Nursing 101 Exam 3 PDF

LECTURE OF OXYGENATION Upper Respiratory System Function: warms, filters, humidified inspired air Composed Of: - Nose - Pharynx - Larynx - Epiglottis Lower Respiratory System Function: conduction of air, mucociliary clearance, production of surfactant Composed Of: - Trachea...

LECTURE OF OXYGENATION Upper Respiratory System Function: warms, filters, humidified inspired air Composed Of: - Nose - Pharynx - Larynx - Epiglottis Lower Respiratory System Function: conduction of air, mucociliary clearance, production of surfactant Composed Of: - Trachea - Right & Left Bronchi - Terminal Bronchiole Anatomy of the Lungs - The organs of respiration - The right lung has 3 lobes; The left lung has 2 lobes - Are composed of elastic tissue - Alveoli: (small air sacs where gas exchange occurs) - Surfactant: (reduces the surface tension between alveoli, preventing collapsing) - Pleura: serous membrane lining in the lungs (Visceral) & thoracic cavity (Parietal) The Cardiovascular System Composed Of: - Heart - Blood Vessels The heart is a muscle divided into 4 chambers (2 Atria & 2 Ventricle) - The atria receive blood from the veins - The ventricles force blood through the arteries Physiology of the Respiratory & Cardiovascular System - Pulmonary Ventilation: is the movement of air in & out of lungs (during inspiration or (active phase of ventilation), the diaphragm moves down, while expiration or (passive phase of ventilation) the diaphragm moves up - Respiration (gas exchange): involves gas exchange between the atmospheric air in alveoli & the blood in the capillaries (intake of oxygen & release of carbon dioxide) - Perfusion: is the process by which oxygenated capillary blood passes through body tissue (how much & how often gas are exchanged depends on amount of blood a person has) carried by plasma & RBCs Required for Normal functioning of the Respiratory System 1. Ability to transport air to & from the lungs 2. Properly functioning of the Alveolar system - oxygenate venous blood - removes carbon dioxide 3. Properly functioning of Cardiovascular & Hematologic system - carries nutrients & waste to & from body cells Alterations in Respiratory Function 1. Hypoxia: inadequate amount of oxygen available to cells S&S - Cyanosis, Tachycardia, Elevated Blood Pressure, Restlessness, Dyspnea, Pallor, Confusion, Increased respiratory rate  2. Dyspnea: difficulty breathing 3. Hypoventilation: decreased rate or depth of air movement into the lungs Factors Affecting Oxygenation - Level of Health - Developmental - Lifestyle - Meds - Environment - Psychological Health Respiratory Factors - Lung Compliance - Strength of Surrounding Muscles - Thickening of Alveolar-Capillary membrane - Decreased Cardiac Output - Decrease in RBC - Use of accessory muscles Factors Affecting Oxygenation in Older Adult - Tissue and airways become less elastic - Power of muscles is reduced - Diaphragm movies less efficiently - Chest is unable to stretch as much - Airways collapse more easily - Decreased Activity Applying the Nursing Process 1. Assessment includes health history, physical examination, diagnostics & labs - Health History includes medications, lifestyle, ADLs, usual patterns of respiration, fatigue, recent changes Assessment Considerations for the Elderly Patient - Bony landmarks are more pronounced - Kyphosis contributes to learning forward - Tissues & airways are less elastic Physical Examination: Inspection, Auscultation, Palpation, Percussion Inspection - General Appearance - Level of Consciousness - Orientation  - Skin - Mucous membranes Auscultation Normal Breath Sounds Vesicular - Low pitched - Soft sound during expiration - Heard over most of the lungs Bronchial - High pitched - Heard over the trachea Bronchovesicular - Medium pitched during expiration - Heard over the upper anterior chest - Intercostal area Adventitious Lung Sounds Crackles - Intermittent - Occurs when air moves through airways - That contain fluid - Fine, medium, or coarse Wheezes - Continuous - Mainly heard on expiration - Air passes through airways constricted by swelling, secretions, or tumors - Sibilant or Sonorous Palpitation - Skin temperature & color - Masses, edema, or tenderness - Presence of vibrations - Capirafillay refill Diagnostic & Lab - Spirometry: measures ventilation, the movement of air in and out of lungs - Pulse Oximetry: noninvasive technique that measures the peripheral arterial oxyhemoglobin saturation of arterial blood - Arterial Blood Gas (ABG): measurement of Blood pH and arterial gases to evaluate acid-base & oxygenation status - Sputum Collection:  - ECG Electrocardiogram: electrodes attached to the skin can detect these electric currents and transmits them to an instrument that produces a record - IS: - Thoracentesis: removal of fluid from pleural space - PFT (Pulmonary Function Test) 1. Tidal Volume (TV): amount of air inhaled & exhaled during normal breathing 2. Vital Capacity (VC): maximum amount of air that can forcibly be exhaled after maximum inhalation 3. Forced Vital Capacity (FVC): amount if air that can forcibly be exhaled after taking a deep breath 4. Forced Expiratory Volume (FEV): the volume of air that is exchanged during forced breath marked at 1 and 6 seconds intervals 5. Total Lung Capacity (TLC): maximum volume to which the lungs can be expanded with the greatest effort 6. Residual Volume (RV): amount of air left in the lung after a full exhalation 7. Peak Expiratory Flow Rate (PERF): measurement of the maximum speed Nursing Diagnoses - Ineffective airway clearance - Ineffective breathing pattern - Impaired gas exchange - Decreased cardiac output - Ineffective tissue perfusion Expected Outcomes The patient will: - Demonstrate improved gas exchanged in lungs as evidenced by absence of cyanosis or chest pain and a pulse oximetry reading > 95% - Relate the causative factors & demonstrate adaptive method of coping - Preserve pulmonary function by maintaining an optimal level of activity - Demonstrate self-care behaviors that provide relief from symptoms and prevent further problems Nursing Interventions for Oxygenation - Promote optimal function - Promote comfort - Meet oxygenation needs with medications - Provide supplemental oxygen Evaluation - Did the patient have improved gas exchange? - Did their pulse oximetry stay above 95%?  - Are they able to perform ADLs? - What else did you want them to achieve? If goal not met, revision of interventions. Oxygen Modalities Nasal Cannula (nasal prongs) - low flow concentrations of O2 - deliver low flow oxygen at 1-6 L/min - deliver high flow oxygen at 10-15 L/min - high flow maximum 60 L/min - can use while eating & performing ADLs - more than 4L can cause drying, dry mucosa, can be dislodge easily Simple Mask - used when increase delivery of oxygen is needed for a short period - delivers low flow oxygen at 5-8 L/min - vents on both sides to allow room air in and CO2 to escape - eating & talking is difficult, anything less than 5 L/min, can cause risk of CO2 retention Non-Rebreather Mask - highest concentration through a mask - delivers low flow oxygen at 10-15 L/min - two one way valves prevent patient from breathing exhaled air - malfunction can cause CO2 buildup Venturi Mask - Most accurate way of delivering O2 via a mask - delivers high flow oxygen at 4-12 L/min - mask with color coded valves - exhaled gas exits through port on valves - valves determine required oxygen to match flow rate - Line, clothing or a pt rolling on the mask can cause oxygen to be delivered at a unsafe concentration (too high or too low) High Flow Oxygen/Positive Airway Pressure 1. Continuous Positive Airway Pressure (CPAP)- provides continuous mild air pressure to keep airways open, it is on one level and works during entire breath & decreases effort needed 2. Bi-Level Positive Airway Pressure (BiPAP)- provides changing levels of air pressure as pt breath in & out, it is on 2 levels and more pressure on inspiration Precautions for Oxygen Administration  - Avoid opens flames - No smoking signs should be placed - Make sure electrical equipment is working - Avoid wearing synthetic fabrics - Avoid using oils in the area Increase Cardiac Output & Tissue Perfusion - manage fluid balance - activity restrictions - assistance with ADL - positioning - administer medications Inhaled Medications - Bronchodilators: dilate the bronchi & bronchioles, decreasing resistance in the airways and increasing airflow to the lungs - Mucolytic Agents: break up & thin mucus & to make it easier to clear from the airways - Corticosteroids: reduce inflammation in the lungs Inhaled Medications Delivery Device - Nebulizer: disperses fine particles of liquid medication into the deeper respiratory tract, stays where absorption occurs - Metered Dose Inhaler (MDI): delivers a controlled dose of medication with each compression of the inhaler, must shake canister & hold upright, may need a spacer, activate canister while inhaling - Dry Powder Inhaler (DPI): breath activated delivery medication, metered dose=measured dose; if its corticosteroids make sure patient rinse with water Cough Medications - Cough Suppressants: used fon nonproductive cough without congestion - Expectorants: facilitates the removal of respiratory tract secretions, pt must congested - Lozenges: relieved mild, non productive cough without congestion Promote Airway Clearance - monitor environmental & lifestyle conditions - introduces artificial airways - suction the airway - teach controlled breathing exercises  - introduce chest drainage systems - chest physiotherapy Facts - patients can help keep their secretions thin by drinking at least 1.5 to 2 L of fluids daily - turning to the prone position on a regular basis promotes improved oxygenation - deep-breathing exercises can be used to overcome hypoventilation. instruct the patient to make each breath deep enough to move the bottom ribs. - an incentive spirometer assists the patient to breathe slowly and deeply and to sustain maximal inspiration - patients who experience dyspnea and feelings of panic can often reduce these symptoms by using pursed-lip breathing. Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration. prevent the collapse of small airways - use of diaphragmatic breathing can help to slow down the person’s breathing and help them “catch their breath - diaphragmatic breathing (belly breathing) helps patients to calm down, better control their breathing, and use less energy to breathe. To do this, the patient should sit upright in a comfortable chair or lie on their back on a flat surface or in bed, with the knees bent and a pillow under the knees to support their legs. - the respiratory secretion expelled by coughing or clearing the throat is called sputum.  LECTURE OF SENSORY - MOTOR ACTIVITY Physiology of Movement 3 systems are required for movement - Nervous System - Muscular System - Skeletal System Movement: results from contracting muscles placing force on a tendon which in turn pulls on a bone Nervous System - The somatic nervous system, part of the peripheral nervous system, controls all voluntary muscles - Sensory information travels to the central nervous system; AFFERENT PATHWAY - Motor information travels from the central nervous system to the muscles; EFFERENT PATHWAY Sensorimotor Function Sensory Processing = needed for movement Includes-> - Sensory Reception: receiving data (visual, auditory, olfactory, gustatory, tactile, kinesthetic) - Sensory Perception: organizing & interpreting the data Impaired sensory processing places the pt at risk for injury Sensory Disorders - Not enough or too much stimuli - Disturbed sensory perception - Sensory deficit (when one or more of the senses is impaired or absent) - Sensory deprivation (not enough stimuli) - Sensory overload (excessive stimuli); brain can’t process, respond or ignore Effects of Sensory Deprivation - Perceptual Disturbances - Cognitive Disturbances - Emotional Disturbances Factors Influencing Sensory Status - Developmental Level (elderly pt can experience sensory decline w/ aging) changes in eyesight, hearing, balance coordination - Personality & Lifestyle different personalities types demand different levels of stimulation lifestyle choices influence the quantity & quality of stimuli received - Stress & Illness illness, stress can affect the reception of sensory stimuli & their transmission & perception - Medication medications that alert or depress the CNS may interfere with the perception of sensory stimuli Narcotics & Sedatives: go down in alertness Antipsychotics: influence how sensory stimuli are perceived & processed States of Arousal & Awareness Conscious State - Delirium - Dementia - Confusion - Normal Consciousness; x3 or x4 - Minimally conscious states - Locked-in-syndrome Unconscious State - Asleep - Somnolence - Stupor - Coma - Vegetative State Nursing Process - Assessments sensory alteration Hx, mental status, presences of hazards, ability to perform self-care, use of sensory aids, risk factors for impaired sensory function - Nursing Diagnosis disturbed sensory perception, social isolation, risk for injury, disturbed thought process, impaired verbal communication, risk for impaired skin integrity - Interventions prevent sensory alterations, assist pt to improve sensory functioning, ensure safe environment, ensure pt maintains adequate & varied sensory stimuli like Visual: glasses; Auditory: hearing aid; Olfactory: varied smell; Tactile: varied textures; Communications: face pt, enunciate - Outcomes the pt will: demonstrate intact functioning of the senses, respond appropriately to sensory stimuli, demonstrate appropriate self-care behaviors, remain safe & free from injury - Evaluation Were the EO met/partially met/not met? Functions of The Skeletal System - Protection - Support - Storage - Hematopoiesis (process of producing blood cells WBC, RBC, platelets) - Sites for attachment; muscles, ligaments, tendons Types of bones - Long bones - Short bones - Flat bones - Irregular bone Factors Influencing Mobility - Growth & Development - Physical health - Mental health - Lifestyles - Attitudes & values - Fatigue & Stress - External Factors - Pathological Influences - Postural abnormalities - Impaired muscle development - Damage to the central nervous system - Direct trauma to the musculoskeletal system Psychosocial: Possible Implications - Feelings worthlessness - Ineffective coping  - Depression - Anxiety - Altered thought process - Sleep-wake pattern disturbance - Unable to interact socially Continuous Passive Motion (CMP): preserves joint mobility after surgery - Skeletal muscles produce movements by pulling on bones - Bones serves as levers - Joints acts as fulcrums for the levers - The lever & fulcrums principle is shown by a forearm lifting a weight Tendons, Cartilage, & Ligaments Tendons - Attaches to the bone - Sturdy - Non Elastic - Size changes depending on muscles - Anchor Cartilage - Tough - Flexible - At the end of the bone - Cushions Ligaments - Attaches bone to bone - Elastic - Stabilize - Made of many fibers - Strong Muscles: Types & Roles Skeletal - Motion - Support - Protection - Maintenance of posture - Heat production  Smooth (responsible for movement in - Internal organs for the digestive, urinary, & reproductive systems & airways & blood vessels Cardiac - Rhythmicity - Excitability - Contractility - Conductivity Physiological Response to Immobility Cardiovascular Changes - Increased cardiac workload - Decreased venous return - Thrombus formation (DVT); blood clots forms in veins, usually pain, red, swollen, warm - Orthostatic hypotension - Dependent edema Prevention for DVTs - TED knee high - Sequential Compression Device (SCD) - Early ambulation - Pharmacological (anticoagulants) Respiratory Changes - Decreased ventilatory effort - Decreased depth/rate of respiration - Increased respiratory secretions - Atelectasis - Acid base imbalance - Hypostatic pneumonia - Bacterial growth-pooled secretion Musculoskeletal System - Decreased muscle size (atrophy) - Decreased muscle tone & strength - Decreased joint mobility & flexibility - Increased bone demineralization (osteoporosis)  - Decreased endurance/problem ADL Gastrointestinal System - Decreased appetite - Altered protein metabolism - Poor digestion/utilization - Decreased peristalsis - Constipation - Weight gain Metabolic Process - Decreased metabolic rate - Tissue catabolism - Negative nitrogen balance - Calcium loss - Anorexia - Poor nutrition - Fluid & electrolyte disturbances Urinary System - Urinary Stasis (urine cant be emptied from the bladder) - UTI - Urinary retention - Renal calculi (hard deposits of mineral & salts that from in urinary tract) Integumentary System - Impaired circulation - Tissue ischemia - Increased risk of pressure ulcers - Decreased wound healing - Effects of Exercise Cardiovascular System - Increased efficiency of the heart - Decreased heart rate & blood pressure - Increased blood flow to all body parts - Improved venous return - Increased circulating fibrinolysin (substance that breaks up small clots) Respiratory System - Improved alveolar ventilation - Decreased work of breathing - Improved diaphragmatic excursion Metabolic System  - Increased triglyceride breakdown - Increased gastric motility - Increased production of body heat Musculoskeletal System - Increased muscle efficiency (strength mass, tone, joint mobility) - Increased coordination - Reduce bone