Funds test 2 blue print

Documentation

Documentation

Act of documenting patient assessments and care in written or electronic form

• if it wasn’t charted it wasn’t done

Purpose of communication

1. communication

2. continuity of care

3. quality improvement

4. planning and evaluation of patient outcomes

5. leal record

6. professional standards

7. reimbursement and ultilization review

8. education and research

Confidentiality

All information about patients written on paper, spoken aloud, saved on computer

• name, address, phone number, fax, SSN, reason person is sick, treatment patient receives, information about past health conditions

Pontential Confidentiality Breaches

• displaying information on public screen

• sending confidential e-mail messages via public networks

• sharing printers among units with different functions

• discarding copies of patient information in trash cans

• holding conversation that can be overheard

• faxing confidential information to unauthorized persons

• sending confidential messages on overhead pages

Patient Rights

1. right to see and copy their health records

2. request updates to their health record

3. get a list of disclosures

4. request a restriction on certain uses of disclosures

5. choose how to receive health information

Source oriented documentation

members of each disciple record their findings in a separated section of medical record

• ad: easily find information

• disad: data is fragmented

Problem oriented documentation

organized around client’s problems; there are no separated sections for each discipline; database, problem list, plan of care, progress notes

• Ad: input from all disciplines, easy to monitor

• Disad: requires cooperative spirit and diligence in maintaining database

Charting by exception

only document significant findings or exceptions

• Ad: reduced amount of time spent on documentation, easy to read document, highlighted variations

• Disad: omissions of pertinent information

Electronic health records

records entered into the computer; combination of source oriented and problem oriented record styles

• Ad: enhanced communication and collaboration, improved access to information, time savings, improved quality of care, information is private an safe

• Disad: expensive, downtime, difficulties associated with change, lack of intedgration

Narrative nursing progress notes

source-oriented and problem-oriented charts

• tells the story of the client’s experience in the order that it happens

PIE nursing progress notes

organizing information according the clients problems

• Problem: use data from you original assessment to identify appropriate nursing interventions

• Intervention: document the nursing actions you take for each nursing diagnosis

• Evaluation: document the clients response to interventions and treatments

SOAP or SOAPIE nursing progress notes

source-oriented, problem oriented, and EHRs

• Subjective data: what the client or family members say about the client’s s/s

• Objective: factual, measurable clinical findings such as vital signs, test results, and quality of breath sounds

• Assessment: conclusions drawn from the subjective and objective data, usually client problems or nursing diagnosis

• Plan: short-term and losing-term goals and strategies that will be used to relieve the clients problems

• Interventions: actions of the healthcare team performed to achieve expected outcomes

• Evaluation: an analysis of effectiveness of intervention s

• Revision: changes made to the original care plan

Focus nursing progress notes

views client’s status form a positive rather than a problem-oriented perspective

• Focuses one: nursing diagnosis, s/s, client behavior, a special need, an acute change in condition, a significant event

FACT nursing progress notes

incorporates CBE principles and disadvantages

• F: Flow sheets individualized to specific services

• A: Assessment features standardized with baseline parameters

• C: concise, integrated progress notes and flow sheets

• T: timely entries documented when care is given

Electronic entry nursing progress notes

streamlines documentation process, make them more accurate and efficient and reuce the risk of human error

Verbal prescription/orders (VO)

spoken to you, often during a patient emergency, should be made for critical change in patient condition

Telephone prescription/orders

received by phone and transcribed onto the provider prescription sheet, increased risk for errors

Reporting

Method to inform other caregivers about the patient’s condition (nurse to nurse, nurse to provider)

• Communication of vital information related to patient’s status/plan of care

• Types: handoff report, transfer report

Change of shift/Hand-off reports

Basic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicians

• Includes: Current appraisal of each patient’s health status, Current orders, abnormal occurrences during your shift, any unfilled orders that need to be continued onto the next shift, patient/family questions, concerns, needs; reports on transfers/discharge

• SBAR: Situation, Background, Assessment, Recommendation

Purposeful Rounding

Using opening key words with presence

• Include: accomplish schedule tasks, address 4 P’s, address additional personal needs, conduct environmental assessment; tell patient when you will be back

• Document the round

Documenting patient care

Document immediately, document chronologically, date and time all documentation

• ABC’s: Accurate, Bias-free, Complete,  Detailed, Easy to read, Factual, Grammatical, Harmless (legally)

Chemical drug name

the exact description of the drug’s chemical composition and molecular

Generic/offical drug name

US adopted names council when the developing manufacturer is ready to market the drug

• name that is listed on publications

Brand drug name

what the drug is sold as in stores

Mechanisms to promote drug safety

When in doubt look it up

• References: pharmacopoeia and formularies, nursing drug handbook, physicians desk reference, pharmacy texts, electronic and internet-based formularies, a clinical pharmacists, medication package inserts, institutional medication policies and procedures

Legal Considerations for medication administration

  U.S. Legal legislation

• Sets official drug standard

• Defines prescription drugs

• Regulates controlled substances

• Improves safety

• Requires proof of efficacy

Nurse practice acts: identify nursing responsibilities for administration and patient monitoring

