CPL for exam 1

Order for inserting air and drawing up insulin

• Air into NPH(cloudy), Air into Regular(clear)

• Draw up regular(clear), Draw up NPH(cloudy)

NR, then RN

Regular Insulin

• Regular insulin=Real Fast 

• Dose on sliding scale according to BS

NPH Insulin

• NPH Insulin=Not dropping right now 

• Roll in palms (couple moments) 

• Dose based on provider 

Insulin Reminders

• Insulin is a powerful and dangerous medicine!

• You will NEVER administer insulin in anything but an insulin syringe!!!

• Always double check with another RN

• UNITS and ML are TWO DIFFERENT MEASUREMENTS! They DO NOT equal each other!

• 50 units is 0.5 ML!

• 100 units is 1 ML!

Aspirating

pulling back syringe while in body

Antiseptic wipe

** DO NOT USE AN ALCOHOL WIPE

 Place drop of blood on test strip

• • May have to “milk” the finger to get a good drop

• • Do no smear the blood on the strip

• • Offer client cotton ball or gauze to apply over puncture site

random glucose >200 indicates

hyperglycemia

a glucose <70

hypoglycemia

A nurse is providing education on how to check blood glucose levels to a client who has a new diagnosis of type 1 diabetes. The nurse should include which of the following instructions about transferring blood onto the test strip?

Squeeze the blood onto the strip

A nurse attempts to collect a capillary blood specimen for a blood glucose from a client with diabetes. The nurse is unable to obtain an adequate drop of blood for the strip. Which of the following actions should the nurse take first?

Wrap the hand in a warm cloth

Why do we use precautions?

Isolation guidelines are used to identify actions such as hand hygiene and barrier protection intended to REDUCE THE TRANSMISSION OF INFECTION!

Standard Precautions (Gold Standard)

• • Applies to ALL CLIENTS!

• • A nurse should practice standard precautions in every single client room and every single client interaction!

• • The purpose is to protect the nurse & also prevent infection from spreading from patient to patient.

Standard Precaution Requirements:

• • Hand hygiene: upon entering and exiting the room

• • Clean gloves

• • Properly clean all equipment

Standard Precautions

Applies to ALL client care activities regardless of suspected or confirmed infection status!

Transmission Precautions

Are added protective measures to prevent the spread of disease from patients with known or suspected disease.

Airborne Precautions

• “very small respiratory particles that remain viable and suspended in the air over long distances”

• • Purpose: Protect against droplet infections that are smaller than 5 mcg

  • • Examples: measles, varicella (Chicken Pox), tuberculosis

• • Requirements:

  • • Private room*

  • • Negative pressure airflow room*

    • • Air pressure inside the room is LOWER than the air pressure outside the room, so when the door opens, the contaminated air/particles will not flow outside the room. Instead the clean, outside, air is sucked inside the room.

  • • N95 or HEPA (high-efficiency particulate air) respirator mask*

Droplet Precautions

• “Large respiratory droplets”

• • Purpose: Protect against droplets larger than 5 mcg and are spread by coughing, sneezing or talking

  • • Examples: pneumonia*, seasonal influenza*, bacterial meningitis* scarlet fever, rubella, pertussis & mumps

• • Requirements:

  • • Private room

  • • Masks upon entry of room

  • • Standard precaution when handling contaminated respiratory secretions

  • • some organizations may require eye protection

  • • PPE removal upon exit

Contact Precautions

• • Purpose: to protect & contain diseases that are spread by direct (contact with patient) or indirect (contact with environment)

  • • Examples: Clostridium difficile (C.diff)*, MRSA*, Herpes simplex, respiratory syncytial virus, shigella, wound infections, impetigo, & scabies

• Requirements

  • • Private room or room with clients with the same infection

  • • Gloves & Gown at entry of room

  • • Dedicated equipment in room (stethoscope, etc.)

  • • Clean & disinfect reusable equipment (vital sign cart) before using on other clients

  • • PPE removed at point of exit

Protective Precautions

• • Purpose: to protect clients who are immunocompromised

  • • Examples: stem cell transplant, chemotherapy patients

• • Requirements:

  • • Private room

  • • Positive airflow

  • • HEPA filtration for incoming air

  • • Masks for the client when out of room

Mitten restraints

Mittens restrain patient’s hands. Place mitten on hand and secure with Velcro strap around wrist. Least restrictive, patients can still move their arms but lose the ability grab at tubing, dressings etc.

Elbow restraint

Rigidly padded fabric that wraps around arm and is closed with Velcro. Patients can still move their arms but lose the ability to bend their elbows and grab at tubing, dressings etc.

