(2004) Administering subcutaneous methotrexate for inflammatory

HOB PCT LOGO

Protocol For Registered Rheumatology Nurses To

Administer Subcutaneous Methotrexate And To

Educate Patients And Carers In The

Self-Administration Of Subcutaneous Methotrexate

CATEGORY:

CLASSIFICATION:

PURPOSE

Controlled Document

Number:

Procedural Document

Clinical

This protocol supports the administration, by registered rheumatology nurses, of subcutaneous methotrexate, (a cytotoxic agent) for patients with rheumatic disease. In addition it supports registered nurses to educate, support and monitor the patient and carers’ self-administration of methotrexate.

Version Number:


Sponsor:


Lead:

Approved By:

Rheumatology Nurse Consultant

On:

Review Date:

Distribution:



Essential Reading for:



Information for:

Rheumatology Nurse Consultant

Clinical Service Lead

November 2008

October 2011

All registered rheumatology nurses who currently undertake this practice and all registered rheumatology nurses who wish to expand their practice to include this skill.

All registered clinical staff

Document index no: Page 1 of 20

Protocol for registered rheumatology nurses to administer subcutaneous methotrexate and to educate patients and carers in the self administration of subcutaneous methotrexate.

EVIDENCE FOR PRACTICE

The efficacy of oral methotrexate in rheumatology is well established (Maini,

2003) and is recognised as the gold standard for treating people with a range of rheumatological disorders.

Currently inflammatory joint disease is being treated earlier and more aggressively with optimisation of the methotrexate dose in order to control symptoms and disease progression (Porter et al 2003). This approach can be limited due to poor tolerability of the oral form of the drug. Giving methotrexate by the subcutaneous route improves drug tolerability and therefore patients who could not otherwise be treated can benefit.

Patients with a variety of rheumatological conditions attend rheumatology nurse led clinics to be taught how to self-administer their own subcutaneous methotrexate. When patients prefer not to self-administer the therapy a carer can be taught to administer the injection. Although the quantities of methotrexate used in rheumatology practice are small, methotrexate is a cytotoxic drug. Therefore, registered nurses, patient and carers require appropriate training to ensure safe administration (Hiley et al 2008) (Appendix

3). This includes handling of accidental spillage, and injection technique.

Appropriate follow up and telephone support are also required.

Some GP’s are reluctant to engage in prescribing and supervising the treatment because of a lack of knowledge in this specialist area and concerns about cytotoxic drugs and their disposal.

Experience of training patients/ carers to administer methotrexate by the subcutaneous route at University Hospital Birmingham NHS Foundation Trust

(UHB), has enable more patients able to receive therapy, has reduced the number of hospital visits for the individual patient and patients have become more involved in their care.

Initially a registered rheumatology nurse competent in the administration of subcutaneous methotrexate will initially administer the injections to the patient in the rheumatology outpatient clinic as prescribed. Patients/carers will receive written information devised to support this document and the arthritis research campaign and these will be discussed with the patient.

Patients are followed up on a regular basis until stable on treatment. Blood monitoring is carried out in accordance with the hospitals monitoring protocols.

CONSENT

1. Although formal written consent is not required for minor procedures, verbal consent for the procedure must be obtained where possible and this must be documented on the patient’s record.

2. If the patient is unable to give their consent, the registered practitioner must act in accordance with the Mental Capacity Act (2005) and document



in the patient's notes why they believe the procedure to be in the patient's best interests, including any involvement from other health professionals, family or carers in reaching that decision.

INDICATIONS

1. An independent non medical prescriber who is providing nurse led care for the patient will prescribe licensed subcutaneous methotrexate for the patient and adjust the methotrexate dose in accordance with the local hospitals monitoring protocol.

2. The referral criteria for patients who may be considered suitable for self-administration of subcutaneous methotrexate include:



Inefficacy of oral methotrexate at a dose of up to 20mgs per week



Loss of efficacy of oral methotrexate at a dose of up to 20mgs per week



Evidence of mucosal irritation and gastrointestinal side effects such as nausea and diarrhoea caused by oral methotrexate



Where efficacy is not established following a prior trial of oral methotrexate and there is a likelihood that the patient may require the use of anti-tumour necrosis factor therapy.

