Nursing Skills Exam 4

10 Rights of Medication Administration

Right Medication

Dose

Time

Route

Client

Client Education

Documentation

Right to Refuse

Assessment

Evaluation

“I’m Safe” includes

Illness, Medication, Stress, Alcohol/Drugs, Fatigue, Eating and Elimination

Any preventable event that may lead to patient harm while in control of a healthcare professional describes ____

medical error

Partners in the Medication Process

Pharmacist, Physician, Nurse, Patient

Things to check before giving a medication:

Allergies, swallowing ability, N/V, BP, BGT, labs, pulse, reason for taking medication

True or false: It is okay to pick up a medication off the table and give it to a patient without wearing gloves

False

3 checks before giving a medication:

1. When taking the medication out of the cart

2. When reviewing med sheet with instructor

3. After reviewing med sheet with instructor and determine it is safe to administer

or

1. Before drawing it up

2. Before entering room

3. Before giving to patient

What is nasolacriminal press used for?

Prevents meds from running in nasolacrimal duct and alter BP, HR, etc. while being absorbed

parenteral route means

pertaining to treatment other than through the digestive system

parenteral routes

intradermal

subcutaneous

intramuscular

intravenous

reason why medication may need to be given parentally

if patient is NPO or cannot swallowing medication, if medication is unstable in GI tract

Intramuscular angle

90

Subcutaneous angle

normally 45 degrees, otherwise 90 degrees with a shorter needle

intradermal angle

15

intradermal injection have the ___ absorption rate

slowest

Sites for allergy testing

with an intradermal injection, the upper ches

What gauge needle is used for an intradermal injection?

25-27 gauge

How long is your needle for an intradermal injection?

¼ to 5/8

SItes for intradermal injection?

Upper back, upper chest, inner aspect of forearm

Subcutaneous injections have a ___ absorption rate and a _____ drug effect

slow, prolonged

Common sites for subcutaneous injection

upper arms, anterior thigh, lower abdominal wall, scapular area of the back, upper ventral and dorsal gluteal

Common drugs given subcutaneously

heparin, insulin, immunizations, and analgesics

possible complications of subcutaneous injections include

sterile abscess, lipohypertrophy, lipdystrophy

The max amount of mL given in a subcutaneous injection

1 mL, unless TB or insulin, then 3 mL

What gauge needle is used for a subcutaneous injection?

25-30 gauge needle

How long of a needle is needed?

3/8 to 5/8 inch

What should the angle of administration be for a subcutaneous injection?

45-90 degrees

Sites for subcutaneous injection

upper arms, fat pads on back, love handles, anterior aspect of thigh

Intramuscular has a _____ absorption rate

rapid

Common IM sites

ventrogluteal (preferred site in adults, children, and infants)

dorsogluteal (last choice due to sciatic nerve)

vastus lateralis (second choice maybe)

Max amount for a IM injection anywhere besides the deltoid

2 mL

Max amount for IM injection in deltoid

1 mL

Max amount in children and older or emaciated adults

1 mL

What size syringe do you need for an IM injection?

3-5 mL syringe

How long of a needle do you need for an IM injection?

½ inch for newborns

1-2 inches for others

What gauge needle do you use for an IM injection?

21 to 25

What is the angle of administration for IM injections?

90 degrees

Potential complications with IM injections?

abscess formations

continued site pain

nerve injury

skin sloughing and necrosis (particularly if medication seeps up into subcutaneous tissue)

5 parts to a needle

hub

shaft

bevel

size (length)

gauge

Deltoid needle gauge

23-25 gauge

Deltoid needle length

1 inch

max amount of solution for deltoid IM

up to 1 mL

Ventro gluteal needle gauge

21-25 gauge

Needle length for ventro gluteal IM

1-1.5 inch

amount of solution for ventro gluteal IM

up to 2 mL

needle gauge for a vastus lateralis IM

21-25 gauge

needle length for a vastus lateralis

1-1.5 inch

max amount of mLs that can be used in an IM injection into the vastus lateralis

up to 2mL

reconstituted medication

the diluted medication (medication + saline or whatever diluent)

Why would you use Z tracking?

used for medications that would be irritating to tissues and you want to make sure they stay in tissues

Moving over skin will allow it to cover muscle like a band aid after administering medication

What is the main cause of high blood pressure?

Obesity

What ethnic group has the highest rate of high blood pressure?

