Fundamentals Test 2

now medication order

when a medication is needed right away, but not STAT. within 90 min timeframe

great vessels

superior and inferior vena cava. pulmonary artery. pulmonary veins. aorta.

layers of the heart wall

epicardium (outer), myocardium (middle), endocardium (inner), pericardium (muscle covering the heart)

CV physical examination: auscultation

"APE TO MAN" A(ortic) E(rb's point) T(ricuspid) M(itral) note rate and rhythm: regular or irregular? pulse deficit. identify S1 and S2: S1 is louder at the apex (S1 coincides with carotid artery pulse. S1 coincides with R wave on ECG). S2 is louder than S1 at the base. listen to S1 and S2 separately. listen for murmurs (swooshing sounds) and extra heart sounds

vascular structures in the neck

carotid artery. jugular veins. internal and external. reflect efficiency of cardiac function

hypodermic syringe

2, 2.5, and 3 mL sizes (marked in .1 of milliliters). available in other sizes, marked in different increments

timing of medication dose responses

1 hour window (30 before, 30 after) to give med on time. if early or late, document why. medications administered intravenously enter the bloodstream and act immediately, whereas medications given by other routes take time to enter the bloodstream and have an effect. the quantity and distribution of a medication in different body compartments change constantly. medications are ordered at various times, depending on when their response begins, becomes most intense, and ceases. the minimum effective concentration (MEC) is the plasma level of a medication below which the effect of the medication does not occur. the toxic concentration is the level at which toxic effects occur. safe drug administration involves adherence to prescribed doses and dosage schedules. some agencies set schedules for medication administration. however, nurses are able to alter this schedule on the basis of knowledge about a medication. according to ISMP guidelines, hospitals need to determine which medications are time critical and which are non-time critical. time-critical medications are medications in which early or delayed administration of maintenance doses (more than 30 minutes before or after the scheduled dose) will most likely result in harm or subtherapeutic responses in a client. you need to administer time-critical medications at a precise time or within 30 minutes before or after the scheduled time. you administer non-time-critical medications within 1 to 2 hours of their scheduled time. follow the medication administration policies of your agency. when you teach patients about medication schedules, use familiar language. for example, instruct a client who needs to take a medication twice a day to take it in the morning and again in the evening.

8 rights of medication administration

1. right Dose (check order and MAR against pill). 2. right Education (educate client about medication). 3. right Route (IM, SQ, etc). 4. right Medication (check order and MAR). 5. right Documentation (document after giving medication). 6. right Effect or indication (why you are giving the medication). 7. right Patient (check name and DOB against armband and MAR). 8. right Time (check against MAR).

4 heart valves

2 atrioventricular (AV) and 2 semilunar (SL). valves are there because blood is supposed to flow one way. valves open due to pressure.

automatic medication dispensing systems (AMDS)

AMDSs are used throughout the country. the systems within an agency are networked with one another and with other agency computer systems. AMDSs control the dispensing of all medications including narcotics. each nurse accesses the system by entering a security code. some systems require bioidentification as well. you select the client's name and his or her drug profile before the AMDS dispenses a medication. in these systems, you are allowed to select the desired medication, dosage, and route from a lost displayed on the computer screen. the system causes the drawer containing medication to open, records it, and charges it to the client. systems that are connected to the client's computerized medical record then record information about the medication and the nurse's name in the client's medical record. the barcode medication administration (BCMA) system is often used with AMDSs. BCMA requires nurses to scan bar codes to identify the client, the medication, and an identification tag of the nurse administering the medication before recording this information in the client's computerized medical record. agencies that implement AMDS with BCMA often reduce the incidence of medication errors.

therapeutic range

constant level of medicine in body. taking meds at different times can mess with this. when a medication is prescribed, the goal is to achieve a constant blood level within a safe therapeutic range, which falls between the MEC and the toxic concentration. when a medication is administered repeatedly, its serum level fluctuates between doses.

insulin syringe

U-100 (100 units) U-50 (50 units) measured in units. can be 50 or 100 units.

unit dose system

a storage system that varies by health care agency. pharmacists provide the medications in single-unit packages that contain the ordered dose of medication that a client receives at one time. nurses distribute the medications to patients. each tablet or capsule is wrapped separately. usually no more than a 24-hour supply of medication is available at any given time. some unit-dose systems use carts containing a drawer with a 24-hour supply of medications for each client. each drawer is labeled with the name of the client and the client's designated room. at a designated time each day the pharmacist or a pharmacy technician refills the drawers in the cart with a fresh medication supply. the cart also contains limited amounts of prn and stock medications for special situations. controlled substances are not kept in an individual client drawer. instead they are kept in a larger locked drawer to keep them secure. the unit-dose system reduces medication errors, decreases the amount of medication that is stocked in client care areas, and saves time for nurses and pharmacists.

medication

a substance used in the diagnosis, treatment, cure, relief, or prevention of health problems. nurses play an essential role in safe medication preparation and administration, and in evaluation of medication effects. in all settings, nurses are responsible for evaluating the effects of medications on patients' ongoing health status, teaching them about their medications and side effects, ensuring adherence to the medication regimen, and evaluating the client's and family caregiver's ability to self-administer medications.

breath-actuated metered-dose inhalers (BAIs)

activate by breathing in. release depends on strength of client's breath. a good choice for patients who have difficulty using pMDIs because it eliminates the need for hand-breath coordination.

dry powder inhalers (DPIs)

activated by client's breath. delivers more medication to lungs. hold dry powder medication and create an aerosol when the client inhales through a reservoir that contains a dose of the medication. some DPIs are unit dosed. these inhalers require patients to load a single dose of medication into the inhaler with each use. other DPIs hold enough medication for 1 month.

standing or routine medication order

administered until the dosage is changed or another medication is prescribed. carried out until the prescriber cancels it by another order, or the prescribed number of days elapses. it often indicates a final date or number of treatments or doses.

precordium

adult: anterior chest wall over the heart; on left side. infant: more horizontally rather than shifted to the left; apex is 3rd or 4th intercostal space just left of the midclavicular line. in taller people, heart is more central and vertical. in short and stocky people, heart is more horizontal and to the left.

