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147 Cards in this Set

  • Front
  • Back
Normal temperature
97-99.5 F (oral)
97.5-100 (tympanic)
98-100.5 (rectal)
96-98.5 (axillary)
Normal pulse
60-100 BPM
Normal BP
100/60 - 139/89
140/90 = hypertensive
Pulse Pressure
Difference between systolic (top) number and diastolic (bottom) number.
Normal respirations
12-18 per minute
Process order of operations
Assess, Plan, Implement, Evaluate
Assess
1. Collect documented data
2. Interview for subjective information
3. Collect objective information (appearance, vitals, etc.)
Plan
Prioritize, determine needs, prioritize needs
Data to determine nursing diagnosis
Determine goals/outcomes
Implement
Prepare equipment
Perform procedures
Aftercare
Report & record
Evaluation
Assess the extent to which needs have been met
Re-evaluate problem list
Purpose of Charting
Continuity of care
Legal documentation
Communication between staff members
Charting best practices
Ink for date and time
No blanks
No erasures (correct errors by lining out and initialling)
No changes once the note has been signed
Sign when complete, with credentials (RN, LPN, VN)
Chart Notes Record
1. Initial assessment
2. Changes in condition
3. Care given (treatments, education, etc.)
4. Response to care, laboratory data
5. Physician and other professional visits
6. Meds after they are given
Care Plans
1. Update regularly- every 24-48 hours
2. Cross out resolved problems with colored felt-tip pen
Pain Management
Assess:
1. Characteristics (sharp, dull, aching)
2. Onset (when did it begin)
3. Duration (how long does it last)
4. Location (stable, radiating, moving)
5. Severity (usually rated 1-10)
6. Precipitating, Aggravating and Alleviating factors
Non-Pharma Pain Treatment
1. Cold (decreases pain and swelling)
2. Distraction
3. Heat (decreases tension)
4. Imagery (using positive mental images)
5. Nerve blocks (local anesthetic injected around the nerve)
6. Pressure
7. Relaxation (reduces muscle tension)
Pain Management Best Practices:
1. Don't argue about whether patient is in pain
2. Do not use a placebo to determine whether pain is "real"
3. Offer pain relief alternatives
4. Assess client for depression, anxiety and stress
Fat Soluble Vitamins
A, D, E and K
Vitamin A
Retinol: Liver, egg yolk, butter, milk
Carotene (provitamin A): green and yellow vegetables and fruit)

Deficiency: Poor night vision

Excess: Hair loss; rough, dry skin; cracked lips; liver damage
Vitamin D
Cholecalciferol: Fortified milk, sun exposure, fish oil, butter, egg yolk, liver

Deficiency: rickets (children), osteomalacia (adults). Dark-skinned clients, those with gallbladder disease, infants and the elderly are more prone to D deficiency.

Excess: Hypercalcemia, anorexia, vomiting, polyuria

Required for: Absorption of calcium and phosporous, bone calcification.
Vitamin E
Tocopherol: Vegetable oils, greens, milk, eggs, meat, cereal, wheat germ

Deficiency: Breakdown of red blood cells

Excess: Skeletal muscle weakness, reproductive disturbances, GI upset.

Required: To prevent cell damage
Vitamin K
Aqua mephyton: Leafy greens, cheese, egg yolks, liver. Primary source is intestinal bacterial synthesis (e. Coli)

Deficiency: Increased bleeding
Excess: Hyperbilirubinemia, kernicterus, severe hemolytic anemia (in newborns)

Required for prothrombin formation, clotting

Note: Be alert to K deficiency when fat intake is low, or when antibiotics (e.g. neomycin, vancomycin, etc.) destroy intestinal bacteria. Excessive K intake can counteract the blood-thinning actions of coumadin.
Water Soluble Vitamins:
B-family (1, 6, 12), C,
Vitamin B-1
Thiamine: Beef, liver, pork, whole-grains, legumes

Deficiency: Beri-beri, mental confusion, polyneuritis, muscle-weakness, tachycardia

Required for: Growth; nervous system, heart and muscle function

Thiamine needs depend on carbohydrate intake and metabolism. Alcoholics, clients on long-term IV therapy, and those with prolonged fevers may be prone to thiamine deficiency.
Vitamin B-6
Pyridoxine: Liver, meat, wheat-germ, corn, yeast, legumes.

