Module 3 quiz

What is opposite of non-parenteral?

Parenteral route

Parenteral Route

• Injection can be into

  • Vein (IV)

  • Muscle (IM)

  • Subcutaneous (Sub-Q)

  • Intradermal

• Others: epidural, intra arterial, intraperitoneal, etc. (outside of nursing scope)

Non-parenteral routes

• Oral

• Inhalation

• Topical

• Suppositories

Oral route

• By mouth (pills)

• Sublingual (nitro)

• Buccal (liquid fentanyl)

• Most convenient & most used

• Absorbed into the system through the digestive tract

• Slower onset of action by, but has more prolonged effect

• Quick acting sublingual and buccal

• Malabsorption, vomiting, NPO all affect absorption.

Buccal route of administration

Sublingual route of administration

Topical

• Skin (ointment, powder, duragesic)

• Eyes (drops, ointments)

• Ears (drops)

• Medication placed on skin or mucous membranes

• Absorbed into the skin and then the blood stream

• Slowest onset

• Avoid with open wounds and signs of trauma

Suppositories

• Vaginal (miconazole)

• Rectal (bisacodyl)

• Typically quick acting

• Absorbed through the membranes into the blood stream

Medication administration

• AN essential part of nursing practice

• Complex and time consuming

• Multiple health care members and factors involved in the process

• Much potential for error

• Chief responsibility falls to the nurse; occupies 1/3 of our nursing time

• Under appreciated how much time is put on medication administration→ very complex and multiple time that an error can occur

• Usually, error of the nurse as we are the last line of defense but truly system issues

Participants in Medication Administration

• Drug manufacturer→ name and label the drug

• Prescriber→ provider

• Pharmacist→ supply the medication

• System process→ pyxis machine, scan ban, verify name & DOB, scanning medication

• Nurse→ Knowing the medication

• Patient→ should be encouraged to know what they are taking and why.

AC

Before meals

PC

After meals

HS

Hours of sleep

Avoid q2hr PRN

Instead Every 2 hours prn

Daily

Avoid QD

Three times daily

Avoid TID

Every 8 hours

Avoid Q8H

Why is it important to write things out?

Helps avoid miscommunication

Types of orders in acute care agencies

• Standing or Routine

• PRN

• Single one-time

• STAT

• Now

• Prescriptions

Standing or Routine order

Administered until the dosage is changed or another medication is prescribed (ex: multivitamin)

PRN order

Given when the patient requires it ALWAYS will need a frequency and reason (ex: stool softener)

Single one-time order

Given one time only for a specific reason (ex: vaccine)

STAT order

Given immediately in an emergency (ex: epinephrin in a code situation)

Now order

When a medication is needed right away, but not STAT; can be looked at as urgent, but not emergent

Prescription orders

Medication to be taken outside of the hospital

Verbal orders (in person or telephone)

• Avoid if possible→ cannot be performed by a student nurse

• If you must take→ write on patients chart ASAP

• Always do a “read back”

• Don’t use abbreviations

• State numbers individually

• Ask prescriber to spell drug names that are unfamiliar or sound like another drug name

Similar names/labels

Ex:

• Hydroxyzine is an antihistamine

• Hydralazine lower blood pressure

Nurse’s Role

Medication administration requires knowledge and skill set unique to a nurse and “critical thinking” at each step of the way.

• Medication knowledge

• Patient assessment skills

• Critical thinking regarding medication→ given patient diagnosis, exam, lab findings

• Skill to correctly administer medication→ the “how to”

• Knowledge to monitor the effects of the medication

• Ability to evaluate/educate patient and family

Medication Knowledge

Any drug you give→ you are always expected to know what the drug is for, how it works, why its being given, what the usual does is, and the anticipated outcome.

Patient assessment skills

• Is the patient able to safely take medication the route it’s ordered? → Mental status, swallow, currently NPO, Allergy, etc.

• Is your patient allergic to medications ordered?

• Vital sign assessment, Symptom assessment (PRN medication?)

• Does the medication ordered make since?

• Going to be able to manage regimen in anticipated care setting→ dexterity, vision, mental activity?

Administration Skills/ Medication Rights

1. Right Medication

2. Right Does

3. Right Route

4. Right Time

5. Right Person

6. Right Documentation

What is the first medication right?

Right Medication

What is the second medication right?

Right Does

What is the third medication right?

Right Route

What is the fourth medication right?

Right Time

What is the fifth medication right?

Right Person

What is the sixth medication right?

Right Documentation

When preparing medications…

Compare the medication to the MAR THREE times!!!

When preparing a medication from a bottle or container compare with the MAR:

1. Before removing from the drawer or shelf

2. As you remove the amount from the container

3. Before returning the container to the drawer or shelf

When preparing a medication with unit does or are pre-packaged compare with the MAR:

1. When taking the medication out of the dispensing system

2. Check the MAR to the label again

3. Verify all medications at the bedside with the MAR

Right patient?

