[blueberrybon]

Well, I'm sure I'm not the first one in this predicament. If I spent enough time, I'm sure I would find the thread that answers this question to a T.

I'm orienting in a new LTC, on the acute care side of the building. There are a few residents who have orders for crush meds. Wouldn't you know it, of course, there are meds that are on the "do not crush" list that are being crushed.

What do I do? I know there are the nurses who are going to answer and say "Are you kidding?! Don't crush them!" But understand that the nurses who are orienting me are crushing the meds. I don't remember what the meds are, but I know at least one of them are enterically coated. One particular patient is on a peg-tube, has been at this facility for some time, and is doing quite well, so is it a problem? I wonder.

I don't want to make a big deal out of it if I'm going to be working with the nurses who are orienting me, and who I will be working with.

I know that the patient is more important than the working relationships, but try to see this from a newbies point of view please, before you start telling me I'm stupid for even asking for advice.

Blue

[EmilyUSFRN]

First off, I don't work in LTC, so I'm not sure if anything I say is or is not possible. My mom works LTC, so I'm somewhat familiar with funding problems, management, etc.
For some meds, would it be possible to talk to pharmacy and get the liquified or dissolving form of the med? i know that they tend to be more expensive and mediciad/medicare may not cover it?
Thats a tough question and i wish I had more answers for you, but definitely it is not a stupid question... I'm new too and I feel like an idiot for asking legitimate questions and I think you have a good question-- can your preceptor answer it-- or is it "we've always just done it this way?"
consult the pharmacist and pt's doctor i would think and see what they have to say about this?

[abundantjoy07]

That's not a stupid question at all. I would definately get some input from the physicians prescribing these medications, also the pharmacy and the input of nursing management. This is something you need to know. It's good that you are alert to this issue it means that you're a smart cookie...and smart cookies don't ask stupid questions!

I'd definately get to the bottom of this and go from there!

Good luck.

[Myxel67]

Most of the DO NOT CRUSH meds are sustained release formulations that allow once a day dosing for meds that might require tid or qid dosing in the regular formulation. If the med is crushed, the patient gets the entire dose at one time. This could be dangerous with high doses of OxyContin or MS Contin.

One remedy would be for the doctor to order the regular formulation to be given more frequently. An order for 80 mg Oxycontin q12 hrs could be changed to 20 mg Oxy IR q 3 hrs. A lot more work for the nurse, safer for the pt.

Many cardiac meds are available in regular and sustained release forms. Crushing a 90 mg Procardia XL could result in dangerous hypotension.

[earle58]

the nurses who are crushing these "do not crush" meds, are utilizing extremely poor judgment.
you need to call pharmacy and tell them the dilemmas.
they will provide you w/possible substitutes.
you then call the md, w/the recommendations.
most md's (if not all) would be happy to oblige.
afterall, they do understand the implications of crushing a med that shouldn't be.
and they certainly do not need any additional liabilities.

best of everything.

leslie

[blueberrybon]

Good input everyone, thanks.

I'm figuring it out little by little. One of the meds that has been being crushed also comes in a liquid form and a couple of the nurses didn't know the liquid was in the cart. Not an unreasonable reason in my mind. Another one is iron, but I neglected to check on that one today to see what my options were. I know there are others but the day is a blur and I lose track of what is/is not crushable during the crazy morning meds pass! Too much distraction! When I can think straight, I'll make sure to get it right, I just hope I'm not contributing to a harmful thing during this orientation.

I'm going to be good some day!

Blue

[jam2007]

I am a new grad as well, working in a facility where we crush meds and we have a list (poster) in the med room of all the meds that cannot be crushed. Iron, protonix, some abx, (b/c of the taste), KCL, and others that have been mentioned. If I have a question, I call the pharmacy and then ask the MD to re-write order. I find things aren't always done correctly, but don't be one of those nurses. Don't be a follower, be a leader. If it's not appreciated, then it's not the right facility for you. Keep asking questions!

[Suesquatch]

Originally Posted by earle58

the nurses who are crushing these "do not crush" meds, are utilizing extremely poor judgment.
you need to call pharmacy and tell them the dilemmas.
they will provide you w/possible substitutes.
you then call the md, w/the recommendations.
most md's (if not all) would be happy to oblige.
afterall, they do understand the implications of crushing a med that shouldn't be.
and they certainly do not need any additional liabilities.

best of everything.

leslie

Well, I would inform the charge nurse rather than go over her head to the pharmacy or doctor. And I would not be surprised if the charge nurse ignored me.

And "poor judgment" is a harsh call when Mr. Jones, risk for aspiration and altered nutrition less than requirements 2o Parkinsons & hemiplegia 2o CVA is put on Sinemet CR. Great. Thank you, assclown neuro who ignored the dysphagia that led to the swallowing consult that led to the pureed diet. He'll simply choke if I don't crush it.

I routinely crushed enterics for those who couldn't swallow. I avoided crushing time released meds except, again, for those who couldn't swallow. And for those who were ambulatory and could pretend to swallow and then went off to spit them out (can we say, dementia?) I crushed.

[earle58]

Originally Posted by Suesquatch

I routinely crushed enterics for those who couldn't swallow. I avoided crushing time released meds except, again, for those who couldn't swallow.

an er med should never be crushed.
that is why the md should be notified:
so s/he can prescribe an appropriate alternative.

leslie

[Suesquatch]

Originally Posted by earle58

an er med should never be crushed.
that is why the md should be notified:
so s/he can prescribe an appropriate alternative.

leslie

Of course the MD should be notified.

But until the order is changed - and that could take days in LTC and certainly past the stated time on the MAR anywhere - would you rather choke Mr Jones, let his Parkinsonism creep up on him because you withheld his Sinemet, or crush?

Now that I'm in a hospital it's much simpler. But LTC was a joke for this kind of thing and, believe me, had I gone over my charge's head to the MD I wouldn't have had a head left.