Guidelines for Completing the

Medication Administration Clinical Skills Checklist

DHSR/AC 4653 (Rev 10/10) NCDHHS
Section 1: Basic Medication Administration
Information and Medical Terminology

A. Match common medical abbreviations with
their meaning

B. List/Describe common dosage forms of
medications and routes of administration




C. List the 6 rights of medication
administration






D. Describe what constitutes a medication error
and actions to take when a medication error
is made or detected





E. Describes residents rights regarding
medications, i.e., refusal, privacy, respect













Section 1:
The employee must be knowledgeable of at least:

A. The common abbreviations on ATTACHMENT A. The employee is to be familiar with the common medical
abbreviations and be able to find a list when needed.

B. The common dosage forms and routes of administration on ATTACHMENT A & B. The employee is to be
familiar with the common dosage forms. Medications are available as different dosage forms, e.g., tablets,
capsules, liquids, suppositories, topicals which include lotions, creams, ointments and patches, inhalants and
injections. An order is to indicate the route of administration. Some medications may come in several dosage
forms. An example is Phenergan. It is available in tablet, liquid, suppository and injectable.

C. Six Rights of Medication Administration:
1.Right Resident
2.Right Medication
3.Right Dose
4.Right Route
5.Right Time
6.Right Documentation

D. A medication error occurs when a medication is not administered as prescribed. Examples of medication errors
include: omissions; administration of a medication not prescribed by the prescribing practitioner; wrong dosage;
wrong time, wrong route; crushing a medication that shouldnt be crushed; and documentation errors. The
employee must be able to explain the facilitys medication error policy and procedure or at least be knowledgeable
of where to find it. The procedure is to include who to notify, i.e., supervisor and health professional and forms to
complete. The employee is to be able to recognize medication errors. The employee needs to understand that
recognizing medication errors and acting quickly to correct them help prevent more serious problems.

E. Medication administration can effect a residents rights which include, but not limited to, the following:
1. Respect How the resident is addressed; The resident should not be interrupted while eating for the
administration of medications such as oral inhalers and eye drops. The resident should not be awakened to
administer a medication that could be scheduled or administered at other times; Explain to the resident the
procedure that the employee is about to perform; Answer questions the resident may have about the medication.
2. Refusal The resident has a right to refuse medications. A resident should never be forced to take a
medication. The facility should have a policy and procedure to be followed when residents refuse medications.
The policy and procedure is to ensure the physician is notified timely (based on the residents mental and physical
condition and the medication).
3. Privacy Knock on closed doors before entering; Do not administer medications when the resident is
receiving personal care or in the bathroom; Administration of injections outside the residents room is not
acceptable if the resident receiving the injection or other residents present are offended by this; Administration of
medications requiring privacy, e.g., vaginal and rectal administrations, dressing changes and treatments requiring
removal of clothing.
4. Chemical Restraint Medications, especially psychotropics, are not to be administered for staff convenience.
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M ication Administration Clinical Skills Checklist
F. Medication Allergy: a reaction occurring as the result of an unusual sensitivity to a medication or other substance.
The reaction may be mild or life-threatening situation. These may include rashes, swelling, itching, significant
discomfort or an undesirable change in mental status, which should be reported to the physician. A severe rash or
life-threatening breathing difficulties require immediate emergency care. The employee should understand that
information on allergies should be reported to the pharmacy and physician and this information is recorded in the
residents record. Upon admission, it is important to document any known allergies. If there are no known
allergies, this should be indicated also.

F. Define medication allergy and describe
responsibility in relation to identified
allergies and suspected allergic reactions





G. Demonstrate the use of medication
resources or references




Section 2: Medication Orders


A. List/Recognize the components of a
complete medication order
























G. The employee should be familiar with medication resources or references, including the facilitys policy and
procedure manual, and be able to find information. Resources written for non-health professionals, including
information sheets from the pharmacy, are recommended instead of references written for health professionals, such
as the PDR.


Section 2


A. Components of a complete order:
1.Medication name;
2.Strength of medication (if one is required);
3.Dosage of medication to be administered;
4.Route of administration;
5.Specific directions for use, including frequency of administration; and,
6.PRN or as needed orders must also clearly state the reason for administration

Orders for psychotropic medications prescribed for PRN administration must include symptoms that require the
administration of the medication, exact dosage, exact time frame between dosages and maximum dosage to be
administered in 24 hour period. Example: Ativan 0.5 mg. by mouth every 4 hours prn for pacing or agitation.
Physician is to be contacted if more than 4 doses are needed in 24-hour period.

