?1. Review the generalized areas of nursing knowledge Responsible for the actions and effects of medications Responsible to understand disease processes and common treatment regimens Responsible to know why a med is prescribed for a patient Accountable to utilize available resources as a guide Accountable to serve as a patient advocate and know patients rights 2. Define the proper technique for ear drop administration for adults and children? Adults: pull upward and toward back of head Child: (under the age of three) pull down and back 3.
Identify nursing responsibility when accuracy of an order is in question Review drug book; check with pharmacist; clarify with physician, solicit opinion of senior/charge nurse 4. Discuss the procedure for proper patient identification 2 forms for patient identification Compare name and birthdate on ID band with name on MAR ALWAYS identify your patient with each administration Ask patient to state his/her patient with each administration Ask patient to state his/her name and birthdate Never say “Are you….? ”-they could say yes to name The confused patient Check the ID band against the name on the MAR.
Ask family if available, identify with another staff person during report 5. Discuss nursing responsibility in passing medications prepared by another nurse DO NOT give meds someone else has prepared!!!!!!!! YOU are accountable if an error is made!!!!!!! 6. Define the acceptable time-frame a nurse is allowed to pass scheduled medications Drugs may be given 30 min before and 30 min after prescribed time (some facilities allow 1 hour before and 1 hour after) 7. Define each rule related to the “six rights”, and define how the nurse is absolutely sure he/she has the correct medication Right Patient.
Two forms for patient identification Compare name and birthdate on ID band with name on MAR ALWAYS identify your patient with each administration Ask patient to state his/her name and birth date-never say “Are you….? ”-can say yes to any name The confused patient Check the ID band against the name on the MAR Ask family if available, Identify with another staff person during report Right Drug Know intended action of the drug Double-check orders and meds that have sound alike, look alike characteristics Ex. Digoxin or digitoxin If a patient questions the drug-thouroughly double check before giving Check the name on the med 3 times.
Before selecting the drug Before preparing or measuring the drug Before opening unit dose package at the bedside Right Dose Ask yourself, is this dose within normal range Carefully review the units of measurement ordered against the units of measurement supplied Gram-milligrams Micrograms-milligrams During clinical, work on developing familiarity and skills using med cups, eye/ear droppers, and needles/syringes Shake all liquid suspensions well before pouring Double check pediatric dosages with another nurse Double check high risk meds with another nurse Clarify all your questions first.
Right Route Physicians order the route to be given If no route is ordered-clarify with the physician and rewrite order correctly If patient cannot tolerate the ordered route, clarify and obtain or write the new order Assure the route ordered is compatible with drug reference recommended route When mixing powders, be reasonable in amount you mix in-make sure patient will be able to drink all of it. Right Time The physician orders the number of times per day Bid, tid, quid, q 6 h, daily Know the standard administration times policy in your facility Daily’s @0900 or HS @2100.
Drugs may be given 30 minutes before and 30 minutes after prescribed time (some facilities allow 1 hour before and 1 hour after) For PRN drugs, know the purpose for which the drug was ordered, assuring it corresponds to why you are giving it Always check on time it was last given Chart immediately after administration Always perform a follow up evaluation Right Documentation DO record with a drug is NOT given and why-include who was notified A patient has the right to refuse a medication unless they are court ordered to take a med Do NOT record a med until AFTER it has been given.
Do NOT leave meds at a bedside for patient to take lator-esception-Dr. orders it to be left at bedside When drug error has been made-error documented in patient’s chart stating what was given, who was notified, and follow-up assessment of patient-state only the facts, not that it was an error. Complete a variance, explaining specifics here Be cautious in checking orders regularly and looking for signals that a med has been changed or discontinued 8. Define which areas of a syringe and needle are kept sterile The shaft and barrel 9.
Discuss subcutaneous (SQ) injections related to each of the areas below: Where are they given and what sites are acceptable Injected into adipose tissue Sites-upper outer arms, abdomen, anterior thighs What influences SQ site selection Choose an injection site that is free of skin lesions, bony prominences, and large underlying muscles or nerves Rotating injections within the same body part for a sequence of injections provides more consistency in the absorption of insulin If you inject the morning insulin into a patient’s arm, give the next injection in a different place in the same arm, at least 2.
