NSG 212 Exam 3 pt 1

topical meds

-Apply with a gloved finger, tongue blade, or cotton-tipped applicator. Never apply with bare hand. -Example: Nitroglycerin Remove old patch and clean prior to placing a new one. Ordered in inches Rotate sites.

PRN dosing

not as effective as we once thought, difficult to treat pain that already exists! (pt often ask for more when its al gone)

push or pull with transferring?

push!

how to give liquid meds to infant and dec risk of aspiration?

put b/w cheek and gums

maintaining emergency preparedness

•Addressing biological, chem, radiation threats •Addressing cyber terror •Preparing for mass trauma terrorism •Identifying disaster resources •Addressing psychological aspects of disasters

nursing hx in safety

•Assess for history of falls or accidents. (Previous fall=high risk to fall again) •Note assistive devices. •Be alert to history of drug or alcohol abuse. (think ab withdrawal?) •Obtain knowledge of family support systems and home environment.

can you leave meds at bedside?

no, except some facilities allow this with topical meds

under tx for pain

-a serious complication and can lead to increased anxiety with acute pain and depression with chronic pain. -Assess clients for pain frequently, and intervene as appropriate.

Analgesics -- Non-Opioid

--Acetaminophen -Adverse effect: Liver dysfunction --NSAIDS -Act peripherally: Decrease inflammation/inhibit prostaglandins -Aspirin, Ibuprofen, Naproxen, Indomethacin, Toradol -Adverse effects: GI upset (many enteric coated to prevent), bleeding, renal dysfunction -COX-2 inhibitors (Celebrex, Vioxx) -- less chance of GI upset (we now have safety concerns with this class or meds!) (big risk of bleeding)

Addiction management

--Effective medications exist to treat addiction but only a fraction of people with addiction have access to them (buprenorphine, methadone, naltrexone) --Lots of research going on right now looking for newer, longer lasting, safer ways to treat addiction -Depot formulation injections (Vivitrol - blocks effects of opioids in body for 4 weeks) -Implants (Probuphine) --Don't judge or be bias if pt is addicted to IV meds, tx them like any other pt

absorption time for rectal suppository

-Absorption times may vary -In general... 60 minutes for full absorption 20-30 minutes for stimulation

Analgesics - Opioid (Narcotic)

-Act on CNS: Block release of NT that promote transmission of pain pathways -Morphine, codeine, hydromorphone, fentanyl, oxycodone, meperidine -Opioid Antagonist - NALOXONE (NARCAN) (in ampule) Reverses effects of opioids, both side effects & analgesia. Used only to counteract an overdose of opioid. IM and intranasal versions available for purchase at pharmacies and carried with all first responders

environment for med safety

-Adequate lighting -Reduced noise -Minimal to no interruptions -When taking orders make sure decimals have been placed in correct spot and units are recorded! -DO NOT LEAVE UNATTENDED! (not even w/ instructor) -DO NOT TRUST OTHERS TO "WATCH" OVER THE MEDICATIONS! -you prep meds, you give them! you dont prep them, dont

adjuvant analgesics

-Adjuvant analgesics enhance the effects of nonopioids, help alleviate other manifestations that aggravate pain(depression, seizures, inflammation), and are useful for treating neuropathic pain. -Anticonvulsants: carbamazepine, gabapentin -Antianxiety agents: diazepam, lorazepam -Tricyclic antidepressants: amitriptyline, nortriptyline -Anesthetics: infusional lidocaine -Antihistamine: hydroxyzine -Glucocorticoids: dexamethasone -Anti-emetics: ondansetron -Bisphosphonates and calcitonin: for bone pain -inc use over past few yrs to get away from opioids

SQ injections

-Administer medication into subcutaneous/adipose tissue. -There are few blood vessels in this tissue. -Slow-sustained release, eventually absorbed by capillaries -Examples: Heparin, Lovenox, Insulin -Do not aspirate (pull back on the syringe to see if there is blood return). -sites: upper arm, stomach above hip bones, front thighs, scapula, top of butt -Use a 3/8- to 1-inch, 25- to 30-gauge needle or an insulin syringe of 28- to 31-gauge. -Inject no more than 1.5 mL solution. (THAT IS A LOT!) -For an average size client, pinch up the skin and inject at a 45 to 90 degree angle. -obese=90 degree angle. -Base degree on amount of SQ tissue. -Smaller needles (3/8") admin at a 90 degree angle. -Pinch or spread skin to determine amount of SQ tissue. -Insert needle using a dart-like motion. -DO NOT Aspirate. -Avoid bruised, tender, inflamed, hard, and/or scarred areas.

better/worse for pain

-Aggravating/relieving factors -QUESTIONS "What makes the pain better?" "What makes the pain worse?" "Are you currently taking any prescription, herbal, or over‑the‑counter medications?"

nursing considerations w/ oral meds

-Assess for aspiration risk. -Assess swallowing prior to med administration. -Give 4-6 ounces of water to take meds. -Know if they are on a fluid restriction. -Offer the patient the pills IN THE CUP or place on their tongue with a GLOVED hand. -Instruct the patient not to chew lozenges -MAKE SURE the patient is sitting in Fowler's. -Do not mix with large amounts of food, beverage. GRAPEFRUIT JUICE! (Allows more of the drug to be absorbed, which increases blood levels.) -If using a pill bottle, put the pill into the lid and then into the medicine cup.

buccal

-Between the cheek and the gum -No chewing/swallowing the medication. No eating or drinking. We wear gloves and place the medication in position.

Stimulator of Nociceptors or Pain Receptors.. INCREASE PAIN RESPONSE

-Bradykinin: a powerful vasodilator that increases capillary permeability and constricts smooth muscle -Prostaglandins: important hormone-like substances that send additional pain stimuli to the CNS Makes us feel or interpret pain! MANY medications work by inhibiting prostaglandin (ex. Aspirin) -Substance P: sensitizes receptors on nerves to feel pain and also increases the rate of firing of nerves (blocked w/ Tylenol) Makes us feel or interpret pain! -Histamine.. Generation of pain hypersensitivity (ex. Things get red)

Sedation, respiratory depression, and coma

-Can occur as a result of overdosing. -Sedation always precedes respiratory depression. -Identify high‑risk clients (older adult clients, clients who are opioid‑naïve). -Carefully titrate (adjust dose) client dose while closely monitoring respiratory status. -Stop the opioid and give the antagonist naloxone if respiratory rate is below 8/min and shallow, or the client is difficult to arouse. -Identify the cause of sedation. -Use a sedation scale in addition to a pain rating scale to assess pain, especially when administering opioids -Count rr b4 anything dec resp drive -Look at last time they had pain med going on floor

insulin pens

-Commonly used in facilities/home environment. -Need separate needle caps. -Must be primed w/ TWO units of insulin prior to injection. -Use a 90 degree injection angle. -Hold for AT LEAST 6-10 seconds after injection. SEE TAYLOR TEXT PAGE 851. Scrub the self-sealing seal end of the pen cartridge holder with an antimicrobial swab. Remove the protective paper tab from the needle. Screw the needle onto the reservoir. prime. Hold the pen upright and tap to force any air bubbles to the top. Hold the pen upright and press the injection button or plunger firmly. Watch for a drop of insulin at the needle tip. Check the drug reservoir to make sure enough insulin is available for the dose. Check that the dose selector is at 0 (zero), then dial the units of insulin for the dose. Put on gloves. Clean the injection site. If the pen needle is longer than 5 mm, gently pinch the skin at the injection site to form a skin fold. Hold the pen in the palm of the hand, perpendicular to the forearm, with the thumb at the injection button end of the pen. Use the thumb for injection. Administer the subcutaneous injection. Press the injection button on the pen all the way in. Keep the button depressed and count to 10 before removing from the skin. The safety shield automatically covers the needle when the needle is removed from the skin. Remove the needle from the pen; a second safety shield automatically covers the back end of the needle when removed from the pen. Dispose of the needle in a sharps container.

role of the nurse with addiction

-Consider addiction history as we assess pain -What meds do they abuse? -What meds are they on for addiction? -How will those meds affect our ability to achieve pain relief? -Can we safely give pain meds if abused or addiction meds are on board? -What will we look for in addicted patients?

