-
What is impaired skin integrity?
Intactness of the skin is interrupted by any type of wound.
-
What are the components of a drug order?
- full name
- date written
- drug name
- dosage
- route of administration
- time and frequency of administration
- signature of physician.
-
Types of Mediation orders?
- standing
- prn
- one time
- stat
- prescription
- verbal
- telephone
-
What are routes of administration?
- oral-buccal SL
- parenteral-subq, iv, im,id
- topical-transdermal patch
- suppository
- irrigation
- sprays
- inhalation
- intraocular
-
What are the 5 rights of med admin?
- right medication
- right dose
- right client
- right route
- right time
-
What are nursing responsibilities for medication administration?
- knowledge
- experience
- accountability
- report and document effects good and bad
- report and document errors
-
What are some more indepth nursing responsibilities?
- client and family teaching
- receiving medication orders
- correct transcription of orders
- accurate dosage calculation and measur.
- documentation
-
Every client has a right to?
- information related to med.
- refuse
- advised of experimental drugs
- receive labeled meds
- receive appropritate supp. therapy
- not receive unnecessary med.
-
What is the first check procedure?
- check med order
- wash hands
- prepare one drug at a time
- select correct drug and compare name and dose with MAR
-
What is the second check procedure?
- calculate drug dose
- break scored tabs(pill cutter)
- place drug in cup
- continue selecting other drugs
- after all drugs are in cup, check against MAR again- name, dose ,expiration, date,time route
-
What are the third check procedures?
- take med to client
- check armband against MAR
- be prepared to explain drugs
- check drugs against MAR and open
- assist client to proper positioning
- ask if client wants pills one at a time or all at once.
-
How do you properly administer a medication?
- offer water or juice
- place pill in clients hand
- do not touch med
- confirm all medication is taken
- document administration
- evaluate effect of med
-
Where do you place eye medication?
in the conjuctival sac 1/2 inch above side of eye.
-
How do you give ear medication?
- adult: pulled up and back
- child: pulled down and back.
-
How far in should a suppository be inserted?
1 inch pas the internal anal sphincter. patient is on left side.
-
List some types of syringes.
- hypodermic
- insulin
- tuberculin
- tubex
- carpojet
-
What are factors that determine needle size.
- size of pt
- viscoscity of med
- type of injection
-
How much liquid is used for an intradermal injection
0.1 ml
-
How do you perform a Sub-Q injection?
- 45-90 degree angle
- .5-1. cc
- pinch the skin.
-
How do you perform an IM injection?
90 degrees , spread the skin, it by passes the GI tract and its faster then the SQ route. Avoid BV bones and nerves.
-
Wheres the ventrogluteal site
form a "V" with fingers inject in the middle on the greater trochanter. its a safe site because of no large nerves.
-
Wheres the dorsogluteal site?
divide buttocks into 4 quads, upper upper right.
-
Where is the vastus lateralis.
in between the knee and hip, on the lateral side.
-
Where is the rectus femoris site
middle thigh, front
-
Deltoid injection?
shoulder/arm area
-
How do you perform a Z track method injection?
- pull tissue laterally to side
- inject into muscle
- aspirate
- injects medication
- count 10 second then withdraw needle
- release skin, do NOT massage area
-
Why are IVs used?
- supply fluid if not able to take po
- hydration
- facilitate blood and blood products
- adminster meds
- life line
- first choice for emergency/ pain relief
-
What is diffusion?
solid matter moves from higher concentration to lower concentration distributing particles.
-
What is osmosis?
movement of fluid(solvent) via semi-perieable membrane from lower concentration to higher concentration.
-
What is active transport?
ions move lesser to higher against concentration gradient-need ATP
-
What is filtration?
water and substances move together in response to fluid pressure high hydrostatic pressure(arterial) to low hydrostatic pressure(venous)
-
What is osmolality?
what is osmolarity?
- 1. concentration of particles in plasma
- 2. number of molecules in a liter of solution.
- *measure in miliosmoles per liter
- normal serum osmolality=280-295
- over = dehydration under=overhydration
-
When an IV bad has the osmolarity level what does that determine?
tonicity of the solution and how it affects fluid movement.
