RN - Crushing medications

CapeCodMermaid, RN · Mar 1, 2015

That arguement doesn't hold up. You don.t give uncrushed meds oine at a time so you would know which med the patient was having a reaction to so why would crushing them make a difference? Most medications can be given together---crushed or whole. The thing to remember is: follow YOUR facility's policy. If you think it's wrong, speak to your DNS or SDC.

NurseQT · Mar 1, 2015

iamkel--- in long term care, a majority of a resident's meds are ones they've been on for quite some time, the likelyhood of a reaction to a med they've been on for some time is slim. Furthermore if they take 10 different meds at one time and they were to have a reaction they're going to have that reaction whether the pills were crushed and given together, crushed and given separately, or given whole. You'd have no way of knowing which med it was regardless of how they were given.

I learned to crush meds all together in school and I have crushed meds in front of a surveyor. Never had a problem.

caliotter3 · Mar 1, 2015

VIA ISMP (Institute for safe medication practices) states:
Improper administration technique
Most nurses rely primarily on their own experience and that of coworkers for information regarding the preparation and administration of enteral medications; few rely on pharmacists, nutritionists, or printed guidelines, which has resulted in a variety of improper techniques and an overall lack of consistency. The most common improper administration techniques include mixing multiple drugs together to give at once and failing to flush the tube before giving the first drug and between subsequent drugs.
Appropriate administration techniques must be used to prevent compatibility issues (between medications and the feeding formula) and tube occlusions. Information about drug compatibility with feeding formulas is limited and may not be applicable to different formulations of the same drug or drugs within the same class. For example, liquid morphine in a 2 mg/mL concentration decreases the pH of the feeding formula and results in a precipitate, but a 20 mg/mL concentration does not. Compatibility issues between the formula and drug can result in tube occlusions.
Compatibility between multiple drugs being administered together can also be a problem, particularly if two or more drugs are crushed and mixed together before administration. Mixing two or more drugs together, whether solid or liquid forms, creates a brand new, unknown entity with an unpredictable mechanism of release and bioavailability. Proper flushing of the tube before, between, and after each drug can help avoid problems.

I've read this in the past but like others find it is not practical in practice.

litbitblack, ASN, RN · Mar 2, 2015

I also learned to crush medications together in school and have never had an issue. If your starting a new medication and the others have been on board for a long time you will know which medication caused the problem. Who in the world has time to crush 10 different pills and administer them separately? For those instances where there would be a medication problem with a tube feeding formula then the pharmacist and dietician would already be aware and it could be adjusted for that patient. If it is a facility policy I would be on the fast track to getting it changed.

HeyNurse2014, ASN, RN · Mar 23, 2015

right and in the perfect NCLEX world we all have the time, staff and supplies needed.

keatinkp · Jul 28, 2015

It is essential that medication be given correctly. Giving medication incorrectly at best inactivates many medications and at worst puts patients in serious jeopardy of serious, potentially life threatening, adverse drug reactions.

I have worked and administered medications to literally hundreds of individuals with developmental disabilities, TBI, significant dysphagia and other conditions that require either crushed or liquid medications over the last 20+ years. I have worked on state level work groups, along with the AMA, APA, Institute of Safe Medical Practices, pharmacy professors, and other very knowledgeable individuals to establish rules and policies for administration of medication. Here is what we have come up with:

1. Whenever possible, request the medication, or another medication with the same therapeutic effect, in liquid form. While not perfect (if you do not shake it there is very little medication at the top of the bottle and toxic levels at the bottom) for most people it is the best alternative available.

2. NEVER mix liquid medication together, or with feeding formulas such as Jevity, Boost, Ensure etc. Mixing the liquids together allows the chemicals in each medication to combine, forming new, unknown combinations with equally unknown effects, either therapeutic or otherwise.

3. Certain medications, including all extended release medications, cannot be crushed. They have a covering that is intended to by pass the stomach and to be digested in either the small or large intestine. Crushing them puts the individual at very high risk for GI bleeds, ulcers and perforation of the stomach which can lead to peritonitis.

4. Crush each tablet separately to prevent contamination from other drugs. Recommended: put a "souffle" cup in a counter top crusher (do NOT USE the cheap plastic twist crushers you can get at Walmart's. They do a poor job and are impossible to clean well) put a second souffle cup on top of the med and THEN crush. This method ensures that all of the medication stays in the med cup, and none gets stuck on the crusher.

5. Check with the issuing pharmacy about which meds can be mixed in the same tablespoon of applesauce. NEVER mix more than 3 together, and ensure that they are in a similar base so that they are not changing the pH (and thus inactivating) the other medication it is mixed with.

6. NEVER give medication with Calcium with other meds, or mix meds in anything that has a high calcium content (like Ensure). Calcium is a base (Ca=TUMS=antacid) Calcium negatively interacts with literally thousands of other meds. Use the same rules for Ca, and multivitamins with Ca, as are recommended for TUMS: give one hour after or AT LEAST 2 hours before any other medication.

