Nurse 3130 Exam 2 (Unit 5)

PHYSICAL EXAMINATION: AUSCULTATION

"APE TO MAN" •A(ortic)- 2nd ICS on right sternal border •P(ulmonic)- 2nd ICS on the left sternal border •E(rb's point)- 3rd ICS- left border •T(tricuspid)-5th ICS- left sternal border •M(itral)- 5th ICS at the Midclavicular line

Medication Administration

-A medication is 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 patient's 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 -We, as nurses, are the patient's last ditch effort to remain safe, save their life, the last check to make sure everything is correct for that patient, and to make sure there are no medication errors -It is our responsibility to question and clarify and orders and ask about a drug that does not seem right.

NURSING PROCESS: ASSESS & RECOGNIZE CUES -Assessing for peripheral vascular insufficiency

-Absent or diminished pulses (especially pedal pulses) -Abnormal skin color (especially in the lower extremities [calves, ankles, feet]) -Poor hair growth -Cool skin -Hard for wounds to heal bc not getting adequate blood flow

NURSING PROCESS: NURSING DIAGNOSIS AND ANALYZING CUES for peripheral vascular insufficiency

-Activity intolerance -Dehydration (bc not good blood flow) -Hypervolaemia (too much blood flow, too much fluids in body) -Impaired Cardiac Function -Impaired Peripheral Tissue Perfusion

Medication Administration Record (MAR)

-Always have to have an MAR in order to administer a medication -Most of the time they are electronic, sometimes they can be a paper copy depending on what facility you work at, and what their policy is. -You will see who verified it (usually that is the pharmacy initial and then the charge nurse or whoever on night shift that received the paper MARs would verify, usually not it is the pharmacy that verifies it. -The date, the clients diagnosis they have, any allergies (either written as NKA or no known allergy or no known drug allergies NKDA and should always be at the veery top of the title bar- do not just look at what the allergies are, ask them exactly what they are allergic to) -Medical record number, age, sex, dob, etc.

Planning

-Always organize your care activities to ensure the safe administration of medications. -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 •It is important to minimize distractions or interruptions when preparing and administering medications. No-interruption zones (NIZs) have been recommended to reduce distractions and interruptions during medication administration. •Setting goals and related outcomes contributes to client safety and allows for effective use of time during medication administration. •Prioritize care when administering medications. Use client assessment data to determine which medications to give first, whether it is time to evaluate a client's response to a medication, or if it is appropriate to administer prn medications. •Collaboration during medication administration is essential. Family caregivers and significant others often reinforce the importance of medication schedules when a client is at home. Nurses often collaborate with patients' health care providers, pharmacists, and case managers to ensure that patients are able to afford their medications. Also collaborate with community resources when clients have significant literacy issues or difficulty understanding medication instructions.

PHYSICAL EXAMINATION: JUGULAR VEINS

-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 b/c 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 for 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 w/ the client sitting up. Lower the HOB and have client lean back to a 45 degree anglee JVD is not palpable -Anything greater than 3cm for jugular Vein distention has potential for CHF. This is an advanced assessment

NURSING PROCESS: ASSESSMENT & RECOGNIZING CUES- CV HEALTH HX

-Chest pain -Dyspnea (difficulty breathing- bc you really can't divorce the 2 between respiratory and cardiac) -Orthopnea (SOB or difficulty breathing when lying down) -Cough -Fatigue (bc body is working to hard to circulate that blood and oxygen) -Cyanosis or pallor -Edema(swelling)-especially in arms and feet -Nocturia (frequent nighttime urination; > 2x per night) -Cardiac hx -Family cardiac hx -Personal habits (risk factors)

NURSING PROCESS: NURSING DIAGNOSIS AND ANALYZING CUES

-Decreased cardiac output -Ineffective tissue perfusion -Fatigue -Activity Intolerance -Knowledge deficit

Safety in Administering Medications by Injection (Cont.)

-Dispose of sharps in marked containers -Use puncture- and leak-proof containers -Never force needles into receptacle -Never place used needles into wastebaskets, your pockets, or client's tray or bedside

ALTERATIONS IN CARDIAC FUNCTIONING

-Disturbances in conduction (Ex: caused by electrolyte imbalances, specifically potassium that can cause dysrhythmias) -Altered Cardiac Output •Left-sided heart failure- Left sided HF, you will have more pulmonary issues (dizziness, etc. everything that is related to hypoxia) •Right-sided heart failure- you will see more edema or. sudden weight gain with right sided HF. These patients get weighted daily at the same time so that they can assess. -Impaired valvular function (Ex: septal defect) -Myocardial ischemia •Angina (transient imbalance between myocardial oxygen supply and demand)- Only lasts for about. 3-5 min •Myocardial infarction (MI; "Heart Attack")- Sudden decrease in coronary blood flow or increase of myocardial oxygen demand without perfusion.- pain for ab 20 min or longer -Both angina and MI start off with pain in the chest but angina is usually tight and feel pressure, and can burning or tingling. Both have. pain that radiates to the neck or jaw, left arm.

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

Oral Administration

-Easiest and most desirable route. -Food sometimes affects absorption. -Aspiration precautions. -Enteral or small-bore feedings: -Verify that the tube location is compatible with medication absorption. -Use liquids 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.

Intramuscular Injections:

-Faster absorption than subcutaneous route -Many risks, so verify the injection is justified -Angle of administration: 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 -Ztrack method -Use of the Z-track method in intramuscular injections -Zigzag path seals needle track -Medication cannot escape from the muscle tissue

Essential parts of a drug order:

-Full name of the client -Date and time the order is written -Name of the drug to be administered -Dosage of the drug -Route of administration -Time and frequency of administration -Signature of the person writing the order We would like if it is a prn order, for it to have a reason for giving it.