Belt or Body

restraint Place the patient in a sitting position in bed. Apply belt over clothes or gown. Place restraint at waist, not at chest or abdomen. Remove wrinkles in clothing. Bring ties through slots in belt. Help patient lie down in bed. Have patient roll to side to make sure you do not have the belt too tight. Secure straps to bedframe. Can also use a vest restraint for a patient in a wheelchair. Same guidelines apply for the restraint used in bed.

Soft Extremity (Ankle or Wrist)

• ▪ Restraint made of soft quilted material or sheepskin with foam padding. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly (not tightly) in place by Velcro strap. Insert two fingers under secured restraint.

  • ▪ Patient with wrist and ankle restraints is at risk for aspiration if positioned supine. Place patient in lateral position or with head of bed elevated rather than supine.

  • ▪ Attach straps to bedframe (NOT to siderails)

  • ▪ Use quick release (NOT a true knot)

  • ▪ Put call light within reach, bed locked, bed in lowest position

Posey Bed

Peds, enclosed bed, tube/drainage ports 

Papoose restraint

• Across the forehead, arms, and stomach

• Children in urgent care

• Restraint Evaluation

  • ▪ Assess the patient’s response and document all of the following

• ▪ Behavior

• ▪ VS

• ▪ ROM

• ▪ Skin breakdown

• ▪ Circulation

• ▪ Release restraint every 2 hours and offer (order within an hour) (good for 24 hours) 

• ▪ Toileting/elimination

• ▪ Nutrition and fluids

• ▪ Hygiene

Evaluate the patient for complications related to immobility

• ▪ Skin breakdown

• ▪ Decreased peristalsis (constipation)

• ▪ Risk for atelectasis (lung collapse)

• ▪ Risk for blood clots

Renewal of Restraints

• ▪ Discontinue at the earliest possible time or remove them while in the room with the patient (especially if they are in them because they are pulling at tubes, etc and you can gently redirect them while performing other tasks)

• ▪ Orders may be renewed at different time intervals for a maximum of 24 hours

• ▪ After 24 hours, the restraints must be removed unless the order is renewed and justified by the HCP

• ▪ Assess IVs, catheters, drainage tubes to maker sure that they aren’t caught up in a restraint

• ▪ Document restraint use per agency policy

Montgomery strap

paired adhesive strips that are used to secure the wound dressing

Binders and Mesh

hold drains, hold gauze, underwear for new moms

Circular Wrap & Tube Gauze

Small parts (fingers and toes)

Spiral Wrap

• ▪ Each turn overlapping the previous turn by ½ width of the bandage

• ▪ Used on wrist, arms, and legs

Reverse Spiral

• ▪ Covers cone-shaped parts such as thigh and forearms that could fall during ambulation.

Figure Eight

Around ankle, around foot

Recurrent Dressing

• ▪ Secure with 2 circular turns then fold back and forth until covered and secure again with a circular turn.

• ▪ Head or stump

Blood pressure 

• systolic/diastolic 

• Optimal range: 90-140/60-90

• Hypertention 140+/90+

• Hypotension less than 90

• Appropriate size BP cuff 

  • Too large- low 

  • Too small- high

Pulse

• Rate 60-100

  • - bradycardia

  • +tachycardia 

• Rhythym reg or ireg 

• Strength 

  • 0- absent 

  • 1- faint 

  • 2- diminished 

  • 3- normal 

  • 4- bounding 

Temperature

• Normal 96.8-100.4

  • Oral 

  • Axillary +1 

  • Tympanic -1

  • Rectal -1

• Use same site consistently 

Respirations

• Rate 

  • Normal rate 12-20 bpm 

  • Bradypnea -12

  • Tachypnea +12

• Depth 

  • hyperpnea - increased depth 

  • Apnea- respirations cease for several seconds 

  • Hyperventilation- increase rate and depth 

• Rhythm 

  • Regular- 30 sec x2

  • Irregular- full min. 