Deficiency: Hypochromic anemia, irritability, convulsions, neuritis, skin lesions

Required for: Energy production, heme production

The more protein in the diet, the greater the B-6 requirement. Isoniazid and oral contraceptives may cause a pyridoxine deficiency.
Vitamin B-12
Cobalamin: Liver, meat, eggs, milk, cheese, salt-water fish

Deficiency: Pernicious anemia (Post total-gastrectomy, deficiency must be addressed with injections)

Required for: Red blood cell production, nerve function, growth

Note that vegans/vegetarians are especially prone to deficiency
Vitamin C
Ascorbic acid: citrus, tomatoes, peppers, cabbage, potatoes, strawberries, melon, broccoli, turnip greens, etc.
Deficiency: Scurvy, bruising, hemorrhages, sore gums, stress reactions

Required for: iron absorption, collagen formation (specifically of note, capillary walls)

Note that elevated metabolic rate (from hyper-thyroidism, fever, burns, neoplasms, etc.) increases vitamin C requirements
Minerals
Iron, calcium, magnesium, potassium
Iron
Fe (e.g. Ferrous sulfate): liver, meat, egg yolks, whole grains, enriched bread, dark greens, vegetables

Deficiency: Anemia, poor growth

Excess: Can be deposited in liver, other tissues (hemosiderosis), resulting in damage

Required for hemoglobin production
Calcium
Ca: milk, milk products, cheese, leafy green vegetables (particularly cruciferous)

Deficiency: Rickets, osteoporosis, poor blood clotting, tetany (muscle spasm).

Required for boner and tooth formation, blood clotting, muscle contraction
Nutritional Assessment Screening:
-Overweight
-Underweight
-Long-term IV therapy
-Digestive system problems/metabolic disorders
-Elderly/Infants
-Alcoholics
Nutritional Assessment: Assessment
Anthropometric measures, biochemical tests, clinical observations.
Patient dietary history and health history

(Action plan, if necessary)
Therapeutic Diets
1. Clear liquid
2. Full-liquid
3. Soft
4. Bland
5. Low-Residue
6. High-Fiber
7. Sodium-Restricted
8. Gluten-Free
9. Lactose-Free
10. Low Cholesterol
11. Low Purine
Clear Liquid Diet
Purpose: Provides hydration (typically post-op)
Allowed: Tea, coffee, fat-free broth, boullion, fruit ices, popsicles, gelatin, soda.
Not Allowed: Milk products, fruit-juices with pulp
Full-Liquid Diet
Purpose: Introduce nutrition (typically following clear liquids, post-op)
Allowed: All foods that are liquid (or liquid at room temperature)
Not Allowed: nuts, beans, any solid food
Soft Diet
Purpose: Post-op, infection, GI issues
Allowed: All soft, tender, minced, stewed or creamed foods
Not Allowed: Coarse/whole-grain breads, meats, sharp cheeses, dried fruit, nuts
Bland Diet
Purpose: To eliminate irritants and allow the stomach lining to heal
Allowed: Milk, custards, white bread, cooked cereals, creamed or pureed soups, baked or boiled potatoes
Not Allowed: Strongly flavored or highly-seasoned foods, coffee, tea, citrus, raw fruits/vegetables, whole grains, very hot or cold beverages
Low-Residue Diet
Purpose: To reduce fiber in cases of Crohn's, colo-rectal surgery, esophagitis, diarrhea
Allowed: Clear fluids, sugar, salt, meats, fats, eggs, some milk, refined cereals and white breads, peeled white potatoes.
Not Allowed: Cheese, fried foods, highly-seasoned foods, high-fiber foods
High-Fiber Diet
Purpose: To provide bulk in the stool, and bring water into the colon for clients with constipation or diverticulitis
Allowed: Raw fruits and veggies, whole grains
Not Allowed: minimize low-fiber foods
Sodium Restricted Diet
Purpose: Kidney disease, cardiovascular disease or hypertension--reduces the retention of water, reduces blood-pressure