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 -Index finger, the middle finger, and the iliac crest form a V-shaped triangle -Injection site is the center of the triangle

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.

NURSING PROCESS: PLANNING AND GENERATING SOLUTIONS for peripheral vascular insufficiency

-Individualized plan of care based on etiology of the diagnosis and related risk factors -Client-centered plan of care is key to developing an exercise plan to which the client can adhere to -Teach client how to measure HR during exercise or if they are taking medications to improve their own pulse -ASK THE CLIENT HOW THEY FEEL AFTER EXERCISING. -MEASURE ACTUAL HR TO THEIR TARGET HR

What 3 things would you do when assessing the heart?

-Inspection -Palpation -Auscultate

Ear instillation

-Instill eardrops at room temperature. -Use sterile solutions. -Check for eardrum rupture if client has ear drainage. -Never occlude the ear canal.

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. Lots more on this

Subcutaneous injections:

-Medications placed into loose connective tissue under dermis •Subcutaneous injections involve placing medications into the loose connective tissue under the dermis. Because subcutaneous 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 subcutaneous tissue contains pain receptors, a client often experiences slight discomfort. •The best subcutaneous 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 subcutaneous 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.

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 United States 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. Most needlestick injuries are preventable with the implementation of safe needle devices. •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.

PATIENT EDUCATION R/T CARDIOVASCULAR HEALTH

-Nutrition- promote good nutrition bc we want them to be as healthy as possible to promote good cellular functioning -Smoking (have them stop) -Alcohol (have them stop) -Exercise (30-60 min a day) -Drugs (some drugs speed up, some slow down HR)

NURSING CUES FOR CONGENITAL HEART DISEASE in infants

-Poor weight gain -Developmental delay -Persistent tachycardia -Tachypnea (rapid RR) -Dyspnea on exertion (tired when trying to crawl) -Cyanosis -(Congenital) Clubbing (born with clubbed nails bc they can't get that oxygen)

Medication Errors:

-Report all medication errors. -Client safety is top priority when an error occurs- you need to check and assess the client first before anything, and explain to them what happened, then document. -Documentation is required- if it wasn't documented it was not done. -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. As a nursing student, if you. make a mistake, we have to tell the clinical instructor •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. •Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors. •When an error occurs, the client's safety and well-being are the top priorities. You first assess and examine the client's condition and notify the health care provider of the incident as soon as possible. Once the client is stable, report the incident to the appropriate person in the agency. You are responsible for preparing and filing an occurrence or incident report as soon as possible after the error occurs. 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.

Systems of Medication Measurement:

-Require the ability to compute medication doses accurately and measure medications correctly •As a nurse you are responsible for checking calculations carefully before giving a medication. (all the rights of medication administration) Metric system (0 before the decimal only) -Most logically organized, most accurate -Meter, liter, gram -We typically use a Metric system in the hospital -When we are discharging clients from the hospital or from the doctor's office and we are sending them home with medication, then a lot of times we use a Household system bc they may not have med cups and things like that -Most familiar to individuals (teaspoon, Tablespoon) -Disadvantage: inaccuracy due to either overfilling or under-filling the spoon. It is our responsibility to teach them about the medication they may be going home with ** Look at the chart- there will be dose calc questions

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 needleless access device before administering the injection

Routes of Administration: Oral routes

-Sublingual administration -Buccal administration •The oral route is the easiest and the most commonly used route of medication administration. Medications are given by mouth and swallowed with fluid. Oral medications have a slower onset of action and a more prolonged effect than parenteral medications. Patients generally prefer the oral route. •Sublingual Administration. Some medications (e.g., nitroglycerin) are readily absorbed after being placed under the tongue to dissolve. Instruct patients not to swallow a medication given by the sublingual route or drink anything until the medication is completely dissolved to ensure that the medication will have the desired effect. •Buccal Administration. Administration of a medication by the buccal route involves placing the solid medication in the mouth against the mucous membranes of the cheek until it dissolves. Teach clients to alternate cheeks with each subsequent dose to avoid mucosal irritation. Warn patients not to chew or swallow the medication or to take any liquids with it. A buccal medication acts locally on the mucosa or systemically as it is swallowed in a person's saliva.

PHYSICAL EXAMINATION: CAROTID ARTERIES

-Supplies oxygenated blood to the head and neck -Inspect: •Have client lay supine or have HOB elevated at 30o •Examine each carotid artery one at a time •Have client slightly turn head away from the artery you are examining •Sometime the wave of the pulse is visible •An absent pulse wave indicates arterial occlusion or stenosis -Palpate: -NEVER occlude both carotid arteries at the same time--> 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) •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 •Have 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). Use the bell not the diaphragm to listen •Normally you do not hear any sounds during carotid auscultation •If you heard a bruit, then palpate lightly for a thrill (palpable bruit); indicates turbulent blood flow

Nursing Process: Assessment

-Through the client's eyes -History: Allergies, medications, diet history, client's perceptual or coordination problems -client's current condition -client's attitude about medication use -Factors affecting adherence to medication therapy -client's learning needs

Minimizing client Discomfort:

-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.

Vastus Lateralis:

-Used for adults and children -Use middle third of muscle for injection -Often used for infants, toddlers, and children receiving biologicals

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 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, ¼ to 5/8 inch long. Use at a 15 degree angle, with the bevel of the needle up. Do not massage afterward.

