NUR 231 Week 6 Notes
NUR 231 Week 6 Notes NUR 231
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This 37 page Class Notes was uploaded by Issy Notetaker on Saturday October 3, 2015. The Class Notes belongs to NUR 231 at Ball State University taught by Marsann Shafer, Jane Edwards, Kathryn Humphrey in Summer 2015. Since its upload, it has received 16 views. For similar materials see Fundamental nursing skills in Nursing and Health Sciences at Ball State University.
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Date Created: 10/03/15
Fundamentals Book Notes Objectives Clinical Lecture Chapter 17 0 Diagnosis is a clinical judgement based on the information that was gathered during assessment 0 O O 0 Information includes cues and patterns Subjective and Objective data Conclusions include problems treated by nurses and other disciplines Wide range of conditions that nurses treat Medical diagnosis identi cation of disease conditions based on evaluation of physiological and medical assessments From physician Ex CVA Nursing Diagnosis clinical judgement about individual Family or community responses to actual and potential health problemslife processes that the nurse is licensed and competent to treat Pt is involved in determining what is wrong and what should be done to help Ex Impaired swallowing Keep pt involved Collaborative problem is a complication that nurses monitor to detect a change in pt status Ex Work w other disciplines speech therapy Nurses manage collaborative problems intervene in collaboration Use assessment data as the basis of the diagnosis Accurate diagnosis of the problem ensures more effective and ef cient intervention Improves timing 0 History of Nursing Diagnosis 0 O O O Introduced in 1950 Fry in 1953 proposed nursing diagnosis and individualized care plans Made nursing practice more independent Independence of nursing diagnosis wasn t originally supported 1973 nursing diagnosis was identi ed and designed Included 80 diagnosis listed in North American Nursing Diagnosis Association International NANDA Nurses make diagnostic conclusions and clinical decisions for safe practice Treatment of human responses to illness Research in the eld grows and new diagnosis are continuously added NANDA purposes Precise de nition of the problem Allows for communication Distinguishes the nurses role Focus on scope of practice Develops nursing knowledge Promotes creation of practice guidelines 0 Critical Thinking and the Nursing Diagnostic Process O O 0 Diagnostic process requires critical thinking Know nursing diagnosis de nitions de ning characteristics related factors and interventions Involves assessment of information gathered to explain the clinical judgement made If there is inconsistent or unclear information Critical thinking guides and directs lines of questionings and examination to reveal detailed and relevant database All data validate w other data Questions need to asked in order to go more in depth about the issue Data Clustering Set of 55 gathered during assessment that are grouped in a logical way Clusters contain de ning characteristics Criteria are observable and veri able O or S 55 or risk factor that leads to a diagnosis Identify the pt needs Formulate a diagnosis and collaborative problems Each approved diagnosis has a set of de ning characteristics to support the diagnosis Each pt requires individualized approach Data Cluster A set of 55 gathered during assessment that was grouped together in a logical way Interpretation Identifying Problems Allows for selection of diagnosis Critical to select the right one General to speci c is the movement pattern from assessment to diagnosis De ning characteristics can be applied to more than one diagnosis 0 De ning characteristics are the observable and veri able Gather more characteristics to narrow down diagnosis 0 An absence of a characteristic rejects a diagnosis 0 Examine diagnosis carefully review all characteristics eliminate irrelevant ones con rms relevant ones 0 Formulating Diagnosis Related Factor condition factor etiology giving context for a characteristic showing a relationship to the diagnosis Allows for individualized diagnosis Placing a characteristic in contest allows for better understanding of diagnosis Compare the pattern of data w normal and healthy data Use lab values standards normal physiological and anatomical limits Determine if 55 that are grouped are normally grouped together Nurse is responsible for interventions that are created from the nursing diagnosis 0 Nurse is accountable for outcomes Focuses on actual or potential health problem Nursing Diagnostic Statements 0 Provides a precise de nition of pt problem that gives a nurse and other members of HC team a common language for understanding pt needs Allows nurses to communicate among themselves and others Distinguishes role of nurse 0 Help nurses focus on the scope of nursing practice 0 Types of Diagnosis Actual Nursing Diagnosis Human responses to health conditions or life processes that exist in individual family or community 0 Selection of a diagnosis indicates suf cient assessment data for the establishment of a diagnosis Risk Nursing Diagnosis Response that may develop in a vulnerable individual family or community 0 Don39t have related factors or characteristics 0 Not yet occurred 0 Risk factors are environmental physiological psychological genetic chemical elements placing a person at risk Health Promotion Nursing Diagnosis Clinical judgement motivation desire readiness to increase WB to actualize health potential as expressed in readiness to enhance speci c health behaviors Don39t require current levels of wellness and are applied in any level of health 0 Components of a Nursing Diagnosis Use the language that the agency uses Two part formula 0 Diagnosis 0 Relevance Diagnostic Label 0 Name of nursing diagnosis from NANDA list Describes pt response to health conditions 0 De nition comes along w diagnosis 0 Assist in identifying correct diagnosis 0 Include descriptors o Impaired compromised decreased Related Factors 0 Reason for display of diagnosis 0 Can change as the pt response to the health problem changes 0 Four categories 0 Pathophysiological 0 Treatment Related 0 Situational o Maturational Indicates etiology contribute to or is associated w diagnosis 0 Etiology Related factor win domain of nursing practice and a condition responding to interventions Nursing interventions don39t change medical diagnosis 0 Direct interventions toward behaviors and conditions you are able to treat 0 The diagnostic process results in the formation of a total diagnostic label allowing the development of appropriate pt centered care plan PES Format 0 Three part nursing diagnostic label 0 NANDA label Related factor De ning characteristics Problem Etiology o Symptomsde ning characteristics 0000 0 Cultural Relevance in Nursing Diagnosis Consider culture diversity Cultural differences affect pt de nition of health and illness Provide sensitive health care Consider how culture will in uence the related factors and health care Study how different cultures will express pain Awareness and