How much should the client participate in the admission assessment?
As much as possible
The client in distress or with mental status changes may need to have a family member to provide necessary information
When does the therapeutic relationship start?
During the admission process
When should equipment for the admission assessment be obtained?
Obtain all necessary equipment prior to arrival of the client and have it in the room
What equipment should be included in the admission assessment?
Appropriate documentation forms
Equipment needed for vital signs
Pulse oximeter
Hospital attire for the client
What is the first step of the admission process?
Introduce yourself
After introducing yourself to your client during the admission process, what should you have the client do?
Change into hospital attire
After positioning the client comfortably apply ________ and ________ (if needed) to their wrist.
Identification bracelet
Allergy band - if needed
What baseline data needs to be obtained during the admission assessment?
Vital signs
Height
Weight
Allergy status
Home medications
List the data that needs to be obtained from the admission assessment:
Baseline data
Biographical information
Client's reason for seeking healthcare
Health history
Family history
Psychosocial assessment
Nutrition
Spiritual
ROS
Safety assessment
Discharge information
What data is included in the health history?
Current illness
Current medications (prescription and OTC)
Prior illness
Chronic diseases
Surgeries
Previous hospitalizations
Any other relevant data
What data is included in the psychosocial assessment?
ETOH use
Tobacco use
Drug use
Caffeine use
History of mental illness
History of abuse or homelessness
Home situation/significant others
What data is included in the nutrition assessment?
Current diet
Chewing or swallowing problems
Recent weight gain/loss
What data is included in the spiritual health/quality of life assessment?
Religion
Beliefs
Advance directives/living will
What data is included in the safety assessment?
History of falls
Sensory impairments
Use of assistive devices
What data is included in the discharge information?
Family members in the home
Transportation for discharge
Any relevant phone numbers
Medical equipment needs at home
What needs to be done with the client's personal items?
Inventory them and document how each item was disposed of (left at bedside, in room closet, home with family, locked in facilities safe)
Orient the client and family to the room/facility and include information on:
Call light operation
Electric bed operation
Telephone services/television controls
Overhead lighting operation
Smoking policy
Restroom locations
Waiting areas
Dining/vending services
Visiting policies
Which of the following is the best source for client data during the admission process?
A. The client
After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse?
B. Orient the client to his room
What is the importance of performing a thorough and accurate admission assessment?
To obtain baseline data for comparison with future client assessments and to develop and effective nursing care plan
True or false: Clients should be advised to send jewelry and money home with family members.
True - to prevent theft and loss
True or false: The primary care provider is responsible for documenting an inventory of a client's personal items
False - the nurse is responsible as part of the admission process
What are the indications for transfer and discharge?
Client's level of care changed
Another setting is required to provide necessary care for the client
The facility doesn't offer the type of care the client now requires
The client no longer needs inpatient care and is ready to return home
When should discharge planning begin?
On client admission to the facility, unless the facility is to be the client's permanent residence
Assessing whether or not the client will be able to return to his previous resident, determining whether or not the client will need and/or have someone to assist him at home, assessing the residence to see if adaptations are required to accommodate the client, making referrals to the social worker to arrange for community services, and communicating client health status and needs to community service providers are all done with what planning?
Discharge planning
The standards for discharge education include
Identifying safety concerns for the client at home
Reviewing s/s of potential complications and when to contact either emergency care or the primary care provider
Providing the phone number of the primary care provider
Providing names and phone numbers of community resources
Step-by-step instructions for performing continuing treatments
Dietary restrictions and guidelines
Amount and frequency of therapies the client is to perform to support continued independence at home
Directions on how to take medications
Explanations for why each medication is being prescribed
What equipment is needed for transferring/discharging a client?
The client's personal belongings
Medications
Assistive devices
Medical records or a transfer form
Responsibilities of the nurse for transferring/discharging the client are
Confirmation that the receiving facility/unit is expecting the client and the room/bed is available
Communicate the time the client will transfer to the receiving facility/unit
Complete documentation
Give a verbal transfer report in person or via telephone
Confirm the mode of transportation
Make sure the client is dressed appropriately if going outside
Account for all the client's valuables
Responsibilities of the nurse receiving the transferred client
Have any specialized equipment ready
If appropriate, inform the client's roommate of the admission
Inform other health care team members of the client's arrival and needs
Meet with the client and family on arrival to complete the admission process and orientation to new facility/unit
Assess how the client tolerates the transfer
Review transfer documentation
Implement appropriate nursing interventions in a timely manner
What is included in transfer documentation?
