B260 Exam 1
list the steps to patient identification
FIRST: and best way to identify for the RIGHT patient is to have them STATE their name and birthday SECOND: is to check the name bracelet BOTH of these should be done prior to any patient contact Bar Scan when giving medications
lotion
liquid suspension for skin
toxic effect
med accumulates in the blood stream (EX: morphine & respiratory depression)
what systemic effects can immobility cause?
metabolic changes; psychosocial effects; respiratory changes; cardiovascular changes; musculoskeletal changes; integumentary changes; urinary elimination; bowel elimination
what is the QSEN safety competency for a nurse?
minimizes risk of harm to pts and providers through both system effectiveness and individual performance
trough
minimum blood serum concentration (of drug) before next scheduled dose
solution
mixed in water. can be sterile for dressing changes (NS), or for IM, SQ, or IV routes
elixir
mixed w/ water or alcohol and a sweetener. oral drug
what nursing interventions can be used to counteract immobility caused metabolic changes?
monitor I&O; monitor % of food intake; monitor wound healing; monitor lab values: electrolytes, serum protein, BUN; monitor elimination patterns
morse fall scale
number 1 risk is if they have history of falls. pt may have something else going on (secondary disease). needs assistance (ambulatory aid, BR, nurse assist, etc). IV/heparin lock can be dangerous b/c pt could rip it out or trip over it. numbers ARE cumulative
define mobility
the ability to move freely, easily, rhythmically, and purposefully in the environment, is an essential part of living
what does safety refer to?
the prevention of pt injury caused by health care errors
peak
time @ which a med reaches its highest effective concentration (EX: IV vs. po)
duration
time during which the med is present in concentration great enough to produce a response
serum half-life
time for serum med concentration to be halved (excreted out of body)
onset
time it takes for a med to produce a response
what's the pharmacist's (and pharmacy staff's) role?
to prepare and distribute meds
what is the nurses responsibility for hygiene?
to provide the patient w/ the opportunity for hygiene. the skill may be delegated but not always; depends on facility policy.
side effect (not severe)
unintended, secondary effect (EX: ace inhibitor and cough)
allergic reaction
unpredictable response to a med
what are examples of good use of body mechanics?
use good ergonomics; lift teams/mobility devices; refrain from twisting motions and bending at the waist; push, don't pull; self-care
what shots do you not have to aspirate?
vaccines
what does it mean to aspirate an injection?
when injected into skin, you must withdraw the plunger and if blood comes into needle then you're in the blood stream and NOT muscle, and you'll have to start over. • if no blood shows then you're good to inject med
what are safe mobility practices?
when moving a patient, knowledge of safe transfer and positioning is crucial. • pathological influences on body alignment and mobility: congenital defects, disorders of bones, joints, and muscles; CNS damage; musculoskeletal trauma; any equipment or devices to protect (IV line, oxygenation equipment, etc)
what nursing interventions can be used to counteract urinary elimination changes caused by immobility?
• FLUIDS (give more fluids to help flush out stagnant fluid) • semi-full fowlers position when able
what nursing interventions can be used to counteract bowel elimination changes caused by immobility?
• FLUIDS (will help soften the stool; the longer the stool is in the intestine = the harder it is to get out b/c the body will pull from from the stool) • assess/diet choices • questions meds
what are common fall assessment screening tools?
• John Hopkins • Morse Fall Scale • Hendrich II • Stratify Falls Risk Assessment
what are the seven rights (medication)?
• Right patient: 2 identifiers (compare name/ID w/ MAR) • Right drug: need order, match MAR • Right dose • Right Route • Right time: institutional • Right documentation: after it is given • Right to refuse: pt can refuse med
what do you do when brushing an unconscious patient?
• SAFETY FIRST • prevent aspiration - positioning - lateral position w/ head turned to the side or side-lying; position back of head on a pillow so that the face tips forward and fluid/secretions will flow out of mouth - place a bulb syringe or suction machine w/ suction equipment nearby; yankuer end on suction device
what are the criteria to discontinue restraints?