sensitivity to a pts culture will improve accuracy in determining clinical diagnosis Concept Mapping Nursing Diagnosis OOOO Holistic view Sows all needs and problems lnterconnections bw sets of data For each diagnosis list de ning characteristics and make connections bw items 00 Organizes and links information Allows for visualization of whole pt and appreciate the pt care 0 Central focus is on the pt Promotes pt involvement and concentration on pt speci c health problems and diagnosis Sources of Diagnostic Errors O O Occur during collection interpretation clustering and labeling Errors in Interpretation and Analysis of Data Review database for accuracy and completeness Validate measureable objective ndings and subjective ndings Inability to validate signals an inaccurate match bw cue and diagnosis Errors in Data Clustering Occur in premature incorrect or absence of clustering data occur Nursing diagnosis is ALWAYS identi ed from the data Errors in Diagnostic Statement More competent more likely to choose correct diagnosis Select appropriate concise and precise language form NANDA Be sure it is win scope of nursing practice to treat Guidelines 0 Identify pt response not medical diagnosis 0 Identify NANDA Diagnostic statement Rather than a symptom Identify treatable etiology or risk factor rather than a clinical sign or chronic problem 0 Identify the problem caused by the treatment or diagnostic study rather than treatment or study itself 0 Identify pt response to equipment rather tan equipment itself 0 Identify pt problems rather tan own problems w nursing care Identify pt problem rather than nursing intervention Identify pt problem rather than goal of care Make professional rather than prejudicial judgements Avoid legally inadvisable statements Identify problem w etiology to avoid circular statement 0 Identify only one pt problem in diagnostic statement Documentation and Informatics Enter diagnosis into written plan of care and electronic health information record List diagnosis chronologically Highest priority diagnosis is rst in initiating original care plan Date diagnosis at time of entry Review list and identify highest priority 0 Nursing Diagnosis Application to Care Planning 0 0 Diagnosis is mechanism for identi cation of the domain of nursing and proper selection of nursing interventions and to direct planning Helps achieve outcomes Care plan is a map for nursing care that demonstrates accountability for pt care Chapter 31 0 Medication is used in diagnosis treatment cure relief and prevention 0 Every HC facility plays a role in the safe administration of medication and the evaluation of the effects 0 Nurses are responsible in all settings for the evaluation of the effects teaching about medications and effects adherence to dosage schedule and evaluating ability to selfadminister Scienti c Knowledge Base 0 To administer drugs safely nurse must have an understanding of the legal aspects of HC Pharmacology pharmacokinetics life sciences pathophysiology anatomy and math Allows use to why we are giving it what it will do to the body therefore we know it was the right decisions to administer 0 Medication in Legislation and Standards Federal Regulates pharmaceutical industry to protect people Ensures medications are safe and effective 1St law was Pure Food and Drug Act Sets standards for safety potency and ef cacy FDA enforces laws 0 Ensures all medications have gone under rigorous testing To be in pure and controlled form for pt Re nes and controls distribution testing naming and labeling regulation of controlled substances USP set standards for strength purity quality packaging safety labeling dose form Medwatch was implemented to encourage HC staff to report when a medication is improperly labeled o If a medication I found to have an adverse effect physician lls out a form and turns it in Medication then goes under more testing State and Local must conform to federal Additional controls control of substances that are not regulated by federal 0 Alcohol and tobacco Health Care Institutions and Medication Laws 0 Meet federal state and local 0 Size of agency determines services provided 0 More restrictive than governmental Medication Regulations and Nursing Practice 0 Nurse Practice Acts have large in uence over nursing 0 Protect pt from nurses 0 De ne scope of practice 0 Broad 0 HC agencies are not able to modify expand or restrict to intent of the act 0 Main purpose is to protect people from those uanensed Controlled Substance Acts are to be followed strictly o If not followed nes imprisonment or loss of license can occur 0 PharmacologicalConcepts Medication Names 0 Chemical Name exact description of composition and molecular structure 0 Generic Name Given by manufacturer 0 Becomes official name listed in US pharmacopeia 0 Ex Acetaminophen Trade namebrand name name medication is marketed under 0 Ex Tylenol Be sure to obtain exact spelling of medications Classi cation 0 Indicates effect of medication on the body symptoms relieved desired effects 0 More than one medication can be in a classi cation 0 One medication can be in more than one classi cation 0 A medication can have more than one desired effect Medication Forms 0 Form determines route of administration 0 Composition of medication determines absorption and metabolism 0 Tablets Capsules elixirs suppositories 0 Solid liquid oral topical parenteral instillation o Pharmacokinetics as the basis of Medication Actions Study of how medications enter the body are absorbed reach action site alter function metabolize and then leave the body Used when timing administration selecting route considering risks for alterations to actions evaluating pt response Absorption Passage of molecules into the blood from site of administration and has many in uencing factors 0 Route of Administration 0 Each routedifferent absorption rate Skin Slow Mucus membranes and Respiratory system Fast Oral Slow IV most rapid Ability of medication to dissolve o Depends on preparation form 0 Body absorbs solutions and suspensions in liquid state faster than tablets and capsules 0 Acidic will pass through mucosa quickly Blood Flow to Administration Site 0 Richer suppyquicker absorption Body SA 0 LargerQuicker absorption 0 Reason why more are absorbed in small intestine instead of stomach Lipid Solubility o Lipid soluble cross cell membranes easily and absorb quickly 0 Some are absorbed quickly when food is in stomach Food changes medication structure 0 Also why sometimes food should not be taken w medication Time administration to have meds before during or after feeding 0 Some medications interfere w each other Make sure they are not given at the same time 0 Know medication medication or medicationfood interactions before administering the medication Distribution Moved to site of action Rate and extent are dependent upon factors Physical and chemical properties of the medication and physiology of person taking medication Circulation 0 Medication enter blood and are passed through system 0 More circulation to sitequicker effect 0 Impaired circulationslows distribution Membrane Permeability 0 Ability