guidelines developed for the practice of nursing

definedby

1. each state

2. sate and fed laws

3. JCAHO (Joint Commission on Accreditation of Healthcare Organization)

4.professional organizations (ANA)

• current license to practice

• clear policy statement authorizing the act

• Signed medication order

• understading of rationale for drug use

• understanding of drug action, dosing, diluting, route and rate of administration, side effects, adverse effects to report and contradictions

CONTENTS INCLUDE:

1. summary sheet

2. Consent Forms

3. physicians order form

4. History and physical examination form

5. Progress Notes

6. Crtical Pathways

7. Nurses' notes

8. Laboratory tests record

9. graphic record

10. flow sheets

11. consulatation reports

12. other diagnostic reports

13. Medication Administration Record (MAR) or med profile

14. PRN or unscheduled medication record

15. Case management

16. The Kardex

all procedures are ordered by the health care provider

e.g. activity, diet, frequency of vital signs, lab tests to be completed, etc.

care plans;

comprehensive standardized plan of care that is individualized at admission by the physician and nurse care manager

PRN (Pro Re Nata meaing as circumstances require)

some places uses this instead of nurses' notes to record date, time, PRN medication administered and dose, reason for administering the PRN med, and patient's respnse to the drug given.

DRUG DISTRIBUTION SYSTEMS

1. floor or ward stock system

2. individual prescription order system

3. computer-controlled dispensing system

4. unit dose drug distribution system

5. long-term care unit dose system

FLOOR OR WARD STOCK SYSTEM

• dispensed from the pharmacy upon receipt of a prescritoin or drug order for an indivdual patient

• Usually a 3-5 day supply for patient

• Newer system for med ordering and admin

• supplied by the pharmacy daily

• stocked with single-unit packages

• When a drug order received the pharmacy for patient, it is entered into the computerized system and selects patient's name, med profile, and drugs due for administration.

• drug appears on screen and specific section of cart automatically opens so nurse can take the single dose of med out of the cart

• use single-unit packages of drugs, dispensed to fill each dose requirement as it is ordered.

• placed in individual patient's order in a drawer

• an adaptation of the system used in the acute care setting

• holds one resident's meds for a week

• easier to prevent drug errors

• color -coded

• Laws regulating use of controlled substances

• narcotics kept single packet and locked

• This makes sure all doses were charted to patients needing these narcotics

Stat Order - emergency; asap but only once

Single Order - one time dose

Standing Order - specified # of doses

Renewal Order - Need to give additional doses; signed by dr.

PRN Order - Administer if needed

Verbal orders - signed w/in 24 hrs increased drug orders

Electronic Transmission of Patients Orders - faxed orders by dr. where patient admitted or transfered must have original signature w/in 24 hours

MEDICATION ERRORS

ADVERSE DRUG EVENTS

(ADE's)

Medication Errors can result in serious complications

suboptimal drug therapy deicisions

drug for patient with known allergy or intolerability

incorrect dose for diagnosis

unauthorized drug prescribed

Mininterpretation/misunderstanding of drug ordewred or directions

Illegible handwriting

Unapproved abbreviations

omission of orders

wrong dose of drug sent to nursing unit

wrong formulation or dosage form

incorrect strength (dose) given

Extra dose given or missed dose

wrong administration time

incorrect administration technique

suboptimal monitoring

suboptimal assessments of drug response/revision of regimen

Suboptimal patient education

Verification - nurse makes professional judgment regarding acceptability and safety of the durg order, including type of drug, dose and dose preparation, therapeutic intent, route, potential allergic reactions or contraindications

transcription - Nurse is responsible for verification of orders transcribed by others

THE SIX RIGHTS

RIGHT DRUG

• compare exact spelling and concentration of drug with

medication card and drug container; drug label should be read three times

• 3 x means

- before removing from the drug from the shelf or unit dose cart

- before preparing or measuring the actual prescribed dose

- before replacing the drug on the shelf or before opening a unit dose container (before administration)

SIX RIGHTS

RIGHT TIME

• standard abbreviations

• standarized administration times

• Maintenance of conssitent blood levels

• maximum drub aborsption

• Diagnostic testing

• PRN Meds

SIX RIGHTS

RIGHT DOSE

• Abnormal hepatic or renal functions

• Nausea or vomitting (withheld)

• Accurate dose forms (Dont break unless scored dont crush and administer IV)

• Accurate Calculations

• Correct Measuring devices (Use right volume)

SIX RIGHTS

RIGHT PATIENT

•Bracelet Checking (Always!)

