Zagazig University Faculty of Nursing Medical Surgical Department Past Exam Paper 2023-2024 PDF

Zagazig University Faculty of Nursing Medical Surgical Department First year First Semester 2023-2024 1  ‫‪Zagazig Universi...

Zagazig University Faculty of Nursing Medical Surgical Department First year First Semester 2023-2024 1  ‫‪Zagazig University‬‬ ‫‪Faculty of‬‬ ‫‪Nursing‬‬ ‫رؤية الكلية‪:‬‬ ‫تطمح كلية التمريض ‪ -‬جامعة الزقازيق أن تكون مؤسسة تعليمية وبحثية و مساهمة فى‬ ‫التنمية المجتمعية بكفاءة تنافسية مع كليات التمريض علي المستوي المحلي والقليمي‪.‬‬ ‫رسالة الكلية‪:‬‬ ‫تلتزم كلية التمريض – جامعة الزقازيق بتقديم تعليم تمريضي يستوفى معايير الجودة و يحث‬ ‫على احترام أالقيات المهنة ويلبى احتياجات المؤسسات الصحية وانتاج أبحاث علمية تساهم فى‬ ‫رفع كفاءة الرعاية الصحية وتوفيرادمات مجتمعية لتنمية البيئة المحلية فى اطار من الحداثة و‬ ‫التنافسية‪.‬‬ ‫‪2‬‬  :‫رؤية القسم‬ ‫يتطلع قسم التمريض الباطني الجراحي كلية التمريض جامعة الزقازيق الي شغل مكان الصدارة بين‬ ‫كافة القسام العلمية المختلفة في الكلية والكليات المناظرة ويكون قادراا على منافسة كل مؤسسات‬.‫التعليم العالي والبحث العلمى للتمريض على المستوى القليمي والدولي‬ :‫رسالة القسم‬ ‫تكمن رسالة قسم التمريض الباطنى والجراحى فى إعداد طالب مؤهل معرفيا ومهاريا ومهنيا لتقديم‬ ‫رعاية تمريضية شامله ذات جوده عاليه للتمريض الباطنى والجراحى وللمرضى والصحاء‬ ‫بالمستشفيات والمراكز الصحية المختلفة والقيام بإجراء البحاث العلمية المتطورة لتلبية احتياجات‬.‫ومتطلبات سوق العمل محليا‬ Mission: The mission of Medical Surgical Nursing Department in the preparation of qualified student cognitive, skillfully and professionals to provide a comprehensive high-quality nursing care for Medical Surgical nursing, patients and healthy people in hospitals and different health centers and conduct evolving scientific research to meet the needs and requirements of the market locally. Vision: Medical Surgical Nursing Department, Faculty of Nursing, Zagazig University looks to take the lead among all the various scientific departments in the faculty and faculties counterpart and be able to compete with all higher educational institutions and scientific research for nursing at regional and international level. 3  Content List of content Page  Asepsis 5  Medication 25  Vital Signs 52  Urinary Catheterization 62  Enema 89  Bed making 101  Wound Care 114  Cardio Pulmonary Resuscitation 121 4  Asepsis Objective: At the end of the lecture, the student should be able to:  Define asepsis  List type of asepsis  Determine purpose of hand washing, wearing mask, gloves and gown  List equipment needed for each procedure  Perform the technique of asepsis  Perform preparation of sterile field Definition of Asepsis: Is the absence of pathogenic (disease-producing) microorganisms. Aseptic technique: is practices/procedures that help reduce the risk for infection. Types of aseptic technique: 1) Medical asepsis: uses practices to reduce the number, growth, and spread of microorganisms. Medical asepsis is also referred to as “clean technique،،. The purpose of medical asepsis is to prevent by all means of cross- infection from patient to another, including communicable disease infections. Indication, for all patients even when no infection is diagnosed. Examples of medical asepsis: Hand hygiene, barrier techniques, and routine environmental cleaning. 2) Surgical asepsis: or ،،sterile technique،، consists of those practices that eliminate all microorganisms and spores from an object or area. The purpose of surgical asepsis is to prevent by all means contamination of an open wound, serves to isolate an operative area from the unsterile environment, and maintains a sterile field for surgery. Indication: 1. during procedures that require intentional perforation of the patient’s skin e.g, insertion of peripheral IV catheter. 2. When the integrity of the skin is broken as a result of trauma, surgical incision, or burns. 3. during invasive procedures such as, insertion of urinary catheter. 4. Operating room, labor and delivery area and major diagnostic area. Surgical asepsis refers to surgical hand washing, the donning of surgical attire (caps, masks, and eyewear, shoes cover, sterile gown, and gloves), handling of sterile instruments and equipment, and establishing and maintaining sterile fields. 5 Hand hygiene: The most effective basic technique in preventing and controlling the transmission of infection. It includes using an instant alcohol hand antiseptic before and after providing patient care, washing hands with soap and water when they are visibly soiled, and performing a surgical scrub. Hand washing is the rubbing together of all surfaces of the hands using soap or chemical and water. Followed by rinsing under a stream of water for 15 seconds. Antiseptic hand wash: means washing hands with warm water and soap or other detergents containing an antiseptic agent. e.g, Ethanol- based hand antiseptics. Surgical hand antisepsis: is an antiseptic hand wash or hand rub technique that surgical personnel perform before surgery to eliminate transient and reduce resident hand flora. HAND HYGIENE Equipment Antiseptic hand rub Alcohol-based, waterless, antiseptic-containing emollient Hand washing Easy-to-reach sink with warm running water Antimicrobial or non-antimicrobial soap Paper towels or air dryer Disposable nail cleaner (optional) Procedure Step Rational 1 Inspect surface of your hands for breaks Open cuts or wounds can harbor high or cuts in skin. concentrations of microorganisms. 2 Inspect hands for visible soiling. If hands are visibly soiled, use soap and water until soil is removed. 3 Inspect condition of nails. Natural tips Subungual areas of hands harbor high should be 1/4 inch from fingertip and concentrations of bacteria. Long nails smooth. DO NOT WEAR artificial nails and chipped or old polish increase the or extensions. number of bacteria residing on hands. 4 Push wristwatch and long uniform Provides complete access to fingers, 6 sleeves above wrists. Avoid wearing rings. hands, and wrists. 5 Antiseptic hand rub Covering all aspects of the hands kills a. Apply an ample amount of product to transient bacteria; ensures complete palm of one hand. Enough product is antimicrobial action. needed to thoroughly cover the hands. b. Rub hands together, covering all surfaces of hands and fingers with antiseptic c. Rub hands together for several seconds Provides enough time for antimicrobial until alcohol is dry. Allow hands to dry solution to work. before applying gloves. STEP 5a Rub hands thoroughly. STEP 5a Apply waterless antiseptic to hands. 6 Handwashing using antiseptic soap 1. Remove jewelry. Wristwatch may be Provides access to skin surfaces for pushed up above the wrist (mid cleaning. Facilitates cleaning of fingers, forearm). Roll up the sleeves well hands, and forearms. above your elbows. 2. Stand 6 inches away from the sink Don't allow your uniform to touch the during the procedure. sink during the washing because it is contaminated with soil and bacteria. 3. Turn on the water Adjust the flow and Running water removes microorganisms. temperature. Temperature of the water Warm water removes less of the natural should be warm. skin oils. 4. Wet hands and lower forearms Water should flow from the least completely by holding under running contaminated to the most contaminated water. Keep hands and Forearms in the areas of the skin. Hands are considered down position with elbows straight. Avoid more contaminated than arms. Splashing splashing water and touching the sides of of water facilitates transfer of the sink. microorganisms. Touching of any surface during cleaning contaminates the skin. 5. Apply about 5 ml (1 teaspoon) of Lather facilitates removal of 7  liquid soap. Lather thoroughly microorganisms. Liquid soap harbors less bacteria than bar soap. 6. Thoroughly rub hands together for Friction with circular motion at least 5 about 10 to 15 second on the palm, times each. Keep fingertips down to back of the hand, each finger, and facilitate removal of microorganisms. between fingers, then wrists and From the skin surface. Friction loosens forearm. Special attention should be dirt from soiled areas. provided to areas such as the knuckles and fingernails, which are known to harbor organisms. Note: clean under each finger nails with orange wood stick. 7. Rinse with hands in the down position, Flow of water rinses away dirt and elbows straight. Rinse in the direction microorganisms of forearm to wrist to fingers. 8. Blot hands and forearms to dry Blotting reduces chapping of skin. thoroughly. Dry in the direction of Drying from cleanest (hand) to least fingers to wrist and forearms. clean area (forearms) prevents transfer of microorganisms to cleanest area. 9. Discard the paper towels in the proper receptacle. 10. Turn off the water faucet with a clean, Prevents contamination of clean hands dry paper towel by a less clean faucet. Turn off faucet. Rinse hands. Surgical Hand Asepsis 8 Definition: scrubbing hand and arms with antiseptic and brushes before participating in operating room. Is used to remove soil and all transient microorganisms from the skin. Purpose: To remove spread of microorganism in operating field. Equipment: Deep sink with foot or knee controls for dispensing water and soap (faucets should be high enough for hands and forearms to fit comfortably) Antimicrobial agent approved by the health care facility Surgical scrub sponge with plastic nail pick (optional) Paper face mask, cap or hood, surgical shoe covers Sterile towel Sterile pack containing sterile gown Protective eyewear (glasses or goggles) Procedure Action Rational 1. Remove bracelets, rings, and Jewelry may harbor or protect watches. microorganisms from removal. Allergic skin reactions may occur as a result of scrub agent or glove powder accumulating under jewelry. 