Comprehensive Nursing Skills and Medication Administration Guide

Medication Administration and Patient Education Requirements

• Adverse Effects Knowledge: At a minimum, students must know the two most significant adverse effects for every medication on the term list.
• Patient Education at the Nurses’ Station: When administering medication via the Pyxis next week, students must be prepared to educate the patient.     * Example: When giving Metoprolol, the nurse should tell the patient they might feel certain effects. Failure to do so might result in a patient calling the nurse in a panic, stating, "I feel like my heart is racing."
• Midterm Medication Selection: At midterm, students will not know which medication they will be assigned until it is picked by the instructor from a provided list.     * Types of administration to be tested: PO (oral) and either SubQ (subcutaneous) or IM (intramuscular).
• Preparation Timeline: Documentation such as patient diagnosis and collateral information will be provided two weeks in advance. Students are expected to know all medications and symptoms to verbalize them to the instructor during the skill assessment.

Injection Techniques and Needle Specifications

• Directives and Corrections: During practice and midterms, instructors will use a directive approach. If a step is missed, the instructor will stop the student and ask what was missed to ensure the wrong medication or dose is never given to a patient in a real-world setting.
• Subcutaneous (SubQ) Injections:     * Insulin Syringes: These are specifically designed for SubQ use and typically feature an orange top for easy identification.     * Needle Length: These use short needles because insulin is delivered into the fatty tissue, not deep tissue.
• Intramuscular (IM) Injections:     * Needle Length: These require longer needles to reach deep tissue. Although the length of the needle may appear intimidating, correct technique ensures the patient feels minimal discomfort.     * Clinical Example: The instructor mentions running a vaccination clinic where all COVID-19 vaccines were IM; with proper technique, patients reported feeling nothing.
• Intradermal and Other Volumes: Intradermal and SubQ injections typically involve very small amounts of medication.

Advanced Clinical Procedures and Pharmacy Collaboration

• IV Administration and Reconstitution:     * Reconstitution is generally not performed by nurses in acute care settings; this is handled by the pharmacy.     * IV Piggybacks: These will be covered before the final exam and require a thorough understanding of medication compatibility (e.g., with $D5W$ or $0.9\,\text{normal saline}$).     * Utility of Pharmacy: In the real world, nurses should utilize the pharmacy for medication preparation and compatibility inquiries.

Hygiene, Bed Making, and Oral Care

• Bed Making Practices:     * While many hospitals now use fitted sheets rather than traditional mitered corners, the critical skill to master is changing an occupied bed.     * Occupied Bed Technique: This is essential for patients in the ICU or those who are immobile and attached to multiple tubes. Nurses must learn how to move the patient to specific sides to replace the bottom sheets, middle sheets, chucks, and top sheets.     * Soiled Sheet Policy: Hospitals typically change sheets every other day or only when soiled, though a patient always retains the right to request a sheet change if they are uncomfortable (e.g., from sweating).
• Oral Care Techniques:     * Safety Warning: Never use fingers to open a patient's mouth due to the risk of involuntary biting, even in unconscious patients.     * Tools: Use a suction catheter or suction tube to manage fluids and perform cleanings. If necessary, ask a peer to help keep the patient’s mouth open.     * Protective Gear: Always wear gloves during oral care.

Professionalism and Patient Communication

• Verbal Communication During Skills: Every procedure must be explained to the patient before it begins.     * Phrasing: "Mr. Jones, I’m going to be doing oral care on you," or "Mr. Jones, I am going to be starting an IV."
• Pain Assessment: During painful procedures like deep wound care, the nurse must communicate and ask, "Are you in any pain?" or "Do you need any pain medication?"
• Introduction and Identification: Always introduce yourself by name and role.     * Color Coding: Many hospitals color-code staff uniforms to help patients identify providers (e.g., Nurses in blue, Nursing Assistants/MHAs in different colors). This allows patients to identify who was in their room by color if they cannot remember names.

Patient Rights and Documentation Requirements

• The Right to Refuse: Patients have the legal right to refuse any medication or treatment.     * Nursing Action: If a patient refuses, the nurse must notify the physician and document the refusal immediately.     * Clinical Communication: Decisions about the patient's continued stay are often made based on these refusals; if they refuse all treatment, they may not be able to get better in the hospital setting.
• Medication Reconciliation:     * Nurses must reconcile home medications by gathering a list from the patient or family (e.g., $8\,\text{mg}$ of Jardiance once a day or $10\,\text{mg}$ of Metoprolol twice a day).     * Manufacturer Differences: Medications may look different (different colors) because of different manufacturers (e.g., Pfizer vs. Bristol), though the dosage remains the same. The nurse must verify this and educate the patient to prevent fear.
• Safety Checks: There are multiple layers of safety: Pharmacy verification, the Pyxis system, the MAR (Medication Administration Record), and bedside scanning. Bedside scanning of the patient ID and the medication is the final double-check.

Wound Care and Legal Implications

• Preventing Decubitus Ulcers: Failure to turn and clean an incontinent patient can lead to serious wounds. The combination of urine and feces breaks down skin rapidly.
• Documentation and Protection of License:     * Rule of Nursing: "If it was not documented, it was not done."     * Legal Anecdote: The instructor shares a story of being deposed by an attorney as a new nurse because a patient died from a septic wound. Even though the instructor only had the patient for 4 hours, the attorney focused on the lack of documentation regarding a small area of redness.
• Wound Staging:     * General nurses should document what they see (e.g., size, "quarter-inch shape," redness, irritation).     * A Stage 1 wound: Specifically identified by the start of skin breakdown or persistent redness.     * In many facilities, a specialized Wound Care Nurse is responsible for official staging.
• Sepsis Risk: Wounds and infections (like pneumonia) can lead to multi-organ failure and sepsis.     * Example: A NASCAR driver recently died from sepsis that developed from pneumonia.

Midterm Practicum Logistics and Lab Practice

• Important Dates:     * July 4: No class/No lab.     * June 28: PO and IM Medication Midterm.     * June 29: Wound Dressing Midterm.
• Testing Protocol: Students have a strict $15\,\text{minute}$ window to perform the skill and must arrive $15\,\text{minutes}$ early.
• Rubric Usage: Students must follow the grading criteria rubric exactly. During the assessment, students should verbalize steps like "Mark check 1 complete, Mark check 2 complete."
• Open Lab: Students are strongly encouraged to attend open lab to practice with peers and critique each other according to the rubric.
• Sterile Gloving: Part of the wound care midterm.     * Proper sizing is critical; gloves must be snug so the nurse can feel veins and maneuver catheters.     * Students should retain their practice gloves to reuse during training sessions.