of medications to pass through tissues and membranes 0 Some membranes are barriers BBB or placental membrane Protein Binding 0 Degree to which medications bind to serum proteins 0 Protein levels will affect binding ability Older have less albumin Metabolism After reaching site of action it is metabolized into a lessinactive form to excretion Biotransformation Enzymes detoxify breakdown remove biologically active chemicals 0 Occurs in liver lungs kidneys blood intestines Liver oxidizes and transforms toxic substances 0 O Excretion Degrades harmful chemicals Function decreases with age or liver disease Decrease in rate of metabolism and excretion Increased risk for toxicity 0 Exit body from kidneys liver bowel lungs exocrine glands Chemical makeup of medication determines exit route 0 O O Lungs Gaseous and Volatile Exocrine Lipid soluble Good hygiene is needed GI Medication that enter hepatic circulation and are excreted into bile Kidneys Main route Renal function decrease increase in risk for toxicity 0 Types of Medication Action Va ry Every pt will respond differently Don39t always respond in same way to repeated doses Therapeutic Effects Expected or predicted effect Desired effect Some medications have multiple Know this in order to provide pt education and evaluate accurately Side EffectsAdverse Effects 0 Side Predicable and unavoidable secondary effects 0 O O Harmless or can cause injury If more serious than therapeutic effect drug will be stopped Major cause of pt stopping medication use Adverse Unintended and undesirable unpredictable severe responses 0 O O 0 If these occur a Medwatch form is led Immediate or delayed Recognize early for discontinuation of medication HCP must report to FDA Toxic Effects 0 0 Develop after prolonged intake or when there is an accumulation in the blood Can have lethal effects 0 Some antidotes are available Idiosyncratic Reactions unpredictable overunder reaction or has a different reaction to the medication that is not normal Allergic Reactions Unpredictable immunoglobulin reactions 0 Common w antibiotics 0 1st dose causes sensitization and every dose after elicits and antibody attacking response 0 Medication allergy symptom may vary 0 Can be life threatening o If known history of allergies it should be documented and pt should wear a bracelet 0 Medication Interactions When one medication modi es the action of another medication Common Can increase or diminish effects Synergistic When the effect of the medications together is greater than the effect of the medications alone Can be desired when the effect is bene cial 0 Timing of Medication Dose Responses lV administration act immediately Other routes take time for effect to begin Quantity and distribution are constantly changing MEC minimum effective concentration is plasma level concentration that is too low to give off an effect Toxic Concentration level of concentration when toxicity occurs Therapeutic Range Between MEC and toxic Highest level is the peak and lowest is the trough concentration 0 Peak Time when medication reaches highest effective concentration 0 Trough Minimum blood serum concentration level before the next dose 0 Onset Time taken for medication to create a response 0 Time is takes for medication to produce greatest result 0 Plateau Where blood serum concentration is maintained 0 IV infusion peaks are reached quickly and levels fall quickly Trough levels are drawn 30 minutes before administering the next dose and peak 30 minutes after Biological 12 life time taken for a the concentration to be lowered to 12 by the excretion process 0 Half every interval until is it completely excreted To maintain a therapeutic plateau then the drug must be administered at regular intervals around the clock 0 One dose is given and then another when the rst reaches 12 life Some facilities have drug schedules that can be altered by the nurse and their knowledge about the medication A hospital needs to identify 0 Time critical medications Must be given w 30 minutes before or after schedule 0 Non time critical medications must be give 60120 minutes before or after schedule 0 Teach pt about time schedules in words that they are able to understand 0 Routes of Administration Depends on properties and desired effect of medications and pt mental and physical condition Oral routes Easiest and most commonly used 0 Given by mouth and swallowed w food generally more preferred Slower onset prolonged effect Sublingual Administration Placed under tongue and dissolved not swallowed 0 Don t eat or drink anything until drug is completely dissolved Buccal Administration Place medication in mucus membrane of the cheek until it dissolves 0 Alternate cheeks with each dose 0 Don t chew swallow or drink w tablet Parenteral Routes Injection of medication into tissues 0 Four sites 0 Intradermal into dermis o Subcutaneous into subcutaneous tissue 0 Intramuscular Into mm o Intravenous Into vein 0 The other ways listed are not normally done by a nurse but they are responsible for monitoring the medication delivery system understanding the medication given and evaluation of the pt response Epidural into epidural space through a catheter 0 Regional analgesia 0 Nurses w advanced education can place and administer medication via epidural IntrathecaI Catheter placed in subarachnoid space or in a ventricle in the brain 0 Medication is delivered by Physicians and specially educated nurses 0 Usually long term medication lntraosseous lnfusing medication into the bone marrow o Commonly used in children lntraperitoneal Administered into peritoneal cavity to be absorbed o Chemotherapeutic agents insulin antibiotics lntrapleural administered in pleural space 0 Chemotherapeutic agents 0 Medications to relieve pleural effusion promoting adhesion lntraarterial Medication into arteries 0 Common w arterial clots lntracardiac into the heart and lntraarticular into joint are also used TopicalAdministration Direct or in the body cavity Applied to skin and mucus membranes Local effects Apply by 0 Spreading over area 0 Applying moist dressings o Soaking body parts 0 Giving medical baths Thins or breaks down skins Transdermal disks or patches have more systemic effects 0 Fixed to skin and left in place for 12 hours to 7 days Mucus membrane administration 0 Liquid or ointment direct application Inserting medication into body cavity lnstilling medication into a body cavity lrrigating body cavity Spraying medication onto body cavity OOOO Inhalation Through nasal and oral passages Endotracheal or tracheostomy tubes are also used if inserted Absorbed quickly into the rich vascularized lungs Local or systemic effects lntraocular Inserting medication into eye on a contact like lens Can remain for up to a week 0 Systems of Medication Measurement Proper administration depends on ability to correctly calculate and measure dosages Errors can be fatal 0 Nursing Knowledge 0 O 0 Clinical calculations must be held wout error Most facilities use the metric system Apothecary system is hardly used Metric System Most logically set up Decimal system Easily convertible Basic units 0 Length Meters m 0 Weight