Exam 2 Study Guide Fall 2024 PDF

Exam 2: Study Guide **Medication Administration** - Safety - The 7 rights (Potter & Perry, p. 642) Right Medication: Most hospitals have an electronic medication administration record (eMAR) system. Right Dose: To minimize errors the unit-dose method is utilized. It was created to...

Exam 2: Study Guide **Medication Administration** - Safety - The 7 rights (Potter & Perry, p. 642) Right Medication: Most hospitals have an electronic medication administration record (eMAR) system. Right Dose: To minimize errors the unit-dose method is utilized. It was created to help decrease medication errors. Right Patient: ALWAYS use TWO methods to identify patients. Right Route: If route of administration is not listed, consult the healthcare provider. Alert healthcare provider if the route listed is not the recommended route of administration. Right Time: As the nurse you need to know why medications are administered at a certain time and whether that time could be altered if needed. Acceptable patient identifiers: Patient's name, his/her medical record number assigned by the healthcare agency -- to identify patient correctly you must compare patient identifiers on the electronic medical record (eMar) with the patient's identification bracelet while at the bedside -- scanning armbands is common practice in healthcare settings. Your text states that if this check is done, it isn't necessary to have the patient state his/her name; but that asking for name and date of birth and comparing it to the wristband can serve as a third verification. Right Documentation: Proper documentation is critical to proper care! Special systems have been developed to record current medications and document their administration. NEVER chart a medication prior to administering it. Right Indication: This is now considered the seventh right of medication administration and enhances the safety of every medication order, ensuring the patient is receiving the right medication for the right reason, reduces the risk of the wrong medication being prescribed. - How and why do nurses apply these rights? - 2022 Vanderbilt case -- what went wrong? - 3 checks of medication administration: When removing medication from automatic dispenser system or patient's medication drawer, Just before opening the unit dose package (or getting the dose out of the container, if not unit dose), and Just before giving the unit dose to the patient. - Patient identifiers / allergy alerts - Principles to reduce needlestick injury - Prevention of medication errors - How to prevent errors- distraction free space - What to do if error happens- notify and document - Roles - Provider: ORDERING "Written" (hand or electronic), Verbal, and Telephone\ ERRORS: Transcription/Translation, Prohibited & Error-Prone Abbreviations (see table p. 636) - Pharmacy: ORDERING: Prepare, Distribute, Inform, and Educates\ ERRORS: Not catching mistakes and Preparing incorrectly - Nursing: Verification, calculation, preparation, administration, education, and evaluation - Using the Medication Administration Record (MAR) - How to read an order (abbreviations, military time, etc.) - Priorities of administration - Routes -- how do you administer all of these safely? - Enteral (refers to medications that are administered into the GI tract including orally, sublingual, rectally, through a stomach tube like NG tube or G-tube) - Parenteral (Subcutaneous, Intramuscular, Intravenous, Intradermal) - Gauge / length of needle -- which is bigger? Subcutaneous- 25 gauge (3/8 to 5/8 in long), Intradermal- 25-27 gauge (1/2 to 5/8), IM- 21- 23 gauge (1 ½) - Sites: Subcutaneous: Common sites are the upper arms, abdomen, on the back underneath the shoulder blades (subscapular), anterior thighs, and iliac crest. IM: Ventrogluteal: Potter & Perry list the ventrogluteal site as the - preferred site for all IM injections, Deltoid: Often not as large and well-developed as other muscles. Except in "mass injection" situations (such as school vaccinations, where large numbers of people must be dealt with quickly and it is difficult to maintain modesty/privacy), acromion process, and Vastus Lateralis: It is located on the anterior-lateral aspect of the thigh anywhere from one handbreadth above the knee to one handbreadth below the greater trochanter of the femur. Intradermal: Forearm - Landmarks - Angles: Subcutaneous: 45- 90 degrees. IM: 90 degrees, and Intradermal: 10- 15 degrees - To aspirate or not aspirate: No aspiration with subcutaneous injections\ 2. No aspiration when administering immunizations.