2. Be sure that fingernails are short, Long nails and chipped or old polish clean, and healthy. Artificial increase number of bacteria residing nails should be removed. Natural on nails. nails should be less than 1/4 inch Long fingernails can puncture gloves, long. causing contamination. Artificial nails are known to harbor gram-negative microorganisms and fungus. 3. Inspect condition of cuticles, These conditions increase likelihood hands, and forearms for of more microorganisms residing on abrasions, cuts, or open lesions. skin surfaces. Broken skin permits microorganisms to enter layers of the skin. 4. Apply surgical shoe covers, cap Mask prevents escape into air of or hood, face mask, and microorganisms that can contaminate protective eyewear. hands. Other protective wear prevents exposure to blood and body fluid splashes during the procedure 5. Turn on water using knee or foot Knee or foot controls prevent controls and adjust to contamination of hands after scrub. 9  comfortable temperature. 6. Prescrub wash/rinse: Wet hands Water runs by gravity from fingertips and arms under running to elbows. lukewarm water and lather with Hands become cleanest part of upper detergent to 5 cm (2 inches) extremity. above elbows. (Hands need to be Keeping hands elevated allows water above elbows at all times.) to flow from least to most contaminated areas. Washing a wide area reduces risk of contaminating overlying gown that the nurse later applies. 7. Rinse hands and arms thoroughly Rinsing removes transient bacteria under running water. Remember from fingers, hands, and forearms. to keep hands above elbows. 8. Under running water clean under Removes dirt and organic material nails of both hands with nail that harbor large numbers of pick. Discard after use microorganisms. 9. Surgical hand scrub (with Friction loosens resident bacteria that brush) adhere to skin surfaces. Ensures a. Wet clean sponge and apply coverage of all surfaces. Scrubbing is antimicrobial agent. Visualize performed from cleanest area (hands) each finger, hand, and arm as to marginal having four sides. Wash all four area (upper arms). sides effectively. Scrub the nails of one hand with 15 strokes. Scrub the palm, each side of thumb and fingers, and posterior side of hand with 10 strokes each. 10 b. Divide the arm mentally into Eliminates transient microorganisms thirds: scrub each third 10 times. and reduces resident hand flora. Rinse brush and repeat sequence for the other arm. A two-brush method may be substituted (check health care facility policy). c. Discard brush. Flex arms and Hands remain the cleanest part of rinse from fingertips to elbows in upper extremities. one continuous motion, allowing water to run off at elbow d. Turn off water with foot or knee Keeps hands free of microorganisms. control, with hands elevated in front of and away from body. Enter operating room suite by backing into 11 room. e. Approach sterile setup; grasp Water contaminates sterile setup. sterile towel, taking care not to drip water onto sterile setup. f. Bending slightly at waist, keeping Avoids sterile towel from contacting hands and arms above waist and unsterile scrub attire and transferring outstretched, grasp one end of sterile contamination to hands. Dry skin towel and dry one hand, moving from cleanest (hands) to least clean from (elbows). fingers to elbow in a rotating motion g. Repeat drying method for other Prevents accidental contamination. hand by carefully reversing towel or using a new sterile towel. h. Drop towel into linen hamper or Prevents accidental contamination. circulating nurse’s hand. 11 Optional: Brushless antiseptic Promotes reduction in hand rub microorganisms on all surfaces of a. After pre scrub wash, dry hands hands and arms. and forearms thoroughly with paper towel. b. Dispense 2 mL of antimicrobial agent hand preparation into palm of one hand. Dip fingertips of opposite hand into hand preparation and work it under nails. Spread remaining hand preparation over hand and up to just above elbow, covering all surfaces 12  c. Using another 2 mL of hand preparation, repeat with other hand. d. Dispense another 2 mL of hand Ensures complete antiseptic coverage preparation into either hand and of all hand surfaces. reapply to all aspects of both hands up to wrist. Allow to dry before donning gloves. 12. Proceed with sterile gowning Personal protective equipment (PPE) - Personal protective equipment is specialized clothing or equipment (e.g, gown, masks or respirators, protective eye wear, caps, and gloves) which wear for protection against exposure to infectious materials. - For sterile surgical procedures, first apply a clean cap that covers all of your hair and then the surgical mask and eyewear. - Remove PPE in the following order: gloves, face shield or goggles, gown, and then mask. After removing all PPE, perform hand hygiene. Applying surgical mask Purpose:  Prevent inhalation of pathogenic of microorganism.  Discourage the wearer from touching the mucous membrane of the eye, nose and mouth until after hands are washed. Equipment  Surgical mask Procedure Action Rational 1. Grasp the two top strings or loops of Metal strip fits snugly against the the mask (the top part of the mask usually bridge of nose has a lightweight metal strip that goes over the bridge of the nose). 13 2. Position mask to cover your nose and Establishes a respiratory barrier. mouth. 3. Tie the top strings above your ears at Provides for a tight fit of the mask. the top back of your head. 4. Tie the bottom strings at the back-base Prevents irritation to the ears. of your neck so that the bottom part of the mask fits snugly around your chin. 5. Grasp and pinch the metal strip around Minimizes number of microorganisms bridge of nose. that can escape around nose. Removing surgical mask Prevent organisms on them from being 1. Wash your hands. transferred to your hand and neck. 2. Untie the lower strings first, then the This prevents the mask from falling on top ones. your clothes or around your neck. 3. Discard the disposable mask in To prevent spread of microorganism. receptacle. 4. Wash your hands. Gloving Technique There are two methods for applying sterile gloves: open and closed. - The open method is used most frequently when performing procedures that require the sterile technique Such as dressing changes. 14  - The closed method is used when the nurse wears a sterile gown and the cuff of the gloves over and covers the sleeves of gown. Purpose: To prevent spread of microorganism into surgical field. Equipment - Package of proper-sized sterile gloves. Procedure (open method) Action Rational 1. Wash hands. Prevents transmission of infection 2. Read the manufacturer’s instructions on the Manufacturers package gloves package of sterile gloves; proceed as directed in differently; the instructions will tell removing the outer wrapper from the package, you how to properly open to avoid placing the inner wrapper onto a clean, dry contamination of the inner wrapper; surface. any moisture on the surface will contaminate the gloves. 3. Identify right and left hand; glove dominant Dominant hand should facilitate motor hand first. dexterity during gloving. 4. Open package by grasping wide cuff with the Maintains sterility of the outer surfaces thumb and first two fingers of the no dominant of the sterile glove. hand, touching only the inside of the cuff. 5. Gently pull the glove over dominant hand, Prevents tearing the glove material; making sure the thumb and fingers fit into guiding the fingers into proper places proper space of glove. facilitates gloving. 15 6. With gloved dominant hand, slip your finger Cuff protects gloved fingers, under cuff of other glove, gloved thumb maintaining sterility. abducted, making sure it doesn't touch any part on your non dominant hand. 7. Gently slip the glove onto your non dominant Contact is made with two sterile hand, making sure the finger slip into proper gloves. space. 8. With gloved hands, interlock fingers to fit the Promotes proper fit over the fingers gloves onto each finger. Removing gloves 1. Grasp the cuff of the first glove to be Contact is made with two sterile gloves removed 2 to 3 inches below edge. 16 2. Pull the first glove off your hand, turning it Removes glove without contact with out and crumpling it into the palm of your soiled surfaces. gloved hand. 3. Insert the fingers of your ungloved hand Exposes only the clean surface of the under the cuff and pull the glove off. gloves 4. Discard of gloves in proper container. Prevents the transfer of microorganisms 5. Wash hand. Prevent spread of microorganism Applying sterile gloves and gown (Closed Method) Purpose: To prevent spread of infection into sterile field Equipment  Sterile gown  Sterile and proper-sized gloves Procedure Action Rational Gowning 1. The sterile gown is folded inside out. Allows ungloved hands to touch only the inside 2. Grasp the folded gown inside the Keeps the outside of the gown sterile. neckline, step back, and allow the gown to open in front of you; keep the inside of the gown toward you; do not allow it 17 to touch anything. 3. Push right hand into inside of the arm Prevents the gown from touching non sterile hole. objects; allows sterile items to come in contact only with other sterile items 4. Grasp outside of the second sleeve with your covered hand and push your second hand inside of arm hole. 5. Ask the nurse to secure tie at the neck Prevents any part of the gown from touching and waist. anon sterile object; provides complete coverage of undergarments Closed gloving 1. With hands still inside the gown Maintains sterility of the gloves sleeves, open the inner wrapper of the gloves on sterile gown field 18 2. With your non dominant hand sleeved hand, grasp the cuff of the glove for the Only sterile items come in contact with each dominant hand and lay it on the other. extended dominant forearm with palm up; place the palm of the glove against the sleeved palm, with fingers of the glove pointing toward elbow. 