Grams g 0 Volume Liters L Convert fractions to decimals Leading zero is always placed in front of a decimal but there is NO trailing zero Household Measurements Most familiar to people Inaccurate Usually used for dischrage Items used in measurement often vary in size Scales are not well calibrated Include o Drops teaspoons Tablespoons cups pints quarts Convenient when accuracy is not critical Solutions Various concentrations Used for o Injections irrigations and infusions A given mass of a solid substance that is dissolved in a speci c volume of liquid Concentration when dissolved is known as gL or mgmL ect or as a percentage 98000 people die a year form medical errors 35 billion dollars in costs annually Some medications heparin require more than one nurse to verify correct calculation Veri cation on calculations from a another nurse is critical Clinical Calculations Need to understand basic mathematics skills To calculate doses mix solutions perform other activities Conversions Within One System Simple dividing or multiplying Conversion Between Systems Equivalent tables are used Compare order w medication system used Dosage Calculations 0 Before using a system make a reasonable estimate in your head and then calculate Recheck calculation before administering Have another nurse check to calculation also 0 Always do this when you are unsure or calculations seem unreasonable Ratio Proportion Method 0 O 0 Relationship between two numbers shown by First and last numbers are called extremes and secondthird are means Always label the answer Steps Estimate the Answer Set up the Proportion Cross Multiply the Means and Extremes Divide both sides by the number before Compare to estimate 0 Formula Method 0 0 First memorize the formula dose ordereddose on handX Amount on hand Amount to Administer Amount to Administer will be the same unit as the amount on hand Estimate the answer Label all parts Step Estimate Answer Set up Formula Calculate Answer Compare to Estimate 0 Dimensional Analysis 0 Factorlabel or unit factor method 0 More accurate 0 Steps Identify unit of measure needed to administer Estimate answer Place appropriate abbreviation for x on the left Place available information from problem in fraction format 0 Place so canceling units is an option Cancelun s Reduce to lowest terms Solve for x and label answer Compare to estimate Pediatric Doses 0 Children are at 3x higher risk for having a medication errors 0 Common reasons 0 O O O O O Confusion in formulations Availability of pediatric concentrations Inaccurate prep of medication that need to be diluted Similar packaging and medication names Unknowledgeable parents Errors in cacuation an use of inaccurate measuring devices Calculations require caution bc small errors can create big problems 0 Child weight height and maturity of body systems affect metabolism and excretion Dif cult to evaluation nonverbal or verbal children 0 Guidelines 0 O 0 Make sure pt weight is in kg Convert to kg before calculating medication dose Doses are much smaller mcg rather than mg or g Use smaller syringes IM doses don39t exceed 1mL for a child or 5 ml for an infant UsuaHy Subcutaneous usually don39t exceed 5 mL Medications aren39t round off to nearest tenth Less than 1 mL measure in syringe with 110 markings Tuberculin is used when 11000 doses are needed Estimate does before beginning Compare and Evaluate amount ordered over 24 hour to dose about to give 0 Common method of calculation is based on weight 0 o Prescriber s Role BSA is used rarely Can be physician NP or PA Written or verbal or telephone order 0 Telephone requires a read back and verify Abbreviations are often used to indicate Dosage Frequency Routes 0 Special instructions Medication errors often occur bc of abbreviations 0 Check agency policy for list they use Each order must include pt name order date medication name dosage route time of administration drug interaction signature of prescriber NS cannot take telephone orders 0 Types and Orders in Acute Care Agencies Must have order before administration of medication Orders are commonly based on FrequencyUrgency of administration 0 Change in status Standing orders or Routine Medication Orders Carried out until prescriber cancels or a certain amount of days go by Often indicate a termination date prn Orders 0 Medication is to be given when pt requires it 0 Objective and Subjective assessment should be used to determine need 0 Document assessment ndings for why the medication was needed time of administration evaluation of effectiveness of medication Single OneTime Orders 0 Given once at a speci ed time STAT Orders 0 Single dose given immediately Often used for emergencies or sudden change in condition Now Orders 0 More speci c than one time 0 Medication is need quickly but not STAT or right away 0 Up to 90 minutes to administer the medication 0 Only administered one time Prescriptions Prescriber writes a prescription for pt to take outside to HC facility 0 More detailed to help pt to understand how to take the medications and when re ll is needed 0 Pharmacist39s Role Prepares and distributes medication Work w all members of HC team Fill prescriptions accurately must know is prescription is valid Rarely mix solutions most come pre mixed from manufacturer Dispensing correct medication in correct dosage with correct label is the main job Provides information on side effects toxicity interactions incompatibilities 0 Distribution Systems AMDS Systems for storage and distribution of medications Special medication rooms portable locked carts computerized medication cabinets individual storage units Locked when unattended Unit Dose 0 Uses carts w a 24 hr supply of medication for each pt 0 Each drawer is labeled for each pt 0 Cart is re lled at a certain time each day 0 Limited amounts of pm and stock meds are kept here but NO controlled substances 0 Reduced medication errors saves steps Automated Medication Dispensing System 0 Control dispensing of all medications You select the patient medication dose and route 0 A drawer will open record it in the chart and charge the patient 0 Connected to medical record and the nurses name in the record Some require bio identi cation some require bar code scanning Reduce incidence of medication errors 0 Nurse39s Role Assess medication ordered to make sure it is the correct medication Assess pt ability to selfadminister Determine time to give medication administer the medications correctly evaluate pt response to medication Pt and family education 0 Medication Errors There is room for administration of medication one hour before or after time Federal regulations are in place to enforce correct administration times o If these are broken severe punishment can result Inaccurate prescribing administration of the wrong medication giving medication at wrong time or route giving extra doses or failing to give a dose Prevention is essential When occurred 0 Pt safety and wellbeing should be rst to be assessed Document Notify HC provider When stable report to supervisor Create incident win 24 hours of incident 0 Must be accurate and factual description of what