Seven Rights of Medication:

1. Right medication To make sure it is the right medication, you check it first at the MAR in the med room when pulling it out of the pyxis to verify it is the correct medication on the vial, etc. 2. Right dose To make sure it is the right dose, we check the right amount and make sure if something says 1mg, then it is 1mg 3. Right client We verify it is the right client through the 2 patient identifiers- Name and DOB. When they are in the hospital, you will verify that on the client's wrist band and as then to state name and DOB and checking against MAR 4. Right route Whether we are giving the meds IM, ID, SQ, SL, PO, IV, etc. 5. Right time We talked ab the STAT, prn, one-time, etc. orders. You have to make sure it is the right time. For routine medications, you have a 30 minute time frame (30 min before and 30 min after before the medication is considered too early or too late) If outside of that time frame, you have to document why you are giving it too early or too later. 6. Right documentation You would not document before you give a medication because they could refuse the meds, they could vomit, a wrong med could have pulled out of the drawer 7. Right indication The right indication is why is the client getting this medication. When talking to client, this is why you want to talk about what you are giving them and there are medications that could be used for several different reasons so it is important why your particular client is taking that medication. The 8th right is the right education-educate them on what you are giving them and what signs and symptoms to look for and how to call them on the call light. The way we know clients have understood something is return demonstration -The first thing you will do each and every time before you administer a medication is checking allergies, if they have allergies they should have a red arm band. It should also be listed on the patient's MAR and their chart, but you do not just go by what is listed by the chart because our best source of information is the client themselves. -You need to check the meds 3 times- so when you are pulling it out of the pyxis, check it against the MAR, and third and final check at the clients bedside (min of 3 times) -Also, it is very important that you don't pull more than 1 clients' medication at one time (some clients have so many medications, and you may have to put them in many cups You check all of this in the medication room and at the client's bedside as well.

Patho review

1. The right atrium receives deoxygenated blood from the body via the superior & inferior vena cava 2. The right ventricle receives blood from the RA and pumps it into the lungs via the pulmonary artery 3. The LA receives oxygenated blood from the lungs via the 4 pulmonary veins 4. 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.

If a nurse experiences a problem reading a physician's medication order, the most appropriate action will be to: A. call the physician to verify order. B. call the pharmacist to verify order. C. consult with other nursing staff to verify. D. withhold the medication until physician makes rounds.

A; always call the provider to verify the order. You would not call the pharmacist bc the pharmacist did not write the order. If there was an error, you probably would withhold the medication, but not until the physician makes round, but you don't know when that will be, and your patient was ordered this medication for a reason, so wee need to go ahead and solve the issue then.

Nurses are legally required to document medications that are administered to patients. The nurse is mandated to document which of the following? A. Medication before administering it. B. Medication after administering it. C. Rationale for administering it. D. Prescriber rationale for prescribing it.

B; We would only have to give rationale if we withhold their medication (ex: you have done VS an their BP is 100/80; they have an antihypertensive order and at that point you would withhold the meds bc you don't want to bottom them out, and you have to document why.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? A. Call a code B. Check the client's health status C. Call the healthcare provider D. Document the lack of complexes

B; Always check the client first before doing anything

A nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss and dry skin B. Flat neck veins and decreased urine output C. An increase in blood pressure and increased respirations D. Weakness and decreased central venous pressure

C

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the findings as described as which sound? A. Lub-dub sound B. Scratchy, leathery heart noise C. A blowing or swooshing noise D. Abrupt, high-pitched snapping noise

C

COMMON FLUID IMBALANCES CONT. Hypernatremia (water deficit, body fluids too concentrated)

CAUSES 1.Decreased sodium excretion: Kidney disease, Cushing's disease, corticosteroids, hyperaldosteronism 2.Increased sodium intake: Excessive PO sodium intake, excessive administration of sodium containing IVF 3.Decreased water intake: NPO, fasting 4.Increased water loss: diabetes insipidus, fever, infection, watery diarrhea, excessive diaphoresis, hyperventilation Physical exam cues: Decreased LOC (confusion, lethargy, coma), extreme thirst, decreased UOP, dry & mouth, flushed skin, seizure (if develops rapidly or is very severe) Laboratory cues: -Serum Na+ above 145 mEq (ave. range is 135-145) -Serum osmolality below 285 mOsm/kg (285 mmol/kg), increased urine specific gravity

COMMON FLUID IMBALANCES- Extracellular Fluid Volume Deficit Causes, Physical exam cues

CAUSES •Inadequate intake of water & salt •Increased GI output (diarrhea, vomiting, overuse of laxatives, drainage from fistulas or tubes) •Increased renal output (use of diuretics, adrenal insufficiency) •Loss of blood or plasma (hemorrhage, burns) •Massive perspiration w/o water & salt intake Physical exam cues: •Sudden weight loss (overnight), postural hypotension, tachycardia, diminished or thready peripheral pulse, poor skin turgor, dry mouth/skin, slow vein filling, flat neck veins when supine, dark yellow urine, constipation, decreased bowel sounds If severe thirst: restlessness, confusion, hypotension, oliguria (urine output below 30 mL/hr), cold, clammy skin, hypovolemic shock Laboratory cues: Increased hematocrit, increased BUN (above 20 mg/dL) urine specific gravity usually above 1.030 (unless renal cause)

Causes of Clinical Dehydration:

