Administration Practice Questions

1. From hospital nurse: I have a patient with swallowing difficulties. He is prescribed the
following medicines, do they come as liquids? Finasteride 5mg and amoxicillin 500mg. I
don't want him to miss a dose of his antibiotics, can I crush a tablet to give the first dose
before the tablet arrives?
2. From nurse: A patient has been assessed by SALT and has an unsafe swallow. It may be
short term and she will be reviewed in 2 days. How can we give the following
medication? Clopidogrel 75mg OD, Lansoprazole 30mg OD, Ferrous sulphate 200mg OD,
Amlodipine 5mg OD - currently on hold for 2 days, then will be reviewed. Citalopram
10mg OD, Diazepam 2mg OD, Adcal D3 1 tablet BD 750/200 units
3. 1. From ward technician: Can Naloxegol and linaclotide be administered via NG? I have
a patient on ICU that needs these.
4. From F1: I have a patient with a PEG tube needing liquid preparations. The patient
cannot have crushed meds (specified in care plan). Dispersible tablets may be alright.
Current medications: co-caraldopa25/100 every 2 hours, co-beneldopa CR 25/100 ON.
How do I give these?
5. From nurse: A patient is prescribed phenytoin via NG. He has 400mg prescribed per dose
but the liquid is 30mg in 5ml. This is a large amount to give. Does it come as a higher
concentration? We know that the feed has to be stopped. He is taking a small amount of
puree food now. He has been on phenytoin via the NG for some time now (via Derriford
and Torbay), but we want to check.
6. From children’s community nurse: I have two queries which are very similar for two
different children and concern the same medication. It is regarding levetiracetam
granules and whether they can be administered by sprinkling the sachets onto food. The
leaflets state they should be poured into the mouth which for both of your young people
who have significant additional needs will not be achievable. They can be mixed in 10ml
of water according to the leaflet but again neither of these young people take
medication in water or even drink.
One of the young people is taking the granules sprinkled onto a spoon of yoghurt and the
other is taking them sprinkled onto a spoon of Weetabix mixed with milk. Considering
the challenges both these young people present with taking liquid medication and
drinking I think that is why they have been prescribed this form of the medication. One
of the young people has just been changed from the liquid version to the granules (the
one who has it on yoghurt) and the other has recently started on levetiracetam but
already takes the granule form of sodium valproate (again on Weetabix).
Please could you advise us if administering the levetiracetam granules is appropriate on
yoghurt and Weetabix.
7. From patient’s wife: My husband has a fine bore 4 Fr JEJ tube which was blocked and
resulted in his admission. He was discharged on Monday. He was given amoxicillin liquid
but metronidazole tablets which I was told to crush and mix with water. I have been
trying to do this but they do not disperse and it's very difficult to administer. I've very
cross and upset about this. He had a dreadful discharge and I was given no information.
His community pharmacy are able to source a liquid and it's wrong that I was given the
tablets. Can I have the liquid please? I want to complain about this.
8. From PD nurse specialist: Is it possible to use thickener in Movicol? I have suggested a
switch to Lactulose for now but would be interested in your view for future reference.
This is for a Parkinson’s patient with dysphasia?
9. From Sexual health nurse: I have received a phone call from a patient. She wants to take
emergency contraception and has been to Boots to enquire about it. She told them that
she cannot swallow tablets and she was told that she could not crush the tablets and
they refused to provide the medication. I would like to check with you if either Levonelle
or Ella one can be crushed.
Answers
No. Databank Question
No.
1 21195 I have a patient with swallowing difficulties. He is
prescribed the following medicines, do they come as
liquids?
Finasteride 5mg
amoxicillin 500mg
I don't want him to miss a dose of his antibiotics, can I
crush a tablet to give the first dose before the tablet
arrives?
2 21042 A patient has been assessed by SALT and has an
unsafe swallow. It may be short term and she will be
reviewed in 2 days. How can we give the following
medication? Clopidogrel 75mg OD, Lansoprazole 30mg
OD, Ferrous sulphate 200mg OD, Amlodipine 5mg OD -
currently on hold for 2 days, then will be reviewed.
