exam 2 Flashcards
What the clinical judgement model is not…
-The nursing process, instead it aims to help the nurse apply the nursing process to patient care
-Diagnose or use NANDA diagnosis
-A theory but a way of processing information
Clinical judgement model?
-Recognize cues
-Analyze cues
-Prioritize hypotheses
-Generate solution/ expected outcomes
-Take action/ interventions
-Evaluate outcomes
why does clinical judgement work?
-By following this model you become a self-directed thinker
-You don’t need a set nursing diagnosis to tell you how to analyze the data, you can do this yourself by applying all the content you have learned to situation you are in
what is step 1 of clinical judgement?
recognize cues: gathering data phase, validate information, vital signs, scanning your environment
why can we not believe report at face value?
many things are passed nurse to nurse, and not validated, changes no one has seen, always check your orders, new lab values, bias, patient can change in minutes
step 2 of clinical judgement?
analyzing cues: cluster data in groups, distinguish relevant and irrelevant data, label each group
step 3 of clinical judgement?
prioritize: which is more important, always pick airway, breathing, and circulation first, judgement call after ABCs
step 4 of clinical judgement?
generate outcomes/solutions: providing quality patient care to improve patient, create solutions, timeframe, must be appropriate for nurse, scope of practice
step 5 of clinical judgement?
interventions: how do you plan to accomplish a goal, assessing patient, tasks, teaching
step 6 of clinical judgement?
evaluate: early and often, reduce healthcare errors, include assessment, state improving, unchanged, suggest modification
drug nomenclature
chemical name, generic name, official name, trade name
Drug classification?
-Drugs are classified by their effect on the body, chemical composition, clinical indication, or therapeutic action
-Two primary classifications: pharmaceutical class and therapeutic class
six rights of medication administration?
right client, medication, dose, route, time, and documentation
additional patient rights related to medication administration?
right to refuse, right assessment, right education, right response/evaluation
Additional safety strategies for medication administration:
Checking the medication against the MAR and dispensing device, checking the drug once prepared, checking the drug again prior to administration
medication reconciliation?
preformed every time the patient is transferred from one healthcare professional to another (readmissions or transfer within hospital)
pharamcodynamics:
study of how a drug effects the body
Therapeutic actions: medications
-Drugs turn on, off, promote, or block responses that are part of body’s processes
-Drug receptor interaction ?
-Drugs can also combine with other molecules to achieve their effect
-Other drugs act on cell membranes or alter the cell environment to achieve their effect
Factors affecting drug action:
developmental, weight, gender, cultural/ genetic, psychological, pathology, environment, timing of admin.
Therapeutic range:
concentration of drug in the blood serum that produces the desired effect without causing toxicity
Half-life:
amount of time it takes for 50% of blood concentration of a drug to be eliminated from the body
Peak plasma level:
when a drug is at its highest concentration, does not mean it is at its most therapeutic level
Trough serum level:
the lowest levels of concentration of a medication that correlates to the rate of elimination
Drug reactions:
side effects, allergic reactions, drug tolerance, toxic effect, idiosyncratic effect, drug interactions
Serious adverse drug event (ADE):
life threatening reaction that requires medical intervention to prevent death or permanent disability
Allergic reactions:
allergic or hypersensitivity, develops when body perceives a foreign substance as an allergen
Pharmacokinetics:
study of ADME, of drugs in the human body, what the body does to the drug
Absorption:
route of administration, lipid solubility, pH, blood flow, local conditions at site of admin., drug dosage
Metabolism:
biotransformation is the process of converting a medication to a form that is easily excreted , liver is where most metabolized, kidneys and small intestine too
Prodrugs:
inactive chemicals that are transformed through metabolism to become active before they have therapeutic effect
First pass effect:
results in lower concentration of the meds in the systemic circulation
Excretion:
process of removing drugs from the body, kidneys are primary organ responsible
Teratogenesis:
known to cause fetal defects (ex. Anti-infectives)
Medication order: a complete medication order should contain:
Patient name, date/time order written, drug name, dosage, route of administration, frequency, indication for use, provider name
Identifying the patient
Checking the identification bracelet, validating the patients name, validating the patients identification number, MRN, and birthdate, comparing with the MAR, asking the patient to state their name
Types of medication orders:
standing order-routine carried out until it is cancelled by another order, PRN order- as needed, single or one time order, STAT order- carried out immediately
High-alert medications:
drugs that are associated with an increased risk of causing harm when administered error, insulin, opiates, narcotics, IV heparin, injectable KCI, to reduce the risk of harm is an independent double check with two nurses verifying the drug and order before administration (A PINCH)
Oral medications:
-Solid form: tablets, capsules, pills
-Liquid form: elixirs, spirits, suspensions, syrups
-Oral route: having patient swallow drug
-Enteral route: administering drug through enteral tube
-Sublingual: placing drug under tongue
-Buccal: placing drug between tongue and cheek
Topical medications:
skin application, eye installation and irrigation, ear installation and irrigation, nasal installation, vaginal application, rectal instillation
Parenteral medications:
-Subcutaneous injections: subcutaneous tissue
-Intramuscular injection: intradermal injection: under epidermis
-Intravenous injection: vein
-Intra-arterial: artery
-Intracardial injection: heart tissue
-Intraperitoneal injection: peritoneal cavity
-Intraspinal injection: spinal canal
-Intraosseous injection: bone
Sites of IM injections:
ventrogluteal, vastus lateralis, deltoid, dorsogluteal- not recommended
Preparing medication for injection:
ampules, vials, prefilled cartridges or syringes, mixing medication in one syringe, mixing insulin in one syringe, reconstituting powdered medications
Intradermal injections:
-Administered into the dermis
-Longest absorption time of all parenteral routes
-Used for sensitivity tests and local anesthesia
-Bodys reaction to substances is easily visible
-Sites commonly used are inner surface of forearm, upper back, under scapula
-¼” to ½”
-25- or 27- gauge needle
-Angle is 5-15 degrees
-Dosage given intradermally is small, usually less than 0.5 ml
Subcutaneous injections:
-Administered into adipose tissue layer just below epidermis and dermis
-Sites used: Outer aspect of upper arm, Abdomen, Anterior aspects of thigh,
Upper back, Upper ventral or Dorso gluteal area
Intravenous administration:
-Delivers drug directly into bloodstream
-Immediate effect and cannot be recalled or slowed
-Route most often used in emergency situations
time:
Time critical medications are those administered either 30 minutes after the scheduled time that can cause harm to the client or have less than desired effects
Documentation:
-Scanning into eMAR- does not eliminate need to identify rights of administration
-Name and dosage
-Route and time
-Name of person administering
-Site used for injection
-Location of topical or transdermal application
-Nares, eyes, or ear used
-Omitted drugs (intentional or inadvertent)
-Refused drugs
-Medication errors
Types of medication errors:
-Inappropriate prescribing of the drug
-Extra, omitted, or wrong doses
-Administration of drug to wrong patient
-Administration of drug by wrong route or rate
-Failure to give medication within prescribed time
-Incorrect preparation of drug
-Improper technique when administering drug
-Giving drug that has deteriorated
Medication errors:
-Check patient’s condition immediately
-Observe for adverse effects
-Notify provider
-Notify nurse manager
-Complete form used for reporting errors
-Do you tell the patient?