CAUSES •Severely decreased PO intake of water & salt •Increased GI output (diarrhea, vomiting, overuse of laxatives, drainage from fistulas or tubes) •Increased renal output (use of diuretics, adrenal insufficiency) •Loss of blood or plasma (hemorrhage, burns) •Massive sweating w/o water & salt intake •Diabetes insipidus •Osmotic diuresis •Large insensible perspiration & respiratory water output w/o increased water intake •Administration of tube feedings, hypertonic parenteral fluids, or salt tablets •Lack of access of water, deliberate water deprivation, inability to respond to thirst (e.g. immobility, aphasia) •Dysfunction of osmoreceptor-driven thirst drive

NURSING PROCESS: ASSESSMENT LABORATORY AND DIAGNOSTIC TEST CUES (these examine the heart health)

Cardiac Enzyme •Creatine Kinase (CK) (not very specific test, but enzyme levels may double if client had a heart attack) Cardiac Troponins (very specific biomarkers that enter bloodstream after a heart attack) •Troponin I (high affinity for myocardial injury; rises w/in 3 hours and lasts 7-10 days)- they do serials when you. go to the hospital, if you just had a heart attack this would probably not show up, especially if you had it in less than 3 hours ago. They redo this test after every 6-8 hours. Troponin II is where you really start to see issues and Troponin III is where it would be skyrocketed and really bad. •Troponin T Serum Electrolytes •Potassium (K+) 3.5-5.0 mEq/L •hypo= cardiac electricity instability &ventricular dysrhythmias •hyper= asystole & ventricular dysrhythmias Cholesterol (plaque buildup or narrowing of arteries) •Total cholesterol, LDL "bad", HDL "good" •Brain Natriuretic Peptide (BNP) (Heart failure)

COMMON FLUID IMBALANCES CONT. Hyponatremia Water excess; Water intoxication- body fluids too dilute)

Causes: 1. Increased sodium excretion: Excessive diaphoresis, diuretics, vomiting, diarrhea, wound drainage (especially GI), kidney disease, decreased secretion of aldosterone 2. Inadequate sodium intake: NPO, fasting, low-salt diet 3. Dilution of serum sodium: Kidney disease, Syndrome of inappropriate antidiuretic hormone (SIADH), HF, hyperglycemia CUES •Physical exam cues : Decreased LOC (confusion, lethargy, coma), increased bowel sounds, dry mucous membranes, muscle weakness, diminished DTR, shallow respirations seizure if develops rapidly or is very severe Laboratory cues: Serum Na+ level below 136 mEq/L, serum osmolality below 285 mOsm/kg (285 mmol/kg), decreased urine specific gravity

Pharmacological Concepts: Medication Names

Chemical: provides the exact description of medication's composition (N-acetyl-para-aminophenol) Generic: the manufacturer who first develops the drug assigns the name, and it is then listed in the U.S. Pharmacopeia (acetaminophen) Trade: also known as brand or proprietary name. This is the name under which a manufacturer markets the medication (Tyelonol, Panadol, Tempra). This is the kind that most people can pronounce and understand

You are caring for a client who has diabetes complicated by kidney disease. You need to make a detailed assessment when administering medications because this client may experience problems with: A. absorption. B. biotransformation. C. distribution. D. excretion.

D; Do not just look at medication, you need to look at vital signs, lab values, assessments, etc. before giving a medication

Parenteral Administration of Medications Equipment

Equipment: Syringes: -Luer-Lok (A and B): •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 (C and D): •syringes have needles that slip onto the tip. Syringes have safety devices to prevent needlestick 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 milliliter 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. A. 5-mL syringe B. 3-mL syringe C. Tuberculin syringe marked in 0.01 d. Insulin syringe marked in units

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 (this is the sternal angle) •The 2nd rib is continuous w/ the sternal angle •Slide your finger down to localize the 2nd intercostal space •The intercostal spaces are bordered by the rib (above & below)

Eye Instillation

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 medications. Intraocular instillation -Disk resembles a contact lens. -Teach patients how to insert and remove the disk. -Teach about adverse effects.

Health Care Provider's Role

Medications and. prescriptions can be written by different people. -It can be written by a physician, nurse practitioner (NP), physician assistant (PA) and can also give order for medication in the hospital as long as they have PRESCRIPTIVE AUTHORITY. -Orders can be written (hand or electronic), verbal, or given by telephone. -Most facilities are going to all electronic prescriptions to minimize errors in the hospital because people's handwriting can not be the best and medication errors mainly happen because some one will misinterpret or mistranscribe a written order. -Orders can also be verbal (you may call a healthcare provider in the middle of the night and they are not going to go all the way to the hospital and put in an order in the computer. When you get a verbal order over the phone, you the nurse, will write the order or type it into the electronic system and it will be "verbal order received and verified" meaning you have typed the order in the chart, you read it back to the health care provider bc you want to make sure that what you have written or typed in is correct, and then it is verified by the health care provider on the other end of the phone. (You always read back the order whether its medication, lab work, anything you receive from a health care provider so that you can verify it at least once to help prevent errors -Any verbal order has to be electronically signed, or hand signed within 24 hours -The use of abbreviations can cause errors; use caution. These are prohibited abbreviations (Ex:writing OD, OS, and OU- OD is right eye, OS is left eye, and OU is both eyes- you need to actually write the actual words bc it can get confused)

Mixing medications:

Mixing medications 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. •Apply these principles when mixing medications from two vials: 1. Do not contaminate one medication with another. 2. Ensure that the final dose is accurate. 3. Maintain aseptic technique.