Allowed: Natural foods without salt, milk and meat in limited quantities

Not Allowed: Canned/prepared foods, table salt, most prepared seasonings (other than low/no-sodium)
Gluten-Free Diet
Purpose: Eliminate gluten in cases of malabsorption syndrome (e.g. celiac disease)

Allowed: Rice, corn, soy, fruit, vegetables, meat, milk, eggs
Not Allowed: All wheat, rye, rye, barley, oats and prepared foods not labeled gluten-free
Lactose-Free Diet
Purpose: To eliminate lactose for those who cannot digest it

Allowed: Most meats, fruits, vegetables, cereals and grains

Not Allowed: Dairy products (non-lactose free), processed foods containing lactose.
Low-Cholesterol Diet
Purpose: Reduce dietary cholesterol to reduce blood cholesterol

Allowed: Fruit, vegetables, lean meat and fish, skinless poultry, skim milk

Not Allowed: Organ meats, egg yolks, shrimp, beef, lamb, pork (other than extremely lean)
Low-Purine Diet
Purpose: Reduce purine, a precursor of uric acid for cases of gout or uric-acid kidney stones

Allowed: Most vegetables (other than cauliflower), spinach, asparagus, peas, fruit juices, cereals, eggs cottage cheese.

Not Allowed: Organ meats, fish, poultry, lentils, dried peas, nuts, beans, oatmeal or whole-wheat.
Infection Control: Chain of Transmission
Pathogen
Reservoir
Exit port
Route of Transmission
Portal of Entry
Pathogen
Anything that can produce disease:

Virus
Bacteria
Fungi
Chlamydia
Protozoa
Mycoplasma
Reservoir
Where pathogens grow and multiply. Examples can include a host (person, animal, bird, etc.) or materials on which the pathogen can grow (e.g. saturated wound-dressings, contaminated equipment)
Exit Port
How the pathogen leaves the host:
-Explosive diarrhea (a mental image to keep "exit port" with you forever...)
-Nasal secretions
-Intermediate carrier (e.g. mosquito, flea, water, food)
Route of Transmission
How the pathogen moves to another host.
-Direct transmission (e.g. sexual activity)
-Indirect transmission (e.g. via indirect carrier: a mosquito, contaminated water, food, door-knob, etc.)
Portal of Entry
How the pathogen enters another host:
-Inhalation
-Ingestion
-Percutaneously.
Whether disease occurs depends on the new host's immune system, considering factors such as age, nutritional status, stress, existing illnesses.
Transmission Control
Anything that interferes in the Chain of Transmission:
-Barriers (gloves, masks, gowns, condoms)
-Sanitation (proper handling of food and water, sewage, bio-waste)
-Avoidance of high-risk behaviors (no unlicensed, back-alley taco-trucks; no truck-stop hookers)
-Good hand-washing and personal hygiene
-Immunization
Infection Control Procedures:
-Standard Precautions
-Airborne Precautions
-Droplet precautions
-Contact-Transmission Precautions
Standard Precautions:
(Replaced universal precautions)
Barriers (usually gloves) to protect against blood, body-fluids and secretions.
Hand-washing.
Airborne Precautions
TB, Chickenpox
Private, negative-pressure room
Masks or face-shields
Minimize movement of patient from room
Droplet Precautions
Rubella, strep, pneumonia, pertussis, mumps, mycoplasma, meningococcal pneumonia

Private room
Mask when working within 3' of patient
Visitors kept at minimum 3' distance from patient
Limit movement of patient from the room. Patient should be masked for transport.
Contact-Transmission Precautions
Respiratory syncytial virus (RSV), shigella, other enteric pathogens; major wound infections; herpes simplex; scabies.