Client demographic information, medical diagnosis and care providers
Overview of the client's health status, plan of care and recent progress
Any alterations that may precipitate and immediate concern
Notification of assessments or client care that will be needed within the next few hours
Most recent set of vital signs and any medications, including PRN medications
Allergies, diet, and activity orders
Advance directives and emergency code status
Family involvement in care and health care proxy if applicable
Presence of or need of special equipment
Discharge summary documentation is used to close the client's record. What nursing documentation is needed at discharge?
Type of discharge (order by physician, AMA)
Actual date and time of discharge, who went with the client, and how the client was transported
Where the client was discharged to
A summary of the client's condition at discharge
A description of any unresolved difficulties and procedures for follow-up
Disposition of valuables, client's meds from home and/or prescriptions
A copy of the client's discharge instructions
When transferring a client with a fractured radius from the ED to the orthopedic unit, which of the following information is the most important for the nurse to include in the transfer report?
C. Information regarding the pain medication recently administered
Which of the following information should be included in a transfer report? (select all that apply)
- The client is alert and oriented
- The client does not like spinach
- The client has an allergy to shellfish
- The client needs morphine every 4 hr
- The client has two cats at home
- The client is alert and oriented
- The client has an allergy to shellfish
- The client needs morphine every 4 hr
Who is responsible for making sure all documentation is finished prior to transfer ofa client to a new health care facility/agency?
B. Nurse transferring the client
A client with a new diagnosis of type 2 diabetes is being discharged home. Which of the following should be included in the client's discharge teaching? (select all that apply)
- Proper use of a glucometer
- Foot care
- S/S of hyper/hypoglycemia
- Measurement of intake and output
- Management of sick days
- Date of follow-up appointment
- Proper use of a glucometer
- Foot care
- S/S of hyper/hypoglycemia
- Management of sick days
- Date of follow-up appointment
What data should be included in a client's discharge summary? (select all that apply)
- Interventions performed by the physical therapist 2 days ago
- Where the client needs to go for follow-up care
- Instructions given on medication and treatments
- Summary of the client's condition at time of discharge
- The phone numbers of the home health agency that will be making home visits
- Where the client needs to go for follow-up care
- Instructions given on medication and treatments
- Summary of the client's condition at time of discharge
- The phone numbers of the home health agency that will be making home visits
Pharmacokinetics is
How medication travels through the body
The movement of a medication from its site of administration to the bloodstream.
Absorption
Most common routes of medication administration
Enteral (GI tract)
Parenteral (injection)
The transportation of a medication to its site of action by bodily fluids.
Distribution
Distribution of medication in the body may be influenced by
Circulation to site of action
Number of plasma protein binding sites
Barriers (blood-brain)
What changes a medication into a less active form or an inactive form by the action of enzymes?
Metabolism (biotransformation)
Where does metabolism of medication occur in the body?
Primarily the liver
Also in kidneys, lungs, bowel and blood
Elimination of a medication from the body primarily through the kidneys
Excretion
Where does excretion of medication take place in the body?
Primarily the kidneys
Also the liver, lungs, bowel and exocrine glands
Describes the interactions between medications and target cells, body systems, and organ to produce pharmacological effects.
Pharmacodynamics
These interactions result in the functional changes that are considered the mechanism of action of the medication.
Pharmacodynamics
Medication category and classification of medications administered under the supervision of primary care providers. These medications may be habit forming, have potential harmful effects, and require supervision.
Prescription medications
Prescription medications that require monitoring by a primary care provider, but do not pose risk of abuse and/or addiction (antibiotics, NSAIDs, insulin)
Uncontrolled substances
Prescription medications that have a potential for abuse and dependence
Controlled substances
What prescription medications are categorized into schedules?
Controlled substances
True or false: medications categorized in Schedules II through V all have approved applications
True
What schedule is Heroin?
Schedule I
Each level of medication schedules has an increasing or decreasing risk of abuse and dependence?