trade name of medication

also known as brand or proprietary name. this is the name under which a manufacturer markets the medication. usually easier to pronounce and remember. manufacturers choose trade names that are easy to pronounce, spell, and remember. many companies produce the same medication, and similarities in trade names are often confusing. therefore, be careful to obtain the exact name and spelling for each medication you administer to your patients.

nasal instillation

always check for irritation in nasal passages. spray: most common: allergy, decongestant (flonase). used to relieve symptoms of sinus congestion and colds. caution patients to avoid abuse of medications because overuse leads to a rebound effect in which the nasal congestion worsens. when excess decongestant solution is swallowed, serious systemic effects also develop, especially in children. saline drops are safer than nasal preparations that contain sypmathomimetics as a decongestant for children. it is easier to have patients self-administer sprays because they are able to control the spray and inhale as the medication enters the nasal passages. for patients who use nasal sprays repeatedly, check the nares for irritation. when used to treat a sinus infection, position clients to permit the nasal medication to reach the affected sinus. drops: want client to self-administer if they can. tampons: severe nosebleeds are usually treated with packing or nasal tampons, which are treated with epinephrine, to reduce blood flow. usually a physician or advanced practice clinician places nasal tampons.

dub heart sound

aortic and pulmonic valves close. S2. end of systole/beginning of diastole

CV anatomical landmarks

aortic: only one on the right side. 2nd ICS to the right sternal border. pulmonic: 2nd ICS to the left sternal border. Erb's point: 3rd ICS to the left sternal border. tricuspid: 5th ICS to the lower left sternal border. mitral: apex. PMI and 5th ICS at MCL (midclavicular line which is right at the nipple line)

prn medication order

as needed. given when the client requires it. need a time frame (ex: Q 4-6 hr).

nursing process: assessment and recognizing cues--CV health history

ask these questions: chest pain, dyspnea (difficulty breathing), orthopnea (SOB or difficulty breathing when lying down), cough, fatigue, cyanosis or pallor, edema (swelling), nocturia (frequent night time urination; >2x per night), cardiac history, family cardiac history, personal habits (risk factors like smoking, diet that is high in cholesterol, exercise, caffeine intake)

chambers of the heart

atrium (upper): right atrium and left atrium ventricle (lower): right ventricle and left ventricle

cardiac conduction

automaticity: the ability to spontaneously depolarize and generate an action potential. specialized cells that can initiate the electrical impulse: -SA node = main "pacemaker" 60-100 -AV node = 40-60 (doesn't work as well as SA node) -Purkinje fibers = 20-40 orderly sequence: SA node-->AV node-->Bundle of His-->R and L bundle branches-->Purkinje fibers if SA node isn't working, it goes to AV node, and on and on

safety of med admin

be vigilant. verify expiration date. use at least 2 client identifiers. check accuracy 3 times. clarify unclear orders. use technology if available. strict aseptic technique. educate client on each med. do not delegate med admin. prevent needle sticks.

medication administration record (MAR)

cannot give a medication without an MAR. includes: patients' full name date and time the order was written medication name dose route of administration time and frequency of administration signature of HCP

nursing process: assessment laboratory and diagnostic test cues

cardiac enzyme: more specific (to rule out a disease). creatinine kinase (CK) is a blood test. cardiac troponins: first thing to do when suspected of heart attack. heart attack won't show up in troponin until a few hours. serial troponins are troponin I and troponin T. troponin T must be done 6 hours later than troponin I. serum electrolytes: Potassium (K+) 3.5-5.0 mEq/L. hypo= cardiac electricity instability and ventricular dysrhythmias. hyper= asystole and ventricular dysrhythmias. cholesterol: total cholesterol, LDL "bad", HDL "good". brain natriuretic peptide (BNP): biomarker for heart.

heart sounds: murmurs

caused by turbulent blood flow (blood flowing so fast). gentle, blowing, swooshing sound. as the nurse, note where they are heard best and their location and if new, alert HCP. murmurs can be caused by: increased blood flow through a normal valve. forward flow through stenotic valve. backward flow/regurgitation through incompetent valve. septal defect.

medication names

chemical, generic, and trade. example of a well-known medication: chemical: N-acetyl-para-aminophenol generic: acetaminophen trade: Tylenol, Panadol, Tempra because similarities in drug names are a common cause of medical errors, the Institute for Safe Medication Practices (ISMP) publishes a list of medications that are frequently confused with one another.

nurse's role in medication administration

determining medications ordered are correct assessing, assessing client's ability to self-administer, determining whether client should receive medications at a given time, administering medications correctly, and closely monitoring effects. keep in mind the client's ability to take med (oral-does it need to be crushed?). cannot be delegated especially to an unlicensed professional. includes client teaching (cannot be delegated to an unlicensed professional). client and family education about proper medication administration and monitoring is an integral part of your role. begin instruction about medications that the client will be taking home as soon as possible. this often does not occur until the day of discharge, but if you can obtain this information sooner, the client will benefit.

cardiac cycle

diastole is the heart at rest. heart stays at work 1/3 of cycle. heart is at rest 2/3 of cycle. when diastole is high, the heart is at work when it should be at rest.

administering injections

each injection route differs based on the types of tissues the medication enters. before injecting know: the volume of medication to administer. the characteristics and viscosity of the medication. the location of anatomical structures underlying the injection site. if a nurse does not administer injections correctly, negative client outcomes may result. the characteristics of the tissues influence the rate of medication absorption and thus the onset of medication action. failure to select an injection site in relation to anatomical landmarks results in nerve or bone damage during needle insertion. inability to maintain stability of the needle and syringe unit can result in pain and tissue damage. if you fail to aspirate the syringe before injecting an IM medication, the medication may accidentally be injected directly into an artery or vein. injecting too large a volume of medication for the site selected causes extreme pain and results in local tissue damage.

oral administration

easiest and most desirable route. slowest onset and affect. food sometimes affects absorption (look to see if food or empty stomach is contraindicated). aspiration precautions. contraindications could be vomiting, suctioning, unconscious, cannot swallow. most tablets and capsules need to be swallowed and administered with approximately 60 to 240 mL of fluid. eneteral or small-bore feedings: verify that the tube location is compatible with medication absorption. use liquid medications when possible. if medication is to be given on an empty stomach, allow at least 30 minutes before or after feeding. risk of drug-drug interactions is higher when two or more medications are given in this route because they can interact together as soon as they are administered.

