NR 224 Final Exam Key Concepts (FUNDS) LATEST
NOTE: Remember NR 224 requires you to answer exam questions in which you will have to not only understand
... [Show More] but also apply information related to the concepts covered in the course. The intent of this study tool is to outline the major content that will be covered on the exam. Additional content may be included on the exam.
Critical Thinking
Be prepared to prioritize and to consider the
best option when answering exam questions.
What considerations are important when determining the best option?
Whatever decision is best for the patient
When should the nurse delegate vs not delegate?
Delegation: “transferring responsibility for a performance of an activity or task while retaining accountability for an outcome”
• assigning tasks to other healthcare professionals (vitals, labs); UAP (unlicensed assistive personnel),
LPNs
Not delegate: “to do on your own or not share the tasks”
• give meds, change in status, receive new meds, new admission, teaching
What are essential steps the nurse should do prior to performing any skill on a patient?
-AIDET
A-Acknowledge (greet the patient)
I- Introduce yourself
D- duration of assessment
E- explain the procedure
T- thank you
-Hand hygiene and provide privacy
-Identify your patient using name and DOB
-Assess allergies
-Assess pain
-Determine level of consciousness (LOC)
What are principles related to HIPAA?
• Patients’ privacy, who the patient give right to have his information
• Patient information can be used or disclosed by a health plan, provider
• HIPAA enables patients to find out how their information may be used and how it has been disclosed
• gives patients the right to examine and obtain a copy of their own health records and to request corrections.
What is HIPAA?
• Health Insurance Portability and Accountability Act
• Focuses on Patient Health Information
• Stipulates how healthcare workers can share information
A major component of the Health Insurance Portability and Accountability Act (HIPAA), the Privacy Rule, was introduced to promote the use of standard methods of maintaining the privacy of protected health information (PHI) among health care agencies.
Nursing Process
Review the steps in the nursing process. Be prepared to interpret a scenario/situation to determine the corresponding step in the nursing process.
• Assessment: gather all subjective and objective data
• Diagnosis: NANDA, nursing diagnosis for actual problems,
Potential problems, or risk for problems.
• Outcome identification: SMART goals for pt (patient)
• Planning: nurse/pt make a plan to achieve the goal
• Implementation: how the nurse will put the plan into action &
Interventions
• Evaluation: was the goal met and what needs to be adjusted
Consider nursing diagnoses that are applicable to a given situation/scenario.
Infection Prevention and Control What is the difference between clean (aseptic) and sterile technique?
• Clean is the routine hand hygiene, drying and use of nonsterile gloves, it uses for taking blood, examining patients, and feeding patients.
• Sterile techniques used for surgery and invasive procedures with high rates of infection. It involves
surgical hand rub with long actin antiseptic, dry hands with sterile towel, sterile field (gown, mask, gloves, supplies), skin prep, a dedicated room.
• While clean means free from marks and stains, sterile goes even further and is free from bacteria or
microorganisms
• Sterile: No SPORES or microorganisms
What are examples of skills and procedures that should be performed using clean technique? Sterile technique?
1. During procedures that require intentional perforation of the patient’s skin, such as insertion of
peripheral IV catheters or a central intravenous line.
2. when the integrity of the skin is broken as a result of trauma, surgical incision, or burns
3. during procedures that involves invasive procedures such as insertion of a urinary catheter or surgical instruments into sterile body cavities such as insertion of a wound drain
List strategies/interventions that may prevent infection transmission.
• Standard precaution (wash hands, gloves) => apply when contact with blood, body fluid, non-intact skin, and mucous membrane.
• Hand hygiene is the most effective basic technique in preventing and controlling the transmission of infection.
What are principles associated with creating and maintaining a sterile field?
consider the 2.5cm (1 inch) around the sterile gloving contaminated
must be waist level
What is PPE?
PPE: Personal protective equipment for protection against exposure to infectious materials. This includes gloves, mask, goggles, hair net and gown.
Removal: gloves comes off first, then gown, mask, head pieces, and first thing that goes on
Standard precautions: handwashing
What are the different types of isolation precautions and considerations are associated with each type?