Decreasing
Examples of controlled substances
Codeine
Phenobarbital
Methylphenidate (Ritalin)
The FDA pregnancy risk category categorizes medications in terms of
Their potential harm during pregnancy
Category A of the FDA pregnancy category is
The safest
Category X of the FDA pregnancy category is
The most dangerous
The process by which congenital malformations are produced in an embryo or fetus (due to medications)
Teratogenesis - most likely to occur in the first trimester
For this route of administration of medication the client should be sitting
Oral or enteral (tablets, capsules, liquids, suspensions, and elixirs)
Contraindications for this type of medication administration include vomiting, absence of gag reflex, difficulty swallowing, and decreased LOC
Oral or enteral
True or false: Mix oral medications with large amounts of food or beverages
False
True or false: Enteric-coated or time-release medications must be swallowed whole
Avoid administration of oral medications with contraindicated foods or beverages such as ________
Grapefruit
Administer irritating oral medications with _______ amounts of food
Small
True or false: In general, oral medications should be administered on an empty stomach
True
Administer oral medications ____ hr(s) before meals and ____ hr(s) after meals
1; 2
What medications are given under the tongue or between the cheek and gum?
Sublingual and buccal
For what type of medication do you instruct the client to keep in place until absorbed?
Sublingual and buccal
True or false: The client may eat or drink while a sublingual or buccal tablet is in place
False
Determine whether shaking or dilution is required of what type of medications?
Liquids, suspensions and elixirs
When measuring doses for liquids, suspensions and elixirs, measure from where?
The meniscus (lowest fluid line)
A medication stored in a skin patch and absorbed through the skin producing systemic effects uses what route of administration?
Transdermal
To prevent over or underdosing of transdermal patches what should be done?
Do not cut the patches
Where should the client place a transdermal patch?
Hairless area of skin
Should the client rotate sites? If so, why?
Yes to prevent skin irritation
Prior to applying a new transdermal patch, what should be done to the area of application?
Wash skin with soap and water and dry thoroughly
How are topical medications applied?
With a glove, tongue blade, or cotton-tipped applicator
Can topical medications be applied with a bare hand?
No
Instillations (drops, ointments and sprays) are generally used for?
Eyes
Ears
Nose
When instilling medications in the eyes use a ______ aseptic technique.
Surgical
When instilling medications in the ears and nose use a ______ aseptic technique.
Medical
What position should the client be in while receiving instillation of medication in the eyes?
Sitting or supine with head tilted slightly back
Have the client look up at the ceiling
How high above the conjunctival sac should the dropper be held when administering drops?
Approximately 1 to 2 cm
Where in the conjunctival sac should drops be administered?
Center
True of false: The client should close their eye gently after drops have been instilled
True
To prevent systemic absorption of eye medication, what should be done?
Apply gentle pressure with the finger and a clean tissue on the nasolacrimal duct for 30-60 seconds
In what position should the client be in to receive ear drops?
Sitting up or in a side lying position with the ear receiving the medication facing up
True or false: Pull the auricle upward and outward for adults
True
What direction do you pull the auricle when administering ear drops in children?
Down and back
After instilling medication in the ear, what should the nurse do?
Apply gentle pressure with the finger to the tragus of the ear
What position should the client be in when receiving nasal medications?
Supine with head positioned to allow the medication to enter the appropriate nasal passage
After administering a nasal medication, what should the nurse instruct the client to do?
Breathe through the mouth, stay in a supine position and not blow his nose for 5 minutes after drop insertion
Medications usually administered through metered dose inhalers (MDI) or dry powder inhalers (DPI)
Inhalation
For MDI and DPI inhalers, the client should ______ and then ______ the medication deeply through the mouth for __ to ___ seconds and then hold the breath for __ to __ seconds.
exhale; inhale; 3 to 5; 5 to 10
How long should the client wait between puffs if taking two puffs of the same medication for inhalers?
1 minute
How many times should MID medication be shaken prior to use?
5 to 6
Where should the MDI be placed when administering the medication?
Either between the lips or 2 to 4 cm in front of the mouth
What does a spacer do for an MDI?
Keeps the medication in the device longer, facilitating delivery of the medication to the lungs and decreasing the amount of the medication deposited into the oropharynx
True or false: DPI medications need to be shaken before use
False
Where should the DPI be placed when administering the medication?
Between the lips
When giving medications through nasogastric or gastrostomy tubes, what type of syringe should be used?
A syringe without a plunger or bulb
How should medication flow into a nasogastric or gastrostomy tube?
By gravity
What form does the medication have to be in for nasogastric or gastrostomy tubes?
Liquid
Before mixing medications what needs to be done?
Check for compatibility
True or false: Medications can be mixed with enteral feedings
False
What should be done to prevent clogging of nasogastric or gastrostomy tubes?