7. For medications via tube: mix each crushed med with a minimum of 15 cc of water, 30 cc is better. Only one medication at a time. . .no mixing meds EVER)

a. stop the feeding;

b. flush with a MINIMUM of 60 cc of water (to clear the formula out of the tube)

c. administer ONE medication at a time

d. flush with a minimum of 30 CC water BETWEEN each dose of medication

e. at the end of the mad pass, flush tube again with 60 cc water BEFORE restarting the feeding.

In reply to the comments that we do not do this for individuals that we administer whole medications to: True! Because all medication has a covering that helps to protect it from interference from other meds. Once that is crushed, and the chemicals inside are exposed, all bets are off. Capsules are made of gelatin that is designed to bypass the enzymes in the mouth and stomach acid totally and dissolve in the small intestine. Once you open that capsule and pour out the contents there is no such protection.

Is all of this inconvenient? Yes. is it time consuming? yes. Is it what has to be done to ensure that the patient gets the correct medication and not some unknown combination of chemicals that may be harmful? A resounding YES!

Timing is important. We schedule all of the "none altered medication" individuals at one time as they are the fastest and easiest to do, say at 6 AM.

we schedule the individuals requiring "crushed" medications next, maybe a half hour to an hour later, say 6:30 or 7 AM depending on how many individuals we have in the whole med category and how long it typically takes to pass their meds.

Lastly we schedule the individuals requiring meds via tube as they take the longest to do.

So does the med nurse do nothing but give meds all day. . .no not really. The overnight med nurse starts 6 AM meds around 5:30. The days med nurse does meds from the time s/he comes on duty (7ish) to about 8:30-8:45 AM) We have very few 10 AM meds, so that takes about 20 minutes. Ditto for 12 N. 2 PM meds are sort of a medium size med pass so maybe an hour in all. So in an 8 hour day the med nurse is giving meds about 3 1/2 to 4 hours tops which leaves a full 4 hours for other things.Oh, and that is for 24 patients.

Where we use a primary care nurse model where each nurse gives his/her own patients meds it is a breeze.

Medication is such an important part of the medical regime, it is critical that they are administered in such a manner as to maximize their effects. Just pushing medications into folks the quickest, easiest way possible just so we can say we "gave the meds" is a true disservice to the individuals we serve.

onedayitllbeme · Jul 28, 2015

I have had CHF patients with a gtube that have between 10-15 meds at 10am. With previous suggestion we would get to half of their liquid requirement for the day by 10am with no nutrients. Here is a sample made up from my head of meds I seen scheduled for one time in an elderly for 10am

Low dose aspirin

Plavix

Lasix

Protonix liquid

Lopressor

Colace liquid

Vitamin b-12

Vitamin c

Multivitamin

Acidophilus

Seroquel

Just an example, very common though, some of those are 2 or 3 times daily

onedayitllbeme · Jul 28, 2015

I generally combine vitamins at the very least.