-
What are isotonic solution?
- resemble same osmolality of the blood. (250-350)
- no fluid movement in the compartment
-
What is a hypotonic solution?
- has less concentration that our plasma solutes (<250)
- fluid will shift from the vascular compartment to the cell, thus causing the cell to swell.
-
What is a hypertonic solution?
- has greater solute concentration that plasma (>350)
- fluid moves from the cell into the vascular compartment, thus shrinking the cell, and expanding the vascular compartment.
-
What are the different types of IV meds?
- iv drip infusion
- ivpb
- ivp or iv bolus
-
what are the nurses responsibilities for monitoring IV therapy?
- change and labe solution Q 24 hours
- change and label tubing Q 72 hours
- patient teaching
- discontinue IV
- *observe site and document, clean , dry ,intact, no redness, leaking, swelling,
-
What are complications at the IV site?
- hematoma
- phlebitis
- inflitration/extravasion
- venous spasm
-
Describe a hematoma?
- mass of blood in tissue space
- hard and tender at site
- iv rate decreased
- nurse should remove IV and restart
- observe for bleeding
- apply warm soaks
-
Describe phlebitis
- inflammations of vein
- irritated, reddened, hard to palpate
- red line may be present
- nurse removes IV and restart
- apply warm soaks
- notify MD if increased temp.
-
Describe infiltration
- seepage of fluid into surrounding tissue
- swelling
- discomfort, burning, pain
- tight feeling/edema
- nurse remove and restart
- apply warm soaks, elevate limb, check pulse and CRT
-
Describe a venous spasm
- sudden onset of pain along vein
- cause= irritating drug of cold solution
- nurse decrease flow rate, remove if needed and restart
- apply warm soaks
- infuse solutions at room temp
-
What are some systemic complications?
- septicemia
- air embolism
- speed shock
- circulatory overload
- pulmonary edema
- catheter embolism
-
What is septicemia?
- systemic infection, patient is extremely sick. fever chills N/v hypotension, tachycardia, pain, altered mental status
- start new site
- obtain blood cultures
- administer meds as ordered
- monitor patient
-
What is an air embolism?
- large amount of air entered the IV
- emergency situation- air occludes circul.
- light headedness, dyspnea, tachypnea, wheezes, cp, hypotension, seizures
- get help call phys.
- place in trendelenberg rigth side, monitor VS give 02 and meds as ordered
-
What is speed shock?
- patient is in shock position
- medical emergency as shock progresses
- irregular pulse, hypotension, chest pain, dizziness
- resuscitation may be necessary anticipate code procedures
-
What is circulatory overload?
- condition of FVE fluid volume excess
- weight gain, puffy eyelids, hypertension, SOB, crackles in lungs, moist cough
- nurse will decrease IV rate, place in fowlers position, administer o2 and medications as orderd(diuretics) monitor VS
-
What is pulmonary edema?
- worst case of circulatory overload
- lungs are filled with fluid
- emergency situation
- SOB , labored breathing, apprehensie, frothy pink sputum
- 02 therapy, meds given as ordered, anticipate code
-
What is a catheter embolism?
- catheter breaks off in vein
- sharp sudden pain at site, chest pain, tachycardia, sob
- apply tourniquet above elbow, contact md immediately, plan for venogram and establish another iv site
- always check catheter for intactness
-
Describe heparin?
- anticoagulant
- does not dissolve clots, prevent them from forming or increasing
- maybe give subQ or IV
- do not rub site afte subq
- do not aspirate
- monitor PTT
- antagonist-protamine sulfate
-
Describe coumadin?
- prevents clots from forming
- given PO
- monitor PT
- monitor INR
- monitor for bleeding tendencies
- antagonist= vit K
-
What is LMWH?
- lovenox
- 1/2 of heparin
- longer half life then heparin -administer less frequently
- low incident of antiplatelet formation
- greater bioavaliablity
- give sub Q rather than IV
-
What are nursing responsibilities with anticoagulants?