Oxygen saturation

• Diffusion and perfusion 

  • O2 stat 

• Normal range 92-100%

• COPD may be unable to reach normal 

  • 88-90%

• What kind of oxygen 

  • Room air 

  • Nasal cannula 

  • Face mask 

Key nursing points 

• Abnormal reading, recheck 

• Compare findings to patient normal readings 

• Review medications 

• Assess for associated signs/symptoms 

  • Low BP ( dizzy/ light head) 

  • Low pulse ( dizzy/weak)

• PCA reports abnormal VS, you recheck

• Know when to be concerned 

Chemical Name

• • Chemical composition of med

• • Ex: N-acetyl-para-aminophenol

Generic Name

• • Name the US Adopted Names Council gives a med

• • Ex: Acetominophen

Trade Name

• • Brand of proprietary mane a company that manufactures med gives it

• • Ex: Tylenol

Major Six Rights of Med Admin

• Patient 

• Dose 

• Medication

• Time 

• Route 

• Documentation

Other rights of Med admin

• To refuse

• Assessment

• Evaluation 

• Education 

contraindications for the oral route:

• • Dysphagia

• • Inability to swallow (i.e., neuromuscular disorders, esophageal strictures, and mouth lesions)

• • N/V

• • NPO

• • Recent GI surgery

• • Reduced GI motility (i.e., bowel inflammation)

• • Gastric suction (NG tube to suction)

• • Unconscious, confused, unable or unwilling to swallow or hold medication under tongue

Oral medications 

• • Tabs that need to be cut in half must be scored. Use a needle, gloved fingers, or pill splitter

• • If individually packaged, place entire package in cup and take extra cup to give to patient

• • May crush (not enteric coated, long acting, slow release, or capsules) & place in one bite of food

• • Protect patients receiving oral medications from aspiration

• • Assess his or her ability to swallow

• • Proper positioning is essential

cannot take PO Meds

Patient may be NPO and have a Nasogastric (NGT) or G-Tube (Gastrostomy)/PEG Tube (Percutaneous Endoscopic Gastrostomy tube)

NG Tube (Nasogastric Tube)

• • Through NOSE → Stomach; inserted by nurse

• • Not surgically placed

• • Temporary; short-term

G-tube or PEG

• • Through abdomen → stomach

• • Surgically placed in endoscopy suite or OR

• • Long-term

Meds through NGT, G-Tube/PEG

• • Patients with NG and G-tubes/PEG tubes are often NPO.

• • Usually do not administer meds through a NG or intestinal tube that is being used for continuous decompression (suction). If necessary: stop suction prior to giving med and leave off for 1 hour to allow for absorption.

• • Crush the pill or dissolve the tablet or get the medication in a liquid form.

• • Sustained release, chewable, long acting, or enteric coated tablets and capsules should generally not be crushed and administered via NG/PEG tube. Check with the pharmacy for possible options. Check placement and residual. Aspirate stomach contents using the 60ml syringe.

• Measure it and return it to the patient to prevent electrolyte imbalances. If the residual is more than 200ml (or less/more per agency policy), return the residual to the patient, withhold the medication, and contact the HCP.

• • Another method to check placement is to instill 30ml of air into the NG/PEG tube while listening to the stomach with your stethoscope. You should hear a gurgling sound when the air is instilled into the stomach.

• • NG placement is initially verified by x-ray but you must still check placement prior to feedings and medication administration as per your facility policy.

Silent knight 

• • Crush each tablet/capsule and dissolve in 30ml of warm water (use a separate medicine cup for each medication).

• • Elevate head of bed to minimum 30 degrees and preferably 45 degrees or sit patient up in a chair to reduce the risk of aspiration.

• • Irrigate the tubing with 30 mL of water then draw up prepared medication in syringe

• • Administer the first dose of medication to the patient by unclamping the tube (if clamped), attach the syringe and administer the medication, and follow it with 30ml of water.

• • Once all medications are administered, follow with a final flush of 30-60ml of water. Be sure to keep up with how much water you are administering for your intake and output record. Reclamp the tube (if required) when completed.

• • Nursing judgment: If your patient is on fluid restriction or has a moderately high residual, reduce the amount of flush in between each medication, as low as 5ml.

• • If the patient is on continuous tube feeding, follow the same steps as outlined above. Stop the tube feeding for 1 hour (check the agency policy) and then restart the feeding. Leave this patient in fowler’s position at all times!

Topical Medications

• • Always wear gloves when applying these to avoid absorption into your skin

• • Be sure site is clean and dry, be sure all prior meds are gone, assess for irritation

• • Usually requires a thin, even layer of meds

Powder

Dust powder lightly to cover the affected area with a thin layer

Lotions, creams, ointments

• • Put med on gloved hand

• • Spread evenly using long, even strokes following the direction of hair growth

Nitroglycerin ointment

• • Remove prior med first, wipe away excess w/tissue.

• • Apply dose to paper (inches).

• • Apply to different site. Sites include chest, back, upper arm, legs. Avoid hairy surfaces and scars

• • Date and time paper after applying.

• • Secure w/ a piece of tape, rotate sites

• • Document administration and location of paper. Document prior patch removed.