African Americans

A person with high blood pressure also has a high risk of

stroke and myocardial infarction

Determinants of Blood pressure

pumping action of the heart

peripheral vascular resistance

blood volume

blood viscosity

Normal blood pressure

120/80 or below

Elevated blood pressure

120-129 systolic

less than 80 diastolic

Stage 1 hypertension

130-139 sys

80-89 diastolic

Stage 2 hypertension

Above 140-180 sys or

90-120 diastolic

Hypertensive Crisis

over 180 systolic and/or

120 diastolic

How to diagnose hypertension

use an average based on 2 or more readings obtained on 2 or more occasions to estimate the individual’s level of BP (self monitoring are recommended to confirm diagnosis)

White Coat Hypertension

Adults with SBP 130-160 and DBP 80-100

How to follow up with someone with elevated or stage 1

repeat BP after 3-6 months of lifestyle changes

How to follow up with Stage 1 and high CVD risk

implement medication and lifestyle changes with repeat BP in 1 month

How to follow up with someone who is Stage 2

evaluated by PCP within 1 month and treated with 2 antihypertensive drugs and lifestyle changes

BP more than 160 sys and 100 diastolic should be

promptly evaluated by HCP and drug treatment with frequent monitoring

How much should you pump the cuff up when taking a blood pressure?

30 mm Hg above where you could no longer palpate the radial or brachial pulse

Times to assess vital signs

Upon admission

Change in health status

Before and after surgery

before and after administering medication that may affect the cardiovascular or respiratory system

before and after any nursing intervention that could affect pt vital signs

hypotension

a blood pressure that is below normal, sys consistently between 85-110 mm Hg

a decrease of blood pressure of __ mmHg sys or _ diastolic when client sits or stands

20, 10

How to take orthostatic vitals

1. Supine for 10 minutes

2. Sit for 3 minutes

3. Stand for 3 minutes

Where do you take an apical pulse in adults?

the left side, 5th intercostal midclavicular

How many apical pulse locations are there and what are their names?

aortic, pulmonic, erb’s point, tricuspid, and mitral/apical

S1 is the ___ sound and is when the ___ and ___ valve close

lub, mitral and tricuspid

S2 is the ___ sound and when the ___ and ___ valves close

dub, aortic and pulmonic

where is S2 best heard?

aortic

where is S1 best heard?

mitral (apical)

Where is the PMI (point of maximal impulse)?

the midclavicular line, near the apical point

If an apical pulse is higher than the radial pulse, this is indicative of

lack of adequate blood flow to the peripheral vascular system. May mean that the thrust of the blood from the heart is too weak to be palpated peripherally or there is a vascular disease that is preventing impulses from being transmitted

What part of the stethoscope do you auscultate the carotid artery with?

the bell

How to you check for JVD?

jugular vein distention can be checked by laying patient flat in the bed and seeing if you can see the external or internal vein. If you could, put patient to 45 degrees and then 90 degrees if still observed.

In the peripheral vascular assessment, palpate for ___, ___,___, and ____ pulses.

radial, brachial, dorsalis pedis, and posterior tibial

Pulse amplitude scale

0= absent pulse

+1= weak or thready

+2= present but diminished

+3= normal, easily palpable

+4= bounding

What do the 3 Ps stand for in peripheral vascular assessment?

Pain, pallor, and pulselesness

What can be done if you cannot feel a peripheral pulse?

use a doppler!

What should be inspected in the lower extremities?

varicosities- varicose veins (distended, swollen, knotted), calves for redness and swelling, C/O pain or dull ache

what is thrombophlebitis

inflammation of a vein followed by formation of a blood clot?

how to inspect calves for thrombophlebitis

localized redness, tenderness, and swelling over vein sites

CMTS

stands for color, motion, temp, and sensation

+1, +2, +3, +4 pitting edema

multiply each by two for mm

what to assess for a neurological assessment

mental status

cranial nerves

motor function

sensory function

coordination

reflexes

cerebral function / mental status assessment

LOC

orientation

memory

attention span and calculation

abstract reasoning

language

LOC and orientation

assess arousal state using minimal stimuli, orientation to time, place, and person, assess mood, affect, and appropriateness of behavior

normal orientation

awake alert and oriented x3

What score in the gas glow coma scale defines a coma in 90% of the cases

8 or less

how to test short term memory

name three objects and ask client to recall them later

how to test long term memory

ask client’s birth date, major, historical event, and surgery or illness

test sensory function by

light touch, pain, and temp on various areas of the body, having patients close eyes to test side to side

babinski reflex

draw reflex hammer handle on lateral aspect of foot from heel forward

toes downgoing= - babinski

toes upgoing= + babinski

POSITIVE is never normal except in newborns