-Do you tell the family?
patient teaching:
review, remind, instruct, discuss
Formula method:
-used when calculating the same units of measure during drug calculation, volume or actual dose is calculated based on this formula, the dose equals the amount to be given (dose ordered x quantity/ available dose)
-1 kilogram = 1000 grams
-1 gram = 1000 milligrams
-1 milligram = 1000 micrograms
-1 liter = 1000 milters
Role of skeletal system in movement
-Supports the soft tissues of the body
-Protects crucial components of the body
-Furnishes surfaces for the attachment of muscles, tendons, and ligaments
-Provides storage areas for minerals and fat
-Produces blood cells
Freely moveable joints :
ball and socket, condyloid, gliding, hinge, pivot, saddle
Bones classified by shape:
-Long bones: upper and lower extremities
-Short bones: wrist and ankle
-Flat bones: ribs and skull
-Irregular bones: spinal column and jaw
Joint movements:
Abduction, adduction, circumduction, flexion, extension, hyperextension, dorsiflexion, plantar flexion, rotation, internal rotation, external rotation, supination, pronation, inversion, eversion
Three types of muscles and important functions of muscle:
-skeletal, cardiac, and smooth or visceral
-motion, maintenance of posture, support, heat production
Ergonomics:
practice of designing equipment and work tasks to confirm to the capability of the worker
Factors influencing mobility:
Developmental considerations
Physical health: muscular, skeletal, or nervous system problems, problems involving other body systems
Mental health
Lifestyle
Attitude and values
Fatigue and stress
External factors
Effects of immobility on the body
Cardiovascular system, respiratory system, musculoskeletal system, metabolic processes, GI system, urinary system, skin, psychosocial outlook
Health history:
Daily activity level, endurance, exercise/fitness goals, mobility problems, physical or mental health alterations, external factors affecting mobility
Proper body mechanics
Use of proper body movement in daily activities
The prevention and correction of problems associated with posture
The enhancement of coordination and endurance
Equipment and assistive devices
Gait belts
Stand-assist and repositioning aids
Lateral-assist devices
Friction-reducing sheets
Mechanical lateral-assist devices
Transfer chairs
Powered stand-assist and repositioning lifts
Powered full-body lifts
Positioning patients :
Pillows, mattresses, adjustable beds, bed side rails, trapeze bar, additional equipment
Protective :
Fowlers, supine or dorsal recumbent, side-lying or lateral position, sims position, prone position
Physical conditioning:
quadriceps/ gluteal setting drills, push-ups, dangling
mechanical aids for walking:
walker, cane, braces, crutches
Developmental considerations
Neonate and infant:
Fetal considerations, mobility, car seats
Toddler and preschooler:
Environment, poisoning, asphyxiation, child abuse
School age:
Accidents, child abduction, bullying
Adolescent:
Driving, substance use, misuse, abuse, piercings/tattoos, firearms, internet and social, sex trafficking
Adult:
Drug use and poisoning, intimate partner violence
Older adults:
Falls, motor vehicle accidents, fire, polypharmacy and poisoning, elder abuse
Indications of a concussion
Physical: headache, vomiting, problems with balance, fatigue, dazed or stunned appearance
Cognitive: mental foggy, difficulty concentrating and remembering, confusion, forgets recent activities
Emotional: irritability, nervousness, very emotional behavior
Sleep: drowsiness, difficulty falling asleep, sleeping more or less than usual
Safety plan for victims of domestic abuse
Safety while living with an abusive partner
Safety planning with children
Safety planning for pets
Safety planning during pregnancy
Leaving a relationship
Patient environments:
work, social, home
Physiologic Hazards Associated
With Restraints
-Increased possibility of serious injury due to fall
Skin breakdown
Contractures
Incontinence
Depression
Delirium
Anxiety
Aspiration and respiratory difficulties
Death
RACE:
-R—Rescue anyone in immediate danger.
-A—Activate the fire code and notify appropriate
person.
-C—Confine the fire by closing doors and windows.
-E—Evacuate patients and other people to safe area.
safety event report
must be completed after any incident or accident in a health care facility that compromises safety, immediately after, should not be mentioned in documentation