PCA - very common post-op

-Constant plasma levels are maintained by small frequent doses -Less lag time between need and delivery -Increases patient sense of control -May decrease amount of medication needed -Morphine sulfate and hydromorphone are commonly used -Patients need educated - only they should push button! -Patient determines when analgesia is administered (predetermined safety limits) Loading dose (bigger) Demand dose (when pressed) Basal dose Rescue dose (bolus) (if higher pain lvl) Lockout interval (pt can push button, but no med delivered in time interval) Can go into IV, SQ, Epidural cath Nurses must assess RR (opioids can => resp depression) Families, RNs, CAs, and students should not push the button for pts! -Can judge effectiveness or pt knowledge based on # of times they press the button per hour (ex. 400x=in pain, up dose?)

when crushing meds...

-Crush one at a time. -Put each pill in an individual cup. -Keep the wrapper w/the medication so you can ID the medication. -CLEAN the crushing device EACH time after using it. -DON'T use a dirty crusher. -Know what you can/cannot crush

Pain Influences

-Cultural beliefs, (spirit telling them smth, bc they have been bad, don't want to be addict to meds. Edu and imp to give them a choice to take meds or not) -Healing (some believe pain is healing, so don't wanna take pain meds) -Environment -Belief that comfort will come.. (ex. Having a baby, knowing smth good will come from pain makes it better. Opposite can make it worse) -Anger, anxiety, control, sleeplessness.. -It exists whenever the patient says it exists It's an unpleasant sensory and emotional experience associated with actual or potential tissue damage -Pain is a personal and individual experience

Gate Control Theory of Pain

-Describes the transmission of painful stimuli and recognizes a relationship between pain and emotions. -Small- and large-diameter nerve fibers conduct and inhibit pain stimuli toward the brain. -Gating mechanism determines the impulses that reach the brain. -vid: -Happy thoughts=excrete endorphins

aspiration

-Do not aspirate! Per Taylor text page 903 -According to the CDC and current evidence, aspiration (pulling back on the syringe immediately after injecting the needle into the skin) is NOT required for IM injections. However, some literature suggests that aspiration MAY be indicated when administering large molecule medications, such as penicillin. -Consult facility policy and the manufacturer's recommendations to ensure safe medication administration.

transdermal meds

-Do not cut the patch. -Rotate sites. -Apply to a hairless area. -NO HEAT!!! -Remove old patch and clean skin prior to applying a new one. -Dispose of properly... per facility policy (flush or sharps). -DO NOT rub or massage! -DO NOT CUT unless indicated! -Write date/time/initials on the patch.

nursing interventions for pain

-Establishing trusting nurse-patient relationship -Manipulating factors affecting pain experience (make room dark/quiet, plan rest for pt) -Initiating non-pharmacologic pain relief measures -Managing pharmacologic interventions -Reviewing additional pain control measures, including complementary and alternative relief measures -Considering ethical and legal responsibility to relieve pain (don't let them hurt, don't OD them) -Teaching patient about pain

Pain Assessment.. Objective ( non-verbal)

-Facial grimacing -Moaning, crying -Guarding -Decreased attention span -Physiologic measures.. Increase blood sugar, change in vital signs. Over time, the these measures will "stabilize" even if the patient is experiencing pain. -What we see -Pain=>flight or flight till used to it

liquid meds PO

-Faster absorption than pills -Elixers, suspensions, and syrups -Palm the label. -Make sure cap is top side down. -DO NOT return extra to the bottle. -Syringe (needleless) use: For less than 5 ml or if cannot drink from medicine cup -Pour on a flat surface -Pour to the meniscus

Pain Management Regimens for Cancer or Chronic Pain

-Give medications orally if possible. (lots of patches w/ chronic tho) -Adjust the dose to achieve maximum benefit with minimum side effects. (so they can live life) -Allow patients as much control as possible over the regimen. -May use multiple methods of pain management -Oral, transdermal, IV, PRN, scheduled Opioids, adjuvant, Tylenol. -Not prn, use preventative dosing (around clock like patch, dec tolerance, allows smaller doses). Preventative dosing can be used for other things too

SQ anticoagulants

-Heparin/Lovenox (Enoxaparin)/Arixtra (Fondaparinux) -Lovenox (Enoxaparin)/Arixtra (Fondaparinux)...DO NOT discard air bubble. -May need to invert to adjust dose. -Cleanse site with alcohol. -Inject into the abdomen only. (This is where it is MADE to be absorbed.) -Rotate sites. -Avoid 2'' around umbilicus and belt line. -DO NOT MASSAGE after injecting. -Use with EXTREME caution in people with bleeding disorders and/or taking medications (NSAIDS) that can increase bleeding times. -Watch for occult bleeding (blood in stool or urine, nose bleeds, etc.) -THEY WILL BLEED...WATCH PROCEDURES! Protamine Sulfate is the antidote for Heparin.

sublingual

-Highly vascular area -Under the tongue -No chewing/swallowing the medication. No eating or drinking. We wear gloves and place the medication in position.

oral inhalation: MDI (metered dose inhaler)

-Hold 1-2 inches (2-4 cm) away from the mouth. -Hold the inhaler w/the mouthpiece on the bottom. -Hold w/the thumb near the mouthpiece and the index and middle fingers at the top. -Shake 5-6 times before use; first-time used, use 1-2 puffs to prime. -Instruct patient to tip the head back, exhale and then inhale the medication through the mouth for 3-5 seconds via a slow deep breath, then hold their breath for 10 seconds before exhaling slowly via pursed lips, and wait 1 minute between puffs if taking 2 puffs of the same medication. -WAIT 2-5 minutes in between different medications. -RINSE the mouth with water and blow the nose when finished w/inhalers to reduce irritation from residual. -Empty=will float in water -May also have a dial on the top to show how many doses remain. -They should remove the canister and rinse the inhaler cap and spacer (if one is being used) once a day w/warm water and dry it. -Spacers

age related changes in older adults

-Incidence of pain is higher due to prevalence of acute and chronic diseases -Pain threshold does not change; -Lower doses of analgesics/ narcotics needed due to change in metabolism of medications; -May under report pain because they feel is it an "expected" result of aging and nothing can be done.

IM sites per age

-Infants (1yr and younger)...Vastus lateralis -Toddlers/children...Vastus lateralis or deltoid -Adults...Ventrogluteal or deltoid -ventrogluteal for older children and adults and volumes greater than 2 mL.

at risk populations

-Infants/ children: cannot verbalize or fully understand pain -Older adults: may have multiple pathologies that cause pain/ limit function -Substance abuse patients Tolerance -Fatigued patients .. Fatigue can increase sensitivity to pain -Prior experiences .. Increase or decreased sensitivity depending on whether or not relief was achieved Lack of support systems .. If support is there, can decrease sensitivity to pain -Cultures Not socially acceptable to show pain (edu on pain and tx, they may believe that the pain is from smth outside body) -Body doesn't know diff b/w endorphins, morphine, heroin (hx of addiction but now sober=easier to get addicted, may need higher dose bc tolerance)

ID injection

-Inject into dermis (just under epidermal layer) with bevel up. -Slowest absorption rate -Used for sensitivity tests (TB, allergy, local anesthesia). -Body reaction is easily visible/can gauge level of reaction. -Injection leaves "wheal"/bump under skin. -Sites: inner forearm, upper back, under scapula(Lightly pigmented, thin‑skinned, hairless sites (the inner surface of the mid‑forearm or scapular area of the back)) -Use TB syringe for injections: ¼ inch to ½ inch needle, 25-27 gauge -Dose: 0.o1-0.1 mL (Usually, less than 0.5 mL.) -Angle 10-15 degrees

IM injections

-Inject through skin and SQ tissue and into muscle. -Muscles have a greater # of blood vessels than SQ tissue. -Faster onset than SQ (15-20 minutes) -Painful (can numb with ice, apply EMLA cream if ordered, have patient relax muscle, push med slowly, apply pressure after injection) •Use a needle size 18- to 25-gauge (usually 22- to 25-gauge). •Use a needle that is 5/8- to 1.5-inches long. •Inject at a 90° angle. •Volume injected is usually 1 to 3 mL. •If a greater amount is required, it should be divided into two syringes and two different sites should be used. -Choose location based on the patient's age and size, med type, and amount of med. if possible, patient preference. -1-3 mL per site for adults (except deltoid 1 mL). -1-2 mL for less developed muscles of elderly and children. Depends on muscle mass. -Assess muscle mass and amount of adipose tissue Increased adipose tissue—use a needle longer than 1.5 inches. -Consider infection risk with IM injections!

