Exam 1

what should happen before restraints are considered?

1) pt has been assessed

2) interventions to relieve discomforting behaviors have been used

3) precipitating factors have been identified and eliminated

4) other healthcare professionals have been consulted

restraints can only be applied when…

alternatives to restraints and less restrictive interventions have been implemented and failed (and this has been documented)

restraints cannot be used when…

there are contraindications upon assessment

who orders the restraints?

the doctor or physician responsible for the pt

how often does a pt with restraints need to be assessed?

every hour or consult facility policy

how often do pts with restraints need their personal needs met?

every 2 hrs

how often should a pt with restraints be examined for skin integrity?

every 2 hrs

what must be documented when restraints are used?

why, how, where, and for how long

therapeutic communication

techniques used to improve communication (ex. active listening)

verbal communication

oral communication (talking face to face or via phone)

nonverbal communication

body language (ex. eye contact, facial gestures, posture, overall appearance)

aggressive communication

verbally and sometimes physically abusive expression; often uses “you” statements

passive communication

expression that avoids conflict, expressing feelings or opinions, and standing up for oneself when boundaries are crossed

assertive communication

most effective mode of expression; allows one to advocate for their opinions, rights, and needs without crossing boundaries

passive aggressive communication

form of expression where person seems passive but is acting out of anger in a subtle, indirect, or secretive way

therapeutic communication techniques

active listening, asking open ended questions, giving recognition, summarizing, and reflecting

restating

paraphrasing or summarizing a pts message to repeat it back to them for clear communication

reflection

attempting to understand a pts feelings based on the information they give you

motivational interviewing

a form of therapeutic communication

O - open ended questions

A - affirmations

R - reflective listening

S - summarizing

source-oriented medical record

traditional form of medical record that divides pt information into specific sections; not really used anymore because information is not as shareable amongst the interdisciplinary team

problem-oriented medical record

medical record that uses a comprehensive and organized approach that involves all the members of the interdisciplinary team

• database with assessment data

• chronological problem list

• initial plan and goals

• progress notes using SOAP

SOAP documentation

S - subjective data

O - objective data

A - assessment

P - plan

PIE model

P - problems

I - interventions

E - evaluations

focus charting

documents data, action, and response (issue, how it was addressed, how pt feels after)

charting by exception

only documenting unusual findings

abbreviations that should NOT be used

cc

D/C

IU

MS

MSO4 and MgSO4

per os

qd, q.d, Q.D, or QD

qhs

qod, q.o.d, Q.O.D, QOD

SC, SQ, sub q

TIW or tiw

trailing zero (ex. 5.0 mg)

U, u

verbal order

spoken order from a physician (cam be in person or via phone; should only be used for emergencies and the medication, route, frequency, time, and indication should be documented along with prescriber name

pressure injury

localized damage to skin and underlying soft tissue over a bony prominence

stage 1 pressure injury

nonblanchable erythema of intact skin

stage 2 pressure injury

partial thickness loss with exposed dermis (pink or red, moist, intact or ruptured blisters)

stage 3 pressure injury

full thickness skin loss with exposed adipose (epibole, granulation, slough, and eschar may be present)

stage 4 pressure injury

full thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone (epibole, slough, eschar, undermining, and tunneling may be present)

deep tissue pressure injury

persistent nonblanchable deep red, maroon, or purple discoloration; intact or nonintact skin

medical asepsis

clean technique; involves procedures and practices that reduce the number and transfer of pathogens

surgical asepsis

sterile technique; involves practices used to render and keep objects and areas free from pathogens

when should hand hygiene be performed?

1) before touching a patient

2) before a clean or aseptic procedure

3) after body fluid exposure risk or risk of exposure

4) after touching a patient

5) after touching patient surroundings

what should a nurse do to prevent a pt from coughing or sneezing on others?

provide pts with disposable tissues and instruct them to cover their mouths to prevent airborne droplets from spreading

how should areas be cleaned?

from least to most soiled

where should soiled items be disposed?

directly into appropriate containers; wrap items soiled with bodily discharge into waterproof containers (plastic bags) before disposal

how should a sterile package be opened?

peel the wrapper away from you

where should sterile objects be held?

waist level or above

is a field considered sterile if you turn your back on it?

no

what items need to be kept sterile?

dressings used to cover primary incisional wounds, needles for injection, and tubes (catheders)

how many inches around a sterile field are contaminated?

the 1 inch border surrounding the field

standard precautions (tier 1)

hand hygiene

wear clean gloves and replace as needed

wear appropriate PPE (gloves, gown, goggles, face shield) when coming into contact with bodily fluids or non intact skin

avoid recapping needles (if must then use scoop method)

follow respiratory hygiene/ cough etiquette (use masks, maintain distance)

use safe injection practices

airborne precautions (tier 2)

patient must be placed in private negative air pressure room with 6-12 air changes per hour

keep door closed

requires mask/respirator

if pt must leave room, ensure they have a surgical mask on

what are conditions requiring airborne precautions?

