class IV]

5.24 Bill of rights for persons with mental retardation. Facilities/programs serving persons with mental retardation shall post and comply with the Bill of Rights for Persons with Mental Retardation, Title 34-B M.R.S.A. § 5601 et seq. [Class IV]

5.25 Mandatory report of rights violations. Any person or professional who provides health care, social services or mental health services or who administers a long term care facility or program who believes that the regulations pertaining to residents’ rights or the conduct of resident care have been violated, shall report the alleged violation to the Department of Health and Human Services ((800) 383-2441) and to one or more of the following:

Disability Rights Center (DRC), pursuant to Title 5 M.R.S.A. § 19501 through § 19508 for incidents involving persons with mental illness; the Long Term Care Ombudsman Program, pursuant to Title 22 M.R.S.A. § 5107-A for incidents involving elderly persons; the Office of Advocacy, pursuant to Title 34-B M.R.S.A. § 1205 for incidents involving persons with mental retardation; or Adult Protective Services, pursuant to Title 22 M.R.S.A. § 3470 through § 3487.

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Reporting suspected abuse, neglect and exploitation is mandatory in all cases. Documentation shall be maintained in the facility that a report has been made.

Mandated reporters shall contact the Department of Health and Human Services ((800) 383-2441) within one (1) working day of receiving and/or obtaining information about any rights violations. [Class IV]

5.26 Reasonable modifications and accommodations. To afford individuals with disabilities the opportunity to reside in an assisted living program, residential care facility, or a private non-medical institution, the provider shall:

5.26.1 Permit directly, or through an agreement with the property owner, if the property owner is a separate entity, reasonable modification of the existing premises, at the expense of the disabled individual or other willing payer. Where it is reasonable to do so, the provider may require the disabled individual to return the premises to the condition that existed before the modification, upon discharge of that individual. The provider is not required to make the modification at his/her own expense, if it imposes a financial burden. [Class IV]

5.26.2 Make reasonable accommodation in regulations, policies, practices or services, including permitting reasonable supplementary services to be brought into the facility/program. The provider is not required to make the accommodation, if it imposes an undue financial burden or results in a fundamental change in the program. [Class IV]

5.27 Right of action. In addition to any remedies contained herein, any resident whose rights have been violated may commence a civil action in Superior Court for injunctive and declaratory relief pursuant to Title 22 M.R.S.A. § 7948 et seq. [Class IV]

5.28 Right to appeal an involuntary transfer or discharge. The resident has the right to an expedited administrative hearing to appeal an involuntary transfer or discharge. A resident may not appeal a discharge due to the impending closure of the program unless he/she believes the transfer or discharge is not safe or appropriate. To file an appeal regarding an involuntary transfer or discharge, the resident must submit the appeal within five (5) calendar days of receipt of a written notice. If the resident has already been discharged on an emergency basis, the provider shall hold a space available for the resident pending receipt of an administrative decision. Requests for appeals shall be submitted to Assisted Living Licensing Services for submission to the Office of Administrative Hearings, 11 State House Station, Augusta, Maine 04333-0011. The provider is responsible for defending its decision to transfer or discharge the resident at the administrative hearing. [Class IV]

5.29 Resident adjudicated incompetent. In the case of a resident adjudicated incompetent, the rights of the resident are exercised by the resident’s legal representative, as defined in Section 2.29 of these Regulations. [Class IV]

5.30 Resident councils

5.30.1 Residents of assisted living programs, residential care facilities and private non-medical institutions have the right to establish a resident council, pursuant to Title 22 M.R.S.A. § 7923. Residents and their families shall be notified of this right, orally and in writing, within the first month after admission, in a manner understood by each resident and by a notice of the right to form a council being posted prominently in a public area.

5.30.2 If a majority of the residents choose not to establish a council, they shall be given the opportunity to choose otherwise at least once each year thereafter.