pain intensity

-Intensity, strength, and severity are "measures" of the pain. Use a pain intensity scale (visual analog, description, or number rating scales) to measure pain, monitor pain, and evaluate the effectiveness of interventions. -QUESTIONS "How much pain do you have now?" "What is the worst/best the pain has been?" "Rate your pain on a scale of 0 to 10."

types of injections + angles

-Intradermal (ID) 10-15d -Subcutaneous (SQ) 45d -Intramuscular (IM) 90d

med prep:

-Know what you are giving. -Know why you are giving each medication. -Check 6 rights! -Know VS, labs, etc. PRIOR to administering medications. -Question incomplete orders...DO NOT GIVE! -Be "ready" to give meds! -NEVER give something someone else has poured or prepared.

patient id's

-Name -Identification number -Telephone number -Date of birth -Other form of person-specific identification, such as a photo identification card

Pain Assessment.. Subjective (verbal)

-Location: Where does it hurt? -Intensity.. Visual scale (7 and older) -Quality.. sharp, dull, piercing.. Use the patients EXACT words -Pattern.. onset, duration, frequency, intervals without pain -Setting.. In a particular place/ area.. Driving in a car.. Sitting in hard chair -Precipitating/ alleviating factors (want to mimic what brings it on/makes it better in the hospital) (ex. loud noises) -Associated symptoms; nausea, headache, hot, cold, sweaty -Effects on daily living ; can't sleep, eat, drive, cook, read, play -Coping strategies; support from family, prayer, -Affective/ behavioral responses; anxiety, depression, grimacing, moaning, change in vital signs

check and balance system

-MAR (medication administration record) -Legally responsible---any suspected error should be questioned -Right to refuse to administer (but need to provide rationale) -Always know the reason WHY YOUR PATIENT IS ON THE MED! No reason, no administration. -6 Rights of Safe Medication Administration

age related changes in cognitive impaired

-May not be able to accurately report pain or assessment -Pain may cause aggressive/ impulsive behavior.. Up/down, out of bed. FALLS! -Assessment: breathing, vocalization, facial expression, body language, consolabiity -Think. IS this/ would this cause pain?

age related changes in infants

-May show: Irritability, restlessness, crying, screaming, or other verbal expressions Grimacing or grinding of teeth, clenching of fists, Touching or grabbing painful body part Kicking or thrashing to move away from painful stimuli -Young children and infants experience pain too.. Sometimes harder to assess Cry for diff reasons sounds diff

roles in med admin

-Medication order written by practitioner (MD or NP) (won't include size of needle or angle or to crush) -Pharmacist fills the prescription -Nurse (RN or LPN) administers -Need to work as a check and balance system!!! -If you don't understand an order, call the pharm, and if they don't know they will call the provider. -If you hold a med for whatever reason, call provider who ordered it

controlled substances

-Medications that have a potential for abuse and dependence and have a "schedule" classification. -Heroin is in Schedule I and has no medical use in the United States. -Medications in Schedules II through V have legitimate applications. -Each subsequent level has a decreasing risk of abuse and dependence. -For example, morphine is a Schedule II medication that has a greater risk for abuse and dependence than phenobarbital, which is a Schedule IV medication. -Follow all laws and regulations for preparing and administering controlled substances. -Keep them in a secure area. (locked) -Have another nurse witness the discarding of controlled substances. -Controlled substances are often stored in an AccuDose/Pyxis system. These medications are counted. -Anything scheduled is locked. Must count as you take them out (open, count # in holder and compare to what computer says is in there. If wrong, don't take and figure it out). Very serious!! (ex. Missed epidural, police called, bags searched) -If you must discard: ex. 10mg order, pill in 20mg so must break in half. Another RN must witness you break it and discard it in right receptacle in med room (not toilet or sink bc contaminate water). Cant witness as a student!

Pain Sensation and Relief

-Meds to tx fast pathways and slow pathways

Pain Response

-Mild; increased RR rate, dilation of bronchial tubes, increased HR; Pallor and increased BP; increased blood glucose; release of adrenaline; diaphoresis; muscle tension; decreased GI motility -Severe, deep pain; Pallor; rapid, irregular breathing, n/v; weakness, fatigue; fainting, LOC, decreased HR and BP -Behavioral: Moving away from painful stimuli, clenching of teeth; holding painful part; grimacing; bending over; tensing abdominal muscles; crying, moaning, refusing to move; restlessness; -Affective responses: Withdrawal, anxiety, fear, depression, anger, anorexia, hopelessness, powerlessness

SQ insulin

-Mixing Insulin: -Regular and NPH -Short acting is clear. -Intermediate/long acting is cloudy. -Draw up clear before cloudy. -Air to cloudy - Air to clear - Draw up clear - Draw up cloudy -BEWARE: LANTUS (24hr insulin) is CLEAR— CAN NOT MIX! -SQ route of administration for all types of insulin. Rapid-acting, short-acting, intermediate-acting, long-acting -Regular can be mixed with ANY OTHER type of insulin except for long-acting -NOTHING can be mixed with long acting insulin! -USE INSULIN SYRINGES ONLY! -Rotate vial before administering; DO NOT SHAKE; administer within 5 minutes of mixing insulins. -Can be stored at room temp for about 1 month; DO NOT administer cold insulin. -KNOW BLOOD GLUCOSE BEFORE YOU ADMINISTER INSULIN! -Rotate sites. -DOUBLE CHECK! -sliding scale insulin to determine dose

ventrogluteal placement

-Most preferred site -Palm of the hand on the greater trochanter -Anterior superior iliac crest -"V" for ventrogluteal -THUMB FACES THEIR FRONT -Form triangle, place right in the center -SWITCH HANDS -Involves the gluteus medius and gluteus minimus muscles in the hip area. -Large muscle mass that is generally FREE from major nerves and blood vessels. -Patient can be on their back, abdomen, or side. -To relax the muscle, the patient can bend their knees, if they are laying on their side.

bias in pain

-Myths.. -Patients who are in pain are " drug seekers" -Patient's will lie about their pain " just to get drugs" -Medicating patients routinely will make them addicted. -Infants do not feel pain -Patients who are unconscious/ asleep do not feel pain -Patients who do not complain of pain do not have pain -Pain is an " expected" experience and, therefor, should not be treated.

sharps disposal

-NEVER recap a "dirty" needle!!! -ALWAYS use safety devices. -In the home, the patient can use old milk jugs or laundry detergent bottles to dispose of needles (BARRIER). The patient can take these to pharmacies for disposal.

parts of needle / syringe

-Needle: Varies in length/gauge (gauge-higher the #, smaller the circumference) Hub Shaft Bevel -Syringe: Barrel Plunger

The Pain Process... BLOCK pain response

-Neuromodulators.. Endogenous opioid compounds "natural" pain relief -Endorphin.. Powerful pain blocking chemicals (released when thinking of happy thought) Dynorphin.. Most potent endorphin.. NATURAL PAIN RELIEF! Enkephalins ..inhibit the release of substance P Substance P.... MAKES US FEEL OR INTERPRET PAIN! -If someone is in pain, block it! -Opioids are these but way stronger -These are similar to morphine

opioid crisis

-Overdose now the leading cause of accidental death in WV -Involves patients, families, children -Concerns with increase in HEP C and HIV -Often patients are prescribed medication for a valid reason and then become addicted with continued prescriptions or illegally obtained meds

nursing interventions if pt in pain

-PCA .. Patient Controlled Analgesia (esp in surgical pt) ONLY THE PATIENT SHOULD PUSH THE BUTTON! (may dec amt of med needed (press button as much as they want, device is time locked and only gives dose every - min). If not pca, late pain med dose=inc pain=need of higher dose Sometimes a basal dose (small amount every now and then w/o having to press the button)) -Pain assessment/ Pain reassessment -TREAT THE PAIN BEFORE IT BECOMES TOO SEVERE! -Reassess 30 -60 minutes after pain medication/ intervention -PRN.. Not automatic.. Explain this to your patient (they will need to say they want it)

med admin routes

-PO, SL, transdermal, topical -Instillation (drops, ointments, sprays) Eyes, ears, nose -Inhalation [metered dose inhalers (MDI), dry powder inhalers (DPI)] -Oxygen is a medication - six rights must be checked! -Nasogastric or gastrostomy tubes -Suppositories (rectal or vaginal) -Intravenous -Intradermal (ID) -Subcutaneous (SQ) -Intramuscular (IM)

