Chapter 10

Medication Management
Definitions
Allergic Reaction: a reaction caused by an unusual hypersensitivity to a medication (allergic reactions can also occur with
foods, animals and other environmental substances).
Counter Indicative: a condition or factor that increases the risks involved in using a particular drug or engaging in a
particular activity (e.g., smoking).
Drug: a word often used interchangeably with the word medication.
Generic Name: the name given by the federal government to a drug.
Medication: substance taken into (or applied to) the body for the purpose of prevention, treatment, relief of symptoms, or
cure.
Medication administration: the direct application of a prescribed medication—whether by injection, inhalation, ingestion,
or other means—to the body of the individual by an individual legally authorized to do so.
Medication assistance: assistance with self-administration of medication rendered by a non-practitioner to an individual
receiving supported living residential services and supports.
Medication (Drug) Interactions: the result, either desirable or undesirable, of drugs interacting with themselves, other
drugs, foods, alcohol, or other substances (e.g., herbs or nutrients).
Medication Error: any time the right medication is not taken as prescribed.
Nurse Delegation: the procedure following a specific set of guidelines and standards that allow staff with a prescribed
training and certification to perform medical tasks.
Ophthalmic: referring to the eyes.
Otic: referring to the ears.
Over-the-Counter (OTC) Medications: all nonprescription medications including aspirin, antihistamines, vitamin
supplements, and herbal remedies.
Pharmacist: licensed individual who prepares and dispenses drugs and is knowledgeable about their contents.
Physician/Doctor: an individual licensed to practice medicine; for the purpose of prescribing medications only, the term is
interpreted to mean any health care professional authorized by law to prescribe drugs: physician, dentist, optometrist,
podiatrist, and nurse practitioner or physician’s assistant (who write prescriptions is acting under the supervision of the
individual’s physician).
Prescription Medications: medications that must be ordered by a physician or other licensed health care professional with
authority to write prescriptions, such as a dentist or nurse practitioner.
PRN (pro re nata) Medications: means that the medication is taken as needed to treat a specific symptom; PRN
medications include both prescription and over-the-counter (OTC) medications. [Note: all PRN’s must be documented on
the Medication Administration Record (MAR).]
Psychoactive: possessing the ability to alter mood, anxiety level, behavior, cognitive processes, or mental tension; usually
applied to pharmacological agents.
Psychoactive Medications: refers to medications prescribed to treat a mental illness, improve functioning, or reduce
challenging behaviors.; psychoactive medications include antipsychotics/neuroleptics, atypical antipsychotics,
antidepressants, anticonvulsants, stimulants, sedatives/hypnotics, and anti-mania and anti-anxiety drugs; anticonvulsants
and other classes of drugs are included in this category when they are prescribed for behavioral purposes. [Note: If a
psychoactive medication is used solely to treat a physical condition (e.g., sleep aid, seizures) or dementia, and is not also
used to treat a mental illness or for challenging behavior, it is not considered a psychoactive medication.]
Side Effects: unintended effects produced by medication other than those for which it was prescribed; sometimes side
effects, such as a severe allergic reaction, can be deadly.
Topical: applied to a certain area of the skin.
Trade Name/Brand Name: the name given by the manufacturer to a medication.

MEDICATION ASSISTANCE AND MEDICATION ADMINISTRATION

Medication Assistance
Many of the individuals you support take one or more medications on an ongoing basis. Some of you have been assisting
with medication for a long time; for others, this may be a new responsibility. Whatever your level of experience, assisting
with medication is a very important activity. The critical skills you will learn are designed to increase safety and reduce the
risk of error, thereby providing maximum protection for the individuals you assist as well as yourself. No one wants to be
responsible for causing injury or harm to someone else. The information being shared in this training will help prevent that.
The health of many individuals you support depends on your skills in assisting them in taking medications. Your role in
assisting individuals to take the right medication, in the right dose, by the right route, and at the right time is a very
important function. Medications are substances taken into (or applied to) the body for the purpose of prevention,
treatment, relief of symptoms, or cure. Knowing about medications, their use and abuse, and how to assist individuals in
using them is vital to the health and wellbeing of those you serve. Some people you support may be independent in all
aspects of taking their medications. This means that they maintain their medications independently and are responsible for
ensuring they take the medications as prescribed. When this is the case, it will be documented in the person’s individual
support plan.