VANurse2010 · Aug 3, 2015

It is essential that medication be given correctly. Giving medication incorrectly at best inactivates many medications and at worst puts patients in serious jeopardy of serious, potentially life threatening, adverse drug reactions.
I have worked and administered medications to literally hundreds of individuals with developmental disabilities, TBI, significant dysphagia and other conditions that require either crushed or liquid medications over the last 20+ years. I have worked on state level work groups, along with the AMA, APA, Institute of Safe Medical Practices, pharmacy professors, and other very knowledgeable individuals to establish rules and policies for administration of medication. Here is what we have come up with:
1. Whenever possible, request the medication, or another medication with the same therapeutic effect, in liquid form. While not perfect (if you do not shake it there is very little medication at the top of the bottle and toxic levels at the bottom) for most people it is the best alternative available.
2. NEVER mix liquid medication together, or with feeding formulas such as Jevity, Boost, Ensure etc. Mixing the liquids together allows the chemicals in each medication to combine, forming new, unknown combinations with equally unknown effects, either therapeutic or otherwise.
3. Certain medications, including all extended release medications, cannot be crushed. They have a covering that is intended to by pass the stomach and to be digested in either the small or large intestine. Crushing them puts the individual at very high risk for GI bleeds, ulcers and perforation of the stomach which can lead to peritonitis.
4. Crush each tablet separately to prevent contamination from other drugs. Recommended: put a "souffle" cup in a counter top crusher (do NOT USE the cheap plastic twist crushers you can get at Walmart's. They do a poor job and are impossible to clean well) put a second souffle cup on top of the med and THEN crush. This method ensures that all of the medication stays in the med cup, and none gets stuck on the crusher.
5. Check with the issuing pharmacy about which meds can be mixed in the same tablespoon of applesauce. NEVER mix more than 3 together, and ensure that they are in a similar base so that they are not changing the pH (and thus inactivating) the other medication it is mixed with.
6. NEVER give medication with Calcium with other meds, or mix meds in anything that has a high calcium content (like Ensure). Calcium is a base (Ca=TUMS=antacid) Calcium negatively interacts with literally thousands of other meds. Use the same rules for Ca, and multivitamins with Ca, as are recommended for TUMS: give one hour after or AT LEAST 2 hours before any other medication.
7. For medications via tube: mix each crushed med with a minimum of 15 cc of water, 30 cc is better. Only one medication at a time. . .no mixing meds EVER)
a. stop the feeding;
b. flush with a MINIMUM of 60 cc of water (to clear the formula out of the tube)
c. administer ONE medication at a time
d. flush with a minimum of 30 CC water BETWEEN each dose of medication
e. at the end of the mad pass, flush tube again with 60 cc water BEFORE restarting the feeding.
In reply to the comments that we do not do this for individuals that we administer whole medications to: True! Because all medication has a covering that helps to protect it from interference from other meds. Once that is crushed, and the chemicals inside are exposed, all bets are off. Capsules are made of gelatin that is designed to bypass the enzymes in the mouth and stomach acid totally and dissolve in the small intestine. Once you open that capsule and pour out the contents there is no such protection.
Is all of this inconvenient? Yes. is it time consuming? yes. Is it what has to be done to ensure that the patient gets the correct medication and not some unknown combination of chemicals that may be harmful? A resounding YES!
Timing is important. We schedule all of the "none altered medication" individuals at one time as they are the fastest and easiest to do, say at 6 AM.
we schedule the individuals requiring "crushed" medications next, maybe a half hour to an hour later, say 6:30 or 7 AM depending on how many individuals we have in the whole med category and how long it typically takes to pass their meds.
Lastly we schedule the individuals requiring meds via tube as they take the longest to do.
So does the med nurse do nothing but give meds all day. . .no not really. The overnight med nurse starts 6 AM meds around 5:30. The days med nurse does meds from the time s/he comes on duty (7ish) to about 8:30-8:45 AM) We have very few 10 AM meds, so that takes about 20 minutes. Ditto for 12 N. 2 PM meds are sort of a medium size med pass so maybe an hour in all. So in an 8 hour day the med nurse is giving meds about 3 1/2 to 4 hours tops which leaves a full 4 hours for other things.Oh, and that is for 24 patients.
Where we use a primary care nurse model where each nurse gives his/her own patients meds it is a breeze.
Medication is such an important part of the medical regime, it is critical that they are administered in such a manner as to maximize their effects. Just pushing medications into folks the quickest, easiest way possible just so we can say we "gave the meds" is a true disservice to the individuals we serve.

If you actually did #7 to someone who's critically ill from heart failure, you could easily kill them from fluid overload.

NurseQT · Sep 21, 2015

Keatinkp's med administration plan is not practical and a follows some standards that are not accurate at all...

In all my years as a nurse I have never crushed meds separately and/or administered separately, besides ER meds that is. If you look in a drug book it will list what meds will negatively interact with the med you're looking up so you know not to give them together.. Many ER capsules can be opened and mixed with pudding or applesauce ie: omeprazole or depakote sprinkles. Kcl tablets can't be crushed but it can be dissolved in a little bit of water.

There are plenty of medications that can be mixed and administered together via tube, and a pharmacist can easily help you out with that. It was one of the pharmacists that I worked with that educated me on the ER capsules, Kcl, and meds through a TF.

As for the water flushes, I have NEVER seen such high amounts of a flush and in fact our ordering docs write orders for the amount to flush.

This plan is not patient centered, a.m. medications are given started at 0530?! That's crazy! A med pass for 24 patients should not take close to 5 hours and an overlap of shifts. I care for 28 patients, my a.m. Pass which is the heaviest takes 2 hours and I'm off the floor by 0930 at the latest..

marlen · Jun 22, 2016

Hi, the state was recently at the facility that I work, and yes we had to crushed every single medication separate, and administered one by one. The way we came up to was after popping the med we wrote the name of the medication on the med cup, that way if the patient end up not taking that one medication at least we knew what was, and properly documented. Yes it's time consuming but you know its only done when they're there.

ltcnurse4u, CNA, LPN · Jun 22, 2016

If you actually did #7 to someone who's critically ill from heart failure, you could easily kill them from fluid overload.

This is very true. I have a current patient who is NPO and has a peg. We had to get an MD order to get the okay to mix meds to prevent fluid over load.

However, 99% of my other peg tube patients, we *must* give each med separately f/b 30cc of water.

For my other patients, any one who is crushed, I do not crush them separately and mix them with either applesauce or pudding.

As a staff relief nurse, I worked at many different places before finding my "forever work home." I find it truly amazing how different each facility's polices are and at the end of the day...we are all trying to do the same thing....care for our patients the best way we know how.