Transdermal patch

• • Remove old patch/es first.

• • Handle carefully and do not touch the adhesive sides.

• • Apply to a dry, clean area free of hair and press for 10 seconds making sure edges are secure.

• • Date and initial patch after applying and rotate sites.

• • Document administration and location of patch and removal of old patch

Opthalmic Medications

• • Wear gloves

• • Review order and double check abbreviations (i.e, OD = right eye, OS = left eye, Both = OU

OD

right eye

OS

left eye

Both eyes

OU

Eye Drops

• • Have patient lie supine or lean back in a chair

• • Assess that eyes are clean (gently cleanse if not)

• • Use cotton ball or tissue to press on lower orbit to pull lower conjunctiva down

• • Place dominant hand on forehead about 1-2 cm above eye and talk to patient to try to not blink

• • Drop in conjunctival sac

Eye Ointment

• • Have patient look at ceiling

• • Pull lower conjunctival sac down

• • Spread ointment along inner edge of eyelid from inner to outer canthus

• • Have patient rub in circular motion w/ cotton ball if not contraindicated

• • Document administration

Otic

• • Wear gloves

• • Review order and double check abbreviations (i.e, AD = right ear, AS = left ear, Both = AU)

• • Be sure meds are at room temperature to prevent vertigo and nausea

• • Use sterile drops in case eardrum has ruptured

• • Do not force anything into ear; do not occlude ear canal w/dropper

• • Place patient in side lying if possible

• • For adults and children over age 3-pull up and back

• • For children age 3 or less-pull down and back

• Check for cerumen in outer canal and remove if present

• • Instill drops holding dropper 1 cm above ear canal

• • Ask patient to remain on side for a few minutes

• • Apply gentle massage to help med move inward if needed

• • Place cotton if ordered; remove after 15 minutes

AD

right ear

AS

left ear

Both ears

AU

Nasal

• Wear gloves

• • Instruct the patient to blow nose gently before administration (except if the patient has nosebleeds or other contraindicatio ns.)

• • Afterward admin, have the patient avoid blowing their nose unless absolutely necessary.

• • Document

Nasal Drops:

• Draw the prescribed amount medicine to be administered into the dropper

• • Have the patient lie down and tilt the head backward by elevating the shoulders.

• • Hold dropper ½ inch above nares and instill prescribed number of drops

• • Have the patient remain in this position for several minutes to allow the medication to be absorbed

• • Wipe the dropper off with a clean gauze pad to remove mucus.

Nasal Spray:

• Prepare the spray container as directed on label (i.e., shaking it)

• • Allow the patient to administer the prepared spray if able.

• • Have the patient remain in this position for several minutes to allow the medication to be absorbed.

Rectal

• • Always assess for level of assistance. Allow patients to insert own rectal medication if able

• • Relatively safe and rarely cause local irritation or side-effects

• • Contraindicated in patients with rectal surgery or active rectal bleeding

Rectal suppositories

• • Thinner and bullet shaped with rounded end (prevents trauma)

• • May need to be refrigerated to maintain shape and firmness

• • Open package and put in medicine Cup with water-soluble lubricant

• • Position patient in left side-lying Sim’s position with leg flexed upward. Provide for privacy

• • Retract patient’s upper buttocks (right) with non-dominant hand and inspect rectum (may palpate rectal wall for stool, may be necessary to give cleansing enema first)

• • If active bleeding noted, do not give suppository

• • Have patient take slow, deep breaths (relaxes patient)

• • Insert rounded end with lubricated gloved index finger

• • Insert gently through anus past internal rectal sphincter; insert finger 3-4 inches

• • Withdraw finger, wipe/cleanse patient’s anal area

• • Remove glove by turning inside-out and discard

• • Have patient remain lying flat or on side for 5 minutes and place call light within reach

Common Med Admin Errors

• • Wrong medication

• • Wrong IV fluid

• • Wrong dose/infusion rate

• • Wrong client, route, or time

• • Failure to check for allergies

• • Omission of dose

• • Additional dose

• • Incorrect discontinuation

• • Inaccurate prescribing

Uncontrolled meds

• • Monitored by a provider

• • Do not pose major risk of addiction

• • Ex: Antibiotic

Controlled

• • Potential for abuse and addiction

• • Have a “scheduled” classification

  • • Dependence risk decreases the higher the classification

  • • Ex: Morphine (schedule II) is more potent than phenobarbital (schedule IV)

Pregnancy Risk

• FDA assigns Pregnancy Risk Categories (A, B, C, D, & X) according to potential harm during pregnancy

• • Category A is least potential harm while Category X is most potential harm

A nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention?