loss - Increased efficiency of nerve impulse transmission - Slow effect of aging Gastrointestinal System - Increased appetite - Improve digestion & elimination - Weight control Urinary System - Increased blood flow to the kidneys - Improves waste excretion - Maintain fluid balance - Maintain acid-base balance Integumentary - Increased circulation nourishes the skin - Promote general health of the skin Psychosocial - Increased energy, vitality, general well-being - Improve sleep - Improve appearance - Improve self-concept - Increased positive health behaviors Nursing Process - Assessments Hx: daily activity pattern, activity & exercise intolerance, external factors, ability to performs ADLs, type & frequency of exercise PE: gait, body alignment, inspection & palpation of joints & bones, muscles mass, tone & strength, ROM active & passive, activity Intolerance - Nursing Diagnosis Impaired physical mobility, activity intolerance, ineffective airway clearance, gas exchange impaired, social isolation, sleep pattern disturbance, risk for infection altered tissue perfusion, disuse syndrome, fluid volume deficit - EO the pt will: be free of contractures, be free from signs of skin breakdown, maintain effective airway clearance, show signs of adequate venous return, demonstrate correct body alignment, demonstrate full range of joint motion - Interventions frequent repositioning - Fowler’s (semi sitting position) - Supine (lying face up in back) - Side - Lying - Prone (lying face down on stomach) Assisting with ROM exercises; Passive ( w/ help) vs Active (w/o help) ROM Teach Center of Gravity (ambulatory pts) - Imaginary balancing point - Body’s weight is concentrated & equally distributed - Point at which the mass of an object is centered - Point of exact center where the body can rotate freely in all directions Moving pt up to the bed - Move close to the side of the bed - Provide explanations - Increased HOB, remove pillow, pt lift head up - 1 Nurse: pt cooperative - 2 Nurse: heavy pt, or cannot assist  - back straight, knees bent, one foot forward - If cannot assist, pt bend knees, hands of side rails, or across chest, - Count to 3 - Encourage pt independence & participation -> self esteem - Evaluation Determine: effectiveness of activity & exercise interventions, improvement in body alignment, joint mobility, walking, moving or transferring, absence of complications of immobility, present level of strength & endurance Types of Exercise - Isotonic: muscle contraction & change in muscle length (isotonic contraction) benefits- increased circulation & respiratory functioning, increased osteoblastic activity , increased muscle tone, mass, & strength Ex: walking, swimming, moving arms & legs with light resistance - Isometric: tightening or tensing of muscles without moving body parts benefits- increased muscle mass, tone & strength, increased circulation to the involved body part; increased osteoblastic activity Ex: quadriceps set exercises & contraction of the gluteal muscles - Resistive Isometric: contracts the muscles while pushing against a stationary object or resisting the movement of an object benefits- promote muscle strength, provides sufficient stress against bone to promote osteoblastic activity Ex: push-ups, pushing against a footboard to move up in bed, & hip lifting Safe Patient Handling & Mobility (SPHM) - Ergonomics: practice of designing equipment & work tasks to confirm to the capability of the worker (postures) Variables that can lead to pt handling injuries - Uncoordinated lifts - High extersion - Awkward or static postures - Manual lifting & transferring - Repetitive movements or tasks - Standing for long periods of time  Lab Discussion Musculoskeletal Assessment HX - Family health Hx - General health maintenance - Nutrition - Occupation - Learning needs - Socioeconomic factors - Medications PE - Function ability - Ability to perform ADL - Note any problems related to mobility - Assessments of pain & altered sensation - posture & gait - Joint function & muscle strength - Active vs Passive ROM; upper & lower strength & compare bilaterally - Diagnostic Tests: X-rays, MRI, Bone Scan, Bone Densitometry, CT Scan 3 Abnormalities for Spine - Kyphosis: round back or hunchback - Lordosis: swayback, excessive curvature of the lower back has - Scoliosis: an S or C shape curvature of the spine Gait Assessment - Normal gait: arms swing, center of gravity moves forward-not side to side, even stance Note if gait is even or uneven, steady or unsteady, shuffled or stooped forward Detecting Fluid in the Knee 1. Milk downward 2. Apply medial pressure 3. Tap & watch for fluid wave Atrophy: is shrinkage or decrease in the size of the muscle Rheumatoid Arthritis ROM Assessment  LECTURE OF LEGAL ASPECTS OF NURSING (Fox states that she does not need us to memorize the four different sources, she just needs us to know how the issue is dealt with depends on which category of law it falls under and that healthcare is typically under civil law and criminal law) Types of Law - Public - Private: civil - Criminal: crimes & torts Criminal law 1. Crime - wrong against a person and public 2 Types - Misdemeanor: punishable by fines or less than 1 year imprisonment - Felony: Punishable by imprisonment for more than 1 year 2. Tort - wrong commitment by a person against another (Can be action that causes harm; tried in civil court (private law) 2 Types - Intentional: meant to do harm to a pt - Unintentional: accidental harm to the pt Intentional & Unintentional Torts Intentional torts: - Assault: Forcing (without touching) Ex: Threatening and telling a pt you won’t give them their pain medication if they do not eat - Battery: Actually touching the pt or administering treatment that the pt refused - Invasion of Privacy: False imprisonment (restraints) & Inappropriate