• Standard precautions should be used in all settings and it includes hand washing, when hands are visibly soiled used antibacterial soap and water, when not visibly soiled use hand
sanitizer or hand rub and it must be 60% and above alcohol
• Airborne - smaller than 5 microns. Negative air pressure, 6-12 exchanges using HEPA filter, N95 respirator, mask, private room. Measles, Tuberculosis and
Varicella (chicken pox)(MTV)
• droplets - larger than 5 microns. private room or cohort, mask or respirator
• contact - must have gloves and gown, private room or cohort patients.
• PPE - positive air pressure, private room, 12 and above air exchanges using HEPA filter, mask worn by the patients
Remove gloves, eyewear, gown, then mask (top first then bottom), Removing = Gloves, eyewear, gown and mask.
Why? gloves could be visibly or non-visibly soiled, so get rid of it first, then eye wear or goggles, gown to avoid the contaminants from spreading then mask
Sterile field
● Sterile object remains sterile if touched by another sterile object
● Only objects that are sterile must be placed on a sterile field
● Sterile object is assumed contaminated if it is out of field of vision or below the waist
● A sterile object of field becomes contaminated by prolonged exposure to air. It becomes contaminated with in time
● Sterile surface come in contact with wet surface it becomes contaminated by capillary action
● Fluid flows in the direction of gravity
● The edges of a sterile field or container are considered contaminated
○ (Think of the edges when opening the sterile gloves in lab)
What item should be removed first? Why?
Vital Signs
What are the normal ranges associated with each vital sign?
● Temperature (normal): thermometer (15 min drink/smoke)
○ Body: 36-38 C/ 96.8-100.4 F
○ Oral: 37 C
○ Rectal: 37.5 C (red probe)
○ Axillary: 36.5 C
Core vs. surface (core slightly higher and more accurate)
● Alterations:
Hyperthermia (>39C/102.2F) - Factors: fever, infection, ingesting warm substances, recent smoking, stress, metabolism increases, physical exercise.
Hypothermia (<35C/95F) : Factors: ingesting cold substances, advanced aged and young infants,
● Pulse - number of times a heartbeat is auscultated or a pulsation is palpated in one minute.
○ Assess rate, rhythm, strength (amplitude), equality
○ Sites for pulse assessment
■ Apical
○ 60-100 bpm, regular
● Pulse ox:
○ 95% +
● Respirations
○ 12-20, regular and deep
○ No accessory muscles
○ Hyperventilation: Anxiousness, meds (narcotics), sleep
● BP
Temperature
• Axillary or armpit is 97.7
• Oral temperature is 98.6
• rectal temperature is 99.5
• normal core body temperature range is 98.6 to 100.4
Oxygen Saturation above 95%-100%
Respiration is between 12-20 for adults
Blood Pressure is 120/80 bpm normal range but can vary depending on the individual
Pulse Rate is 60-100 beats 3+ full bounding
2+ normal
1+ weak or thready
0+ nonexistent needs doppler technique Rhythm should always be regular
What are the principles and techniques for measuring each vital sign?
Temperature is done using a thermometer and a location in the body
Oxygen Saturation is done using a pulse oximetry
Respiration is done through inspection of the patients chest movements during inhalation and exhalation
Blood Pressure is done using a BP cuff, inspection to see the needle move, palpation for the radial or brachial pulse and auscultation to listen to the sounds
○ Systolic: < 120
○ Diastolic: < 80
○ PP: 30-50
○ Causes: age (up), exercise, stress, pain
● Capnography
○ 35-45
Pulse Rate is done using palpation using 2 fingers and auscultation to listen to the apical pulse -5th intercostal space to the left
Activity and Exercise
What should the nurse include in a teaching session to a client who is using a gait belt/cane/walker/crutches for the first time?
Crutch fitting
● Have patient stand upright, shoulders relaxed, shoes on.
● Adjust the length of crutch and handle
○ Crutch pads: 2-3 finger lengths from axilla
○ Hand grips: elbows bent 30 degrees and able to fully extend upon pushing down to take a step (body weight rests on hands)
Walking with crutches
● Maintain good posture
● Well-fitting, low-head, supported shoe
● Look ahead
● NO hanging or leaning on crutches
○ Weight supported on hands
● Begin in tripod → put weight on unaffected leg
● Crutches first then unaffected leg the affected leg
Stairs - Going up “Good leg goes to heaven”
● Begin with crutch tips on same level as stairs
● Place unaffected leg on the next step, while supporting injured leg with the crutches
● Push down on crutches, then step up with the injured leg
● Once both feet are on the same step, bring crutches up.