occurred Report all errors even if there were no adverse effects Medication Reconciliation is important and nurse play essential role 0 Compare current medication orders to the medications that were given before a transfer or admittance Done on admission and discharge 0 Always clarify information 0 Consulting may be needed Critical Thinking 0 Knowledge Use from many disciplines Understand why the medication is prescribed what will the medication will alter physiology to have therapeutic effect Consult experts when a medication is not known to you 0 Experience How to skills Gaining experience will make the process easier 0 Attitudes Discipline for taking time for methods of veri cation and to look up medications that are unknown Responsibility and Accountability for safe administration Medication right on time correct dose If normal dose is unknown notify HCP All action you preform or don39t you are responsible Responsible for information you give pt and family Responsible for safe administration and assessing ability to selfadminister medication 0 Standards Actions to ensure the care given is safe Set by HC facilities and nursing profession Check nurse procedure manuals Avoid distractions or interruptions when preparing and administering medication Focus on medications only until you have nished gathering and deHve ng The ANA Scope and Standards of practice apply to medication Six rights of medication administration Right Medication Order is required for every medication administered 0 Written CPOE verbal telephone 0 Compare to written orders w MAR when it is ordered to verify 0 Once MAR is veri ed and correct use it verify medication 0 Done at every new medication order 0 Compare label on medication wo MAR 3 times 0 Before removal from container drawer self 0 Amount ordered is removed from container 0 At pt bedside before administration Never prepare unmarked or illegible medication Only administer medication that is personally prepared Listen to questions and concerns from the pt 0 May notice if the medication being given is different from one that has been previously given If pt is refusing medication discard it 0 Unit doses can be saved if unopened o If refusing narcotic have a second person verify the disposal Use clinical judgement wen giving prn medications 0 Give pain meds to the pt before starting assessment If a mistake is made speak up Right Dose Unitdose reduces errors When medication is prescribed in a dose that is different from what I supplied errors occur Have another nurse check calculations Prepare using standard measurement devices Errors often occur in splitting pills Assess pt ability to split pills if not able avoid ordering medications that are to be split Crushing devices need to be completely cleaned between uses 0 Mix crushed with food that is not their favorite food bc altered taste may occur 0 Some forms of medications can t be crushed Right Patient Use 2 identi ers before administering a medication 0 Pt name identi cation number telephone number Compare identi ers to MAR to bracelet while at bedside Barcodes may be used to scan to nurses ID badge pt wrist band and medication package 0 Help to eliminate errors Right Route Consult if order doesn39t have assigned route o If given route isn39t recommended notify HC provider 0 Label syringes after adding medication 0 Use different colored syringes for enteral and parenteral medication Right Time Know why the medication is ordered for certain times and if schedule can be altered HC provider should write this information in order 0 Can be On ca PC STAT prn requires nurses judgement Priority is given to timecritical medication Document when HC provider was contacted for clari cation Evaluate need for home care and ability to selfadminister 0 Help plan schedules for medication administration at home Right Documentation Many errors are result of inaccurate documentation Ensure MAR is re ecting pt full name ordered medication written in full time medication is to be administered dosage route frequency If there is a question contact the HC provider Nurse is responsible to start the chain of command in the situation where HCP are unable to make clearly written orders Document preassessment data After administration 0 Indicate medication was given as ordered in MAR 0 Immediately after administration 0 Name of medication dose route time site of injection pt response positive or negative Notify HCP is there was a negative effect and document time date and name of HCP contacted Never document that a medication was given until it has been given Never place medication in the room and then leave Check mouth to ensure is were swallowed After giving medication wash hands and don39t touch pis unless you are applying topical solution Maintain Patient39s Rights To be informed of name purpose action and potential undesired effects of a medication To refuse medication 0 Don39t become defensive To have quali ed nurses or physicians assess a medication history To be properly advised of the experimental nature of medication therapy and give written consent 0 Nursing Process 0 Assessment To received labeled medications wout discomfort in accordance w 6 rights To receive supportive therapy w medication To not receive unneeded medications To be informed if the medication is part of a study Handle all questions the pt and family have Through Patient Eyes Use professional knowledge skills and attitudes Compassionate coordinated care As pt values beliefs preferences and needs when determining responses to medication therapy Begin assessment by asking questions 0 Medication management 0 Routine 0 Ability to afford medications o Beliefs and expectations attached to medication History Review medical history 0 Provides contradictions to medications o Risks for adverse effects Illnesses diseases and longterm health related problems Allergies 0 Inform team members of all food or medication allergies Food products are sometimes used in medications Cross check 0 Note reactions to allergen in medical record admission notes history Medications 0 About each medication Length of use Current dose Sideadverse effects experienced Action Purpose Normal Dose Route Side effects Nursing Implications for administration and monitoring 0 Consult texts and professionals 0000 Diet History 0 Normal eating patterns 0 Food Preferences 0 Dosage schedule should be planned around them 0 Teach to avoid foods that can interact w medication Note Say which interact positively and negatively Pt Perceptual or Coordination Problems 0 Dif culty selfadministering 0 Assess ability to prepare and take medications If unable assess family Pt Current Condition Ongoing physical or mental assessment needs to occur in order to determine whether or not to continue medication 0 A careful assessment should be done before any medication is given HCP should be noti ed if pt is unable to take the medication 0 Assessment ndings are a baseline Pt Attitude About Medication Use Reveals level of medication dependence or avoidance Observe pt behavior 0 Be aware of culture beliefs that can interfere Pt Understanding of and Adherence to