ECG- ELECTROCARDIOGRAPH

P wave - depolarization (contraction) of atria QRS complex - depolarization (contraction) of ventricles T wave - repolarization (relaxation) of ventricles

Routes of Administration (Cont.) Parenteral routes

Parenteral routes: Four major sites of injection -Intradermal: Injection into the dermis just under the epidermis -Subcutaneous: Injection into tissues just below the dermis of the skin -Intramuscular: Injection into a muscle -Intravenous: : Injection into a vein 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

Pharmacists and Nurses role:

Pharmacist's role: -Prepares and distributes medication -The pharmacist prepares and distributes prescribed medications. Pharmacists 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 -The pharmacy interprets and delivers medication and we put in medication dispensing machine called a pyxis. -The healthcare provider has to verify the order, the pharmacist has to verify the order. -The pharmacy technician does not verify a order, their job is to deliver it to a unit and put it in an appropriate bin in a medication pyxis. Nurses role: Determining medications ordered are correct (verifying medication again- ensuring it is all the rights of medications and make sure does not contraindicate with another medication), assessing client's ability to self-administer, determining whether client should receive medications at a given time, administering medications correctly, and closely monitoring effects. -Cannot be delegated- to. unlicensed people such as techs, assistants, etc. You are responsible for your patient and giving thee client their medication. When we say it can't be delegated, the entire process can't be delegated to another nurse. But, if things come up and you have a client coding and a medical emergency, then. another nurse can give one of your patients medication if needed, but the entire process can not be delegated. (and if another nurse gave a medication, that nurse would chart it.) Also, if has to be an RN to administer blood (not even LNP bc outside of scope of practice) -Do not delegate any part of the medication administration process to nursing assistive personnel (NAP) and use the nursing process to integrate medication therapy into care. -Includes client teaching: -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. (drug they are taking, side effects, when. they should press the call light, how to use the call light) and explain the signs and symptoms of an allergic reaction) -Also, always explain what you are going to be giving to the patient in case there is a reason you can't before you actually get the meds out bc it can cost the hospital money, waste of drug, etc.

Clinical Dehydration physical exam cues and lab cues:

Physical exam cues: Decreased LOC (confusion, lethargy, coma), restlessness, thirst, seizure (if develops rapidly or is very severe)Sudden weight loss (overnight), postural hypotension, tachycardia, thready pulse, poor skin turgor, slow vein filling, flat neck veins when supine, dark yellow urine, oliguria (urine output below 30 mL/hr), cold, clammy skin, hypovolemic shock Laboratory cues: Increased hematocrit, increased BUN (above 20 mg/dL), urine specific gravity usually above 1.030 (unless renal cause), Serum Na+above 145 mEq, Serum osmolality below 285 mOsm/kg (285 mmol/kg)

Administering Medications By Inhalation

Pressurized metered-dose inhalers (pMDIs) -Need sufficient hand strength for use -May be used with a spacer Breath-actuated metered-dose inhalers (BAIs) -Release depends on strength of client's breath Dry powder inhalers (DPIs) -Activated by client's breath -Delivers more medication to lungs

Jane Doe 8/28/2014 Amoxicillin 500 mg every 6 hours for infection What is missing on these orders? John Jones 8/28/2014 Heparin 5000u SC twice a day

Route; the u needs to be written out for units. the SC needs to be written out for subcutaneous; this is not a prn but. sometimes we would need a reason for giving

Topical Medication Applications:

Skin applications -Use gloves and applicators; clean skin first. -Use sterile technique if the 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. •Topical medications are 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.

Nasal Instillation

Spray Drops Tampons •The most commonly administered form of nasal instillation is decongestant spray or drops, 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.

Types of Orders in Acute Care Agencies:

Standing or routine: Administered until the dosage is changed or another medication is prescribed, or discontinued, or changed amount- the standing order will stay on the MAR until someone writes an order to discontinue it. -Other types of standing orders: prewritten orders that are on your specific unit from your unit specific doctors ex: on orthopedics, there could be standing orders for Tylenol so that we aren't calling the surgeon in the middle of the night if a patient spikes a temperature. -There are not a lot of standing orders because there is a lot that goes into giving medications bc some people may not need Tylenol because of some other contraindication, or they are pregnant so they can't take Ibuprofen, etc. -Example of standing order: Tetracycline 500mg PO q6hrs (until someone wrote an order to stop it) prn: Given when the client requires it, as needed (when a client asks or requires it). -These orders must have the drug name, amount, time frame, and reason for giving it. Ex: Morphine 1-6mg IV q4-6 hrs prn pain Single (one-time): Given one time only for a specific reason -Ex: Adaban 1mg IV on call MRI (maybe if they are claustrophobic or get really anxious when they have an MRI done) Once it is given, it goes away and is no longer on the MAR STAT: Given immediately in an emergency, and one time (single dose) -Ex: Presseline 10 mg IV STAT -It has name of drug, dose, route, and time Now: When a medication is needed right away, but not STAT. -It is more specific than a single one-time, bc a patient may get bumped to not go into MRI until the next day, so it will stay in the MAR, but a Now order, when it gets put in the system, it needs to be given right away (within 90 min) It is not as emergent as the STAT Ex: Vancomycin 1g IV piggyback Now Prescriptions: Medication to be taken outside of the hospital -We usually discharge clients with prescriptions. These are the ones that will either get filled now and before they leave the hospital, or after discharge they can go to their local pharmacy and done that way. -We don't do a lot of faxing of written prescriptions because they can get lost, people can use them, etc. so things will either get things electronically sent over, or it has to be the physical copy of the prescription. -Narcotics can not be called in, you have to come in and get a physical prescription. ex: if you have had surgery and you are in a lot of pain and taken all the narcotics they have already given you, you can't just call the doctor to call them in some more. (bc of drug seekers and abuse) so you have to go back into the office, get reevaluated and they will give you another prescription.

