The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [540]
Drugs suspended, mixed or dispersed in liquids are often referred to as syrups. However, syrups do not contain active ingredients but are used as a vehicle for medications in order to decrease crystallization, increase solubility and provide aromatic and flavouring properties (British Pharmacopoeia 2007).
Evidence-based approaches
Observational studies suggest that medication administration errors for oral medicine range from 3% to 8% (Ho et al. 1997, Taxis et al. 1999) but this has been found to be twice as high in mental health patients who have swallowing difficulties (Haw et al. 2007). A proportion of these difficulties are due to an aversion to swallowing tablets, the most common cause being dysphagia (Kelly and Wright 2009). Guidance on medicines management related to dysphagia can be found within the NMC Standards for Medicines Management (NMC 2008a). When giving medicines to patients with dysphagia, both the patient and the medicine should be reviewed on a regular basis. If they cannot swallow tablets then liquid or dispersible medications should be the first consideration (Kelly and Wright 2009). If the oral route is not patent then alternative routes should be used.
Covert drug administration
The NMC recognizes that ‘this is a complex issue’, as covert drug administration involves the fundamental principles of patient and client autonomy and consent to treatment, which are set out in common law and statute and underpinned by the Human Rights Act 1998 (NMC 2008a). The covert administration of medicines should not be confused with the administration of medicines against someone’s will, which in itself may not be deceptive, but may be unlawful (NMC 2008a).
Some vulnerable groups of patients, such as those who are confused, may refuse to take medication. Traditionally, in some places, medication has therefore been hidden or disguised in food. The NMC ((2001a), 2001b, 2008a) offered the following position statement.
As a general principle, by disguising medication in food or drink, the patient or client is being led to believe that they are not receiving medication when in fact they are. The registered nurse, midwife or health visitor will need to be sure that what they are doing is in the best interests of the patient or client and be accountable for this decision.
Disguising medication in food and drink is acceptable under exceptional circumstances in which covert administration may be considered to prevent a patient, who is incapable of informed consent, from missing out on essential treatment (NMC 2001b, NMC 2008a). The following principles should be followed when making such a decision.
The medication must be considered essential for the patient’s health and well-being.
The decision to administer medication covertly should be considered only as a contingency in an emergency, not as regular practice.
The registered practitioner must make the decision only after discussion and with the support of the multiprofessional team and, if appropriate, the patient’s relatives, carers or advocates.
The pharmacist must be involved in these decisions as adding medication to food or drink can alter its pharmacological properties and thereby affect its performance.
The decision and action taken must be fully documented in the patient’s care plan and regularly reviewed.
Regular attempts should continue to be made to encourage the patient to take the medication voluntarily (NMC 2001b, NMC 2008a, Treloar et al. 2000).
Preprocedural considerations
Equipment
Medicine pots
Medicine pots (Figure 13.3) allow a dosage form to be taken from its original container to allow immediate administration to a patient. The person who removes medication from its original container and places it into a medicine