- monitor for bleeding tendencies
- note any excessive tiredness or weaknes
- uncontrolled bleeding from cuts - hold pressure for 5 mins
- avoid OTC meds
- wear medic alert bracelet
- soft toothbrush
- watch diet leafy greens no good
-
What are the stages of med variance?
- level one- meds not charted or transcribed correctly
- level two- meds not administered on time, not checking with instructor befor giving, incorrect dose, date or rate, omission of med, incorrect route
- level three- incorrect patient, give un ordered med error causes harm, failure to report controlled substance discrepancy
-
set standards for manufacture and sale of all drugs. all drugs had to meet purity and strength standards. US Pharmcaopeia and National Formulary
Federal Food Drug and Cosmetic Act of 1906
-
toxicity tests on animals for all drugs before FDA approval. FDA emowered to keep drug from being marketed and can order recalls if a drug is dangerous of if its safety is questioned. Responsible for standardization of pharmacy
Food and Drug Administartion
-
over the counter drugs could be sold without a prescription
differentiated to those requiring prescriptions
Durham Humphrey Amendment of 1952
-
provided that drugs must be effective prior to marketing
Kefauver Harris- Drug Amendment of 1962
-
prevents abuse and misuse of drugs
provides research and funding for abuse and treatment for drug abuse
controlled drug schedule was created based on abuse potential and medical effectiveness
comprehensive drug abuse prevention and controlled substances act of 1970
-
in 1983 the DEA became the governments sole legal drug enforcement agency. It is under and Justice Department. It is replaced the Bureau of Narcotics and Dangerous Drugs.
DEA
-
grants longer patent protection for new drugs and allows drug companies to maket generic drugs by proving bioequivalence rather than duplicating original company's clinical trials
Drug Price Competition and Patent Term Restoration Act of 1984
-
name given by drug company before it becomes official
generic name
-
name list in USp
official name
-
name that describes it chemically
chemical name
-
given by company, protected by patent
ex) tylenol
brand name - trade name
-
action only where applied
local
-
absorbed into systemic circulation
systemic
-
when 2 or more drugs are given
may have a different effect than expected
drug interaction
-
2 drugs with similar actions are given together for a greater effect. can use smaller doses ex - tylenol #3
additive effect
-
when one drug increases the effect of the other greater than one drug given alone ex) demerol and phenergan
potentiation/synergistic effect
-
a drug that produces the desired or predicted effect at the site. the therapeutic effect
agonist
-
a drug that blocks or counteracts the effect of another drug- may bind to receptor site
narcan,. vitk/ coumadin
antagonist
-
harmful or unintended reaction to a drug at a normal dose.
side effects
ex) cancer chemo: n/v hair loss
ADR- adverse drug reactions.
-
unusual or abnormal response to a drug by an individual
may be a genetic reaction.
ex) a tranquilizer that causes agitation
idiosyncratic reactions
-
hypersensitivity to a drug
antigen/antibody process
mild to severe
allergic reaction
-
when 2 drugs can be mixed together without an interaction
usually for mixing in a syringe or at an IV site
compatibility
-
when 2 drugs are mixed together and there is a chemical reaction
cloudy solution, crystallize, precipitate
could also counteract each other and change desired effects
incompatibility
-
prolonged use or misuse of a drug may require more medication to achieve the desired effect
needed for alcohol.drug abusers
tolerance
-
physical or psychologic need for a drug
psychologic need can exist after physical need or withdrawal has occurred
dependence
-
effect of the drug causes structural defects in an unborn fetus resulting in congenital anomalies
teratogenic effects
-
the drug accumulates in the body and the patient can experience toxic effects
frequently seen in renal/liver patients/elderly unable to metabolize and excrete drug
cumulative effect
-
the smallest amount of a drug taht will produre a therapeutic effect
minimum dose
-
the largest amount of a medication that can be safely given
maximum dose
-
gives rise to signs and symptoms of overdose or poisoning
toxic dose
-
-
1. oj enhances the absorption of ?
2. milk decreases the absorption of :?