Citalopram 10mg OD, Diazepam 2mg OD, Adcal D3 1
tablet BD 750/200 units
Answer
Answer
Finasteride cannot be crushed as this exposes females to potentially
harmful medication. However, the tablet can be dissolved using the
closed system, where the tablet is placed in the barrel of a syringe
and approximately 10ml of water drawn up to dissolve the tablet.
This solution can then be administered orally
Please note that the use of finasteride in this way would be off-
license
Amoxicillin are available from pharmacy as liquid. Antibiotic tablets
should never be crushed as it can lead to sensitivity reactions in
nurses if the powder is breathed in. Pharmacy can arrange an urgent
supply for you.
Clopidogrel - you can crush the tablets but this will be off -license
Lansoprazole - switch to using orodispersible.
Ferrous sulphate - switch to Sytron 5ml TDS, then adjust according
to iron levels.
Amlodipine - we usually keep a liquid, but we don't currently have
any. As it's on hold for now, we will order some more in for when
the patient is reviewed.
Citalopram - switch to oral drops. 4 drops = 10mg
Diazepam - switch to liquid
Adcal D3 - switch to soluble. Because the strength is different, it will

3 20964 Can Naloxegol and linaclotide be administered via NG?
I have a patient on ICU that needs these.
4 17044 I have a patient with a PEG tube needing liquid
preparations. The patient cannot have crushed meds
(specified in care plan). Dispersible tablets may be
alright.
Current medications:
co-caraldopa25/100 every 2 hours
co-beneldopa CR 25/100 ON
5 17064 A patient is prescribed phenytoin via NG. He has
400mg prescribed per dose but the liquid is 30mg in
5ml. This is a large amount to give. Does it come as a
just be 1 soluble tablet OD of 1500/400units.
Please speak to the Dr about changing the prescription for the Adcal
D3 and ferrous sulphate. We will order the required medicines and
send them up to the ward.
Naloxegol tablets can be crushed and dispersed in 120ml of water
and administered via NG. It is important that the NG tube is flushed
well after administration. This is listed in the SmPC so this practice is
licensed.
Linaclotide capsules can be opened, the contents sprinkled into
water and the resulting solution administered via NG. This practice
is unlicensed.
co-caredopa (SINEMET) 100/25 - direct switch to madopar 125mg
disp tablets
co-beneldopa cr (MADOPAR) - mr caps/CAPS/DISPERSIBLE TABLETS
give an extra dispersible 25/100 at night same time - if is affecting
PD control especially in morning then consider splitting to 62.5 on
and early am
There is not an easy answer to this. Giving phenytoin via a feeding
tube is very difficult as the absorption can vary enormously
depending on the patient's bowel function, other food, and
 higher concentration? We know that the feed has to
be stopped. He is taking a small amount of puree food
now. He has been on phenytoin via the NG for some
time now(via Derriford and Torbay), but we want to
check.
6 20180 From children’s community nurse: I have two queries
which are very similar for two different children and
concern the same medication. It is regarding
levetiracetam granules and whether they can be
administered by sprinkling the sachets onto food. The
leaflets state they should be poured into the mouth
which for both of your young people who have
significant additional needs will not be achievable.
They can be mixed in 10ml of water according to the
leaflet but again neither of these young people take
medication in water or even drink.
One of the young people is taking the granules
sprinkled onto a spoon of yoghurt and the other is
taking them sprinkled onto a spoon of Weetabix mixed
with milk. Considering the challenges both these
young people present with taking liquid medication
and drinking I think that is why they have been
prescribed this form of the medication. One of the
young people has just been changed from the liquid
version to the granules (the one who has it on
adsorption to the tube. If given via a tube, the feed must be stopped
for 2 hours before and after, and the tube must be flushed with
60ml of water after administration.
If your patient can manage to swallow some pureed food, it might
be better to open the capsules, and mix the contents into the puree
for him to swallow. This would be less problematic than giving via
the feeding tube.
Thank you for your enquiry about the administration of
levetiracetam granules in two children with limited oral intake. You
explained that the granules are currently sprinkled onto yogurt or
Weetabix mixed with milk before administering.
The manufacturer advises that levetiracetam granules can be taken
with or without food, and the efficacy is not affected. They do state
that the granules should not be chewed as they are bitter. There are
no interactions between levetiracetam and any foods.
Therefore, sprinkling the levetiracetam granules onto soft food is a
safe way to administer the medication to your patients.