5 cm away from the previous site. Avoid using the same site for at least 1 month The abdomen has the quickest absorption rate, followed by the arms, thighs, and buttocks What length/size of needle is acceptable Adult: 20-23 gauge, 1 ? inch needle Children: 25-27 gauge, ? -1 inch needle What angle is acceptable 45 or 90 degree angle (45 if 1 inch is pinched-90 if 2 inches pinched up) What class of medications administered SQ require specific SQ sites SQ anti-coagulants are given in the abdomen and have air-locking injection technique used How much medication can be injected into a SQ site.
SQ tissue holds maximum of 1 mL The difference between a regular SQ syringe and an insulin syringe Insulin Syringes are used only for insulin Cannot change needles on insulin syringes. In normal syringes, you would change needles when mixing two drugs from multi-dose vials Technique for the patient with daily SQ injections If you inject the morning insulin into a patient’s arm, give the next injection in a different place in the same arm, at least 2. 5 cm away from the previous site. 10. Discuss intramuscular (IM) injections related to each of the areas below: Where are they given and what sites are acceptable.
Given in the muscle Vastus lateralis Use middle 1/3 of muscle for injection; hand breadth above knee and below greater trochanter. Position patient supine with knee slightly flexed. Recommended for infants and toddlers. Maximum amount for injection is 2 mL Ventrogluteal Heel of hand on greater trochanter-index finger on anterior superior iliac spine-middle finger bac k toward iliac crest. This makes a “V” with the hand—inject inside the “V”. Position patient on side opposite of injection with knees flexed. Safest and deepest muscle even when emaciated; with fewer nerves.
Maximum amount for injection is 3 mL. Dorsogluteal Upper outer quad of buttocks (gluteus medius). Locate posterior superior iliac spine and greater trochanter. Position patient prone with knees turned in. Be cautious as hitting sciatic nerve or major blood vessels in this area is possible. Maximum amount for injection is 3 mL. Deltoid Palpate lower edge of acromion process-note triangular shaped area below process. Inject in center of triangle (1-2 inches blow process and 3 finger breadths below). Position of patient either sitting or lying flat with lower arm flexed.
Caution this is a small muscle and in close proximity to the radial and ulnar nerve. Do not inject medications that are irritating in this site. Maximum amount for injection is 1 mL. What influences choice of needle gauge and length Special considerations: Use smaller gauge needle for elderly, emaciated, or atrophied muscles What length/size of needle is acceptable Adult: 20-30 gauge, 1 ? inch needle Children: 25-27 gauge ? -1 inch needle What angle is acceptable 90 degree angle Which site is least desirable and why.
Dorsogluteal is the least desirable site because there is a possibility of hitting the sciatic nerve or major blood vessels in this area How much medication can be injected into each IM site Vastus lateralus—-2mL Ventrogluteal—-3mL Dorsogluteal—-3 mL Deltoid—-1mL What is the purpose of “Z-track” Used for irritating substances to minimize irritation by sealing drug in muscle-keeps it from leaking out and irritating sq tissue Give in deeper muscles; ex. Ventrogluteal or gluteus medius What is the technique and purpose of creating an “air-lock” Draw up.
2 ml air into syringe after med dosage is drawn up and measured leaving an air-bubble in the syringe at end of syringe The air-bubble is injected after medication is injected Commonly used for subcutaneous anticoagulants, insulin, medications that sting, and medications given via Z track method Prevents bruising, stinging, and disperses medication throughout the tissue avoiding nerve endings Which IM site is preferred for infants & toddlers; for adults and why Vastus lateralis is recommended for infants and toddlers because the muscle is thick and well developed.
Ventrogluteal is the site preferred and safte site for all adults, children, and infants. This is the safest and deepest muscle even when emaciated; with fewer nerves 11. Verbalize the procedures for pouring a liquid medication Place the medication on a flat surface at eye level Carefully pour into a medication cup taking caution to not allow the medication to run over the label causing it to become indecipherable If the label is indecipherable, send it back to pharmacy and ask for a replacement 12.
State your responsibility for handling a medication that is dropped or contaminated If a medication is dropped on the floor, throw it away and notify pharmacy for replacement 13. Describe your actions when a patient does not believe the medication you are delivering is correct THOROUGHLY double check before giving 14. Define the proper technique for accepting a verbal or telephone order Must include the same information plus the name and credentials of person giving order 8/25/10, 2100 Demerol 100 mg IM q4 h PRN for pain DR.
