EXAM 1- no CPL

people die/year due to medical errors

7,000-9,000

Nurses are often the ___ step to prevent an error

last

Nursing Responsibilities

• • Know federal, state nurse practice acts, local, facility, and unit polices

• • Prepare, administer, and evaluate patient response

• • UTD knowledge base on

  • • Use

  • • Mechanisms of action

  • • Routes

  • • Safe dosage range

  • • Adverse reactions and side effects

  • • Precautions

  • • Contraindications

  • • Interactions

• • UTD competency on required skills for administration

• • Patient education

• • Patient advocacy

• • Process for reporting errors and adverse events

• • Safeguarding and storing medications

• • Collaborating with the health care team

Types of Medication Orders

• ❖Standing/Protocol Order

• ❖Routine/Scheduled Order

• ❖PRN Order

• ❖One-Time Order

• ❖STAT

• ❖NOW Order

• ❖Phone Order/ Verbal Order/ Telephone Order (P.O./V.O./T.O)

Guidelines for Telephone and Verbal Orders

• ❖ Only authorized staff receive and record TO and VO.

• ❖ Clearly identify patient’s name, room number, and diagnosis.

• ❖ Read back all orders!!!!!

• ❖ A second RN should listen to prevent errors in communication (do this as a new nurse!)

• ❖ Write TO or VO, including date and time, name of patient, and complete order; sign the name of the HCP and nurse.

• ❖ Follow agency guidelines.

• ❖ The HCP co-signs the order within the time frame required by the agency.

• CCN students will NOT take TO or VO!

A nurse is orienting a newly licensed nurse on telephone orders. Which of the following statements indicates that the new nurse understands the process?

“Another nurse should listen to the phone call.”

Components of Medication Orders

• ❖Patient’s full name

• ❖Age and weight if needed

• ❖Date and time of order

• ❖Medication name (brand or generic)

• ❖Dosage (amount or strength)

• ❖Route of administration

• ❖Time and frequency

• ❖Signature of HCP (MD/NP/PA) ordering the medication

Prior To Medication Administration ALWAYS Assess Patient’s…

• ❖ Age

• ❖ Body Weight

• ❖ Diet

• ❖ Health History

• ❖Drug and medication history

• ❖ OTC meds/supplements

• ❖ Allergies

• ❖ Existing disease/illness

• ❖ Lab values

• ❖ Patient understanding of their medications

Special Considerations: The Older Adult

• ❖Adverse medication effects occur in 22% of older adults presenting to HC agencies

• ❖Falls, orthostatic hypotension, heart failure, delirium

• ❖Know the physiological changes of aging

• ❖Assess functional status

• ❖Vision, fine motor skills

• ❖Use of memory aids

• ❖Monitor responses

• ❖Provide written instructions

1: Right Drug

• ❖ Compare the EMAR (electronic medication administration record) to med order in the chart as per policy

• ❖ Compare EMAR to medication label three times

• ❖When removing from storage unit

• ❖Before taking to patient’s room

• ❖Before giving the medication

• ❖ Do NOT give meds from an unmarked container, or from a package with illegible labeling

2: Right Dose

• ❖ Ascertain the available concentration of the medication

  • ❖Ex: Lasix 40 mg; have 20 mg tabs; give ____

  • ❖How many tabs are given if 10 mg ordered? ____

• ❖ Ask a peer or coworker to confirm your dosage calculation

• ❖ VERY important with vasoactive meds, heparin, and insulin

• ❖ALWAYS have another RN double check insulin

• ❖ Visually examine scanned meds

3: Right Route

• ❖Consult the healthcare provider who wrote order if…

  • ◦ Route was not specified

  • ◦ Med is not available via ordered route

  • ◦ Unable to access specified route (i.e. no IV, unconscious)

What would you do? Your client is NPO and all meds are administered crushed via gastrostomy tube. The healthcare provider had ordered a medication that is enteric coated.

I would hold the enteric-coated medication, notify the provider, and request an alternative form that is safe for administration through the gastrostomy tube. Enteric-coated medications should never be crushed because the coating protects the stomach from irritation or protects the drug from being destroyed by stomach acid. Crushing destroys this protection and can cause harm or make the medication ineffective.