Requirements for Assisting with Medications

DDA Policies and Board of Pharmacy regulations are very specific regarding requirements for assisting with medications.
You may only assist individuals with self-administration of medications that have been ordered and prescribed by a doctor,
dentist, or nurse practitioner. This includes both prescription and over the-counter medications. The doctor’s signed and
dated order or prescription provides instructions for preparation and administration of the medication.

Self-Administration of Medications
Unless you are a licensed health professional, or have been authorized and trained to perform a specifically delegated
nursing task, you may only assist the individual to take medications. Assisting with medications includes:
 Communicating the prescriber’s order to the individual in such a manner that s/he self-administers his/her
medication properly.
 Reminding or coaching the individual when it is time to take a medication.
 Opening the individual's medication container.
 Handing the individual the medication container.
 Placing the medication in the individual's hand.
 Transferring medication from one container to another for the purpose of an individual dose (e.g., pouring a liquid
medication from the container to a calibrated spoon or medication cup or using adaptive devices).
 Altering a medication by crushing, mixing, etc., as long as the individual is aware that the medication is being
altered or added to food or beverage. A pharmacist or other qualified practitioner must determine that it is safe to
alter a medication and this must be documented on the prescription container or in the individual’s record.
 Guiding or assist the individual to apply or instill skin, nose, eye, and ear preparations.

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Medication Administration and Nurse Delegation
If an individual requires assistance with the use of medication beyond that which is described above, the assistance must be
provided either by a licensed healthcare professional or a Registered Nurse who delegates the administration of the
medication accordingly. You are considered to be “Nurse Delegated” when:
 You have completed Nurse Delegation Core Training.
 You have a current Nursing Assistant Registered (NAR) license Issued by Department of Health (DOH).
 A Registered Nurse has trained you to the specific tasks for specific individuals.
NOTE: The delegated authority to perform the nursing care task is not transferable to another Nursing Assistant.

The following are examples of things that you are NOT allowed to do without being specifically delegated for the task:
1. Putting medications into an individual’s mouth
2. Hand-over-hand administration
3. Applying a cream, instilling an eye drop or ear drop
4. Glucometer testing (you can, however, read and document blood sugars)
5. Injections--Insulin Only

THE INDIVIDUAL’S RIGHT TO REFUSE MEDICATION

Although the medication prescribed for individuals is typically important for them to take as prescribed, the individual does
have the right to refuse to take the medication. Your role as an ISS Staff is to encourage them to take the medication,
ensure that they have the information and support in order to do so. Ultimately, if the individual continues to refuse, you
must honor the individual’s right and document the choice. You should follow your agency’s procedures for reporting and
documenting refusals. If an individual refuses to take the medication, ask, “Why?” Do not try to crush or hide the
medication in the individual’s food to get him or her to take the medicine.

Reasons for Medication Refusal and Possible Helpful Suggestions

The following is a list of some common reasons an individual might refuse to take his or her medication, and suggestions on
how to provide assistance.
Unpleasant Taste
Tips: Give the individual ice chips to suck on just before taking the medication. This will often help mask the bad taste. Ask
the doctor or pharmacist if the medication can be diluted to cover a bad taste. Ask the physician or pharmacist if there is a
juice compatible with the medication that can be used (for example, apple juice). A note to this effect should be on the
prescription label. Provide crackers, apple, or juices afterwards to help cover up the bad taste.
Drowsiness
Tips: Report the unpleasant side effect and ask the prescribing doctor if the individual can take the medication at a different
time (such as before bedtime). Ask about changing the medication or treating the side effect.
Pills Difficult to Swallow The individual may be afraid they will choke or it will hurt their throat when they try to swallow a
pill. Ask the physician or pharmacist if the pill comes in a coated or capsule form, or if it can be taken with food such as
yogurt, applesauce or ice cream, or if it can be crushed and added to food or a liquid. It is important that medication never
be altered or mixed with food unless ordered by the physician or pharmacist. Always inform the individual if you have
mixed medication with food.
Lack of Understanding Tips: Provide simple reminders on what the name of the medication is and what the medication
does. For example: “This is Depekene, a medication that stops your seizures.”
Denial of Need for Medication

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Discuss the need for the medication, but do not argue. It may help to show the individual a statement written by the
physician. For example: “Alma, you take your heart medication every day.”