Stairs- Going down “Bad leg goes to Hades”
● Begin with crutch tips on the step below
● Step down with an injured leg
● While supporting injured legs, down with unaffected leg
● Once both feet are on the same step, lower crutches to the step
Considerations: how many floors? stairs?
Walker
● Patient hold the hand grips on the upper bars, takes a step and moves the walker forward and takes another step.
● Measure
○ With shoes on and hands at side, hands on grip should be even with wrists
● Walk forward
○ Advance walker 12”
○ Move affected leg forward
○ Move unaffected leg
Cane:
● Measure
○ With shoes on, the handgrip on cane should be even with greater trochanter
● Use
○ On unaffected side (strong side)
○ Two points on the floor
○ Cane moves at the same time as affected leg
● Walk forward
○ Cane first for (6” to 10”)
○ Affected leg first with cane (divide weight between cane and stronger leg)
○ Unaffected leg next
Cane
Hold the cane on the unaffected side (Can we succeed?): Cane, weak leg, strong leg Step: cane 1st
affected side unaffected (good) side
Walker
Step: Advanced walker 12”, move affected (weak) leg, move unaffected leg
Crutches
Going up stairs: begin with crutch, feet same level, unaffected leg first,
Downstairs: step down with injured leg then unaffected
Immobility
What are potential complications of immobility?
• pressure ulcer for skin or integumentary changes
• Metabolic changes - slowed peristalsis
• muscular changes - muscle atrophy due to not using the muscle “you lose what you don't use” contractures can also occur. contractures is the shortening of a muscle causing it to lose the ability to stretch
• skeletal changes - bone resorption cause weak bones and can lead to fractures
• urinary changes - urine retention
• Constipation: decrease in GI movement
o Low fiber
o Side effects meds (opioids, tricyclic antidepressants)
o Decrease water intake
o IBS
o Decreased activity
o Bowel obstruction
o Hypothyroidism
o Inadequate toilet facilities
• Weak bones: decrease in calcium resorption (no weight bearing)
• Atelectasis: when the alveoli do not get filled up with air becomes sticky and collapse
o Tachypnea
o Diminished breath sounds
o Decrease O2
o Help: position, INSP,
• Hypostatic pneumonia
o Accumulation of mucus
o Sit for a long time → harden
• Orthostatic hypotension
o Slow to respond to changes
o Dangle feet off the bed
• Increased cardiac workload
• Thrombus formation
o Lack of movement
o Can lead to embolism
▪ Can go to the Heart, lungs, or brain
o Help: compression socks, TED, ambulate
• Muscle effects
o Body mass loss
o Muscle atrophy
• Skeletal effect
o Osteoporosis
o Joint contracture: permanent joint deformity
• Urinary elimination
o Urinary stasis
o renal calculi (kidney stones) due to excess calcium in blood
o Infection (bacteria build up)
o Look for output, odor, frequency, pain
• Integumentary changes
o Pressure ulcers (bed sores)
▪ Inflammation
▪ Ischemia
▪ Look for skin breakdown
▪ During shower/bath
o Older adults at risk (decreased sensation, adipose tissues)
• Psychosocial
o Emotional and behavior responses
▪ Hostility, giddiness,
fear, anxiety
o Sensory
▪ Altered sleep
o Changes in coping
▪ Depression, sadness, dejection
What are strategies to prevent complications of immobility?
Implementation: of acute care
● Metabolic
○ High protein diet, vitamin B &C
● Respiratory
○ Cough and deep breathe every 1-2 hours
○ Provide chest physiotherapy (percussion)
■ Break up mucus build up, ask the patient to cough
● Cardiovascular (slide # 32)
■ Reduce Orthostatic (hypotension)
○ Reduce cardiac workload
○ Prevent thrombus formation
○ Use
■ SCD (sequential compression devices)looks like a blood pressure cuff for both legs; used by post-operative
■ Thromboembolic deterrent (TED); compression stockings, change every 1-2 days
■ Leg exercises.
● Musculoskeletal
○ ROM exercises to prevent atrophy and contractures
● Integumentary system
○ Reposition every 1 to 2 hours (sacrum, heel, turn head too)
○ Provide skin care
● Elimination system
○ Provide adequate hydration; promote urination
○ Serve a diet rich in fluids, fruits, vegetables and fiber; avoid constipation
Skin Integrity and Wound Care
What factors contribute to risk for impaired skin integrity?