4: Right Assessment

• ❖ Labs

• ❖ Vital Sign

5: Right Time

• ❖ Know military time! Ex. 1400____ 1900____

• ❖ Actual time not always ordered, go by facility’s “schedule”

  • ❖ i.e., “daily” could be 0900 or 1000

  • ❖ i.e., “TID” could be 0600, 1400, and 2200 or 0700, 1300, 2100

• ❖ EMAR will have actual times assigned by pharmacy

• ❖ Clinical judgment may be required

• ❖ Some meds have “priority” Ex. first-dose antibiotics or insulin

• ❖ Given within 30 min to 1 hour before/after time drug is scheduled

A nurse is preparing to administer a 0900 medication to a client. Which of the following are acceptable times for this medication?

• A. 0905

• B. 0825

• C. 0840

• D. 0935

  • Depends on your facility’s procedures of 30 minutes before or after or 60 minutes before or after

Special Note About Insulin

• ❖ Regular insulin is fast acting (within 30 minutes)

  • ❖ Must have food available

• ❖ Long-acting insulin (i.e., NPH) acts over 12-24 hours

• ❖ Long-acting insulin (Lantus, Basaglar) insulin glargine: 24hrs,

• ❖ Both can be ordered to maintain BG during hospitalization

  • ❖ “NPH 20 units SQ every am”

  • ❖ Lantus 80U SQ every evening

  • ❖ “Regular Insulin SQ at ac and hs per Sliding Scale below”

    • ❖ BG<70 follow hypoglycemic protocol and give 0 units

    • ❖ BG 71-120 give 0 units

    • ❖ BG 121-180 give 2 units

    • ❖ BG 181-250 give 4 units

    • ❖ BG 251-325 give 6 units

    • ❖ BG 326-400 give 8 units

    • ❖ BG >400 give 10 units, draw blood and send to lab, and notify HCP

• ❖ Check BG @ 0600, 1100, 1600, and 2100 ( before meals and bedtime)

• Insulin ALWAYS requires critical thinking before automatically administering a dose as scheduled. Hypoglycemia is more dangerous than hyperglycemia!

Which is more dangerous: hyperglycemia, or hypoglycemia)

hypoglycemia

6: Right Patient

• ❖ Watch for same patient names on nursing unit

• ❖ Must check at least 2 patient identifiers:

  • ❖Check client’s identification bracelet

  • ❖Ask client to state their name

  • ❖Date of birth

  • ❖Ask another nurse to identify the client

  • ❖Check chart for a photo of the client, or other photo identification card.

  • ❖Scan patient’s armband

• ❖ Use caution in semi-private rooms

7: Right Documentation

• ❖ Record details regarding administration of medications

  • ❖ PRNs: follow-up assessment indicating success/failure of drug’s effects after 30 min

  • ❖ Meds held on purpose: reason why

  • ❖ Any missed meds: reason why

  • ❖ Refused meds: assess reasons and educate

• ❖ Record pre-assessment data required of the drug such as HR, BP,labs

• ❖ If it’s not charted, it was not done!

• ❖ Chart administration after the patient has taken the medication.

8: Right Indication

• ❖ ISMP is considering adding this step to enhance safety

• ❖ Narrow medication choices, dosage forms and dosing regimens

• ❖ Ultimately, reducing the risk of the wrong med being chosen

• ❖ Empower and educate patients

• ❖ Improve medication adherence

• ❖ Improve interprofessional communication

• ❖ Aid in preventing re-prescribing

9: Right Patient Education

• ❖ Ask why they are taking the med to assess their understanding

  • ❖ Avoid yes or no questions

• ❖ Provide information on

  • ❖ Purpose

  • ❖ Side effects and ways to minimize them

  • ❖ Adverse reactions to report

  • ❖ Foods/supplements to avoid

• ❖ Empowers patient and improves medication adherence

• ❖ Can prevent medication errors

• ❖ Include cultural considerations when teaching about medications

• ❖ Use teach back method/demonstration for special applications

10: Right Evaluation

• ❖Verify therapeutic effect

  • ❖Pain relieved?

  • ❖GI upset or nausea resolved?

  • ❖VS improved?

  • ❖Labs changed?

• ❖Side effects or adverse reactions?

A nurse educator is reviewing safe medication administration with newly licensed nurses. Which statements indicate their understanding? (Select all that apply)

• A. “I will observe for adverse effects.”