3. Manipulate the glove so that the Prevents the hands from contaminating the sleeved thumb of your dominant hand is sterile glove. grasping the cuff; with your non dominant hand, turn the cuff over the end of dominant hand and gown’s cuff. 4. With sleeved non dominant hand, Provides a closed sterile method for gloving; the grasp the cuff of the glove and the glove cuff over the gown prevents contamination gown’s sleeve of the dominant hand; of the operative field with microorganisms. slowly extend the fingers into the glove, making sure the cuff of the glove remains above the cuff of the gown’s sleeve. 19 5. With the gloved dominant hand, Only sterile items can touch each other. repeat steps2 and 3. 6. Interlock gloved fingers, secure fit. Promotes dexterity of gloved hands. Preparing and maintaining sterile field Purpose: To provide sterile work area when performing those procedures those require sterile technique such as changing burn dressings or large wound dressings. Equipment  Antimicrobial soap for hand washing.  Clean towel as rape in square shape ball.  One kidney basin  Number of dressing  Number of gauze  Number of cotton sponge.  Adhesive tape.  Sterile forceps  Scissors for removal of suture Procedure Action Rational Preparing package 1. Wash hand with soap and water and dry it. Prevent transmission of infection. 2. prepare equipment's as needed e.g a) Clean dressing towel as rape in square Prevents break in technique during shape ball. procedure b) One kidney basin 20  c) Number of dressing d) Number of gauze e) Number of cotton sponge. f) Adhesive tape. g) Sterile forceps h) Scissors for removal of suture. N.B: Dressing towel or material used to pack items that will be subjected to gas sterilization, must allow penetration and release of gas and moisture. 3. Ensure that the towel is clean and intact. 4. Check the efficiency of the equipment 5. Place the towel as diamond shape in the Prevents you from reaching over the middle area table as following: sterile field; stepping back decreases A. Proximal flap D risk that drape will touch your B. Right flap C B uniform. C. Left flap D. Distal flap A 6. Place the kidney basin in the middle of towel. 7. Place a thin layer of cotton in the bottom of kidney basin. 8. Place inside of iodine a number of gauze and sponges 9. Put in another side a number of dressings. 10. Place metal articles according to a type of package. 11. Close the package as follows. *Close the proximal flap then two lateral flaps (right then left) and the latest distal flap. Avoids contamination 21 12. Fix the pack with adhesive tape. To maintain closure and prevent exposure and contamination after sterilization. 13. Label the package to know type of it. Ensures proper solution and strength. Opening a sterile package The principle to observe when opening sterile package are as follows: * Hand washing and wearing the mask are necessary before opening any sterile item. *Sterile package must be opened after being placed on a flat surface. *Opening the flap in the appropriate sequence eliminates reach in over the sterile field and maintains the sterility of the contents, therefore open: -The distal flap first, - The lateral flap next and - The proximal flap toward the body. *A sterile items needs to be covered if it isn't being used immediately. *Reapply the cover by touching only the outside of the wrapper. *Always face the sterile field. *Allow sufficient space between your body and the sterile field. *To pour antiseptic solution to sterile sponge in a sterile bowel:  Before pouring any solution, read the label carefully to make sure you have the correct solution.  Remove the lid or cap from the bottle and invert the cap before placing it on a surface that is not sterile.  Hold the bottle so that the label is upper most, to prevent damage or obliterate the label.  Hold the bottle of solution at a high of 10-15 cm over the bowel and to the side of the sterile field so that as a little of the bottle as possible is over the sterile field. 22   Pour the solution gently so as not to splash the liquid.(if the sterile bowel is on an unsterile surface, any moisture will contaminate the field by facilitating the movement of microorganism through the sterile drape. Action Rational Opening sterile package 1. Wash hands with soap and water and Prevent transmission of dry it. infection 2. Wear mask. 3. Wear sterile gloves. 4. Place the Package in the center of This position prevents sterile field. So that the top flap of the subsequent reaching directly wrapper opens away from you. over the exposed sterile content which could contaminate them. 5. Remove the adhesive tape. 6. Bending our dominant hand around the It is important to open the distal Package to pinch the distal flap and the flap first, so that your unsterile outside of wrapper between your thumb arm doesn't reach across the and index finger. sterile content. 7. Lift the distal flap up and toward the Touching only the outside of the back away from the wrapper. wrapper to maintain the sterility of the inside the wrapper. 8. Start to open the lateral flaps of the Both hands are used to avoid towel, use the right hand for the right flap reaching over the sterile and the left hand for the left flap. contents. 23 10.Open the proximal flap and lift the flap Make sure that flap doesn't up and toward you. touch your uniform. If the inner surface touches any unsterile article, it is considered contaminated 10. If you need anything from the Prevent touching of sterile field package, hold the proximal flap with left hand and take the thing by right hand and then return the proximal flap to cover the contents of package. 24  Medication Aim: Teach the students how to administer medication with safety Objectives: By the end of this lecture the student will be able to:  Discuss principles of safe medication administration including the five rights of medication administration.  Identify routes of the administration of medications  Describe types of parental route of medication administration  Describe the complications of I.V therapy Introduction: We take medications to diagnose, treat, or prevent illness. They come in lots of different forms and we take them in many different ways. You may take a drug yourself, or a healthcare provider may give it to you. Routes for administrating drugs Route Explanation Buccal held inside the cheek delivered directly into the stomach or intestine (with a G- Enteral tube or J-tube) Inhalable breathed in through a tube or mask injected into a vein with an IV line and slowly dripped in Infused over time Intramuscular injected into muscle with a syringe Intrathecal injected into your spine Intravenous injected into a vein or into an IV line Nasal given into the nose by spray or pump Ophthalmic given into the eye by drops, gel, or ointment 25 Oral swallowed by mouth as a tablet, capsule, lozenge, or liquid Otic given by drops into the ear Rectal inserted into the rectum Subcutaneous injected just under the skin Sublingual held under the tongue Topical applied to the skin Transdermal given through a patch placed on the skin Principle of Medication Administration  Step the principle procedure for safety and the best-efficacy based on The 10 Rights of Medications Administration 1. Right patient  Check the name on the prescription and wristband.  Ideally, use 2 or more identifiers and ask the patient to identify themselves. 2. Right medication  Check the name of the medication, brand names should be avoided.  Check the expiry date.  Check the prescription.  Make sure medications, especially antibiotics, are reviewed regularly. 3. Right dose  Check the prescription.  Confirm appropriateness of the dose using the BNF or local guidelines.  If necessary, calculate the dose and have another nurse calculate the dose as well. 4. Right route  Again, check the order and appropriateness of the route prescribed.  Confirm that the patient can take or receive the medication by the ordered route. 26 5. Right time  Check the frequency of the prescribed medication.  Double-check that you are giving the prescribed at the correct time.  Confirm when the last dose was given. 6. Right patient education  Check if the patient understands what the medication is for.  Make them aware they should contact a healthcare professional if they experience side-effects or reactions. 7. Right documentation  Ensure you have signed for the medication AFTER it has been administered.  Ensure the medication is prescribed correctly with a start and end date if appropriate. 8. Right to refuse  Ensure you have the patient consent to administer medications.  Be aware that patients do have a right to refuse medication if they have the capacity to do so. 9. Right assessment  Check your patient actually needs the medication.  Check for contraindications.  Baseline observations if required. 10. Right evaluation  Ensure the medication is working the way it should.  Ensure medications are reviewed regularly.  Ongoing observations if required.  Perform hand hygiene. (Rationale: to prevent the spread of infection)  Collect prescription and ensure that the patient is available and understandable to take the medication.(Rationale: to secure informed- consent)  Check the medicine as the points: name, components, dose, expiry date (Rationale: to provide safe and efficient medication)  Prior to administration ensure you are knowledgeable about the drug(s) to be administered. This should include: therapeutic use, normal dosage, routes/forms, potential side effects, contra-indications. (Rationale: to ensure safety and well-being of client and enable you to identify any errors in prescribing). 27   Confirm identity of client verbally and with chart, prescription, checking full name, age, date of birth: Right patient.(Rationale: to ensure that the correct drug is being administered to the correct client)  Ensure that the medication has not been given till that time (Rationale: to ensure right dose).  