• Nutrition
• age
• decreased mobility
• decreased skin turgor
• tissue tolerance
• tissue intensity (ischemia, blanching)
• pressure duration
How can the nurse minimize the risk of skin breakdown or prevent further skin breakdown?
• turn the patient every 2 hours
• keep patient dry
• promote the use of cushions on bony prominence, raise bed 30 degree
• help patient ambulate to promote blood flow and circulation
• proper nutrition protein
What are findings associated with each stage of skin breakdown?
• Stage 1 – non- blanchable red skin (erythematous skin)
• stage 2 - partial loss of the epidermis or dermis
• stage 3 - full skin loss and subcutaneous fat
• stage 4 - muscle, bone, tendons are lost
• unstageable - when its covered by eschar (necrotic tissue) that needs to be removed to stage the wound
○ Stage 1: intact skin appears red,
unbroken, non-blanching.
○ Stage 2: partial thickness, skin erosion (broken skin) with loss epidermis that you can see the dermis; superficial, shallow; red-pink wound bed.
○ Stage 3: full-thickness pressure ulcer; subcutaneous, deep like a crater
○ Stage 4: full-thickness pressure ulcer; see bone, muscle
○ Unstageable: Can not see the bottom of the wound, covered by scar or eschar.
What are considerations associated with performing wound care?
• braden risk scale
o Patients with a total score of 16 or less are considered to be at risk of developing pressure ulcers.
• explain the steps to the patient and have them perform it back
(15 or 16 = low risk; 13 or 14 = moderate risk; 12 or less = high risk)
o categories: sensory perception, moisture, activity, mobility, nutrition, friction
and shear
• make sure to clean the wound from the inside going outwards
• make sure the periwound area is dry before applying any dressing
• keep in mind wound healing consist of primary and secondary intention
• primary intention is to apply a technique to enable the wound heal from inside out (ex. surgeries)
• secondary intention is leaving the wound open to heal (ex. burns)
• proper nutrition Skin integrity = Skin intact
Skin
● Epidermis
● Dermis
● Dermal-epidermal junction Pressure ulcers
● Pressure sore, bedsores (decubitus ulcer)
● Can lead to tunneling (damage is deep and can’t see superficially)
● Increase fluids, proteins, pain relief to avoid pressure ulcers
Hygiene
What strategies may the nurse consider promoting independence with hygiene practices?
• Handwashing techniques
• promote and educate the advantages of using alcohol based hand sanitizer
Oxygenation
What safety considerations apply to oxygen administration?
• patient might get addicted to it
• does not allow for patients to be independent
• might make patient feel claustrophobic
• interferes with feeding
What are types of oxygen administration devices and indications?
• simple face mask
o (6-12 L/ min, 35-50%);
mouth breather
o Advantage: Useful for short periods & for patient transport
o Disadvantage: Contraindicated who retain CO2
• nasal cannula
o Nasal cannula (1-6L/ min, 24-44%); low oxygen
o Chronic disease
o Advantage: Safe and simple
o Disadvantage: Unable to use when nasal obstruction & Drying mucus membranes
• venturi mask
o (high flow, 24-50%); most precise, chronic patient
o Advantage: Provides specific amount of O2 w/ humidity
o Disadvantage: Mask and humidity may irritate skin
o
• non rebreather mask
o (10-15 L/ min, 60-90%); only oxygen in bag
• advantage: Useful for short periods
• disadvantage: Hot and confining, Irritate skin, Tight seal
• Oxygen-conserving cannula
o Advantage: Indicated for
long-term use
o Disadvantage: Cannula can’t be cleaned
What interventions may prevent clinical decline/ promote optimal oxygenation?
● Respiratory muscle training
○ Improves muscle strength and endurance
○ Prevents respiratory failure with COPD patients
○ Use incentive spirometer resistive breathing device (ISRBD) (pursed-lip)
● Breathing exercises
○ Improves ventilation and oxygenation
○ Pursed lip breathing through straw), diaphragmatic breathing, breathing and coughing exercises
○ Turn, deep breath and cough
● Elevate 30 degrees
What are causes and clinical manifestations associated with hypoxia?