-
prescribing many drugs at one time
excessive use of drugs
common in elderly, chronically ill, AIDS
polypharmacy
-
the stuyd of drugs and their actions on the body
pharmacology
-
how the body handles a drug from ingestion of the drug until all metabolites of the drug have been cleared by the body
pharmacokinetics
-
Steps of pharmacokinetics
- absorption
- distribution
- metabolism
- excretion
-
What are ways of absorption
?
- by mouth, enteric coated,
- IV
- IM
- Transdermal
-
the transport of the drug by the bloodstream through the body to the desired receptor sites
distribution
-
Where does drug first go to during distribution?
the most vascular organs .
-
how a drug is broken down into inactive metabolites. liver enzymes most commonly responsible.
metabolism aka biotransformation
-
how the drug and its metabolites are removed from the body. primarily through the kidneys
elimination/excretion
-
the time it take for half of the original dose of the drug to be eliminated
half life
-
when amount of drug eliminated is equal to the drug absored = plateau
steady state blood levels
-
the time it takes fro a drug to begin to work = therapeutic effect . will vary on route of administration
onset of action
-
the time it takes for maximum effect
peak actions
-
the time the medication has an effect
duration of action
-
What are the factors that influence medication dose/response?
- age- very young/old -liver/kidney limitations
- weight-
- physical well being
- psychologic state
- gender-women have more fat and less water.
- amount of food in stomach
- dosage form/ route of admin
-
What are some concerns related to older adults?
- polypharmacy
- self prescribing meds
- OTC meds
- misuse of meds
- noncompliance
-
How are controlled substances classified?
- I-street drugs, heroin MJ
- II-high abuse potential-
- III-moderate to low dependency
- IV-Limited dependency
- V-abuse potential < class IV
-
How are drugs classified?
- indicates effect on body system
- drugs can have more than one classification
- each class has nursing implication
- learn the broad characteristics first
- then learn the specific drugs in a classification
-
a disease resulting from the body's inability to produre or utilize insulin
DM-diabetes mellitus
-
multi system disease,
insidious, silent killer
major public health problem
diabetic mellitus
-
inability of the body to produce insulin
originally called juvenile Dm/IDDM
patients require exogenous insuline
type 1 diabetes
-
body produces less insulin or insuline resistance develops
originally called NIDDM/adult onset
Rx=diet, exercise,oral hypoglycemic agents and possibly insulin
Type 2 Diabetes
-
glucose levels higher than normal but not diagnostic of diabetes mellitus
(25% will develop DM)
impared glucose tolerance (IGT)
-
glucose intolerance during pregnancy
gestationa diabetes mellitus (GDM)
-
other types of diabetes?
- drug induced
- surgically induced
- disease induced
-
symptoms of diabetes
- polyuria
- polydipsia
- polyphagia
- vision changes
- weakness,fatigue
- leg ulcer, wounds that wont heal
- vaginal, fungal, yeast infections
- impotence
- obesity.inability to lose weight
-
a result of glycosuria, hypertonic, draws in water to normalize=osmotic diuresis
can lead to dehydration
rental threshold for glucose- 180mg/dl
increased frequency ort volume of urinary ouput
polyuria
-
chronic excessive intake of water
a result of polyuria
polydipsia
-
excessive eating
a result of the bodys inability to use glucose
the cells are starving and will break down fat >ketoacidosis
polyphagia
-
whats a normal blood glucose
70-110 mg
-
1. randoma plasma glucose level?
2. Fasting PG?
3.2 hour OGTT
- 1. >/= 200mg/dl
- 2.>126mg/dl two separate times
- 3. >200 mg/dl at two hours
-
What are the endocrinologists guidelines?
2 hours post prandial >140
Fasting blood glucose >110
-
Describe hypoglycemia
- BS<60 -sweating,shaking,palpitations, nervousness, confusion, visual disturbance,unconsciousness
- Treatment= 15/15 rule : 15 CHO wait 15 mins and if needed another 15 CHO
-
Sites and speed of insulin
- abdomen: absorbed quick ,duration is shortest
- arm, leg, buttock: absorbed slower and has longer duration
-
Long term complication of insulin
?
microvascular: retinopathy, nephropathy,neuropathy
macrovascular: cardiovascular disease, peripheral vascular disease
-
What is the key to preventing complications?