Surgical Pain Management

-Pain is a normal part of the surgical experience -Pain must be assessed q 2 hours after surgery -Unresolved pain can increase length of recovery -Teach the patient to ask for pain meds while the pain is low to moderate intensity. (3-5, don't wait till bad!) -Consider pharmacological and non-pharmacological treatment -Assess for sources of pain that may indicate surgical complication (DVT (pain in calf), dehiscence/evisceration, internal bleeding (sharp, pressure), etc) -include pt in deciding tx; higher pain=harder to tx; fix pain to help heal (won't wanna do IS or move)

neuropathic pain

-Pain is caused by stimulation of the CNS; damage to nerve fibers, -Can include phantom pain (pain in extremity that no longer exists), diabetic neuropathy, -People describe as burning, shooting, intense pain; pins and needles -Typical pain meds usually do not relieve pain -Requires adjuvant medications

Joint Commission National Patient Safety Goals

-Patient Identification (still wrong med to wrong pt issue) -Improve the safety of using medications (know the details of a med!!) -Medication reconciliation -Anticoagulant Sentinel Event (inc risk for bleeding)

Pain management in addicted patients

-Understand the difference between medication dependent and medication addicted -Dependent: experience improved quality of life and increased functioning with treatment (Ex. DMT1 dependent on insulin, not addicted) -Addicted: exhibit a lack of control and compulsive need for medication

Basic Methods of Assessing Pain

-Patient self-report -Identify pathologic conditions or procedures that may be causing pain; consider physiologic measures (increased blood pressure and pulse) -Report of family member, other person close to the patient or caregiver familiar with the person -Nonverbal behaviors: restlessness, grimacing, crying, clenching fists, protecting the painful area -Physiologic measures: increased blood pressure and pulse -Attempt an analgesic trial (smth for pain, not necessarily opioids) and monitor the results

other types of pain

-Physical: cause of pain can be identified -Psychogenic: cause of pain cannot be identified Phantom -Referred pain.. Moves from the site (next slide) -Vascular Pain .. Vasodialation (in bv in scalp) Migraines -Breakthrough.. occurs between doses of pain medications -Intractable (15/10) -Pain is whatever the patient believes it to be...

Rectal Suppositories

-Position patient in left lateral position, wash hands, don clean gloves -Don't cut in half; NOT for patients after rectal surgery or rectal bleeding; keep in refrigerator to keep from melting -Insert just beyond internal sphincter (about 1 inch) -For a child, may need to hold their buttocks closed for 5-10 minutes, as they may not be able to hold in the suppository.

vaginal suppositories

-Position patient in modified lithotomy or dorsal recumbent position. -If the patient is able, they may want to insert themselves. -If needed, provide perineal care. 0May be inserted with applicator. (If disposable, discard after administration. If reusable, wash with soap and water.) -Lubricate the suppository or fill the applicator. -Insert 3 to 4 inches (7.5 to 10 cm) along the posterior wall of the vagina. -Instruct to remain supine for a minimum of 5 minutes to retain the suppository.

oral inhalation: DPI (dry powder inhaler)

-Put in their mouth; DO NOT shake. -Exhale and then inhale; hold for 5-10 seconds; exhale via pursed lips.

Pain quality

-Quality refers to how the pain feels: Sharp, dull, aching, burning, stabbing, pounding, throbbing, shooting, gnawing, tender, heavy, tight, tiring, exhausting, sickening, terrifying, torturing, nagging, annoying, intense, or unbearable. -QUESTIONS "What does the pain feel like?" Give more than two choices: "Is the pain throbbing, burning, or stabbing?"

Manipulating Pain Experience Factors

-Remove or alter cause of pain. -Alter factors affecting pain tolerance. -Initiate non-pharmacologic relief measures

med error procedure

-Report all errors, and implement corrective measures immediately. -Complete an incident report within the specified time frame, usually 24 hr. Include the client's identification, the time and place of the incident, an accurate account of the event, who you notified, what actions you took, and your signature. Do not reference or include this report in the client's medical record. -Medication errors relate to systems, procedures, product design, or practice patterns. Report all errors to assist the facility's risk managers to learn how errors occur and what changes to make to avoid similar errors in the future.

academic integrity in clinical

-Research finds that students do not uphold academic integrity in the clinical setting when giving medications by doing the following: -Dropping medications on the floor without replacing them -Diversion (using as not indicated) of medications for personal use -Given too much/too little of a medication and not reported it because the patient was not harmed. -Performed nursing interventions without supervision. -Taking hospital supplies/ meds for personal use (even a band-aid!) -Recording meds were administered when they were not -Giving the wrong med and not reporting -Report your med errors! Never in trouble unless you don't report. AS SOON AS YOU REALIZE YOU ARE WRONG

ASE of opioids

-Respiratory Depression (increased with age, other CNS meds) -Circulatory Depression (not overload) -Constipation (dose related, occurs frequently with long term use, ^ after surgery secondary to immobility and decreased fluid intake) -Nausea & Vomiting (try to increase hydration, can administer anti-emetics) -Urinary retention (especially with epidural) -Pruritus (does not = allergy, can give antihistamines) -Physical Dependence (w/d symptoms when w/o drug) -Tolerance (need increased dosing pattern for same effect, not good) -Addiction (psychological /behavioral pattern; taking drug for euphoric effects) -Inadequate pain relief (may be to changing route, ie. If switch from IV to PO will need 3x dose. Need to switch in hospital and assess them on the PO meds b4 d/c) -Assess all b4 an opioid, esp if another med taken to dec resp drive too!!

nociceptive pain

-Respond well to meds -Caused from damage or inflammation.to normal tissues.. Throbbing, aching.. Usually responds well to meds -Somatic.. Originates from skeletal muscles, ligaments and joints Somatic pain ( deep); originates tendons, ligaments, bones, blood vessels and nerves (pull muscle) -Visceral.. Originates from organs and smooth muscle: Visceral pain ( organs) ; pain occurs as organs stretch abnormally and become distended/ inflamed; GUARDING may occur as protective mechanism (inflamed appendix; ischemic, obstruction) -Superficial.. From the skin and mucous membranes Cutaneous( superficial).. Involves skin or cutaneous tissue; paper cut

strict regulations with restraints

-Restraints only at last resort; only with WRITTEN order; use of restraints without an order is considered false imprisonment and is illegal; the order must specify why the restraint is used and how long it will be used, type of restraint, location of the restraint, type of behaviors that the patient demonstrated to necessitate the restraint; the patient must agree to be restrained; must not have any physical restraints except those to tx his/her medical symptoms; Restraining a patient w/out an order is false imprisionment Physican MUST come to see the patieent to order a restraint.. NO PRN Orders -If restrained in an EMERGENT situation, physician must come to see the patient w/in 1 hour MD must renew the order every 24 hours

Substances that DECREASE PAIN RESPONSE

-Serotonin... neurotransmitter -Endorphin.. some chemicals in the body acted similarly to natural opioid medications, binding to the pain receptors (blocking pain). These chemicals are called endorphins. (works like morphine).Enkephalins are thought to reduce pain by inhibiting the release of substance P from the terminals of afferent neurons. Endorphins and dynorphins are released when certain measures are used to relieve pain.