tuberculosis, varicella, rubeola, SARS, COVID

droplet precautions (tier 2)

patient should be placed in a private room if available

door remains open

wear PPE for all interactions with pt and their room

if pt must leave room, ensure they have a surgical mask on

keep visitors 3 ft away

conditions requiring droplet precautions

influenza, COVID, rubella, mumps, diphtheria, adenovirus

contact precautions (tier 2)

patient should be placed in a private room if available

a gown and gloves should be worn when interacting with pt and room

gloves should be changed after contact with infective material

remove PPE before leaving room

wash hands after

conditions requiring contact precautions

c diff, RSV, impetigo, norovirus, scabies mrsa

the rights of medication administration

right client

right medication

right dose

right route

right time

right assessment

right documentation

right to refuse

right education

right evaluation

how do you verify client identity?

ask them for full name and DOB

medication administration record (MAR)

a record of medications prescribed for the client by the provider; used by the nurse to record and confirm medication administration per the prescription

when should time critical meds be administered?

no later than 30 min after the scheduled administration

when should non time ciritcal meds be administered?

1-2 hrs before or after scheduled administration

how does medication reconciliation work?

1) obtain current medication list

2) create an in-hospital medication list

3) reconcile lists and resolve discrepancies

4) share updated list, including reasons for changes with care team

fastest to slowest med onset

liquid → suspension → powder → capsule → tablet → coated tablet → enteric coated tablet

what position should pts be in to take oral meds?

high fowlers

where are buccal meds placed?

between the cheek and gum line (allow to dissolve)

how long should a pt wait on their side after a rectal med?

5 minutes

eye med administration steps

1) slightly pull down under eye

2) administer drops into eye

3) place index finger on inner corner for 30-60 seconds

otic med administration steps

1) warm drops to room temp

2) position pt so they’re leaning to the opposite side of impacted ear

3) pull pinna up and back gently

4) administer drops

5) pt should stay on side for 5 min

what are intrademal meds usually used for?

diagnostic purposes such as allergies or TB test

how many mL should be injected for intradermal injections?

0.1 mL

where are intradermals usually injected?

ventral forearm right under the dermis

where is subcutaneous usually injected?

any area with a good amount of adipose tissue; sites should be rotated

how many mL for subcutaneous injection?

maximum 1.5 mL

what is special about subcutaneous injections?

the site should be pinched before injection to reduce the risk of administering to muscle

what angle should subcutaneous injections be done at?

between 45 and 90 degrees

where are IMs usually injected?

into the large skeletal muscle; usually vastus lateral, ventrogluteal, or deltoid

how many mL for an IM injection?

ventrogluteal: up to 5 mL

deltoid: up to 2 mL

vastus lateralis: up to 5 mL

deltoid

usually used for vaccinations or IM injections no greater than 1 mL

ventrogluteal

usually used for larger volume IM injections

vastus lateralis

usually used for self administered IM injections

IV therapy

delivers fluids, nutrients, blood, blood products, or diluted and undiluted medications quickly into the vein

what amount of liquid can an IV be diluted in for piggyback?

50-500 mL

IV push

pushing a small amount of medication slowly directly into the pts IV catheter (usually done to treat life threatening conditions)

what are IV meds usually diluted with?

0.9% sodium chloride or dextrose 5% in water (50-250 mL)

how long are IV meds usually administered?

usually 30-90 minutes

what are the two ways piggyback IVs can be administered?

1) delivered via secondary infusion by connecting the medication tubing to the primary infusion tubing

2) delivered via intermittent venous access device (peripheral IV catheter inserted via venipucture)

what must be done to use a venous access device?

the catheter must be treated aseptically and flushed before and after med

central venous access devices (CVAD)

catheters inserted into a large centrally located vein to administer blood products, meds, fluids, and other therapies

where are CVADs commonly seen?

in pts that require long term or frequent IV therapy

what are the types of CVADs?

1) peripherally inserted catheter (PICC): shorter term IV therapy

2) central venous catheter (CVC): larger vein access

infiltration

infusing IV fluid or med enters surrounding tissue due to catheter dislodgment

what should be done to prevent infection from IV access?

• maintain sterile dressing over insertion site

• clean port when accessing with alcohol wipe

• allow alcohol to dry before accessing the port

• hand hygiene before donning gloves

• clamp tubing before last 0.5 mL of flush is delivered to prevent blood from dwelling in tubing

oral meds for babies

use syringe or dropper for liquid and semi recline child while slowly administering liquid towards the babies cheek

infant IM injections

no more than 0.5 mL into vastus lateralis at a 90 degree angle

toddler IM injections

no more than 0.5 to 1 mL into deltoid; 2 mL into vastus lateralis

what amount can children receive via IV?

no more than 100-250 mL over 30 min

can transdermal meds be used for infants?

yes in very very small amounts due to the thinness of their skin

how to convert mcg to mg?

1000 mcg = 1 mg

how to convert lbs to kg?

1 kg = 2.2 lbs

1 teaspoon

5 mL

1 tablespoon

15 mL

SBAR

used to share critical info clearly and concisely in high stress environments

S - situation (state who you are, who you’re calling about, and the concern)

B - background (state why pt was admitted, whats happened, the normal condition, and the change)

A - assessment (state assessment, vitals, etc.)

R - recommendation or request (ask about interventions)

how long should you rub your hands together with hand sani?

20 seconds

how far up should you wash your hands?

1 inch above area of contamination