- tight glycemic control
- patient self management
-
How do you describe wound depth?
- deep or superficial
- partial thickness
- full thickness
-
redness of tissues due to ischemia
hyperemia
-
What are risk factors of wounds?
- pressuer ulcer, shearing force, ischmia
- decreased mental status
- inactivity/ immobility
- mositure/incontinence
- malnutrition
- decreased sensation
- friction
- body weight
- aging
-
What are the stages of a pressure ulcer?
- Stage I: involves the epidermis
- Stage II:a partial thickness skin loss involes the dermis and epidermis
- Stage III: full thickness skin loss, involving damage or necrosis of subcutaneous tissue and may extend to fascia
- Stage IV: full thickness skin lose with damage to muscle, bone, and supporting structures.
-
What do you do during wound assessment?
- measure the wound in cm
- note the staging or depth
- note appearance of surrounding skin
- note odor
- note color of wound RYB
-
What are types of wound treatment?
- debridement - mechanical, biochemical, sharp, autolytic
- nutrition- fluids, proteins, calories, vitamins
- avoidance of pressure
- maintenance of skin hygiene
-
How do you describe a wound?
- intentional/unintentional
- closed/open
- external/internal
- non-infected/infected
-
What are types of wounds?
- laceration
- contusion
- abrasion
- puncture
- incision
-
What are the phases of wound healing?
- inflammatory phase- 3-6 days
- proliferative phase- 4-21 days
- maturation phase- 21 days to 1-2 years after injury
-
What are the phases of wound closure?
- first intention: approximated edges
- second intetnion: heal from inside out, from edges to center
- tertiary intention: delay in healing ensues wound closure, closed surgically
-
What are the types of exudate
- serous
- sanguinous
- serosanguinous
- purulent
- pursanguinous
-
What are some factors that affect wound healing?
- vasculature/age
- immune status
- nutrition
- obesity
- smoking
- stress
- meds
-
What are complications of wound healing?
- infection
- hematoma
- foreign objects
- localized ischemia
- diabetes
- hemorrhage
-
partial or total rupture of a sutured wound
4-5 days post op
before collagen is implanted into the wound
dehiscence
-
protrusion of internal viscera through the incision.
sudden straing with a cough or sneeze
evisceration
-
What are types of drainage devices
- jackson prat
- hemovac
- penrose
-
What are outcomes of wound care?
- prevent infection/ promote healing
- prevent further tissue damage
- wounds remain free of foreign debris
- provide means of absorbing exudate and promoting drainage
- prevention of hemorrhage
- prevention of skin excoriation
-
Whate are dressing types?
- transparent
- moisture retentive: hyrocolloid, hydrogels, alignates, foam
-
What are kinds of dressing of wounds?
- dry
- wet to dry
- packing
- sprays
-
What do you document on awound?
- appearance
- odor
- exudate- how much
- wound approximation
- wound care provided
- types of dressing applied
- patient tolerance
-
What are factors influencing heat and cold effectiveness?
- duration of application
- protection of skin
- body part
- damage to body surface
- body surface area
- age and physical condition
-
What is mosit heat?
- decreases drying of skin
- softens wound exudates
- penetrates deeply
- does not promote sweating
- greater risk for burns
- prologned exposure causes maceration o skin
-
What is dry heat?
- less risk of burns
- doesent cause skin maceration
- retains temperature longer
- increases sweating
- does not penetrat deeply
- caused increased drying of skin.
-
What are the therapeutic effects of heat?
- vasodilation
- reduced blood viscosity
- reduced muscle tension
- increased tissue metabolism
- increased capillary permeability
-
What are the therapeutic effects of cold?
- vasoconstriction
- local anesthesia
- reduced cell meatbolism
- increased blood viscosity
- decreased muslce tension
-
Types of heat and cold applications
- compresses and soaks
- sitz bath
- aqua k pad
- hot cool packs
- hot water bottles
- heating pads
- and heat lamp
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