Do not crush time-release capsules or enteric-coated tablets (Rational: Enteric-coated tablets that are crushed may irritate the stomach’s mucosal lining. Opening and crushing the contents of a time-release capsule may interfere with its absorption.  Stay with patient until all medication has been swallowed.  Don't use drug that differs from normal color, odor or consistency.  The nurse who prepares a given medication should administer it.  Don't permit one patient to carry medicine to another.  Record if the patient refuses an ordered medication.  Record only unusual effect of medication.  Never record medication before it has been administered.  An error in medication must be reported immediately. Removing Medications from an Ampoule Definition: To remove medication form an ampoule defines that you prepare medication from an ampoule for IV, IM or another administration of medication. Purpose: 1. To prepare medication for administration of medication by sterilized method Equipment's required: 1. Medication chart 2. Sterile syringe (1) 3. Sterile needle (1) 4. Second needle (optional) 5. Spirit swab 6. Ampoule of medication prescribed 7. Ampoule cutter if available (1) 8. Kidney tray (1) 9. Steel Tray (1) 10. Container for discards if possible Note: Syringe Composed of 3 parts tip, barrel and plunger Needle: Composed of: bevel, shaft and hub 28  Procedure Action Rational 1. Gather equipment's. Check the This comparison helps to identify medication order against the original that may have occurred when Dr.'s order according to hospital/ orders were transcribed agency policy. 2.Performhand hygiene To prevent the spread of infection 3. Tap the stem of ampoule or twist This facilitates movement of your wrist Quickly while holding the medication in the stem to the body ampoule vertically. of the ampoule. 4. Wipe the neck around of the To prevent entering of dust and ampoule by spirit swab microorganisms. 5. After drying spirit, put and round To cut smoothly and avoid making ampoule cutter to the neck of the any shattered glass fragments ampoule roundly. 6. Put spirit swab to the neck of the This protects the nurses' face and ampoule. Use a snapping motion to finger from any shattered glass break off the top of the ampoule fragments. along the pre-scored line at its neck. Always break away from your body. 7. 1) Remove the cap from the needle by pulling it straight off. The rim of the ampoule is 2) Hold the ampoule by your non- considered dominant hand (usually left hand) contaminated.use of a needle and insert the needle into the prevents the accidental ampoule, being careful not to touch withdrawing of small glass the rim. particles with the medication. 29  Cut-point on the ampoule Cut the ampoule with holding cut- point up Tapping the stem of an ample Twisting your wrist holding it vertically 8. Withdraw medication in the  By withdrawing a small amount amount ordered plus a small amount more of medication, any air more (- 30 %). Do not inject air into bubbles in the syringe can bed is solutions. placed once the syringe is 1) Insert the tip of the needle into the removed. ampoule.  Handling the plunger at the 2) Withdraw fluid into the syringe knob only will keep the shaft of touch the plunger at the knob only. the plunger sterile. 30  9.  Ejecting air into the solution 1) Do not expel any air bubbles that increases pressure in the may form in the solution. ampoule and can force the 2) Wait until the needle has been medication to spill out over the withdrawn to tap the syringe and ampoule. Ampoules may have expel the air carefully. over fill. 3) Check the amount of medication  Careful measurement ensures in the syringe and discard any that the correct dose is surplus. withdrawn. 10. Discard the ampoule in a kidney If not all of the medication has been tray or a suitable container after removed from the ampoule, it must comparing with the medication chart. be discarded because there is no way to maintain the sterility of the contents in an unopened ampoule. 11. Recap to the syringe by sterilized Used needle might be touched with method and keep the syringe in safe the inside of the ampoule so the and clean tray. If the medication is to lumen might become dull. If you be given IM or if agency policy give IM, needle should be changed requires the use of a needle to to new one to insert smoothly into administer medication, attach the muscle. selected needle to the syringe. 12. Perform hand hygiene. To prevent the spread of infection Removing medications from a vial Definition: To remove medication form a vial defines that you prepare medication from an ampoule for IV, IM or another administration of medication. Purpose: 1. To prepare medication for administration of medication by sterilized method 31  Equipment's required: 1. Medication chart 2. Sterile syringe (1) 3. Sterile needle (1): Size depends on medication being administration and patient. 4. Vial of medication prescribed 5. Spirit swabs 6. Second needle (optional) 7. Kidney Tray (1) 8. Steel Tray Procedure Action Rational 1. Gather equipment's. Check medication This comparison helps to identify order against the original Dr.’s order errors that may have occurred when according to agency policy. orders were transcribed. 2. Perform hand hygiene. To prevent the spread of infection 3. Remove the metal or plastic cap on the The metal or plastic cap prevents vial that protects the rubber stopper. contamination of the rubber top. 4. Swab the rubber top with the spirit Sprit removes surface bacteria swab. contamination. This should be done the first the rubber stopper is entered, and with any subsequent re-entries into the vial. 5. Remove the cap from the needle by Before fluid is removed, injection of pulling it straight off. Draw back an an equal amount of air is required to amount of air into the syringe that is prevent the formation of a partial equal to the specific dose of medication vacuum because a vial is a sealed to be withdrawn. container. If not enough air is injected, the negative pressure makes it difficult to withdraw the medication 6. Pierce the rubber stopper in the center Air bubbled through the solution with the needle tip and inject the could result in withdrawal of an measured air into the space above the inaccurate amount of medication. solution. The vial may be positioned upright on a flat surface or inverted. 7. Invert the vial and withdraw the This prevents air from being needle tip slightly so that it is below the aspirated into the Syringe. fluid level. 8. Draw up the prescribed amount of Holding the syringe at eye level medication while holding the syringe at facilitates accurate reading, and eye level and vertically. vertical position makes removal of "Nursing Alert" air bubbles from the syringe easy. Be careful to touch the plunger at the  Handling the plunger at the knob knob only. only will keep the shaft of the 32  plunger sterile. 9. Removal of air: 1) If any bubbles accumulate in the  Removal of air bubbles is syringe , tap the barrel of the syringe necessary to ensure that the dose sharply and move the needle past the of medication is accurate. fluid into the air space to re-inject the air bubble into the vial. 2) Return the needle tip to the solution and continue withdrawing the medication. 10. After the correct dose is withdrawn, This prevents contamination of he remove the needle from the vial and needle and protects the nurse against carefully replace the cap over the needle. accidental needle sticks. 11. If a multidose vial is being used, Because the vial is sealed, the label the vial with the date and time medication inside remains sterile and opened, and store the vial containing the can be used for future injections. remaining medication according to agency policy 12. Perform hand hygiene. To prevent the spread of infection Intra-Muscular Injection (IM) Definition: Intra-muscular injection is the injection of medicine into muscle tissue. Intramuscular injections are often given in the deltoid, vastus laterials, ventrogluteal and dorsogluteal muscles. Intramuscular injections are a common practice in modern medicine. They’re used to deliver drugs and vaccines.  Intramuscular route provides faster medication absorption than SC because of a muscle greater vascularity. 33  There is less danger of causing tissue damage when medication enters deep muscle, but the risk of inadvertently injecting medications directly into the blood vessels exists.  Weight and the amount of adipose tissue can influence needle size.  The angle of insertion for IM is 90 degree.  A normal well developed patients can tolerate 3ml of medication into a large muscle without sever muscle discomfort. No more than 4ml should be injected into a single injection site for an adult with well-developed muscle. Children and older adults and thin patient can tolerate only 2ml of IM injection. Sites of IM Injection 1. Ventrogluteal: is situated deep and away from major nerves and blood vessels.  Is recommended for both adults and children older than 7 months of ages as a safe for IM injection.  To locate the ventrogluteal site, the nurse places the palm over the greater trochanter, with the finger facing the patient's head, the right hand is used for the patient's left hip, or the left hand for the right hip, to identify landmarks, the index finger is placed on the anterosuperior iliac spine and middle fingers extend dorsally palpating the crest of the ileum. A triangle is formed. The injection is made in the center of the triangle. 2. Dorsogluteal: is located in the buttock.  The dorsogluteal muscle has been a traditional site for IM injections; however a risk exists of striking the underlying sciatic nerve or major blood vessels. Insertion the needle into the sciatic nerve can cause permanent or partial paralysis of the involved leg.  