Flush the tubing before and after each medication with 5 to 10 mL of water
For which medication administration should the nurse wear gloves?
A. NG tubes
B. Oral
C. Suppositories
D. Inhalation
Suppositories
Before inserting a suppository, the nurse should?
Remove the foil wrapper and apply lubricant (if necessary)
What position should the client be in for rectal suppositories?
Left lateral
How long should the client retain the suppository for defecation?
20 to 30 minutes
How long should the client retain the suppository for systemic absorption of medication?
60 minutes
What position should the client be in for vaginal suppositories?
Knees bent, feet flat on the bed and close to the hips (modified lithotomy position)
True or false: Vaginal suppositories are generally inserted with an applicator
True
What site is used in infants and children < 2 years of age for parenteral medication administration?
Vastus lateralis
After age 2, what sites can be used for parenteral medication administration?
Ventral gluteal or vastus lateralis
How much fluid can be injected into the ventral gluteal and vastus lateralis sites?
up to 2 mL
How much fluid can be injected into the deltoid site?
up to 1 mL
The gauge of the needle is/is not the size of the diameter of the needle
Is
The ______ the gauge, the ______ the diameter of the needle
Larger, smaller
What amount of solution volume should be used for a tuberculin syringe?
< 0.5 mL
What benefits do rotating injection sites provide?
Enhanced medication absorption and less tissue trauma
For insulin injections, what should the site be washed with?
Soap and water
For all injections, besides insulin, what should the site be washed with?
Alcohol
What types of injection sites should be avoided?
Edematous, inflamed, moles, birthmarks or scars
What type of injection is used for TB testing or checking for medication/allergy sensitivities and some cancer immunotherapy?
Intradermal
What amount of solution and why gauge needle should be used for intradermal injections?
0.01 to 0.1 mL and 26-27 gauge
What are the best sites and technique for administering intradermal injections?
Lightly pigmented, thin-skinned, hairless sites (anterior mid-forearm or scapular area of back); inject at a 10 to 15 degree angle
What type of injection is appropriate for small doses of nonirritating, water-soluble medications and is commonly used for insulin and heparin?
Subcutaneous
What length and gauge needle should be used for subcutaneous injections?
3/8 to 5/8 inch length and 25 to 27 gauge
Insulin syringes can be 26 to 29 gauge
How much solution can be injected with a subcutaneous injection?
No more than 1.5 mL
How are sites selected for subcutaneous injections?
Based on fat-pad size
- Abdomen
- Upper hips
- Lateral upper arms
- Thighs
What angle should a 3/8 inch, 25-gauge needle be inserted at?
45 degrees
What angle should a 1/2 inch, 25-gauge needle be inserted at?
90 degrees
What type of injection is used for irritating medications, solutions in oils and aqueous suspensions?
Intramuscular
For what type of injection do you use a needle that is 18 to 27 gauge and 1 to 1 and 1/2 inches long?
Intramuscular
(Usually 20 to 25 gauge)
What volume is injected with intramuscular injections?
1 to 3 mL
If a greater amount is required, it should be divided into two syringes and in two different sites
What are the most common sites for intramuscular injections?
Ventrogluteal
Dorsogluteal
Deltoid
Vastus lateralis (pediatric)
According to ATI, do you aspirate prior to medication injection for intramuscular injections?
Yes
What do you do if there is blood on aspiration while giving an intramuscular injection?
Discard the needle and syringe and prepare new medication
What technique is commonly used for intramuscular medication injections and why?
Z-track; to prevent medication from leaking back into subcutaneous tissue
What type of injection is used for administration of medications, fluid and blood products?
Intravenous
Are catheters used for short-term or long-term use for IV administration?
Short-term
Are infusion ports used for short-term or long-term use for IV administration?
Long-term
What gauge IV is used for trauma clients?
16
What gauge IV is used for surgical clients?
18
What gauge IV is used for children, older adults, medical clients and stable postoperative clients?
22 to 24
What are the preferred sites for IV insertion?
Peripheral veins in the arm or hand
In newborns, what veins may be used for IV insertion?
Veins of the head, lower legs and feet
What type of injection is used for administration of intravenous opiod analgesia?
Epidural
What equipment is necessary for epidural injections?
Infusion pump
For what type of injection is the catheter advanced through the needle that is inserted into the ______ space at the level of the fourth or fifth vertebrae?
Epidural
What are the advantages of oral medication administration?