\ 3. Slow (5-10 second) aspiration prior to any other intramuscular injection - Z-track method: Always used for IM injections which are irritating or\ stain the skin (i.e. iron). - How is it done: Change the needle after drawing up the medication (to avoid medication on outside of needle) Pull the overlying skin and subcutaneous tissues 1-1.5 inches to the side. Hold it there, insert the needle then aspirate to ensure you haven't hit a blood vessel, and inject slowly (1 mL per 10 seconds) with the dominate hand. Count to 10 (to allow medicine to be distributed into the tissue) before removing the needle. Release the skin you pulled to the side only\ AFTER withdrawing the needle. Don't massage the site for Z-track - Why would this method of administration be used? Potter & Perry recommend that the Z-track technique should be used for all IM injections. However, this is not the\ universally accepted standard - Topical: Applied to the skin. Usually for local effect (act only on the skin in the\ area where they are placed) but some may be given for systemic effect (designed\ to be absorbed and affect the entire body; like an oral medication does). Wear\ gloves to keep topical medications that have a systemic effect off your hands to\ prevent them from being absorbed by YOUR body. If topical medications are\ covered with a dressing, put date, time, and initials on the dressing so that staff\ know how long the medication has been in place. Some systemic topical\ medications are delivered via a pre-manufactured adhesive patch that already\ has the medication "built in" (this distribution system is called transdermal).\ ALWAYS MAKE SURE TO REMOVE THE OLD PATCH! Not doing so\ might lead to an overdose. Ointments, lotions, liniments, pastes, and tinctures\ (medication dissolved in alcohol) are other topical forms. - Inhalation - Optic: Eye drops. Have patient tilt head back slightly and look toward\ the ceiling. Insert drop into lower conjunctival sac (NOT onto the pupil or iris).\ Use thumb on non-dominant hand to pull down lower lid, place the dropper ½ - ¾ inch above the conjunctival sac, making sure it doesn't touch anything. Make\ sure contact lenses are out --- may interfere with absorption. Eye drops are\ intended for local effect, but it is possible for some medications to enter the\ circulation via the nasolacrimal ducts and exert an unwanted "systemic effect".\ To prevent this from happening, put pressure on inner canthus for 30-60\ seconds after drops are inserted - Otic: In ears, eardrops. Remember to straighten ear canal, pull the pinna of ear\ back and up for children over 3 years of age and pull the pinna of ear down and\ back for children under 3 years of age - Transdermal - Special considerations for insulin - Dosage Calculations - How to calculate dosages with enteral and parenteral medications, including insulin - How to convert common household units to metric units (e.g. ounces to mL) - How to convert metric units (e.g. mg to g) - Alternative and complementary therapies - Patient considerations - Nursing responsibilities - Medication reconciliation - What are the required times to perform medication reconciliation? Obtain, Verify, Document -- obtain comprehensive list of patient's current medications\ whenever he or she experiences a change in health status\ Consider and Compare -- review what patient was taking at home prior to admission and make sure medications, dosages, and frequencies are accurate\ Reconcile -- compare new medication orders with current list; investigate discrepancies with patient's health care provider\ Communicate -- ensure that all of the patient's providers have the most updated medication list; communicate changes with patient/family\ Watch for polypharmacy - Why is medication reconciliation required? **Skin Integrity and Wound Care** - Pressure Injuries - Stages of pressure injuries - Prevention of pressure injuries (Potter & Perry, p. 1341, Table 48.8) - Braden Scale -- have a general sense of how it is used - Drainage terms - Serous: Clear, watery plasma - Sanguinous: Bright red; indicates active bleeding - Serosanguinous: Pale, pink, watery; mixture of clear and red fluid - Purulent: Thick, yellow, green, tan, or brown - Drains -- how to safely use the following: - Penrose: flexible rubber tube, usually lie under the wound dressing and often a\ clip is placed to prevent the drain from slipping further into the\ open wound. The provider is the person responsible for pulling or\ advancing the Penrose drain. Remember wounds heal from\ inside out and an excessive amount of drainage prevents proper\ healing - Hemovac: pancake device with its own suction when fully\ compressed - Jackson-Pratt (JP) bulb device with its own suction when fully\ compressed, both of these devices exert a constant amount of low pressure\ suction when fully compressed. - Wound vac -- know how it works: Designed to exert a safe, constant,\ low-pressure vacuum to remove and collect drainage (Packing a wound- Negative-pressure wound therapy) - Wound repair / healing -- definitions and purpose - Primary intention: Acute wounds without tissue loss. The skin edges \"approximate\" and are easily pulled closed with sutures, clips, or "Steri-strips" (thin strips of tape that are placed across an\ incision; usually at one-inch intervals. These wounds heal in an\ orderly and predictable fashion\--all the tissue layers heal at once.