Private room
Gloves on entry, fresh gloves after contact with infectious material. Remove gloves before leaving room, and wash hands.
Gown if clothing will be in contact with patient, surfaces, or if client is incontinent. Remove gown prior to leaving the room.
Limit movement of patient from the room
Avoid sharing any patient-care equipment
Vitals
Temperature
Pulse
Blood Pressure
Respiration
Methods of obtaining temperature
Rectal (not for rectal surgery post-op)
Oral (not for infants, oral-surgery post-op, unconscious, or using an oxygen mask)
Axillary
Tympanic (not for infants under 3 months)
Celcius to Fahrenheit Conversion
1 degree C = 1.8 degrees F

37 C = 98.6 F
Pulse- Locations
Radial (wrist-radial artery)
Apical (4th-5th intracostal space, used on infants and those with irregular heartbeat)
Carotid (neck-carotid artery)
Brachial (inside the elbow-brachial artery)
Femoral (groin-femoral artery)
Popliteal (behind the knee-popliteal artery)
PTA (ankle joint-posterior tibila artery)
Dorsalis (on the foot-dorsalis pedis artery)

Peripheral pulse: Used to evaluate circulation, Doppler ultrasound may be used if the pulse is not palpable.

Pulse Deficit: Apical rate is higher than radial rate--deficit is apical minus radial.
Evaluating Pulse
Adult: 60-100
Child (6-10): 100
Child (2-4): 900-130
Newborn: 100-160
Blood Pressure:
Systolic 90-139 mmHg (heart contracted)
Diastolic 60-89 mmHg (heart relaxed)

Adult: 90/60 - 139/89
Child (6-10): 80/40 - 110/80
Respiration:
Per Minute:
Adult: 12-18
Child (6-10): 20-26
Child (2-4): 24-32
Newborn: 30-60
Assess depth, regularity, rate
Hygiene:
-Bathing:
Privacy
Warm Room/Bath Blanket
Rinse and dry all skin surfaces
Moisturize (except patients receiving radiation-- no soap, lotion, powder on radiation site)
-Clean dentures, teeth and gums every 24 hours
-Brush hair daily
-Change linens (minimum: check to be sure they're clean and make the bed-occupied, unoccupied, surgical--top covers not tucked in, but fan-folded to side or bottom for patient returning from surgery)
Mobility:
ROM-Passive ROM, or teach active ROM to prevent contractures.
-Each joint through full ROM (but never forced), 2x daily on immobile patients
Body Alignment:
Supine, face-up, arms at sides, feet parallel with toes pointed up and slightly out.

Trochanter rolls may be used by the hip to prevent abduction and external rotation of the hip.

