Injectible Administration & Nursing Process

Fundamentals Final Review

problem solving method
- use it every day
- organized systematic method of giving individualized nursing care that focuses upon identifying and treating unique response of individuals or groups to actual or potential alterations in health

nursing process

nursing process order

assessment
diagnosis
planning
implementation
evaluation

step of nursing process

gather and examine info (data) to obtain all facts necessary to determine your patient's health status and to describe strengths and problems

"to what extend can he manage his own health"

"To what extent does he need nursing intervention"

"assist client in achieving or maintaining independence"

assessment

during this step of nursing process you
- establish a data base
- nursing hx and physical exam
- review of records/ lit
- consult w/ support persons and healthcare professionals
- update, validate, and communicate database

assessment

cues that lead you to a diagnosis.

cues are obtained through the use of the 5 senses

defining characteristics

true or false

if you got the report from another nurse, you want to validate the info w/ the patient

true

once necessary facts are obtained through assessment, ______ data to identify

- strengths of patient
- actual and or potential problems that nursing interventions can prevent or resolve
- clinical judgement is being made

analyze

step of nursing process
- interpret and analyze data
- formulate and validate nursing diagnoses
- develop a prioritized list of diagnoses

nursing diagnosis

breathing
pain
safety

are all priorities

true or false

true

does the medical diagnosis always determine the priority nursing diagnosis

no

sources of _____________
- lack of knowledge or skill
- innacurrate or missing data
- failure to validate
- problems w/ interpreting the data
- labeling the data incorrectly

diagnostic error

examples of what

ineffective airway clearance r/t weak cough and pain

impaired tissue integrity r/t decreased blood and nutrients to tissues

total incontinence r/t diminished bladder cues

impaired physical mobility r/t decreased strength and endurance

diagnosis

true or false

diagnosis can be
- problem focused
- risk
- health promotion

true

should you use their medical diagnosis as a part of our nursing diagnosis

no

should you state 2 problems in one diagnosis

no

is it correct to say

pain and fear r/t diagnosed procedures

no (you're stating two problems in one diagnosis....you should separate it into 2 diagnosis)

don't write a diagnosis that could be _______ incriminating

"at risk for injury r/t to no side rails on bed"

legally

step of nursing process

where you develop plans for the patient's care
- care plan
- set priorities
- establish patient centered goals
- choose pertinent nursing interventions
- write in such a way that each nurse who uses it can understand and follow
- remember cost effectiveness

- individualize the plan
- make it realistic and feasible

planning

during this step of nursing process, you do priority setting.

planning

highest, intermediate, or lower priority


acute pain, anxiety, impaired gas exchange, decreased CO, risk for other directed violence
- ABCs
- maslows (physical needs like air, water, o2)

highest

highest, intermediate, lower priority

impaired physical mobility

intermediate

highest, intermediate, or lower priority?

risk for impaired skin integrity

lower

these things direct nursing care bc they are the desired physiological psychological social developmental or spiritual responses that indicate resolution of a patient's health problems

- taken from both long and short term goals, they will help determine if specific patient centered goal has been fully met, partially met, or not met

expected outcomes

true or false

goals must be patient centered

true

short or long term goal

less than one week

short

short or long term goal

weeks to months
- assess client ability to manage care in home environment and plan accordingly (ex: equipment, community resources)

long

true or false

when considering outcomes for patients of different cultures, remember that nurses achieve culturally congruent care through the assessment of patient's values beliefs and practices

true

when planning culturally congruent spiritual care, successful outcomes reveal the patient developing an increased or restored sense of __________ w/ family and maintaining, renewing, or reforming a sense of purpose in life

connectedness

expected outcomes must be what 2 things

measureable
observable

should you avoid using these words when writing expected outcomes

- stable
- acceptable
- sufficient
- average
- appears
- seems
- apparently

yes

step of nursing process

putting the plan into action
- continued data collection from daily assessments
- setting daily priorities for nursing care
- performing nursing interventions
- documenting nursing care
- giving report
-teaching/discharge planning

implementation

when you do this you should
- ensure age and reading level appropriate
- consider language
- be mindful of sensory overload and readiness to learn
- excessive stimuli may prevent brain from responding appropriately and then ignoring this
- consider patient's fatigue, attitude and emotional wellbeing to prevent anxiety

teaching

what are the 3 areas of interventions in care plans

ongoing assessment

therapeutic intervention

education

these are tips for what?

- know and explain rationale, expected positive effects and possible adverse effects
- continually reasses your patient's response to interventions
- include patient and his family explain to both
- be aware of institutional protocols and procedures

(conducting) nursing interventions

step of nursing process

nurse and patient must determine how well plan has worked
- to what extend has patient achieved the goals specific in the plan of care
- what factors have postiively or negativel influenced this achievement of goals

evaluation

fully met, partially met, or not met

100% of expected outcomes have been fufilled

fully met

fully met, partially met, or not met

some but not all expected outcomes have been fufilled

partially met

fully met, partially met, or not met

none of expected outcomes have been fulfilled

not met

do we evaluate nursing interventions or expected outcomes

nursing outcomes

nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses in a health reccord

documentation

_______ documentation is one of the best defenses for legal claims.

accurate

when you document do not remove patient info that is printed from a clinical agency unless you de identify all patient health info keep the docs secure and destroy by shredding or dispoing of them in a locked receptacle as soon as possible

true or false

true

is it wrong to document

"patient asleep at 2300"

yes (instead write "patient lying in bed with eyes closed at 2300)

as nurses we keep promises by following through on our actions and interventions
- includes revisiting plan as necessary to achieve client goals - do not abandon patient if care becomes controversial or complex

fidelity

true or false

you should clean the injection site and rubber stopper of a vial w/ alcohol and then allow to dry

true

true or false

clean the skin
horizontally
vertically and then
in a circulation w/ an alcohol pad

true

what size syringe do you usually use for an injection

5ml (or less)

a way a needle can attach onto the syringe

you twist it to the right and that keeps it in place

luer lok

the higher the gauge the THICKER OR THINNER the needle

thinner

19 gauge needle = _____ in

1 1/2 (in)