The gluteal muscle are developed by walking, therefore, the dorsogluteal site isn't to be used for children younger than three of age because their gluteal muscle is too small. 3. Vastus lateralis: is another site used in the adult patient.  The muscle is thick and well developed, is located on the anterior lateral aspect of the thigh and extends in an adult from hand breath above the knee to a hand breadth below the greater trochanter of the 34  femur; the middle third of the muscle is the suggested site for injection.  With young children, it helps to grasp the body of the muscle during injection to be sure that the medication is deposited in muscle tissue.  To help relax the muscles, the nurse asks the patient to lie with knee slightly flexed or in sitting position. 4. Deltoid: is located in lateral aspect of the upper arm.  It is not often used because it is a small muscle and isn't capable of absorbing large amounts of solution.  The radial and ulnar nerves and brachial artery lie within the upper arm along the humerus.  The nurse should use this site for small injection volumes or when other sites are inaccessible.  The patient has patient relax the arm at the side and flex the elbow then palpates the lower edge of the acromion process, which forms the base of a triangle the injection is in the center of triangle, the nurse can also locates the site by placing four fingers across the deltoid muscle, with the top finger along the acromion process, the injection site is then three fingers below the acromion process. 35 Z- Track Technique:  Is used to minimize irritation by sealing the medication in the muscle tissue.  Anew needle must be applied to the syringe after preparing the medication so that no solutions remain on the outside needle shift.  After preparing skin with antiseptic swab, the nurse pulls the overlying skin and SC tissue approximately 2.5-3.5 cm laterally to the side holding the skin taut with non-dominant hand, the nurse injects the needle deep into the muscle.  The nurse injects the medication slowly if there is no blood return on aspiration then release the skin after withdrawing the needle. this leaves a zigzag path that the needle track where tissue layers slides across each other's.  The medication can't escape from the muscle tissue.  Massage the site isn't recommended because it may cause irritation by forcing the medication to leak back into the needle track, but gentle pressure may be applied with a dry sponge. Purpose of Z-Track Injection:  The Z-track method is not often recommended, but can be particularly useful with medication that must be absorbed by muscle to work. It also helps to prevent medication from seeping into the subcutaneous tissue and ensures a full dosage. Some medications are dark colored and can cause staining of the skin. If this is a side effect of the medication you will be taking, the doctor may recommend using this technique to prevent injection site discoloration or lesions. Z-Track Injection Sites: Z-track injections can be performed at any intramuscular injection location, though the thigh and buttocks are the most common sites.  Thigh (vastus lateralis muscle): Divide the upper thigh in thirds. Use the middle third, on the outside or middle of the muscle for the injection.  Hip (ventrogluteal): Place the heel of your hand on the head of the greater trochanter (hip bone) with your thumb pointing toward the abdomen. Extend your index finger up to the anterior 36  superior iliac spine then spread your other fingers back along the iliac crest. Insert the needle in the “V” formed between your index and third fingers. Risks and Side Effects: Z-track injection is generally considered a common and safe procedure. Mild side effects include swelling, site pain, and bruising. Less common, but more serious risks include:  formation of abscess  infection – redness, swelling, warmth or drainage  damage to tissues, nerves, blood vessels, or bones  hemorrhage, especially in people with bleeding disorders If you notice any unusual side effects or signs of an infection, promptly notify your physician. Administration an intramuscular injection Equipment's required: 1. Patient’s chart and kardex 2.Prescribed medication 3. Sterile syringe (3-5mL) (1) 4. Sterile needle in appropriate size: commonly used 21 to 23G with 1.5”(3.8cm) needle (1) 5. Disposable gloves if available (1) 6. Pen 7. Spirit swabs Procedure Action Rational 1. Assemble equipment's and check This ensures that the patient receives the right the Dr.’s order. medication at the right time by the proper route. 2.Explain the procedure to the patient Explanation fosters his/her cooperation and allays anxiety 3.Perform hand hygiene and put on  To prevent the spread of infection gloves if available  Gloves act as a barrier and protect the nurse’s hands from accidental exposure to blood during the injection procedure 4.Withdraw medications from an To prepare correct medication safely before ampoule or a vial as described in the using. procedure 37 5.Identify the patient carefully using the following way: a. Check the name in the  This is the most reliable method if identification bracelet available b. Ask the patient his/her name  This requires an answer from the patient. c. Verify the patient’s identification In the elderly and/or illness the method with a staff member who knows the may causes confusion. patient  This is double-checked identify 6. Close the door and put a screen. To provide for privacy 7.1) Assist the patient to a  Collect site identification decreases the comfortable position. risk of injury. 2)Select the appropriate injection site  God visualization is necessary to establish using anatomic landmarks the correct location of the site and avoid 3) Locate the site of choice damage to tissues. "Nursing Alert"  Nodules or lumps may indicate a previous Ensure that the area is not tender and injection site where absorption was is free of Lumps or nodule inadequate. 8.Cleanse the skin with a spirit swab: 1) Start from the injection site and  Cleansing the injection site prepares it for move outward in the injection a circular motion to a circumference  This method remove pathogen away from of about 2” (5cm) from the injection the injection site site  Alcohol or spirit gives full play to 2)Allow the area to dry disinfect after dried to prepare a dry gauze Place a small, dry gauze or spirit or spirit swab to give light pressure swab on a clean, nearby surface or immediately after I.M. hold it between the fingers of your non-dominant hand. 9. Remove the needle cap by pulling This technique lessens the risk of accidental it straight off. needle-stick and also prevents inadvertently unscrewing the needle from the barrel of the syringe. 10. Spread the skin at the injection This makes the tissue taut and facilitates site using your non-dominant hand needle entry. You may minimize his/her discomfort 11. Hold the syringe in your This position keeps your fingers off the dominant hand like a pencil or dart. plunger, preventing accidental medication loss while inserting the needle 12. Insert the needle quickly into the  A quick insertion is less painful tissue at a 90 degree angle.  This angle ensures you will enter muscle tissue. 13. Release the skin and move your To prevent movement of the syringe 38 non-dominant hand to steady the syringe’s lower end. 14.Aspiration blood:  A blood return indicates IV needle 1) Aspirate gently for blood return by placement pulling back on the plunger with your  Possibly a serious reaction may occur if a dominant hand drug intended for intramuscular use is 2) If blood enters the syringe on injected into a vein aspiration, withdraw the needle and  Blood contaminates the medication, which prepare a new injection with a new must be redrawn. sterile set-up. 15. If no blood appears, inject the Rapid injection may be painful for the patient. medication at a slow and steady rate(; Injecting slowly reduces discomfort be 10 seconds/ mL of medication) allowing time for the solution to disperse in the tissues 16. Remove the needle quickly at the Slow needle withdrawal may be same angle you inserted it. uncomfortable for the client 17. Massage the site gently with a  Massaging the site promotes medication small, dry gauze or spirit swab, unless absorption and increases the client’s comfort. contraindicated for specific  Do not massage a heparin site because of Medication. If there are the medication’s anticoagulant action contraindications to massage, apply  Light pressure causes less trauma and gentle pressure at the site with small, irritation the tissues. Massage can force dry gauze or a spirit swab. medication into the subcutaneous tissues in some medications. 18.Discard the needle:  Most accidental needle-sticks occur while 1) Do not recap the needle recapping needles 2) Discard uncapped needle and  Proper disposal prevents injury syringe in appropriate container if available 19. Assist the client to a position of  To facilitate comfort and make him/her comfort. relax 20. Remove your gloves and perform To prevent the spread of infection hand hygiene. Contraindication: IM injections may be contraindicated in patients with;  Impaired coagulation mechanisms  Occlusive peripheral vascular disease  Edema  Shock  After thrombolytic therapy 39  During myocardial infarction (Rationale: These conditions impair peripheral absorption)  The nurse may be able to minimize the patient's discomfort by:  Using a sharp beveled needle in the smallest suitable length and gauge.  Positioning the patient as comfortable as possible to reduce muscular tension.  Select the proper injection site use anatomical landmarks.  Diverting the patient's attention from injection through conversation  Inserting the needle quickly and smoothly.  Holding the syringe steady while the needle remains in tissues.  Injecting the medication slowly and steadily.  Don't administer more solution I one injection than is recommended for site.  