• able to follow directions • able to participate in care • able to participate in program • behavior improves/changes • line tubes discontinued • positive response to med intervention
identify common patient problems associated with hygiene (nursing process: pt. problem)
• activity intolerance • bathing self-care deficit • dressing self-care deficit • impaired physical mobility • impaired oral mucous membrane • ineffective health maintenance • potential for infection
administering drugs via inhalation
• aerosol spray, mist, or powder via handheld inhalers; used fo respiratory "rescue" and "maintenance" - pressurized metered-dose inhalers (pMDIs): need sufficient hand strength for use - breath-actuated metered-dose inhalers (BAIs): release depends on strength of pt's breath - dry power inhalers (DPIs) • produce local effects such as broncho dilation • some meds create serious systemic side effects • spacer used when pt is unable to do correctly
what nursing interventions can be used to counteract integumentary changes caused by immobility?
• assess, assess, assess (assess every 2 hrs) • frequent turning use of pillow/waffle items/etc to elevate body parts
what nursing interventions can be used to counteract musculoskeletal changes caused by immobility?
• assess/screening • calcium supplements & foods • up when able • ROM • splints/boots
what should the nurse assess when helping the pt walk?
• assessment of pt strength, coordination, vitals, environment for safety • have pt wear non-skid shoes/socks • assist to sitting; dangle legs for 1-2 min • use gait belt • assisting w/ falls/syncope • use assistive devices PRN
eye administration
• avoid cornea • avoid touching eye w/ applicator • assess ability to self-adminster
what are essential components of medication administration?
• check chart for new orders first • medical history • drug allergies/interactions • tolerance/appropriateness of route • ordered diet • clients knowledge, educate if necessary • and ALL 7 RIGHTS prior to administration
what is the purpose of bathing?
• cleansing the skin • stimulation of circulation • improve self-image • reduction of body odors • promotion of ROM
list safety guidelines for patient hygiene
• communicate clearly w/ team members • incorporate pts priorities • move from the cleanest to less clean areas • use clean gloves for contact w/ nonintact skin, mucous membranes, secretions, excretions, or blood • test the temp of water or solutions • use principles of body mechanics and safe pt handling • be sensitive to the invasion of privacy
when and what should you evaluate the patient for?
• during and after ea. intervention • observe for changes in pts behavior • consider the pts perspective • often it takes time, repeated measures, and a combo of interventions for improvement • were the expected outcomes met? • were the pts expectations met? • ask questions to determine appropriate changes to interventions
clinical management: what are collaborative interventions that can be used for an immobile pt?
• exercise therapy - ambulation, joint mobility (ROM), stretching, balance • pharmacologic agents - anti-inflammatory agents, analgesics, nutrition supplementation • surgical interventions - curative vs palliative - joint replacement, spinal fusion, ligament repair • immobilization - casts & splints, braces, traction, slings, shoulder immobilizers, pillows, etc • assistive devices - crutches, canes, walkers, w/cs, prostheses • last THREE are for pts w/ true inury • start w/ least invasive then move to more invasive
what should the nurse assess for patient's hygiene?
• factors that influence a patient's personal hygiene • use communication skills to promote the therapeutic relationship • hygiene care is NEVER routine • during hygiene, assess: emotional status, health promotion practices, and health care education needs
how can the nurse help plan with the patient ways to better the patient's hygiene (nursing process: planning)?
• figure out goals and outcomes -partner w/ the pt and family -measurable, achievable, individualized • set priorities based on assistance required, extent of problems, nature of diagnoses • teamwork and collaboration -health care team members -family -community agencies
parenteral routes
ID, sub-Q, IM, IV
what does the fire emergency response acronym, "RACE", stand for?
R - Rescue A - Alarm C - Contain E - Extinguish
define restraints
any manual method, physical or mechanical device, or material or equipment that immobilizes or reduces the ability of a patient to more his or her arms, legs or head freely
what are distribution systems (unit dose or automatic med dispensing sys [AMDS])?
area for stocking and dispensing meds
what is the nurse's role in medication administration?
assess pt's ability to self-administer, determine whether pt should receive, administer med correctly, and closely monitor effects; do not delegate this task
how can fall assessment help patients?
assessment of a patient's risk factors for falling is essential in determining specific needs and developing targeted interventions to prevent falls
what is an automated medication dispensing system?