Documenting and Reporting Refusals

Medication refusal needs to be documented on the medication record and brought to the attention of your supervisor. Any
unused dose should be set aside and destroyed in an acceptable way.

ASSISTING WITH SELF-ADMINISTRATION OF MEDICATIONS

The following is a step-by-step process for assisting an individual with self-administration of medications.
1. Assist the individual to wash his or her hands.
2. Wash your hands. Hand washing reduces the risk of contamination.
3. Get the Medication Administration Record (MAR) for the individual you are assisting. Double check that you have
the MAR for the right individual. It is important for you to work with only one individual at a time and to complete
the task with that individual before assisting another.
4. Gather supplies:
 Take the medications out of the storage container or area. It is a good idea to keep all medications for one
individual in one storage unit labeled with the individual’s name.
 Get a calibrated measuring cup or medication spoon for liquid. If person cannot or does not want to take the
medication by hand; get paper cup or other container for tablets capsules.
 Get a glass of water or other food/liquid the individual uses to take the medication. NOTE: you may only add
medication to food or liquid if the person is aware that you are adding it.
 Get a pen for documentation.
5. As you take each medication container from the individual’s storage unit, read the medication label and compare
to the MAR for the Five Rights:
 Right Person
 Right medication
 Right dose
 Right time
 Right route

6. For tablets or capsules, pour the correct dose into the lid of the container, person’s hand, or into a small cup.
7. For bubble packs, push all the tablets/capsules from the bubble pack into a small container, your gloved hand, or
the person’s hand.
8. For liquid medication, pour the correct dose into the measuring cup held at eye level.
 View the medication in the cup on a flat surface.
 Pour away from the medication label to avoid staining it with spills.
 If any medication spills on the bottle, wipe it away.
—OR—
 When using a measuring spoon:
 Locate the marking for the dose.
 Hold the device at eye level and fill to the correct dosage marking.
 Pour away from the medication label to avoid spills.
 If any spills on the bottle, wipe away.
Additional tips for liquid medication:
 Check the label to see if the bottle needs to be shaken.
 Use only a measuring device designed for medications. Regular eating spoons are not accurate enough and
should never be used.

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  If too much liquid is poured, do not pour it back into the bottle—discard it.
 Wash the measuring device and air dry on a paper towel.
9. Talk with the individual you are assisting about what you are doing and about why he or she is taking each
medication.
10. Place the medication within the individual’s reach.
11. Offer a glass of water. It is a good idea to suggest to the individual that he tilt his head forward slightly and take a
small sip of water before the individual places the pill in their mouth. Wetting the mouth may make swallowing
easier and tilting the head slightly forward (as opposed to throwing it back) may decrease the risk of choking.
If pills are not taken with liquids they can irritate the throat and intestinal tract and they may not be correctly
absorbed.
Some medications are designed to dissolve instantly and are labeled as “fast dissolve”; for these medications it is
not necessary to take with water.
Some medications must be taken with food, and there may be other special instructions. Make sure that you have
read any warning labels and are familiar with any special instructions for taking the medication.
12. Make sure that the individual takes the medication and drinks water.
 Stay with the individual until you are sure that he or she has swallowed the medication.
 If the individual has difficulty drinking an adequate amount of water or swallowing liquids, you should discuss
this with your supervisor.
 Medications should never be disguised by putting them in food or liquid. The person must put the medication
into his own mouth.
 Tablets should never be crushed and capsules should not be opened unless the prescribing physician gives the
specific direction to do so. If the individual has trouble taking a medication, talk to the individual about his
needs and preferences and then talk to the doctor about optional ways to take the medication.
13. Record that the individual took his or her medication by initialing the date and time in the proper box on the MAR.
14. Return the medication containers to the proper area and ensure they are secure.
15. If the person has refused to take some or all of their medication, document this and follow your agency’s policies
for reporting.
Never leave the medication container unattended or give to someone else to return to the locked storage
container or area.
IF YOU HAVE ANY DOUBT AS TO WHETHER THE MEDICATION IS CORRECT— WHEN IN DOUBT, CHECK IT OUT