• Two identifiers always

• Name

• ID arm band

• Bar codes on patient armband

• Birthdate

• Medical ID number

Right Medication?

• RN responsible for comparing the prescriber’s written order with the medication administration record (MAR)→ “transcribing orders” or reviewing prescribers computerized orders

• Need to complete a medication reconciliation whenever patients transfer from one care setting to another (home to hospital, NH to hospital, unit to unit in hospital, vice versa)

  • this is a comparison of the most recent medication list against the orders

• NO drugs can be administered without an order→ not even the OTC drugs people take by themselves when at home

Never-Ever: right medication?

• Never give medications someone else has prepared

• Never give a medication you are not familiar with

• Never ignore when a patient questions a medication (may be an error)

• Never “borrow” medication from another patients bin

• Every time you give a medication you are EXPECTED to know what drug you are giving, the usual dose, and the anticipated outcome you expect from it.

Right Dose?

• you are always expected to know the usual dose of any medication you are giving

• Check dose carefully! “0” always leads, never follows→ 0.5 mg, never 5.0 mg; 100000 or 100,000

• Only break tablets scored by manufacturer

• Error increases when preparing medication from a larger volume or strength than needed→ unit dose tries to address this

• Know med calculations and conversions

• Ask another qualified nurse to check calculated doses

• Use standard measuring devices

Right Route?

• Oral, inhalation, topical, vaginal, or rectal?

• If it is an injection: IM, IV, or SubQ?

Right Time?

• This can also be viewed as “frequency” or “when”

• Understand why medication is ordered for a certain time and whether can be altered? → 3 times daily medications vs. every 8 hours

• Understand STAT, now, “on call”, ac, once, etc.

• Each agency will have standards on how close to scheduled time a medication should be given, ex: give all medications within 60 minutes (or 30?) of scheduled time.

• Critical thinking is needed!

Right Documentation

• Record→ record medication as soon as it is given

• Leave→ never leave medications unattended at the bedside→ observe patient taking (avoids hoarding, abuse, or misuse of medication)

• Document→ document after medication is given (never before)

• Document→ Document pertinent assessment prior to giving medication when indicated (heart rate prior to rate control medication)

• Assess/document→ assess/document the effectiveness and any adverse response of medication you gave

• Document→ document if patient refuses a medication or if medication is held and why

Medication Errors

• Most common: wrong medication, wrong dose (or failing to administer a medication) wrong route.

• Best is to prevent errors: report potential errors (an error waiting to happen) and near misses (errors that were caught before reaching the patient)

Identifying a Medication Error

• Best person to report an error is whoever discovered or witnessed it (remember you’re not reporting a peer for an error→ you’re reporting the error itself).

• Legally and ethically the right thing to do for the patient’s safety→ check patient safety first and then notify the patient and provider of the error that occurred

• Agencies vary in how to report→ most use an “incident report” and not documented in the patients chart

• Value of incident reporting is that it looks at how the system failed and allowed the error to reach the patient→ thereby rectifying the underlying causes and making the medication use process safer for patients

• Establishing a climate of trust is necessary

Instilling ear drops

Inserting a Rectal Suppository

• Have the patient lie on their left side→ with their right leg pulled up towards their chest (maintain dignity)

• APPLY GLOVES→ Remove suppository from package. Lubricate the tip of the suppository with either water or a water-based lubricant (ex: KY jelly)

• Insert→ the lubricated tip of the suppository into the rectal opening

• For adults, insert the suppository just past the internal rectal sphincter, which is about a finger length, and hold against the rectal wall for a few seconds (this will keep it in place)

What is missing from this order: Oxycodone 1 tab PO every 4 hours PRN

Dose and Indication

What is missing from this order: Ondansetron 4 mg tab for nausea or vomiting

Route and Frequency

Anatomy and Phys of Female breast

• Extended vertically from second to sixth ribs; laterally from sternal margin to maxillary line. Normal to see some mild asymmetry.

• Divided into 4 quadrants by vertical & horizontal lines intersecting at nipple.

Three types of breast tissue

1. Glandular tissue: Largest amount lies in outer quadrant of each breast→ could be why we see more breast cancers in this quadrant.

   • Where breastmilk is produced

2. Fibrous tissue

3. Subcutaneous & retromammary fat tissue

Tanner staging of breast development

Stages 1-5 of female breast development.

Tanner state 1

Preadolescent. Elevation of the papilla only.

Tanner stage 2

• A small mount is formed by the elevation of the breast and papilla

• Areolar diameter enlarges

Tanner stage 3

Further enlargement of breast and areola.

Tanner stage 4

Projection of the areola and papilla to form a secondary mound above the level of the breast.