3. Following referral, patients and carers will be assessed and where appropriate selected for training to follow a programme of tuition for self/carer injection of subcutaneous methotrexate at home. This will involve assessing the patient or carer’s:



Willingness to administer injections



Ability to administer injections



Ability to safely store and transport injections



Knowledge of reasons for the therapy, how to administer the injections subcutaneously, recognition and action when experiencing side effects, attendance for monitoring and follow up, dealing with spillage, disposal of sharps and waste and self care whilst at home. See patient/carer education package and competencies (Appendix 3)

4. The registered rheumatology nurse will assess the patient’s/carer’s understanding of the process by discussing the training programme with them (Appendix 3)

CONTRAINDICATIONS

1. The patient is under the age of 16

2. The patient refuses treatment/the training programme

3. Patients and carers will be excluded from self-administration if they:





Are unable to administer the injection because of poor dexterity as indicated in a practical demonstration to the rheumatology nurse



Show poor concordance with attendance and monitoring



Are unable to safely store the methotrexate injections at home or are unable to demonstrate an understanding of the need for safe storage

(including that the drug, syringes & needles must be kept where children cannot access them)



Demonstrate a lack of understanding of the safety and self care requirements

4. If, in the registered rheumatology nurse’s professional opinion, the patients’ condition requires that the injection should not be administered.

(E.g., skin rashes, infection, neutropenia, leucopenia, thrombocytopenia, abnormal liver function tests, pregnancy, breast-feeding and planning to conceive) the registered rheumatology nurse will seek a medical opionion.

LIMITATIONS TO PRACTICE

The patient will be referred for a medical opinion if they:

1. Develop a new health problem

2. Existing health problems require medical supervision

3. Have poorly controlled side effects

4. Have evidence of developing a blood dyscrasia

5. Have failed to respond to treatment and there is evidence of disease progression

6. Have toxicity related to methotrexate therapy

CRITERIA FOR COMPETENCE

1. Registered rheumatology nurses will attend an initial Trust in-house course on chemotherapeutic agents and attend an update bi-annually.

2. Evidence of satisfactory supervised practice must be provided by the registered rheumatology nurse and witnessed by a practitioner who is already competent in the administration of subcutaneous methotrexate

(Appendix 2).

3.

The number of supervised practices required will reflect the individual registered rheumatology nurse ’s learning needs.

4. Evidence of competence must be provided and a copy kept in the registered rheumatology nurse ’s personal file and in the department where the skill is practiced. (Appendix 1)



5. Registered rheumatology nurses working in HOB musculoskeletal and rheumatology service who are responsible for teaching patients and carers to administer subcutaneous methotrexate, must be fully conversant with the Trusts’ policy on handling, spillage and administration of cytotoxic drugs.

6. Evidence of continuing professional development and maintenance of skill level will be required and checked on an annual basis by the registered rheumatology nurse’s line manager.

7. A practitioner who is already competent in the administration of subcutaneous methotrexate and the teaching of patient’s to administer subcutaneous methotrexate, will assess registered rheumatology nurses new to the Trust, who have been administering and teaching and carers to administer subcutaneous methotrexate elsewhere. This will include:



Introduction to the Trust’s protocol, standards of care and training requirements



Attendance on the a course course on chemotherapeutic agents



Provision, by the registered nurse, of evidence of satisfactory education, supervised practice and competence



A formal, practical assessment of the registered rheumatology nurse in the administration of subcutaneous methotrexate and in the ability to teach and monitor patients and carers.

PROTOCOL AND SKILLS AUDIT

The rheumatology nurse consultant, will lead the audit of the protocol with support of the clinical governance department. The audit will be undertaken in accordance with the review date.

The audit will include:

1. Adherence of staff to the protocol

2. Untoward incidences and adverse events arising from the administration of subcutaneous methotrexate administered by nurses in the department and by patients and carers at home and in the hospital setting Eg. allergy, inoculation injury, spillage etc.

3. Details of those patients declining treatment and those referred for a medical assessment

4. Any adverse drug reactions with methotrexate that are reported on a yellow report card and forwarded to the centre for adverse drug event reporting

5. Any identified problems relating to patients/carers ability to obtain injections, giving injections, spillage, local skin irritation and disposal of sharps

6. Patient satisfaction with:



The teaching procedure and information for patients/carers

(Appendices 2 & 3)





Giving the injections



The service provided by the rheumatology nursing team

All audits will be logged with the Clinical Governance Support Unit.

CLINICAL INCIDENT REPORTING AND MANAGEMENT

Any untoward incidents and near misses should be dealt with by the appropriate management team. An incident form must be completed. The risk management team must be notified by telephone of any serious untoward incidents.