For items B. through E. of this section: If the employee has any responsibility for transcription of orders and
processing admissions, the employee is to describe and demonstrate the procedures involved in these areas. If the
employee does not have any responsibility for transcription or processing orders, the employee still needs to have
general knowledge of the procedures and be able to screen orders to determine correctness.




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M dication Administration Clinical Skills Checklist
B. Transcription of orders onto the medication administration record is to include: B. Transcribe orders onto the MAR
1. Use proper abbreviations
2. Calculate stop dates correctly
3. Transcribe PRN orders appropriately
4. Copy orders completely and legibly
and/or checked computer sheets against
orders and applied to the MAR
5. Discontinue orders properly















C. Describe responsibility in relation to
telephone orders




D. Describe responsibility in relation to
admission and readmission orders and FL2
forms










1. Orders are to be transcribed onto the medication administration record when obtained or written. The
employee is to initial or sign and date orders written on the medication administration record. (Waiting until
the medication arrives from the pharmacy before transcription of an order onto the medication administration
record is not correct. The directions on the medication label from the pharmacy must be checked against the
order on the medication administration record. If there is a discrepancy between the information on the
medication administration record and the medication label, the order in the residents record is to be checked.
When there are discrepancies between the medication label and the order, the employee is to follow the
facilitys policy and procedure, which would address who to contact.)
2. Transcribe using proper abbreviations or written out completely. The order is to be complete.
3. When calculating stop dates for medication orders such as antibiotics that have been prescribed for a
specific time period, the number of dosages to be administered should be counted instead of the number of
days.
4. PRN orders are not scheduled for administration at specific times. PRN medications are given when
the resident needs the medication for a certain circumstance.
5. Review medication administration records monthly at the beginning of the cycle to assure accuracy
and the update the medication administration records as needed.
6. A discontinue order has to be obtained for an order to be discontinued, unless the prescribing
practitioner has specified the number of days or dosages to be administered or indicates that a dosage is to be
changed. For example, a prescription with No Refills does not automatically mean the order is to be
discontinued.


C. Telephone or verbal orders may be accepted only by a licensed nurse, registered pharmacist or qualified staff
responsible for medication administration. The order is to be dated and signed by the person receiving the order
and signed by the prescribing practitioner within 15 days of when the order is received. It is important that the
employee understands that a copy of an order, including a telephone order, is always kept in the residents record.


D. A FL2 form is required for new admissions. It is important that all the information on the FL-2 is reviewed for
accuracy. If any clarification is needed, the prescribing practitioner is to be contacted. If the FL-2 has not been
signed within 24 hours of admission, the orders are to be verified by the facility with the prescribing practitioner.
Verification of orders may be by fax or telephone. There has to be documentation of this verification in the
residents record, e.g., a note in the progress notes or the orders may be rewritten as telephone orders and signed by
the prescribing practitioner. The orders could also be faxed to the prescribing practitioner for review, signature and
date.

Readmission from the hospital requires a transfer form, discharge summary or FL-2 signed by the prescribing
practitioner. Often, the facility may receive a discharge summary or transfer form and a FL-2. The employee must
be able to describe the procedures for readmission, especially when two or more forms with orders are received.
Orders are to be verified by facility staff with the prescribing practitioner if the orders have not been signed within
24 hours of admissions, if clarification is needed or if the prescribing practitioner has not signed the orders. If a
Guidelines for Completing the
Medication Administration Clinical Skills Checklist


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E. Describe or demonstrate the process for
ordering medications and receiving
medications from pharmacy




F. Identify required information on the
medication label





Section 3 : Using appropriate technique to
obtain and record the following:
A. * Blood Pressure








prescribing practitioner does not sign orders, the orders are to be processed per facility policy and signed by the
prescribing practitioner. This may be by telephone or facsimile.

Medication orders are to be reviewed and signed by the physician at least every 6 months. When the orders are
renewed and there are changes without any reason, the physician or prescribing practitioner should be contacted for
clarification. A medication could have been accidentally left off or the wrong dosage could have been written.

Clarification is obtained whenever orders are unclear, incomplete or conflicting. New orders will need to be written
as necessary for these clarifications.

Continue previous medications or Same Medications are not complete medication orders and are not to be
accepted for medication orders.

An order has to be obtained for any medication administered, i.e., overthecounter or prescription. The employee
is to understand the difference between a prescription and an order. The facility needs an order to administer a
medication. The prescription may be used for the signed order.

E. The employee should be knowledgeable of the facilitys procedures on ordering medications, including refills,
procedures for emergency pharmaceutical services and on receiving medications when delivered from the
pharmacy. The facility is to be able to account for medications administered by staff; therefore, the facility is to
have procedures to ensure that dispensing information, i.e., date, name, strength and quantity of medication, can be
readily available. For situations such as admissions when the resident or responsible party brings medications into
the facility, the name, strength and quantity of medication brought in should be documented.