chronic pain

-Slow.. Days to months -Constant or intermittent -1-6 months in duration -Dull, persistent ache -On going, may have no known cause, could be malignant in nature -Management is aimed at helping the symptoms NOT curing the cause. -may lead to depression/ fatigue, disability -May have periods of remission.. Disease is present but NO sx -Exacerbation.. sx are present.. Ex rheumatoid arthritis -Pain does not always respond to interventions -Treatment: Long active or controlled release opioids (transdermal=over 3days) -Administer around the clock... NOT as needed (PRN)

deltoid injection

-Small muscle...Used in older children and adults. NEVER INJECT MORE THAN 1 mL of a medication here -Acromion process -Mid-axillary line -Two/three finger breaths -In the middle of the triangle Inject NO MORE than 1 ml at this site. -NOT for used for infants (not dvlpd). -risk: radial n (posterior) and brachial artery -Adults: 5/8 - 1 1/2 inch needle -Children: 5/8- 1 inch needle

oral form

-Solid: -Tablets/pills -Capsules...May be opened if need to place in NG. See drug book. May have special instructions. -Enteric coated*** Bypasses the stomach for intestinal absorption. -Sustained release***Released over time. -Scored meds ...Can be split on the score. -Lozenges...Do not chew or swallow whole.

acute pain

-Sudden onset -Usually subsides when treated -Protective (so don't touch), temporary, -May see patients flinch, guard, moan -Examples.. Head ache, stub toe. -Pain is associated with tissue healing -Systemic: May also see other signs and symptoms such as tachycardia, increased respiratory rate, hypertension, anxiety, diaphoresis, muscle tension, pallor, dry mouth, nausea, increased blood sugar, decreased urine output. -Treatment: Treat the underlying cause -remember pain is also subjective

medication reconciliation

-The Joint Commission requires policies and procedures for medication reconciliation. -Nurses compile a list of each client's current medications with correct dosages and frequency. -They compare the list with new medication prescriptions and reconcile it to resolve any discrepancies. -This process takes place at admission, when transferring clients between units or facilities, and at discharge. (part of continuity of care) -Incl OTC (vit, melatonin, etc) Compare list to provider orders to ensure nothing is missed (so pt is getting all needed meds)

pain tolerance

-The amount of pain a patient can endure without its interfering with normal function -Varies from person to person -Subjective response to pain, not a physiologic function -The point beyond which pain becomes unbearable

pt outcomes for safety

-assess 1st!!! •Identify real and potential unsafe environmental situations. •Implement safety measures in the environment. •Use available resources for safety information. •Incorporate accident prevention practices into ADLs. •Remain free of injury.

Non-Pharm Pain

-The nurse should not require the client to use nonpharmacological strategies in place of pharmacological pain measures, although the patient has the right to choose whether to use both types. -Ensure bed linens are clean and smooth, and that the client is not lying on tubing or other equipment that could cause discomfort. -Position the patient in anatomic position, using gentle positioning techniques, and reposition frequently to minimize discomfort. -Instruct patients on the use of strategies to reduce pain. -Go in w/ menu of options (that don't req order) and let pt decide Ex. Breathing, teaching, massage, imagery -Distraction Includes ambulation, deep breathing, visitors, television, games, prayer, and music Decreased attention to the presence of pain can decrease perceived pain level. Relaxation: Includes meditation, yoga, and progressive muscle relaxation -Humor (good w/ kids) -Music -Imagery.. Focusing on a pleasant thought to divert focus (esp in OB) -Relaxation/ Massage -Cutaneous stimulation Heat/ cold application.. Cold for inflammation or Heat to increase blood flow and to reduce stiffness) TENS: Transcutaneous Electrical Nerve Stimulation (leads that have small electrical impulse for pain control) -Cognitive-behavioral measures: Changing the way a client perceives pain, and physical approaches to improve comfort -Acupuncture and acupressure: (complementary ways to tx): Stimulating subcutaneous tissues at specific points using needles (acupuncture) or the digits (acupressure) Reduction of pain stimuli in the environment -Elevation of edematous extremities to promote venous return and decrease swelling -Hypnosis -Biofeedback -Therapeutic touch -Animal-facilitated therapy -Analgesic administration -Non-opioid analgesics -Opioids or narcotic analgesics (try to mix it up and not go str8 to these) -Adjuvant drugs

focus of safety assessments

-The person •Occupation •Social Behavior •Lifestyle -The environment •Neighborhood •Smoker in the home -Specific risk factors •Mobility •Sensory (hearing/vision impairment) •Knowledge •Communication •Physical health state

age related changes toddlers and school-age/adolescent

-Toddlers.. Can describe the location/ intensity.. May associate as punishment.. They will hold someone accountable.. Blame someone else -School aged/ adolescent.. May think they need to be brave and not report or c/o pain.. -School aged kids may show regression as a coping mechanism (can only conc on 1 thing at a time) (Traumatic event like pain/sick can cause regression and wont meet milestone/will go backwards) -CRIES ( 0-6 months): Crying Requires O2 for <95% Increased vital signs (HR, BP) Expression Sleepless high=more pain -FLACC ( 2 months-7 years): Faces, Legs, Activity, Cry, Consolability high=more pain

the pain process

-Transduction: activation of pain receptors (ex. Cut in finger) -Transmission: conduction along pathways (A-delta and C-delta fibers) (finger to brain, fast and slow pain) -Perception of pain: awareness of the characteristics of pain -Modulation: inhibition or modification of pain; occurs in the spinal cord and causes muscles to contract to move people away from pain. (ex. Immediately move away from blade/heat) -Changes in these w/ stroke/numbness/sensory issues, incl modulating

Diagnosing Pain

-Type of pain (acute or chronic?) -Etiologic factors -Behavioral, physiologic, affective response -Other factors affecting pain process -Nursing Dx. Acute pain Chronic pain NO "at risk" May have both acute AND chronic pain -pain won't kill, ABCs will (priority)

idiopathic pain

-Type of pain without a known cause -Form of chronic pain -OR pain that exceeds typical pain levels that we may expect based on the patient's presentation.

pain region

-Use anatomical terminology and landmarks to describe location (superficial deep, referred, or radiating). -QUESTIONS "Where is your pain? Does it radiate anywhere else?" Ask clients to point to the location

Z-track

-Use this technique for IM injections, because it is less painful, prevents medication from leaking back into subcutaneous tissue, and prevents skin stains (e.g., iron preparations). -Method to help prevent medication from coming in contact w/ SQ tissue when injecting medication into a large muscle using a needle and syringe. -seals the med deeply within the muscle and allows no exit path back into the subcutaneous tissue and skin. -displacing the skin and subcutaneous tissue 1.5 inches (3.81 cm) laterally prior to injection and releasing the tissue immediately after the injection. -used primarily when giving dark-colored medication solutions, such as iron solutions, that can stain the subcutaneous tissue or skin. -method of choice when giving IM medications that are very irritating to the tissue, such as haloperidol or Vistaril. -Check your drug book to see if the medication is indicated to be given via Z-track method. -Change the needle after drawing up the medication. -Use a long needle (1 ½-2 inches) with a 21 or 22 gauge. -Inject in large muscles (glutes). -Don't inject into limbs with decreased circulation. -No more than 5 mL in single site; divide into 2 sites or injections if > 5 mL is required. -Dart at a 90 degree angle into tissue then return displaced skin and subcutaneous tissue immediately. -Nondom Ulnar hand beside inj spot, stabilizes syringe and push in slow over 3-5s, hold 10sec, withdraw, move hand

IM injection sites

-Vastus lateralis: outer middle third of thigh, site for infants and kids (Quadricept femoris muscle, Use 5/8-1 inch needle.. 5/8 for SMALL PERSON) -Deltoid (5/8-1in kids, 5/8-1.5in adults) -Ventrogluteal (1-1.5in in adults) -Dorsogluteal: top of butt cheek

principles of all injections

-Wear gloves. -Clean site with alcohol prior to injection...Clean using a circular motion...Clean inside to out. -NEVER RECAP the needle! -Route depends on frequency of administration, medication, and rate of absorption

types of restraints for adults and kids

-Wrist: punching, pulling -Elbow: young, prevent pulling out iv -Mummy: look at baby's eyes or put in iv, keeps baby from moving -also punching/picking: mitt restraints

common med errors

-Wrong medication -Incorrect dose (too much or not enough) -Wrong client, route or time -Administration of known allergic meds -Omission of dose (without order) (unless you have good reason. Ex. Pt on laxative but diarrhea all morning. Notify provider) -Incorrect discontinuation of med (without order)

preventative dosing

-giving predetermined medications at set intervals to prevent pain (q4h, to prevent drugs out of system) -Prevent serum drug levels from falling to sub therapeutic levels -Allows around the clock pain relief -Allows smaller doses -Decreases tolerance -Especially important in post-op period

vest restraint

-least restrictive. Good for patients who frequently get up out of the bed or chair. They still have use of arms, they scan still eat, drink, etc. -try this first

most frequent cause of mortality and morbidity in hospitals is....