A list of registered rheumatology nurses competent to perform this skill will be kept by the rheumatology nurse consultant.

REFERENCES

Hiley J, Homer D, Clifford C (2005) Patient self-injection of methotrexate for inflammatory arthritis: a study evaluating the introduction of a new type of syringe and exploring patients’ sense of empowerment. Musculoskeletal Care

6(1):15-30

Maini RN, Ferdinand CB, Kalden JR Smollen JS, Davis D, Macfarlane JD,

Elliott MJ, Woody JN, Schaible TF, Feldmen M (1998) Therapeutic efficacy of multiple intravenous infusion of anti-tumour necrosis factor alpha monoclonal antibody combined with low dose weekly methotrexate in rheumatoid arthritis.

Arthritis and Rheumatism 41(9):1552-1563.

Porter D R, Grigor C, Stirling A, Capell H (2003) A randomized controlled trial of a strategy of tight control of disease activity in rheumatoid arthritis:

Outcome over 18 months: Glasgow: Gartnavel General Hospital and Glasgow

Royal Infirmary.

University Hospital Birmingham NHS Foundation Trust. Guidelines for the treatment and monitoring of methotrexate therapy. University Hospital

Birmingham NHS Foundation Trust, Birmingham. www.uhb.nhs.uk/depts/rheumatology/clinicians/guidelines.htm

BIBLIOGRAPHY



Arthur VAM, Jubb RW, Homer DC (2002) A study of parenteral use of methotrexate in rheumatic conditions Journal of Clinical Nursing 11:256-

263.

Arthur VAM, Jubb RW, Homer DC (2001) Self Injection of Gold and

Methotrexate Journal of Rheumatology 28(1):212.

Arthur VAM, Jubb RW, Homer DC (2000) Study of parenteral use of methotrexate in rheumatic conditions Rheumatology Abstracts Supplement

May P.167.

Brookes PJ, Spurill WJ, Parish RC and Birchmore DA (1990) Pharmokinetics of methotrexate administered by intramuscular and subcutaneous injections in patients with rheumatoid arthritis. Arthritis and Rheumatism ; 33:91-95.

Dougherty, L. Lister, S. (2005) (Eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures Sixth Edition. Blackwell Publishing, Oxford.

Nursing and Midwifery Council (2007) Standards for Medicines

Management . Nursing and Midwifery Council, London.

Royal College of Nursing (1998) Clinical Practice Guidelines: The administration of cytotoxic chemotherapy recommendations, Royal

College of Nursing, London.

Royal College of Nursing (2004) Administering subcutaneous methotrexate for inflammatory arthritis Royal College of Nursing, London.

Suarez-Almazor ME, Belseck E, Shea B, Wells G, Tugwell P (1997)

Methotrexate for Rheumatoid Arthritis, The Cochrane Library, Systematic

Review.

November.

Wallace CA (1998) The use of methotrexate in childhood rheumatic diseases.

Arthritis and Rheumatism 41; 3: 381-391



PROTOCOL SUBMISSION DETAILS

Protocol Reviewed by: University Hospital Birmingham NHS foundation

Trust

Dawn Homer

Emily Hartwell

Dr Jubb

Rheumatology Nurse Consultant

Associate Director of Pharmacy- Clinical Services

Consultant Rheumatologist

Elaine Spellman

Louise Denner

Lead Chemotherapy Nurse

Practice Development Nurse



Appendix 1

HOB PCT

CRITERIA FOR COMPETENCE

END COMPETENCE: PROTOCOL FOR REGISTERED RHEUMATOLOGY NURSES TO ADMINISTER SUBCUTANEOUS METHOTREXATE AND TO EDUCATE

PATIENTS AND CARERS IN THE SELF-ADMINISTRATION OF SUBCUTANEOUS METHOTREXATE

Date(s) of Education and supervised practice: …………………………………………….

Name of Registered Rheumatology Nurse:

…………………………………………….

Name of Supervisor: …………………………………………….