\ These wounds heal quickly (usually within 14 days), scarring is\ minimal, and the risk of infection is low. Examples of this wound\ type are surgical incisions and lacerations. - Secondary intention: Tissue is lost, and therefore wound\ edges can\'t be pulled together\--there is a \"cavity left underneath\ and a high risk of infection. Thus, the wound has to be left open\ (not sutured). These types of wounds heal from the \"bottom up\" as\ the wound fills with granulation tissue. Healing takes a long time.\ Examples include burns and pressure injuries. There is usually\ more extensive scarring. Granulation tissue itself becomes a scar,\ as the dermis never is replaced. New epithelium ("skin") will cover\ the wound as soon as the wound "fills" with granulation tissue to the\ level of the surrounding tissue. - Tertiary intention: Also called delayed primary closure. A\ wound in which the edges could be pulled together and closed with\ sutures or staples, but is purposely left open for 3-5 days due to\ excessive drainage, hemorrhage, or infection in the wound before it\ is closed. - - Debridement -- definition and types: a French word that means removal of dead tissue. This promotes healing by providing a clean and stable base for new epithelial\ cells and prevents them from having to "climb over' the margins of dead\ crusts. Types: Mechanical: removal of dead tissue by direct pressure or\ force\ a. Wet-to-dry dressings. The theory: As the saline\ soaked dressing dries, it "sticks to" the wound and\ pulls away dead tissue when it is removed.\ b. Pulsed low-pressure irrigation - requires special\ equipment.\ c. Whirlpool treatments - used to be a very popular\ method of mechanical debridement, but now thought\ by many to be too "rough" for wounds with good\ granulation tissue; and no longer considered within\ the standard of care. There is a high risk of\ maceration of peri-wound skin. Also, whirlpool\ treatment is inconvenient---the patient must travel to\ the physical therapy department, and the tank has to\ be drained and disinfected between patients. Even if\ this is done, bacterial organisms can survive;\ particularly pseudomonas, which is often found in\ water pipes from which the whirlpool is filled. Autolytic: covering the wound with a dressing that supports\ moisture at the wound surface. It seals the wound, keeps it\ moist, and promotes the removal of the dead tissue via lysis\ (breaking down membranes of the cells) of the dead tissue\ by using the body's natural enzymes and white blood cells.\ Examples of the dressings used are transparent film and\ hydrocolloid.\ 3. Chemical: application of a topical enzyme preparation such\ as Dakin's solution or sterile maggots that either dissolve or\ digest dead tissue (requires a physician's order). The\ Dakin's solution actually breaks down and loosens tissue and is applied to a gauze that is place directly to the wound.\ Sterile maggots are thought to ingest the dead tissue and\ are taped in place with an occlusive dressing to the wound.\ 4. Surgical (sharp): using a scalpel, scissors, or other sharp\ instrument to cut away dead tissue. A surgical procedure\--\ only done by physicians, nurse practitioners, physician's\ assistants, some physical therapists, or specially trained and\ certified wound care nurses - Nursing diagnoses associated with impaired skin integrity - See Potter & Perry, p. 1337 - Wound complications -- define and know what action to take if it happens - Hemorrhage - Infection - Dehiscence: partial separation of wound layers at the surface of\ the wound. The layers of the skin and tissue separate -- this\ commonly occurs before collagen formation which is 3 to 11 days\ after injury or surgery. Most commonly seen with abdominal\ wounds / abdominal surgeries. Obese patients are especially at\ risk (constant strain on the wound, plus the fact that that fatty tissue\ heals poorly). Patients with poor nutritional status, underlying\ infection, history of chronic disease such as diabetes or peripheral\ vascular disease are also at high risk for dehiscence - Evisceration : total separation of all layers of a wound with\ protrusion of abdominal organs. Evisceration is a medical\ emergency which requires surgical repair. If it occurs, cover the\ wound with sterile cloths or dressings soaked in sterile saline (helps\ keep bacteria from getting in and the organs from drying out). - Fistula: an abnormal passageway connecting one epithelial\ surface with another epithelial surface