Paralyzed hands may be positioned around a rolled washcloth to maintain functional position.
Patient Transfer (Types)
Bed to stretcher:
Bed to chair
Pulling Up in Bed
Turning
Bed-to-Stretcher:
2-3 people
Use drawsheet to pull patient to edge of bed, with stretcher (wheels locked) next to bed.
Reach across stretcher & pull patient toward you.
Bed-to-Chair
Lower bed as much as possible
Move the client to a sitting position, and then to the side of the bed with the legs dangling
Face client with a wide stance, and her knees between your legs
Have client lean forward and place her hands on your shoulders and pull her to a sitting position and then pivot her to the chair
If possible, have client assist in lowering herself into the chair.
Pulling Patient up in Bed
Stand beside patient
Lower bed to flat position
Have patient bend knees and push as you pull him up (with another person, if possible) by a drawsheet, or by reaching under patient's shoulders
Turning Patient
Turn patient every 2 hours while in bed
Lower bed and cross patient's arms to stabilize
Use drawsheet to turn patient, stabilize with pillows
Assistive Devices (Mobility)
Cane
Crutches
Walker
Cane
Stand on affected side, and stabilize patient with security belt and a hand on patient's shoulder
Cane should be on unaffected side so it can work with the affected side as patient steps forward
Top of the cane shoudl reach patient's greater trochanter
Crutches
Position to be able to place two fingers between patient's axilla and the axillary bars.
Stand on affected side, and stabilize with security belt and a hand on patient's shoulder
Instruct patient not to rest underarms on axillary bars (potential for brachial plexus palsy)
Walker
Position to be on affected side.
Instruct patient to move walker forward, and walk into it.
Feeding types
Oral
Tube
Oral Feeding
Place tray in patient's line of sight
Check gag reflex if this is the first time patient is being fed
Raise bed head
Prepare food, allow patient as much independence in feeding as possible, including finger food
Provide straw for liquids
Offer patient choice of what to eat, when
Offer small quantities of food, alternating liquids and solids
Wash patient's hands and provide oral care before and after meal
Tube Feeding
Use NG or Gastronomy tube for patients unable to swallow
Feedings may be continuous or intermittent
Feeding solution should be at room temperature
Flush tube with water before and after each feeding and medication administered
Raise bed head during feedings, and maintain 45 degree angle for 45 minutes following feeding
Feeding rate should be gravity infusion, don't force
Aspirate stomach contents prior to feeding or one hour after to assess for residual solution in stomach
Oral care every 2 hours
Provide emotional support
Elimination (Bowel)
Enema
-Cleansing
-Oil Retention
Manual extraction of impaction
Colostomy Irrigation
Cleansing Enema
Cleansing:
-Tap water, soap and water or saline
-105 degrees F or lower
-L. lateral Sims position
-500-1000 mL fluid
-Lubricated tube 3-4" into rectum, hold fluid 18" above rectum
-Stop if cramping occurs, patient should take several deep breaths
-Observe results, and record quantity of fecal matter expelled. If order is to clear, do not give more than 3 enemas without specific request by physician
Oil Retention Enema
-Oil at about 100 degrees F
-L. lateral Sims position
-100 mL fluid
-Lubricated tube 3-4" into rectum, hold fluid 18" above rectum
-Stop if cramping occurs, patient should take several deep breaths
-Encourage client to retain oil about 30 minutes
Manual Impaction Extraction
-Order is required for cardiac patients
-Glove, and lubricate index finger
-Patient in L. lateral Sims position
-Insert finger, and gently break off and extract impaction
-Stop if vitals change or patient is uncomfortable
-Provide patient bedpan for evacuation
Colostomy Irrigation
Performed daily or every other day
Special ostomy pouch for irrigation and fecal matter collection
Warm saline or tap water
Record results (output)
Urinary Problems
Incontinence: Can't control urination
Retention: Can't urinate
Dysuria: Hurts to urinate
Polyuria: Excessive urination
Oliguria: Insufficient urination (less than 400 mL/day)
Anuria: No urination
Catheter types
Straight: Inserted to empty the bladder, then removed
Foley: Inserted and remain in place
Catheterization Procedure
Sterile technique
Explain procedure, ensure privacy, position patient
Gloves on
Open sterile kit
Cleanse urinary meatus--front to back
Lubricate catheter and insert: 3-4" for females, 6-8" for males (no matter how long a catheter they believe to be necessary...)
Foley: Inflate balloon (in bladder) with 5-10 cc water. Tape tube to thigh and connect tube to bag.
Catheter Irrigation
Sterile technique
Irrigation kit, 50-60 mL syringe, pad, drainage tray
Explain procedure, ensure privacy, position patient
Pour irrigation solution into syringe, instill irrigant, and allow to drain.
Record amount of irrigant and output
Foley Catheter Removal Procedure
Explain procedure, ensure privacy and position patient
Use syringe to draw water from inflated balloon
Gently withdraw tube, discard tube and bag
Monitor patient for voiding (should void within 8 hours of removal)
Encourage fluid intake
Heat Therapy
Indications: stiffness, arthritis, pain
Contraindications: trauma, edema, malignancies, burns, testes, sensory impairment/confusion/unconsciousness

Local effects: Vasodilation, increased oxygenation, muscle relaxation, decreased stiffness/spasm
Cold Therapy
Indications: Sprains, fractures, swelling, bleeding
Contraindications: Open wounds, impaired circulation, sensory impairment/confusion/unconsciousness