Medication Therapy In uences willingness or ability to follow regimen If poor adherence investigate why 0 Determine understanding of importance of regular doses purpose proper administration methods and side effects Pt Learning Needs 0 Assess health literacy Determine instruction needs Diagnosis Anxiety Ineffective health Maintenance Readiness for enhanced immunization status De cient Knowledge medications Noncompliance medications Impaired swallowing Effective therapeutic regimen management Planning Organize so there is no rushing and ensure safe administration Rushing makes error Minimize distractions and interruptions during preparation and administration Goals and Outcomes Contribute goals to safety 0 Contribute to patient understanding 0 Provide most important information about the medication rst 0 At discharge ensure pt is able to receive medications Setting Priorities Prioritize which medications need to be given rst Note if it is appropriate to give prn medications is an op on Provide pain medication rst if patient is in pain Provide most pressing education about medication rst in the teaching process Teamwork and Collaboration Family and friends will help to reinforce practices Collaborate w pharmacist prescriber and case mangers 0 Ability to afford medication Obtaining medications Health literacy Basic dosage calculations Community resources 0000 0 Implementation Health Promotion Identify WB diminishing factors Everything about pt will in uence adherence to medication Teach bene ts and knowledge needed about the mediation Create a treatment plan and schedule to t pt routine Make referrals and arraignment of resources Pt and Family Teaching 0 Bene ts of medication how to make the medication correctly symptoms and side effects use and storage Help to establish a routine 0 Provide information on Purpose Actionseffects Proper administration and risks of improper administration Accurately measure Symptoms of side effect and toxicity 0 Change in behavior is rst sign Basic safety guidelines for medication administration 0 Use and storing properly 0 Special teaching should be applied to those w daily 0 injections Teach prep and administration to pt and family Acute Care 0 Receiving Transcribing and Communicating Medication Orders 0 Order is required to administer all medication 0 CPOE are used for direct entrance for orders Help reduce errors and mortality rates o If handwritten be sure these are legible Medication names Doses Symbols If not legible order MUST be rewritten o Verifying of orders varies from agency 0 NS cannot take verbal or telephone orders Read backs are required Follow institutional policy 0 Must include Pt Full name Date and Time order is written Medication name Dose Route Time and frequency of administration Signature of HCP 0 Check all orders for accuracy at least 3 times before administration and always when medication is ordered 0 Always determine if medication is compatible with condition and other medications 0 Once medication is deemed safe it is place on the MAR or eMAR Includes all information about medication order AND room an bed number medical record numbers medical or food allergies other patients 0 Verify accuracy of medications before each administration If there is missing information or non corresponding information DO NOT give the medication until the HCP is noti ed and xes the order 0 Follow 6 rights of medication administration Accurate Dose Calculation and Measurement 0 O O 0 Use standard measuring containers for liquids Calculate each dose when preparing the medication Ask for another nurse to double check calculations If you are ever in doubt have someone double check the calculation 0 Correct Administration 0000 0 Follow 6 rights Verify identify using 2 identi ers Compare pt armband to MAR Aseptic technique and proper procedures assessment before administration Monitor the response carefully Recording Medication Administration 0 O O 0 Follow agency policy of documentation Record name of medication dose route and exact time of administration Record site of injection Explain why if a dose is refused or missed and notify HCP Restorative Care 0 Administration activities will vary bw facilities 0 Nurse is responsible for correct instruction of action administration side effects monitoring compliance and determining effectiveness Special Consideration for Administering Medications to Speci c AgeGroups Infants and Children 0 CO 000 O Vary in age weight height SA metabolism and excretion of medication Doses are lower Special caution is needed for preparation Require psychological prep before medication administration Supportive are is needed Explain at appropriate level Involve in choices when possible Praise after taking the medication 0 Older Adults 0 Physiological economical and behavioral factors in uence Polypharmacy O A pt takes 2 medications to treat same illness 2 medications in same chemical class uses 2 medications for similar actions or mixes herbals and nutritional substances OTC medication use lack of knowledge incorrect beliefs and visiting more than one HCP are all factors More common before computer systems Older adults are more likely bc often suffer from chronic health problems Can be unavoidable o Frequent communication is needed to minimize risks 0 Evaluation Essential Gather data and create a holistic evaluation Goal safe and effective response to therapeutic treatment and ability to selfadminister Be alter for restrictions in pts on more than one medication Physiological measures behavioral responses rating scales and pt statements Through Pt Eyes 0 More effective w pt cooperation Do they understand how to safely administer medication 0 Are they able to understand the schedule 0 Do they understand why they are taking the medications they are taking Can they describe the effectiveness of the medication 0 Include pt to enable them to feel more empowered about their care Pt Outcomes Clinical condition changes on a minute by minute basis 0 Compare desired with actual outcome 0 Be alert for reactions 0 Measure HR BPP behavior change what pt states 0 Medication Administration 0 Oral Administration By Mouth Easiest and most desirable way Food may decrease the effect More are able to selfadminister and ingest these Best if given 30 minutes before meals or w food depends on medication 0 Know medication interactions t determine best time to give the medication Protect pt from aspiration Assess ability to swallow 90 degree angle for meds admin unless contradicted Use multiple disciplines if needed Special care needs to be given to those with a feeding tube 0 Risk for tube obstruction reduced medication effects increased risk for toxicity 0 Veri cation is necessary for tube placement and if placement is compatible w medication absorption 0 Use liquids when possible 0 Can crush simple tablets open gel capsules 0 Dilute in sterile water NOT tap water Flush w AT LEAST 15 mL of sterile water bf and after each medication One medication at a time do not mix medications If given on empty stomach allow 30 minutes before or after eating Determine compatibility w enteral feeding 0 