automated: control the dispensing of meds, may be networked w/ computerized medical record, may include controlled substances
factors influencing routes: oral
convenience vs. tolerance, easy to give, often produces local or systemic effects
Hendrick || Fall Risk Model
risk factor (≥ 5 = high risk)
what does the z-track injection method do?
seals track where you injected med; skin traps the medicine into the muscle. decreases irritation in injection site b/c it prevents med from leaking out onto skin. helps absorption
transdermal disk or patch
semi-permeable membrane disk or patch w/ drug applied to skin
ointment
semisolid (salve another name)
paste
semisolid, but thicker than ointment - slower absorption
factors influencing routes: mucous membranes
sensitive, less pleasant
adverse effect
severe response to med (EX: seizure)
suppository
solid drug mixed w/ gelatin inserted into body cavity to melt (rectum vagina) - may come w/ applicator
oral routes
sublingual, buccal
syrup
sugar solution. oral drug
action
alter physiological functions
tablet
compressed powder. oral drug
mixing insulin
draw cloudy > draw clear > mix clear > mix cloudy
suspension
drug particles in a liquid medium. oral drug
absorption
from site into blood (from administration)
topical
(EX: nitro, fentanyl)
what angle should you inject intradermal shots at?
15 degrees
what angle should you inject sub-q shots at?
45 or 90 degrees
what angle should you inject IM shots at?
90 degree
what is AIDET
Acknowledge Introduce Duration Explain Thank you
what does the acronym, "PASS", stand for when using a fire extinguisher?
P - Pull A - Aim S - Squeeze S - Sweep
what are elements of musculoskeletal assessment: the history?
PMH, family history, current meds, lifestyle behaviors, occupation, social environment, problem-based history
what is atelectasis?
a complete or partial collapse of the lung or area (lobe) of the lung
define a patient fall
a sudden, unintentional change in position, coming to rest on the lower ground or other lower level, is among the most commonly reported adverse hospital events, with more than 1 million occurring annually
standing or routine
administered until the dosage is changed or another med is prescribd
what is an example of alternative restraints, less restrictive restraints, and more restrictive restraints?
alternative - covering (IV) line less restrictive - self release lap belt more restrictive - lap belt; patient cannot release
why are falls a serious hazard for older adults?
because of their increased causation of morbidity and mortality
plateau
blood serum (of drug) is reached and maintained
what is orthostatic hypotension
bp drops w/ change of positions (lying to standing or standing to lying down) - risk for falling
how can immobility effect the respiratory system?
can cause atelectasis and/or hypostatic pneumonia
how can immobility cause bowel elimination changes?
can cause consitpation
how can immobility cause cardiovascular changes?
can cause orthostatic hypotension and/or thrombus
how can immobility cause integumentary changes?
can cause pressure ulcers
how can immobility cause urinary elimination changes?
can cause urinary status & renal calculi (kidney stones)
metabolism
changed to prepare for excretion
what is thrombus?
clot formation in legs
caplet
coated for easier swallowing. oral drug
define restraint alternative
devices or techniques employed to avoid the use of restraints. depending on the intent and how it is used, it can be an alternative or a restraint
what is the z-track injection method?
displace skin w/ non-dominant hand (move skin). inject needle > hold barrel w/ non-dominant fingers > aspirate > no blood = inject med; blood = start over > take out needle > release skin
lozenge
dissolves in mouth. oral drug
enteric coated
dissolves in small intestine. oral drug
how often should you assess patient to remove restraints?
every 15 minutes; when able(?)
therapeutic effect
expected or predictable (EX: nitroglycerin increases myocardial o2 supply)
for hygiene, what nursing process (assessment) can be implemented?
explore the pt's viewpoint/preferences. assess self-care ability (oral cavity, use of sensory aids), skin (hair and hair care, hygiene care practices), and feet and nails (eyes, ears, and nose; cultural influences). ALWAYS ASK PATIENT TOO
intraocular
eye drops
define safety
freedom from psychological and physical injury
distribution
from blood into cells, tissues, or organs (to use)
what should you do when a patient is falling?
gently lower then to the ground
single (one-time)
given 1 tine only for a reason of specific
prn
given when the pt requires it
time release
granules w/ different coatings, or some tablets that dissolve slowly. oral drug
actions
how medications act/how drugs work
excretion
how they exit the body
route
how to enter the body (orally, IV, sublingual, etc)
what are causes of back injuries?