Tanner stage 5

• Mature breast

• Areola recessed to the general contour of the breast

Anatomy and phys of Male breast

• Male breast undergoes little development after birth; gland remains rudimentary

• Consists of think layer of undeveloped tissue beneath nipple; areola small compared with that in female

• During puberty, male breast may become slightly enlarged, producing temporary gynecomastia

• Older men may also have gynecomastia (enlargement of male breast) secondary to decrease in testosterone.

Anatomy and phys Lymphatic system

• Each breast contains extensive lymphatic network, which drains into lymph nodes:

  • More than 75% of lymph drainage is outward toward axillary lymph nodes, then upward to subclavicular and supraclavicular nodes.

• Other drainage routes flow through:

  • Anterior axillae (pectoral) nodes above breast

  • Internal mammary nodes in thorax

  • Sub-diaphragmatic nodes toward abdomen and cross-mammary pathways ti opposite breast

Heath history: Subjective

• Breast

• Axilla

• Family history

Heath history: Subjective→ Breast

1. pain

2. Lump

3. Discharge

4. Rash

5. Swelling

6. Trauma

7. History of breast disease

8. Surgery

9. Self-care behaviors

   • Breast self-examination

   • Last mammogram

Heath history: Subjective→ Axilla

1. tenderness, lump or swelling

2. Rush

Heath history: Subjective→ Family history

1. breast disease

2. Gynecological cancer

Female breast examination: Objective

• Inspect both breast: note size, shape, contour, and symmetry

• Inspect skin for color pigmentation, vascularity, surface characteristics and lesions

• Inspect areolae for color and surface characteristics

• inspect nipples for position, symmetry, surface characteristics, lesions, bleeding, and discharge

Male breast examination: Objective

• Inspect breasts and nipples

• Palpate breast and nipples

• Palpate axilla

If any lumps present, Note:

1. Location→ quadrant and clock

2. Size→ cm

3. Shape→ round, oval

4. Consistency→ hard, soft

5. Mobility→ fixed or mobile

6. Distinctness→ clear borders

7. Nipple retraction

8. Overlying skin→ edema, dimpling

9. Tenderness→ painful or not

10. Lymphadenopathy

Fibrocystic Changes to Breast

• Age range→ 20-49

• Occurrence→ usually bilateral

• Number→ multiple or single

• Shape→ rounded

• Consistency→ soft to firm; tense

• Mobility→ mobile

• Skin or nipple retraction→ absent

• Tenderness→ usually tender

• Borders→ well delineated

• Variations with menses→ yes

Fibroadenoma

• Age range→ 15-55

• Occurrence→ usually bilateral

• Number→ single; may be multiple

• Shape→ rounded or discoid

• Consistency→ firm, rubbery

• Mobility→ mobile

• Skin or nipple retraction→ absent

• Tenderness→ usually non-tender

• Borders→ well delineated

• Variations with menses→ no

Cancer

• Age range→ 30-80

• Occurrence→ usually unilateral

• Number→ single

• Shape→ irregular or stellate

• Consistency→ hard, stone like

• Mobility→ fixed

• Skin or nipple retraction→ often present

• Tenderness→ usually non-tender

• Borders→ poorly delineated; irregular

• Variations with menses→ no

Gynecomastia

• Enlargement of male breast tissue

• Occasional and temporary in adolescent males but very distressing.

• May occur in adult men with obesity, liver cirrhosis, and numerous medications

When is it best to preform a self breast examination?

• just following menstruation cycle (day 4-7)

• if no menstruation, note on the same day each month

Identifying suspicious signs/lumps?

• retraction

• dimpling

• nipple changes

• nipple discharge

• changes in skin/surface characteristics

Female reproductive system: external genitalia

• Mons pubis

• Labia majora

• Labia minora

• Clitoris

• Vestibule

Mons pubis

Adipose tissue covered with hair

Labia majora

Tissue folds that extend downward from mons, surround vestibule, and meet at perineum

Labia minora

• Lies inside majora, are darker, smoother, hairless folds, divided into medial & lateral aspects

• Medial meet superior to clitoris and prepuce to form cliteroal hood

• Lateral meet inferior to clitoris to form frenulum

Clitoris

Small, cylindric bud of erectile tissue that is primary center of sexual stimulation

Vestibule

Lies between labia minora & contains: urethral meatus, introitus, hymenal tissue, bartholins, & shenes glands