Verify w drug reference or consult pharmacist Monitor closely for adverse reactions Higher risk of drug interaction 0 Topical Medication Application Use gloves Medication goes through the skin Applied locally to usually intact skin or mucus membranes Skin Applications Local applications Systemic or local effects Wear gloves and applicators Use sterile technique w open wound Clean skin thoroughly bf administering medication Apply according to medication instructions Cover well but not overly thick layer 0 Apply gauze cover if indicated in order 0 Lightly spread creams and lotions 0 Apply liniment by a gentle but rm rub 0 Dust powder Some are given through a transdermal patch 0 Remove old patch before applying a new one if not an OD can occur 0 Carefully assess skin where patch was 0 Guidelines Document location on pt body where medication was placed Ask pt if there is an existing patch During history ask if they are taking medications via patch or any route other than oral Apply noticeable label on the patch Document removal and application in MAR Nasal lnstillation Sprays Drops Tampons Different positions will reach different sinuses Decongestant is most common 0 Can become quotaddictedquot o If swallowed serious systemic effects occur Saline drops are the safest Easier for pt to selfadminister If used often assess for irritation Nose bleeds are treated w epinephrine infused tampons EyelnsUHann Eye drops and ointments Ophthalmic medications are for eye conditions Age reated problems impair selfadministration ability lnclude family in instruction and determine ability to administer 0 Have family demo Guidelines 0 Avoid instilling directly on cornea 0 Avoid touching eyelids or structure w tip of applicator 0 Use medication only for the affected eye 0 Use different medication for each pt Do all other activities before administration because vision can be blurred lntraocular Administration 0 Contact lens like delivery vessel 0 Can remain for week 0 Teach about monitoring for the adverse effects of the lens insertions and removal Ear lnstillation Internal ear structures are sensitive Use sterile solutions Drainage may indicate eardrum rupture Don t force in medication Drops should be at room temperature Sterile solutions are used when eardrum is ruptured Nonsterile solutions into the middle ear can result in infection Vaginal lnstillation Suppositories foam jellies creams Sometime stored in refrigerators Give w gloved hands Some can selfadminister provide privacy Discharge is foul smelling Teach proper pericare Rectal lnstillation Suppos ones Local effects for promoting defecation Systemic effects reduction of Nausea Stored in refrigerator Enema might be needed before administration 0 Administering Medications by Inhalation Aerosol Spray mist powder penetrating lungs Used for maintenance or rescue Rapid absorption Pressurized MeteredDose lnhalers Breath Actuated Metered Dose and Dry Powder Inhalers Mainly local effects Serious systemic side effects can occur pMDl chemical propellant Doesn39t require a lot of pressure to press down canister in order to administer medication but does need some hand strength 0 Gets medication further in lungs Children and Elderly Spacers break up medication for a faster acting response BAls Medication is released upon raising a lever and inhaling Release is dependent on breath DPls Aerosol is created upon inhaling through reservoir 0 Medication is activated by pt breath Unit singled dosed or month long doses 0 Powder Clumps w humidity To fast inhalation will not get all of dose Different Respiratory problems require different medications Rescues are used for fast action situations Maintenance medications have a schedule Slower actions Need to learn selfadministration Safe and Effective use is key Education on when medication is empty and needs replacing Counting down numbers occur 0 Divide number of dose by the number a patient uses per day Re ll 710 days before suspected emptying Administering Medications by lrrigations Wash out body cavity or consistent stream of solution Sterile water saline antiseptic solutions in eyes ears throat vagina urinary tract Aseptic if a tear in mucus membrane or skin 0 Clean otherwise Parenteral Administration of Medications Injection into body tissues lnvasive Aseptic techniques Risk of infection after piercing the skin Action of medication is quick Closely observe pt response Equipment 0 Variety of sizes and types for the different volumes of medications and tissue type Synnges O O O LuerLok Needles are twisted onto tip and lock themselves into place preventing accidental removal NonLuer Lok needles slip onto tip w safety devices to prevent needlestick injury Number of sizes 560 mL Hardly use gt5mL for medication injection Large volumediscomfort Prepacked w needle Needle can be changed and removed Tuberculin calibrated into 116 of a minim and 1100 mm 1mL max Small precise doses lnsulin are small and calibrated Don t let an unsterile object to the inside of the syringe tip Needles O O 0 Some are packaged in individual sheaths for ability to change needles Usually stainless steel Disposable Parts Hub ts on syringe Shaft Connects to hub Bevel Slanted tip 14 3 inches Size is chosen based on size weight and tissue of pt IM 115 inches Subcut 38 58 Smaller gauge Larger diameter Gauge depends on viscosity of concentration Disposal lnjection Units 0 000 There are pre lled syringes and needles Safely dispose of needle and all glass used Check medication concentration Don39t prepare medication dose but expel unneeded portions Preparing and lnjection From an Ampule Contain single dose of medication Several sizes Glass w constricted neck that is snapped off for access to the medication Aspirate medication into syringe using and lter needle 0 Replace w real needle before use Preparing and Injection From a Vial Single or multidose vial w a rubber seal Liquid or dry forms of medication 0 O Unstable meds are dry Vial notes if it is dilution or solvent it needed and amount Closed system 0 Air must be injected for easy removal After mixing multidose note date and time of mixing concentration and refrigerate rest of solution Mixing Medications Minimizes injections received at a time Mixing Medication From and Vial and an Ampule 0 Prepare medication from vial rst using same syringe and needle then ampule Mixing Medication from 2 Vials O 0 Principles Don t contaminate one medication with another Ensure nal dose is accurate Maintain aseptic technique Use only one syringe and needleneedless device Aspirate amount of air equal to dose in vial A Inject air into vial A make sure needle doesn39t touch solution Aspirate amount of air equivalent to dose B lnject air into vial B Withdrawal medication immediately lnsert needle back into vial A and withdraw medication Don t press on plunger to reinsert B medication into A Withdrawal needle and apply a new safety needle needless device lnsulin Preparation Prescribed in concentrations of 100 mL of solution or 500mL more rare Classi ed by rate of action Know onset peak and duration of each pt ordered dose lmitate normal insulin release in body Insulin