F. The employee has to be able to identify the following information on the label: medication name and strength;
quantity dispensed and dispensing date; directions for use; the pharmacy that dispensed the medication and the
prescription number; and expiration date. The employee should understand the difference between generic and
brand names and know that an equivalency statement should be on the medication label when the brand dispensed
is different than the brand prescribed. The employee should also know labeling requirements for over-the-counter
(OTC) medications, according to the regulation 10A NCAC 13F/13G .1004.

Section 3

A. Blood Pressure (B/P) The employee is to know how to check a blood pressure by using the facilitys blood
pressure device. If electronic machines are used, the employee should understand that the device needs to be
checked for accuracy according to the manufacturers recommendations. The instructor needs to indicate on the
checklist how the employee obtained the residents blood pressure, i.e., electronically or manually with a
stethoscope and blood pressure cuff. The employee should know that blood pressure cuffs that are too small or
large for the residents arm might result in an inaccurate reading. Ranges for high and low blood pressures that
indicate the residents blood pressure should be reported are to be established by the facilitys policy or physicians
order.

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M dication Administration Clinical Skills Checklist
B. Temperature (T or TEMP.) The employee should know how to obtain the residents temperature using the
facilitys thermometer: i.e., electronic, glass or tympanic. The employee should know the normal oral temperature
and that temperature is measured using either the Fahrenheit or Celsius scale. Normal oral temperature is 36.5
37.5 degrees Celsius or 96.7 99.6 degrees Fahrenheit. The employee should know that activity, food, beverages
and smoking all affect body temperature.

B. * Temperature





C. * Pulse




D. * Respirations



E. Fingersticks/Glucose Monitoring (Only
required to be validated if the employee
will be performing this task.)






Section 4: If medications are prepared in
advance, procedures, including
documentation, are in accordance with
regulation 10A NCAC 13F/13G .1004. (only
has to be completed if applicable to facility)






Section 5: Administration of Medications

A. Identify resident





C. Pulse Number of heartbeats counted in one full minute. The employee should know how to take a radial (heart
rate measured at the thumb side of the inner wrist) and apical pulse (heart rate measured directly over the heart
using a stethoscope). A pulse may be obtained by using an electronic device. Normal range is 60 to 100
beats/minute.

D. Respirations ( R) Number of breaths a person takes per minute. The normal range is 10 to 24 breaths per minute.
One full breath is counted after the resident has inhaled and exhaled. The most accurate rate is taken when the
resident is not aware that his/her respirations are being monitored.

E. The employee is to know how to operate the facilitys glucose monitoring device, including calibrating and
cleaning the machine. The range of the glucose-monitoring device should be posted with the MARs or available for
staff for reference. Since ranges for the machines vary, the facility should have procedures developed for when the
blood sugar reading is low or high. The employee is to be knowledgeable of the procedures and know where to
locate the information if needed. The employee is to be knowledgeable of infection control measures such as
wearing gloves, disposal of lancets in sharps container and the difference between multi-use machines and ones not
for multi-use.


Section 4

The containers must be prepared and labeled according to regulation 10A NCAC 13F/13G .1004. If the medications are
not dispensed in sealed packages, the container has to be capped or sealed and each medication prepared is to be
identified on the container. The MAR is to be used when prepouring or preparing medications. If the person who
prepares the medication is not the same person to administer the medication, the person preparing the medication must
document each medication prepared. (This is in addition to documentation by the person who actually administers the
medications. The administration of medications is not to be documented until after the resident is observed to take the
medications.)


Section 5

A. The employee is to know the procedures for identifying residents. The most common method used is photographs
of residents in the medication administration records. The photos should be kept updated and the photograph is to
have the name of the resident on it. Relying on other staff to identify residents is not appropriate.


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M dication Administration Clinical Skills Checklist
B. This will depend on the medications to be administered. Supplies/equipment to have for medication administration
need to include at least the following:

B. Gathered appropriate equipment and keeps
equipment clean









C. Medication administration records utilized
when medications are prepared and
administered. They are also used when
medications are prepoured, if prepouring is
allowed.


D. Read the label 3 times; Check label against
order on the medication administration
record.






E. Use sanitary technique when pouring or
preparing medications into the appropriate
container





F. Offer sufficient fluids with medications




G. Observe resident taking medications and
assures all medications have been swallowed.
1. Medication administration records
2. Medication cups for oral medications, i.e., liquids and tablets
3. Sufficient fluids available to administer medications
4. Food substance, i.e., applesauce or pudding, if needed.
5. If soap and water is not available for washing hands, an appropriate antiseptic is to be available for use.
Supplies and equipment used in the process of administering medications is to be kept clean and orderly, i.e.,
medication carts, trays and pill crusher.


