Help with Medications

By: Simone Stenekes RN, MN, CHPCN(C), CNS and Lisa Streeter

Medications are commonly used to help manage pain or other symptoms that are troubling.  It is important to know about the medications that you are prescribed: how much to take, when to take them, why you are using them, potential side effects that might be expected and what to do about them.

Be sure to discuss your medications (both the ones you are prescribed and medications or herbal supplements that you may consider taking from a pharmacy or health store) with your health care team and pharmacist. They will advise you about how best to manage your medications.

There are two important points to follow with medications:

• Keep track of the medications that are taken.
• Keep the medications organized.

Ideally these tasks should be organized by a single person. Anyone else who visits can be asked to work within whatever system has been established.

If you are helping someone take pills or tablets at the appropriate time, there are a few simple rules to follow:

• Wash your hands before touching any medication.
• As with eating, help the person to sit comfortably and upright to make swallowing comfortable.
• Offer the person a drink of water prior to taking a pill. Moistening the mouth will make swallowing easier.
• Follow specific instructions for giving the medication. For example, the label may specify that it needs to be given with milk or food.
• If the person is having difficulty swallowing the pills, try mixing them with applesauce, jam, ice cream or pudding to help move the pills down the throat. Check with a pharmacist before changing how medications are delivered, as some medications should not be crushed or removed from a capsule. It also may be necessary to consider alternative ways to give medication.

Often pain relievers or other types of medications will be prescribed to help manage symptoms that flare up between doses of scheduled medication. These are commonly called “breakthrough medications”, “PRN”, or “as needed” medications.  It is helpful to write down and keep track of what was happening at the time of the flare up.  This information can help your health care team decide if adjustments should be made in your medications.

You may want to consider keeping track of your use of breakthrough medications using a pain diary or symptom diary. Answers to these questions are helpful diary entries:

• Can you describe the symptom? (Where did it happen? How strong? What did it feel like?)
• What medication was given? (How much? What time?)
• How effective was the medication? (Did it completely relieve the symptom or partially?  How long did it take to work?)
• What seemed to be happening at the time of the flare up?(What were you doing and feeling at the time?)

Here is an example of a symptom diary you can download and use.
 

Alternatives to swallowing

Swallowing tends to become more difficult near the end of life. This may be due to the disease, to general weakness, or to the fact that the person is not as alert.

Often one of the first clues a person is having trouble swallowing is when they experience a sensation of choking or an episode of coughing after eating or drinking. If you see this happening, let the health care team know.

When swallowing medications is no longer possible, the health care team may want to consider other methods of delivering medication. There are several alternatives.

Under the tongue or through the lining of the mouth
(Sublingual or Buccal)

Medications can be given sublingually or buccally. This means a liquid or pill is placed under the tongue (sublingual) or in the space between the cheek and gums (buccal) so that the medication is absorbed into the blood stream.

The large number of blood vessels under the tongue and in the cheek helps the medication to be absorbed into the body. The hope is that most of the medication is absorbed in the mouth, but some of it will likely be swallowed or trickle slowly down into the esophagus and the stomach.

When administering a medication this way, only a small amount should be given at a time. A general rule is to administer no more than 1 milliliter (1cc) by this route at one time. If a dose is greater than 1 milliliter, then it should be divided into two doses and given about 5 to 10 minutes apart.

Individuals at the end of life often have a dry mouth, so it is essential to provide frequent mouth care. Sometimes mouth care may be needed before administering a dose by the sublingual or buccal route, to ensure the medication is well absorbed.
See also: Care of the Mouth

The sublingual or buccal route can be more challenging to use when someone is experiencing shortness of breath, because the person may have difficulty holding medications under the tongue.  If this is the case, another method may be more suitable.

Through the skin (Transdermal)

The transdermal route involves applying medication directly to the skin. Typically these medications can be applied either as a lotion or gel, or in the form of a patch. Several types of medications can be given this way, including pain medications and medications for nausea or increased secretions.

A common pain medication patch is the fentanyl patch. This is used for people who have stable, chronic (recurring) pain and require scheduled pain medication. When using a patch, follow the directions on the packaging and change the patch as ordered by your physician. Try not to get the patch wet. It is important to dispose of a patch properly, as there may still be some medication left in it, which could harm a child or pet.

People receiving pain medication through a patch will also require short-acting medication in case there are episodes of increased pain. This short-acting medication can be given by various methods.

Under the surface of the skin (Subcutaneous)

A subcutaneous infusion or injection involves using a needle to send medicine into the fatty tissue under the surface of the skin. Medication that is administered regularly under the skin is often given through a device that looks similar to an intravenous. This is left in the fatty tissue of the skin to prevent a needle poke each time a medication is required.

Health care providers often teach family caregivers how to inject medications into the subcutaneous device.

Into the nose (Intranasal)

Your health care team or pharmacist may suggest squirting a liquid medication through a device that creates a fine mist in the nose. The medication is then absorbed into the blood vessels in the nose and circulated through the body. A benefit of this method is that it is easy to use and medications start working minutes after the dose is given.

Generally about 1 milliliter (1cc) of medication can be given into a nostril at a time. If the dose is greater than this, it can be divided into two doses (each given in a separate nostril). Some medications may be irritating to the lining of the nose and may not be well suited to this method. Also, if many medications are required, only some of them may be administered through the nose.

Into the rectum (Rectal) 

The rectal route involves administering medications through the rectum and into the large intestine, where the medication is absorbed. It is important that there is no stool in the rectum. Otherwise, the person may defecate and force out the suppository before it is fully dissolved.

To help someone with a suppository, you will need a glove and petroleum jelly or some other lubricant for the anal area. Suppositories should be well lubricated and pushed as far into the rectum as the gloved forefinger can reach.

This route is usually a last resort, as families are often concerned about the dignity of the person being given the medication. With the availability of the sublingual, transdermal or subcutaneous routes, the rectal route is not commonly required for pain medication administration.

See Videos
Administering medications - Applying a medicated patch
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Administering medications - Giving medications by mouth
Administering medications - Giving medications through the nose
Administering medications - Giving medications under the tongue
Administering medications - Giving medications by suppository