Local effects: Vasoconstriction, decreasd oxygenation, increased cell death, decreased metabolism, decreased pain and swelling (edema)
Wound healing speed is impacted by:
Nutritional Status
Circulation
Location of wound
Type of wound
Underlying pathologies (e.g. diabetes)
Sterile Dressing Procedure
Wash hands, assemble equipment, put on clean gloves
Remove old dressing with clean gloves, assess drainage, wound status
Dispose of old dressing in closed container
Sterile gloves
Clean wound from center to edges. Do not recontaminate cleaned area. Discard cleansing swab after each stroke
Apply sterile dressing--tape or anchor with binder
Document drainage (color, quantity, odor) and wound status
Wet to Dry Dressing
Wash hands, assemble equipment, put on clean gloves
Remove old dressing with clean gloves, assess drainage, wound status
Dispose of old dressing in closed container
Sterile gloves
Clean wound from center to edges. Do not recontaminate cleaned area. Discard cleansing swab after each stroke
Moisten sterile dressing with saline--don't saturate it, it should dry within 4-6 hours
Apply wet sterile dressing--tape or anchor with binder
Cover with dry
Document drainage (color, quantity, odor) and wound status
Wound Culture Procedure
Must be done prior to administering antibiotics or applying antimicrobial agent to wound
Sterile technique
Use sterile swab, and gently roll in purulent drainage.
Jackson-Pratt Drainage System
Prevents excessive buildup of drainage
Consists of a bulb that must be compressed to allow air to escape, and uses suction to draw drainage away from surgical site.
Bulb is recapped to maintain suction
Hemovac
Used to remove drainage from deep wound (deep incision-post-surgical) Hemovac is placed by surgeon prior to closing
Compressed every 4 hours to maintain suction
Drainage emptied from pouring spout
Procedures requiring sterile technique
Surgical
Catheterization of body cavities
Injections/infusions
Dressing Changes: particularly dressings over catheters entering body cavities
Dressings of Immunocompromised patients/burn patients
Sterile Field
Specified area, as within a tray or towel, considered free of microorganisms, or an area immediately around a patient that has been prepared for a surgical procedure. The sterile field includes the scrubbed team members, who are properly attired, and all furniture and fixtures in the area
Sterile Field Rules:
Must be within your view at all times. Anything below waist-level is not a sterile field, because it's out of view.

Moisture will carry bacteria through a cloth barrier, so any wet area is unsterile

The edges (1" border) of a sterile filed are not sterile

Talking over a sterile field will render it unsterile
Setting up a Sterile Field
1. Wash hands
2. Place pack on clean, dry surface with outer flap away from you. Open pack by lifting outer flap up and away from you. Position your arms to avoid reaching over sterile area.
3. Open side flaps--flap closest to you, ensuring that clothing does not touch flap or field
4. Peel outer flaps of pack apart and drop inner sterile packaging onto sterile field. Do not touch the inside of the sterile packaging, and prevent unsterile container from touching sterile field by holding it at least 6" above sterile field.
Donning Sterile Gloves
Wash hands. Open outer wrap of sterile glove pack, and remove inner wrap.
Place inner wrap on clean, dry surface.
Unfold inner wrap, touching only the edges.
Once open, use your dominant hand to grasp the opposite glove on the inner fold of the cuff, and slide your non-dominant hand in.
Pull up the glove, still holding the inner cuff.
Using your sterile, gloved hand, slip your fingers under the folded cuff of the second glove.
Slip second glove over your fingers, and pull glove over your hand.
Sterile Specimen Collection Methods
-Straight catheterization
-Foley: Use access port with sterile needle, after wiping port with alcohol
Voided Clean-Catch
Clean perineal area
Collect mid-stream specimen by having patient start to void, stop, then continue voiding into sterile collection container.
Clean catches are used for urinalysis, and may be a single-specimen or 24 hour cumulative specimen
With 24-hour specimen, discard first void, and record the time. Collect all urine for next 24 hours.
Double Voided Specimen
Patient voids as usual
Patient then collects *next* voided specimen. Used for glucose and acetone
Culture and Sensitivity Specimens
Used to identify organisms causing infection and drugs that may be used to treat it.
Specimens must be collected prior to antibiotics being administered--topically, orally or IV
Use sterile technique to collect and store specimen
Specimen Collection General Principles
1) Use the correct container for each specimen
2) Containers must be sterile
3) Use standard (universal) precautions
4) Properly label each specimen with patient's name, date and time and your name or initials
Physical Care of the Dying
Comfort Measures: mouth care, skin care, artificial tears for dry-eyes, suctioning to clear airways, adequate hydration, frequent position changes, clean linens and gown, adequate pain management
Spiritual/Cultural Care of the Dying
Support to family and patient
Continue observance of religious customs
Open communication with patient and family
Allow family time alone with patient
Be honest with family and provide updates of patient's status
Catholic Care of the Dying
-Anoint the dying
-Sacraments of reconciliation and communion
Muslim Care of the Dying
May wish to face Mecca
May wish to recite verses from the Q'uran over the dying
Typically refuse autopsy (may consent only when absolutely necessary)
Jewish Care of the Dying
Typically refuse routine autopsy
Burial occurs within 3 days
Post-Mortem Procedures
Post physician pronouncement
Position body in natural position--pillow under head, close eyes
Place dentures in mouth, and close mouth as soon as possible
Clean body, and remove all IVs, tubing, dressings (as appropriate), etc.
Allow family time alone with patient after above preparations are complete
Wrap body in shroud, and label with tags per organizational policy
Gather and label patient's belonging
Record observations, procedures, disposition of property, and time of death.
Pure Food and Drug Act (1906)
USP and National Formulary set standards for strength, quality, safety, labeling and dosage forms
Food, Drug and Cosmetic Act (1938)
Regulations to ensure safety and effectiveness
Physician's prescription required for purchase of certain drugs
Controlled Substances Act (1970)
1) Defined drug dependency and addiction
2) Drugs classified (scheduled) by abuse potential
3) Methods determined for regulating manufacture, distribution and sale of controlled substances
4) Education and treatment programs for drug abuse established
Schedule of Controlled Substances
Schedule I - V