C. Employee is to use the medication administration record when administering medications.






D. Reading the label - The employee should compare the label to the MAR 3 times:
1. when selecting the medication from the storage area
2. prior to pouring the medication
3. after pouring and prior to returning the medication to the storage area.
The information on the MAR and the medication label should match, unless there has been a change in the
directions. The employee is to be familiar with the facilitys policy on direction changes. A medication label can
only be changed or altered by the dispensing practitioner.


E. Medications are not to be touched or handled by the employees hands. Medications are to be poured from the
medication container into an appropriate medication container or cup and given to the resident. It is not acceptable
for the employee to use his/her hands to administer the medications or for the resident to have to use his/her hands
to receive the medications. (This is referring to the facility not having adequate or appropriate supplies or the
employee not using the supplies to administer medications. This is not referring to residents pouring the
medication, e.g., tablet, or wanting the medication poured into their hands.)


F. The resident should be offered sufficient fluids following the administration of medications even if the medication
is administered in a food substance.



G. The employee is to observe the resident taking the medication to assure the medication is swallowed. This must be
before documenting the administration of the medications.
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Medication Administration Clinical Skills Checklist


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Section 6: Utilized Special
Administration/Monitoring Techniques as
indicated(vital signs, crush medications.
check blood sugar, mix with food or liquid)













Section 7: Administer medications at the
appropriate time









Section 8: Describe methods used to monitor
a residents condition and reactions to
medications and what to do when there
appears to be a change in the residents
condition or health status





Section 9: Utilize appropriate hand-washing
technique and infection control principles
during medication pass

Section 6

The employee is to be knowledgeable of the facilitys policy on crushing medications and mixing medications in food.
A current list of medications that should not be crushed may be available for staff to use or facility policy should require
that no medications be crushed prior to checking with the pharmacist. Medications are not crushed until immediately
before the medications are administered to a resident.

One of the objectives with crushing medications is to avoid cross-contamination. Facilities may use different devices to
crush medications. The most common method is using a pill crusher and crushing the medications using two
medication souffle cups. If the medications are unit dose, the employee may crush the medication in the unit dose
package and empty into a medication cup. If the facility uses a device such as a mortar and pestle, and the residue from
the medications is present, the device has to be cleaned thoroughly before crushing another residents medications.

When a vital sign, i.e., pulse or blood pressure, is to be obtained prior to the administration of a medication, the
employee should have the results prior to preparing the medications for administration.


Section 7:

The employee is to be knowledgeable of what before meals, after meals and with meals mean. Medications
prescribed before meals are generally to be administered about 30 minutes prior to the resident eating. When the
medications are prescribed to be administered with or after meals, the medication is to be administered sometime after
the resident has started eating up to 60 minutes after the resident has finished eating. The employee also has to be
knowledgeable of the time period allowed by state regulations to administer medications, one hour prior to and one hour
after the scheduled administration time. The employee must know that this does not apply to medications prescribed for
administration in accordance with meals or for medications such as insulin.


Section 8

The employee should know that there are various side effects of medications. Side effects of medications include but
not limited to the following: change in behavior, change in alertness, change in eating or swallowing, change in mobility
and skin rashes. When there is a change in the resident, the employee is to follow the facilitys policy on what to do
which may include the following: using a medication reference and looking up possible side effects of a medication,
asking the resident how they are feeling, observing the resident and notifying the supervisor or a health professional.
The employee is to know that information regarding the residents behavior and action taken should be documented.


Section 9

Universal Precautions are to be implemented. This includes employees wearing gloves when there may be exposure to
bodily fluids. The employee is to be knowledgeable of when to wear gloves and when to change gloves. Handwashing
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Medication Administration Clinical Skills Checklist


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Section 10 Documentation of Medication
Administration

A. Initial the MAR immediately after the
medications are administered and prior to
the administration of medications to another
resident. Equivalent signature for initials is
documented.


B. Document medications that are refused, held
or not administered, appropriately











C. Administer and document PRN medications
appropriately








D. Record information on other facility forms
as required

should be with soap and water. When soap and water is not readily available, an antiseptic gel or product must be used
in place of soap and water. Handwashing is required when there has been contact with the residents body or bodily
fluids during the administration of medications. Gloves should be worn and handwashing must also be done when
transdermal products, i.e., Nitroglycerin or Durgesic patches, are applied or removed.