Types of Medication Actions:

Therapeutic effect: Expected or predicted physiological response (ex: if someone has a fever and you are trying to bring the fever down, you would give them Tylenol because the expected response is to decrease the fever. However, every single medication that you find on the market has an adverse effect because when they are in clinical trials before they are approved for use, even if one person says they had a reaction of some sort, they have to put it as a potential side effects. Adverse effect: Unintended, undesirable, often unpredictable, not expected -Side effect: Predictable, unavoidable secondary effect -Toxic effect: Accumulation of medication in the bloodstream (any medication can become toxic if enough of it builds up in the patient's blood stream. Ex. If someone liver and kidney is not working well, it can make a medication build up and that is why we need to look at values because we give a medication bc it could give a toxic effect Ex: if morphine builds up in blood stream, it could cause respiratory depression and make a patient stop breathing) •Antidotes are available to treat specific types of medication toxicity. -Idiosyncratic reaction: Overreaction or under reaction or different reaction from normal (opposite of what you expect that medication to do- Ex. Benadryl normally makes you very sleepy, but if it makes you really hyper, this is an example of an idiosyncratic effect because it is the opposite of what it was intended to do. -Allergic Reactions: unpredictable response to a medication. (YOU ALWAYS NEED TO CHECK ALLERGIES BEFORE GIVING A MEDICATION TO A PATIENT). They need to be specific and tell you exactly what they are allergic to, and the type of reaction they get from it. -Typically, an allergic reaction will not happen. until the 2nd time that person is exposed to the medication (not to say it. won't happen the first time, but most of the time it happens on the 2nd exposure- which is why it is important to ask if they have had the medication before or if they have only taken it once, and in that case you should monitor them very closely -Allergies will vary in degree. Your severe allergy will by your anaphylaxis reaction where your throat and airway start to close up, which is a medical emergency. A mild allergic reaction is where the client develops hives or itching, welps. (Just diarrhea and N/V is not an allergic reaction) -It is very important for your client to keep an up-to-date list of the medications they take •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 if a client is unable to communicate when receiving medical care. (red arm band) Medication interactions: when one medication modifies the action of another they 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.

Timing of Medication Dose Responses:

Therapeutic range: Is when the medication reaches that constant level in the blood stream (this is why it is very important for use to educate our patients to take their medication at the same time everyday bc if those times get off, that is when that therapeutic range or level gets off. Take the medication the way it is supposed to be taken, and take all of the medication prescribed Peak: the highest level of concentration before they go down the slope and have the Trough: which is the lowest amount of medication in their system (Trough level is drawn 30 minutes before administration of that antibiotic because we want to see how it is maintaining in their system and how much is left when it is supposed to be at its lowest level- because if there is too much, then they need to adjust the dosage of the medication and if there is none at all, then they would need to bump it up a little so that it lasts a little bit longer in their system. -When you are giving medications, there is a 30 minute window on MOST medications (Ex: if you have 6 patients in the hospital, you have to give all 6 patients their medication and all due at 9:00, we can start giving medication 30 minutes before it is scheduled, up to 30 minutes after it is scheduled for it to not be considered too early or too late, and in that case you would need to document why you gave it early or late.(8:30-9:30)

COMMON FLUID IMBALANCES CONT.Extracellular Fluid Volume Excess (AKA fluid overload) Causes, Physical exam cues

This is what you commonly see if congestive heart failure, its having too much fluid and your body can't get rid of it CAUSES •Fluid intake or fluid retention that exceeds the fluid needs of the body •Renal retention of Na+ & water: heart failure, cirrhosis, aldosterone or glucocorticoid excess, acute or chronic oliguric renal disease Physical exam cues: Sudden weight gain (>2 lbs overnight), edema (especially in dependent areas), full neck veins when upright or semi-upright, crackles in lungs, bounding pulse, elevated BP, distended H& N, neck veins, increased respiratory rate dyspnea, ascites (collection of fluid in the belly) If severe: confusion, pulmonary edema Laboratory cues: decreased hematocrit, decreased BUN (below 10 mg/dL), hyponatremia, decreased serum osmolyte's

Syringes:

Three most common types of syringes: -Hypodermic syringe: 2, 2.5, and 3 ml sizes (marked in .1 of milliliters) Insulin syringe: -U-100 (100 units) -U-50 (50 units) Tuberculin syringe: -Marked in tenths and hundredths (.01) of cubic millimeters up to 1cc -Good to use for pediatric doses

Routes of Administration (Cont.)

Topical administration -Skin -Mucous membranes Inhalation route Intraocular route

4 HEARTVALVES

•2 Atrioventricular (AV) •Tricuspid (Right) •Mitral (Left) •Open during diastole •Closed during systole •2 Semilunar (SL) •Pulmonic (Right) •Aortic (Left) •Closed during diastole •Open during systole -Valves are unidirectional- if you have backflow of blood from valves, that is an issue

Angle of SQ:

•A client's body weight indicates the depth of the subcutaneous 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 subcutaneous tissue. Nurses typically 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 subcutaneous 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 do not have sufficient tissue for subcutaneous injections; the upper abdomen is usually the best site in this case. To ensure that a subcutaneous medication reaches the subcutaneous tissue, follow this rule: If you can grasp 2 inches (5 cm) of tissue, insert the needle at a 90-degree angle; if you can grasp 2.5 cm (1 inch) of tissue, insert the needle at a 45-degree angle.