Safe
Inexpensive
Easy
Convenient
What are the disadvantages of oral medication administration?
Highly variable absorption
Inactivation can occur by GI tract or first-pass effect
Client must be cooperative and conscious
Contraindications include nausea and vomiting
What are the advantages of IM and Sub-Q medication administration?
Use for poorly-soluble medications
Appropriate for preparing medications that are absorbed slowly for an extended period of time
What are the disadvantages of IM and Sub-Q medication administration?
IM injections are associated with a higher cost
IM injections are inconvenient
Pain with risk of local tissue damage and nerve damage
Risk for infection at injection site
What are the advantages of IV medication administration?
Rapid onset and immediate absorption into the blood
Allows control over the precise amount of medication given
Allows for administration of large volumes of fluid
Irritating medications can be given with free-flowing IV
What are the disadvantages of IV medication administration?
Associated with high cost
Inconvenient
Potentially dangerous if wrong amount or wrong medication is given because of rapid absorption rate
Increased risk for infection or embolism
True or false: Capsules containing powder can be broken apart and powdered medication dissolved according to manufacturer's instructions
True
True of false: Time release capsules may be crushed or diluted
False
True or false: Enteric-coated (hard shell) tablets must not be crushed because of the potential for irritation to gastric mucosa
True
A glass container holding medication in a solution
Ampule
What does preparation of medications from ampules require?
Syringe
Filter needle for withdrawing medication into the syringe
Needle for injection into the client
Why should the ampule be rotated when preparing the medication?
To place all liquid in the bottom of the container
How should you break the glass top of an ampule?
By holding the top with a 2 in by 2 in gauze pad and quickly snapping the glass away from the body
A single or multiple-dose closed system glass container
Vial
What form can medication be in in a vial?
Liquid
Powder
What should be done before inserting a needle into a vial?
Wipe top with alcohol
How much air should be drawn into a syringe for withdrawal from a vial?
Equal amount to the amount of solution to be withdrawn
What are the steps for mixing injectable medications from two vials?
Draw air into a syringe equal to the amount of solution to be drawn from the second vial
Inject the air into the second vial
Withdraw the needle
Draw air into the syringe equal to the amount of solution to be drawn from the first vial
Inject the air into the first vial, invert vial and withdraw the desired amount of solution
Remove the needle from the vial
Insert needle into second vial, invert vial and withdraw the desired amount of solution, then remove needle from vial
What aseptic technique is used when administering epidural medication and providing other care of epidural catheter?
Surgical
What should be monitored when giving an epidural infusion?
Vital signs and pulse oximetry
Discontinue infusion if respirations are less than 12/min and notify PCP
I&O
Urinary and bowel function - notify PCP if urinary retention and/or constipation occur
Pruritus and treat with benadryl
Nausea and vomiting and treat with antiemetic
A nurse is preparing insulin from two different vials. Which of the following actions indicates that she understands correct medication preparation?
D. The nurse discards medication if medications are mixed during preparation
An older adult client has had a CVA and is prescribed a MDI. Which nursing consideration is a priority when teaching the client how to take the medication?
B. Coordination and cognition of client
Identify the correct client position for each of the following routes of administration:
1. Oral
2. Otic
3. Vaginal
4. Rectal
A. Lying on the left side with right knee brought up toward the chest (Sims' position)
B. Sitting, semi-Fowler's or Fowler's position
C. Supine with knees bent, feet flat on the bed and close to the hips
D. Client lying on side with the ear that is receiving the drops facing up
1-B
2-D
3-C
4-A
Proper administration of eye drops includes which of the following nursing interventions? (select all that apply)
- Using medical aseptic technique
- Asking the client to look up at the ceiling
- Having the client lie in a side-lying position
- Dropping medication into the center of the client's conjunctival sac
- Instructing the client to close the eye gently
Asking the client to look up at the ceiling
Dropping medication into the center of the client's conjunctival sac
Instructing the client to close the eye gently
Identify the correct equipment needed for each of the following types of injections.
1. Intradermal
2. Subcutaneous
3. Intramuscular
4. Intravenous
A. 16-24 gauge catheters appropriate for most adults
B. A tuberculin syringe with a fine-gauge needle (26-27)
C. A short, fine-gauge needle (3/8-5/8 inch, 25-27 gauge)
D. Needle size 18 to 27 (1 to 1 and 1/2 inch, 22 to 25 gauge)