• B. “I will monitor for therapeutic effects.”

• C. “I will administer the appropriate dose.”

• E. “I will refuse to give a medication and contact the HCP if I believe it is unsafe.”

A patient has the right:

• ◦ To be informed about a medication

• ◦ To refuse a medication

• ◦ To have a medication history assessed

• ◦ To be properly advised about experimental nature of medication

• ◦ To receive labeled medications safely

• ◦ To receive appropriate supportive therapy

• ◦ To not receive unnecessary medications

• ◦ To be informed if medications are part of a research study

Nurses are advocates for patients! Do NOT assume that

the HCP knows what is best. It is a team effort to provide safe and effective care.

Solid Forms

• ❖Caplet

• ❖Capsule

• ❖Tablet

• ❖Enteric Coated

Liquid Forms

• ❖Elixir

• ❖Extract

• ❖Aqueous solution

• ❖Aqueous suspension

• ❖Syrup

• ❖Tincture

Other Oral Forms

• ❖Troche (lozenge)

• ❖Aerosol

• ❖Sustained release

Topical Forms

• ❖Ointment/salve/cream

• ❖Liniment

• ❖Lotion

• ❖Paste

• ❖Transdermal patch/disk

Parenteral Forms

• ❖Solution

• ❖Powder

Body Cavity Forms

• ❖Intraocular disk

• ❖Suppository

Oral

• Buccal

• Sublingual

Topical

• Skin

•  Mucous membranes

•  Nasal instillations

•  Eyes

•  Ears

•  Rectal

• Vaginal

Parenteral

• ◦ Intradermal (ID)

• ◦ Subcutaneous (SQ)

• ◦ Intramuscular (IM)

• ◦ Intravenous (IV)

Routes of Administration: Oral

• ❖ Pills, rinses, liquids, etc

• ❖ Advantages:

  • ❖ Easiest and most preferred route

• ❖ Disadvantages:

  • ❖ Slower onset

  • ❖ Many contraindications

• ❖ Key Points:

  • ❖ Administer GI-irritating meds ac or pc

  • ❖ For oral liquids that work on mucous membranes, do not follow with a “chaser”

  • ❖ Give unpleasant oral liquids cold or at room temperature, flavoring may be added

  • ❖ Give teeth-staining meds via straw

  • ❖ Position client upright to swallow

  • ❖ Mix meds with small amount of food or liquids

  • ❖ Never leave meds at the bedside

  • ❖ Ensure the medication has been consumed

  • ❖ Avoid crushing extended release or enteric coated meds

Buccal

place in the cheek to dissolve

Sublingual

place under the tongue to dissolve

Sublingual and buccal advantages

• ❖ Rapid absorption (sublingual > buccal)

• ❖ Not digested (avoids GI tract and liver)

• ❖ Easier than swallowing

sublingual and buccal disadvantages

• ❖ Eating/drinking can decrease absorption

• ❖ Can’t use for extended release meds

• ❖ Mouth irritation

A nurse is teaching a client about medications in preparation for discharge. Which of the following statements indicates that the client understands the instructions?

“I will eat two crackers with the pain pills.”

Enteral Meds (ie.NG/P EG tube)

• ❖ Advantages:

  • ❖ Patients who are NPO or can’t swallow

• ❖ Disadvantages:

  • ❖ Must prepare medications

  • ❖ Not all meds can be crushed

  • ❖ Time consuming to administer

  • ❖ Potential for fluid overload

  • ❖ Aspiration risk!

  • ❖ Potential to clog tubes

• ❖ Key Points:

  • ❖ Position patient in semi-fowlers

  • ❖ Must verify tube placement & residual PRIOR to admin

  • ❖ Flush tube with 30 ml of H2O before, between, and after meds but use nursing judgment!

  • ❖ Maintain semi-fowler’s for at least 30 minutes following medication administration

  • ❖ For patients with tubes to suction -> turn off suction -> give med -> keep suction off for @60 min -> Resume suction

A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include?