exposure of a pt (always make sure curtain is closed and pt is covered during bed bath) - Fraud: misrepresentation (saying you are licensed but your aren’t) - False Imprisonment: all 4 side rails up without pt being a fall risk or restraints - Defamation of Character: inappropriate discussing a pt in a negative way that can result in how they are treated Unintentional torts: - Negligence: Performing an act that a person under similar circumstances would not do or failing to perform an act that a person under similar circumstances would do. - Malpractice: Act of negligence; Failure to follow standards/use equipment/ assess & monitor/ communicate/ document/advocate. Reporting a crime/tort or unsafe practice - Stop the unsafe behavior - Follow the chain of command (Charge nurse → Unit manager → Supervisor → Higher ups) - Follow hospital policies and protocols - Typically report to direct supervisor, follow up, complete incident report * When reporting crimes/torts/unsafe practice follow hospital protocols and chain or command* (Fox states that she does not need us to memorize the four different sources, she just needs us to know how the issue is dealt with depends on which category of law it falls under and that healthcare is typically under civil law and criminal law) The Four Sources of Law Which Impact Nursing 1. Constitutional- gives authority & states principles for establishing specific laws 2. Statutory Law- defines written laws, (Ex: Nurse Practice Acts) 3. Administrative Law- regulates procedures of government agencies 4. Common Law- established by previous court decisions, (Ex: malpractice) Three types of law - Public law - government is directly involved; regulates relationship between individual and government - Private (civil law) - contracts; individuals/personal rights guaranteed by law; includes most healthcare issues ← need to know this law - Criminal law - defines criminal actions (murder, theft, manslaughter, criminal negligence, illegal drug possession) and protects the public ← need to know this law *Private (civil) law are where most health care issues fall* *Torts can be intentional or unintentional* (Fox states that we will get questions where we will get examples of pt cases and we have to identify what type of crime was performed) Four elements to prove liability Malpractice/Professional Negligence 1. Duty → RN’s responsibility to pt, what reasonable prudent Nurse would do, Appropriate standard of care  2. Breach of duty → Failure to act appropriately, failure to meet the standard of care 3. Causation → Failure to meet care standard causes injury (proven by the lawyer) ex: no bed rails/alarm, pt falls out of bed 4. Damages → Injury results in longer hospital stay (can be physical or mental) Malpractice Litigation - Results in three outcomes 1. Work towards a settlement, 2. Presented to the malpractice arbitration panel 3. Brought to trial court Different Laws That Regulate Nursing Practice - NPA defines scope of nursing in each state - To practice nursing, students must graduate from an accredited school + pass NCLEX + meet all state standards - Standards of nursing care must be met to protect → what would a responsible nurse do or not so in the same situation - Nursing credentialing = Licensure (required to practice) - The Good samaritan act: Protects healthcare workers outside the hospital providing emergency care - Patient self - determination act: allows patients to refuse care (Educate and confirm advanced directives such as DNR, living will, POA) - HIPAA - Maintain pt privacy - ADA (american with disabilities act) - End discrimination equal opportunity for all - Nurse practice act - Determines that practice of nursing in each state. Protects public by defining nursing legal scope of practice - EMTALA (Emergency Medical Treatment & Active Labor law) - Everyone should receive the same care regardless of financial status. - Nursing home reform act - Long Term pt has the right to remain free from restraints or chemicals for punishment Law terminology Nursing: Patient abandonment - Leave pt without appropriate care replacement (wrongful termination of care) Assault - Mental or physical threat without touching; Forcing treatment without touching Battery - intentional touching with or without intent of harm; Forcing refused treatment Emancipated minor - Legal decisions of pt under 18 being considered as an adult (EX: parents, lives alone/self-supporting, military, married) Liability Duty - use due care Breach of duty - failure to meet care standards Causation - failure to meet care standards caused injury Damages - actual harm/injury Malpractice - Damage, injury, loss; act of negligence; Failure to follow standards/use equipment/ assess & monitor/ communicate/ document/advocate. Negligence - Performing an act that a person under similar circumstances would not do or failing to perform an act that a person under similar circumstances would do. Whistle Blowing - a warning to the public concerning serious wrongdoing Misdemeanor - punishable by fines or less than 1 year imprisonment Felony - Punishable by imprisonment for more than 1 year Intentional tort - meant to do harm to a pt Unintentional tort - accidental harm to the pt Litigation- taking legal action; process of bringing a lawsuit Plaintiff- person or government bringing a lawsuit (Ex. pt, family, government) Defendant- person being accused of a crime or tort (RN) Alanis Leite Nursing 101 11/7/2024 Principles of Pharmacology Outline Responsibilities in New Jersey ○ Prescriber Orders the medication (prescription) ○ Pharmacist Responsible for preparing the meds ○ Nurse Responsible for administration of those meds ○ Checks and balances in place to keep from error If an error is made The pharmacist & nurse has time to note that ○ If pharmacy