Medication Errors
Every medication error is serious and could be life threatening. Your job is to safely assist individuals to receive the benefits
of medications. Preventing medication errors is a priority. In this training you have learned the best way to assist individuals
take medication safely and to reduce the risk of errors; however, even in the best of situations, errors may occur. When
they do, you need to know what to do. A medication error occurs in the following situations:
 The wrong person takes the wrong medication.
 The wrong dosage is taken.
 Medication is taken at the wrong time.
 Medication is taken by the wrong route.
 Medication is not taken (other than when the individual refuses).
 Medication is not documented.
Every medication must be documented in accordance with your agency’s policies. Remember: prevention of medication
errors is the #1 Priority. You can prevent errors by observing the following practices:
 Knowing the individual and his or her medications
 Asking your supervisor for help if you are unsure about any step in preparing,
 Staying alert
 Following the Five Rights

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  Avoiding distractions
 Assisting, or documenting medications

The Five Rights

Observing the Five Rights is the key to preventing medication errors. Be sure you verify the following Rights:

1. Right Individual
First, read the name of the individual on the pharmacy label for whom the medication is prescribed. If you are uncertain of
an individual’s name or identity, consult another staff member who knows the individual.
2. Right Medication
After you have verified that you have the right individual, read the name of the medication on the label. To make sure that
you have the right medication for the right individual, read the label three times and compare it to the information on the
individual’s MAR.
3. Right Dose
Read the medication label for the correct dosage. Be alert to any changes in the dosage. Pay attention to the use of multiple
tablets providing a single dose of medication. Pay attention to any change in the color, size, or form of medication. Be
suspicious of sudden large increases in medication dosages.
4. Right Time
Read the medication label for directions as to when and how often the medication should be taken. Medication must be
taken at a specific time(s) of the day. Stay with the individual until you are certain that he or she has taken the medication.
You should supervise the medication within one hour of prescribed time as written on MAR. This means: as early as one
hour before and as late as one hour after time written on MAR. Pay attention to the following details:
 Are foods or liquids to be taken with the medication?
 Are there certain foods or liquids to avoid when taking the medication?
 Is there a certain period of time to take the medication in relation to foods or liquids?
 Is it the right time of day, such as morning or evening?
5. Right Route
Read the medication label for the appropriate route (or way) to take the medication. The route for tablets, capsules, and
liquids is oral. This means that the medication enters the body through the mouth. Other routes include: nasal sprays;
topical (which includes dermal patches or ointments to be applied to the skin); eye drops (ophthalmic); and ear
(otic) drops. Other more intrusive routes, such as intravenous administrations, intramuscular, or subcutaneous injections;
rectal and vaginal suppositories; or enemas are only to be self- administered, nurse delegated, or administered by a licensed
health care professional.

When assisting an individual, you must read and compare the information on the medication label to the information on
the MAR before the individual takes the medication. By doing so, you are helping to ensure that you are assisting the right
individual with the right medication and dose at the right time, and in the right route (way). Never assist an individual with
medication from a container that has no label! If, at any time, you discover that the information does not match, stop and
resolve the issue before supervising the medication. If you are unsure, you may need to get help. Ask another staff, your
supervisor, or in some situations, you may need to call the doctor or pharmacist.