-med errors (26-32% of which were during med admin by nurses) -recent years, adverse drug reactions (mixing w/ smth or another drug) were responsible for almost 1 million preventable deaths in the United States

pain timing

-onset, duration, frequency -QUESTIONS "When did it start?" "How long does it last?" "How often does it occur?" "Is it constant or intermittent?"

Dorsogluteal injection

-should be avoided (due to concern for nerve damage). -Traditional site -Different theories on if acceptable to use due to concern for sciatic nerve. -Inject in upper, outer quadrant of buttocks. -Check with institution to see if this site is acceptable per facility policy. -NOT TO BE USED IN KIDS UNDER 3. -Have them point toes inward to increase comfort.

Numeric Sedation Scale

0: sleep, easy to arouse: no action necessary 1: awake and alert; no action necessary 2: occasionally drowsy, but easy to arouse; no action necessary 3: frequently drowsy, drifts off to sleep during conversation; reduce dosage 4: somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone

6 right of safe med admin

1)Right Patient: 2 ID's (armband and pt state (just armband if pt cant talk), compare to MAR not preplan) 2)Right Medication: Three checks 3)Right Dose: Calculation and APPROPRIATE/ SAFE does 4)Right Time: 30min- 1 hour before or after..(facility specific) NOT with PRN.. PRN (no b4 range, only after) must be given as ordered 5)Right Route: Per providers order/ proper technique 6)Right Documentation also Right to refuse (pt's right to say no. edu 1st on what drug does. Inform so pt knows and can then consent or not. If still refuse, doc it and notify provider); right to knowledge (pt should know what med is) for every drug!!

3 med safety checks

1)When retrieving the container/package 2)After retrieval, compare with MAR 3)RIGHT before administering to the patient -barcode scanning isn't a brain

steps to med admin

1.) Wash hands 2.) Verify medication against the MAR (check 2) 3.) Complete any pre-administration assessments (BP, HR) * Must be completed w/ in a timely manner before administration. (yourself) 4.) Prepare Medications for only one patient 5.) Calculate correct dosage if necessary 6.) Prepare selected Medications 7.) Identify patient—using 2 patient identifiers 8.) Compare medication to MAR and recheck the 6 rights (last check) 9.) Explain medication's purpose to patient (right to knowledge in lang they understand) 10.) Assist patient to sitting position if necessary (high-fowlers ideal) (and check if can swallow) 11.) Assist with medication is necessary (med in cup not in pt hand, place SL) 12.) Stay with client until all medications are swallowed (ensure swallowed and not aspirate) 13.) Wash hands 14.) Record time medication was administered

pain assessment ABCDE

A- ask about pain regularly; ASSESS pain systematically B.. Believe the patient and family C.. Choose the appropriate pain control options D.. Deliver interventions in a timely manor E.. Empower the patient and family

PRN order

Can only be given for that reason " fever", "nausea", "headache"

A and P of pain vid

For diff ppl, pain distracts them from a task or may be a way for them to focus on a task to distract them from the pain. Pain is response to actual or potential tissue damage. Nociceptors (tissue damage sensing nerve cells) fight when you get hurt, sending signals to the spinal cord to brain. There, its processed by neurons and glia. Sensing pathway is the path traveled, ending in the cortex. Salience network decides what to pay attn to. Modulation pathways deliver endorphins and enkephalins when in pain

Standing order

If...... then... (ex. insulin)

referred pain organs

Lots of things present w/ stomach pain Back: heart attack in women

PQRST

P.. Provoked.. What causes the pain; makes it better, worse Q.. Quality.. What does it feel like? Dull, sharp.. R.. Region/ Radiation.. Where is it.. Does it spread? S.. Severity . Intensity.. Use scale T .. Timing.. When did it start? Consistent? What makes it better? What makes it worse?

a med order MUST include...

Patient's name Date & time order written Name of medication (generic or trade) Dosage of the medication Route by which the medication is administered Frequency of administration Signature of prescriber

What role does an RN have in the safe administration of medications?

Safety, route/way to admin, what is the med

The Who 3 step analgesic ladder

Step 1: nonopioids (with or without adjuvant medications) after the pain has been identified and assessed. If pain persists or increases, treatment moves to Step 2: opioids for mild to mod with or without nonopioids and with or without adjuvants. If pain persists or increases, management then rises to Step 3: opioids indicated for moderate to severe pain, administered with or without nonopioids or adjuvant medications. => free from cancer pain

pain threshold

The level of stimulus needed to produce the perception of pain A measure of the physiologic response of the nervous system

physical dependence

The physiologic adaptation of the body to the presence of an opioid

a med label includes...

Trade and/or Generic name Dosage Expiration Date Lot #

nebulizers

Use a machine to deliver a mist form of medication via a mask or tube device

a med error is...

any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication in in control of the health care professional, patient, or consumer

stat order

asap but be safe (cant give till it comes but its priority)

Faces scale for pain

best for 3yr+

single/one-time order

do it once, abx hung on call (to go to floor)

routine/standard order

give ?QH until d/c

when to give oral meds

on an empty stomach unless otherwise indicated...30 min-1 hour before or 2 hours after meal.

safety devices to prevent falls

rails, brakes, non slip socks

sentinel event

smth really bad that happened. Unpredictable

if a pt refuses med...

this is okay, edu pt and if still a no, doc that and notify provider

CI to oral admin

unconscious, vomiting, and/or comatose and/or has difficulty swallowing, an absent gag reflex, decreased GI motility, and/or decreased LOC.

can a pt have acute and chronic pain?

yes

passive smoking

•2nd hand.. Breathing it in.. •3rd hand.. Clothing •Risks and detriments: • Cancer, heart disease, lung disease • Low birthweight infants, prematurity, SIDS • Ear infections/ pneumonia in kids • Increased frequency/ severity of asthma attacks

physical examination in safety

•Assess mobility status. •Assess ability to communicate. (lang they understand) •Assess level of awareness or orientation. •Assess sensory perception. •Identify potential safety hazards. (nothing on floor!) •Recognize manifestations of domestic violence or neglect. (bruises, dirty, told bypt)

safety considerations for neonates

•Avoid behaviors that might harm the fetus. (drinking, smoking) •Never leave the infant unattended. •Use crib rails. •Monitor setting for objects that are choking hazards. •Use car seats properly. •Handle infant securely while supporting the head. •Place infant on back to sleep. (suffocate on tummy. Tummy time to dvlp neck muscles is supervised) -4-5mths: start rolling, end of back to sleep In crib: only sheet (no blanket or bears)

carbon monoxide poisoning

•Carbon Monoxide is odorless, colorless, tasteless •S/s of c02 poisoning: nausea, vomiting, headache, weakness, unconsciousness, sleepy=>cease breathing •Interventions •Proper ventilation of lawn mowers, fireplaces, hot water heaters, chimneys • Install carbon monoxide detectors -C02 binds with hemoglobin and reduces the amount of oxgen available to the body,

ear instillation

•Clean ears first if there is drainage blocking. •Clean technique; have the patient stand or lay with affected ear up. •GENTLY PULL UP and BACK...ADULTS or kids older than 3. •GENTLY PULL DOWN AND BACK...children younger than 3. •Hold dropper 1 cm from the ear; instill medication; gently apply pressure/ massage the tragus of the ear. •Don't touch the dropper to the ear. •A cotton ball to the outside of the ear may be ordered; remove after 15 minutes. •Have the patient stay on their side for 2-3 minutes. •DO NOT administer cold ear drops. This could cause nausea, dizziness and pain.