makes the error the nurse can note it with the 7 rights FDA Process ○ Pre Clinical Phase Development of the drug Animal Testing (Looking @ Toxicity) & Sponsoring of the drug ○ Investigational Phase New Drug Application Application is sent to the FDA once it’s met that criteria  ○ Clinical Phase New Drug Tested on small groups of people Larger groups: People with diseases for that drug and usually some placebos Largest group: Patients will be taking the med and further studying of effectiveness and safety ○ New Drug Review Application Process FDA Final Review application process and marketing Testing on Human Beings ○ Approvations Nursing Process of Med Administration ○ Assessment Med History Medication Reconciliation - it’s a process of questions to know what meds the pt is on, why, when they are taken, when did pt start taking it. ○ Usually this questioning is done in the ED Patient Assessment (Ongoing or After Administration) Vitals & Head to Toe ○ Some medication has special instructions/limitations to give medications  I.e BP Meds, Heart Rate Meds, Lasix, Meds that Require Labs ○ Nursing Diagnosis Developed by assessment data gathered ○ Patient Centered Outcomes Evaluated after implementation of some type of plan of care Medicine/Med Identifiers ○ Generic v.s. Trade Generic The name that identifies the drugs active ingredient or chemical name (Universally Accepted **NOT OWNED BY ANY DRUG COMPANY) ○ I.e. acetaminophen Trade (Referred as NAME BRAND) selected by the pharmaceutical company that sells the actual drug ○ Protected by trademark (can have several trade names) I.e Benadryl, Tylenol ○ Form of the Drug Form in which the drug is prepared is going to determine the route of administration I.e Tablet, injection, transdermal patch, cream A lozenge or a cough drop is also called a TROCHE ○ Slow or Continuous Release Some tablet are enteric coated (prevent stomach irritation)[Extended Release -> ER] Allows for slow and continuous release (large intestine) ○ 12 Common Identifiers NDC# National Drug Code number used to identify a specific drug Generic Name Brand Name Drug Dose Dose available in this product Warnings Specific drug warning Administration Some labels indicate route and dosage Prescription Status Indicates drug is prescription only Drug Manufacturer Pharmaceutical house that produce the drug Quantity Amount of the drug in this package Storage Information Lot number  Specific Drug batch from which this drug was produced ○ Important for recall information Expiration Date Indicates date after which the drug was produced ○ Onset, Peak, & Duration Onset of Action The time it takes to reach the minimum effective concentration after drug is given Peak action Occurs when the drug reaches its highest blood concentration Duration The length of the time the drug has its effect It's important to understand the length to understand dosage and where exactly it will effect ○ Documentation Name of med Dosage Route & Time of Administration Nurse initials Intentional or inadvertently omitted drugs Refused Drugs Medication Errors Factors that affect drug action  ○ Developmental considerations ○ Weight ○ Biological sex ○ Culture & genetic factors Religious restrictions ○ Psychological Factors Pt expectations, compliance ○ Pathology Presence of disease that can affect the drug ○ Environment Sensory deprivation/overload, O2 deprivation, nutrition ○ Time of administration Present of food could delay or food will help irritation Side Effect vs. Adverse Effect (Interactions) ○ Side Effects Non-therapeutic reaction to a drug, the effect could be desirable or undesirable I.e percocet = falling asleep ○ Adverse Effect Pharmacological event that is not expected [considered a dangerous reaction] unpredictable, occurs less than side effects ** ○ Drug Interactions Patient can be sensitive to the drug  Drug can cause some other type of response Patient taking too much or too little dose Hypersensitivity Allergic effect Pharmacokinetics vs. Pharmacodynamics ○ Pharmacokinetics The effect that the body has on a drug Absorption Factor ○ The process by which a drug is transferred from its site of entry Influencing Factor Route of Administration Lipid Solubility (absorbed more readily and pass more easily) pH (well absorbed in the stomach) Blood Flow (Increased flow increased absorption) Location Condition of Site of Administration (different conditions = different absorption abilities) Drug Dose Distribution  ○ After a drug has entered into blood stream, transported throughout the body the drug molecules take action Depends on: Person's ability to circulate blood Protein Binding capacity (drugs ability to leave the bloodstream or storage areas) Selectively permeable blood brain barrier of CNS (protects CNS and drugs from entering) Metabolism ○ The change of an active drug from its original form to an inactivated or a new form Liver is primary source GI Tract, Lungs, and kidneys have a role in metabolism of meds Excretion ○ Occurs when the drug is broken down (removing the drug from the body) Kidney is the main route for excretion Lungs excrete gaseous substances/meds Factors that affect Impaired renal function can = toxicity in body (bad)  Aging, diseases, etc ○ Pharmacodynamics The process of drugs acting in specific or target cells resulting in a change in cellular function and reaction Drug Orders ○ Standing Order (a.k.a Routine Order) Carried out until canceled by another order Specific Instructions/limitations ○ PRN - As Needed Received when requested by patient or required by physician when the specifics of the orders are met Clinical Parameters or timing btwn doses ○ I.e every 4 hours if patient has a pain level between 5-7 ○ Usually Pain, nausea, & sleep meds ○ Stat order - immediate order, one time order carried out at once Seven Parts of a