Section 10


A. The employee is to sign the MAR only after observing the resident take the medications. Precharting is not
permitted and this includes signing the MAR anytime prior to the medications being administered. The MAR is to
be signed immediately after the medications are administered and prior to the administration of the next residents
medications. The employee is also to document an equivalent signature to correspond with the initials used on the
MAR.


B. The facility is to have procedures to ensure that there is a consistent method of documenting why a medication was
not administered. The employee is to be knowledgeable of the facilitys policy and procedures. If the facility uses
abbreviations such as R or H, there is to be documentation on the medication administration records of the
abbreviations and what the abbreviations mean. The facility may have staff circle their initials and document the
reason a medication was not administered on the back of the MAR.

The employee is also to be knowledgeable of the facilitys policy when a resident refuses medications, i.e.,
notifying the supervisor or physician.

If the medications are not administered because the resident is out of the facility, i.e., leave of absence and
workshops, there should also be documentation of the medications sent with the resident. (A medication release
form is often used for leave of absence.)

C. Documentation of PRN medications is to include the amount administered, the time of administration and the
reason for administration. The reason a PRN medication is to be administered is to be indicated in the order. The
effectiveness of the medication is to also be documented when determined. A different employee, depending on the
time of administration and shift schedules may record the effectiveness of the medication. If a resident is
requesting or requiring administration of a prn medication on a frequent or routine basis, the employee should
report this to the supervisor or the physician. PRN medications are to be administered when a resident needs the
medication but may not be administered more frequently than the physician has ordered. The need for medication
may be based upon the residents request for the medication or observation by staff, i.e., resident exhibiting pain but
does not request medications or may not be able to request the medication.

D. The forms to be completed would depend on the facilitys policy and procedures. The employee is to be
knowledgeable of forms to complete, i.e., administration of controlled substances and documentation of
medications provided for leave of absence.
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E. Write a note in the residents record when
indicated





Section 11:Completion of Medication Pass

A. Store medications properly







B. Dispose of contaminated or refused
medications per policy



C. Recheck medication administration records
to make sure all medications are
administered and documented




Section 12: Medication Storage


A. Maintain security of medications during
medication administration


B. Store controlled substances appropriately
and count and sign controlled substances per
facility policy



E. Any contact with the prescribing practitioner is documented in the residents record. The employee needs to be
knowledgeable of how to write a note in the residents record appropriately, i.e., date and employees signature.
The employee also must be knowledgeable of the facilitys procedures for documenting information that needs to
be communicated to other staff or health professionals. This may be in the residents record or on some other
document used to communicate with staff or health professionals.


Section 11

A. External and internal medications are to be stored in separate designated areas. The employee should store
refrigerated medications in the medication refrigerator or locked container. Medications requiring refrigeration are
to be stored at 36 degrees F to 46 degrees F (2 degrees C to 8 degrees C).

A residents oral solid medications should be stored together and separated from other residents medications. It
may not be possible for other medications, i.e., liquids and topical medications, to be separated by dividers for each
resident. Medication storage areas need to be orderly so medications may be found easily.

B. Dosages of medications that have been opened and prepared for administration and not administered for any reason
should be disposed of promptly. The disposal of these medications should be in accordance with the facilitys
policy and procedures. Loose medications are not to be kept in the facility or returned to the pharmacy.


C. When the medication pass is complete, the employee is to recheck the medication administration records to make
sure all medications have been administered and documented appropriately. At the end of the medication pass if a
medication is not signed off upon recheck of the medication administration record, and the employee is certain the
medication was administered, it is acceptable for the employee to document the administration. This is acceptable
when there are only a few, i.e., one or two, omissions. It is not acceptable for the employee to have omitted
documentation of the administration of medications for multiple residents.

Section 12


A. Medications are to be stored in a locked area, unless the medications are under the direct supervision of staff.
Direct supervision means the cart is in sight and the staff person can get to the cart quickly, if necessary.


B. The storage of controlled substances is to be in accordance with the facilitys policy and procedures. Controlled
substances may be stored in one location in the medication cart or medication room. When Schedule II medications
are stored in one location together or with other controlled substances, the controlled substances are to be under
double lock. When controlled substances, including Schedule II, are stored with the residents other medications,
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Medication Administration Clinical Skills Checklist
only a single lock is required. There has to be a readily retrievable record of controlled substances by documenting
the receipt, administration and disposition of controlled substances. The employee is to be knowledgeable of any
forms to be completed.




C. Assure medication room/cart/cabinet is
locked when not in use



Section:13: Administer medication utilizing
appropriate technique for dosage form/route
and administer accurate amount









A. Oral tablets and capsules
B. Oral liquids




















C. Medication room/cart/cabinet is locked when not in use. Unless the medication storage area is under the direct
supervision of staff, the medication area including carts is to be locked. When the medication cart is not being
used, it should be stored in a locked area or stored in an area where it is under the supervision of staff.