client teaching

educate on proper timing to take medicines. especially important with new meds. once a day (12 hrs apart). requirements of meds (take on empty stomach). cholesterol meds (taken at bed time, can't be taken with certain juices, time can be adjusted based on convenience).

intramuscular injections

faster absorption than SQ route. many risks, so verify the injection is justified. angle of administration is 90 degrees. body mass index (BMI) and adipose tissue influence needle size selection. amounts: adults: 2 to 5 mL (4 to 5 mL unlikely to be absorbed properly). children, older adults, thin patients: up to 2 mL. small children and older infants: up to 1 mL. smaller infants: up to 0.5 mL. z track method: displace the skin use a longer and heavier gauge needle to pass through SQ tissue and penetrate deep muscle tissue. a client's BMI and the amount of adipose tissue influence needle size selection. many needles available in health care settings are not long enough to reach the muscle, especially in patients who are obese and females. assess a muscle before giving an injection. properly identify the site for the IM injection by palpating bony landmarks and be aware of the potential complications associated with each site. the site needs to be free of tenderness. when selecting an IM site, consider the following: is the area free of infection or necrosis? are there local areas of bruising or abrasions? what is the location of underlying bones, nerves, and major blood vessels? what volume of medication is to be administered? each site has different advantages and disadvantages.

how do i identify the intercostal spaces?

first find the sternal notch: walk your fingers down the manubrium a few centimeters until you feel a distinct bony ridge (the is the sternal angle). the 2nd rib is continuous with the sternal angle. slide your finger down to localize the 2nd intercostal space. the intercostal spaces are bordered by the rib (above and below)

STAT medication order

given immediately in an emergency (1 time)

single (one-time) medication order

given one time only for a specific reason. common for preoperative medications or medications given before diagnostic examinations

ventrogluteal

gluteus medius. deep and away from major nerves and blood vessels. preferred and safest site for all adults, children, and infants. recommended for volumes greater than 2 mL. research shows that injuries such as fibrosis, nerve damage, abscess, tissue necrosis, muscle contraction, gangrene, and pain are associated with all the common IM sites except the ventrogluteal site. it's the preferred site for antibiotics. index finger, the middle finger, and the iliac crest form a V-shaped triangle. injection site is the center of the triangle.

splitting of S2 heart sound

heard on deep inspiration d/t intrathoracic pressure and increase in venous return.

normal heart sounds

heard over chest wall through stethoscope S1: AV (tricuspid and mitral) valves close. start of systole. heard loudest at apex (bottom). S2: SL (pulmonic and aortic) valves close. signal end of systole, beginning of diastole. heard loudest at base (top). split S2

peak

highest level of medicine in bloodstream. goes with antibiotics. after reaching its peak, the serum concentration of the medication falls progressively. with IV infusions, the peak concentration occurs quickly, but the serum level begins to fall immediately. the time it takes for a drug to reach its peak concentration varies, depending on the pharmacokinetics of the medication. after reaching its peak, the serum concentration of the medication falls progressively.

parenteral administration of medications: needles

hub, shaft, bevel. gauges: the larger the number, the smaller the diameter of the shaft. some needles come packaged in individual sheaths to allow flexibility in choosing the right needle for a client, whereas others are preattached to standard-size syringes. most needles are made of stainless steel, and all are disposable. a needle has three parts: the hub which fits onto the tip of a syringe, the shaft which connects to the hub, and the bevel or slanted tip. most needles vary in length from 1/4 to 3 inches. choose the needle length according to a client's size and weight and the type of issue into which the medication is to be injected.

three most common types of syringes

hypodermic syringe, insulin syringe, tuberculin syringe

preparing an injection from a vial

if dry, use solvent or diluent as needed. inject air into vial. label multidose vials after mixing. refrigerate remaining doses if needed. a vial is a single-dose or multidose container with a rubber seal at the top. a metal cap protects the seal until it is ready for use. vials contain liquid or dry forms of medications. medications that are unstable in solution are packaged dry. the vial label specifies the solvent or diluent used to dissolve the medication and the amount of diluent needed to prepare a desired medication concentration. normal saline and sterile distilled water are commonly used to dissolve medications. unlike the ampule, the vial is a closed system, and air needs to be injected into it to permit easy withdrawal of the solution. failure to inject air when withdrawing creates a vacuum within the vial that makes withdrawal difficult. if concerned about drawing up parts of the rubber stopper or other particles into the syringe, use a filter needle when preparing medications from vials. some vials contain powder, which is mixed with a diluent during preparation and before injection. after mixing multidose vials, make a label that includes the date and time of mixing and the concentration of medication per milliliter. some multidose vials require refrigeration after the contents are reconstituted.

CV physical examination: jugular veins

if jugular vein dystension is greater than 3 cm, it could indicate heart failure. both internal and external jugular veins drain bilaterally from the head and neck to the superior vena cava. best to examine the right internal jugular vein because it follows a more direct path to the right atrium and heart. have client lay flat in the supine position; expose head and neck. use a pillow to align head; observe engorgement of the jugular veins. gradually raise the HOB until the jugular venous pulsations become evident between the angle of the jaw and the clavicle. inspect the jugular veins; usually not evident with the client sitting up. lower the HOB and have client lean back to a 45 degree angle.

ear instillation

instill ear drops at room temperature to prevent vertigo and nausea. use sterile solutions. the entrance of nonsterile solutions into middle ear structures often results in infection. check for eardrum rupture if client has ear drainage. never occlude the ear canal. forcing medication into an occluded ear canal creates pressure that injures the eardrum. for adults, pull up and back to do ear drops.