5.30.3 The council has the following rights:

5.30.3.1 To be provided with a copy of the facility's policies and procedures relating to resident rights and to make recommendations to the administrator on how they may be improved; [Class IV]

5.30.3.2 To establish procedures that will ensure that all residents are informed about and understand their rights; [Class IV]

5.30.3.3 To elicit and disseminate information regarding programming in the facility and to make recommendations for improvement; [Class IV]

5.30.3.4 To help identify residents' problems and recommend ways to ensure early resolution; [Class IV]

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5.30.3.5 To inform the administrator of the opinions and concerns of the residents; [Class IV]

5.30.3.6 To find ways of involving the families and residents of the facility; [Class IV]

5.30.3.7 To notify the Department and Long Term Care Ombudsman Program when the council is constituted; and [Class IV]

5.30.3.8 To disseminate records of council meetings and decisions to the residents and the administrator and to make these records available to family members or their designated representatives and the Department, upon request. [Class IV]

5.31 Right to a service plan. The provider shall assist residents to implement any reasonable plan of service developed with community or state agencies. [Class IV]

Section 7

• Medications And Treatments

7.1 Use of safe and acceptable procedures. The administrator shall ensure that all persons administering medications and treatments (except residents who self-administer) use safe and acceptable methods and procedures for ordering, receiving, storing, administering, documentation, packaging, discontinuing, returning for credit and/or destroying of medications and biologicals. All employees must practice proper hand washing and aseptic techniques. A hand-washing sink shall be available for staff administering medications. [Classes I/II/III]

7.1.1 Residents shall receive only the medications ordered by his/her duly authorized licensed practitioner in the correct dose, at the correct time, and by the correct route of administration consistent with pharmaceutical standards. [Classes I/II/III]

7.1.2 No injectable medications may be administered by an unlicensed person, with the exception of bee sting kits and insulin.

7.1.3 Before using a bee sting kit, unlicensed persons must be trained by a registered professional nurse in regard to safe and proper use. Documentation of training shall be included in the employee record.

7.1.4 If a resident has Diabetes, unlicensed persons must be trained by a registered professional nurse in regard to the management of persons with diabetics. The registered professional nurse must provide in-service training and documentation to include: Documentation of training shall be included in the employee record. [Class III]

7.1.4.1 Dietary requirements;

7.1.4.2 Anti-Diabetic Oral medications – inclusive of adverse reactions and interventions, hyper and hypo glycemic reactions;

7.1.4.3 Insulin mixing including insulin action;

7.1.4.4 Insulin storage;

7.1.4.5 Injection techniques and site rotation;

7.1.4.6 Treatment and prevention of insulin reaction including signs/symptoms;

7.1.4.7 Foot care;

7.1.4.8 Lab testing, urine testing and blood glucose monitoring; and

7.1.4.9 Standard Precautions.

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7.1.5 Urine testing shall not be done around medication or areas where food is stored or prepared. Proper Standard Precautions relative to body fluids shall be implemented. Toilets shall be used for the disposal of urine and test sample waste. Toxic urine testing chemicals (tablets, solutions) shall be stored in a locked area totally apart from oral medications.

7.1.6 For those residents for whom the facility is responsible for assistance with medication administration, no medications, including those brought into the facility by the resident, family or friends, shall be administered or discontinued without a written order signed by a duly authorized licensed practitioner or other person licensed to prescribe medications. [Class III]

7.1.7 Orders for medications and treatments shall be in writing, signed and dated by a duly authorized licensed practitioner and shall be in effect for the time specified by the duly authorized licensed practitioner, but in no case to exceed twelve (12) months, unless there is a written reorder. Orders for psychotropic medications shall be reissued every three (3) months, unless otherwise indicated by the duly authorized licensed practitioner. Standing orders for individual residents are acceptable when signed and dated by the duly authorized licensed practitioner.

7.2 Administration of medications.

7.2.1 Self-administration. Upon admission, each individual’s ability to self-administer medications will be determined by an assessment of his/her ability or need for assistance, unless the resident/legal representative elects (in writing) to have the facility administer his/her medications. A final decision will be reached between the resident, his/her legal representative, his/her duly authorized licensed practitioner and a facility representative.

7.2.2 Medications administered by facility. For those medications and/or associated treatments for which the facility is responsible, the following apply:

7.2.2.1 Telephone orders shall be accepted only by a registered or licensed nurse or pharmacist. Written dated orders for telephone orders must be signed by the duly authorized licensed practitioner within five (5) working days. [Class III]

7.2.2.2 Facsimile orders are acceptable legal orders as long as they are in compliance with the Commission on Pharmacy regulations.

7.2.3 Unlicensed assistive personnel. Unlicensed assistive personnel administering medications and/or treatments must successfully complete training approved by the Department. There shall be evidence available in the facility that such training has been successfully completed. Whenever the standards or guidelines of the medication administration course are substantially revised, unlicensed personnel must be re-certified within one (1) year of the revision, by a method approved by the Department. An additional exception will be made on a case-by-case basis for persons who only administer dietary supplements and/or minor medicated treatments, shampoos, lotions and creams that could be obtained over the counter without a physician’s order.