Based on abuse potential
Schedule I
Drugs with a high abuse potential, with no currentlyaccepted medical use in the U.S.
Schedule II
Drugs with a high potential for abuse, but which currently have an accepted medical use for treatment or a currently accepted medical use with severe restrictions
Schedule III
Drugs that have a lower potential for abuse than Schedule I-II, but which may lead to high psychogenic, but moderate to low physical dependency
Schedule IV
Drugs with low potential for abuse relative to those on Schedule III. Use may lead to limited psychologial or physical dependency
Schedule V
Drugs with lower potential for abuse than those on Schedule IV; may be dispensed by pharmacists without prescription, but require some restrictions, e.g recordkeeping
Factors determining individual response to a drug
Age: Infants and the elderly tend to be MORE sensitive, including cumulative effects
History of drug use: tolerance, sensitization, cumulative effect if not clearing efficiently
Interactions: potentiating, neutralizing or otherwise causing or preventing reactions
Liver/Kidney function: affect drug metabolism
Method of Administration: IV, topical, IM, po, etc.
Emotional Responses: A patient who trusts the medical provider and anticipates benefit is more likely to derive benefit than someone anticipating a negative outcome.
Absorption
Movement of a dissolved substance from administration site into the blood stream.
Affected by:
-Dissolution rate
-Exposed surface area
-Blood-flow to exposed site]
-Fat solubility (the more fat soluble, the faster the drug is absorbed)
-Route of administration
-Patient health condition
Distribution
Movement of a drug through the body
Affected by:
-Tissue perfusion
-Ability of drug to leave vascular system
-Ability of drug to enter cells
-Chemical properties of drug
Metabolism
Enzymatic alteration of drug structure- AKA biotransformation.
Occurs primarily in the liver
Prepares the drug for action and/or excretion
Affected by client's age, liver function, nutritional status, and competition for required enzymes
Excretion
Removal of drug from body
Usually occurs through kidneys and voided in urine
Affected by renal function
Some excretion occurs through nonrenal means--bile, feces, expiration, skin secretion, tears, and saliva
Drug Metabolism in the Elderly: Absorption
Slower due to decreased GI motility and decreased blood flow
Drug Metabolism in the Elderly: Distribution
Less body fluid, more relative fat and lower serum protein result in greater concentration of drugs in fluid, drug build-up in fat, and more free drug due to decreased protein binding sites
Drug Metabolism in the Elderly: Metabolism
Decreased liver function and reduced blood-flow lead to a reduction in the metabolism of a drug, resulting in a longer half-life, and drug accumulation
Drug Metabolism in the Elderly: Excretion
Decreased renal blood flow and less effective renal filtration prolong drug excretion which results in drug accumulation
Drug forms: Liquid
Solution: Drug dissolved in liquid (usually water)
Suspension: Drug in small particles suspended in liquid
Emulsion: Suspension of fat soluble drug particles in liquid
Tincture: Drug dissolved in alcohol
Lotion: Liquid dispersion of drug for topical use
Liniment: Drug in oily, soapy, or alcohol/solvent applied topically
Drug Form: Transdermal
Fat soluble medication
Applied to skin, or contained in a covered patch applied to the skin.
Benefit of longer absorption time and longer duration of action.
Drug Form: Solid or Semi-Solid
Capsule
Tablet
Suppository
Ointment
Lozenge
5 'Rights' of Drug Administration
Right patient
Right drug
Right dosage and documentation
Right time
Right route
Familiarity with Medications
1. Why it's being given
2. Side effects
3. Dosage ranges, and safety ranges (if relevant)
4. Specific safety regulations (e.g. heparin, digitalis)
5. Drug interactions-what else is the patient on?
6. Do not administer any medication that you have not prepared
Medication Assessment
Food/Drug allergies
Past medical history, current medical condition
Knowledge deficits and teaching required
Patient Medication Response Evaluation
Report any unfavorable or unexpected response
Report allergic responses: e.g. difficulty breathing, rashes, nausea, vomiting, itching, wheezing, hives, heart palpitations
Drug Interaction Types
Drug to Drug
Drug to Food
Drug-Drug Interactions
Additive: 1+1 = 2 (e.g. diuretic + beta blocker = increased anti-hypertensive effect)