Marc D Ryan/Juliann Kennedy, RN Noted 8/25/11@2110 Juliann Kennedy, RN Must always repeat order back to Doctor to prevent error 15. Discuss how you will prioritize which patient receives their medications first Assess your patient’s clinical condition on an ongoing basis to determine which nursing diagnosis takes the greatest priority and which medications you need to administer first Medications that are to be administered around the clock (antibiotics for example) need to be given in a timely manner to maintain therapeutic serum levels.
Frequently medications given for pain or to prevent serious harm to a patient such as antihypertensives, cardiac meds, and antiseizure drugs are of a higher priority than other medications 16. Discuss the parameters you will utilize for evaluation of patients prior to administering medications Evaluate the patients current condition History Medical, surgical, medications, allergies, diet Patient’s mental and physical capacity Coordination deficits Current condition Attitudes regarding medication use Learning needs.
Family involvement Community services 17. Describe your actions when you question any part of a physicians order 18. Discuss expectations for all physician orders in a patient going to surgery 19. Discuss your actions when delivering medications to a patients who is not quite ready to take the medication 20. What is meant by “parenteral routes” in medication administration SQ or SC IM, IV, intradermal 21. Verbalize your steps for withdrawing medication from a vial; from an ampule. Then state the rationale for your technique VIAL.
Cap is removed and stopper is considered sterile until touched or used For multi-dose vials you must wipe with alcohol before drawing up medication Date and tie all multi-dose vials as multi-dose vials are only god for 24 hours and must be disposed of after this period (exception insulin) Prior to inserting needle into stopper, draw up air in an amount equal to the amount of drug you plan to withdraw for easier withdrawal; ex. Need 1 mL of medication out-inject 1 mL of air into the vial first. Some vials contain powder and will need to be reconstituted with an acceptable diluent (solution); ex.
Normal saline or sterile water. Follow the manufacturer’s recommendation for reconstituting. Some powders are slow to dissolve; gently shake or roll in your hands, and let sit for a short period to dissolve completely Double check each medications storage requirements-may need refrigerated AMPULE Single dose only Cover neck/stem of Ampule with alcohol wipe to protect fingers and snap top off away from yourself Do not inject air into ampule before withdrawing drug, use filter needle to draw up contents-avoids glass slivers in solution Change needle before giving injection.
22. Discuss how insulin syringes vary from routine medication syringes 23. Discuss how to prevent contamination of multi-dose vials when two medications will be combined in the same syringe, and why this does not apply to insulin When mixing two drugs from multi-dose vials be sure to change needle between 1st and 2nd vial to avoid contamination of one medication into the vial of another. There is an exception for insulin-cannot change needles on insulin syringes 24. Discuss your actions if you drop a medication on the floor Throw it away and notify pharmacy for replacement.
25. Describe all the necessary components of a medication order and the difference between STAT, NOW, PRN, a standing order, a single order Date and time order written Patient’s name and birth date or name and ID number on the physician’s order form Name of drug Dosage of drug to be administered Route of administration Frequency-how often (sometimes orders are for specific number of doses-ex-q 8 hours x8 doses) Signature of physician or licensed independent practitioner (LIP) Any special orders, if applicable, such as STAT, etc The licensed nurse must note/verify each order.
6/15/09, 2100 Morphine 4 mg IV q2 h prn for pain. Dr. Joseph M. Jones Noted 6/15/09 @2120 Tiffany Johnson, RN Telephone and verbal orders Must include the same information plus the name and credentials of person giving the order 8/25/10, 2100, Demerol 100 mg IM q4 h PRN for pain Dr. Marc D. Ryan/Juliann Kennedy, RN Noted 8/25/11 @2110 Juliann Kennedy, RN STAT orders A STAT order means that you guv a single dose of medication immediately and only once. Health care providers usually write STAT orders for emergencies when the patient’s s condition changes suddenly.
Apresoline, 10 mg IV STAT NOW orders A NOW order is more specific than a one tie order and is used when a patient needs a medication quickly but not right away, as in a STAT order. Verify your agency policy to determine how much time you have to administer a NOW medication after it is ordered. Only administer medications ordered NOW one time. For example Give vancomycin 1 g IV piggyback NOW PRN orders A health care provider sometimes orders a medication to be given only when a patient requires it. This is a prn order.