Section 13

The employee is to actually perform or at least be able to demonstrate to the instructor the proper technique for
administering the different dosage forms and routes of administration for A through J prior to the employee being
assigned to administer medications in the adult care home.

Routes of administration for K through P only have to be validated if the employee will be responsible for administering
these medications or medications by these routes.

The information below does not provide step by step procedures for administering medications. It provides
pertinent information on techniques and infection control that the employee is to know.

A. & B. Oral Medications
Appropriate positioning of resident, elevation of head.
The amount of medication to be administered, such as liquids, is never to be approximated. The amount ordered is
to be the amount administered; therefore, a calibrated syringe is often necessary for measuring liquids in amounts
less than 5 ml. and unequal amounts.
Liquid medications must be measured in a calibrated medication cup/device.
Measuring devices used for administering medications are to be calibrated and designed for measuring medications.
Eating utensils or other household devices are not to be used for administering medications.
When measuring liquids, the medication cup should be placed on a flat surface, and measured at eye level to ensure
accuracy.
For liquids, hold the medication container so that the medication flows from the side opposite the label so it doesnt
run down the container and stain or obscure the label.
Powdered medications such as bulk laxatives need to be given with the amount of fluids indicated.
More than one capsule or tablet may be in the same medication cup, but liquid medications are not to be mixed
together.
Special measuring devices for certain medications should only be used for that medication. (These measuring
devices have increments marked off in mgs. instead of mls and usually have the name of the medication on the
measuring device.)
Liquids may have administration requirements such as Shake Well and Requires Dilution prior to administration.
Examples of these liquids are Dilantin Suspension, which must be shaken thoroughly because the medication settles
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Medication Administration Clinical Skills Checklist
after administration and gives inconsistent dosing; Liquid Potassium and bulk laxatives have to be mixed with
sufficient fluids to decrease side effects.

C. Sublingual medications



D. Oral Inhalers







E. Eye drops and ointments






F. Ear drops






G. Nose drops
H. Nasal Sprays/Inhalers






I. Transdermal medications/Patches


Refer to ATTACHMENT C for additional information.

C. Sublingual
The medication is to be placed under the residents tongue. The resident should be instructed not to chew or
swallow the medication. Do not follow with liquid, which might cause the tablet to be swallowed.

D. Oral Inhalers
For information on technique for meter dose inhaler refer to ATTACHMENT D.
Spacing and proper sequence of the different inhalers is important for maximal drug effectiveness.
The prescribing practitioner may specifically order the sequence of administration if multiple inhalers are
prescribed or the pharmacy may provide instruction on the medication label or MAR.
The use of spacer or other devices to aid with administration should be discussed with the employee.
Wait at least one minute between puffs for multiple inhalations

E. Eye drops and ointments
Hands are to be washed prior to and after administration of eye drops and ointments. Gloves are to be worn as
indicated. Gloves are to always be worn when there is redness, drainage or possibility of infection.
When two or more different eye drops must be administered at the same time, a 3 to 5-minute period should be
allowed between each.
Dropper or medication container should not touch the residents eyes.

F. Ear Drops
Wash hands before and after administration of medication. Gloves are to be worn as indicated.
By gently pulling on the ear, straighten the ear canal
The employee should request the resident to remain in same position for 5 minutes to allow medication to penetrate.
It may be necessary to gently plug the ear with cotton to prevent excessive leakage.


G. & H. Nose Drops & Nasal Sprays/Inhalers
Wash hands before and after. Gloves are to be worn as indicated.
For drops: Resident should lie down on his/her back with head tilted back and the employee should request the
resident to remain in the position for about 2 minutes to allow sufficient contact of medication with nasal tissue.
For Sprays: Hold head erect and spray quickly and forcefully while resident sniffs quickly. It may be necessary
to have the resident tilt head back to aid penetration of the medication into the nasal cavity.
The dropper or spray should be at least wiped with a tissue before replacing the cap.

I. Transdermal Products/Patches
Application sites for transderm patches should be rotated to prevent irritation. The application sites should be
documented on the MAR.
Guidelines for Completing the
e c


Revised 10/05; 10/10
12
M di ation Administration Clinical Skills Checklist
If the patch is ordered to be worn for less than 24 hours, documentation on the medication administration record is
to reflect that the patch was removed and the time it was removed.




J. Topical (creams and ointments; not
dressing changes)








K. *Clean dressings




L. *Nebulizers



M. * Suppositories
1. Rectal
2. Vaginal
N. * Enemas



O. * Injections
1. Insulin**
2. Other subcutaneous medications







Gloves should be worn and hands washed after the patch is applied or removed.
When a patch is removed, the area should be cleaned to remove residual medication on the skin.