• Pediatric and older adults don't always know name (peds like to lie)

SIX RIGHTS

RIGHT ROUTE

IV Route - Double  check for IV use

Intramuscular Route

Intravenous Route

Subcutaneous

(Injecting in right sites and rotate place and document)

SIX RIGHTS

RIGHT DOCUMENTATION

•Safety/ethical considerations

• Legal considerations

• Always include date/time, drug name, dose, route, site of administration, your name/initials

SPECIAL DOCUMENTATION CIRCUMSTANCES

• Patient refuses meds

  - thoroughly record incident and reason for refusal in nurses' notes (Why and efforst to get to take it)

- Notify physician

• Medication Errors Occur

- Notify physician

- complete incident report

CLINICAL LANDMINE #1

RIGHT DRUG

CHECK DRUG BEFORE ADMINISTRATION 3 X'S

1. Before removing the drug from the shelf or unit dose cart

2. Before preparing or measuring the actual prescribed dose

3. Before replacing the drug on the sehlf or before opening a unit dose container

CHAPTER 8

PERCUTANEOUS ADMINISTRATION

• topical application of ointments, creams, lotions, or powders to the skin

• inhalation of aerosolized liquids or gases

• installation of solutions into the mucous memberas of the mouth, eye, ear, nose or vagina

PREMEDICATION ASSESSMENT AND EXPLANATION

PATIENT TEACHING

• hygiene requirements

• prper application techniques and timing

• cautions particular to drug or drug administration

• side effects

• when to contact Dr.

cream - semisolid emulsions containing medication

non greasy • removed with water

lotion - usually aqueous preparations that contain suspended materials. Protect the skin, soothe

Ointments - semisolid prepartions of medicinal substances in an oily base • can't be removed w/ water easily

WHEN APPLYING:

• Wash Hands

• put on gloves

• position patient

• clean area as needed

• shake lotion bottle; use tongue blade to remove desired

• amount of ointment or cream from container

• use dressings according to orders

• allergens placed in direct contact w/ back arms or thighs

• left in place for 48 hours

• must have emergency equipment available incase  anaphalactic shock occurs

• wash hands, put on gloves

• position patient

• clean area

• wear gloves

• apply dose-measuring applicator paper

• Do not rub in ointment

• cover area w/ plastic wrap

Wash hands apply gloves

remove old patch, dispose of appropriately (wrap in glove, put in sharps container)

if can't locate, patient might have moved it don't assume it fell off

apply to different site then last time

don't apply to areas of inflammation/lesioins

frequency depends on drug

wash hands after application

label disk with time, date, nurse intials

SUBLINGAL AND BUCCAL TABLETS

• Sublingual - placed under tongue

• Buccal Tablets - held in buccal (Cheek) cavity

• ADVANTAGES: rapid absorption and onset of action (bypass liver and directly absorbed into blood)

• action usually systematic (effects entire body) rather than localized (only one part of the body) to the mouth

do NOT  use OD (right eye) OS (Left eye) OU (both eyes)

wash hands use gloves

position patient

inspect affected eye (lesions, drainage,)

clean appropriately

expose lower conunctival sac (pull eyelid down)

approach eye from below

never touch eye with dropper

apply pressure to inner corner of eyelid 1-2 min.

GIVING EAR DROPS

Ensure ear is clear of wax (geriatric lots of wax)

warm med to room temp (cold painful)

younger than 3 yrs:  pull earlobe downward and back

Older than 3 yrs and adults: pull earlobe upward and back

should remain on side for few mins

loosely insert cotton plug if ordered

GIVING NOSE DROPS, NASAL SPRAYS

patient should blow nose gently

• drops •

position patient lying down w/ head hanging back

• spray •

- patient is upright

- block one nostril

- shake bottle and insert tip in nare

- spray while patient inhales

prepare med and fill nebulizer

patient exhales b4 inhalation

put nebulizer in mouth; do not seal completely

patient inhales

blow out through pursed lips

swish w/ water and spit out

wait 1 min between inhalations

METERED-DOSE INHALERS MDI

DRY POWDER INHALERS DPI

follow instructions on inhaler

SPACERS CAN ENHNCE MED DELIVERY

wash hands, put on gloves

fill applicator

place patient in lithotomy postion, elevate hips w/ pillow

spread labia and insert applicator or suppository

(apply lube to suppository water not oil based)