insulin preparation

insulin is the hormone used to treat diabetes. it is administered by injection because the GI tract breaks down and destroys an oral form of insulin. use the correct syringe (100 unit insulin syringe or an insulin pen to prepare U-100 insulin). insulin is classified by rate of action (rapid, short, intermediate, and long-acting). know the onset, peak, and duration for each of your patients' ordered insulin doses. most patients with diabetes who take insulin injections learn to administer their own injections. only regular insulin can be given intravenously. the timing of insulin injections attempts to imitate the normal pattern of insulin release from the pancreas. some insulins come in a stable premixed solution (e.g. 70/30 insulin is 70% NPH [intermediate] and 30% regular), eliminating the need to mix the insulins in a syringe. other patients use an insulin pen. the insulin pen provides multiple doses and allows the client or nurse to dial in the dose, avoiding the need to use a syringe for insulin preparation.

parenteral routes

involves injecting a medication into body tissues. whether or not you actually administer a medication, you remain responsible for monitoring the integrity of the medication delivery system, understanding the therapeutic value of the medication, and evaluating a client's response to the therapy. four major sites of injection: intradermal (ID): injection into the dermis just under the epidermis. subcutaneous: injection into tissues just below the dermis of the skin. intramuscular (IM): injection into a muscle. intravenous (IV): injection into a vein.

apical impulse (or pulse of maximal impulse or PMI)

located in the 4th-5th intercostal space just medial to the L midclavicular line. about 1-2 cm in diameter. by age 7 a child's PMI is in the same location as the adults.

trough

lowest level of medicine in bloodstream. needs to be drawn 30 min before next scheduled dose.

tuberculin syringe

marked in tenths and hundredths (.01) of cubic millimeters up to 1 cc. good to use for pediatric dose. used for TB skin tests and allergy testing.

prescriptions medication order

medication to be taken outside of the hospital

subcutaneous injections

medications placed into loose connective tissue under dermis. don't need to aspirate. because SQ tissue is not as richly supplied with blood as the muscles, medication absorption is somewhat slower than with IM injections. however, medications are absorbed completely if the client's circulatory status is normal. because SQ tissue contains pain receptors, a client often experiences slight discomfort. the best SQ injection sites include the outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs. the site most frequently recommended for heparin injections is the abdomen. alternative SQ sites for other medications include the scapular areas of the upper back and the upper ventral or dorsal gluteal areas. the injection site you choose needs to be free of skin lesions, bony prominences, and large underlying muscles or nerves. the administration of low-molecular-weight heparin (LMWH) requires special considerations. when injecting the medication, use the right or left side of the abdomen at least 2 inches from the umbilicus and pinch the injection site as you insert the needle. administer LMWH in its prefilled syringe with the attached needle and do not expel the air bubble in the syringe before giving the medication. there is some new evidence to support a slower injection rate of 30 seconds to reduce bruising and pain. use use U-100 insulin syringes with preattached 32 to 25 gauge needles when giving U-100 insulin and 1 mL tuberculin syringes when giving U-500 insulin. recommended sites for insulin injections include the upper arm and the anterior and lateral parts of the thigh, buttocks, and abdomen. rotating injections with the same body part (intrasite rotation) provides more consistency in the absorption of the insulin. the injections are to be given at least 2.5 cm (1 inch) away from the previous site. injection sites should not be used again for at least 1 month. the rate of insulin absorption varies based on the site; the abdomen has the quickest absorption, followed by the arms, thighs, and buttocks. SQ tissue is sensitive to irritating solutions and large volumes of medications. thus you only administer small volumes (0.5 to 1.5 mL) of water-soluble medications subcutaneously to adults. you give smaller volumes, up to 0.5 mL to children. hardened, painful lumps, called sterile abscesses, occur under the skin if medication collects within the tissues. a client's body weight indicates the depth of the SQ layer. therefore, choose the needle length and angle of insertion on the basis of a client's weight and an estimation of the amount of SQ tissue. nurses usually use a 25 gauge, 5/8 inch (16 mm) needle inserted at a 45 degree angle or a 1/2 inch (12 mm) needle inserted at a 90 degree angle to administer SQ medications to a normal size adult client. some children require only a 1/2 inch needle. if the client is obese, pinch the tissue and use a needle long enough to insert through fatty tissue at the base of the skinfold. thin patients often fo not have sufficient tissue for SQ injections; the upper abdomen is usually the best site in this case. to ensure that a SQ medication reaches the SQ tissue, follow this rule: 2 inches, 90 degree angle; 1 inch, 45 degree angle. newer research in insulin administration shows that insulin needles that are 5/16 inches (8mm) or longer often enter the muscles of men and people with a body mass index (BMI) of 25 or less. shorter (3/16 inch or 4 to 5 mm) needles are associated with less pain, adequate control of blood sugars, and minimal leakage of medication. thus, when administering insulin, needles of 3/16 inch (4 to 5 mm) administered at a 90-degree angle should be used to reduce pain and achieve adequate control of blood sugars with minimal adverse effects for people of all BMIs, including children.

topical medication applications

medications that are applied locally, usually to skin, but also to mucous membranes. apply each type of medication according to directions to ensure proper penetration and absorption. skin applications: use gloves and applicators. clean skin first. use sterile technique if client has an open wound. follow directions for each type of medication. transdermal patches: remove old patch before applying new. document the location of the new patch. ask about patches during the medication history. apply a label to the patch if it is difficult to see. document removal of the patch as well.

medication action

medications vary considerably in the way they act and in their types of action. patients do not always respond in the same way to each successive dose of a medication. sometimes the same medication causes very different responses in different patients. therefore it is essential to understand all the effects that medications have on patients.

mixing medications

mixing mediations from a vial and an ampule: prepare medication from the vial first. use the same syringe and filter needle to withdraw medication from the ampule. mixing medications from two vials: do not contaminate one medication with another. ensure that the final dose is accurate. maintain aseptic technique. if two medications are compatible, it is possible to mix them in one injection if the total dose is within accepted limits. this prevents a client from having to receive more than one injection at a time. most nursing units have charts that list common compatible medications. if there is any uncertainty about medication compatibilities, consult a pharmacist or a medication reference. when mixing medication from both a vial and ampule, prepare medication from the vial first. using the same syringe and filter needle, next withdraw medication from the ampule. nurses prepare the combination in this order because it is not necessary to add air to withdraw medication from an ampule. use only one syringe with a needle or needleless access device attached to mix medications from two vials. aspirate the volume of air equivalent to the dose of the first medication (vial A). inject the air into vial A, making sure that the needle does not touch the solution. withdraw the needle and aspirate air equivalent to the dose of the second medication (vial B). inject the volume of air into vial B. immediately withdraw the medication from vial B into the syringe and insert the needle back into vial A, being careful not to push the plunger and expel the medication within the syringe into the vial. withdraw the desired amount of medication from vial A into the syringe. after withdrawing the necessary amount, withdraw the needle and apply a new safety needle or needleless access device suitable for injection. apply these principles when mixing medications from two vials: do not contaminate one medication with another. ensure that the final dose is accurate. maintain aseptic technique.