A person qualified to administer medications must be on site at the facility whenever a resident(s) have medications prescribed “as needed” (PRN) if this medication is not self-administered.

All unlicensed assistive personnel administering medications and/or treatments must complete a Department-approved eight (8) hour refresher course biennially for re-certification within two (2) years of the original certification. [Class III]

7.2.4 PRN Medications.

7.2.4.1 PRN Psychotropic medications. Psychotropic medications ordered "as needed" by the duly authorized licensed practitioner, shall not be administered unless the duly authorized licensed practitioner has provided detailed behavior-specific written instructions, including symptoms that might require use of medication, exact dosage, exact time frames between dosages and the maximum dosage to be given in a twenty-four (24) hour period. Facility staff shall notify the duly authorized licensed practitioner within twenty-four (24) hours when such a medication has been administered, unless otherwise instructed in writing by the duly authorized licensed practitioner.

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7.2.4.2 A person qualified to administer medications must be on site at the assisted living program, residential care facility, or private non-medical institution whenever a resident(s) have medications prescribed “as needed” (PRN) if this medication is not self-administered.

In no event, however, shall antipsychotic-type psychotropic medications be prescribed on a PRN basis only, having no routinely scheduled and administered doses.

7.3 Medication storage.

7.3.1 Residents who self-administer medications and who handle their own medical regime may keep medications in their own room. To ensure the safety of the other residents, the facility will provide a locked area/container, if necessary. [Class III]

7.3.2 Medications administered by the assisted living program, residential care facility, or private non-medical institutions shall be kept in their original containers in a locked storage cabinet. The cabinet shall be equipped with separate cubicles, plainly labeled, or with other physical separation for the storage of each resident's medications. It shall be locked when not in use and the key carried by the person on duty in charge of medication administration. [Class III]

7.3.3 Medications/treatments administered by the assisted living program, residential care facility or private non- medical institution for external use only shall be kept separate from any medications to be taken internally. [Class III]

7.3.4 Medications administered by the assisted living program, residential care facility or private non-medical institution, which require refrigeration, shall be kept safely stored and separate from food by placement in a special tray or container, except vaccines, which must be stored in a separate refrigeration unit that is not used to store food. Refrigeration shall be forty-one (41) degrees Fahrenheit or below. A thermometer shall be used to ensure proper refrigeration. [Class III]

7.4 Temporary absences. When a temporary absence from the facility is expected to be greater than seventy-two (72) hours, medications leaving the facility (except those by residents who self-administer) must be in a form packaged and labeled by a pharmacist. For medications leaving the facility for seventy-two (72) hours or less, the medication shall be packaged in such a way as to facilitate self-administration or administration by a responsible party of the correct medication at the appropriate time. Properly certified or licensed staff will use acceptable methods and procedures for preparing medications for leaving the facility. Staff will follow the same policies used in the facility for administering medications. The name of the resident and the name and strength of each drug, as well as the directions from the original prescription package, should be conveyed to the resident or their responsible party along with all cautionary information in writing, either directly on an envelope containing the appropriate dose or on a separate instruction sheet. If the medication is sent in original container, pills must be counted and documented upon leaving and returning to the facility. [Class III]

7.5 Medication labeling. Each prescription dispensed by a pharmacy shall be clearly labeled in compliance with requirements of the Commission on Pharmacy and shall include at least the following:

7.5.1 Prescription number;

7.5.2 Resident's full name;

7.5.3 Name, strength and dosage of the drug;

7.5.4 Directions for use;

7.5.5 Name of prescribing duly authorized licensed practitioner;

7.5.6 Name and address of issuing pharmacy;

7.5.7 Date of issue of latest refill;

7.5.8 Expiration date; and

7.5.9 Appropriate accessory and cautionary instructions. CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 174 of 177

7.6 Improperly labeled medications. For medications administered by the assisted living program, residential care facility, or private non-medical institution, all pharmaceutical containers having soiled, damaged, incomplete, incorrect, illegible or makeshift labels shall be returned to the original dispensing pharmacy for relabeling within two (2) working days or shall be disposed of in accordance with the requirements contained in Section 7.9. [Class III]

7.7 Expired and discontinued medications. For medications administered by the assisted living program, residential care facility, or private non-medical institution, medications shall be removed from use and properly destroyed after the expiration date and when discontinued, according to procedures contained in Section 7.9. They shall be taken out of service, taped shut and locked separately from other medications until reordered or destroyed. [III]

7.8 Medication owned by residents. Prescribed medicines are the property of the resident and shall not be given to or taken by other residents or any other person.

