Exam 2 blueprint Flashcards
Oral cavity assessment - hygiene (14 points)
- color
- moisture
- lesions
- edema
- bleeding
- odor
- function
- lips
- buccal mucosa
- surface of gums
- teeth (Primary vs adult teeth)
- tongue
- hard and soft palates
- oropharynx
denture care
Hair assessment in hygiene
HAIR AND SCALP
Hair:
- condition
- texture
- cleanliness
- oiliness
Scalp:
- lesions
- inflammation
- infection
- dandruff
- alopecia
- infestations (lice)
Shaving - hygiene
- never trim or shave hair without permission
- apply warm washcloth to skin
- apply shaving cream
- if face, shave with direction of hair growth
- if legs, shave against direction of hair growth (only in certain situations)
- remove residual shaving cream
Complete care in hygiene
Nurse doing everything; patient unable to assist
Partial care in hygiene
Nurse assists - can be helping with hard to reach areas
Self-care in hygiene
Patient typically able to do all and care for themselves
Health history - hygiene (ppt - nursing history - nursing process for skin care and personal hygiene)
Bathing habits
Interfering factors (sensory deficits, mobility issues)
Pain
Exposure risk (sunbathing, chemicals)
History of skin problems (rashes, itching, dryness, anything used to relieve symptoms)
Specific practices for mouth/eyes, ears, nose/hair/feet and nails, perineum, piercings, tattoos
Nursing interventions - hygiene (types of assessments 6)
Skin Assessment
Oral Cavity assessment
Eye, Ear, nose assessment
Hair Assessment
Nails and Feet assessment
Perineal assessment
Respect personal preferences
Encourage self-care as much as possible
Maintain privacy
Warmth
Promote wellness
What are the stages of pressure ulcers
Suspected DTI: purple or maroon intact skin or blood-filled blister
Stage 1: non-blanchable erythema of intact skin
Stage 2: partial-thickness skin loss - shallow, open ulcer
Stage 3: full-thickness skin loss - subcutaneous fat may be visible
Stage 4: full-thickness skin loss with exposure bone, tendon, or muscle
Unstageable - base of ulcer covered by slough and/or eschar in wound bed
Prevention for pressure ulcers?
- assess skin daily
- cleanse skin routinely and as needed
- moisturize dry skin
- avoid massage of bony prominences
- minimize friction and shearing
- use appropriate support surfaces
- administer nutritional supplements as needed
- improve mobility/activity and use ROM
- frequent position changes
- document prevention measures and results
Goal of Wound care. Dressing or no dressings?
Goal: promote tissue repair and regeneration to restore skin integrity
If wounds left open to air (no dressing): heal more slowly since wound dries and produces a scab
Risk factors for skin integrity
- IV drug use
- prolonged sun exposure
- body piercing
- increased age
- dehydration and malnutrition
- reduced sensation
- diabetes
- GI preparations for testing
- bedrest
- casts
- medications
- radiation therapy
- very thin or very obese
- excessive moisture
- jaundice
- eczema and psoriasis
Types of heat therapy
Dry heat:
- hot water bottles
- electric heating pads
- aquathermia pads: water is enclosed
- hot packs (instant)
- warming blankets
Moist heat:
- warm moist compresses
- sitz bath
- warm soaks
Types of cold therapy
Dry cold:
- ice bags/pack
- cold packs (freezer)
- hypothermia blanket or pad
Moist cold:
- cold compresses
What are unintentional wounds
Result of unintentional such as unexpected trauma
Wound edges often jagged and bleeding uncontrolled
Increased risk for infection
Increased healing time
What are intentional wounds
Result of planned invasive therapy or treatment
Wound edges are clean and bleeding is usually controlled
Decreased risk for infections
Healing is facilitated
How to use a cane
Widen a person’s base of support, should not be for bearing weight
- hold can on stronger side
- can about 4 inches to side of foot and extend to wrist crease
- elbow slightly bent; flexed 15 degrees
- teach patients to stand erect and not learn on it
- patient stand w/ weight evenly distributed
- cane on stronger side and advance one small stride ahead
- supporting weight on stronger leg and cane, patient advances the weaker foot forward to parallel to the cane
- supporting weight on weaker leg and cane, patient brings stronger leg forward to finish the step
How to use a walker
- stand between the back legs of the walker with arms relaxed at the side
- top of walker should align w/ the crease on inside of patient wrist
- grip top of the walker at the handles with elbows slightly bent
- lift walker and position about one step ahead; keep back upright
- place one leg inside the walker (ensure doesn’t roll away if wheels)
- push straight down on grips of walker and step forward with remaining eg
- repeat process
How to use crutches
Top of crutches should be 1-2 in below armpit, weight should be on hands not armpit. handgrips should be even with top of hips.
Navigating Stairs
Up Stairs: Lead with your uninjured leg, moving it to the next step first, then move your crutches and injured leg to the same step. Remember the phrase: “Up with the good.”
Down Stairs: Place the crutches on the lower step, move your injured leg down next, and then follow with your uninjured leg. Remember: “Down with the bad.”