Have client in supine position for 5-10 minutes for absorption of med

CHAPTER 9

ENTERAL ROUTE

Most drugs available in oral form

safe convenient and economical

small, cylindrical gelatin containers used to administer unpleasant tasting meds; time-released capsules (gradual and continuous release of drug)

drugs dissolved in water and alcohol

used when drug won't dissolve in water alone

dispersions of small droplets of water in oil or oil in water

made to make taste better

pediatrics

liquid dose forms that contain solid insoluble drug particles dispersed in a liquid base

should be taken well before administration

contain medicinal agents dissolved in a concentrated sugar usually sucrose effective for maksing better taste for drug

pediatrics

SCORED

LAYERED

AND ENTERIC COATED

TABLETS

Scored - intention to divide the dose

Layers - allows incompatiable medicines to be administered at the same time

Enteric Coated - resists dissolution in the acidic pH of the stomach but is dissolved in the alkaline pH of the small intestine used to administer meds that are destroyed by stomach pH acid

single - dose packages

provides single dose of meds in one package ready for dispensing

doses of most liquid meds prescribed in terms using teaspoon as unit of measure

use baking spoon not household

1 tsp = 5 mL

two techniques

the medication card and unit dose distribution

perform premedication assessment in all cases

follow 5 rights (patient, drug, route, dose, time)

Med card safter reduces errors

give the most important meds first

do not touch the meds w/ your hand

encourage liquid intake to ensure swallowing

remain w/ patient whil med is taken; DO NOT leave the med at bedside unless an order to do so exists

discard med container

provide documentation of administration and response therapy

called 6th right

chart date, time, drug name, dosage and route of admin, your name/initials, regularly record patient assessments to evaluate therapeutic effectiveness,

chart and report any sign of ADE

Perform and validate essential education about drug therapy and other aspects of intervention for the individual

gen. procedures same w/ solid-form

perform premed assessment in all cases

all techniques follow 5 rights

measure lowest point of meniscus (curve of liquid)

accurately pour in med cup

give adults and children most important medications first

NEVER dilute meds w/o specific orders

DO NOT leave a med at the besdie w/o an order to do so

check an infant's ID and be certain infant is alert

provide compelete documentation of administration and response to therapy

w/ measuring cup: cover label to prevent smearing; place fingernail at exact level on measuring cup; read the volume at the level of meniscus (curve)

recheck 5 rights

w/ oral syringe: select syringe of appropriate size, draw up prescribed volume of med from bottle or med cup

drugs are administered via NG tube for specific patients, using a liquid form whenever possible

remember: always flush the tube before and after administration (want to make sure going to stomach and doesn't get stuck)

perform premedicated assessment

HOB elevated (head of bed)

assemble equipment before admin

always inspect anres of clients tubes in nose

aspirate fluids (gold standard)

or push air to make sure placement is right

prepare dose as for admin of solid-form or liquid-form oral meds

3 methods for checking NG tube loctaion

follow procedure for admin meds

DO NOT  attach suction for 30+ minutes after

document

ADMIN OF ENTERAL FEEDINGS VIA

GASTROSTOMY (tube in stomach) OR

JEJUNOSTOMY (tube in small intestine) TUBE

admin w/ syringie or pump

during bollus feedings (large meals of the day)

discard unused formual every 24 hours

follow 5 rights

verify placement

flush, then clamp proceed w/ tube feeding technique

HOB elevated (semi-fowlers 30 degrees/30 minutes)

Intermittent - use Toomey syringe

Continuous: use disposable feeding container and enough formula

for a 4-hour period

check residual (left over in stomach) before admin if lots notify Dr.

Apply lube to tip use finger to check for stool

(if not use enema)

equipment simple: finger cot or disposable glove

water-soluable lubricant KY Jelly not vasoline (affects absorbtion)

prescribed suppository

perform standard premed assessment

5 rights

left side to admin

prepackaged, disposable type solution

equipment simple

perofmr standard premed assessment

use 5 rights

explain procedure and check pertinent parameters

time of last defecation

place on left side bends upper most leg

apply lube to rectal area

insert lube tube and insert solution ask client ot hold solution for 30 min

provide domumentation

CHAPTER 10

PARENTERAL ADMINISTRATION

drug administration by any route other than the gastrointestinal tract

 • absorb faster

• last shorter

• cost more

• doses smaller

INTRADERMAL

INTRAMUSCULAR

INTRAVENOUS

Attention to detail necessary

injection requires skill and special care

avoid sharps injuries

syringe has 3 parts:

barrel - measures drug; outer part

plunger - inner cylindrical portion; fits inside barrel

tip - holds the needle

calibration always use mL not minim or cubic centimeters

Only used for insulin; special scale for measuring insulin

insulin measured in U-100 concentration

U-100 per mL

low dose U-50 or less

disposable and have a premeasure amount of med

 • ADVANTAGES: time saved in prep and less chance of contamination

• DISADVANTAGES: additional expense, diferent holders for diferent cartridges, volume of second med limited

