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NURS 1110 Exam 2

med admin 2, assessment, nursing process

QuestionAnswer
Steps of the nursing process and med administration Assessment (medical history, allergies, dosage, side effects, schedule) Diagnosing (knowledge deficiency, issues related to side effects) Outcome Identification and PLanning (expected effects) Implementing (medication administration)
health team members that prescribe medication physician, physician assistant, advance practice nurse (midwife, nurse practitioner, nurse anesthetist)
health team members that prepare medication pharmacist
health team members that administer medication nurse, trained medication assistant
components of a medication order Patient's full name, date/time, name of the drug, dosage, route of administration, frequency of administration, signature and license of the person writing the order, reason for medication (PRN meds)
prn medication order "as needed" medication, may be taken if certain symptoms/conditions are present
single or one time medication order medication that is to be administered one time only, for example - medication given prior to surgery
STAT medication order must be administered immediately after receiving the order
standing medication order general orders for a facility that may include things like oxygen, epinephrine, other drugs that may need to be given in emergency or ICU settings
different systems for calculating drug dosages proportion, ratio, dimensional analysis
special considerations for controlled substances require detailed records, narcotic counts, refused meds must be discarded in a special manner
nursing interventions and actions that minimize the risk for med errors while preparing - right medication, right dose, right reason; before administering - right patient, right time, right route; after administering - right drug, right dose, right rate (is response appropriate?), right documentation
most common med errors, how to minimize incorrect dose, failing to give an ordered drug, giving an unordered drug
high alert medication types adrenergics, anesthetics, antiarrythmics, antithrombotics, cardioplegic solutions, chemotherapeutics, dextrose, dialysis solutions, hypoglycemics, inotropics, liposomal forms, sedation agents, narcotics, neuromuscular blocks, radiocontrasts, TPN solutions
"do not use" abbreviations U or u (unit), IU (international unit), qd (daily), qod (every other day), trailing zeros, non-use of leading zeros, MS (morphine MSO4 or magnesium sulfate MgSO4), >, <, abbreviations for drug names, apothecary units, @, cc, micrograms symbol - use mcg
parenteral medications medications that are administered outside of the intestines
different ways that meds can be administered oral, topical, parental, inhalation, nasal, eye, ear, vaginally, rectally
tips for teaching patients about medications med name, dosage, route, effects, how to take the med (food, drinks, time, missed dose), how long to take the med, how to deal with side effects, sharing meds, traveling with meds, storage of meds, medication list including OTC, supplements, prescriptions
verbal order requires special checks - order must be repeated and verified and physician must write order within a certain time period
MAR Medication Administration Record - medication order and documentation for administration on a single form
specific high alert medications colchicine injection, epoprostenol, insulin, magnesium sulfate, methotrexate, opium tincture, oxytocin, nitroprusside sodium, potassium chloride potassium phosphates, promethazine, sodium chloride, sterile water 100 mL or greater
Six Rights Right Medication, Right Dose, Right Time, Right Route, Right Patient, Right Documentation
3 checks check when pulling the med, check while preparing, check before administering
nursing responsibilities for medication administration follow 6 rights, use 3 checks, 2 patient identifiers, avoid interruptions during med admin, clarify illegible handwriting, question unusual dosages, double check calculations, verify high alert drugs with other RNs, document errors properly
Schedule of Controlled Substances Schedule I: High Potential for Abuse, Schedule II: Potential for Abuse, Schedule III: Intermediate Potential for Abuse, Schedule IV: Less Abuse Potential, Schedule V: Minimal Abuse Potential
Schedule I Controlled Substances no medical indication, example - heroin
Schedule II Controlled Substances physical and psychological abuse potential, no refills, examples - codeine, morphone, oxycodone
Schedule III Controlled Substances intermediate potential, may refill five times, examples - codeine in combination with another medication
Schedule IV Controlled Substances Less abuse potential, may refill 6 times in a 6 month period, examples - certain sedatives, Valium
Schedule V Controlled Substances minimal abuse potential, examples - cough suppressants with codeine
Oral Medication patient swallows the medication
Buccal Medication patient lets the medication dissolve between the cheek and gum; rate of absorption is often faster than oral
Sublingual Medication patient holds medication under the tongue until it dissolves
Special considerations for administering meds to the elderly whether or not pills can be crushed, patient's ability to swallow, dry mouth, increased risk for toxicity
types of drug medication systems Stock supply, unit-dose, automated medication dispensing (Pyxis), Bar code medication (Scanners), self-administered (PCA, inhalers, ointments, etc.)
four types of nursing assessments .
-- assessment .
focused assessment .
-- assessment .