Element of Competence To Be Achieved Date Achieved Registered

Rheumatology

Nurse Sign

Supervisor Sign

Discuss the rationale for the administration of subcutaneous methotrexate in rheumatic conditions in relation to the:



Indications for use



The classification of methotrexate as a cytotoxic agent



Effects of methotrexate on the cell cycle



The possible side effects, their likelihood and severity

Discuss contraindications for the administration of subcutaneous methotrexate as stated in the protocol

Discuss the referral criteria for patients with rheumatic conditions to receive a programme of self injection of subcutaneous methotrexate

Discuss the need for the adjustment or to the withholding of an existing methotrexate prescription in relation to



Side effects



Lack of efficacy



The patient ’s current haematological results



The patient ’s current health status

Discuss limitations to practice as stated in the protocol

Discuss the Trust Policy in relation to the following



Transportation of methotrexate between pharmacy and rheumatology outpatients



Storage of methotrexate in the outpatient clinic



Safe handling of methotrexate



Disposal of waste and equipment used during the administration

Element of Competence To Be Achieved Date Achieved Registered Supervisor Sign



Rheumatology

Nurse Sign

Discuss accountability in relation to the administration of subcutaneous methotrexate

Demonstrate accurate record keeping in relation to subcutaneous administration of subcutaneous methotrexate

Discuss how maintenance of competence will be ensured

Demonstrate the ability to organise the clinics, organise supplies of methotrexate and plan a programme of care for the individual patient

Demonstrate the following for patients referred for subcutaneous methotrexate:



Correct patient assessment and history taking



Appropriate selection of patients/carers for the self administration programme



Correct provision of written informed consent from the patient/ carer



Correct provision of information for patient/carers. This must include both verbal and written information on all aspects of the treatment, self care and action to be taken in the event of side effects



Correct documentation of evidence of training provided to the patient



Arranging appropriate follow up



Knowledge of the mechanisms by which the patient should contact the department/pharmacy/nursing team

Demonstrate safe administration of subcutaneous methotrexate

Demonstrate provision of correct patient information and education using the patient education pack (Appendix 3)

Demonstrate the actions to be taken in the following circumstances:



Skin, eye, or mucosal contamination with methotrexate



Spillage of methotrexate



Anaphylactic reaction

Discuss the rationale for folic acid supplementation in patients receiving subcutaneous methotrexate therapy.

Demonstrate adherence to the UHBFT infection Control policy throughout the procedure

Demonstrate knowledge of the UHBFT incident reporting process

I declare that I have expanded my knowledge and skills and undertake to practice with accountability for my decisions and actions.

I have read and understood the PROTOCOL FOR REGISTERED RHEUMATOLOGY NURSES TO ADMINISTER SUBCUTANEOUS METHOTREXATE AND TO

EDUCATE PATIENTS AND CARERS IN THE SELF-ADMINISTRATION OF SUBCUTANEOUS METHOTREXATE



Signature of Registered Rheumatology Nurse:

…………………………………………Print name:………………………………..

Date: ………………………………………………

I declare that I have supervised this registered rheumatology nurse and found her/him to be competent as judged by the above criteria.

Signature of Supervisor: …………………………………………….. Print name:………………………………..

Date:

……………………………………………..

A copy of this record should be placed in the registered rheumatology nurse ’s personal file, a copy must be stored in the clinical area by the consultant rheumatology nurse and a copy can be retained by the individual for their Professional Portfolio.



Appendix 2

HOB PCT

EVIDENCE OF SUPERVISED PRACTICE

To become a competent practitioner, it is the responsibility of each registered nurse to undertake supervised practice in order to ADMINISTER

SUBCUTANEOUS METHOTREXATE AND TO EDUCATE PATIENTS AND CARERS IN THE SELF-ADMINISTRATION OF SUBCUTANEOUS METHOTREXATE in a safe and skilled manner.

Name of Registered Rheumatology Nurse : ………………………………………………….

DATE DETAILS OF PROCEDURE COMMENTS OBSERVED BY SIGNATURE

AND

DESIGNATION



Appendix 3

HOB PCT LOGO

HEART OF BIRMINGHAM PCT

MUSCULOSKELETAL AND RHEUMATOLOGY SERVICE

EDUCATION PACKAGE

INFORMATION FOR PATIENTS / CARERS



Patient Information: Methotrexate a therapy by unlicensed injection

Your rheumatologist has suggested that you try methotrexate to be given by injection subcutaneously (under the skin). This may be for one of the following reasons:



You are unable to tolerate methotrexate tablets due to side effects such as mouth ulcers, nausea, vomiting or diarrhoea.



You have already taken methotrexate tablets, which over a period of time have not improved your arthritis. Before completely stopping methotrexate it may be worth trying injections. Sometimes injections work better than tablets.