Med Order ○ Patient Name ○ Date & Time order is written ○ Name of drug to be administered ○ Dosage of the drug ○ Route by which the drug is to be administered ○ Frequency of admission of the drug ○ Signature of person writing the order  9 Rights of Medication Administration ○ Right Med ○ Right Patient ○ Right Dose ○ Right Route ○ Right Time ○ Right Reason ○ Right Assessment ○ Right Documentation ○ Right Response Med Checks ○ 3 Med Checks When the nurse reaches for the unit dose package After retrieval from the drawer and compared with the MAR Before giving the unit dose medication to the patient Controlled Substances ○ Record should be kept of each narcotics that is administered to the patient ○ The amount of a C.S. on hands is counted and must be accounted for administrative records ○ Needs to be checked daily Usually each off-going shift must complete a count of all controlled substances ○ A witness (another nurse) when counting and wasting (throwing out) a narcotic  Common Medical Errors & Prevention ○ Common Medical Errors Inappropriate prescribing of the drug Extra omitted, or wrong doses Administration of drug to wrong patient Administration of wrong route or rate Failure of give medication on within prescribed time Incorrect preparation of a drug Improper technique when administering drug Giving a drug that has expired or deteriorated If this happens: Check patient for adverse effects Advise nurse manager and physician Write description of the error in EMR and quality assurance documentation (incident report) ○ Prevention Drug Regamin Process Avoid interruption & distraction Series of Checks ○ Nurse ○ Patient Reporting Medication Errors NEVER LEAVE PREPARED DRUGS UNATTENEDED  Bar-code Medication System Patient has own identifiers (ID, Stickers) Nurse has a unique barcode ○ Get in the Omnicell, MAR, COW Drug has a unique barcode ○ Barcode Identifies the drug form, dosage ○ NDC -> Natural Drug Code Nurse scans patient ID first, than the drug: ○ If it is right it will allow you to continue administering the medication ○ If it is wrong the system will tell you and not let you continue Patient Teaching ○ Describe the medication and what it does to the patient in an understanding language This is done before administration so the patient know what is being given ○ Topics of teaching Name of the drug Dose of the drug Action of the drug The frequency How to store/prepare (discharge)  What OTC and holistic, alternative, therapies should be avoided Comfort and Safety Measures ○ Make sure the patient can restate the information perfectly to know that they understand  LECTURE OF VALUES & ETHICS Common Modes of Value Transmission: - Modeling: observation - Moralizing: instilled value system - Laissez-faire: child develops on their own, little or no guidance → possible confusion - Rewarding & Punishing: (just what it is) - Responsible choice: encourages child to explore Process of Developing Values: - Choosing: Choosing freely from alternatives after careful consideration of the consequences of each alternatives - Prizing (treasuring): Involves pride happiness, and public affirmation - Acting: Combining choice into one’s behavior with consistency and regularity on the value Ethics & Morals: - Ethics: study of rights & wrong principles, virtue, good vs evil as they relate to conduct and human flourishing (what’s right and what's wrong) - Bioethics (Medicine/science): Ask questions such as what kind of person should I be; what are my duties and obligations to other people; what do I owe the common good or the public? - Nursing Ethics (subset of bioethics): formal study of ethical issues that arise in the practice of nursing - Morals: personal/ communal standards of right & wrong 2 principles of Bioethics: - Utilitarian: (Personalized; evaluating what's going to happen to this patient) - Rightness or wrongness of an action depends on the consequences of the action - → Action promotes greater good - Deontologic: (Across the board we can’t do that) - An action is right or wrong independent of its consequences Beauchamp & Childress Principle Based Approach to Bioethics - Autonomy: respect rights of patients to make health care decisions, provide education - Nonmaleficence: Avoid causing/prevent harm; Intervention will NOT cause more harm than good - Beneficence: Benefit the patient, harms vs risk, prior research studies, “Do good” (requires a nurse to act in ways that promote patients well-being) EX: emotional support, ensuring medical needs are met: comforting dying pt; assisting with tasks they cannot perform independently. Beneficial course of action might involve some risk of harm such as pain & scarring from a surgical wound to remove a ruptured appendix. However, the overall expected outcomes should still be positive & outweigh any risks - Justice: Give each their due and act fairly - Nurses add FIDELITY (Keep promises, non abandonment, upholding RN standards), VERACITY (tell the truth), ACCOUNTABILITY, PRIVACY (HIPPA law- maintain patient privacy), CONFIDENTIALITY Non-Maleficence Principles: (Avoid causing harm or minimize harm → Avoiding ACTUAL injury) EX: Holding a medication due to adverse effects,/Ensuring a safe work environment,/ Selecting interventions that cause the LEAST amount of harm to a pt,/ Reporting suicidal or homicidal ideations). 