Most nurses will agree medication administration through an enteral tube is one of the more complicated medication passes. Administering medications via enteral tubes are based on nursing assessment of the resident condition, in consultation with the physician and consultant pharmacist. To be able to administer medications through the enteral tube, the medication must be able to pass through the tube via gravity with the assistance of flushing the tube with water. This can be accomplished by using liquid forms, crushing tablets, or opening capsules.
Prior to crushing tablets or opening capsules for administration through the enteral tube, the nurse must consult appropriate medication crushing guidelines.
Solid dose forms of many medications should not be crushed for a variety of reasons:
- Sublingual and Baccal tabs are designed to dissolve in the oral fluids of the mouth for rapid and more complete absorption than is possible in the stomach. Many of these medications are destroyed by the gastric juices in the stomach. If sublingual form is ordered by the physician, it should be administered sublingually only.
- Enteric Coated tablets are designed to pass through the stomach whole and then dissolve in the intestinal track. These are designed to prevent the destruction of the medication by stomach acid, to prevent the medication from irritating the stomach lining, or to achieve a prolonged action from the medication.
- Time Released medications are designed to release medication over a sustained period, usually 8 to 24 hours.
- Time Released Capsules have beads within the capsule that are designed to dissolve at different times; these beads should not be crushed.
- Time Released Tablets are used to reduce stomach irritations in some cases and to achieve prolonged medication action in other cases. Sometime released tablets may include: Slow Release Core, where the outer coating may dissolve immediately to provide an initial dose of medication followed by the slow dissolving of the tablet core to provide a prolonged dose of the medication.
- Mixed Release Granules, this tablet is made of individual granules with varying rates of dissolution.
- Multilayer tablets are usually composed of two or three layers with one layer designed to dissolve rapidly to provide immediate action and the remaining layers dissolved at much slower rates to provide sustained release.
- Porous Inert Carriers are plastic or wax matrix tablets with thousands of passages filled with medication. The medication leaches out of the passages very slowly. Nurses may have been informed by staff that the plastic or wax tablet was found in a resident’s stool. This is a normal finding with this type of formulation.
- The consultant pharmacist needs to be made aware of all residents that require crushed meds, so he can advise the facility of safety issues and alternatives, if appropriated, during his monthly medication regimen review.
- The pharmacy can also be consulted for guidance on medications that should not be crushed. An alternate form or comparable medication that can be crushed can be recommended to the physician. If the prescriber insists crushing a “non-crushable” medication a SPECIFIC order must be obtained from the prescriber for crushing that particular medication. Also, a physician order must be obtained to change a dosage form.
- Nurses should also be reminded that medications that are GI irritants (such as potassium chloride solution) should be diluted, as recommended for oral administration, before administering via enteral tube.