Don’t inject areas that feel hard on palpation or tender to patient.  Rotate the sites when patient is to receive repeated injection, injections in the same site may cause undue discomfort, irritation or abscesses in tissues. What are the complications of intramuscular injections? It’s normal to experience some discomfort after an intramuscular injection. But certain symptoms may be a sign of a more serious complication. Call your doctor or healthcare provider right away if you experience:  Severe pain at the injection site  Tingling or numbness  Redness, swelling, or warmth at the injection site  Drainage at the injection site  Prolonged bleeding  Signs of an allergic reaction, such as difficulty breathing or facial swelling Intradermal injection  The intradermal injection route has the longest absorption time of all parental routes. For this reason, intradermal injections are used for diagnostic purposes; such as tuberculin test and tests to determine sensitivity to various substances. 40   The advantage of intradermal route for these tests is that the body's reaction to substances is easily visible.  Intradermal injections are placed just below epidermis. The angle of injection is 15 degrees. As the nurse injects the medication a small bleb resembling a mosquito bite should appear on the skin's surface. If a belb doesn't appear or if the site bleeds after needle withdrawal, there is a good chance the medication entered subcutaneous tissue. In this case, tests results will not be valid.  Skin tests require that the nurse be able to clearly see the injection site for change in color and tissue integrity. sites chosen should be free of lesions Sites for Intradermal injection: A. Inner aspect of the forearm, Dorsal aspect of upper arm B. Upper chest C. Upper back. Equipment  Medication administration record (MAR)  Medication  Sterile tuberculin syringe and short bevel  Alcohol swab and sterile 2 gauze pad  Disposable glove Procedure Action Rational 1. Check with patient and the chart for Prevents the occurrence of hypersensitivity any allergy reactions such as urticaria, or anaphylactic shock. 2. Wash hand Reduces transmission of microorganisms. 3. Follow five rights Promotes patient safety. 4. Prepare medication from ampoule or vial. 5. Check the patient identification Accurately identifies the client. armband 6. Explain the procedure to the patient Reduces the patient’s anxiety and enhances cooperation. 7. Place the patient in appropriate Promotes comfort. Promotes absorption of position, , provide for privacy the medication. Decreases anxiety. 41 8. Wash hand, Don disposable gloves. Decreases contact with blood and body fluids. 9. Select and clean the site (assess the Promotes absorption of the drug; reduces patient skin for redness, bruises, or trauma to the body’s tissue. broken tissue.  Select appropriate site using anatomic landmark.  Clean site with alcohol swab, using firm circulation motion 10. Prepare syringe for injection Ensures correct dosage of medication in  Remove the needle guard. the syringe.  Expel any air bubbles from syringe. 13. Inject the medication  Hold the syringe in dominant hand.  With non-dominant hand, grasp  Taut skin facilitates needle insertion. patient's dorsal forearm and gently pull the skin taut on ventral forearm.  Place the needle close the skin, bevel facing up  Insert needle at 10-15 angle, the needle tip should be visible under the  Ensures that medication is injected into skin. the intradermal tissue; initial resistance Administer medication slowly, observe indicates the needle’s tip is in the the development of abelb (resemble a subcutaneous region. mosquito bite),if not appear ,withdraw  Indicates that the medication was the needle injected into the dermis.  Withdraw the needle  Prevents spreading the medication  Pat area gently with dry gauge beyond the point of injection 11.Don't massage the area after removing the needle 11. Discard the needle and syringe in a Prevents needle sticks. sharp container 12. Remove gloves, dispose of in Reduces the spread of microorganisms. appropriate receptacle, and wash hand. 42 13. Observe for signs of allergic reaction. Ensures patient safety. 14. Draw a circle around the perimeter of Allows for easy recognition and the bleb with point pen observation of the injection site. 15. -Document medication and site of Provides a written description of the injection on the MAR. injection site and states the time the medication was administered. Subcutaneous injection  Subcutaneous tissue lies between the epidermis and muscle. Because SC tissue isn't as richly supplied with blood as the muscle.  Medication absorption is slower than IM injections. Because SC tissue contains pain receptors, the patient may experience some discomfort.SC route is used to administer insulin and heparin injections.  The injection site chosen should be free of skin lesions, bony prominences and large underlying muscles or nerves.  Patient with diabetes should practice rotation of insulin injections. Uses of same part of the body for a sequence of injections provide more consistency in the absorption of the insulin. For example, if the morning insulin injected into the patient arm then the subsequent injection should also be in the same arm. The injection is given at least one inch away from the previous site. (No injection site should be used again for at least one month).  only small doses (0.5-1) should be given SC because the tissue is sensitive to irritating solutions and large volume of medications. Collection of medication with the tissue can cause sterile abscesses which appear as hardened painful limps under the skin.  The nurse must choose needle length and angle of insertion based on weight (45or 90).thin patient may have insufficient tissue for SC injections; the upper abdomen is the best site. Sites for Subcutaneous injection 1. Abdomen 2. Lateral and Anterior Aspects of Upper Arm and Thigh 3. Scapular Area on Back 4. Upper Ventrodorsal Gluteal area. Equipment 43   Medication administration record (MAR)  Medication  Sterile syringe and 5/8-inch needle  2Alcohol swab  Disposable glove Procedure Action Rational 1. Check with patient and the chart Prevents the occurrence of for any allergy hypersensitivity reactions such as urticaria, or anaphylactic shock. 2. Wash hand Reduces transmission of microorganisms. 3. Follow five rights Promotes patient safety. 4. Prepare medication from ampoule or vial. 5. Check the patient identification Accurately identifies the client. armband 6. Explain the procedure to the Reduces the patient’s anxiety and patient enhances cooperation. 7. Place the patient in appropriate Promotes comfort. Promotes absorption position, , provide for privacy of the medication. Decreases anxiety. 8. Wash hand, Don disposable Decreases contact with blood and body gloves. fluids. 9. Select and clean the site. Promotes absorption of drug when Assess the client’s skin for bruises, injected into healthy tissue. redness, hard tissue, or broken skin. Cleanse the site with an alcohol swab; cleanse from inside outward. 10. Prepare for the injection. Prevents the injection of air into the Remove the needle guard and subcutaneous tissue. express any air bubbles from the Decreases risk for accidental syringe; check the dosage in the contamination of the needle. syringe. Ensures insertion of the needle into With dominant hand, hold the the subcutaneous tissue. syringe like adart between your thumb and forefingers. Pinch the subcutaneous tissue between the thumb and forefinger with the nondominant hand. If the client has substantial subcutaneous 44 tissue, spread the tissue taut. 11.Administer the injection. Insert the needle quickly at a 45° or Quick insertion decreases the client’s 90°angle. anxiety and the amount of discomfort. Release the subcutaneous tissue and grasp the barrel of the syringe with no dominant hand. With dominant hand, aspirate by pulling back on the plunger gently, Indicates needle has entered a blood except when administering an vessel. anticoagulant injection. Prevents the injection of medication If blood appears, remove needle and into discard in a sharps container. the blood, which causes a faster Inject medication slowly if there is absorption no blood present. rate that may be dangerous to the Remove the needle quickly and patient. lightly massage area with alcohol swab; do not massage the injection Promotes dispersement of medication site after the administration of in the tissues and facilitates absorption. anticoagulant. Do not recap the needle; discard the Prevents needle sticks. needle in a sharps container. 12.Position patient for comfort 13.Remove gloves and wash hands. Reduces the spread of microorganisms. 14.Record on the MAR the route, Provides documentation that the site, and time of injection. medication was administered. 15.Observe the patient for any side or Alerts the nurse to hypersensitivity adverse effects and assess the reactions. effectiveness of the medication at the appropriate time. Complications of subcutaneous injection - If you’ll be doing this type of injection for more than one dose or for multiple days, you’ll need to rotate the injection sites. This means that you shouldn’t inject medicine into the same spot twice in a row. - For example, if you injected medicine into your left thigh this morning, use your right thigh this afternoon. Using the same injection site over and 45  over again can cause discomfort and even tissue damage. As with any injection procedure, infection at the site of injection is a possibility. Signs of infection at the injection site include:  Severe pain  Redness  Swelling  Warmth or drainage Intravenous injection; Medications administrated I.V has immediate absorption and effect, so it is the most common route used in emergency situation. The intravenous route is most dangerous route and has more complication because the drug is placed directly into the blood stream. When using I.V medication the nurse must be: a. Follow aseptic technique b. Observe patient closely for symptoms of adverse reactions. c. Avoid errors in dose calculation and preparation. d. Double checks the six rights of safe medication administration. e. Assess vital signs before, during and after infusion Vein puncture: is technique in which vein is punctured through the skin by sharp rigid sty let e.g. cannula, butterfly,.etc. Purpose of vein puncture: 1-To collect blood specimen 2-To instill medication 3-To start IV infusion. Vascular access devices: there are two types of devices. 