• B. Checking with the provider when a single dose requires administration of multiple tablets.

Basics of I&O

• • Measure for a 24-hour period at a time

• • RN compares the 24-hour intake to the 24-hour output.

• • May require a health care provider order depending on facility policy

• • Can be delegated to a patient care assistant: but it is the RN responsibility to understand the pathophysiology behind the measurements of the I&O

• • RN will assess IV intake, PEG tube intake, drains and/or NGT suction output.

What is Intake?

• Is anything that is LIQUID AT ROOM TEMPERATURE

• Can be oral, parenteral, and/ or enteral

  • ORAL (PO)

    • • Drinks

    • • Gelatin

    • • Ice-cream

    • • Sherbet

  • Parenteral (IV)

    • • IV fluids

    • • Blood components

    • • TPN

  • ENTERAL

    • • Tube feeding via NG, OG, PEG, or J-tube

What is Output?

• Anything that is excreted from the body

  • Urine/ Diarrhea/ Vomitus

  • Gastric suction

  • Drainage from postsurgical wounds (JP drain, hemovac etc.)

How would you document a patient that ambulated to the bedside commode and had 1 solid bowel movement.

• X1 bowel movement

If there is greater intake than output,

• consider if the client is gaining excessive fluid, or returning to normal fluid status to replace previously lost.

If there is greater output than intake,

• consider if the client is losing necessary fluids & may develop hypernatremia, or may be returning to normal fluid status from fluid previously gained.

Which patient needs to be on I&O measurement?

• 21-year-old female patient brought in with diabetes insipidus (pee a lot)

Who should be on I & O measurements?

• ✓Febrile (fever)

• ✓ Nausea/Vomiting/Diarrhea

• ✓ Post-surgical clients with wound or chest tube drainage

• ✓ Gastric suction (NG tube)

• ✓ Burn victims/ Trauma victims

• ✓ Endocrine imbalance (DKA, Addison’s Dz, Cushings Dz)

• ✓ Those having difficulty w/oral intake (unconscious, impaired swallowing, impaired mobility)

• ✓ Heart failure/ Kidney failure

How do we do this? (I/O)

• 1. Start at rounds

• 2. Scan room for drinks and food tray

• 3. Go to IV pump and write down each IV drip and utilize your smart pump!

• 4. Look at foley catheter bag, gastric output, bed pan, rectal tube, surgical drains, etc.

• 5. Educate your patient on keeping a record and/or telling you.

• 6. You will do this THROUGHOUT your entire shift!

• 7. Have a system to record clipboard or dry erase board in room

Nursing Interventions

• 1. Educate family and client about the importance of keeping record (write down intake, notify nursing assistant/nurse about emptying a void/stool)

• 2. Weigh client daily (same scale, same time of day, same clothing)

• 3. Have a urimeter, and/or speci-pan (“hat”) to obtain accurate measurements

• 4. Assess skin turgor and mucous membranes

• 5. Observe color, amount, and characteristics of urine and wound drainage

• 6. Note I & O each shift and report any imbalances

• 7. Monitor vital signs closely

• 8. Provide a bed side commode if needed to assist w/bladder urgency

• 9. When measuring ice, count as half the amount (example: 240 ml cup count 120 ml)

When measuring ice, count as

• half the amount (example: 240 ml cup count 120 ml)

Each kg of weight gained/lost overnight is equal to

•  1L of fluid retained or lost

Labs

• • Urine specific gravity

• • Hematocrit: High=dehydration, Low=suggests blood loss/hemorrhage

• • Electrolytes

High hematocrit=

dehydration

Low hematocrit=

suggests blood loss/hemorrhage

Elements of documentation 

• Factual 

• Accurate 

• Concise

• Complete

• Current 

• Organized 

Legal No-No:

• X No blank spaces

• X No white out

• X No scratching out

• X No blacking out

• X No personal opinions

• X No criticisms about pts

• X No badmouthing other HCP

Legal Yes-Yes:

• √ Date

• √ Time

• √ Write legibly

• √ Non-erasable ink

• √ Assessments

• √ Interventions

• √ Evaluations

• √ Pt response

• √ Sign with name and title

  • Flo Nightingale, CCNS

Subjective

• • Onset

• • Location

• • Duration

• • Characteristics

• • Aggravating & Alleviating Factors

• • Related SX

• • Timing

• • Severity

• • POS (pt thoughts)

Objective 

• • Physical Assessment

• • Systematic Approach

• • Head-to-Toe