documentation w/ restraints

•Date and time initiated •Type of restraint •Alternatives attempted •Notification of (and freq) provider. and family •Frequency of assessments and findings (q2h, rom, circulation) •Restraints are removed at regular intervals (q2h for adults) •Nursing interventions done (ex bath with 1 arm restrained, then switch the restrained arm) •MUST BE EXCELLENT DOCUMENTATION! •Behavior that made the restraint necessary; type of restraint used, explanation to patient and family; patient consent, exact times of application and removal; behavior while restrained, type and frequency of care given while restrained ( circulation, assessment, range of motion, to the BR, helped with meals)

factors affecting safety

•Developmental considerations •Lifestyle •Social behavior (ex. Smoking/vaping) •Environment •Mobility •Sensory perception •Knowledge •Ability to communicate •Physical and psychosocial health state

eye instillation

•Drops or ointment •Aseptic technique...Do NOT want to contaminate the eye (STERILE) •Sitting or supine with head back; DON'T have tilt head back if the patient has a head/neck injury •Make sure to clean eyes (from inner to outer canthus) if dirty. •Ask the patient to look up. •Hold dropper 1-2cm above the eye. •Rest dominant hand on forehead; place drops into the center of the conjunctival sac; NEVER place directly onto the EYE! •Apply pressure on the lacrimal duct for 30-60 seconds to prevent systemic absorption. •DO NOT want to touch the eye dropper on the eye! •If using an ointment, move from inner to outer canthus. •For kids...Can ask the parents to help; have mom or dad hold the child on their lap.Place medication at the nasal corner...When they open their eyes, the medications will go in

Hendrich II Fall Risk Model

•Fall Scene Investigations (FSI) (look at environment and what caused the fall) •Hourly patient rounding •Root cause analysis (RCA) (cause to problem) •Get Up and Go Test (assess pt and strength before getting them up)

risk factor assessments

•Falls: Older adults •Fires •Poisoning: Call poison control •Suffocation and choking (don't leave things in bed) •Firearm injuries Keep firearms unloaded, locked up, and out of reach. Teach to never touch a gun or stay at a friend's house where a gun is accessible. Store bullets in a different location from guns.

safety considerations of school-aged kids

•Help to avoid activities that are potentially dangerous. •Provide interventions for safety at home, school, and neighborhood. •Reinforce teaching about symptoms the require immediate attention. •Continue immunizations as scheduled. •Teach bicycle safety. •Teach about child abduction. •Wear seatbelts. -gun safety (could be at friends houses)

safety considerations for older adults

•Identify safety hazards in the environment. •Modify the environment as necessary. •Attend defensive driving courses or courses designed for older drivers. •Encourage regular vision and hearing tests. •Ensure hearing aids and eyeglasses are available and functioning. •Have operational smoke detectors in place. •Objective document and report any signs of neglect and abuse. -ensure assistive devices present

physiological hazards assoc w/ restraints

•Increased possibility of serious injury due to fall •Skin breakdown •Contractures •Incontinence •Depression •Delirium •Anxiety •Aspiration and respiratory difficulties •Death •Older patients are 8 x's more likely to die while restrained than when non-restrained • Suffocation and/ or entrapment; impaired circulation, altered skin integrity, pressure ulcers and contractures, diminished muscle and bone mass, fractures, altered nutrition and hydration, aspiration and breathing problems, incontinence

for fire safety, all staff must...

•Know the location of exits, alarms, fire extinguishers, and oxygen shut‑off valves. •Make sure equipment does not block fire doors. •Know the evacuation plan for the unit and the facility. -w/ fire alarm, all equipment out of hall and all pt doors shut (keeps fire/smoke from getting in). Unit doors close too

factors that contribute to falls

•Lower body weakness •Poor vision •Gait and/or balance issues •Problems with feet and/or shoes (smth on feet when they get up!) •Use of psychoactive medications •Postural dizziness •Hazards in the home (and community) •hx of falls

Seizure precautions

•Make sure rescue equipment is at the bedside, including oxygen, an oral airway (put in the mouth to keep tongue down to not aspirate), suction equipment, and padding for the side rails. •patients at high risk for generalized seizures should have a saline lock in place for immediate IV access. •Ensure rapid intervention to maintain airway patency. •Inspect the patient's environment for items that could cause injury during a seizure, and remove items that are not necessary for current treatment. •Assist patients at risk for seizures with ambulation and transferring to reduce the risk of injury. •Advise all caregivers and family not to put anything in the patient's mouth (except an oral airway for status epilepticus) during a seizure. •Advise all caregivers and family not to restrain the patient during a seizure but to lower him to the floor or bed, protect his head, remove nearby furniture, provide privacy, put him on his side with his head flexed slightly forward if possible, and loosen his clothing -Biggest issue during seizure: cease to breathe. Co2 trapped in lungs and starts to foam (foaming at the mouth! Need to suction this out) If on floor, put them in rescue position: left lateral side lying, to not aspirate on tongue -Clear environment (bed, chair, etc) from things they could hit -Don't touch pt, work around them -Oral airway just holds tongue down -Need iv start kit too bc may knock it out and will need rescue meds

safety event reports

•Must be completed after any accident or incident in a health care facility that compromises safety •Describes the circumstances of the accident or incident •Details the patient's response to the examination and treatment of the patient after the incident •Completed by the nurse immediately after the incident •Is not part of the medical record and should not be mentioned in documentation -Doc an event twice! Chart (the facts, pt owned) and incidence report (owned by hospital, don't reference in chart)

nose instillation

•Nasal drops, sprays •Position patient supine with head in position to enter the nasal passage; can have patient blow nose to clear prior to med administration. •Instruct patient NOT to blow nose for 5 minutes after and stay in supine position. •For a child...Have them lay supine with their head over the bed; ask parents to help position and hold. •Give 20-30 minutes before feeding, because the medications can cause nasal congestion. They need their nose when they eat!

types of fire extinguishers

•Need the correct fire extinguisher • A: paper, woods, upholstery, rags, • B: Flammable liquids and gas • C: Electrical Fires •ABC fire extinguishers in hospital, baking soda like consistency, on any fire

safety measures when using restraints

•Pad boney prominences under or near the restraint • Allow enough slack for patient to perform ROM • Use slip knots; can be untied with one hand • 2 fingers between the restraint and the person • NEVER tie restraints to the side rails; tie to portion of the bed that moves with the patient; bed frame; • Explain need to patient, family; continually eval need; DC when no longer required -Remove during calm periods (ex. Sleeping, family there)

indications of a concussion

•Physical: headache, vomiting, problems with balance, fatigue, dazed or stunned appearance •Cognitive: mentally foggy, difficulty concentrating and remembering, confusion, forgets recent activities •Emotional: irritability, nervousness, very emotional behavior •Sleep: drowsiness, difficulty falling asleep, sleeping more or less than usual -Common up thru high school -Change in LOC/not acting like them=seek care

car seat considerations for toddlers/preschoolers

•Place infants and toddlers in a rear‑facing car seat until 2 years of age or until they exceed the height and weight limit of the car seat. They can then sit in a forward‑facing car seat. •Use a car seat with a five‑point harness for infants and children. • All car seats should be federally approved and be in the back seat •Use booster seats for children who are less than 4' 9" and less than 40 lb (usually 4 to 8 years old). •The child should be able to sit with his back against the car seat, and his legs should dangle over the seat. •If car has a passenger air bag, place children under 12 years in the back seat

use a vial

•Powder filled vials require reconstitution. •ALWAYS clean top of vial with alcohol prior to use. •Need to inject air into the vial EQUAL to the amount of liquid to be removed. •Insert needle, inject air, invert, withdraw solution •KEEP needle bevel below the level of solution.

