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The Rectal Medication Administration Device (RMAD) Managing Symptoms at the End of Life When the Oral route Fails
Objectives • 1. What is an RMAD? • 2. Indications for the Use of the RMAD • 3. Benefits of RMAD Placement • 4. Making an RMAD • 5. Placing an RMAD • 6. Administering Medications via the RMAD • 7. Documentation
What is an RMAD? A RMAD is a device which allows for easy and comfortable administration of fluids or medications that are in solution or suspension into the rectum.
The RMAD consists of: A balloon inflation port which inflates a 10ml balloon inside the rectum A tube to carry the medication into the rectum A medication port Small holes at the end of the tube to disperse the medication onto the rectal mucosa
Placement of the RMAD in the distal 1/3 of the rectum, showing Tube secured to patients thigh for easy access to the ports. Placement of the RMAD in the distal 1/3 of the rectum. RMAD placement showing easy access to ports.
Indications • The patient is in the last days to week of life, no longer able to swallow, and: • Oral doses of liquid pain medications > 1.5ml • Symptoms spiraling out of control • Family is overwhelmed • Patient is severely Agitated • Multiple oral medications for comfort • Copious oral secretions or vomiting • Bowel obstruction • Seizures
Benefits of RMAD placement • Quick control of severe symptoms • (Pain, Agitation, SOB, Seizures < 1HR) • The patient no longer has to be repositioned for medications • Medication administration is painless • All current comfort medications can be continued
Benefits of RMAD placement • Highly cost effective • More reliable/quicker acting than transdermal gels • Families can give all medications easily by one route • Decreased chance of aspiration of medications
The RMAD Kit 1 Large Zip-lock bag 1 RMAD 1 Package water soluble lubricant 1 Mortar and Pestle 2 -10ml syringes 1-3ml syringe 1-specimen container 1- Catheter securing device 2-Clean barrier pads 1 pair- non-sterile gloves 2- Medication and Instruction Sheets 1- RMAD Quick Reference Sheet
Making an RMAD Step 1: Open one 14fr and one 16fr-5cc Foley catheter, but do not remove the 16fr catheter from its package.
Making an RMAD Step 2: Cut the valve off of the 14fr catheter
Making an RMAD Step 3: Place the cut valve (green) onto the drainage end of the16fr catheter.
Making an RMAD • Step 4: Place tape (cloth-paper tape works well) around the drainage end and valve.
Making an RMAD Step 5: Leave the finished RMAD in the package.
Assessment Guidelines Prior to Placement • Assess rectal opening for wounds, abscesses, or drainage • Assess for diarrhea or hard stool • Assess for allergy to latex, if present, use non-latex catheters to make RMAD.
Six general guidelines for administering • medications via the RMAD. • Use cool tap water (not refrigerated). • Suspend solid medications as follows: • For a small sized tablet (e.g., Valium) add 1ml water • For a medium sized tablet (e.g., Phenobarbital) add 1.5ml water • For a large sized tablet (e.g., Vicodin) add 2 ml water • Total amount should not exceed 13ml (including flush). • Instill over 5 to 10 seconds. • Tip syringe back and forth. • Always flush the RMAD with 3ml water after every dose.
Medications that can be given via RMAD • Liquid Morphine • Benzodiazepines (Ativan, Diazepam, etc.) • Barbiturates (Nembutal, Phenobarbital) • NSAID’s (excluding salicylates) • Oral steroids • Most anti-seizure Medications (not Dilantin) • Anti-nausea Medications • Resperidaland Haloperidol
Medications that cannot be given via RMAD. • Dilantin • Any “Do not Crush” Medications* • Switch to short acting given ATC • ASA and related Medication (Salicilates) • Switch to Indocin
Sample Orders for RMAD Placement and Medications. • Placement: • “RN to place Rectal Medication Administration Device 3 inches into rectum. Inflate balloon to 10ml.” • Medications: • Phenobarbital • Give Phenobarbital 400mg every 12 hours rectally • via RMAD. • Morphine (Scheduled) • Give Liquid morphine (20mg/ml) -4ml every • 4 hours rectally around the clock via RMAD.