pressurized metered-dose inhalers (pMDIs)

need sufficient hand strength for use. may be used with a spacer. use a chemical propellant to push the medication out of the inhaler and require the client to apply approximately 5 to 10 lbs of pressure to the top of the canister to administer the medication. children or older adults with chronic respiratory diseases often use these. some patients use a spacer with the pMDI. the spacer is a 10 to 20 cm (4 to 8 inch) long tube that attaches to the pMDI and allows the particles of medication to slow down and break into smaller pieces, which improves drug absorption in a client's airway.

safety in administering medications by injection

needleless devices: most needlestick injuries are preventable. needlestick safety and prevention act. safety syringes. approximately 5.6 million health care workers in the US are at risk of occupational exposure to bloodborne pathogens such as human immunodeficiency virus (HIV) and the hepatitis B virus. occupational exposure often occurs through accidental needlesticks and sharps injuries. needlestick injuries commonly occur when health care workers recap needles, mishandle IV lines and needles, or leave needles at a client's bedside. exposure to bloodborne pathogens is one of the deadliest hazards to which nurses are exposed on a daily basis. The Needlestick Safety and Prevention Act mandates the use of special needle safety devices to reduce the frequency of needlestick injuries. safety syringes have a sheath or guard that covers a needle immediately after it is withdrawn from the skin. this eliminates the chance for a needlestick injury. the syringe and sheath are disposed of together in a receptacle. use needleless devices whenever possible to reduce the risk of needlestick and sharps injuries. dispose of sharps in marked containers: use puncture and leak proof containers (empty when 3/4 full). never force needles into receptacle. never place used needles into wastebaskets, your pockets, or client's tray or bedside.

idiosyncratic reaction

overreaction or under reaction or different reaction from normal (opposite of expected). medications sometimes cause unpredictable effects, such as idiosyncratic reaction, in which a client overreacts or under reacts to a medication or has a reaction different from normal.

medication interactions

when one medication modifies the action of another. these are common when individuals take several medications. some medications increase or diminish the action of others or alter the way another medication is absorbed, metabolized, or eliminated from the body. when two medications have a synergistic effect, their combined effect is greater than the effect of the medications when given separately.

nursing process: planning

plan ahead. always organize your care activities to ensure the safe administration of medications. gather materials before. check if they need more water. pour liquid with label facing palm of hand so it doesn't leak. oral med less than 5 mL use syringe for accuracy. goals and outcomes: setting goals and related outcomes contributes to client safety and allows for wise use of time during medication administration. setting priorities: provide the most important information about the medications first. teamwork and collaboration: collaboration during medication administration is essential. family caregivers and significant others often reinforce the importance of med schedules when a client is at home. nurses often collaborate with patients' health care providers, pharmacists, and case managers to endure that patients are able to afford their medications. also collaborate with community resources when clients have significant literacy issues or difficulty understanding medication instructions. it is important to minimize distractions or interruptions when preparing and administering meds. no-interruption zones (NIZs) have been recommended to reduce distractions and interruptions during med admin. prioritize care when administering meds. use client assessment data to determine which meds to give first, whether it is time to evaluate a client's response to a med, or if it is appropriate to administer prn meds.

CV assessment

preparation: position (start with the client supine or with upper body elevated at 45 degrees or semi-fowler's). may need to place a drape for females per request. room should be private, quiet, warm and well lit, warm hands. equipment: stethoscope with diaphragm and bell. small centimeter ruler (if checking jugular vein dystension). straight edge (if checking JVD)--this could be a tongue depressor.

pharmacist's role in medication administration

prepares and distributes medication. work with nurses, physicians, and other health care providers to evaluate the effectiveness of patients' medications. they are responsible for filling prescriptions accurately and being sure that prescriptions are valid. pharmacists in health care agencies rarely mix compounds or solutions, except in the case of IV solutions. most medication companies deliver medications in a form ready for use. dispensing the correct medication, in the proper dosage and amount, with an accurate label is the pharmacist's main task. pharmacists also provide information about medication side effects, toxicity, interactions, and incompatibilities.

health care provider's role in med admin

prescriber can be physician, nurse practitioner (in some states), or physician's assistant. orders can be written (hand or electronic), verbal (VORV), or given by telephone. most places are shifting to electronic charting. the use of abbreviations can cause errors (use caution and avoid abbreviations).

heart attack symptoms for men

pressure on chest

chemical name of medication

provides the exact description of medication's composition (don't need to memorize chemical name)

2 semilunar (SL) valves

pulmonic (right) and aortic (left). closed during diastole and open during systole

rectal instillation

rectal suppositories are thinner and more bullet shaped than vaginal suppositories. the rounded end prevents anal trauma during insertion. rectal suppositories contain medications that exert local effects such as promoting defecation, or systemic effects, such as reducing nausea. rectal suppositories are often stored in the refrigerator until administered. sometimes it is necessary to clear the rectum with a small cleansing enema before inserting a suppository.

medication errors

report all medication errors. client 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 medication reconciliation. assess patient first right after medication error. a medication error can cause or lead to inappropriate medication use or client harm. errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, or failing to administer a medication. advances in health care informatics have helped to decrease the occurrence of medication errors. after you assess and once the client is stable, report the incident to the appropriate person in the agency. the occurrence report is not a permanent part of the medical record and is not referred to anywhere in a client's medical record to legally protect the nurse and health care agency. report all medication errors that reach the client, including those that do not cause harm. you also need to report near misses. some medication errors happen when patients experience a transition in care such as when a client is admitted or discharged from a hospital, is transferred from an intensive care unit to a general client care unit, or sees a new health care provider. during these times the risk of unintended changes in medication orders increases. thus reconciling medication information is a key Hospital National Client Safety goal. during medication reconciliation, nurses, pharmacists, and other health care providers compare the medication that a client is taking currently with what the client should be taking and any newly ordered medications. creating and maintaining an accurate list of all client medications helps to ensure safe and effective client care. many agencies have computerized or written forms to facilitate the process of medication reconciliation. accurate medication reconciliation requires consulting with the client, family caregivers, other clinicians, pharmacists, and other members of the health care team.