J. Topical
Wearing gloves and use a tongue bade, gauze or cotton tipped applicator to apply the medication.
A new applicator should be used each time medication is removed from container to prevent contamination.
Privacy should be provided, as necessary. This would depend on the area to be treated.
The lid or cap of the container should be placed to prevent contamination of the inside surface.
Gloves and supplies used should not be discarded in areas accessible to residents.

(Validation for items K. through P is only necessary if the employee will be performing the task. These are tasks
under Licensed Health Professional Support. Refer to regulations 10A NCAC 13F/13G .0504; .0505 and .0903.)

K. *Clean Dressing

The employee is to be knowledgeable of techniques with dressing change to ensure there is no cross-contamination
Information under item J is also applicable to dressing changes.

L. *Nebulizers

Nebulizer equipment, tubing and mask, is to be cleaned and changed in accordance with the facilitys policy.

M.&N. Suppositories & Enemas
Wash hands before and after. Gloves are to be worn and properly disposed of.
Remove foil or wrapper from suppository. A small amount of lubricant applied to the suppository will aid with
administration of rectal preparations.
Privacy is to be provided.
Reusable applicators are to be cleaned with soap and water and properly stored.

O. Injections
Syringes are not to be recapped and must be disposed of in appropriate containers, i.e., Sharps.
**For insulin, the employee is to have also received training according to regulation 10A NCAC 13F/13G .0505.
The employee is to be knowledgeable of the facilitys policy on storage of insulin.
Employee is to be knowledgeable of technique for mixing different insulins.
Employee is to be knowledgeable of facilitys policy and procedure of when insulin should be held and
interventions for hypoglycemia and hyperglycemia reactions.
Wash hands before and after. Gloves are to be worn.

Guidelines for Completing the
Medication Administration ills Checklist

Revised 10/05; 10/10
13
Clinical Sk
Wash hands before and after. Gloves are to be worn.

P. * Gastrostomy Tube







Section 14: Other Tasks/Skills

A. Self-Administration of medications by
residents

B. Received orientation to facilitys policy and
procedures for medication administration
























P. Gastrostomy Tube
Tube should be flushed with sufficient water prior to and after the administration of medications. The amount of
water should be reflected in the physicians order or the facilitys procedure.
Solid medications that are crushed or altered for administration should be dissolved well in water. Employee is to
also check to check with the pharmacist to ensure medications may be crushed or altered.


Section 14

A. The employee is knowledgeable of the facilitys policy and procedure for self-administration. A physicians order is
required for the resident to self-administer medications and be able to store medications in their rooms.

B. The employee has been provided a copy of the facilitys policy and procedures, knowledgeable of the facilitys
policy and procedures and able to locate the manual as a resource and reference.



ATTACHMENT A
DHSR/AC 4653-A NCDHHS

ABBREVIATIONS

DOSES ROUTES OF ADMINISTRATION
gm = gram po = by mouth
mg = milligram pr = per rectum
mcg = microgram OD = right eye
cc = cubic centimeter OS = left eye
ml = milliliter OU = both eyes
tsp = teaspoonful AD = right ear
tbsp = tablespoonful AS = left ear
gtt = drop AU = both ears
ss = 1/2 SL = sublingual(under the tongue)
oz = ounce SQ = subcutaneous (under the skin)
mEq = milliequivalent per GT = through gastrostomy tube


TIMES OTHER
QD = every day MAR = medication administration record
BID = twice a day OTC = over the counter
TID = three times a day SIG = label or directions
QID = four times a day
q_h = every __ hours
qhs = at bedtime
ac = before meals
pc = after meals
PRN = as needed
QOD= every other day
ac/hs= before meals and at bedtime
pc/hs= after meals and at bedtime
stat = immediately

Attachment B


COMMON DOSAGE FORMS


1. Tablet Hard, compressed medication in round, oval, or square shape. Some have
enteric coating or other types of coatings, which delay release of the drug and can not be
crushed or chewed.


2. Capsule Medication in a gelatin container. The capsule may be hard or soft and
dissolves quickly in the stomach.


3. Liquid There are different types of liquid medications:
A. Solution
B. Suspension
C. Syrup
D. Elixir


4. Suppository small solid medicated mass, usually cone-shaped. Suppositories melt at
body temperature. May be administered by rectum or vagina. Refrigerate as directed by
manufacturer.


5. Inhalant medication carried into the respiratory tract through the vehicles of air,
oxygen or steam. There are inhalants used orally and nasally.


