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Interventions
Exam 1
| Question | Answer |
|---|---|
| Documentation: As time Passes | -Memories fail and conflicting arguments are voiced -Jurors tend to believe the written word more than oral testimony -Lawyers can manipulate testimony |
| Guidelines to better documentation | -Date and time all entries -Make sure patient identification is on all pages -Always use ink; never pencil -Chart what you see,hear, feel and smell -Chart specific data and observations -Chart facts only -Chart what occurred without drawing a conclu |
| Guidelines to better documentation: 2 | -Chart any unusual occurrences. Don't enter an incident was filed. -Make sure your writing is legible -Use only standard abbreviations -Watch for time gaps in the record and inconsistencies -Don't argue or criticize in the record |
| Guidelines to better documentation: 3 | -Never leave spaces or lines between entries -Chart objectively. Any subjective comments should be placed in quotes -Use correct grammar and spelling -When in doubt, chart it -If it wasn't documented, it wasn't done -Don't alter the record |
| Correcting a Mistake | -DO: Write mistaken entry Draw a single line through the error Date and initial Make late entries appropriately DO NOT: write error Try to squeeze in info b/w lines Use white out Write over your error |
| Methods of Charting | -Narrative -Source Oriented -Problem Oriented (SOAP) -PIE -Chart by exception -Computerized |
| Incident Report | -A report that is used to document any unusual event or accident while caring for a client -Not part of pt chart -It is a rqt of the facility and federal,state,&national accrediting agencies -Used to protect the pt,not to punish the caregiver |
| Functions of an Incident Report | -To inform agency's administration so that risk mgt. dept. may prevent similar incidents in the future -To alert facility's insurance company of a potential claim and the need for further investigation |
| Distribution Systems | -Stock Supply -Unit dose:Individually wrapped (Don't unwrap med until get to the bedside) -Computer control/Pyxis: plug in pt info and med will be in a specific drawer or drop into container |
| Types of orders | -Standing:ex:Tylenol, there for pt as needed -PRN: as needed -Single: given x 1 -Stat: give right away (within 15-20 min) ex: chest pain, V, BP |
| Nurses' Role | -6 rights -Triple-check before administration -Client assessment |
| Six Rights | 1) Right Medication 2) Right dose 3) Right client (at least 2 identifiers) 4) Right route 5) Right time 6) Right documentation * Right to refuse |
| Oral Administration | -Presence of GI alterations -Ability to swallow -Use of gastric suction (can't use with ng tube) -Positioning - make sure head is up |
| Elixer | -Set on the counter and look at eye level -Don't hold in the air |
| Topical Administration: Skin Applications | -Use of gloves or applicators -Preparation of skin -Thickness of application (apply thin layer) -Don't put over area of drainage |
| Topical Administration | -Local effects:estrogen, xylocaine -Transdermal disk:Nitro,pain control (side effects:HA,drop BP) -Work 24/7 -Always write date and time on patch w/initials -Chart where you put patch, alternate sites -Don't want multiple patches on the body |
| Nasal Instillation | -Asst. of nares -Client instruction and self-administration -Positioning: Sit up and put head back, sniff and breathe when sprayed |
| Eye Instillation | -Drops, ointments, disks -Asst. of eyes -Asepsis -Positioning: lean back, look up, pull lower lid down and have pt look up then drop drop into lower lid; line lower lid - ointment; lay disk in lower lid - disk -Don't rub eye, dot w/ tissue |
| Ear Instillation | -Asst of ear canal -Warming of solution -Straightening of can for children (up, out, down) and adults (up, out) -Positioning: Give time in b/w bilateral drops to let drop go in and then put cotton ball in ear |
| Vaginal Instillation | -Suppositories, foams, creams -Use of gloves and applicator -Positioning, comfort (can be more comfortable on side), hygiene -Pt. can do by themselves if know how |
| Rectal Instillation | -Suppositories -Use of gloves -Positioning, Comfort, and Hygiene -Use lubricant, have wash cloths near by -Give up above anal sphincter -Enema: lay on L side b/c it goes into colon easier |
| Inhalation | -Metered-dose inhalers and dry powder inhalers (Advair-after pt should wash mouth to avoid thrush) -Asst. and Instruction -Use of spacer -Determination of doses in canister |
| Irrigation | -Medications used to wash out a body cavity delivered with a stream of solution (sterile water, saline or antispetic) -Asepsis -Give a bath b/f a colostomy |
| Assessment | -Medical Hx -Hx of allergies -Medication data -Diet Hx -Perceptual or coordination problems -Current Condition -Attitude about med use -Knowledge of therapy -Learning meds |
| Special Considerations | -Infants and Children -Older Adults: polypharmacy, self-prescribing, OTC meds, misuse, noncompliance |
| Implementation | -Intervention: What the nurse will do -Goal: What the patient will do |
| Guidelines for Safe Administration of Medications | -Never give meds prepared by another nurse -Listen carefully to pt who has ?s -If withholding, give exact reason -DON'T leave meds at pt. bedside -Document only meds actually given -Advise pt not to take someone else's meds |
| Drug Safety at Home | -Assist the pt in removing outdated Rx and OTC drugs -Encourage pt to maintain refills -Encourage reminders (whatever works for pt) |
| Dimensional Analysis | -A logical and systematic approach to solving any type of med administration problem -Can yield same correct answer as the ration/proportion method |
| Needle Sizes | -Length: IM:1 - 1.5 inch;SQ: 3/8 - 5/8 inch -Width (gauge): smaller the gauge, the larger the needle; IM: 20-23; SQ: 25; Intradermal: 26 |
| Needle Angles | -IM: 90* -SQ: 45* or 90* -Intradermal: 15* |
| Parenteral Administration: Mixing Meds | -Determine compatibility of the meds -Don't contaminate one med with another -Ensure the final dose is accurate -Maintain aseptic technique |
| Parenteral Administration: Insulin | -Regular: Clear; NPH: Cloudly -Draw clear before cloudy if mixing -Roll, don't shake -Lantix - long acting, clear usually given at night |
| Admin of Injections: Minimize discomfort | -Use smallest suitable needle -Position client comfortably -Select proper site -Divert client's attention -Insert the needle quickly and smoothly -Hold the syringe steady -Inject medication slowly and steadily |
| Administration of Injections: SQ | -Volume: 0.5 - 1.0 mL -Sites: Abdomen, Back of arm, Top of thigh, Lovehandles, right below scapula |
| Administration of Injections: IM | -Volume: 3mL at most -Sites: Deltoid (only 1mL), Dorsal gluteal, Ventral gluteal, Rectus femoris, Vastus lateralis |
| Z-Track Method | -Pull skin to the side so that med can has harder chance to come through skin -Ex: Iron shots |
| Administration of Injections: Intradermal | -Skin testing -Formation of small bleb -Bevel up |
| Prevention of Needle Sticks | -Needleless devices -Sharps disposal -One-handed recapping technique |
| Intravenous Administration | -Large volume infusions -Bolus injection -Volume controlled infusions (piggyback); tandem, volume control set, mini infusor pump -Assess site every 4h |
Created by:
prettyinpink7
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