Stock Supply

bulk quantity, central location, not patient specific

Unit dose

individual packaged, patient-specific drawers, 24-hour supply

Automated Dispenser

password-accessible locked cart, computerized tracking, can combine stock and unit doses

Self-administration medication

individual containers, kept at patient’s bedside

Drug classification

Classified by effect on body system; chemical composition, clinical indication, therapeutic action

• Pharmaceutical class

• therapeutic class

Pharmaceutical class

refers to the MOA, Physiological effect, chemical structure of a drug

• ex: adrenergic, beta blockers, diuretics

Therapeutic Class

refers to the clinical indication for the drug or therapeutic action

Pharmacokinetics

what happens to the drug in the body

• absorption

• distribution

• metabolism

• excretion

Absorption

movement of a drug from its site of administration into the bloodstream for distribution to tissues

Distribution

transport of a drug by the bloodstream to its site of action

• rapid: heart, liver, kidneys, brain

Metabolism

biochemical alteration of a drug into an inactive metabolite, a more soluble compound, a more potent active or less active metabolite

Excretion

elimination of a drug from the body

• primary organs: kidneys, liver, bowel

Antagonist

happens when one drug interferes with the actions of another and decrease the resultant drug

Synergistic

additive effect of both drugs together is greater than the individual effect

Incompatibilities

when multiple drugs are mixed together, causing chemical deterioration of one or both

Tolerance

decreasing response to repeated doses of a medication

Dependence

a person’s reliance on or need for the drug

Drug misuse

nonspecific, indiscriminate, or improper use of drugs include alcohol, OTC and prescription drugs

Drug abuse

inappropriate intake of a substance by amount, type or situation in

Illicit drugs

drugs sold illegally

Written medication orders

on prescription form or on a preprinted standard medication order sheet and protocols

Verbal orders

oral order spoken to the nurse

• when receiving the order write nurses name down along with the providers name

• repeat and spell back prescription to provider;

• increases the risk for miscommunication errors

• should only be used in emergencies

components of a medication prescription

• Patients full name

• Date and time

• Name of medication

• Dosage size, frequency, number of doses

• Route of admin

• Printed name, and signature of prescriber, including relevant credentials and legal registration identifier

Medication errors

Any preventable event that may cause or lead to inappropriate medication use of harm to a patient

Caused by:

• Lack of knowledge of information

• Faculty communication

• Equipment errors

• Calculation and measurement error

Technology to prevent errors

• Computerized prescriber order entry

•   Barcode medication administration

• Smart pumps

• Automated dispensing cabinets

Assessments related to medication administration

before, during, after, medication history, physical examination

Diagnosis related to medication administration

injury, risk-polypharmacy, misuse, overuse, underuse; non-adherence to medication regimen

Teaching Medication Self-Administration

• Know and understand what you are taking

• Take the drug as prescribed

• Communicate with your provider

• Think about safety

• Administer your drugs correctly

• Store your drugs safely

• Maintain your supply

Three checks of medication administration

1. Before pour, mix or draw up a medication check its label against the entry on the MAR

2. After you prepare, and before returning medication cart or discarding anything, check the label against the MAR entry again

3. At the bedside, check the medication again before actually administering

Six rights to mediation administration

• right drug

• right dose

• right time

• right route

• right patient

• right documentation

oral medications

Most common; Swallowed and absorbed from the stomach or small intestines

• Can delegate PO meds to LPN/LVN but NOT UAP

Topical medications

Applied directly to surfaces/body cavities

• Long acting systemic effects

• Effective only for lipid soluble drugs and must be specially formulated

ear drops

1. hold ear drop bottle in hand to warm or place in warm water and shake the bottle before using

2. assist patient to side-lying position whit appropriate ear facing up

3. clean the external ears with cotton topped applicator

4. fill dropper with correct amount of medication

5. straighten ear canal- for children pull pinna down and back, for adults up and back

6. instill prescribed number of drops along the side of the ear canal not touching the end of the dropper to part of the ear

7. tug on ear

8. instruct pt to keep head turned to the side for 5 to 10 minutes; place cotton ball loosely at the opening of canal for 15 minutes

Eye drops

1. rest dominant with the eyedropper on the pts forehead

2. with nondominant hand pull lower lid down to expose the conjunctival sac

3. position the eyedropper about 1.5 to 2 cm above the pts eye, ask pt to look up and drop the prescribed number of drops in to conjunctival sac

4. ask pt to close eyes

Parenteral medications

Injected or infused into the body tissues or into blood stream

Parenteral medications needles

the smaller the gauge, the larger the diameter

• Smaller needles (20- to 30- gauge) cause less pain and trauma to the tissues; useful for patients who must have frequent or long term injections

• Larger needs: (14- to 18-gauge) used for blood and more viscous medications, to mix IV medications or for rapid infusion of iv medications