Hub - base

Shaft  - long part

beveled tip - bottom; at angle

needle gauge - diameter of hole through needle

(bigger number = smaller hole)

selection depends on age of patient and type of administration subQ, IM or IV

NEEDLELESS SYSTEM

major safety development

reduces risk of sharp sticks

alternative for needles for routine procedures

BD Safety-Lok syringe

BD SafetyGlide Shielding Hypodermic Needle

BD SafetyGlide Syringe Tiny Needle Technology

BD Integra Syringe

glass container usually containing a single dose

Glass containers with one dose, and two compartments

upper compartment contains sterile dilute

lower compartment contains powder of drug

• drug in sterile sealed container (make sure package not wet and expiration date ok and seal isn't broken, etc.)

• syringe of the correct volume

• needles of the correct gauge and length

• needleless access device

• Antispetic swab

• MAR or med profile

• always inspec

use 5 rights (patient, drug, route, dose, time)

check the drug dose form ordered against the source you are holding (package says IM or IV dose)

move solution to bottom of ampule

cover ampule neck w/ sterile gauze pledget or antiseptic swab while braking off top (break away from face/body)

use aspiration filled needle, (filters out glass, but don't use same needle when injecting patient)

No air when drawing

if powder mix w/ correct amount of diluent

clean outer stopper before drawing up w/ swab

must have air when drawing up b/c of pressure

(1 mL of air and 1 mL of fluid)

don't shake tap container to mix

mix thoroughly

Don't use air for this administration

CHAPTER 11

PARENTERAL ADMIN: ID, SUBQ AND IM

made into dermal layer of skin below epidermis

key for allergy sensitivity tests, desensitization injections local anesthetics and vaccinations

use tuberculin syringie (minimal dosage) w/ 26 gage

insert needle at 15º angle

can inject anywhere on body as long as it is hairless

Med deposited in loose connective tissue between dermis and muscle layer

45º angle if 1" of adipose tissue can go 90º angle

Don't aspirate (pull out blood)

use needle 3/8 5/8 or 1/2

.5 to 2 mL usually most injected here

gauge 25 to 29

sites: upper arms, anterior thighs, abdomen,

less common: buttocks, upper back and scapular area

Use 90º angle

aspirate after in muscle (if blood pulled out, need to redo very little blood flow in muscle so you are in the wrong spot)

injection deep in muscle mass

syringe size .5 to 2 mL kids no more than 1 mL

needle lenght 1 to 1 1/2 inches long

gauge 20 to 22

site for IM injection

anterior lateral thigh inject one handbreadth from grater trochanter and one handbreadth from knee good for infants under 3 years

healthy adults

good drug absorptioin

medial to vastus lateralis

located same distance as vastus lateralis

chldren and adult use

good for self administration

bad cuz close to sciatic nerve

1. ventrogluteal - upper thigh muscle easy access in prone supine or side position not for children under three

2. dorsogluteal: anterior thigh muscle needs to be in prone position flat table last result b/c of sciatic nerve

often use because of access in thanding sitting or prone position

only in infants when the volume to be injected is very small

intravenous - veins

intramuscle - muscle

intra-aterial - no meds

intraperitoneal - peroneum

intrathecal - eppideral

intracardiac - heart

intrasternal- into sternum

intraosceous - intobone

CHAPTER 12

IV ROUTE

injectiono of a solution into the vein

large volume of fluid quickly administered to the vein with minimal irritation

faster absorption occurs

increased odds for infection

increased ADR's

Increased immobility

IOwa board of nursing says LPN's cannot initiate IV solutions, meds or blood components, can't add IV solutions containing medicines and can't set up the IV

They can change bags not containing meds and take out the IV's

Peripheral deices - hand arm foot

midline catheters - used 2-4 weeks 3-8" long midsize veins

Central devices - advanced veins jugular vena cava verified by X-ray and Dr.

Implantable venous infusion ports - long term therapy central veins placed by surgeon verified by X-ray

Arteries

veins

capillaries

intracellular - inside cell

interstitial - inbetween

extracellular outside cell

osmolality (same as blood;)

Isotonic - IV solution and blood have similar osmolality best kind safest

Hypotonic - fewer electrolytes more free water inbetween cells interstitial

hypertonic - solution has higher concentration of dissolved particles than blood irritable to veins infuse through central device.