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44 Cards in this Set

  • Front
  • Back
Purpose of OSHA & CDC policies
OSHA – protects employee
CDC – protects both
What is Medical/ surgical asepsis
Medical – preventing transmission of microorganisms – clean technique
Surgical – is the absence of microorganisms

Anything invasive must be sterile accept what enters into the GI tract
Standard Precautions?
Protecting yourself from blood and body fluids (not sputum and sweat).
Bloodborne pathogen standards?
Hep B, C and HIV
Primary reason for PPE?
Examples
Primary reason for PPE is to protect ourself.
Gloves, gown, mask, booties – wear all for C Dif in linen change or bath
What are airborne, droplet, contact precautions? For which types of diseases?
Airborne – N95 mask, hepa filters in room, room has air exchangers, no gown (light and float around in
air) Ex TB, measles, chickenpox

Droplet – (heavier, don’t hang in air as long) Ex Strep – mask, gloves, gown depending if suctioning

Contact – gloves,
Ex. MRSA, C Dif
How are Hepatitis A, B, C, HIV transmitted?
A – food and feces B, C & HIV – blood and body fluids (blood, semun, vaginal fluids)
Standards of care to reduce risk of infection?
WASH HANDS!!!
Chain of infection?
Host -
reservoir -
portal of entry -
susceptible host -
portal exit -
transmission -
How do we reduce reservoirs?
soiled bedding, tissues, bandages, urine catheter bag, jewelry, long nails),
Risk factors which increase risk of falls?
Hx of falls, over age 65, meds, unstable gait, assistive devices, med side affects, altered mental status,
How can you reduce fall risk?
Proper use of assistive devices, call light, no throw rugs, toileting schedule (every 2 hrs during day and every 4 hrs at night)…less likely to get up by themselves.
When can restraints be used and for how long?
When physician orders
Family has to give permission
Take them off every 2 hours and assess skin, circulation
Every 24 hours you reassess need for using restraint
Ck patient every hour and then prn if thrashing (every 15 min)
NOTE: Chemical restraints used more often than physical restraints
What are alternatives to restraints?
Posey bed, close to nurse station, bed alarm
Same things as used for fall prevention Massage can calm patient, Music therapy
Protocols in case of fire – What are
RACE – Rescue, Alarm, Contain, Extinguish

PASS – Pull pin, aim, squeeze, sweep
Why do you assess each part?
x
What is PERRLA and how do you assess?
Pupils equil round and reative to light and accommodation
Shine light in eyes
Landmarks for lung sounds.
Back – follow scapula lines
Front – in between sternum and toward the outer fields – listening to lungs and bronchials
Middle lobe - Between 5th and 6th rib
Landmarks for heart sounds?
Heart – APE to MAN –
Aortic – 2ICS, rt sternal border
Pulmonic – 2ICS, lt sternal border
Erbs Point – 3rd ICS, lt sternal border
Tricuspid – 5th ICS, lt sternal border
Mitral (bicuspid valve) aka AP – 5ICS, lt midclavicular aka PMI – (point of maximum impulse Ex: on
a thin person you can see the actual pulse) This is the apex of the heart.
What do S1 & S2 indicate, where are they heard?
S1 is lub which is your tri and bicuspid valves – contraction and begin of systole – rt side out to lung
S2 is dup - aortic and pulmonic valves snap shut – lt pumps out through the aorta to the rest of the body
What are adventitious breath sounds?
Crummy sounds.
Rhonchi – crunchy, course sound – secretions are thick – increase fluids

Wheezing – narrowing of airway – bronchospasm – high pitch musical sound

Crackles – squeezing hair together (CHF, pneumonia) – do not clear with cough
Parts of the stethoscope - Is bell or diaphragm used for low pitch & high pitch sounds
Bell – lower pitch – (carotid brewy or murmur)

Diaphragm – high pitch sounds
Assessment techniques - inspection, palpation, auscultation - what is the order?
Inspect first, then palpate, auscultate
What are clubbing & a barrel chest? Found in patients with what types of pathologies?
Emphysema - COPD patients have clubbing and barrel chest.
Clubbing – base of nail – make a diamond between nails – no space may be sign of clubbing
Barrell chest – cause is from chronic hyperinflation – air gets trapped because they cannot empty lungs, alveoli get misshapened. Good air cannot get in and bad air cannot get out.
1:1 and norm should be 1:2 (infants and elderly have this have 1:1)
How do you assess circulation?
Capillary refill, color, pulses, temp, numbness and tingling, palor, edema
Assessing for anemia, pallor, jaundice? In someone with darker skin?
Anemia – check conjuctiva for pale or buccal for pale
Darker skin – check buccal mucosa or under tongue
Jaundice – first sign is sclera is yellow, skin will be yellow
s/sx dehydration, thrush, edema, other common abnormal assessment findings
Dehydration – turgor – younger person pinch forearm
Geri: pinch under sternum or over clavicle,
What might be an indication of dehydration? mucous membranes dry, lips dry and cracked
less frequent urination and darker in color, orthostatic hypotension