1-Short peripheral catheters: -It used when infusion therapy will be brief -Common IV puncture sites include the hand, arm and foot. -The use of the foot for an IV site is common in children but is avoided 46  in adult because of the danger of thrombophlebitis. Scalp vein is common in infants -Vein puncture is contraindicated in a site that has signs of infection, infiltration to avoid introducing bacteria from infected surface of skin into the blood stream. 2-Central venous access devices: -It is usually introduced into the subclavian or internal jugular vein and passed to the superior vena cava just above the right atrium. -It used for patient with large amount of variety of IV fluids, -It used also for administer medication, blood products, nutritional solution and provide a mean for hemodynamic monitoring. IV sites of injection: 1-Cephalic vein 6-Radial vein 2 -Basilic vein 7 -Superficial dorsal vein 3- Median cubital vein 8- Subclavian vein 4- Dorsal vein 9- internal jugular vein 5 - Median vein of forearm 10 - Auxiliary vein There are three ways to administer IV medications: 1. Continuous infusion: is a mixing medication in large volumes of fluid (500ml or 100ml) of I.V fluid such as normal saline or ringer lactate. This way is the most safe and easy method of administration. 2. Intermittent I.V infusion: the drug is mixed with a small amount of I.V solution (50-100ml) and administered over a short period at prescribed interval e.g. every 4 hrs 3. Intravenous bolus or push: this involves a single injection of a concentrated solution administrated directly into an I.V line. 47 IV administration of medication Equipment  Alcohol wipe  Medication  Sterile syringe  Sterile needle  Label for labeling IV solution.  Tourniquet Technique  Wash your hands, identify the patient and explain the procedure to the patient  Wearing gloves and draw the desired amount of medication into the syringe  Select the vein and round the tourniquet above the selected site.  Wipe the administration site with alcohol for 30sec with Circular motion from the inner part to the outer part and leaves the skin to dry for 30sec.  Inject the syringe into the skin with 45 ْ degree and aspirate the blood to ensure that the needle in the vein.  Inject the medication directly and slow in the vein.  Withdraw the needle once it is completed and Remove the tourniquet.  Check the IV infusion rate if the drug is injected into the IV solution.  Dispose of used equipment properly, remove the gloves.  Wash the hands and Chart medication. Regulating IV infusion: The nurse is responsible for monitoring the proper flow rate while ensuring the comfort and safety for patient.the physician prescribes the amount of solution to be administrated. Many factors can alter the rate of flow of IV infusion  The height of the container in relation to patient  The patient's blood pressure  The patient's position  The potency of IV potency  Infiltration  Any kink in the tubing 48 The nurse periodically checks the infusion every 30 min and maintenance the flow rate to keep the fluid balance through Regulating IV flow rate by:  Check physician order for IV  Check potency of IV line  Verify the number of drops in ml. the most common drop factors are macrodrop system (10-15-20drop/ml), microdrop or pediatric system (60 drop/ml) Volume ml × drop factor Calculate the Flow rate = Time in min Electric infusion control devices: limit the amount of fluid to be infused at one time and are used to regulate the flow rate at preset limit and notify the nurse by an alarm system when air is in the tubing, the flow obstructed, the solution level in the container is getting low. Syringe pumps: they deliver amounts of fluid less than 100ml they are particularly useful with infant and children Nursing Interventions in IV Infusion: a-Verify the doctor’s order b. Know the type, amount, and indication of IV therapy. c. Practice strict asepsis. d. Inform the client and explain the purpose of IV therapy to alleviate client’s anxiety. e. Prime IV tubing to expel air. This will prevent air embolism. f. Clean the insertion site of IV needle from center to the periphery with alcohol zed cotton ball to prevent infection. g. Shave the area of needle insertion if hairy. h. Change the IV tubing every 72 hours to prevent contamination. I. Change IV needle insertion site every 72 hours to prevent thrombophlebitis. j. Regulate IV every 30 minutes. To ensure administration of proper volume of IV fluid as ordered. k. Observe for potential complications 49  Complication of IV Infusion Complication Signs& symptoms Nursing Intervention Infiltration : the needle is -Pain, swelling *Change the site of needle out of vein, and fluids -skin is cold at needle *Apply warm compress. This accumulate in the site; pallor of the site will absorb edema fluids subcutaneous tissues -flow rate has decreases or stops. Circulatory Overload -Headache, Flushed *Slow the rate of infusion Results from skin -Rapid pulse, *Place patient in high fowler’s administration of Increase BP -Weight position. To enhance breathing excessive volume of IV gain, Syncope and - *Monitor vital signs fluids. faintness, Pulmonary *Notify the physician edema. - Tachypnea, Shock Phlebitis: - Pain along the course *discontinue the infusion an inflammation of a vein, of vein immediately. caused by: -Vein may feel hard * Apply cold compress *Mechanical trauma from -Edema and redness at immediately to relieve pain and a needle or catheter needle insertion site. inflammation; later with warm * Chemical trauma from -Arm feels warmer compress to stimulate circulation solution. than the other arm and promotion absorption. *Avoid further use of vein *Restart the infusion in another vein * routine change IV site every 72 hours *Use large veins for irritating fluids Air Embolism : Air into - Chest, shoulder, or *secure system to prevent air the circulatory system; back pain entry. caused break in the I.V - Hypotension *Turn patient to left side in the system allowing air as - Dyspnea trendelenburg position. To allow bolus - Cyanosis air to rise in the right side of the - Tachycardia heart. This prevent pulmonary - Increase venous embolism pressure *Monitor vital signs and pulse -Loss of consciousness oximetry *Notify the physician immediately Sepsis: micro-organisms - Red, tenderness at *Assess the catheter each shift. invade the blood stream insertion site *Notify the physician through the catheter due - Fever ,malaise immediately and take precaution to: poor insertion - Vital signs changes to decrease temperature 50 technique, long term *use a septic technique in catheter. insertion. Prevention of infection and nursing role: 1-Assess knowledge of guidelines periodically for all persons who insert and manage intravascular catheters. 2-Record the operator, date and time of catheter insertion, removal and dressing changes on standardized form. 3-Observe proper hand washing procedures either by conventional antiseptic containing soap and water or alcohol-based gels or foams 4- Use the gloves doesn't obviate the need for hand hygiene. 5- Maintain antiseptic technique during catheter insertion and care of intravascular catheters.(Wear sterile gloves when insertion or changing the dressing intravascular catheters.) 6- Disinfect clean skin with an appropriate antiseptic before catheter insertion 7-Allow the antiseptic to dry before insertion 8- Use either gauze or sterile, transparent, semi permeable dressing to cover the catheter site. 9- Replace catheter-site dressing if the dressing becomes damp, loosened or visibly soiled. 10-Don't routinely replace central venous catheter or arterial catheters solely for purposes of reducing the incidence of infection. 11- Replace peripheral venous catheters at least every 48-72 hours indults phlebitis. 12-Replace any short-term central venous catheter if purulence is observed at insertion site which indicate infection. 13-Don't use any container of parental fluid that has visible turbidity, leaks or manufacture expiration date has passed. 14-Cleanse the access diaphragm of multidose vials with 70 alcohols before inserting a device into the vial. 16- One-handed needle recapping technique to prevent needle sticks injuries for health care workers at risk for blood-borne pathogens.  Before giving injection, place the needle cover on solid, immovable object such as the bedside table. The open end of the cap should face the nurse.  Give the injection. 51   Place tip of the needle at the entrance of cap. Gently slide the needle into needle cover.  Once the needle is inside the cover, use the object's resistance to completely cover the needle.  Dispose the needle at first opportunity.  