Methotrexate tablets have a license for the treatment of rheumatoid and psoriatic arthritis. However, at the moment only one type of subcutaneous methotrexate syringe (Metoject) has a license for the treatment of rheumatoid arthritis. Many specialists throughout the world use methotrexate injections for a variety of rheumatological conditions. It is unlikely that other companies who make methotrexate will apply for a license for giving methotrexate by injection because only a small number of patients require injections with methotrexate.



Methotrexate has been prescribed and given by injection for many years with no apparent safety problems.



A Rheumatology specialist prescribes the drug for you. This doctor takes responsibility for your care, administration and supervision of the treatment.

However the drug can only be safely used if you have regular blood checks and are able to attend either the rheumatology drug monitoring clinic or your GP practice nurse.

If you wish to know more please discuss it with your doctor, nurse or pharmacist.

This information should be read in conjunction with the methotrexate leaflet provided by the Arthritis and Rheumatism Council (ARC).



HOW TO GIVE METHOTREXATE BY SUBCUTANEOUS INJECTION

Getting ready

Do not rush; make sure you have plenty of time. As you get used to giving the injection you will find it much easier. Do make sure there are no distractions such as children or dogs in the room.

1. Wash and dry your hands.

2. Use a clean worktop or table as a workstation.

3. Use a clean upturned plastic lid of a sandwich box as an injection tray.

4. Remove injection from package/ box. Place it on the lid of the sandwich box.

5. Place a cotton wool ball, brown needle and elastoplast on your injection tray.

6. Put your sharps box on your workstation ready to put in the used syringe and needle.

7. Wash and dry your hands once more.

8. Sit or stand comfortably by your workstation.

9. Decide where you are going to put your injection either in your tummy or in the thigh area. Rotate the site used each week.

10. Prepare the equipment.



Peel open or cut the packet with the injection in (use a clean pair of scissors).



Check that the methotrexate injection is in date (if not do not use it and contact the rheumatology department)



Check that the methotrexate packet is labelled with your name and is the correct dose (if not do not use it and contact the rheumatology department)



Open the elastoplast so it is ready



Peel open the packet containing the needle



Put on disposable rubber gloves and an apron now (carer only)





Remove the screw top/rubber bung from the syringe and then screw the needle firmly onto the syringe



Loosen the needle cover. Do not allow the needle to come into contact with the surface of the tray as this will contaminate it



Place the syringe with covered needle back onto the injection tray

Giving the injection

1. Expose the skin where you will give the injection.

2. Remove the cover from the needle and hold the syringe like a pen as if you are going to write your name.

3. Make sure the needle does not come into contact with anything on the way to the skin to avoid contamination and the risk of introducing infection.

4. Pinch the skin and insert the needle into the skin at 90 degrees (right angles). The needle is approximately one third of an inch long and will deliver the injection just below the skin (subcutaneously)

5. Once the needle is in place, release your pinch on the skin, support the syringe with both hands. (If blood comes into the syringe at this time, you may have injected a small blood vessel). Do not inject , remove the syringe and place in the sharps box and use another injection. (You will be one injection short so will need to contact the pharmacy department for a replacement and safe disposal of the wasted injection) Inject the methotrexate slowly, you may feel the drug go in under the skin but this should not be uncomfortable.

6. When you have injected all of the methotrexate remove the syringe and place a cotton wool ball over the injection site. After a minute put an elastoplast over injection site, this can be removed after half an hour.

Do not put the cover back on the needle . Just discard all equipment used into the sharps box.

7. Wash and dry your hands

Do not put any of the items in point 6 in with your normal household rubbish. Use the sharps box provided.



8. Your next injection will be due in one week’s time.

9. You may notice bleeding or bruising at the injection site. Do not worry, this sometimes happens when the needle has punctured a small blood vessel. The bleeding will soon stop and the bruising will gradually disappear.

10. Sometimes when patients receive a subcutaneous injection it may leak in to the surrounding skin causing irritation. Methotrexate is not likely to cause irritation, however, if you notice irritation or redness in the area of the injection or if you have any other problems please contact the rheumatology helpline on (0121 627 8314)

What do I do with the sharps box?

The sharps box should be kept in a safe place out of the reach of children and pets. When the sharps box is two thirds full you must snap the closure on the box shut and return it to the hospital.

What should I do if my carer who is injecting accidentally pricks themselves with the needle having just injected me?

First your carer should make the area bleed as much as possible whilst running it under a cold tap for at least 10 minutes. Then you need to contact your carer’s GP surgery immediately. The surgery will arrange for you both to be blood tested and your carer might have to have some vaccinations. You must also let the rheumatology nurses know that a needle stick injury has occurred. If the needle stick injury occurs out of normal working hours, contact your local accident and emergency department.

