Crushing meds

[CardiacDork, MSN, RN]

So while looking at other threads about med administration it made me wonder something.

When I was on the floor I rarely crushed meds but now I always crush medications. I alway make sure it can be crushed per policy.

What I'm wondering is that it seems like not all of the med gets "given" like when I'm preparing it, it always seems like some of the med poofs into the air into powder no matter how careful I am.

There's really nothing that can be done about this apart from making sure the provider always makes sure the route says enteral. This will ensure you have a correct route AND that pharmacy dispenses the liquid form of the medications that can come in liquid.

For the record I really dislike giving meds via NGT, DHT, and especially through Gtubes and Jtubes. Gtubes and Jtubes clog up so much. You have to be real careful to flush real well and some nurses don't and leave a clogged tube and nobody wants to make an unnecessary ICU travel to IR because of pure laziness.

Rant over. :)

[BonnieSc]

What's your method of crushing? We have Silent Knights and no problem of "poofing"... but it is hard, sometimes, to get all the powder from the bottom of the plastic envelope. I rinse it with water, but usually some still remains. Then when I'm putting it in the syringe, it's hard to get it all out of the container and then out of the syringe. I generally don't think patients who take a lot of crushed meds are getting 100% of the dosage. If it's a BP med or something to do with electrolytes, etc, at least that'll show up and the dosage increased, and we're always monitoring for pain control. I worry about neuro-type meds, where we might not know they were being underdosed until there was a problem.

[CardiacDork, MSN, RN]

What's your method of crushing? We have Silent Knights and no problem of "poofing"... but it is hard, sometimes, to get all the powder from the bottom of the plastic envelope. I rinse it with water, but usually some still remains. Then when I'm putting it in the syringe, it's hard to get it all out of the container and then out of the syringe. I generally don't think patients who take a lot of crushed meds are getting 100% of the dosage. If it's a BP med or something to do with electrolytes, etc, at least that'll show up and the dosage increased, and we're always monitoring for pain control. I worry about neuro-type meds, where we might not know they were being underdosed until there was a problem.

We have the silent knights but I found they don't crush too well. We also have a hard glass med crusher. I crush the med inside the packet. The poof happens when I empty it into the glass I'm mixing them in.

Yeah for me, my main concern are BP meds and aspirins.

[quiltynurse56, LPN, LVN]

I would say that if the crushed BP meds are not keeping the BP where the doctor wants it, the dosage will be upped or there will be a change in the med. What I find difficult is making sure that I get it all. Many of our crushed meds are mixed with applesauce.

As far as the Gtubes and Jtubes, document that they are plugged up. Maybe an inservice on how to flush them properly may be in order.

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

Meds mix better with warm water. If after you crush it and let it sit for a few minutes in warm water, it becomes liquified. It'll then run right through the syringe...no plunger needed. Flushing afterwards with warm water prevents build-up and clogging within the tube as well. I never use hot or cold/tap water. Always warm.

[Kitiger, RN]

If the med is always crushed and given by tube, the dosage will be adjusted according to lab values and clinical presentation. This is true especially for long-term meds. With neuro meds, there is always an initial period of adjustment - both in which med to use, and in finding the correct dose. That's why they are usually started in the hospital. At least, that's true for my home-care kids.

I give tube feedings and medications by tube to almost all of my clients. Most meds go down well. However, chewable vitamins that are crushed are especially good at clogging the tubes. Those are best given with formula and lots of water.

[CardiacDork, MSN, RN]

Interesting about warm water. We are not allowed to use water from faucet. We use sterile water bottles. I guess we could warm those in warmer machines (where we also warm our saline and blankets).

Yeah, typically for anything enteral we are taught to use sterile water and date it and sticker it with a patient label. Idk what other facilities do. What do y'all do?

[Sour Lemon]

We have the silent knights but I found they don't crush too well. We also have a hard glass med crusher. I crush the med inside the packet. The poof happens when I empty it into the glass I'm mixing them in.

Yeah for me, my main concern are BP meds and aspirins.

I've seen people crush them in their packets before, but not often. You really do lose a lot of the medication that way (or so it seems). I like silent knight the best, but it has to be on a very firm surface as opposed to something like a WOW. I also crush by just pressing hard, then maybe jostling the "crumbs" around, then pressing hard again. I see some people just slam it repeatedly as hard as possible, but that doesn't work well for me.

[Wrench Party]

We use the Silent Knights. Many of our transplants/esophagos come out of the unit with feeding tubes, so we always use sterile water on those. One trick I've learned is to crush the meds, get them dissolving in water while I do other things, then come back to them 10-20 minutes later. Almost always dissolved well. Helps if the patient always gets pancreatic enzymes.

[heron, ASN, RN]

I suspect that most of the powder left behind is filler - the amount of med in there is likely too minuscule to be clinically significant. In adults, anyway.

[nutella, MSN, RN]

Interesting about warm water. We are not allowed to use water from faucet. We use sterile water bottles. I guess we could warm those in warmer machines (where we also warm our saline and blankets).

Yeah, typically for anything enteral we are taught to use sterile water and date it and sticker it with a patient label. Idk what other facilities do. What do y'all do?

So - I have crushed plenty of meds in different settings for ultra thin and regular size tubes.

I always had the best results with the use of a pestle and mortar. I would crush everythings very thoroughly, add some water (can be bottled or sterile or whatever your policy is) and let it sit for a minute or so. Because the medication is usually very powdered already it dissolves rather quickly. The only thing is that you have to have a mortar and pestle that is approved by the facility and can be cleaned easily.

I have tried other crushers depending on what the facility provides and nothing beats the old fashioned method IMO - I never had a tube clogged with this method.

The crushers that you turn and twist and not as good I find.

Once in a while I also used tiny bags like zipplog bags for meds (they are very small), closed it and used a small hammer to pulverize. Did a great job!

In homecare it can become a real problem as a lot of people have problems using the crushers sold at pharmacies for cheap - they might not be able to turn and twist enough and so on. Most people at home did well with the old fashioned mortar and pestle or the mini medication bag / hammer method.

But - if you can get medication in the liquid form or dissolvable forms that is really preferred.

Especially for ultra thin tubes - those should only be used with liquid medications as they occlude very easily.

[Julius Seizure]

Yeah for me, my main concern are BP meds and aspirins.

Does your unit use the chewable baby aspirins? Those will dissolve without crushing. Just put it whole into a 3cc syringe and draw up sterile water into the syringe....wait a few minutes and it'll be dissolved. If you are using a different aspiring that doesnt dissolve, maybe you could suggest a switch.