6. Topical applied directly to the skin surface. Topical medications include the following:
A. Ointment
B. Lotion
C. Paste
D. Cream
E. Shampoo
F. Patches (Transdermal)
G. Powder
H. Paste
I. Aerosol Sprays

DHSR/AC 4653-B NCDHHS
Attachment C
DHSR/AC 4653-C NCDHHS
MEASURING TIPS

TI P: use an or al syr i nge f or
amount s l ess t han 5ml
Remi nder : 1c c = 1ml
A c ubi c c ent i met er i s t he same as a mi l l i l i t er .
10c c = 10ml
20c c = 20ml
mg. ml .
A mg i s NOT t he same as a ml ! ! !
TI P: Al w ays r ead t he l abel
c ar ef ul l y t o be sur e you ar e
measur i ng t he r i ght t hi ng.
Thi s 20ml c up
c ont ai ns 20mg of
medi c at i on i n i t .
Thi s 20ml c up
c ont ai ns 40mg of
medi c at i on i n i t .
20ml
YOU CAN' T TELL THE DI FFERENCE BY LOOKI NG
1 TSP. = 5ml .
TI P: Don' t use househol d
t easpoons. They ar e not ac c ur at e!
TI P: To be ac c ur at e, use t he c or r ec t
measur i ng t ool . Ask your
phar mac i st . Some l i qui d
medi c i nes have spec i al
measur i ng t ool s.
=
1 t bsp. = 3 t sp
=
3 t sp. = 15ml
15
10
5
TI P: When measur i ng l i qui ds,
hol d t he c up at eye l evel .
ATTACHMENT D




Equipment Required:
Prescribed Medication
Examination Gloves(optional)

Procedure:

1. Remove the cap and hold inhaler upright.

2. Shake the inhaler.

3. Ask the resident to tilt the head back slightly and breathe out.

4. Position the inhaler in one of the following ways:
Open mouth with inhaler one to two inches away.
Use spacer with inhaler; place spacer in mouth (Spacers are
particularly beneficial for older adults & young children).
Position inhaler in mouth, close lips around inhaler.

5. Press down on inhaler to release medication as the resident starts
to breathe in slowly.

6. Encourage the resident to breathe in slowly (over 3 to 5 seconds).

7. Ask the resident to hold breath for 10 seconds to allow medication
to reach deeply into the lungs.

8. Repeat puffs as directed. (Waiting one minute between puffs may
permit additional puffs to penetrate the lungs better).






DHSR/AC 4653-D NCDHHS
TECHNIQUE FOR PROPER USE OF
METERED DOSE INHALERS
ATTACHMENT D
DHSR/AC 4653-D NCDHHS






1. Bronchodilators / Beta-Agonists
albuterol - Ventolin

, Proventil

;


metaproterenol - Alupent

;


pirbuterol - Maxair

;

bitolterol - Tornalate

These agents work by promoting
Wait one minute between puffs for multiple
inhalations of the same drug
bronchodilation by relaxing bronchial
smooth muscle.

2. Anticholinergic Agents
ipratropium - Atrovent

Antagonizes the action of acetylcholine
with resulting bronchodilation.
Minimal systemic activity.
Is used for maintenance therapy only,
not acute episodes.
Wait five minutes before administering
May be more useful than traditional

bronchodilators in chronic bronchitis.


3. Miscellaneous Agents
Wait one minute between puffs for multiple
inhalations of the same drug
cromolyn - Intal

;
nedocromil - Tilade

Stabilizes mast cells and inhibits the
release of histamine from these cells.
Must be used on a regular basis, not
useful on a PRN basis.
May be used prophylactically prior to
exercise.

4. Corticosteroids Wait five minutes before administering
triamcinolone Azmacort

;
flunisolide Aerobid

;

budesonide Pulmicort


Wait one minute between puffs for multiple
inhalations of the same drug
fluticasone/salmeterol - Advair

Anti-inflammatory agents may have a

variety of actions useful in management
Rinse the mouth out following use (do not
swallow the water) to help prevent
oropharyngeal fungal infections. The use of
a spacer device may also reduce these side
effects.
of COPD.
Must be used on a regular basis, not
PRN agents.
Minimal systemic activity

SPACING AND PROPER SEQUENCE OF
INHALED MEDICATIONS
All Inhalers Must Be Shaken
Well Prior To Use ! !
Bronchodilator: Proventil, Alupent, etc.
Atrovent / Miscellaneous Agents
Corticosteroids; Azmacort, Pulmicort, etc.
Spacing and proper sequence of the different inhalers is important for maximal drug
effectiveness. If more than one inhaler is used, following the sequence listed below
provides the most benefit to the patient.