Wash hands. Vital Signs Vital signs are measurements of the body's most basic functions include the following: body temperature, pulse, respiration and blood pressure. Careful attention to the details of vital signs procedures and accuracy in the interpretation of the findings are extremely important. It is the nurse role to interpret vital signs findings. Equipment / supplies:  Oral, rectal, axillary, or tympanic thermometer  Probe covers if electronic thermometer is used  Lubricant and tissue if rectal site is used  Towel if axillary site is used, Spirit swab or cotton  Disposable gloves, Steel tray ; to set all materials  Record form  Paper bag for discard Guidelines for assessing, implementing, and documenting temperatures Action Rationale 1-Identify the patient -Provides patient safety 2-Explain the procedure to the patient -Reduces patient apprehension and 3-Gather equipment encourages patient cooperation 4-Wash your hands and don gloves -Provides organized approach to task appropriate or indicated prevent the spread of microorganisms 5-Select the appropriate site 6-Follow the steps as outlined below for -Assess the patient's age, mental, and the appropriate type of thermometer physical condition to ensure safety and 7-Wash your hands. If gloves are worn, accuracy of measurement discard them in the proper receptacle. -prevent the spread of microorganisms 8-Record temperature on paper, flow sheet, or computerized record. Report -Provides accurate documentation and 52  abnormal findings to the appropriate reporting person. Identify site of assessment if other than oral. Assessing oral temperature with a glass thermometer 1- Using a firm twisting motion. Wipe - Twisting helps cover the entire surface. thermometer with alcohol swap from Wiping from an area of few or no the bulb toward the fingers. organisms to an area where organisms 2- Grasp the thermometer firmly with the might be present minimizes spread to a thumb and forefinger and, using strong cleaner area. wrist movements, shake it until the -Moves the mercury back into the bulb mercury line reaches at least 35.5°C. below the previous measurement. 3- Read thermometer by holding it -Facilitates reading the mercury line. horizontally at eye level, and rotate it between the fingers until the mercury line can be clearly visualized. 4- Place the mercury bulb of the -When the bulb rests deeply in the thermometer within the back of the posterior sublingual pocket, it is in contact right or left pocket under the patient's with blood vessels lying close to surface. tongue, and tell the patient to close the lips around the thermometer. 5- Leave the thermometer in place for 3 -Allows time for the mercury to expand minutes, or according to agency and accurately measure temperature. protocol. 6- Remove the thermometer, and wipe it -Minimizes spread of organisms from an once from the fingers down to the area of higher concentration to a cleaner mercury bulb, using a firm, twistingarea; friction helps loosen material from motion. the thermometer surface. Mercury may rise a bit above or below the 7- Read the thermometer to the nearest calibration lines. tenth. 8- Dispose of the tissues in a receptacle -Confining contaminated articles helps for contaminated items. reduce the spread of pathogens. 9- Wash thermometer in lukewarm soapy -Mechanical washing action removes water. Dry and replace the thermometer organic material and organisms. in its container 53 Assessing rectal temperature using a glass thermometer 1- Don gloves -Protects nurse from microorganisms in the feces 2- Wipe, shake, and read the rectal See oral thermometer preparation thermometer 3- Lubricate the mercury bulb up to -Lubrication reduces friction and about 2.5cm (1 inch) up the stem facilitates insertion, minimizing irritation or injury to the rectal 4-Provide privacy: Draw curtains mucous membranes around the patient’s bed and/or close. the door. Keep the patient’s upper body and lower extremities covered. 5- Assist patient into Sims’ position, with the upper leg flexed to expose anal area. 6-With the nondominant hand, raise -Gentle insertion prevents trauma to the patient’s upper buttock to expose the mucosa or the breakage of the the anus. thermometer. -Full retraction of the buttocks completely exposes anus. -Having the patient take a deep 7- Ask the patient to take a deep breath breath and blow out. Helps to relax the anal sphincter. 8- Insert the thermometer as the patient takes in a breath. If resistance is felt, immediately remove the thermometer. 9- Gently insert the thermometer into the anus in the direction of the -Insertion length must be adjusted to umbilicus,Insert the thermometer the anatomic size of the rectum about 11/2 in. (3.5 cm) for adults and based on the patient's age; rectal 1/2 in. (1.2 cm) for infants or temperatures are not normally taken children,donot force the thermometer in an infant. 10-Hold the thermometer in place for -The thermometer may be displaced a minimum of 2 minutes or according internally or externally if not held to agency policy. 11-Remove the thermometer and wipe it once with soft tissue from the fingers to the mercury bulb, using a firm twisting motion. -Promotes cleanliness and comfort 12-Wipe the anus of any feces and the 54 remaining lubricant. -Avoids transmission of 13-Read the thermometer and dispose microorganisms of the tissue and gloves in the proper receptacle. (Remove the gloves from the inside out). 14-Wash the thermometer in lukewarm soapy water. Rinse in cool water. Dry and replace the thermometer in a container labeled "rectal thermometer". Assessing axillary's temperature using a glass thermometer. - Draw curtains around the bed -Provides privacy and minimizes and/or close the door. embarrassment for the patient. - Assist the patient into a supine or sitting position. Move clothing away - Ensures accurate placement of the from the patient’s shoulder and arm. thermometer. The deepest area of the Be sure the axillary area is dry. axilla provides the most accurate - Place the thermometer into the measurement; surrounding the bulb center of the patient’s axilla, lower with skin surface ensures a more the arm over the thermometer, and reliable measurement. place the patient’s forearm across the chest. -In the axilla Hold the thermometer -Staying with the patient ensures that in place for; 5 to 10 minutes or the thermometer remains in the according to agency policy correct position and prevents break - Remain with the patient and hold age the thermometer in place if the patient is unable to do so. -Cleaning the thermometer after use - Remove the thermometer, and read reduces the spread of infection. result at eye level. -Wash the thermometer in tepid, soapy water, rinse in warm water, and dry. Shake down the thermometer and return it to its container. 55  Pulse - Pulse is a wave of blood created by contraction of the left ventricle of the heart; it represents the stroke volume output or the amount of blood that enters the arteries with each ventricular contraction. Guidelines for assessing, implementing, and documenting pulses Action Rationale 1- Identify the patient Provides patient safety 2- Explain the procedure to the patient ;if Reduces patient apprehension and The patient was recently active, wait 5 to encourages patient cooperation 10 minutes. -Activity and anxiety may increase patient’s heart rate 3- Gather equipment Provides organized approach to task 4- Wash your hands and don gloves as Deters the spread of microorganisms appropriate 5- Select the appropriate site Different arteries may be used to assess the pulse; apical pulses are assessed if the peripheral pulse is rapid, irregular, or inaudible 6- Follow the steps as outlined below for Prevent the spread of microorganisms the appropriate pulse assessment 7- Wash your hands 8- Record pulse rate and site on paper, Provides accurate documentation and flow sheet, or computerized record. reporting Report abnormal findings to the appropriate person. Identify site of assessment if other than apical Assessing the radial pulse 56 1- The patient may either be supine These positions are comfortable for with the arm along side the body, the patient and convenient for the wrist extended, and palms of the nurse. hand down or sitting with the forearm at a 90-degree angle to the body resting on a support with the wrist extended and the palm downward. 2- Place the tips of the first two or The sensitive fingertips can feel the three fingers of your hand along the pulsation of the artery. patient's radial artery, and press -Avoid use of the thumb because it gently against the radius. Rest your has pulsation and may interfere thumb on the back of the patient's with accuracy. wrist. 3- Apply only enough pressure so that Moderate pressure facilitates the artery can be felt distinctly. palpation of the pulsations. Too much pressure obliterates the pulse, whereas the pulse is imperceptible with too little pressure. 4- Using a watch with a second hand, Sufficient time must be allowed to count the number of pulsations felt assess the rate, rhythm, and for 30 seconds. Multiply this amplitude of the pulse. When pulse number by 2 to have the rate for 1 characteristics are abnormal, a minute. If the rate, rhythm, or longer time period is necessary for amplitude of the pulse is abnormal accurate assessment. in any way, palpate and count the pulse for 1 minute or longer. Assessing the apical pulse rate 1- Use alcohol swab to clean ear prevent transmission of pieces and diaphragm of the microorganisms stethoscope. 2- Assist patient in sitting in a This position facilitates identification chair or sitting up in bed, and of site for stethoscope placement. expose upper chest area. 3- Hold stethoscope diaphragm Warms diaphragm, promoting patient against comfort 57  the palm of your hand for a few seconds. 4- Palpate fifth intercostals space, This is the point of maximum impulse and move to the left mid-clavicular where the heart beat is best heard. line. Place the diaphragm over the apex of the heart. 4- Listen for heart sounds, These sounds occur as the heart valves identified as a 'lub-dub" sound. close 5- Using a watch with a second A longer time period increases the hand, count the heart beat for 1 accuracy of assessment minute Respiration Human survival depends on the ability of oxygen to reach body cells and for carbon dioxide to be removed from the cells. Respiration is the mechanism the body