• Administer blood: at least an 18 gauge for adults

• IM injections: 1 ½ inch needle is common

Reconstituting from powder

Medications that not stable in solution are dispensed as powders in vials, must add a dilutant or solvent to powder to create solution for injection (usually sterile water or saline);

• each comes with manufacturers instructions for amount and kind of solvent to add

vial

single dose or multi dose plastic or glass container with a rubber stopper that reseals the top after each needle introduction

ampule

thin-walled, disposable glass container with a narrow neck that must be snapped off to access medication

Needle safety issues

never recap a contaminated needle; place sharps container

• use correct site

Discomfort from injections comes form three sources

1. prick of the needle

2. the pressure of the volume of the drug in the tissues

3. chemical irritation caused by certain drugs

Intramuscular angle

90 degrees

Subcutaneous angle

45 degrees

Intradermal angle

10-15 degrees

Intradermal medicaitions

given into the dermis

• Inserted at 5-15 degrees

• Commonly used for allergy or Tb testing

• 1Ml syringe; short small 26- to 28-gauge

Subcutaneous injections

Given into the subcutaneous tissue, the later of fat located below the dermis and above the muscle

• slower than through IM route because subcutaneous tissue does not have as rich a blood supply as does muscle

• Sites: lower and lateral aspect of the lower part of the upper arm, abdomen, thighs, back, lower loins (upper buttocks)

  • Fastest absorption: abdomen and arms

  • Slowest absorption: thigh and upper buttock

  • 45 degree angle; 3/8-3/5 inch needed preferred

Intramuscular injections

Deltoid or Ventrogluteal muscle is site of choice (fatty part of hip)

• Vastus lateralis is preferred site for young infants before walking age

• 1 ½ inch needle is standard

• The smaller the muscle the less fluid it can tolerate

• Large muscles can hold 3-5 ml of liquid

Intravenous medications

Onset of meds takes place within seconds (fastest acting); Useful in emergencies

• IV Push: injected directly into a vein and enter the systemic circulation immediately; very hard to reverse if wrong med is pushed

• IV piggy back:: Small bag of diluted medication (the secondary bag) is attached to the primary IV inflection line for administration

  • The smaller contained is connected to the primary infusion line at the upper primary port; the set up allows for intermittent use only and the infusion of one sultion at a time

Sensory overload

occurs with stimuli such as pain, unfamiliar sights, sounds, odor and routines overwhelm the pts senses

Sensory deprivation

altered sensory preception in which the person does not receive and process meaningful sensory input

• may occur when there is disruption or dysfunction with the nervous system or a deprived environment

Sensory deficits

deficit of the sense

• visual, auditory, tactile

Myopia

near sightedness

Hyperopia

far sightedness

Presbyopia

change in vision associated with aging

Astigmatism

irregular curvature of the cornea or lens and scatters light rays and blurs

Cataracts

clouding of the lens, resulting in blurred vision, sensitivity to glare

glaucoma

increased pressure in the anterior cavity of the eyeball distorts the shape of the cornea and shifts the position of lines

Macular degeneration

loss of central vision due to damage to the macular lutea

Strabismus

one eye deviates from a fixed image

Retinopathy

damage to the retina that cause vision impairment

Conduction deafness

temporary or permanent condition caused by infection of the middle ear, a punctured tympanic membrane, arthritis of the auditory bones, cerumen impaction of a foreign object

Sensorineural hearing loss

nerve deafness that occurs when there is damage to CN VII or the receptors in the cochlea

Presbycusis

age related progressive sensorineural loss; person experiences diminished ability to hear high pitched sounds

Tinnitus

ringing in the ear; damage to nerve endings cause by trauma, Meniere’s disease, hypertension, ear infection, medication (aspirin)

Impacted cerumen

earwax becomes tightly packed in the ear canal, blocking the canal

Otitis media

middle ear infection; common in childhood infections

Otosclerosis

hardening of the bones in the middle ear (stapes)

Tactile deficit

a change or alteration in the ability to feel and or interpret touch, pressure, temperature

Tactile defensiveness

Absence of sensation

Tactile hyposensitivity

decreased sensation

Tactile apraxia

isolated disturbance of hand movements for use of and interaction with an object in the presence of preserved intransitive movements

• Ex: repetitive movement

Tactile aphasia or agnosia

naming impairment in which objects cannot be correctly named on the basis of touch alone

• ex: misnaming a clock as a balloon

Nonpharmacological measures

• Cutaneous stimulation: transcutaneous electrical nerve stimulation (TENS)

• Complementary and alternative modalities

  • Spinal cord stimulator

  • Acupuncture/acupressure

  • Massage

  • Use of heat and cold

  • Contralateral stimulation

• Oral sucrose

• Immobilization

• Cognitive behavior interventions

Pharmacological interventions

• Non-opioid analgesics

  • NSAIDs

  • Acetaminophen

• Adjuvant analgesics

• Opioid analgesics: IV, transdermal, epidural forms, patient control pumps (PCA)

  •   Effectiveness: certain types of pain, no first line option for persistent pain

  • Side effects: N/V, constipation drowsiness; respiratory depression, sedation, paradoxical reaction (reverse reaction)