Pharmacy Abbreviations and Symbols

The following abbreviations and symbols are commonly used on medication labels. In order to read and understand
medication labels, you should be familiar with these abbreviations and symbols:
• Rx = Prescription • tsp. = teaspoon (or 5 ml)
• OTC = Over-the-Counter • Tbsp. = tablespoon (3 tsps or 15 ml)

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• PRN = when necessary, or as needed • oz = ounce
• Qty = quantity • gr = grains
• q (Q) = every • mg = milligrams
• qd = daily • GM, gm = grams (1,000 mg)
• b.i.d. (BID) = twice a day • Cap = capsule
• t.i.d. (TID) = three times a day • Tab = tablet
• q.i.d. (QID) = four times a day • A.M. = morning
• h. = hour • P.M. = afternoon/evening
• h.s. (HS) = hour of sleep (bedtime) • D/C or d/c = discontinue

 Oral medications (capsules or tablets) are usually prescribed in mg (milligrams) or gm(grams).

 Liquid medications are usually prescribed in ml (milliliters), cc (centimeters), or oz(ounces).
 Liquid medications may also be prescribed in tsp (teaspoon), or Tbsp (tablespoon).

USAGE, PURPOSE, AND SIDE EFFECTS OF MEDICATIONS

Medication safety includes learning about the medications that you are assisting another to take. Know the answers to all
of the following questions:
 What is the medication, and why is it prescribed?
 What are the proper dosage, frequency, and route for taking the medication (for example by mouth, topical)?
 How many refills are authorized?
 What are the start and end dates for the medication? Should it be taken for 7 days, 10 days, or ongoing?
 Are there possible side effects? If so, to whom should these side effects be reported?
 What should be done if a dose is missed?
 Are there any special storage requirements?
 Are there any special instructions for use of this medication? For example, should certain foods, beverages, other
medicines, or activities be avoided?
 What improvements should be expected, and when will they start showing?

Most of this information can be obtained by reading the individual’s record. Other sources of information include
medication reference books from your local library or bookstore. Websites such as safemedication.com or rxlist.com also
provide medication information. If you do not find this information in the record, follow your agency’s policies to obtain the
information. You should know why medications are prescribed (their purpose) and what they are intended to do, so that
you can monitor how effective they are. If a medication is not effective, this should be reported to your supervisor and to
the individual’s prescriber so that it can be addressed. Some medications take longer than others in order to be effective.
Your role is to monitor, document and report the effectiveness.

Side Effects of Medication

The unintended effects of medication, called side effects, can occur at any time. Some mild side effects may disappear after
a short time. Others will persist the entire time the medication is taken and sometimes beyond. Some side effects are mild,
while others are life threatening. In the home where you work, it is important to learn about the medications each
individual is taking. It is also important to know what possible side effects may occur. Be sure to ask the doctor what kind of
reactions should be brought immediately to his or her attention. The pharmacy is a good source for information on the
effects of medication. Medication information sheets should come with every new medication. Physical and behavioral
changes that are due to the effect of a medication are often difficult to identify. There may be many different reasons for
the same sign or symptom. A change in behavior may be due to a medication change or a change in the person’s
environment. A sore throat may be one of the first symptoms of a cold or may be a side effect of a medication. Your

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responsibility is to consistently and accurately observe, report, and record any change in the normal daily routine, behavior,
communication, appearance, physical health, and general manner or mood of the individual you support. Interpretation
(deciding the meaning) of an observed side effect is the responsibility of the individual’s doctor. For each individual you
support:
 Know the intended and unintended effects of each medication he or she takes.
 Observe for intended and unintended effects of the medication.
 Document what you observe.
 Report observations to the doctor.
 Follow the doctor’s directions to continue, change, or discontinue the medication.
 Monitor the individual closely for side effects when a new medication has been prescribed or the dosage
increased.
It is not uncommon for two or more medications to interact with one another, causing unwanted side effects. An example
of this would be when iron or Penicillin is given with an antacid. The antacid prevents the iron or Penicillin from being
absorbed in the stomach.

