250 Study Cards for the Final Flashcards
What is the difference between head-to-toe, shift, and focused assessments?
The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition. Any unusual findings should be followed up with a focused assessment specific to the affected body system. A focused assessment may also be done when there is a specific complaint. Shift assessments will be agency specific and may involve vital signs, etc.
What is the Z-track method?
The Z-track method, a technique for pulling the skin…is recommended for IM injections.
What are the benefits of the Z-track method?
It prevents leakage of medication into subcutaneous tissues, seals medication in the muscle, and minimizes irritation.
How do you perform the Z-track method?
- Pull the overlying skin and subcutaneous tissues approximately 2.5 to 3.5 cm (1 to inches) laterally to the side with the ulnar side of the nondominant hand.
- Hold the skin in this position until you have administered the injection.
- Inject the needle deeply into the muscle…
- Keep the needle inserted for 10 seconds to allow the medication to disperse evenly.
- Release the skin after withdrawing the needle.
- This leaves a zigzag path that seals the needle track wherever tissue planes slide across one another.
- The medication is sealed in the muscle tissue.
How do medications enter the body tissues and circulatory system when using the pareteral route?
By injection
What are advantages of the parenteral route of medication administration?
- Can be used for drugs that are poorly absorbed, inactive or ineffective if given orally
- The IV route provides immediate onset of action
- The intramuscular and subcutaneous routes can be used to achieve slow or delayed onset of action
- Patient concordance problems can be avoided
What are disadvantages of the parenteral route of medication administration?
- Staff need additional training and assessment
- Can be costly
- Can be painful
- Aseptic technique is required
- May require additional equipment, for example programmable infusion devices
What are the four most common parenteral routes?
- Subcutaneous
- Intramuscular
- Intradermal
- Intravenous
Define subcutaneous injection.
Injection into tissues just under the dermis of the skin.
Define intramuscular injection.
Injection into the body of a muscle
Define intradermal injection.
Injection into the dermis just under the epidermis.
Define intravenous injection or infusion.
Injection into a vein.
What can the nurse do to promote patient comfort with parenteral injections?
- Use the correct technique
- Rotate injection site to prevent indurations or abscesses
- Explain the benefits of the injection to the patient
- Position the patient so the muscles are relaxed
- Use distraction
- Insert and remove the needle smoothly and quickly
- Hold the syringe steady during the procedure
- Inject medication slowly but smoothly
- Provide education about procedure
Do ampoules contain single or multiple doses?
Single
Do vials contain single or multiple doses?
Both
What do you need to remember to write on a multi-use vial?
The date the vial is opened.
What influences the needle size selection for intramuscular injections?
- Viscosity of the medication
- Injection site
- Patient’s weight
- Amount of adipose tissue
Which medications are only given intramuscularly?
Hepatitis B and tetanus, diphtheria, and pertussis (Tdap) immunizations
What does the concept of Fluid and Electrolytes refer to?
“Process of regulating the extracellular fluid volume, body fluid osmolality, and plasma concentrations of electrolytes”
How is water balanced in the body from a physiological perspective?
Lean body mass is rich in water, while adipose tissue has a lower percentage – because of this, a person who is overweight or obese has a lower % of water mass overall compared with someone who is lean or muscular. – so, women typically have less and elderly have less due to decreased muscle mass due to age. Children tend to have higher.
Name of a solution with the same osmolarity as blood plasma.
Isotonic
Name of a solution with higher osmotic pressure; pulls fluid from cells causing them to shrink.
Hypertonic solution
Name of a solution with an osmotic pressure lower than plasma; moves fluid into the cells causing them to enlarge
Hypotonic
What does the concept of fluids and electrolytes refer to according to Giddens?
Process of regulating the extracellular fluid volume, body fluid osmolality, and plasma concentrations of electrolytes
What percentage is water in the normal adults body?
60%
Why is water % less in women and obese people?
Have more adipose tissue and adipose contains less water.
Define intracellular fluid.
the fluid within the tissue cells, constituting about 30-40% of the body weight.
Define extracellular fluid.
- The interstitial fluid and the plasma, constituting about 20% of the weight of the body.
- Sometimes used to mean all fluid outside the cells, usually excluding transcellular fluid.
Where is extracellular fluid found?
- Vascular compartment (plasma)
- interstitial space
What is the normal extracellular concentration of sodium in the adult body?
135 - 145 mmol/L
What is the normal intracellular concentration of sodium in the adult body?
10-14 mmol/L
What is the normal extracellular concentration of potassium in the normal adult body?
3.5-5 mmol/L
What is the normal intracellular concentration of potassium in the normal adult body?
140-150 mmol/L
What is the normal extracellular concentration of chloride in the adult body?
98-106 mmol/L
What is the normal extracellular concentration of bicarbonate in the adult body?
24-31 mmol/L
What is the normal extracellular concentration of calcium in the adult body?
2.1 - 2.6 mmol/L
What is the normal extracellular concentration of phosphorus in the adult body?
0.8-1.45 mmol/L
What is the normal extracellular concentration of magnesium in the adult body?
0.75 - 1.25 mmol/L
What is the normal intracellular concentration of chloride in the adult body?
3-4 mmol/L
What is the normal intracellular concentration of bicarbonate in the adult body?
7-10 mmol/L
What is the normal intracellular concentration of calcium in the adult body?
<0.25 mmol/L
What is the normal intracellular concentration of phosphorus in the adult body?
75 mmol/L
What is the normal intracellular concentration of magnesium in the adult body?
variable
Define osmosis.
What is the normal range of serum osmolality?
275-295 mOsm/kg
Which types of solutions have the same osmotic pressure as blood?
Isotonic (isomolar)
E.g. Normal saline or 0.9% NaCl, Lactated Ringer’s solution, 5% dextrose in water (D5W)