increase force/stress; repetitive motion/twisting; forward bending; poor or improper lifting techniques; poor posture; poor job design; deconditioned/poor physical fitness
factors influencing routes: injections
infection risk, needle, bleeding, rapid absorption
inhalation
inhaler
what is an alaris pump?
is an infusion pump that delivers fluids, such as nutrients, blood and medications, into a patient's body in controlled amounts. the device is indicated for use in adults, pediatric patients, and infants and only used in hospitals and other health care facilities.
how can immobility cause musculoskeletal changes?
it can cause disuse osteoporosis, joint contracture, and foot drop
what is hypostatic pneumonia?
pneumonia that usually results from the collection of fluid in the dorsal region of the lungs and occurs especially in those (as the bedridden or elderly) confined to a supine position for extended periods
capsule
powder, liquid, or oil inside gelatin shell. oral drug
what can the nurse do distract the patient before ordering for restraints (first try)?
prevention - distraction, conversations, videos, legos, fold towels, tv channels, ambulate
factors influencing routes: transdermal
prolonged systemic effects
how can immobility have psychosocial effects?
promote depression
factors influencing routes: inhalation
provides rapid effect for local respiratory effect, potential serious side effects
idiosyncratic reaction
over- or under- reaction to a med (EX: if child takes benadryl they could become very hyper when benadryl should make them sleepy)
what are symptoms associated w/ altered mobility
pain. reduced joint movement. reduced sensation or loss of sensation. falls. fatigue. altered gait or imbalance. reduced functional ability.
factors influencing routes: skin/topicals
painless, caution w/ abrasions, provides local effects
what are examples of when to remove patient restraints?
patient is no longer confused; now alert. risk factor is no longer present; no need for restraints
what do you need to do for subcutaneous (sub-q) administration?
pink and inject (in fatty areas - stomach, butt, behind arm)
what is the nurse's role in medication?
• follow 7 rights • read labels 3x and compare to MAR • use at least 2 pt identifier • avoid interruption • double check calculations, verify w/ another RN, follow policy • question unusual doses • record after med is given • report errors, near-misses • participate in programs designed to reduce error • pt education about meds
what are the general care guidelines for an immobilized pt?
• frequent turning, positioning, alignment • skin assessment and skin care • ROM • deep breathing • wt bearing (if possible) • measures to optimize elimination • nutrition
nose administration
• have pt blow their nose before • dropper: hold 1/2 inch above nare w/ head tipped back • spray: insert into nare; spray while inhaling
what do yo do for oral hygiene on an unconscious patient?
• keep the mouth open - use a padded tongue blade to open the pts mouth and separate the upper and lower teeth - never place your hand in the pts mouth or open w/ your fingers. oral stimulation often causes the biting-down reflex and serious injuries can occur
what are patient problems (nursing diagnoses) related to medication administration?
• knowledge deficit regarding drug therapy due to unfamiliarity w/ information resources • noncompliance regarding drug therapy due to limited economic resources (or health beliefs) • ineffective management of therapeutic regimen due to complexity of drug therapy (or knowledge deficit) • impaired swallowing due to neuromuscular impairment
walkers
• life all 4 legs @ one time • advance 6-8", then walk up to walker
what nursing interventions can be used to counteract immobility caused psychosocial effects?
• listen to pt • identify changes • assess sleep/wake cycle • promote visitation
crutches
• measuring for crutches (right height; individualized for each pt) • crutch gait • sitting in a chair w/ crutches
what are the principles of safe pt transfer and positioning?
• mechanical lifts and lift teams essential when pt. is unable to assist • when pt CAN assist: - wider base of support (spread feet apart) = greater stability of nurse - lower center of gravity (squat down) = greater stability of nurse - face direction of mvmt prevents abnormal twisting of spine • when pt CANNOT assist: - divide balanced activity btwn arms and legs (reduces back injury) - leverage, rolling, turning, or pivoting requires less work than lifting • when friction is reduced btwn the object to be moved and the surface on which it is moved, less force is required to move it
what nursing interventions can be used to counteract respiratory changes (caused by immobility)?