20 gauge needle = ______ in

1 (in)

21 gauge needle= _______ in

1 (in)

23 gauge needle= _______ in

1 (in)

25 gauge needle = ______ in

5/8 (in)

most needles are made out of ________ and are disposable

stainless steel

0.5 length needle

A) baby or thin patient
B) obese patient

A

3 in needle

A) baby or thin patient
B) obese patient

B

with a child or slender adult you would you use a LONGER OR SHORTER needle

shorter

for IM injections, you would use a LONGER OR SHORTER needle

longer

for subcutaneous injections, you would use a LONGER OR SHORTER needle

shorter

as the needle gauge # becomes smaller, the needle diameter becomes __________

larger

selection of gauge depends on _________ of fluid to be injected or infused

viscosity

(if you had a thick penicillin you may need larger bore needle)

these are refilled unit dose systems that include a reusable plastic syringe holders and disposable, refilled sterile glass cartridge units.

(disposable injection units)

DELETE

this is common for insulin especially w/ kids and older adults who may not be able to see as well

also an epipen

pen

an ____ is made of glass and has a top that has to be broken (neck)
- put gloves on and get alc swab and break neck
- use a _____ straw or needle to draw out liquid
- draw liquid through _____ straw, get rid of excess air
- take _____ straw off and put on injection needle, check dosage and administer med

ampule
filter x3

- clean top w/ alcohol
- draw equal amt of air as the dosage (to equalize pressure)
- put needle into vial and insert air
- turn container upside down and draw the med into the syringe
- recap the needle
- recheck to make sure dosage is accurate

vial

when mixing meds from 2 vials, it is important to not ______ one medication w/ the other and to ensure that the final dose is accurate

contaminate

if you are mixing a med from a vial and an ampule which one do you draw the medication from first

vial (bc ampule doesn't require any air)

what is the most common diluent for when you need to reconstitute a medication

normal saline

when you reconstitute a powder, you have to administer the med within _______ MIN of mixing it with the liquid

5 (Min)

should you rotate or shake a reconstituted powdered med?

rotate

fasting blood sugar target range for someone w/ out diabetes is what?

70-100 (mg/dl)

fasting blood sugar target range for someone w/ diabetes is what?

70-130 (mg/dl)

after a meal blood sugar level should be less than _____ mg/dl but will lower

180 (mg/dl)

hypo or hyperglycemia?

sweating
shaking
anxiety
hungry
fatigue
light headed
nauseated
confusion
tingling lips
blurry vision

hypoglycemia

hypo or hyperglycemia

thirsty
headache
trouble concentrating
blurry vision
increased urination
fatigue
nausea

hyperglycemia

signs and symptoms:
polyuria
polydipsia
polyphagia

DM (diabetes mellitus)

increased urine

polyuria

increased thirst

polydipsia

increased hunger

polyphagia

U-100 means

100 units per ml

(insulin)

what 4 types of insulin are there

fast
short
intermediate
long acting

if you have a premixed insulin that is 70/30

what does the 70 refer to?
what does the 30 refer to?

70% NPH (intermediate)
30% regular

if you are mixing 2 insulins in one syringe

and you have a regular and intermediate acting insulins, prepare which one first?

the regular (to prevent contamination)

(if insulin is cloudy roll it in your hands, wipe off both tops of vials w/ alc swabs, insert air into intermediate, insert air into regular, draw up insulin from regular, draw up insulin from intermediate)

NPH

intermediate or short acting

intermediate

R

intermediate or short acting

short acting

when you have a rapid acting insulin and a NPH insulin, you need to inject how many minutes before a meal

15 (min)

true or false

you should verify insulin dosages w/ another nurse

true

secreted by the pancreas and allows glucose to enter the cell and then body is able to use it for energy

used to treat diabetes

insulin

insulin is administered by injection bc the GI tract destroys breaks down and destroys ______ forms of insulin

oral

roll or shake cloudy insulin

roll

inject insulin how many minutes before a meal

15 (min)

if meal is delayed, provide source of simple sugar, carb, or protein if you already gave the insulin

true or false

true

why shouldn't you shake an insulin vial

create bubbles

refers to the progressive increase in pre meal or nighttime insulin dose based on pre defined blood glucose ranges

sliding scale (correction insulin order)

true or false

the nurse DOESN"T have the decision of choosing needle size, needle gauge, and the syringe

false (you choose all of these as the nurse)

true or false

a tiny air bubble will kill a patient

false (tiny air bubbles won't kill someone if you inject it into something but we try to avoid it because they may not be getting the full dose)

you should choose the SMALLEST OR LARGEST suitable length and gauge

smallest

rub the arm to help the patient relax, this is to __________ muscle tension

reduce

true or false
you should warn the patient prior to sticking them

true