Deltoid

•Although the deltoid site is easily accessible, this muscle is not well developed in many adults. 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 •Use this site for small medication volumes (2 mL or less). •Carefully assess the condition of the deltoid muscle, consult medication references for suitability of the medication, and carefully locate the injection site using anatomical landmarks. •Use this site only for small medication volumes, when giving immunizations, or when other sites are inaccessible because of dressings or casts. •To locate the muscle, fully expose the client's upper arm and shoulder. •Do not roll up a tight-fitting sleeve. Have the client relax the arm at the side and flex the elbow. •The client may sit, stand, or lie down. •Palpate the lower edge of the acromion process, which forms the base of a triangle in line with the midpoint of the lateral aspect of the upper arm. •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.

PHYSICAL EXAMINATION: AUSCULTATION- etc.

•Aortic: Right 2nd ICS- S2 is louder than S1 •Pulmonic: Left 2nd ICS S2 is louder than S1 •Erb's point: Left 3rd ICS S1 and S2 are heard equally •Tricuspid: Left 4th/5th ICS S1 is louder than S2 •Mitral (Apex): Left 5th ICS at the midclavicular line- S1 is louder than S2 "Extra" heart sounds •S3 : heard normally in children & young adults, pregnant women, and athletes; in older people- CHF ("Kentucky) •S4 : Clients w/ stiff L ventricles (HTN, aortic stenosis, cardiomyopathy) ("Tennessee") •Note rate & rhythm (regular or irregular?) •Pulse deficit •Identify S1 and S2 •S1 is louder at the apex •S1 coincides with carotid artery pulse •S1 coincides w/ R wave on ECG •S2 is louder than S1 at the base •Listen to S1 & S2 separately •Listen for murmurs & extra heart sounds (sounds like a swoosh- a lot of people don't even know they have a murmur)

PEDIATRIC ASSESSMENT

•Apical pulse -May be visible on inspection -Until 4 years of age- 4th ICS lateral to MCL -4-6 years of age-at MCL 4th ICS. -7 years of age and older-5th ICS at or medial to MCL (adult position) •Heart rate slows as child grows older •Innocent murmurs and physiologic S3 common in children •Signs of congenital heart disease (poor weight gain, developmental delay, etc.)

PUMPING ABILITY

•Cardiac Output - amount of blood ejected from LV in 1 min •Stroke volume x Heart rate •Stroke volume - amount of blood (in mL) ejected with each systole (contraction)•Rate - number of beats per min •Normal adult = 4-6L/min Preload -Length that ventricular muscle is stretched at end of diastole just before contraction -Venous return that builds during diastole -Also referred to as the end-diastolic volume Afterload -Opposing pressure ventricle generates to open aortic valve against higher aortic pressure -Resistance against which ventricle must pump

HEART SOUNDS: MURMURS

•Caused by turbulent blood flow •Classified according to timing (systole - between S1 and S2; or diastole - between S2 and S1) •Gentle, blowing, swooshing sound •As the nurse, note where they are heard best and their location and if new, alert MD •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 (for babies)

ELECTROLYTE IMBALANCES- CUES

•Causes of electrolyte imbalances: •Diarrhea •Endocrine disorders •Medications that disrupt the electrolyte homeostasis

HEART SOUNDS- NORMAL

•Heard over chest wall through stethoscope •S1 - AV (tricuspid & mitral) valves close •Start of systole •Heard loudest at apex •S2 - SL (pulmonic & aortic) valves close •Signal end of systole, beginning of diastole •Heard loudest at base •Split S2 -S1 and S2 are heard equal at Erbs point

Anatomy Review

•Heart wall •Epicardium (outer) •Myocardium (middle) •Endocardium (inner) •Chambers •Atrium(Upper) •RA •LA• Ventricle (Lower) •RV •LV

NURSING CUES OF IMPAIRED CV ASSESSMENT AND ANALYSIS IN OLDER ADULTS

•Increased Systolic BP due to stiffening and calcification of arterial walls •LV wall thickens •May experience orthostatic hypotension •Dysrhythmias more common •ECG changes •Increased AP diameter due to osteoporosis, COPD, etc. (hard to hear sounds) •S4 is more common in elderly bc it is the sound that indicates hardening or stiffening of ventricles due to plaque buildup over time -Decreased compliance of LV (not as able to stretch)

INFANT ASSESSMENT

•Lungs non-functional until birth (surfactant is not created until 24-28 weeks) •Foramen ovale and patent ductus arterious close by 24-48 hours •Position -Heart is more horizontal in infant than adult, with higher apex (4th ICS, lateral to MCL) -Reaches adult position around age 7 •Auscultate resting heart rate -100-190 bpm in newborns -120-160 bpm in infants •Murmurs - common in first 2-3 days

EXTRA HEART SOUNDS

•Normally diastole is a silent event, but sometimes... •Ventricles are resistant to filling in some way •S3 - beginning of diastole•AV valve opens & atrial blood passively first pours into ventricles •Occurs immediately after S2 (S2/S3 /S1) •Signifies developing heart failure in adults; normal in children/young adults, pregnant women, and athletes •S4 - end of diastole •Atria contract and actively push blood into noncompliant ventricle •Occurs just before S1 --> (S4/S1 /S2) •Signifies ischemia, myocardial infarction, or stiff ventricles

NORMAL SINUS RHYTHM (NSR)•Normal sinus rhythm (NSR)