-- assessment .
nursing assessment vs. medical assessment .
objective data .
subjective data .
five sources of patient data .
nursing observation .
nursing interview .
nursing physical assessment .
nursing history/interview techniques .
assessment priorities .
common problems with data collection .
types of data that needs to be validated .
when to report significant patient data .
documenting assessment data .
purposes and types of health assessments .
guidelines for conducting a health history .
preparing the patient and the environment for a health assessment .
equipment used during health assessments .
positions used during health assessments .
inspection .
palpation .
auscultation .
physical assessment steps .
documenting health assessment findings .
nursing responsibilities before, during and after a procedure .
reasons why personal hygiene is important .
nurse's role in meeting patient hygiene needs .
factors affecting an individual's normal hygiene needs age - activity level - skin type - culture - ethnicity - illness -
normal appearance of skin .
normal appearance of mucous membranes .
normal appearance of hair and nails .
normal appearance of teeth .
factors affecting satisfaction of hygiene needs fatigue - pain - illness - psychological discomfort -
assessment potential in assisting patient with personal hygiene .
common problems of the integument system and possible nursing interventions .
nursing actions related to oral hygiene .
nursing actions related to bathing .
nursing actions related to back care .
nursing actions related to bed making .
nursing actions related to hair care .
nursing actions related to shaving .
nursing actions related to makeup .
nursing actions related to nail care .
nursing actions related to perineal care .
nursing actions related to foley and condom catheter care .
touch as a nursing tool .
situations that have potential for invasion of privacy or personal discomfort .
temperature maintenance .
relationship between metabolism and oxygen consumption .
normal temperature values .
characteristics of patients with abnormal body temperature .
nursing actions that assist a patient with maintaining or regaining normal temperature .
methods for taking temperature oral, rectal, axillary, temporal, tympanic membrane
physiologic basis for oxygen .
O2-CO2 exchange .
O2-CO2 transport .
O20-CO2 regulation .
factors which affect an individual's oxygen needs .
assessment data of patients who are not getting adequate oxygen .
normal O2 saturation levels ,
factors that control and affect blood pressure .
vital signs .
how vital signs reflect changes in vital physiologic functions .
normal ranges for vital signs in children .
normal ranges for vital signs in adults .
normal ranges for vital signs in older adults .
physiologic processes involved in homeostatic regulation of temperature, pulse, respirations and blood pressure k
factors that increase body temperature .
factors that decrease body temperature .
factors that increase pulse .
factors that decrease pulse .
factors that increase respirations .
factors that decrease respirations .
factors that increase blood pressure .
factors that decrease blood pressure .
sites for assessing pulse .
sites for assessing blood pressure .
normal pulse rate, adults 60-100 bpm
normal respiration rate, adults 12-20 breaths per minute
normal blood pressure, adults 120/80
teaching points for taking pulse and blood pressure at home .
processes involved in wound healing .
factors that affect wound healing .
patients at risk for pressure ulcer development ,
staging of pressure ulcers .
how to assess and document conditions of wounds .
nursing interventions to prevent pressure ulcers .
appropriate dressings for different types of wounds .
teaching points for self-care of wounds at home .
hot and cold therapy .
respirations .
breath sounds .
incentive spirometer .
TCDB turn, cough, deep breath
oxygen administration .
pulse oximetry .
chest x-ray .
pulmonary function test .
sputum culture .
arterial blood gas .
bronchoscopy .
pulse oximeter .
historic evolution of nursing process .
five steps of the nursing process (1) Assess, (2) Diagnose, (3) Plan, (4) Implement, (5) Evaluate
Five characteristics of the nursing process .
three approaches to problem solving .
three patient and three nurse benefits to using the nursing process correctly .
four blended skills .
critical thinking model .
four habits that assist in the development of technical skills .
interpersonal skills essential for quality care .
nurse accountability and patient well-being .
concept mapping care planning .
nursing diagnosis .
medical diagnosis .
collaborative problem .
four steps involved in data interpretation and analysis .
guidelines for writing nursing diagnoses .
five types of nursing diagnoses .
means of validating nursing diagnoses .
benefits of nursing diagnoses .
limitations of nursing diagnoses .
purpose and benefits of outcome identification and planning .
prioritizing patient health problems and nursing responses .
nurse-initiated interventions .
physician-initiated interventions .
collaborative interventions .
five common problems related to planing, their possible causes, and remedies .
rationale for standardized outcomes and interventions for nursing .
NOC .
NIC .
NANDA .
advantages of standard classification of nursing interventions and outcomes .
cognitive skills necessary for implementing a plan of nursing care .
interpersonal skills necessary for implementing a plan of nursing care .
technical skills necessary for implementing a plan of nursing care .
ethical/legal skills necessary for implementing a plan of nursing care .
eight guidelines for implementation .
six variables that influence the way a plan of care is implemented .
purpose of reassessment after nursing interventions .
risks and responsibilities of delegating nursing interventions .
purpose of evaluation as part of the nursing process .
four types of outcomes .
factors that can be manipulated in order to facilitate outcome achievement .
quality assurance/quality improvement programs .
AACN standards for establishing and sustaining healthy work environments .
seven crucial conversations in healthcare .
guidelines for effective documentation .
Created by: pinklrt98
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