“Flush the tube before and after each med”

Topical: Skin

• ❖ Comes in the form of:

  • › Lotion, creams, ointments

  • › Powder

  • › Paste

  • › Liquids for bathing

  • › Transdermal patch

• ❖ Advantages:

  • ❖ Painless and easy

  • ❖ Local effects

• ❖ Disadvantages:

  • ❖ Can be messy

  • ❖ Absorption impacted by clothing or edema

  • ❖ Can’t apply to broken/open/irritated skin unless designed to heal open wounds

• ❖ Key Points:

  • ❖ Must wear gloves when applying meds

  • ❖ Apply thin, even amount with gloved hands, cotton applicator, or tongue blade

  • ❖ Assess for skin irritation

  • ❖ Document location

  • ❖ If a transdermal patch, must remove the old one first!

Topical: Nasal

• ❖ Sprays, drops, or ointments

• ❖ Advantages:

  • ❖Easy

  • ❖Local effect

• ❖Disadvantages:

  • ❖Requires proper positioning

  • ❖May be difficult with children

• ❖Key Points:

  • ❖Wear gloves

  • ❖Have patient blow nose prior to med admin

  • ❖Avoid blowing nose

Topical: Opthalmic

• ❖ Come in the form of

  • ❖ Drops

  • ❖ Ointments

• ❖ Advantages:

  • ❖ Local effects

• ❖ Disadvantages:

  • ❖ Can be difficult for some patients (ie children)

  • ❖ Confusion with OD, OS, OU

  • ❖ Blurred vision (temporary)

• ❖ Key Points:

  • ❖ Must wear gloves

  • ❖ Use aseptic technique & don’t contaminate tip/cap

  • ❖ Position head back

  • ❖ Apply to conjunctival sac

  • ❖ Close eye & apply gentle pressure if patient can’t blink

  • ❖ Ointment requires ribbon from inner to outer canthus

Topical: Otic

• ❖ Come in the form of drops

• ❖ Advantages:

  • ❖ Local effects

• ❖ Disadvantages:

  • ❖ Confusion with AD, AS, AU

  • ❖ Can cause vertigo or nausea if not room temperature

  • ❖ Cerumen inhibits absorption

• ❖ Key Points:

  • ❖ Wear gloves

  • ❖ May need to clean ears first if cerumen is blocking

  • ❖ Don’t insert dropper into canal

  • ❖ Place side lying position if possible for @ 15 min

  • ❖ >3 years age pull ear up and back

  • ❖ <3 years age pull down and back

  • ❖ May gently massage the ear

  • ❖ Can apply cotton to the outer ear only

A nurse is teaching an adult client how to administer ear drops. Which of the following statements indicates that the client understands the directions?

“I will gently apply pressure with my finger to the front part of my ear after putting in the drops.

Topical: Vaginal installations

• ❖ Suppositories, creams, foams, or jellies, and douche or vaginal irrigations

• ❖Advantages:

  • ❖ Local effect

  • ❖ Patient may self administer

• ❖Disadvantages:

  • ❖ Uncomfortable or embarrassing for patient

  • ❖ Messy and discharge may be odorous r/t infection

  • ❖ Requires dorsal recumbent position

  • ❖ Sometimes refrigeration is required

• ❖Key points:

  • ❖ Provide for privacy and wear gloves

  • ❖ Lubricate suppositories with water soluble gel

  • ❖ Use warm or room temperature irrigations

  • ❖ Provide perineal care

Topical: Rectal Instillations

• ❖ Suppositories, creams or foams, and enemas

• ❖ Advantages:

  • ❖Option when oral or parenteral route not available

  • ❖Patient may self administer

  • ❖Suppository is an easy route for infants

• ❖ Disadvantages:

  • ❖Uncomfortable or embarrassing for patient

  • ❖May require a cleansing enema first for a suppository

  • ❖Refrigeration may be required for suppositories

• ❖ Key Points:

  • ❖Provide privacy and wear gloves

  • ❖Position in left lateral position

  • ❖Use water soluble gel for lubrication

  • ❖Provide perineal care

  • ❖ Verify if medication is to be inserted into the rectum or applied topically

Inhalation Medications

• ❖ Inhalers and Aerosolized liquids

• ❖ Advantages:

  • ❖ Covers large surface area of respiratory tract

  • ❖ Rapid action and effects

• ❖ Disadvantages:

  • ❖ Local and systemic effects

  • ❖ Inhalers require patient participation, dexterity

• ❖ Key Points:

  • ❖ Patient education is key

  • ❖ Use aerosolized solutions for endotracheal or tracheostomy tubes

  • ❖ Have patient rinse mouth for steroid inhalers

Routes of Administration: Parenteral

• ❖ Medication injection into body tissues

• ❖ Four major types of injection

  • ❖ Intradermal (ID)

  • ❖ Subcutaneous (SQ or Sub-Q)

  • ❖ Intramuscular (IM)

  • ❖ Intravenous (IV)

• ❖Other routes requiring specialized education

  • ❖ Epidural

  • ❖ Intrathecal

  • ❖ Intraosseous

  • ❖ Intraperitoneal

  • ❖ Intrapleural

  • ❖ Intraarterial

  • ❖ Intracardiac

  • ❖ Intra-articular

Angles of Insertion for ID Injections

15 degrees

Angles of Insertion for SQ Injections

45 or 90 degrees

Angles of Insertion for IM Injections

90 degrees

Syringes

• ❖ Various sizes to fit amount/dose/site

• ❖ Luer-lock tip vs catheter tip syringe

• ❖ Measurement markings on the barrel

• ❖ Sterile areas

  • › Entire needle

  • › Tip of the syringe

  • › Inside barrel of syringe

  • › Stopper end of the plunger

• Never place a syringe on counter opened…unless needle attached and cover in place!

Needles

• ❖ Safety devices for your protection

• ❖ Length depends on depth of desired tissue

• ❖ Gauge depends on viscosity of the medication and intended use:

  • ❖ Thicker = larger gauge needle

  • ❖ Thinner = smaller gauge needle

• ❖ One-handed scoop method: used to recap unused needle

• ❖ Never recap a used needle!!!

Smaller the Gauge

Larger the Needle Size

Ampules:

• ❖ Made of glass

• ❖ Single dose only

• ❖ Filter needle to draw up

• ❖ Change needle to inject

Vials:

• ❖ Glass or plastic

• ❖ Rubber seal

• ❖ Single dose or multidose

Pre-packaged, labeled syringe

• ❖ Morphine

• ❖ Lovenox

Intradermal (ID) Medications

• ❖ TB skin test or allergy testing

• ❖ Location:

  • ❖Anterior forearm for TB testing

  • ❖Upper chest & back for allergy testing

• ❖ Needle size:

  • ❖> 27 gauge

• ❖ Angle of needle insertion:

  • ❖10-15 degrees

• ❖Key points:

  • ❖Goal is to make a bleb (mosquito bite)

  • ❖Don’t massage

Subcutaneous (SQ/Sub-Q) Medications

• ❖ Mostly heparin, Lovenox (Enoxaparin), Vitamin K, Insulin

• ❖ Max Volume: @1 ml

• ❖ Locations for SQ injections:

  • ❖ Any SQ fat area for insulin

  • ❖ Only abdomen for heparin, Lovenox

  • ❖ Pinch/bunch skin to deliver to fatty tissue

• ❖ Angle of needle insertion:

  • ❖ 1 inch skin: 45 degrees

  • ❖ 2 inch skin: 90 degrees

Key Points for insulin:

• ❖ Use insulin syringe only

• ❖ 28-31 gauge and 5/8 – ½ inch length

• ❖ Carefully follow sliding scale instructions for dosage

• ❖ Rotate sites to prevent lipodystrophy

Key points for heparin/Lovenox:

• ❖ Use tuberculin or pre-filled syringe

• ❖ Inject in abdomen ONLY

• ❖ Inject slowly and hold

• ❖ Do not massage!

Intramuscular (IM) Medications

• ❖ Max Volume: 2-5 ml depending on muscle

  • ❖>3ml split dose and give 2 injections

• ❖ Locations for IM injections:

  • ❖Deltoid

  • ❖Vastis lateralis

  • ❖Ventrogluteal

• ❖ Needle size: 

  • 18-27g/1-1.5”

• ❖ Angle of needle insertion: 

  • 90 degrees

• ❖ Key points:

  • ❖ Aspirate for blood

  • ❖ Massage

IM: Deltoid Site

• ❖ Landmarks:

  • ❖ 3 finger-widths below acromion process

  • ❖ 2 finger widths above deltoid insertion site

• ❖ Advantages:

  • ❖ Easy access

• ❖ Disadvantages:

  • ❖ Small muscle

  • ❖ For 2ml or less

  • ❖ Near brachial artery & radial and ulnar nerves

IM: Vastus Lateralis

• ❖ Landmarks:

  • ❖ 1 hand-width below greater trochanter

  • ❖ 1 hand-width above the knee

• ❖ Advantages:

  • ❖ Easy access

  • ❖ No major nerves or arteries

• ❖ Disadvantages:

  • ❖ Muscle is long, but not wide

IM: Ventrogluteal

• ❖ Landmarks:

  • ❖ Palm the greater trochanter

  • ❖ Thumb toward abdomen

  • ❖ Index finger to anterior superior iliac spine

  • ❖ Spread the index and middle finger

  • ❖ Middle finger points to posterior iliac crest

  • ❖ Inject in the “V”

• ❖ Advantages:

  • ❖ Deep muscle

  • ❖ No major nerves or arteries

• ❖ Disadvantages:

  • ❖ Difficult to find

IM: Z-track Method

• ❖ Used for irritating or staining medications

• ❖ Do not massage

A nurse is preparing to inject heparin. Which of the following actions should the nurse take?

Select a site on the client’s abdomen

Parenteral: Intravenous (IV) Administration

• ❖ For fluids, medications, blood, or nutrition

• ❖ Types:

  • ❖ Continuous infusions (ie NS 100ml/hr)

  • ❖ Intermittent infusions (ie infrequent IV medications)

  • ❖ Bolus infusions (ie emergencies, treat dehydration or hypotension)

  • ❖ Volume-controlled infusions ie “piggybacks” (ie antibiotics)

  • ❖ IV push (ie emergency meds, pain meds, etc)

• ❖ IV access via:

  • ❖ Peripheral IV (continuous infusion or saline lock)

  • ❖ Central line access

• ❖ Advantages:

  • ❖ Immediate response

  • ❖ Can administer without waking the patient

• ❖ Disadvantages:

  • ❖ Infection – must use aseptic technique

  • ❖ Fluid overload

  • ❖ Little time to correct if wrong med given (especially IVP)

A nurse is caring for a client who is 1 day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client’s medication administration record, which of the following medications should the nurse administer?

Morphine 2 mg IVP

When should you question a medication order?

• ❖ Order is incomplete, unclear, or illegible

• ❖ Dosage range not in therapeutic range

• ❖ Improbable or incorrect route

• ❖ Medication could harm client

• ❖ Patient is allergic

• ❖ Patient and/or family questions the medication

What should you do if the HCP tells you to give it anyway?

• ❖ Clarify their rationale “Please help me understand…..”.

• ❖ If that doesn’t work then

  • ❖ Follow unit policies

  • ❖ Inform the HCP that you won’t give it

  • ❖ Document your reasons and that the HCP was informed

  • ❖ Go “up the chain”

    • ❖ Inform their supervisor

    • ❖ Inform your supervisor

What to do in case of a medication error?

• ❖ Monitor the patient (VS, airway, etc)

• ❖ Notify the prescriber and Charge Nurse

• ❖ While in school, notify your instructor ASAP!

• ❖ Give antidote, if ordered

• ❖ Complete a Quality Assurance Report or Incident Report

• ❖ Don’t point fingers – we are all human

• ❖ Most analysis show that it is a system failure

• ❖ Be part of the improvement process to ensure that it doesn’t happen to others

Safety Guidelines for Nursing

• ❖ Follow the 10 Rights of Med Admin: No short cuts!

• ❖ Ask questions and know your resources

• ❖ Clarify unclear mediation orders. Consult the pharmacist or HCP

• ❖ Verify high risk med and drug calculations with another RN

• ❖ Avoid distractions when preparing meds and don’t rush

• ❖ Prepare medications for 1 patient at a time

• ❖ Do NOT administer medications that you didn’t prepare

• ❖ Educate patients and families. Involve them in the process and incorporate their cultural beliefs

• ❖ Protect your patients

• ❖ Protect your license

• ❖ Know your facility’s policies for who can administer what medications

• ❖ Check for accuracy three times before administering

• ❖ Use safety devices and properly dispose needles to prevent injuries

• ❖ Stay until all meds are taken, do not leave at bedside to “take later.”