systems of medication administration

require the ability to compute medication doses accurately and measure medications correctly. even though pharmacists do most of dosage calc, nurse is responsible for checking correct dosage. metric system: 0 before the decimal only. most logically organized. meter, liter, gram. organized into units of 10. metric units are easy to convert and compute through simple multiplication and division. however, this system must be used with great care because moving a decimal to the right or the left will greatly affect the dose. this is why a zero must always be placed before a decimal but never after a decimal. household system: most familiar to individuals. disadvantage is its inaccuracy. include drops, teaspoons, tablespoons, and cups for volume and pints and quarts for weight. encourage patients to never use household measuring devices to give liquid medicines. the devices are inaccurate and may deliver more or less than prescribed. todays over-the-counter (OTC) liquid medications almost always have their own measuring devices. to calculate medications accurately, you need to know common equivalents of metric and household units. solutions: used for irrigations, injections, and infusions. a solution is defined as a given mass of solid substance dissolved in a known volume of fluid, or as a given volume of liquid dissolved in a known volume of another fluid. when a solid is dissolved in a fluid, the concentration is in units of mass per units of volume (g/L, mg/mL). you can also express a concentration of a solution as a percentage. for example, a 10% solution is 10 g of solid dissolved in 100 mL of solution. a proportion also expresses concentrations. a 1/1000 solution represents a solution containing 1 g of solid in 1000 mL of liquid or 1 mL of liquid mixed with 1000 mL of another liquid.

S3 heart sound

signifies developing heart failure in adults; normal in children/young adults, pregnant women, and athletes. sounds like kentucky

S4 heart sound

signifies ischemia, myocardial infarction, or stiff ventricles. sounds like Tennessee.

preparing an injection from an ampule

snap off ampule neck. aspirate medication into syringe using filter needle. replace filter needle with an appropriate size needle or needless device. administer injection. ampules contain single doses of medication in a liquid. they are available in several sizes, from 1 mL to 10 mL or more. an ampule is made of glass with a constricted neck that must be snapped off to allow access to the medication. a colored ring around the neck indicates where the ampule is prescored so you can break it easily. carefully aspirate the medication into a syringe with a filter needle. the use of a filter needle prevents particulate matter such as small glass fragments from entering the syringe. replace the filter needle with an appropriate-size needle or a needless access device before administering the injection.

CV physical examination: inspection and palpation

stand on patient's right side. look for visible pulsations and exaggerated lifts. palpate for the apical impulse and across precordium (angle of louis. 2nd intercostal space on the R--aortic pulsation. back to the angle of louis, then to the 2nd intercostal space on the L side--pulmonic area. 3rd intercostal space--Erb's point. 4th intercostal space--tricuspid). in adults, PMI should be just medial to the left midclavicular line at the 4th or 5th intercostal space. if they are supine and you can't locate it, place them on their left side (bring heart closer to chest wall).

routes of administration for oral routes

sublingual administration: under tongue. alternate sides. don't drink until dissolved. very vascular under tongue. readily absorbed. doesn't need to be chewed. ex: nitroglyceran. buccal administration: against cheek. alternate sides. don't chew. a buccal medication acts locally on the mucosa or systemically as it is swallowed in a person's saliva. topical administration: local effects. skin: disks, patches (can last 4 hours to 7 days), paper, etc. applied by painting or spreading the medication over an area, applying moist dressings, soaking body parts in a solution, or giving medicated baths. systemic effects often occur if a client's skin is thin or broken down, the medication concentration is high, or contact with the skin is prolonged. a transdermal disk or patch has systemic effects. the disk secures the medicated ointment to the skin. these topical applications are left in place for as little as 12 hours or as long as 7 days. you apply topical medications to mucous membranes through direction application of a liquid or ointment, insertion of a medication into a body cavity. instillation of fluid into a body cavity (fluid is retained), irrigation of a body cavity (fluid is not retained), or spraying medication into a body cavity. mucous membranes: orally. inhalation route: nasal or oral airways. work rapidly because it's very vascular. or through endotracheal or tracheostomy tubes. readily absorbed. many inhaled medications have local or systemic effects. intraocular route: contact discs directly on eye. eye drops. could remain for up to 1 week. the eye medication disk has two soft outer layers that have medication enclosed in them. the nurse inserts the disk into the client's eye, much like a contact lens. let client self-administer if they are able

heart attack symptoms for females

subtle symptoms. GI symptoms (GI cocktail: lots of GI medicine to rule out GI disorder).

CV physical examination: carotid arteries

supplies oxygenated blood to the head and neck. inspect, palpate, auscultate. inspection: have client lay supine or have HOB elevated at 30 degrees. examine each carotid artery one at a time and them compare. have client slightly turn head away from the artery you are examining (sometimes the wave of the pulse is visible. an absent pulse wave indicates arterial occlusion or stenosis which is narrowing). palpate: never occlude both carotid arteries at the same time because loss of consciousness will occur. do not palpate or deep massage the carotid arteries vigorously (especially too high in the neck/close to the jaw line; it will stimulate the vagus nerve and cause syncope especially in older adults). vagus nerve is cranial nerve 10 and is the longest most complex cranial nerve. to palpate the pulse, have client look straight ahead or have them turn their head slightly toward the side you are examining (which relaxes the sternocleidomastoid muscle). slide the tips of the index and middle fingers around the medial edge of the sternocleidomastoid muscle; gently palpate to avoid occlusion. auscultate: most commonly auscultated pulse. place the BELL of the stethoscope over the carotid artery at the lateral end of the clavicle and the posterior margin of the sternocleidomastoid muscle. heave client turn their head slightly away from the side being examined and ask client to hold their breath for a moment (to aid better hearing of the bruit). normally you do not hear sounds during carotid auscultation.