• atelectasis
• anemia
• dyspnea
• slow heart rate
• confusion
• changes in level of consciousness
• skin color change
• tingling
• fatigue
• decreased tissue perfusion
● Decreased hemoglobin level and lowered oxygen-carrying capacity (low hemoglobin, anemia, tissue perfusion)
● Decreased (diminished concentration) inspired oxygen concentration (Denver: high elevation)
● Inability of tissues to extract oxygen from the blood
● Decreased diffusion of oxygen from the alveoli in the blood. Ex: Hypovolemia (plasma level is low)
● Poor tissue perfusion with oxygenated blood (shock)
● Impaired ventilation (multiple rix fx, trauma)
● Increased metabolic rate
Hypoxia: inadequate oxygen to TISSUE Hypoxemia: reduced oxygen in BLOOD
Ischemia: reduced blood supply in TISSUE/ORGANS
What is a pneumothorax? What clinical findings and interventions are associated with a pneumothorax?
● Pneumothorax
○ Is a collection of air in the pleural space
○ Negative pressure
○ Chest tube is high (air)
○ Secondary: chest trauma, rib fx
○ Dyspnea is common, gets worse if pneumothorax increases
○ S&S: sharp pleuritic pain that worsens on inspiration, absent sounds over lung bases on affected lung, worsening dyspnea
● Hemothorax
○ A combination of blood and air
○ Trauma or rupture of small blood vessels
○ Produces a counter pressure and prevents full expansion of lungs
○ Chest tube is low (fluids)
● Bubbling in suction control not the water seal (that means there is a leak)
● Special considerations
○ Three things on bedside
■ Another trach tube
■ Vaseline gauze
● Sterile gauze
● Used if chest tube come out
● Open it up and cover immediately
■ Hemostats
● Dull clamps
■ Bottle of sterile water
● Used when collection tube not working or if it comes off
● Prevent any microorganisms getting into the system
○ Chest tubes: surgery
■ Below chest level
■ Occlusive dressing (tight)
■ Suction chamber: bubbles
■ Water: tidal waves
● Bubble (leak)
■ Clamp when changing system or leak
What are reasons a patient may need a chest tube and considerations will the nurse include when caring for the patient and managing the collection device?
Urinary Elimination
What are considerations when placing and removing an indwelling urinary catheter?
● No kinks
● Below patient, hooked on bed
● Highest risk of UTI
How will the nurse care for the client who has an indwelling urinary catheter?
Female: supine position with knees flexed, it is a sterile procedure which requires a sterile glove
• clean the meatus by separate labia with non-dominant hand to fully
expose urinary meatus.
• Clean labia, urinary meatus and clitoris toward anus. (use new cotton or swab for each area).
• To insert, ask the patient to bear down gently and slowly insert catheter to 5 to 7.5 cm,
• when urine appears add 2.5 to 5 cm and secure the catheter tubing to the inner thigh.
Male: supine with legs extended abs thighs slightly abducted.
• With a nondominant hand, retract foreskin and gently grab the penis at
the shaft just below the glands, hold
the penis with nondominant while using cotton to clean. repeat the process 3 times.
• hold the penis in 90 degree
• advance catheter of 17 to 22 cm
• when the urine appears advance catheter to bifurcation
What strategies/interventions may reduce the risk of UTI development?
● Wash from front to back
● Soap and water every two hours (catheter)
● 1/3 to ½ full before emptying (catheter)
● Hang the catheter bag on a non- movable object
● Hydration
● Hygiene
● Voiding regular interval
● Cleaning catheter
(catheter is the number 1 risk for UTI)
• A key intervention to prevent infection is maintaining a closed urinary drainage system
• Another key intervention is prevention of urine backflow from the tubing and bag into the bladder
• Empty the catheter every 8 hours or as needed
How is 24-hour urine input measures?
● A 24-hour urine collection is done by collecting your urine in a special container over a full 24-hour period. The container must be kept cool until the urine is returned to the lab.
● Discard first void***
What is the procedure for placing and removing an indwelling urinary catheter?
*This is a clean technique
• you provide privacy and identify the patient with 2 identifiers after introducing yourself
• next unsecure the catheter bag and proceed to put a waterproof pad under the patient's leg
• put the syringe in the bifurcation to deflate the balloon after which it will
be wrapped in the waterproof bag and disposed of appropriately
• reassess the patient for any discomfort or pain
• provide hygiene care if required
• reposition the patient and raise rails, lock bed and lower it
• after which documentation is required
• use sterile technique
• Aseptic when removing
Nutrition
What are nutritional considerations related to wound healing?