• ❖ If med falls to the floor, discard, document as indicated and get a new one

• ❖ Know what to do in case of a medication error

• ❖ Never be afraid to ask questions. Ego/pride can kill

oral advantages

• Safe
• Easy and convenient
• Inexpensive

oral disadvantages

• Variable rate of absorption
• Slow onset
• Many contraindications
• Inactivation by GI tract
• Requires patient cooperation

SQ and IM advantages

• Good for poorly soluble medications
• Good for meds that require slow absorption but aren’t in oral forms

SQ and IM disadvantages

• More expensive and inconvenient
• Variable rate of absorption
• Faster onset than oral but slower than IV
• Risk of tissue or nerve injury

IV advantages

• Rapid onset
• Immediate response
• Control over precise amount of medication

IV Disadvantages

• Most expensive & requires IV access
• Immediate response can be deadly
• Risk of infection

Tissue integrity is the

ability of the human body to regenerate and maintain normal physiologic functioning.

The skin, cornea, subcutaneous tissue, and mucous membranes act as

defense mechanisms for the body.

What are the factors that impair tissue integrity?

Age, nutrition, sedentary lifestyle, impaired mobility, oxygenation, impaired sensory

The skin

• 1. The largest organ system of the body accounting for about 15% of the total body weight.

• 2. Main function is protection, providing a barrier from injury, infection, ultraviolet radiation (UV), and heat.

• 3. Plays a crucial role in sensory perceptions such as touch, pain, pressure, and vibration.

• 4. Regulates temperature and protects the body against temperature changes.

• 5. Eliminates waste and supports the underlying structures and synthesis of vitamin D

Epidermis

outer layer of the skin composed mainly of keratinocytes and other cells, such as melanocytes, Merkel cells and Langerhans cells

Dermis

largest portion of the skin; main function is to sustain and support epidermis by providing strength and flexibility; made of connective tissue with capillaries; blood vessels; lymph vessels; nerves; sweat and sebaceous glands; hair roots; elastic fibers; and collagen

Subcutaneous tissue

subcutaneous fat (adipose fat) that insulates the body, absorbs shock, and pads the internal organs and structures.

Three Phases in the Wound Healing Process

Hemostatic/Inflammatory, Proliferative, Remodeling

Hemostatic or Inflammatory:

The damaged tissue releases cytokines which trigger a process called hemostasis; blood coagulates, and the wound starts to heal. In addition, plasma leaks into surrounding tissue and causes swelling

Proliferative:

 New collagen fibers are formed, a new wound bed is created, and capillaries start growing. The wound edges begin pulling closer and new granulation tissue grows.

Remodeling:

Stronger collagen replaces the soft gelatinous collagen; however, this  tissue is much weaker than the original tissue and is susceptible to re-injury.

Pressure Injury

• • A localized damage to the skin and/or underlying tissue as a result of a pressure or pressure in combination with shear.

• • Most often occur over bony prominences but can also be a result of a pressure caused by a medical device, such as urinary catheters, oxygen tubing, endotracheal tubing, or drains.

• • The most susceptible areas are over bony prominences, such as the heels, toes, sacrum, hips, elbows, shoulders and back of the head.

Risk Factors for the Development of Pressure Injuries and Wounds

• 1. Age

• 2. Impaired Mobility

  • • Impaired Sensory

• 3. Weight (Friction/Shear)

• 4. Chronic Conditions:

  • • Spina Bifida

  • • Cerebral Palsy

  • • Renal Disease

  • • Cancer

  • • Malnutrition

• 5. Injury (Altered Level of Consciousness)

• 6. Edema (Moisture)

Aging

• • As adults age, skin becomes thinner, elasticity is lost, subcutaneous fat becomes thinner, blood supply is more sluggish, and the skin becomes less hydrated.

• • Therefore, shear, friction, and pressure can cause problems.

Classification or Staging Wounds

• • Pressure injuries are classified according to how much tissue loss is observed in the wound.

• • Nurses assess how deep the tissue loss is and stage or ‘classify’ the wounds using a scale of 1-4 based on the level of tissue loss.

Slough

• • Comprised of dead white blood cells and cellular debris

• • Yellow or white

• • Stringy substances

• • No progress, muddy, marshy

Granulation

• • Contains new connective tissue and capillaries.

• • Red beefy

• • Desired wound bed