•Originates at the SA node, follows normal sequence through conduction system •PR interval •QRS complex •QT interval -The P wave represents depolarization of the atria in response to signaling from the SA node (i.e. atrial contraction) -The QRS complex represents depolarization of the ventricles (i.e. ventricular contraction), trigged by signals from the AV node -The T wave represents repolarization of the ventricles (i.e. ventricular relaxation) and the completion of a standard heartbeat -Between these periods of electrical activity are intervals allowing for blood flow (PR interval and ST segment)

Peripheral Info

•Peripheral pulses •Fluid Imbalances •Electrolytes Imbalances •Acid-Base Imbalances •Intravenous fluid (IVF) •Flow rates •Drug calculations •Complications of IVF

POSITION & SURFACE LANDMARKS

•Precordium (what completely protects the heart) •Adult: anterior chest wall over the heart; on left side •Infant: more horizontally; apex is 3rd or 4th intercostal space just left of the midclavicular line, PMI is a little moved over •Apical Impulse (or pulse of maximal impulse [PMI]) •Located in the 4th-5th intercostal space just medial to the L midclavicular (clavicle, halfway down) line •About 1-2 cm in diameter •By age 7 a child's PMI is in the same location as the adults •Great Vessels •Superior & Inferior Vena Cava•Pulmonary Artery•Pulmonary Veins•Aorta

CV ASSESSMENT

•Preparation •Position (start w/ the client supine or w/ upper body elevated at 45 degree angle) •May need to place a drape for females per request- modesty •Room should be private, quiet, warm & well lit •Equipment •Stethoscope with diaphragm and bell •Small centimeter ruler (If checking JVD) •Straight edge (If checking JVD) -No matter what a client comes in for, you must do a cardiac and respiratory assessment

PERIPHERAL PULSES

•Pulse is the palpable bounding of blood flow in a peripheral artery •The pulse is an indirect indicator of the circulatory status •Abnormally slow, rapid, or irregular pulse alters cardiac output •Assessment •Usually use the radial artery (b/c it's easy to palpate) •The brachial and/or apical pulse is best to palpate in infants and young children (for an infant, it is easier if you check their apical pulse) •Character of the pulse •Rate, rhythm, strength, equality •Acceptable ranges of HR: -Infant: 120-160 bpm -Toddler: 90-140 bpm -Preschooler: 80-110 bpm -School-Aged: 75-100 -Adolescent: 60-100 bpm -Adults: 60-100 bpm

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.

CARDIAC CYCLE

•Rhythmic movement of blood through the heart •2 phases •Diastole = 2/3 cardiac cycle •Systole = 1/3 cardiac cycle •Blood flows from an area of high pressure to an area of low pressure, unless flow is blocked by a valve .•Atrial systole occurs during ventricular diastole!

Parenteral Administration of Medications (Cont.) -Needles -Hub -Shaft -Bevel

•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 tissue into which the medication is to be injected. Hypodermic needles (left to right): 18 gauge, 1 1/2-inch length; 21 gauge, 1 1/2-inch length; 22 gauge, 1 1/2-inch length; 23 gauge, 1-inch length; and 25 gauge, 5/8 -inch length.

PHYSICAL EXAMINATION: INSPECTION& PALPATION

•Start by easing client anxiety by explaining what you're doing •Stand at the R side of the client •Look for visible pulsations and exaggerated lifts; palpate for the apical impulse & 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 •5th intercostal space, midclavicular line- Mitral

Cardiac Conduction

•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•Purkinje fibers = 20-40 -Orderly sequence•SA node --> AV node --> Bundle of His --> R and L bundle branches--> Purkinje fibers

Distribution system or center of Med Admin:

•The most common medication administration systems include unit dose and automated medication dispensing systems (AMDSs). •Health care agencies have a special area for stocking and dispensing medications. Medication storage areas need to be locked when unattended. -Also, check the expiration date Unit dose systems: -pyxis -On the screen is the clients MAR. -is 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 Automatic medication dispensing system [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 list 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. -You do not want to interrupt a nurse when she is getting a medication out of the pyxis. -You do not have to have a nurse verify every medication, but you do have to have a 2nd registered nurse verify (they have to input their credentials into the pyxis or it won't even let them get the med out) insulin bc it is a high risk; OR a 2nd nurse if you have wasted a narcotic. -Ex: Morphine is a prn order and they can have 1-6 mg IV. It is typically in a multidose vial that you pull out of the pyxis, but it is your discretion to give them 1,2,3,4,5, or 6 mg. How are you going to determine how much pain medicine to give someone? Indications are high HR, BP, RR, diaphoretic. You also can look at behavioral responses including grimacing, gaurding the area, if they seem like they are in a lot of pain, you may want to give them the higher side of doses. But, pain is subjective and it is what the client says it it, if a client is chilling and they say their pain is a 10, we have to give them the upper range of dose. -You can always give less than the prescribed but can never give more of the prescribed dose. Ex: if vial is 6mg/1ml and wee only want to give 3mg, simple dose calc, we will give 1/2 mL. With the remaining half of the narcotic, we will waste it but we have to have witnessed 2nd RN with us to witness and put in their credentials due to people looking for drugs.

Pic of medication

•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. •[Shown is Figure 31.17: A, Injecting air into vial A. B, Injecting air into vial B and withdrawing dose. C, Withdrawing medication from vial A; medications are now mixed.]

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.

ANATOMY REVIEW

•Vascular structures in the neck •Carotid artery •Jugular veins -Internal & External •Reflect efficiency of cardiac function