RACE (acute care)

•R - Rescue anyone in immediate danger. •A - Activate the fire code and notify appropriate person. •C - Confine the fire by closing doors and windows. •E -Extinguish the Fire/Evacuate -In the clinical setting protect and evacuate the peeps in danger; report the fire Contain the fire Extinguish/Evacuate .. RACE

alternatives to restraints

•Remember, restraints are LAST option •When all other less restrictive means have failed •May also use: •Orientation to the environment •Supervision of a family member or sitter •Diversional activities •Electronic devices (sitter select).Taylor:Determine whether behavior pattern exists. Assess for pain and treat appropriately. Rule out causes for agitation. Assess respiratory status, vital signs, blood glucose level, fluid and electrolyte issues, and medications. Use standardized screening tools to evaluate change in function. Involve the family in patient's care. Ask family members or significant other to stay with the patient. Reduce stimulation, noise, and light. Distract and redirect, using a calming voice. Use simple, clear explanations and directions. Check environment for hazards. Use night light. Identify door of room (e.g., use of balloon, sign, patient's picture, ribbon). Use an electronic alarm system on a temporary basis (e.g., bed or position-sensitive alarms) to warn of unassisted activity. Allow restless patient to walk after ensuring that environment is safe. Use a large plant or piece of furniture as a barrier to limit wandering from designated area. Use low-height beds. Place floor mats on each side of the bed. Ensure the use of glasses and hearing aids, if necessary. Use pillows wedged against the side of the chair to keep patient positioned safely. Use full-length body pillows, a swimming pool noodle, or a rolled blanket to indicate the edge of the bed. Assist with toileting at frequent intervals. Arrange for a bedside commode. Make the environment as home-like as possible; provide familiar objects. Provide a warm beverage. Provide comfortable rocking chairs. Use therapeutic touch. Play music or video selections of the patient's choice. Offer diversional activities, such as games and books. Encourage daily exercise/provide exercise and activities or relaxation techniques. Consider relocation of the patient to a room closer to the nursing station. Conceal tubing necessary for care. Anchor tubing securely. Conceal tubing with gauze wrap; unwrap regularly to assess site for complications. Investigate possibility of discontinuing bothersome treatment devices (e.g., intravenous line, catheter, feeding tube).

safety considerations for adults

•Remind them of effects of stress on lifestyle and health. •Enroll in defensive driving course. •Counsel about unsafe health habits (reliance on drugs and alcohol). •Evaluate workplace for safety. •Counsel about domestic violence.

interventions in the home for falls

•Remove small items that can cause falls (décor, non skidrugs) •Place cords/ wires out of walking areas •Steps and side walks are in good repair •Grab bars by toilets/ bathrooms •NON-SKID backing to mats/ rugs in the BR or home •Shower chair/ Adequate lighting •Infants (in carrier high up, ALWAYS PUT ON FLOOR!) •IN THE HOME: INFANTS: keep the crib/ plan pen rails up, NEVER leave in infant on a table or IN a car seat on the table Low bed/ toddler bed when old enough

what do you do after a pt falls

•Report and document all incidents. •This provides valuable information that can help prevent similar incidents. •Leave the patient on the floor where you found them.. YELL for help/ press call button to get help to come to you! •Don't leave the patient! -Doc fall and tell provider Imp to see how they landed! To know what to assess

side rails

•Restraint unless patient requests •The patient must be able to raise/lower them

safety plan for victims of domestic abuse

•Safety while living with an abusive partner •Safety planning with children •Safety planning for pets •Safety planning during pregnancy •Leaving a relationship -Where to go? -Inc abuse in preg -We are mandated reports for any abuse (to instructor/nurse manager) even if only suspected

scalds and burns

•Sensory problems (ex. Neuropathy and can't feel heat): Cannot assess temperature; WE need to be cautious of this also when bathing our patients; If they cannot feel, they may not realize how hot the water is! -NO hotter than 120 degrees •Children: •Pots and pans (over edge of stove) •Bath water •High temps in water heater •Abuse: 2yr old fell in hot tub: head/shoulder burnt. Abuse: toes (submerged), retract legs and bum burned next

during and after a seizure

•Stay with the patient, and call for help. • Maintain airway patency and suction PRN. •Administer medications. (IV or PR) •Note the duration of the seizure and the sequence and type of movements. •After a seizure, determine mental status and measure oxygenation saturation and vital signs. Explain what happened, and provide comfort, understanding, and a quiet environment for recovery. •Document the seizure with any precipitating behavior and a description of the event (movements, injuries, duration of seizures, aura, postictal state (post seizure)), and report it to the provider. -Tired after! Feels like they ran a marathon from the brain activity. Sleep long (couple days), may not remember -What happened b4? Aura: flashing light or smell to predict that its ab to happen (if smth caused it, avoid those things) -postictal state: describe. Ex. Confused, tired, incontinent, needed suction

safety considerations of toddlers/preschoolers

•Supervise child closely to prevent injury. •Select toys appropriate for developmental level. •Use appropriate safety equipment in the home. •Never leave child alone in bathtub. •Childproof home environment; prevent poisoning. •Be alert to manifestations of child maltreatment or abuse. •Use car seats properly. •Teach about fire safety/practice emergency evacuation measures. -seat belt

safety considerations for adolescents

•Teach safe driving skills and avoiding distracted driving. •Teach avoidance of tobacco and alcohol. •Emphasize gun safety. •Follow healthy lifestyle. •Teach about sexuality, STIs, and birth control. •Get physical examination before participating in sports. •Teach risk of infection with body piercing and tattoos. •Teach about guns and violence. •Discuss dangers associated with the Internet. -peers have more influence than adults

PASS

•To use a fire extinguisher, use the PASS sequence. •P: Pull the pin. •A: Aim at the base of the fire. •S: Squeeze the handle. •S: Sweep the extinguisher from side to side, covering the area of the fire

using an ampule

•Use a filter needle/filter straw. •Tap ampule to get solution to the bottom; Use a snapping motion AWAY from self! Do not touch the rim of the ampule with the needle. •AS YOU WITHDRAW THE SOLUTION, KEEP THE NEEDLE BEVEL WITHIN THE SOLUTION. •Discard of the ampule in SHARPS. •Change needle before injecting patient.

parenteral med considerations

•Use a needle size and length appropriate for the type of injection and the client's size. Syringe size should approximate the volume of medication being administered. •Use a tuberculin syringe for solution volumes less than 0.5 mL. • Rotate injection sites to enhance medication absorption, and document each site used. • Do not use injection sites that are edematous, inflamed, or have moles, birthmarks, or scars.

dec equipment-related accidents

•Use only for intended use and be familiar with equipment. •Handle equipment with care so as not to damage it. •Use three-prong plugs. •Do not twist or bend electric cords. •Be alert to signs that equipment is faulty. •Be alert to wet surfaces. •Make certain defibrillator charging indicator light is on. -if looks broken, dont use

seizures

•is a sudden surge of electrical activity in the brain. It can occur at any time due to epilepsy, fever, or a variety of medical problems. •Partial seizures (also called focal seizures) are due to electrical surges in one part of the brain, and generalized seizures involve the entire brain. •Status epilepticus (a prolonged seizure) is a medical emergency •Seizure precautions (measures to protect patients from injury during a seizure) are imperative for patients who have a history of seizures that involve the entire body and/or result in unconsciousness. (if electrolyte imbalance (for ex), have smth that makes them prone to them) -We can see the convulsions -Ex. When withdrawing from alcohol

prescription for restraints

•must include the reason for the restraints, the type of restraints, the location of the restraints, how long to use the restraints, and the type of behavior that warrants using the restraints. •allows only 4 hr of restraints for an adult, 2 hr for clients ages 9 to 17, and 1 hr for clients younger than 9 years of age. •Providers may renew these prescriptions with a maximum of 24 consecutive hours. •Providers cannot write PRN prescriptions for restraints. •If restrained in an EMERGENT situation, physician must come to see the patient w/in 1 hour -never PRN, cont reassessing for need of them, if bilateral then consider things like how pt will scratch nose

restraints

•physical devices used to limit a patient's movement; primarily used to prevent injury to the patient, staff, another person, or property. Although they are designed to protect patient, they can also be a safety hazard. •Chemical Restraints ( medications used to control disruptive behaviors; sedatives, neuroleptics) (LAST LAST): Used only at LAST resort. Confusion, disorientation. May lead to additional falls and injury. hard on elderly •Physical Restraints (try other things 1st): any physical, manual, or mechanical method or device attached to the body to restrict movement; Side rails, gerichairs with attached trays, appliances tied at the wrist, ankles or waist are types of physical restraints.