7.9 Destroying medications. For medications administered by the assisted living program, residential care facility, or private non-medical institutions, all discontinued medications, expired medications or medications prescribed for a deceased resident, except controlled substances and individual doses, shall be destroyed by the administrator or the administrator’s designee and witnessed by one (1) competent person who is not a resident. The destruction shall be conducted so that no person can use, administer, sell or give away the medication. Individual unit doses may be returned to the pharmacist and a credit or rebate made to the person(s) who originally paid for the medication. Amounts destroyed or returned shall be recorded on the resident's record, with the signature of the administrator or the administrator’s designee and witness(es). Destruction or return to the pharmacy shall take place within sixty (60) calendar days of expiration or discontinuation of a medication or following the death of the resident.

7.10 Schedule II controlled substances. Schedule II controlled substances listed in the Comprehensive Drug Abuse Act of 1970, Public Law 91-513, Section 202 and as amended pursuant to Section 202 are subject to the following standards . [Class II]

7.10.1 For all Schedule II controlled substances, there shall be an individual record in which shall be recorded the name of the resident, prescription number, the date, drug name, dosage, frequency and method of administration, the signature of the person administering it and verification of the balance on hand. [Class II]

7.10.2 There shall be a recorded and signed count of all Schedule II controlled substances at least once a day, if such substances have been used in the facility that day. [Class II]

7.10.3 All Schedule II controlled substances on hand shall be counted at least weekly and records kept of the inventory in a bound book with numbered pages, from which no pages shall be removed. [Class II]

7.10.4 All Schedule II controlled substances shall be stored under double lock in a separate locked box or cabinet within the medication cabinet or in an approved double-locked cabinet attached to the wall. [Class II]

7.10.5 All excess and undesired Schedule II controlled substances in the possession of a licensed facility that are no longer required for a resident, shall be disposed of in the following manner. The Administrator or a licensed or registered nurse shall list all such unused substances, tape the cap or cover of the container securely and keep the same in a securely locked area apart from all other drugs. Disposal shall be in the form of incineration or flushing into the sewage system only in the presence of an authorized representative of the Department, a licensed pharmacist, a member of the Commission on Pharmacy or an authorized representative of the Drug Enforcement Agency. At least one (1) of the persons must be a person who did not dispense the drug or who was the last person to inventory the drug. Documentation of such destruction shall be made on the resident's record and in the inventory record required in Section 7.10.3, signed by the individual authorized to dispose of the drug. [Class II]

7.11 Bulk supplies. Facilities may stock in bulk supply those items regularly available without prescription at a pharmacy.

7.12 Medication/treatment administration records (MAR) for medications administered by the assisted living program, residential care facility or private non-medical institution.

7.12.1 Individual medication/treatment administration records shall be maintained for each resident and shall include all treatments and medications ordered by the duly authorized licensed practitioner. The name of the medication, dosage, route and time to be given shall be recorded in the medication/treatment administration record. Documentation of treatments ordered and time to be done shall be maintained in the same manner. These rules apply only to treatments ordered by licensed health care professionals. [Class III] CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 175 of 177

7.12.2 Whenever a medication or treatment is started, given, refused or discontinued, including those ordered to be administered as needed (PRN), the medication or treatment shall be documented on the medication/treatment administration record. It shall be initialed by the administering individual, with the full signature of the individual written on the first page of each month’s MAR . A medication or treatment shall not be discontinued without evidence of a stop order signed and dated by the duly authorized licensed practitioner. [Class III]

7.12.3 Medication errors and reactions shall be recorded in an incident report in the resident's record. Medication errors include errors of omission, as well as errors of commission. Errors in documentation or charting are errors of omission. [Class II]

7.12.4 Administration of medications ordered as needed (PRN) shall be documented and shall include date, time given, medication and dosage, route, reason given, results or response and initials or signature of administering individual. Treatments ordered PRN shall be documented in the same manner.