Female reproductive system: Puberty

• Breast bud development is the first physical change of female puberty

• Adolescents experience menarche approximately 2 years after breast development

• Growth spurt occurs about the time of menarche

• Pubic hair development precedes axillary hair by about 2 years

Tanner staging

1. no pubic hair, only body hair

2. Sparse growth of long, slightly dark, fine pubic hair, slightly curly and located along the labia (ages 11-12)

3. Pubic hair becomes darker, curlier, and spreads over the symphysis (ages 12-13)

4. Texture and curl of pubic hair is similar to that of an adult but not spread to thighs (ages 13-15)

5. Adult appearance in quality and quantity of pubic hair; growth is spread to inner aspect of thighs and abdomen

Female reproductive system: Menopause

• Decreased hormonal function

• Changes associated with aging & estrogen depletion

• One full year with no menses

• Ovulation usually ceases 1-2 years before menopause

Male reproductive system: external genitalia

• a pouch covered with thin, darkly pigmented, rugous skin, divided by septum into 2 sacs

• Contains a testis and epididymis, suspended by spermatic cord, network of nerves, blood vessels, & vas deferens

• Testes are suspended outside body because sperm production a temperature lower than body temperature

• With cold temperature, scrotal sac & its contents move close to body; conversely, with rising temperature, scrotal sac relaxes & testes drop downward

Male reproductive system: internal structures

• Testes

• Urethra

• Prostate gland

• Bulbourethral glands

Testes

• Paired sex organs located within scrotum, oval shaped, with a smooth surface and rubbery texture

• Primary function of testes is production of perm (spermatogenesis)

• Each testicle contains series of coiled ducts (seminiferous tubules), where spermatogenesis occurs

• As sperm cells are produced, they move toward center of testes, traveling into efferent tubules adjacent to epididymis

Urethra

• Inner most tube of penis; 7-10 inches (18-20cm) from bladder to meatus.

• Extends out base of bladder, through prostate gland urethral orifice is small slit at tip of glands, into pelvic floor and through penile shaft

• Terminal passageway for urine and sperm

• During ejaculation, sperm travel away from ejaculatory duct, through urethra, & out of the body

Prostate gland

• Lies beneath urinary bladder & surrounds upper portion of urethra

• Posterior surface of prostate lies adjacent to anterior rectall wall & two of three lobes are palpable through rectum

Bulbourethral glands

On each side of urethra, just below prostate, empty directly into urethra

Health history questions: Male

• Frequency, urgency, and nocturia

• Dysuria

• Hesitancy and straining

• urine color

• Past genitourinary history

• Penis→ pain, lesion, discharge

• Scrotum, self-care behaviors, lump

• Impotence

• Premature ejaculation

• TSE

• Prostate screening

Male reproductive system: puberty

• First sign is enlargement of testes

• Next, pubic hair appears, then penis size increases

• Complete change in development takes around 3 years

Male tanner stage of development

1. Prepubertal, with no pubic hair

2. Scrotum and testes have enlarged and have more textured scrotal skin. growth of slightly pigmented downy hair is sparse

3. The penis has grown, especially in length. hair is darker and curlier

4. Further penile growth, in length and breadth, has occurred. Glans is larger and broader, and hair is adult in typer

5. The testes and scrotum are adult in size. Pubic hair is adult in quantity and pattern and present along the inner borders of the thighs

Male reproductive system: Aging

• No definite end of fertility

• Production of sperm decreases about age 40, but continues into 80’s and 90’s

• After age 55 to 60 years, testosterone production declines

• Prostates normally enlarges with aging

Rectum and anus: anatomy and physiology

• Anal canal extends from anorectal junction to the anus and is lined with mucous membranes arranged in longitudinal folds called rectal columns containing network of arteries and veins, frequently referred to as internal hemorrhoidal plexus

• Anus is terminal portion of rectum, located on perineum

• Hairless, with moist mucosal tissue surrounded by hyper pigmented perianal skin, is normally closed except during defecation

• Internal and external sphincter, two concentric rings of muscles, surround anal canal.

• Internal sphincter consists of smooth muscle and is under involuntary control

• External sphincter, consisting of skeletal muscle, under voluntary control, allows for control of delectation

bowels Health history: subjective

Describe bowel habits (frequency, appearance of stool). Pain or difficulty with defecation; excessive flatus, change in stools (color, consistency); problems with diarrhea or constipation; presence of blood in stool; hemorrhoids; use of digestive or evacuation aids (stool softner, laxatives, enemas)

• Health promotion: use of dietary fiber supplements; colon cancer screening

Rectal examination

Tell the patient the advanced provider is going to perform rectal examination and that is may be uncomfortable.

• Patient may feel pressure like a bowel movement

• They will glove, then lubricate first two fingers of hand

• Place their middle finger, palm side up, over anus

• Ask patient to bear down

• Gently insert middle finger into rectum

• Insert index finger into vagina to locate cervix

Patient should assume either the left lateral position with hips and knees flexed, a knee-chest position, or standing position with hips flexed and patient bending over examination table.

The patient reports tenderness to the right breast-what should the nurse do next?

Perform OLD CARTS assessment

Patient reports a lump in the left breast- OLD CARTS completed amd no pain or change in size reported. upon palpation, feels rubbery. patient more than likely has.

Fibroadenoma