• monitor RR and characteristics of respiratory sys • monitor breath sounds every 2 hours • positioning to provide lung expansion/exercise
what nursing interventions can be used to counteract cardiovascular changes caused by immobility?
• monitor for s/s: ↑ HR, ↓ pulse pressure and ↓BP • mobilize pt ASAP (dangle, OOB, gait belt for safety, call light and assistance) • use of sequential compression devices (SCDs)
list some fall assessment tools
• morse fall scale (used @ Community Hospital and IU Health Hospitals) • Hendricks || Fall Risk Scale • John Hopkins Fall Risk Scale • Humpty Dumpty in Pediatric Pts
medication: interactions
• occurs when 1 med modifies the action of another • a synergistic effect occurs when the combined effect of 2 meds is > the effect of the meds given separately
what on-going monitoring should a nurse considered when restraints are ordered for a patient?
• patient comfort: - food, hydration, toileting, ROM • continuation/discontinuation - mental status, cognitive functioning, level of distress/agitation • patient safety - vital signs, circulation checks, skin integrity, correct application
what is the prescriber's role?
• prescriber can be physician, NP, or PA • orders can be written (hand or electronic), verbal, or PA • the RN Role Computerized provider order entry (CPOE) • the use of abbreviations can cause errors; use caution • ea. med order needs to include the pts name, order date, med name, dosage, route, time of admin, drug indication, and prescribers sub
what are bath guidelines?
• provide privacy • maintain safety • maintain warmth • promote independence • anticipate needs
canes
• pt holds can on unaffected side • advance cane 6-10", step affected leg up to distance of cane FIRST, then advance unaffected leg past cane • positioning of quad cane (straighter side should be towards pt)
how can you maintain patient's right?
• pt is informed about a med • pt can refuse a med • (pt) has medication history • pt is properly advised about experimental nature of med • pt receives labeled meds safely • pt receives appropriate supportive therapy • pt doesn't receive unnecessary meds • pt is to be informed if meds are part of a research study
what are on (medication/rx) orders?
• pt's full name • date and time order written • drug name • dosage • route • time and frequency • signature of provider
clinical management: primary prevention of immobility
• regular physical activity (active and passive ROM) • protection against injury • optimal nutrition • fall prevention measures
what should a nurse do when a medication error occurs?
• report all med errors • pt safety is top priority when an error occurs • documentation is required • the nurse is responsible for preparing a written occurrence or incident report: an accurate, factual description of what occurred and what was done • nurses play an essential role in med reconcilation
ear administration
• room temp • use sterile solutions • side lying/head tilted (for 2-3 minutes after) • pull auricle down/back for children, up/back if >3y/o • hold dropper 1/2 inch above ear canal
the nurse has applied extremity restraints on a pt. what should the nurse assess on a regular basis?
• skin integrity and ROM • pulse and temp of the restrained body part • ability of the pt to breathe w/o restriction • readiness for discontinuation of the restraint • frequency of the patient's visitors • therapy (IV catheters, drainage tubes) remains uninterrupted
what does need size depend on?
• the size of the pt • higher the number = smaller the needle (vice versa)
what implementations/interventions can be used to better the pt's hygiene (nursing process)
• use caring to reduce anxiety, promote comfort • administer meds for symptoms before hygiene • be alert for pt's anxiety or fear • assist and prepare pts to perform hygiene as independently as possible • teach techniques and signs of problems • inform pts about community resources • health promotion (make instructions relevant; adapt instruction to pt's facilities and resources; teach the pt ways to avoid injury; reinforce infection control practices) • consider normal grooming routines and individualize care • bathing and skin care
when should someone have a bone density test?
• womxn age 65 or older • men age 70 or older • if you break a bone after 50y/o • womxn of menopausal age w/ risk factors • postmenopausal womxn under age 65 w/ risk factors • men age 50-69 w/ risk factors
how can immobility effect metabolic changes?
• ↓ appetite → negative nitrogen balance (wt loss; ↓ muscle mass, and weakness) - if not expending a lot of energy, then the body may not crave more energy • hypercalcemia (pathological fractures) energy will come from bones • ↓ GI motility (constipation; fecal impactions)