CLINICAL PROFICIENCY

Normal range for heart rate?

60-100 bpm

normal range for temperature?

96.8-100.4 F

Normal respiratory rate range?

12-20

Intradermal injection needle length?

3/8 in

Intradermal needle gauge range?

26-31

injection sites for intradermal ?

forearm

upper back

What three medications are given subcutaneously?

lovenox, heparin, insulin?

what two medications require a double med check with another RN?

heparin and insulin

which medication comes in pre filled syringe?

lovenox

needle lengths for subcutaneous injections?

3/8, 1/2, 5/8 in

Angle of insertion for intradermal injection?

5-15 degrees

Max amount of medication for an intradermal injection?

0.5mL

Needle gauge range for subcutaneous injection?

25-31g

Injection site for heparin?

2 inches from umbilicus, rotate sites

Injection site for lovenox?

anterior lateral and posterior lateral abdominal girdle

injection sites for insulin ?

-anterior aspect of the thigh

-between the scapula

-outer posterior aspect of the upper arm - the abdomen below the costal margins of the iliac crests

Max medication dose for a subcutaneous injection?

1mL

Important consideration with the needle for an intradermal injection?

Face bevel upward

Important needle consideration for intramuscular injection?

Draw up medication with blunt needle and switch out with injection needle

Three important considerations for intramuscular injections?

-Aspirate the needle for 10 seconds before injection -inject medication over 10 seconds

-z track the skin

Injection angle for subcutaneous injections?

90

45 for insulin depending on how much fat you are able to pinch

How to hold skin for intradermal injection?

taught

How to hold skin for subcutaneous injection?

pinch up an inch or more

Needle length for intramuscular injection?

1-3 in

Needle gauge range for intramuscular injection?

18-25

What determines needle gauge for intramuscular injection?

viscosity of the medication

Injection sites for intramuscular injection?

Deltoid muscle

vastus lateralis ventro gluteal

Max amount of medication for intramuscular injection sites?

Deltoid= 1mL

Ventrogluteal = 3mL Vastus lateralis = 3mL

How long after administering IV/IM pain meds should you reassess pain level?

15-30min

How long after administering oral pain meds should you reassess pain level?

30-60min

Always wear gloves for medications applied to the ___?

skin

Considerations for transdermal patches?

Wear gloves

check for old patch

rotate site

date time and initial patch

How to apply ear drops?

Make sure room temp

pull pinna up out and back

if applying bilaterally use cotton to keep medication in while applying to other ear

How to apply eye drops?

wait 5 min between drops

have patient tilt lead back and look at ceiling

pull lower lid back

do not touch dropper to eyeball

for ointment apply thin ribbon to inner canthus

How to give metered dose inhaler?

20-30 seconds between puffs, hold for 10 sec

can put mouth around or 1-2 in in front of mouth

Use chamber if cannot hold breath for 10sec

rinse mouth out after use to prevent thrush

Nasal spray application considerations?

Alternate nares for frequent use

have patient blow nose prior to admin

Rectal /vaginal medication considerations?

wear gloves

use lubricant

push past sphincter 4 inches

Wait 15-30min to evaluate

Patient can do own vaginal suppositories once taught

Contact precautions?

Patient in private room

Nurse dons gloves and gown

VRE MRSA

Airborne precautions?

Patient in private room/negative airflow

Mask on patient

Nurse wear N95 respirator

TB, measles , chickenpox

Droplet precautions?

Surgical mask on nurse and patient

influenza rubella mumps pertussis

Donning PPE order?

Gown, mask , goggles, gloves

Doffing/removing PPE order?

gloves, gown goggles, mask

_____ insulin should be held if the patient does not eat their meal ?

Daily

____ _____ insulin should always be given regardless if the patient eats?

Sliding scale

____ insulin is given based on how % much the patient eats ?

Bolus

The Liftaem air transfer is used for patients weighing greater than ___ lbs

250lbs

The Slipp sheet can be used for later transfers up to _____ lbs

250lbs

What is the Slipp sheet used for ?

repositioning patient -place in trendelenburg to make easier to reposition

lateral transferring

What is the Sabina used for ?Should you lock casters?

Sit to stand position for transfer to chair

Do not lock

Limb straps can be utilized for ...?

wound dressing changes

foley placement

perineal care

Limb straps can be used with ___ lift or ___ lift

Ceiling or Golvo

The Quick Move can be used for ...

Assisted ambulation

Transfers

How is the Quick Move is used? should the locks be on?

TRANSFERRING Helping patient up in with gaitbelt

1-2 nurses

Yes locks should be on when patient is standing

make sure patient isnt dizzy

AMBULATION

put seat pads in lowest position and remove foot plate

locks on

assist with gait belt if fall risk

Nurse puts one hand on gait belt and one hand on Quick Move

Take breaks if needed

The Quick Move should NOT be used if the patient has...

Neurological deficits

High risk of buckling at knees

What is the Golvo lift used for?

Transferring from bed to chair

When transferring a patient, the bed should be raise to the nurse’s ___height to avoid back strain

hip height

How do you use the Golvo lift? Lock breaks?

Slide sling under patient

loop one leg loop through the other

Attach to device and lift

do NOT lock

The Ceiling Lift can be used for..

Boosting and turning patient

Transferring to chair/stretcher

Transferring to chair

How to use Ceiling lift with Repo sheet ?

Use purple loops with loop 1 for lifting

Use green and black loops for repositioning /boosting and loops II and IV

Purple black red loops I IV and III for upright chair transfer

What two items can you use with the ceiling lift?

Repo sheet

sling