Thrush – yeast infection in mouth – cadidiasis – red and sore, cheesy

Edema – fluid in interstitial space or peripheral edema (pitting) caused by PVD, protein deficit, (fluid
overload), blood clot, etc.
What are the 3 checks & 6 (8) Rights to ensure safe & accurate administration of meds?
MAR to Physician order
MAR to Drug and Exp date
MAR to patient

Right Patient
Right Drug
Right Dose
Right Documentation
Right Route
Right Time
What are the steps for administering oral meds?
3 checks and 6 rights
Other med routes?
Rectal - Left sims, point finger toward belly button, lube finger and suppository

Topical – gloves for patch application

Inhaler – broncho first then steroid…use spacer…hold 2 fingers away from mouth, rinse mouth…less side effects and med goes right into lung

Vaginal – lithotomy position (stirrup position)

Eye – drop into cunjunctiva sac

Ear – warm to room temp, pull up and back for adult and down and out for kids…drop on side of canal
Massage tragus

Sublingual – under the tongue – different from oral dissentigrating
What are symptoms of anaphylaxis, which patients are at greatest risk, nursing interventions?
Swelling, tightening of chest, impending doom, blood pressure drops, hypoxic, shock, hives, tongue is swelling. Antibiotics are the most common med for anaphylaxis. Impending doom! As a student nurse…yell for help! Antibiotics have the greatest risk for anaphylaxis…made with molds, plants.
Tx with epinephrine, benadryl, O2, 911 will be called. (Facility has standing orders)
What are the phases of the Nursing Process and how does this apply to drug administration?
x
How do you take a telephone order?
Nurse takes phone order from physician or representative and writes on physician order sheet in clients chart. Ex: 7/27/10 1100 Ancef 2gm IVP x10 days
T.O. Lezlie Corbin SNGCC
Repeat for accuracy.
What must be included in physician orders?
Date
time
name of drug
dose of the drug
form to be given
route
frequency,
duration if needed
If PRN, reason must be given
signature of prescriber
What is a medication error?
Medication errors include inaccurate prescribing, administration of the wrong medication, giving the medication using the wrong route or time interval, and administering extra doses or failing to administer a medication.
What do you do if a medication error occurs?
The nurse is responsible for preparing a written occurrence or incident report that usually needs to be filed within 24 hours of the error. The report includes client identification information; the location and time of the incident; an accurate, factual description of what occurred and what was done; and the signature of the nurse involved. The occurrence report is not a permanent part of the medical record and is not referred to anywhere in the record
How can you reduce the risk of medication error?
· 3 checks – 6 rights
· • Follow the six rights of medication administration.
· • Be sure to read labels at least three times (comparing medication administration
record [MAR] with label) before administering the medication.
· • Use at least two client identifiers whenever administering a medication.
· • Do not allow any other activity to interrupt administration of medication to a client.
· • Double-check all calculations, and verify with another nurse.
· • Do not interpret illegible handwriting; clarify with prescriber.
· • Question unusually large or small doses.
· • Document all medications as soon as they are given.
· • When you have made an error, reflect on what went wrong and ask how you could
have prevented the error.
· • Evaluate the context or situation in which a medication error occurred. This helps to
determine if nurses have the necessary resources for safe medication administration.
· • When repeated medication errors occur within a work area, identify and analyze the
factors that may have caused the errors and take corrective actions.
· • Attend in-service programs that focus on the medications commonly administered
How do you document med administration?
Document on MAR immediately after giving meds
Cross out time with single line and initial
Identify initials at bottom of page
Instructor must countersign
How do you document if med is held?
Circle the time and document why the med was held. Initial, sign.
What should you teach patient about meds?
Unless a client understands a medication's purpose, the importance of regular dosage schedules, proper administration methods, and the possible side effects,
Identify teaching outcomes that are RUMBA?
Reasonable -
Understandable -
Measurable - goals and expected outcomes that set standards against which to measure the client's response to nursing care.
Believable -
Achievable -
Effect of meds in elderly
Because of the decrease in albumin in the bloodstream and possible change in liver function and malnutrition therefore more med is unbound which puts the elderly at riskfor increase in medication oactivity or toxicity. Because there are usually more than one med used sometimes there are drug interactions which cause confusion, affect balance and mobility, dizziness, nausea, vomiting, constipation, urinary frequency or incontinence. Toxicity is a risk factor as well.
Crushing meds.
Must use a clean pill crusher device or you can place in between 2 cups and crush, mix with small amount of food. DO NOTCRUSH enteric coated or capsules.
Know Medication Abbreviations
STAT – immediately
NOW – within the hour and as soon as possible
PRN – as needed
ID – intradermal IM - intramuscular
IV – intravenous NG – naso gastric
PO – by mouth Sub Q - subcutaneous
PC – after meal AC – before meal
ad lib – as desired bid – twice per day
hs – hour of sleep qid