You use objective ad subjective assessment and nursing discretion to determine whether the patient needs the medication. Often the health care provider sets minimum intervals for the time of administration. This means that you cannot give the medication any more frequently than when it is prescribed. Magnesium hydroxide, 30 mL PO prn for constipation Standing Orders You carry out a standing order until the health care provider cancels it by another order or until a prescribed number of days elapses.
A standing order sometimes indicates a final date or number of dosages. Many institutions have policies for automatically discontinuing standing orders. Quinapril, 20 mg PO q12h Azithromycin, 500 mg PO IV daily for 2 days, then 500 mg PO daily for 7 days Single (One-Time) Orders A prescriber often orders a medication to be given only once at a specified time. This is common for preoperative medications or medications given before diagnostic examinations. Versed, 6 mg IM on call to OR 26. Define the advantage of using intravenous therapy.
Drugs are administered directly into the bloodstream which gives immediate drug action 27. Discuss the assessment and documentation nurses make for patients receiving IV therapy Assess the patency of the infusion system (observe fluid infusing form bag to patient) Assessment includes verifying the IV fluid and rate is correct, and is ongoing being performed at beginning of shit, throughout the shit, and at end of shift. Notify the RN of all abnormal findings Assess the condition of the IV site for.. Infiltration.
Needle is out of the vein, solution is infusing into surrounding tissue s/s=swelling, pain, decreased skin temp in area, pallor, or redness Treatment=DC IV and apply warm or cool washcloth Plebitis Inflammation of the vein, caused by irritation or trauma to vein s/s=redness, puffiness, pain, warmth at site, vein may feel hard or cordlike Treatment=DC IV and apply warm moist soaks to the area. Do not rub or massage extremity (may dislodge any clots present) Infection/inflammation Catheter tip may become contaminated with bacteria.
s/s=redness, warmth, tenderness, swelling at site; possible purulent drainage Treatment=DC IV. Physician will order treatment and may order site cultured Septicemia Microorganisms migrate into blood stream. Usually a result of poor aseptic technique or contaminated equipment s/s=fever, chills or profuse sweating, N/V/D, malaise Treatment=DC IV and notify physician; physician most likely will order blood cultures and a culture of the tip of the IV catheter, antibiotics, and increased observation Circulatory Overload:
Infusing excessive amounts of fluids, infusing fluids too rapidly, or infusing a volume of fluid to great for patient with poor heart pumping function s/s=tachypnea, dyspnea, cough, shortness of breath, inspiratory crackles, tachycardia, arrhythmias, 3rd heart sound, restlessness, change in level of consciousness, decreased oxygen saturation Treatment=slow IV rate to TKO (to keep open) and notify physician immediately, following new physician orders Air Embolism.
Rare but lethal-air enters the blood stream through IV s/s=chest pain, shoulder pain, shortness of breath, cyanosis, tachycardia, arrhythmias, restlessness, loss of consciousness, possible cardiopulmonary arrest Treatment=immediately report assessment findings to a physician.
In case of cardiopulmonary arrest, initiate basic life support Allergic Reactions Associated with blood transfusion or medications s/s=same as any allergy-hives, itching, wheezing, possible anaphylaxis Treatment=DC allergen, but keep IV fluids infusing TKO to provide access for emergency medications. Notify physician immediately and follow facility allergic reaction/anaphylaxis protocols if available 28. Discuss best practice for decreasing the rates associated with needlestick injuries for healthcare workers Avoid using needles when effective needleless systems or sharps with engineered sharps injury protection (SESIP) safety devices are available Do not recap needles of any kind.
Plan safe handling and disposal of needles before beginning a procedure Immediately dispose of needles, needleless systems, and SESPIS into puncture-proof and leak-proof sharps disposal containers 29. Discuss interventions related to patients experiencing a potential complication 30. Discuss unapproved abbreviations and your role as the nurse 31. Discuss sound alike look alike medications and your role as the nurse, and what tool is frequently utilized or available to guard against errors. 32. Verbalize your steps in retrieving, wasting, and administering narcotics.