Some people have allergic reactions to medications. When this is known, it should be documented in the individual’s
record. When a new medication is prescribed, you should verify that it is not one that the person is allergic to. If you notice
signs of a potential allergic reaction (e.g., rash, swelling, difficulty breathing), immediately report this to a health
professional.
Common Side Effects of Medication You Should Report to the Doctor Include:
Skin Rash Abnormal movements (face, tongue, or body)
Increased heart rate or feeling like the heart is racing Muscle pain
Changes in sleep Stooped posture
Decreased energy Blank facial expression
Sedation Feeling dizzy or light-headed
Changes in weight or eating patterns Dry mouth
Tremors, shakiness Constipation
Balance problems Blurred vision
Shuffling when walking Diarrhea
Confusion Nausea
Changes in ability to concentrate Vomiting
Hyperactivity Increased risk of sunburn

Tardive Dyskinesia (TD) is a potential long-term neurological side effect of antipsychotic medications such as Mellaril,
Thorazine, Risperdal, and Zyprexa. Symptoms may include rapid eye blinking, puckering, or chewing motions of the lips and
mouth, or facial grimacing. Symptoms may worsen if the medication is not reduced or discontinued. TD can become
permanent. Discuss this risk with the psychiatrist or doctor before starting antipsychotic medications. You should monitor
individuals for these serious side effects on a regular basis. If any possible side effects are observed, contact the health care
provider immediately.

Following Doctor’s Orders for Tests

Some medications (e.g., Tylenol, Lithium, Depakene) can be toxic and cause damage, especially if taken for a long period of
time. Some individuals respond differently to medications; that is, some use and break down medications in their body
slower (or faster) than others. For this reason, physicians sometimes start a new medication at low doses and increase it in
response to signs of a positive effect, such as a reduction in seizures or the development of better sleep patterns. Checking
blood serum levels by analyzing the concentrations of medications in an individual’s blood can be important. Physicians’
orders for lab tests and follow up appointments must be followed. Blood serum level tests help the physician determine the
effectiveness of the medication and the future course of action.

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Severe, Life-Threatening Allergies (Anaphylaxis)
Some individuals have severe allergies to medications, especially penicillin. The allergic reaction is sudden and severe and
may cause difficulty breathing and a drop in blood pressure (anaphylactic shock). If an individual has had a severe allergic
reaction to a medication (or insect stings or food), s/he should wear an identification bracelet that will tell health
professionals about the allergy.
Call 9-1-1 immediately to get emergency medical care if signs of a severe allergic reaction develop, especially soon after
taking a medication. Signs of an allergic reaction:
 Wheezing or difficulty breathing
 Swelling around the lips, tongue, or face
 Skin rash, itching, feeling of warmth, or hives
Some individuals have a severe allergy to insect stings or certain foods. If an individual shows any of these same signs of a
severe allergic reaction soon after eating a food or being stung by an insect, call 9-1-1 immediately to get emergency
medical care.
Common Categories of Medication Based on Effects
Drugs are classified into categories or classes with other medications that have similar effects. There are thousands of
medications. Many drugs, because of their multiple uses, can be found in more than one category. Some of the common
categories of medications used include: anticonvulsants (to prevent seizures); antibiotics; pain medications; laxatives;
topical ointments or creams; and psychotropic medications that include antidepressants and anti-psychotics.

STORAGE AND DISPOSAL OF MEDICATIONS

Storage of Medications
Medications must be stored so they are not readily available to others. Medications stored in an individual's room must be
kept so that housemates do not have access to them. In most cases, the medications are kept locked and only accessed
with staff supervision. The must be stored under proper conditions for sanitation, temperature, moisture and ventilation,
and separate from food or toxic chemicals; and The must also be stored in the original medication containers with
pharmacist-prepared or manufacturer's label, or in medication organizers which are clearly labeled with the following
information:
 Name of the person for whom the medication is prescribed
 Medications included
 Dosage frequency

You are not allowed to fill medication organizers. Medication organizers can only be used when they are filled by one of the
following persons:
 The individual
 A pharmacist
 A Registered Nurse
 The individual's family member

Disposal of Medications
Medications that have been discontinued, have been dropped, or are expired need to be disposed of properly and
documented appropriately. Be sure you know your agency’s disposal policy and follow it when medications need to be
disposed. Be aware of Confidentiality issues and take appropriate measures to protect information.