What do I do if I accidentally spill methotrexate?

Please keep the spillage kit provided near to where you give your injection.

Even though the quantities of methotrexate you are using are small, it is still possible to spill it. If you spill any methotrexate follow the instructions in the spillage kit. Use plenty of water to mop the spill up and seal the cloths and gloves in the sharps box provided with the spillage kit. Contact the pharmacy department to arrange for safe disposal.

If you accidentally get methotrexate in your eye, wash it out immediately under a running tap for at least 10 minutes and seek advice from your local accident and emergency department or the eye accident and emergency based at the City Hospital (let the rheumatology nurses know the outcome).



If you spill methotrexate on your clothing remove it and wash the clothing at the highest temperature the fabric can withstand. The clothing must be washed on its own in the washing machine and you should wash it twice.

What do I do with methotrexate injections that are out of date?

Each injection is labelled with your details and an expiry date.

If the injection has passed the expiry date or is not labelled for you do not use it . Place it in the sharps box unopened. What you need to do now is listed under the “what will happen when you are stable on methotrexate section”.

What plans to I need to make for going away on holiday with methotrexate injections?

For foreign travel, contact your tour operator so they know you will be carrying methotrexate injections. Speak to the rheumatology nurses in advance about taking a supporting letter with you. If flying, you can travel with methotrexate in your hand luggage, but needles and sharps boxes must be put into your booked in luggage. You will need to take a mini spillage kit with you.

What will happen when I am stable on methotrexate?

It may be possible for you to collect your injections and have your blood test without having to see the rheumatology nurses.

You will collect your methotrexate from the outpatient pharmacy department and they will provide all supplies and sharps boxes.

You need to contact pharmacy on 0121 627 1627 extension 51328 for the following reasons:

1. You are unable to collect your injections on the date you are due

2. You have a problem with the actual injection

3. To arrange disposal of out of date injection or injections that you have spilled.

4. If you are due to run out of injections and you are not sure a further supply has been ordered. It is best to check the week before you are due to collect your injections in any case, so if they are not ready further injection supplies can be arranged.

For what reasons should I call the rheumatology helpline?

1. If you are unable to make contact with the pharmacy department



2. If you are unable to keep your planned appointment with the rheumatology nurses

3. If you are experiencing side effects such as recurrent infections, severe mouth ulcers, nausea and vomiting or anything else about your health that you think may be due to the methotrexate therapy.

You may need to see your GP

4. You are not currently seeing the rheumatology nurses and your arthritis is not being very well controlled by the methotrexate injections

5. You need a supporting letter for foreign travel

6. If you have any worries or queries about the treatment



PATIENT/ CARER COMPETENCY CHECKLIST

Patient Name, Hospital number

Identification Label

You have been taught how to give methotrexate injections by the subcutaneous route and on ______ occasions and you have given the injection under the supervision of the rheumatology nurses. They now consider that you are competent to *receive/give these injections at home using the techniques *you/your carer have been taught. Before this happens it is important to check that you/your carer are happy to do this and fully understand the procedure.

(* delete as appropriate)

Please read the statements below and initial the box

1. I have been given ARC patient information on methotrexate and the rheumatology patient/carer education package on how to give subcutaneous methotrexate injections. [ ]

2. I can safely store the methotrexate injections in the correct conditions and out of the reach of children. [ ]

3. I know I must safely dispose of needle and syringe into the sharps box provided and that the sharps box must be brought back to the practice when it is two thirds full. [ ]

4. I know what to do if I have a spillage. [ ]

5. I know what to do if I have a problem and or any other queries about my treatment. [ ]

6. I am confident that I am able *to administer the methotrexate injection /for my carer to

administer the methotrexate injection (*delete as appropriate).

Name of Registered Rheumatology Nurse……………………………………………..

Signature……………………………. Designation……………………………………..

Date …………………………………. Time ……………………………………………..

[ ]



(2004) Administering subcutaneous methotrexate for inflammatory

EDUCATION PACKAGE

INFORMATION FOR PATIENTS / CARERS

Related documents

Products

Support

(2004) Administering subcutaneous methotrexate for inflammatory

EDUCATION PACKAGE

INFORMATION FOR PATIENTS / CARERS

Related documents

Add this document to collection(s)

Add this document to saved

Suggest us how to improve StudyLib