7.13 Medication containers. Graduated medicine containers, for the accurate measurement of liquid medications, shall be used. If not disposable, medicine containers shall be returned to the facility's dishwashing unit for sanitization after each use. Only sterile disposable syringes and needles shall be used for insulin injection. Disposable medicine containers shall not be reused. [Class III]

7.14 Breathing apparatus. When the facility assists a resident with a hand-held bronchodilator, metered dose nebulizers, intermittent positive pressure breathing machine or oxygen machine, there shall be documentation of the following:

7.14.1 The names of staff who are qualified or trained to use the equipment and/or to mix medications, the nature of their training, the date and who provided it;

7.14.2 The name of the distributing agency and the frequency and specific directions for cleaning the equipment; and

7.14.3 The resident’s record shall contain a copy of the duly authorized licensed practitioner’s order, possible side effects to be monitored, specific instructions as to when the duly authorized licensed practitioner must be notified regarding side effects and instructions to the resident on the use of the breathing apparatus.

7.15 First aid kit. A first aid kit containing supplies which may be necessary for the first aid treatment of minor injuries such as cuts, scrapes or first degree burns shall be included and available in the facility. All staff shall be instructed in the use of any item in the kit.

7.16 Whenever a Registered Nurse teaches or provides in-service training to unlicensed personnel on medical issues, treatments and/or medical equipment not specifically outlined in these Regulations, there must be documentation in the employee file.

7.17 Whenever employees are provided in service training or are taught procedures, the use of equipment or anything else which impacts resident care, there must be documentation in the employee file. This in service training could be taught by other professionals including a Physician, Registered Nurse, Practitioner, Dietician, Physical Therapist, Occupation Therapist, Speech Therapist, product company representative, or other experts in their field

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Section 8

• Verification of Credentials

8.1 Licensed Staff. Prior to employing licensed staff, the facility must verify that the person has a valid and current license.

8.2 Employing CNA’s and CNA-M’s. Prior to employing a CNA or CNA-M (in the capacity of a CNA or CNA-M), the facility must contact the CNA Registry and determine that the CNA or CNA-M is on the Registry and has not been annotated. If the CNA or CNA-M is not on the Registry, or if the CNA or CNA-M has been annotated for abuse, neglect or misappropriation of patient/client/resident funds in a health care setting, or if the CNA or CNA-M has been the subject of a substantiated complaint involving abuse, neglect or misappropriation of patient/client/resident funds in a health care setting by the Department, the individual cannot be employed to function as a CNA or CNA-M.

8.3 Prohibited Employment. The facility may not hire as unlicensed assistive personnel as defined in section 2.58 an individual who is prohibited from employment as a certified nursing assistant as outlined below and in section 8.4:

8.3.1 An individual may not be employed in a hospital, nursing facility, home health agency or assisted housing program as a certified nursing assistant if that individual has been convicted in a court of law of a crime involving abuse, neglect or misappropriation of property in a health care setting; and

8.3.2 An individual may not be employed in a hospital, nursing facility, home health agency or assisted housing program as a certified nursing assistant if that individual:

8.3.2.1 Has been the subject of a complaint involving abuse or neglect that was substantiated by the department pursuant to its responsibility to license hospitals, nursing facilities, home health agencies and assisted housing programs and that was entered on the Maine Registry of Certified Nursing Assistants; or

8.3.2.2 Has been the subject of a complaint involving the misappropriation of property in a health care setting that was substantiated by the department and entered on the Maine Registry of Certified Nursing Assistants.

8.4 Time Limit on Consideration of Prior Criminal Conviction: Except as otherwise provided in this section, an individual may not be employed in a hospital, nursing facility, home health agency or assisted housing program as a certified nursing assistant if that individual has a prior criminal conviction within the last 10 years of:

8.4.1 A crime for which incarceration of 3 years or more may be imposed under the laws of the state in which the conviction occurred;

8.4.2 A crime for which incarceration of less than 3 years may be imposed under the laws of the state in which the conviction occurred involving sexual misconduct or involving abuse, neglect or exploitation in a setting other than a health care setting.

8.5 Exception: The restrictions on employment under sections 8.3.1 and 8.3.2 do not apply to an individual listed and active on the Maine Registry of Certified Nursing Assistants prior to the effective date of these regulations as long as the individual meets other state and federal requirements for certified nursing assistants and continues to maintain an active status by timely re-registration as required by the rules.

8.6 Notification: A nursing assistant training program must notify applicants to that program of the restrictions under 8.3.1 and 8.3.2 prior to the acceptance of any applicant.

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