parenteral administration of medications: equipment

syringes (Luer-Lok and Non-Luer-Lok). each type of syringe is designed to deliver a certain volume of a medication to a specific type of tissue. use nursing judgement when determining the syringe size or needle length and gauge that will be most effective. syringes consist of a cylindrical barrel with a tip designed to fit the hub of a hypodermic needle and a close-fitting plunger. luer-lok syringes have needles that are twisted onto the tip and lock themselves in place. this design prevents the inadvertent removal of the needle. non-luer-lok syringes have needles that slip onto the tip. syringes have safety devices to prevent needle stick injury. syringes come in a number of sizes, from 0.5 to 60 mL. the tuberculin syringe is calibrated in sixteenths of a minim and hundredths of a millimeter and has a capacity of 1 mL. insulin syringes are available in sizes that hold 0.3 to 1 mL and are calibrated in units. fill a syringe by pulling the plunger outward while the needle tip remains immersed in the prepared solution. only touch the outside of the syringe barrel and the handle of the plunger to maintain sterility. avoid letting any unsterile object touch the tip or inside of the barrel, the hub, the shaft of the plunger, or the needle.

generic name of medication

the manufacturer who first develops the drug assigns the name, and it is then listed in the U.S. Pharmacopeia.

direction of blood in the heart

the right atrium receives deoxygenated blood from the body via the superior and inferior vena cava. the right ventricle receives blood from the RA and pumps it into the lungs via the pulmonary artery. the LA receives oxygenated blood from the lungs via the 4 pulmonary veins. the LV is the largest and most muscular chamber; it receives oxygenated blood from the lungs via the left atrium and pumps blood into the systemic circulation via the aorta.

distribution systems of medication administration

unit dose systems, automatic medication dispensing system (AMDS). nurse cannot be interrupted during med admin process. check expiration date of medication. never leave meds unattended. med waste requires a second nurse to verify. you have to have a second nurse to verify insulin dose. health care agencies have a special area for stocking and dispensing medications. medication storage areas need to be locked when unattended.

nursing process: assessment

through the client's eyes. history: allergies, medication, diet history, client's perceptual or coordination problems. client's current condition (know vital signs). client's attitude about medication use. factors affecting adherence to medication therapy. client's learning needs. do assessment before med admin. always be talking to the client. client can refuse meds (document why med wasn't given). consider patients' preferences, values, and needs while determining their need for and possible responses to medication therapy. inform the other members of the health care team if a client has a history of allergies to medications and foods. many medications have ingredients also found in food sources. ask your patients questions to find out about each medication they take. in addition, review the action, purpose, normal dosage, routes, side effects, and nursing implications for administering and monitoring each medication. a diet history reveals a client's normal eating patterns and food preferences. use your client's diet history to plan an effective and individualized medication dosage schedule. teach your client to avoid foods that interact with medications. patients with perceptual, fine motor, or coordination limitations often have difficulty self-administering medications. if a client is unable to self-administer medications, assess if family or friends are available to help or make a home care referral. the ongoing physical or metal status of a client affects whether a medication is given and how it is administered. a client's attitudes about medications sometimes reveals a level of medication dependence or drug avoidance. also be aware that cultural beliefs about Western medicine sometimes interfere with medication adherence. many complex factors affect a client's ability to adhere to prescribed medication therapy. without adequate funding (economic resources), knowledge, and motivation, adherence to medication schedules is unlikely. serious errors can occur when patients do not understand information about their medications. assess clients' health literacy regarding medication administration to determine their need for instruction.

eye instillation

tip under cap needs to stay sterile. check expiration date. instillation: avoid the cornea. avoid the eyelids with droppers or tubes to decrease the risk of infection. use only on the affected eye. never share medication. the cornea of the eye has many pain fibers and thus is very sensitive to anything applied to it. intraocular instillation: disk resembles a contact lens. teach patients how to insert and remove the disk. teach about adverse effects. place the medication into the conjunctival sac, where it remains in place for up to 1 week. medications commonly used by patients include eye drops and ointments, including OTC preparations such as artificial tears and vasoconstrictors. many patients, especially older adults, receive prescribed opthhalmic medications for eye conditions such as glaucoma or after cataract extraction. age-related problems, including poor vision, hand tremors, and difficulty grasping or manipulating containers, affect the older adult's ability to self-administer eye medications. instruct patients and family members about proper techniques for administering them. determine the client's and the family's ability to self-administer through a return demonstration of the procedure. showing patients each step of the procedure for instilling eyedrops can improve adherence.

importance of the 8 rights of medication administration

to prevent medication errors, follow these rights consistently every time you administer medications. many medication errors can be linked in some way to an inconsistency in adhering to these rights. regardless of how the nurse receives a medication order, he or she compares the prescriber's written orders with the medication administration record (MAR) or the electronic medication administration record (eMAR) when medication is initially ordered. when performing medication calculations or conversions, have another qualified nurse check the calculated doses. always consult the prescriber if an order does not designate a route of administration. likewise, if the specified route is not the recommended route, alert the prescriber immediately. you need to know why a medication is ordered for certain times of the day, and whether you are able to alter the time schedule. a medication order is required for every medication that you administer to a client. if any question arises about a medication order because it is incomplete, illegible, vague, or not understood, contact the prescribing health care provider before administering the medication.