Protein, Vitamin, carbohydrates, nitrogen, balance diet and hydrated well
What interventions can the nurse use to assess for and minimize the risk of aspiration?
Assess for dysphagia, swallowing, and appropriate kinds of food for the patients. By raising the head of the bed, we can minimize the risk of aspiration make sure they are sitting upright, no straws.
Bowel Elimination
What are psychosocial and cultural considerations related to bowel elimination? Environment, some patients can’t eliminate when strangers are around, and sharing toilet with others. Example, some hospitals have one bathroom for more than one patient.
Self-concept, culture, and sexuality.
Factors affecting bowel elimination
○ Age (younger child can have impaction when overlying constipation not resolved)
○ Fluid intake (2-3L per day)
○ Diet (high fiber: fruits, vegs, whole grain)
○ Physical activity (keeps it regular)
○ Personal habits (privacy, find out norms)
○ Position during defecation (challenging when supine)
○ Pregnancy (abdomen constriction; straining, constipation, hemorrhoids)
○ Meds (can speed up or slow down)
○ Surgery/ anesthesia (hypo or no movement); paralytic ileus (no bowel sounds but is expected) → when getting better the patient passes gas
■ Anesthesia (slows down)
○ Pain (stool softener, fluid, diet changes)
○ Diagnostic test
What are normal assessment findings associated with this body system? What findings would warrant immediate action by the nurse?
● Normal: Defecation at least one to two times a day
● Warrant immediate action: no movement for days or too much movement 6+ a day (diarrhea)
● Regular elimination of bowel waste products is essential for normal body functioning. Normal color yellow for infants and brown for adults. consistency (soft, formed) frequency (4 to 6 time for infants, and 1 to 3 X for adults) shape (resembles diameter of rectum)
● Abnormal finding and need immediate action: color (white or clay, red, pale, and black) odor (noxious change) consistency (liquid and hard) frequency (more than 6 times for infants or less than 1 to 2 days; and more than 3 time for adults or less than once a week)
What is constipation? What is a paralytic ileus? What are causes, assessment findings and interventions associated with these conditions?
● Constipation
○ A symptom not a disease. Infrequent stool and/or hard, dry small stools that are hard to eliminate
○ Causes: lack of fiber, opioids, dehydration
● Paralytic ileus
○ No movement of bowels in all quadrants
○ Causes: surgery
○ No movement of stool/gas
○ Flatulence is first sign of movement
● it is caused by obstruction of the intestinal muscles impairing gastric motility and emptying assessment findings include bloated stomach, cramps, vomiting, nausea, constipation, flatulence in the stomach interventions include medications, dietary changes and surgery
What are stoma care and stoma pouching considerations?
stoma is a temporary or permanently opening either on the colon (colostomy) or ileostomy (small intestine, ileum) . The location determines stool considerations. The nurse needs to check for amount, color, consistency of drainage from ostomy.
Appearance of the stoma (normal color red, abnormal color dark red represent compromise of circulation need to be reported). Empty pouch when it is ⅓ or ½ full and equipment
• clear drainage can be one-piece or two pieces
• pouch closure
• ostomy measuring guide (we can go
⅛ over the measurement)
• adhesive remover
• clean gloves
• tap water
Medication Administration
What needle lengths, techniques, and sites are associated with each type of parenteral medication administration (subcutaneous, intramuscular, and intradermal)?
Subcutaneous: Needle lengths ( ⅜-⅝)
technique: (pinch skin) Location: posterior aspect of upper arms abdomen from below the costal margins to iliac crest
anterior aspects of the thighs scapular areas of upper back upper ventral or dorsal gluteal areas
Angle (45-90 degree)
Intramuscular: Needle lengths: typically (1- 1 ½)
Technique: ( z track method; pull overlying skin 2-3cm laterally or downward)
make sure blood doesn't come in the needle (Aspirate) (except vaccines)
Locations: Ventrogluteal, vastus lateralis, deltoid
Angle ( 90 degree)
Intradermal : Needle lengths( ½ - ⅝) Techniques (needle level up, bled will appear if administered to correct depth, do not massage after administration) Locations: Inner forearm and upper back Angle (5 - 15 degree)
What techniques and considerations are associated with transdermal patches?
Sublingual medications? Ophthalmic drops?
