Journal of Community Nursing - page 84

84 JCN
2013,Vol 27, No 4
implification and switches:
have new formulations become
available that are more
Once the need for each medication
has been established it is important
to consider the formulation. Most
medicines are prescribed as tablets
and capsules and sometimes simple
adjustments to their shape and
size can overcome problems with
Patients generally prefer torpedo-
shaped medicines and, therefore,
asking the pharmacy to change the
shape or size of a tablet may be all
that is required. In some instances it
may be appropriate for the patient to
chew a medicine before swallowing,
however, the coating and formulation
requires consideration as does the
palatability of the resultant mixture.
Chewing, crushing, or dispersing
a tablet can cause a previously
palatable tablet to become inedible
or unpleasant and, therefore,
patients should always be asked
about acceptability.
Unfortunately, patients with a
learning disability might struggle
to communicate this information.
Therefore, a speech and language
therapist may involve the patient
and the carers in preparing a
communication passport. These
are small booklets that include the
patient’s personal likes and dislikes
and which use past experiences,
history and current information
to help the clinician recognise the
individual within the situation.
If tablets cannot be swallowed, an
alternative liquid medicine or route
of administration (such as patches,
oro-dispersibles, or suppositories)
should be considered. Licensed
liquid medicines are not the same as
crushed or dispersed tablets as they
are designed to be palatable and have
an even drug distribution, ensuring
that the patient receives the full
measured dose.
Unlike thin fluids or tablets
dispersed in water, liquid medicines
are designed to cohere during
swallowing and, therefore, minimise
the risk of aspiration. As stated
earlier, thickeners should be used
with caution as they may alter the
effect of the medicine, taking it
outside the terms of its license.
Where licensed liquids are
unavailable then unlicensed‘specials’
might be available. A special is
a specific preparation, usually a
variation of a licensed medication,
made by a specialist manufacturer
or pharmacist and which has
not undergone the same testing
procedures as a medicine. However,
in most clinical cases, licensed
preparations should be considered
before unlicensed products or
unlicensed activities, such as tablet
crushing or dispersing.
Tablets and capsules are
frequently designed to optimise
how and where a drug is released
into the body (e.g. gastro-resistant
coatings and modified-release
preparations), or are coated to mask
the medicine’s flavour (e.g. film and
sugar coatings). Crushing, dispersing
or chewing tablets/capsules to
make them easier to swallow can
significantly affect how and where
the drug is released into the body
and, therefore, the consequences
of such actions should always be
considered. Simple products such as
ibuprofen are sugar- or film-coated
to disguise their flavour and any
tampering before administration
can make them very unpleasant for
patients, who may simply refuse
them if they are unable to effectively
communicate their distaste.
Enteric or ‘gastro-resistant’
coatings are designed to either
protect the drug from stomach
acid, i.e. omeprazole; protect the
stomach lining from the drug itself,
i.e. diclofenac; or to release the
drug where it needs to work, i.e.
sulfasalazine. Therefore, it is not
appropriate to tamper with the
coating before it is taken.
Modified-release preparations
should never be crushed, dispersed
or chewed as the resultant release
of the full dose increases the chance
of side-effects. Also, as the body will
subsequently excrete the full dose
more quickly, there will be a period
when there is not enough of the
medication remaining in the body for
it to work.
Learning disability patients may
have difficulty in swallowing and
involuntarily grind their teeth. In this
case, a modified-release preparation
is best avoided unless absolutely
necessary, i.e. if an alternative
preparation cannot be sourced.
Community pharmacists
If a community nurse is faced with a
patient with a learning disability and
dysphagia, he or she should contact
the patient’s community pharmacist
to determine what formulations are
available and the safe options for
administering any medication.
All medicines should be
administered in strict accordance
with the conditions of their licence,
i.e. without prior tampering. The
Human Medicines Regulations 2012
only allow independent prescribers to
authorise unlicensed administration
of medicines to patients. However,
crushing, dispersing, and mixing can
be undertaken by a person acting
under the written instructions of an
independent prescriber.
Answer the following questions
about this article, either to test the
new knowledge you have gained or
to form part of your ongoing practice
development portfolio.
1 – What is dysphagia?
2 – Name some of the symptoms
of dysphagia.
3 – Outline some of the problems
with eating and drinking for
people with a learning disability
and dysphagia.
4 – Name some of the primary issues
in administering medicine to this
patient group.
5 – Can you explain the principles
behind the concept of‘duty
of care’?
Five-minute test
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