pen give multiple doses in on pen Correction insulin is provided upon Blood Glucose Levels to correct elevated levels 0 Temporary 0 Before injection gently roll insulin vital in hands to suspendinsan 0 Don39t shake You can mix insulins IF they are compatible 0 Rules Maintain individual routine to those on mixed insulin Don39t mix w any other medications or dilutions Never mix insulin glargine or insulin detemir Inject rapid acting insulins mixed w NPH insulin w 15 minutes of meal Verify insulin dose w another nurse while preparing them 0 Administering Injections Injection route varies based on tissue Tissue characteristics in uence rate of absorption Before injection 0 Know Volume injecting Characteristics of viscosity 0 Location of anatomical structures Nerve and bone damage can occur when a medication is wrongly administered 0 Tissue damage and extreme pain can also occur Minimize discomfort Use sharpbeveled needle in smaIIest Iength suitable Position comfortably Elect proper injection site Apply vapocooIant spray Divert pt attention Insert needle quickly and smoothly Hold syringe steady while needle is in tissue Inject medication slowly and smoothly Subcut Into Ioose connective tissue under dermis Slower absorption than IM Slight Discomfort Best Sites 0 Outer posterior of upper arms 0 Abdomen o Anterior thighs Alternative sites 0 ScapuIar areas 0 Upper ventral or dorsal quteaI areas 0 Site must be free of lesions boney prom and large mm or nerves Abdomen is quickest absorption for insulin 0 Site should be alternated w each injection Only small volume water soluble medications are given subcut Size of needle is based on person weight 0 25 Gauge 58 needles is inserted at a 45 degree angle or 12 at 90 degrees Norma pt 0 If you can grasp 2 inches of tissue needle goes in at a 90 degree angle 1 inches is 45 degree angle Faster absorption More risks 1St verify that injection is justi ed Use longer and heavier needle Weight and adipose tissue determine length 90 degree angle insertion 25 mL of medication is normal Assess mm before giving the injection Site should be free of tenderness lesions relaxed Change position to reduce the strain on the mm Distract and apply pressure Sites 0 Ventrogluteal Glutues medius is deep and far away from major nerves and blood vessels Safest for all 0 Especially if larger amounts of medications Place pt supin or lateral w knee exed and hip to relax mm Place palm over greater trochanter w thumb pointing to groin index toward anterior superior iliac crest an middle along back of iliac crest to form a V o L hip R hand lnjection site is in middle of the V o Vastus Lateralis Anterior Lateral aspect of thigh Good site Middle third of mm is used for injection Lie at w knee exed or in sitting position 0 Deltoid Not as well developed and more injury risk Use for small V of medications or when other sites are not accessible Relax are and ex elbow Lower edge of acromion process forms the base and midpoint of lateral aspect forms tip Inject in middle Three nger widths from acromion process Use of ZTrack Method in IM injections 0000 CO Minimize local skin irritation Depress skin just below site of injection Clean skin w swab Insert needle and depress syringe at a rate of 1 mL per 1 seconds Leave needle in for 10 seconds Pull out needle release skin This leaves a separation bw where the needle entered and where the medication was administered Used for skin testing Potent medications Absorption is slow Requires a clear view of the injection site Inner forearm or upper back Use tuberculin or small hypodermic 515 degree angle of insertion Bevel of needle is pointed up Injections will cause the skin to bubble up Safety in Administering Medications by Injection Needless Devices 0 Needle sticks are common and occur when HC workers recap needles Mishandling of IV lines and needles Leaving needles at the pt bedside Exposure to blood borne pathogens is a deadly hazard to nurses Most are preventable w needle safety devices Safety syringes have a sheath to cover needle upon withdrawal Always dispose of needle and sharps in appropriate containers Puncture and leak proof Never force a needle in a full container Methods 0 Mixtures in large V IV uids 0 0 Injection of bolus or small V through existing IV quotPiggybackquot infusion 0 Existing IV line is running or there is an existing IV site placed 0 IV Fluid is primary way of uid replacement in pt unable to have oral uids 0 Means of electrolyte and nutrients Observe closely for adverse effects 0 Immediate action 0 Errors can be deadly o 6 rights 0 Double check calculations 0 Know desired action and side effects 0 Asses vitals before after and during 0 Advantages 0 Fast acting o Constant therapy blood levels 0 Less discomfort Serve adverse reactions occur if administered to quickly 0 Large Voume Infusions 0 Mix medications w large volumes of uids 0 Safest and easiest 0 Risk of fatal side effects are minimal 0 Disadvantage If too quickly risk of OD and circulatory uid ove oad 0 Nurses only mix in IV uids in emergency situations 0 Nurse never prepare high alert medications o If you have to mix a medication verify w pharmacist and have another check calculations and watch mixing 0 Steps Check medication compatibility Prepare medication in syringe w aseptic technique Clean injections port and stick in needle Mix by turning bag gently Attach medication label 0 DON T add medication to hanging bags ONLY NEW bags 0 Regulate rate 0 Frequently check site Intravenous Bolus quotPUSHquot o Concentrated dose into systemic circulation o Advantage when there is a uid restriction on the pt 0 Most dangerous method No correction time o Bf administration check IV line and site 0 Never give if the line is in amed or edemas Improper blood ow Volume Controlled Infusions 0 Small amounts of compatible IV uids Secondary connects to primary line or to a separate tube that is inserted into the primary line 0 Advantage Reduces rapid dose risks Diluted and longer diffusion rate Allow for administration of medications that are stable Control of IV intake 0 Piggyback Small bagbottle connected to short tubing connecting to upper Y port of primary Label Micro or Macro drip The smaller is higher than the primary Main line doesn39t infuse when piggy is Once piggy is empty primary will begin again 0 VolumeControl Administration Small containers attached below to primary Used w regular IV ow 0 MiniInfusion Pump Battery operated Allows small amounts of medications to be given w controlled infusion rates Intermittent Venous Access IV catheter capped off at one end w a small chamber covered by a rubber diaphragm or special design cap Advantages 0 Saves costs 0 Effectiveness of time is enhanced 0 Increased Mobility safety and control Assess IV site before administering Flush after administration Administration of IV Therapy in the Home Central venous catheter inserted before discharge Assess ability to manage therapy at home Begin instruction when pt is in hospital Teach to recognize problems signs of infections complications and to notify HCP when these occur Give information regarding maintenance of equipment