Transdermal patches:( remains in place for 12 hours or 7 days
• Remove the old patch before applying new.
• Document the location of the new patch.
• Ask about patches during the medication history.
• Apply a label to the patch if it is difficult to see.
• Document removal of the patch as well.
can experiences respiratory depression, coma, and death when the patches are not removed
Sublingual Medications
The medication placed under the tongue to dissolve
Instruct the patient to not swallow and not drink anything until the medication is completed dissolved
Ophthalmic drops
Avoid instilling any form of eye medications directly onto the cornea
Avoid touching the eyelids or other eye structures with eyedropers or ointment tubes
Use eye medication only for the patient’s affected eye
Never allow a patient to use another patient’s eye medication
What patient education should the nurse provide with regard to medication administration?
The purpose of the medication The dosage of the medication The side effects of the medication
The possible adverse effects of the medication
● When to take it?
● How to take it?
● How much should be taken?
● Route?
How can the nurse minimize the risk of medication errors? What should the nurse do if a medication error occurs?
1. When administering medication, using the six right of medication administration
2. Compare the label of the medication container with the MAR three times (before removing the container from the drawer, amount of medication ordered, and at the patient’s bedside)
3. In case errors occur, assess the patient and report the errors to your supervisor or manager, depending on the facility policies.
Nurse’s role
● Determines meds ordered is correct; assessing patient’s ability to self- administer; determines whether the patient should receive at a given time, administer meds correctly and closely monitor.
● CANNOT be delegated
● Includes patient’s teaching
● Six rights of medication administration***********
○ Right patient
○ Right Medication
○ Right Dose
○ Right Time
○ Right Route (Oral, IV, IM, topical)
○ Right Documentation (what and when the meds we gave)
What should the nurse do if a medication error occurs?
● Report all med errors
● Patient safety is a top priority when an error occurs
● Documentation is required
● The nurse is responsible for preparing a written occurrence or incident report (not in the patient’s chart, let charge nurse and doctor
know); an accurate factual description of what occurred and what was done.
● The nurse plays an essential role in medication reconciliation
What route is associated with the fastest absorption time? The slowest absorption time? (po, SQ, IM, IV)
Fast to slow: IV → IM (intramuscular: injections to muscle) → SQ (subcutaneous: injections into tissues) → po (by mouth)
What strategies can the nurse use to minimize the risk of needle stick injuries?
• Avoid using needles when effective needleless systems or sharps with
engineered sharps injury protection (SEIP) safety devices are available
• Do not recap any needle after medication administration
• Plan safe handling and disposal of needles before beginning a procedure
• Immediate dispose of needles, needleless systems, and SESIP into
puncture-proof, leak-proof sharps disposal containers
• Maintain a sharps injury log that includes the following: Type and
brand of device involved in the incident, location of the incident, description of the incident, and privacy of the employees who have had sharps injuries
• Attend education offerings on bloodborne pathogens and follow
recommendations for infection prevention, including receiving the Hep B
• Participate in the selection and evaluation of SESIP devices
What should the nurse do if a medication becomes contaminated prior to administration?
Throw away and get new meds
What is the purpose of completing critical medication checks (your book refers to this as “accuracy checks”)? How many are there? Where do they occur?
● The first check is when the medications are retrieved from the automated dispensing machine/the medication drawer
● The second check is when preparation of the medications for administration takes place.
● The final check occurs at the patient's bedside just before medications are given. This is also an outstanding opportunity to teach the patient about the medications.
• To avoid any mistake, to make sure we have the correct
medications(mostly medication errors)
• They are 3 accuracy checks, referring to MAR
1. check the prescription with the MAR
2. check the medications with the MAR
3. check the medications with the patients and prescription
• Use MAR when taking out the medications
• Check MAR after removing by checking for any expiration date
• Compared the MAR with the patient bedside
What are the components of a medication order?
PMDTRD
● Patient’s full name
● Date and time of order written
● Medication name
● Dosage
● Route of administration
● Time and frequency of administration
● Signature of health care provider
What should the nurse do if a component is missing or illegible?
Contact healthcare provider
● Prescribers: physician, NP or PA
● Order be written with signature, verbal or telephone (repeat back and verify)
● The use of abbreviations can cause errors; use caution*********
● If illegible contact physician, NP or PA who wrote the component for confirmation [Show Less]