2 atrioventricular (AV) valves

tricuspid (right) and mitral (left). open during diastole and closed during systole

lub heart sound

tricuspid and mitral valves close. S1. beginning of systole

toxic effect

type of adverse effect. accumulation of medication in the bloodstream. morphine will build up in bloodstream. people who have renal issues. often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. excess amounts of a medication within the body sometimes have lethal effects, depending on the medication's action. antidotes are available to treat specific types of medication toxicity.

side effect

type of adverse effect. predictable, unavoidable secondary effect. range from being harmless to causing serious symptoms or injury. patients often stop taking medications because of side effects.

therapeutic effect

type of medication action. expected or predicted physiological response (why you are giving the medication). knowing the desired therapeutic effect for each medication allows you to provide client education and accurately evaluate the desired effect of a medication. some medications have more than one therapeutic effect. adverse drug effects range from mild to severe. some happen immediately, whereas others develop over time.

adverse effect

unintended, undesirable, often unpredictable. adverse drug effects range from mild to severe. some happen immediately, whereas others develop over time.

allergic reaction

unpredictable response to a medication. always ask about allergies before giving meds. ask about reaction (codeine makes you N/V, but that is expected, so it's not a true allergic reaction). usually an allergic reaction will occur on second exposure of medication, not the first. can range from mild to severe (anaphylactic shock). if they are severely allergic (anaphylactic reaction), they should a bracelet or necklace and also carry an epipen. some patients become immunologically sensitized to the initial dose of a medication. with repeated administration the client develops an allergic response to it, its chemical preservatives, or a metabolite. the medication or chemical acts as an antigen, triggering the release of the antibodies in the body. a client's medication allergy symptoms vary, depending on the individual and the medication. among the different classes of medications, antibiotics cause a high incidence of allergic reactions. severe or anaphylactic reactions are life threatening. a client with a known history of an allergy to a medication needs to avoid taking that medication in the future and wear an identification bracelet or medal that alerts nurses and other health care providers to the allergy is a client is unable to communicate when receiving medical care.

vastus lateralis

up to 3 mL. used for adults and children. use middle third of muscle for injection. often used for infants, toddlers, and children receiving biologicals. the muscle is thick and well developed, is located in the anterior lateral aspect of the thigh, and extends in an adult from a hand breadth above the knee to a hand breadth below the greater trochanter of the femur. the width of the muscle usually extends from the midline of the thigh to the midline of the outer side of the thigh. with young children or cachectic patients, it helps to grasp the body of the muscle during injection to be sure that the medication is deposited in muscle tissue. to help relax the muscle, ask a client to lie flat with the knee slightly flexed or in a sitting position.

minimizing client discomfort for parenteral administration of medications

use a sharp-beveled needle in the smallest suitable length and gauge; position client comfortably. select the proper injection site. apply a vapocoolant spray or topical anesthetic. divert the client's attention from the injection. insert the needle quickly and smoothly. hold the syringe steady while the needle remains in tissues. inject the medication slowly and steadily. many patients, particularly children, fear injections. patients with serious or chronic illness often are given several injections daily. minimize discomfort in the following ways: use a sharp-beveled needle in the smallest suitable length and gauge. position a client as comfortably as possible to reduce muscular tension. select the proper injection site, using anatomical landmarks. apply a vapocoolant spray (e.g. Fluori-Methane spray or ethyl chloride) or topical anesthetic (e.g. EMLA cream) to the injection site before giving the medication when possible. divert the client's attention from the injection through conversation using open-ended questioning. insert the needle quickly and smoothly to minimize tissue pulling. hold the syringe steady while the needle remains in tissues. inject the medication slowly and steadily.

deltoid

used for many vaccines. 2 mL or less. don't have to aspirate. find acromium process. not a site for infants, elderly, small children, malnourished. easily accessible. there is a potential for injury because the axillary, radial, brachial, and ulnar nerves and the brachial artery lie within the upper arm under the triceps and along the humerus. to locate the muscle, fully expose the client's upper arm and shoulder. the injection site is in the center of the triangle about 3 to 5 cm (1 to 2 inches) below the acromion process. you can also locate the site by placing four fingers across the deltoid muscle, with the top finger along the acromion process. the injection site is then three finger widths below the acromion process.

intradermal injections

used for skin testing (tuberculosis [TB], allergies). slow absorption from dermis. skin testing requires the nurse to be able to clearly see the injection site for changes. use a tuberculin or small hypodermic syringe for skin testing. angle of insertion is 5 to 15 degrees with bevel up. a small bleb will form. if a bleb does not appear or if the site bleeds after the needle withdrawal, there is a good chance that the medication entered subcutaneous tissues. in this case, test results will not be valid. because these medications are potent, they are injected into the dermis, where blood supply is reduced and medication absorption occurs slowly. some patients have a severe anaphylactic reaction if medications enter the circulation too rapidly. you need to choose skin-testing sites that allow you to easily assess for changes in color and tissue integrity. thus ID sites need to be lightly pigmented, free of lesions, and relatively hairless. the inner forearm and upper back are ideal locations. usually only a small amount of liquid is used, for example, 0.1 mL. equipment used is a 1 mL syringe calibrated into hundredths of a milliliter. the needle is short and fine, frequently a 25, 26, or 27 gauge, 1/4 to 5/8 inch long. bevel up. do not massage afterward.

vaginal instillation

vaginal medications are available as suppositories, foam, jellies, or creams. because vaginal medications are often given to treat infection, discharge is usually foul smelling. follow aseptic technique, and offer the client frequent opportunities to maintain perineal hygiene. solid, oval suppositories come individually packaged in foil wrappers and sometimes are stored in the refrigerator to prevent them from melting. after a suppository is inserted into the vaginal cavity, body temperature causes it to melt and be distributed and absorbed. give a suppository with a gloved hand in accordance with standard precautions. patients often prefer administering their own vaginal medications and need privacy. foam, jellies, and creams are administered with an applicator inserter.

use of the Z-track method in intramuscular injections

zig zag path seals needle track. medication cannot escape from the muscle tissue. it minimizes local skin irritation by sealing the medication in muscle tissue. to use the Z-track method, put a new needle on the syringe after preparing the medication so no solution remains on the outside needle shaft. then select an IM site, preferably in a large, deep muscle such as the ventrogluteal muscle. place the ulnar side of the nondominant hand just below the site and pull the overlying skin and SQ tissues approximately 2 to 3 cm (1 to 1.2 inches) laterally or downward. hold the skin in this position until you administer the injection. after preparing the site with an antiseptic swab, inject the needle into the muscle. grasp the barrel of the syringe with the thumb and index finger of the nondominant hand and slowly inject the medication if there is no blood return on aspiration. the CDC no longer recommends aspiration when administering immunizations to reduce discomfort. the needle remains inserted for 10 seconds to allow medication to disperse evenly rather than channeling back up the track of the needle. release the skin after withdrawing the needle. this leaves a zigzag path that seals the needle track where tissue planes slide across one another. the medication cannot escape from the muscle tissue.