1. An intervention should not be inherently negative 2. The action must be meant to have a beneficial impact 3. A positive result cannot be a consequence of an adverse effect 4. If an action has negative consequences, the potential benefits must outweigh the negative repercussions (Beneficence entails taking actions to help others, whereas non-maleficence entails avoiding behaviors that injure others.) Characteristics of the care-based approach to bioethics: - Centrality of the caring relationship - Promotion of dignity and respect as people - Attention to the particulars of individual patients - Cultivation of responsiveness to others - Redefinition of fundamental moral skills to include virtues Ethical Conduct: Practice based on professional standards of ethical conduct + professional values Nurse should: - Cultivate the virtues of nursing - Understand ethical theories that dictate and justify professional conduct - Be familiar with codes of ethics for nurses and standards for professional nursing conduct - Moral agency: the capacity to be ethical and do the ethically right thing for the right reasons. Professional Values Fox stated “a lot of times you will be given a patient scenario and you have to identify which professional value it is or you have to identify which response will reflect eligibly” MIGHT BE ON EXAM IN THIS FORMAT - Altruism: concern for the welfare and well-being being of others - Autonomy: right to self-determination (in order to make an informed decision you have to be able to educate the pt & educate them on alternative treatments in addition to what the possible outcome) - Human Dignity: Respect for inherent worth and uniqueness of individuals and populations (we understand that certain populations would not like a blood transfusion because it is not their standard of care that they would like to proceed with → as the nurse, you need to educate the pt what could happen by providing that care for them but also provide alternative options.) - Integrity: Acting according to the code of ethics and standards of practice (standards are set by “ANA” American Nursing Association) - Social Justice: upholding moral, legal, and humanistic rights (legal issues, advocating for human rights) Nurse Virtues (what is needed to perform competently and not harm the pt): - Competence: (need to know your individual skills and why are you performing the individual skills) - Compassionate Caring: (Never make the situation about yourself but about the pt) - Subordination of Self-Interest to Patient Interest: (Address the the patient what you are doing and why, make it about them regardless of the circumstances) - Self-Effacement: (you need to be humble & modest, always put the patient first PT centered care) - Trustworthiness: (never lie to the pt and need to have honesty)  - Conscientiousness: (being aware of how you present yourself to a pt & how you communicate with the pt) - Intelligence: (need to know why you are doing the treatment, what other alternatives there are and possible side effects so that you can assess if the benefit of the treatment will outweigh the rest) - Practical Wisdom: (why are you doing things? Need to be confidently spike an IV bag, know what type of fluid you’re supposed to give, know what that fluid can do for you patient) - Humility: (you can’t take things personal in healthcare, you have to be empathetic and put yourself in your pt’s shoes to better understand what their needs are) - Courage: (you will encounter experiences that you neve thought you would, you have to be able to advocate for you pt even if it would benefit you) - Integrity: (You need to be sure you are doing things & in the field for the right reason) *Everything in Red came out of Fox’s mouth* Moral Distress and Resiliency - Moral Dilemma: (both things are correct but which one do I choose?) - Moral Distress: you know the right thing to do, but either personal or institutional factors make it difficult to follow the correct course of action - Moral Resilience: the developed capacity to respond well and morally distressing experiences and to emerge strong Ways to Build Resilience - Cultivating good relationships - Accepting that changes is a part of living - Refusing to view crises as insurmountable - Nurturing a positive view of self and taking care of self - Keeping things in perspective Ethically Relevant Considerations: - Balance between benefits and harms in the care of patients - Disclosure, informed consent (educating consent to pt) and shared decision making - Norms of family life (if pt consents to it, allow other family member to make decisions for pt and be present) → be considerate of their family dynamics - Relationship between clinicians and patients (need to build relationship so that trust is built) - Professional integrity of clinicians  - Cost effectiveness and allocation - Issues of cultural and/or religious variations - Considerations of power (who is delegating treatments to prevent ethical dilemma) Examples of Ethical Problems #1 - Paternalism: Clinicians decide what's to be done to benefit pt → inform pt, patient’s role is to comply (provider decides what type of tx is being done for the pt and bypassing autonomy) - Deception: (lying to a pt is a no, you must tell the the truth but still make them feel comfortable) EX: when you are in clinical and are about to give pt a shot & they ask you if this is your first time giving a shot, you must be honest and reply “yes it is my first time but in order for us to be in clinical we must practice in a lab multiple times to be proficient” - Privacy & Social Media: (never post about a patient and close curtain) - Confidentiality: (think about HIPPA, never share passwords nor print out things and taking home pt’s stuff) - Allocation of Scarce Nursing Resources: (knowing why you are using resources, what resources are available and prioritizing pt use) - Valid Consent or Refusal: (pt has to be educated before signing consent, what they are getting and why, and alternative tx. - Conflicts Concerning New Technologies: (know when it is appropriate to use technology and when it is not.) Functions of Ethics Committees - Education - Policy Making - Case Review - Consultation - Occasionally Research *When making ethical decisions you must use ADPIE guidelines*