There is also a website that I thought might be useful for you as it
gives information and advice on administering medications to
children, including levetiracetam granules:
www.medicinesforchildren.org.uk
I hope that this information is helpful. Please get in touch if you
have any further questions or other enquiries.
 yoghurt) and the other has recently started on
levetiracetam but already takes the granule form of
sodium valproate (again on Weetabix).
Please could you advise us if administering the
levetiracetam granules is appropriate on yoghurt and
Weetabix.From patient’s wife: My husband has a fine
bore 4 Fr JEJ tube which was blocked and resulted in
his admission. He was discharged on Monday. He was
given amoxicillin liquid but metronidazole tablets
which I was told to crush and mix with water. I have
been trying to do this but they do not disperse and it's
very difficult to administer. I've very cross and upset
about this. He had a dreadful discharge and I was
given no information. His community pharmacy are
able to source a liquid and it's wrong that I was given
the tablets. I want to complain about this.
7 20357 My husband has a fine bore 4 Fr JEJ tube which was I'm sorry that you've had such a difficult time and that your
blocked and resulted in his admission. He was husband's discharge wasn't better managed.
discharged on Monday. He was given amoxicillin liquid
but metronidazole tablets which I was told to crush It was actually right that your husband wasn't given the liquid from
and mix with water. I have been trying to do this but of metronidazole. The type of metronidazole in the liquid needs to
they do not disperse and it's very difficult to be broken down by the acid in the stomach before it can be
administer. I've very cross and upset about this. He absorbed. As your husband's tube bypasses his stomach, the liquid
had a dreadful discharge and I was given no metronidazole wouldn't be effective at all for him. In these
information. His community pharmacy are able to situations, crushed tablets can be used instead as the type of
source a liquid and it's wrong that I was given the metronidazole in the tablets doesn't need to be processed by the
tablets. Can I have the liquid please? I want to stomach acid.
complain about this.
However, the problem for your husband is that he has a particularly
small tube and so the tablets are not flushing down well.

8 20363 Is it possible to use thickener in Movicol or would this
affect efficacy?
I have suggested a switch to Lactulose for now but
would be interested in your view for future reference
This is for a Parkinson’s patient with dysphasia?
9 21802 I have received a phone call from a patient. She wants
We discussed whether your husband was able to take rectal
medicines as the metronidazole is available as suppositories. You
felt that this would be OK and so I arranged for a new prescription
to be written and the suppositories to be delivered out to you by
taxi.
Thank you for your enquiry regarding thickening Movicol for a
patient with swallowing difficulties.
There is an interesting article on the specialist pharmacy services
website that provides information on this topic. It states that starch-
based thickeners should not be used. When Movicol is mixed with a
starch-based thickener the Movicol became a thin watery liquid
essentially undoing the act of thickening.
Movicol should only be thickened with xanthan gum based
thickening agents. However not all gum based thickening agents are
the same and it appears that thickening agents based on carob gum
(also called locust bean gum) are not suitable for thickening
Movicol.
I have found a xanthan-based thickener called Swalloweze Clear
that gives instructions on how to thicken Movicol and to different
consistencies.
I have attached the Swalloweze Clear instructions to this email.
If Movicol thickened with Swalloweze Clear is not appropriate, you
would have to consider an alternative laxative like lactulose as you
suggested.
Discussed with the nurse. They have already explored the IUD
to take emergency contraception and has been to
Boots to enquire about it. She told them that she
cannot swallow tablets and she was told that she
could not crush the tablets and they refused to
provide the medication.
I would like to check with you if either
Levonelle or Ella one can be crushed.
option. Unfortunately, there is no one who can perform IUD
insertion and given that the patient has autism she is likely to refuse
it. The nurse will explore this option with her when she speaks to
her on the phone.
There is no data for crushing EC. There are two primary concerns:
safety and efficacy.
Generally hormonal tablet if crushable is dissolved in a 'closed
system' where a tablet is placed in an oral syringe to be dissolved in
water and given via the oral syringe. This can prevent any inhalation
of the power or fume by the others. If oral syringe is not available
the patient can try to dissolve it in a cup of water with no one
around to minimise the risk of exposure to others.
Efficacy may be reduced but the odds of successful contraception is
higher than not taking any EC. Again, there is no data on this.
Patient has capacity to make an informed decision and the nurse
will discuss with her.