Synergistic: 1+1 = 3 (e.g. vistaril + demerol = super depressant)

Antagonistic: 1+ 1 = 0 (beta-blocker + beta-stimulant = neutralized)
Drug-Food Interactions
Food may bind with a drug and decrease rate of absorption (e.g. tetracycline + dairy = decreated level of ciruclating tetracycline)

Food may increase the absorption of a drug (lopressor + food = increased circulating lopressor)

MAOIs combined with tyramine-containing foods can result in hpertensive crisis (e.g. cheese, beer, yogurt, etc.)
Legal aspects of drug administration
1. Physician or other authorized prescriber's order required.

-Responsible for:
--Verifying dosage and route (consult provider if there are questions)
--Verifying patient ID--ID band and asking patient to ID themselves
--Assessing client before and after administering drug
--Charting medication on MAR immediately after administration
--Verify orders with provider when taking orders over the phone--provider must sign ASAP
--Immediately report medication errors to physician. Client must be assessed for detrimental effects and an incident report filled out.
--Medication should never be left on client's bedside.
Routes of medication administration
PO (swallowed, sublingual, buccal)
PR (suppository, enema)
Parenteral (IV, Intradermal (ID), SQ, IM)
Ocular
Otic
Transdermal
Suppository
Medication PO
Swallowed
Sublingual (absorbed directly through the mucosa when held under the tongue)
Buccal (absorbed directly through the mucosa when held between cheek and gum)
Medication PR
Suppository-Solid or semi-solid, absorbed through mucosa of rectum

Liquid - Administered via enema.
Parenteral: IV
Medication delivered into a vein
Slowly administered in diluted form, delivers immediate response.

More than 5 mL may be given via IV
Parenteral: ID
Usually used for allergy shots or TB skin-test, usual site is the inner surface of the forearm.

26 gauge needle, bevel-up, inserted at appx. 15 degree angle

Typically no more than .1mL
Parenteral: SQ
Injection into the fatty layer under the skin.
Typical sites include upper abdomen, upper thigh, lateral upper arm
25 gauge needle
Slow absorption for prolonged effect.
For regular injection (e.g. insulin) rotate sites
Typically .5 - 1.5 mL