Powered Stand lift (pts are able to….)
Powered Stand-assist and repositioning lifts: for patients with weight-bearing ability, able to follow directions, and cooperation
Hoyer lift (2 types)
Hoyer lifts: allow person to be lifted and transferred with a minimum of physical effort
– sit-to-stand hoyer lift
– manual and powered hoyer lifts
Powered full body lift
designed for patients who cannot bear any weight
Using a gait belt
When to avoid using them?
used to steady patients, not to lift them
avoid using them on patients with abdominal or thoracic issues
Protective positioning and promoting alignment (keep patients safe and comfortable)
Pillows/wedges: provide support and elevate body part
Mattresses: firm but with sufficient “give”
Adjustable beds: can elevate head or foot
Trapeze bars: facilitate moving and turning
Foot supports: support foot in dorsiflexion position
Bed cradles: keep pressure of linens off feet
Sandbags: immobilize extremity and support body alignment
Trochanter rolls: support hips and upper legs
Hand-wrist splints: keep thumb slightly adducted
Side rails: assist patient to roll from side to side
Timing of medications (CLARIFY)
idk really how to clarify - will think on it - in review she had said timing and asked about diuretics
diuretics (gone over in review) - give during day and not before bed
Amount of sleep needed across the lifespan
Teen and children: more than 9hr
Adult: 7-9 hours
Older adult (70s/80s): 5-6 hours
Types of insomnia
Insomnia - most common sleep disorder
Transient insomnia: less than one month
Short-term insomnia: between 1-6 months
Chronic insomnia: more than 6 months
Smoking effects on sleep/rest/activity
Reduced the quality of sleep, especially REM
What is sleep apnea
stopping breathing during sleep
What are risk factors of sleep apnea
obesity, high BMI, snoring
What are the effects of exercise on sleep and rest?
exercise gives better sleep and rest, but needs to be done 2+ hours before going to bed
Technique and steps of administering oral medication
- intended for absorption in stomach and small intestines
- most common method
- solid or liquid forms
- enteral - within the intestines
When administering:
- assess swallowing function
- use adequate amount of fluid
- one at a time
- only break if scored
- know rules on crushing
- pour away from label (liquid)
Technique and steps of administering sublingual medication
- under tongue/side of gum between cheek
- absorbed quickly; patient must be AAO x 3
- administer last after all oral medications
Oral then sublingual what would order be?
Oral then sublingual
Techniques and steps of administering transdermal medication (what do you do after it’s placed on the skin) ( example of some uses )
- can be worn while showering
- increased absorption by cleaning skin prior to administration and with local heat
- wear gloves, assess skin
- remove old patch and fold in half
- document date/time administration on label and initials of nurse
- disc of medication applied to skin: use palm of hand to press 10 seconds (do not massage!)
uses: scopolamine, nitroglycerine, duragesic, smoking cessation
Technique and steps of administering eye medication
- abbreviations should not be used - write out right eye, left eye, both eyes
- uses: local anesthetic, anti-inflammatory, anti-infection, irrigations, anti-histamine
- sterile/asepsis
- single patient use
Procedure:
- hand hygiene, patient ID, explain procedure
- gloves, clean eyelid if needed
- tilt patient’s head back, have patient look up and ofcus
- expose conjunctival sac, place drop in sac (avoid touching eye)
- have patient close eyes, gently apply pressure
- remove gloves, hand hygiene
- document, evaluate patient response
Timing with medication administration
Ac/pc
Serum half life
Onset
Peak and trough
Presence of food in stomach (ac/pc)
Serum half life: time it takes for 50% of drug to be eliminated
Onset: time to produce a response
Peak and Trough
Verifying medications: nursing assessment - medication history
- previous and current drug use
- allergies, response to drugs
- compliance with regimen
- attitude/understanding of drugs
- perceptual/coordination problems related to administration
What/when are the three medication checks
- when you reach for container
- before pouring
- upon replacing container
What are the 11 rights of medication administration
- right patient
- right medication
- right dose
- right route
- right time
- right reason
- right assessment
- right education
- right refuse
- right response
- right documentation: drug, dose, route, time, initials, full signature, site of injection, clinical info
Syringe sizes (needle?)
the smaller the number - the larger the diameter
sizes range from 18-30
18 is larger; 30 is smaller
gauge - diameter
Needle sizes
needle length depends on the route of administration
What are peak levels
time of HIGHEST concentration; when absorption is complete
What are trough levels
MINIMUM (lowest) concentration; drawn 30 minutes before next dose
Drug nomenclature:
Chemical
Generic
Official
Brand
Chemical name: drugs chemical composition
Generic name: assigned by the manufacturer who first develops it
Official: listed in USP-NF
Trade, Brand, or Proprietary name: name under which the drug is marketed, copyrighted; can have several trade names (Advil, Motrin, etc)
What is enteric coated medication (i just typed this from head so feel free to edit)
Coated medication to allow slower release and prevent stomach irritation
PRN
as needed or requested
Multidose vials
- can use multidose vials or single dose vials; remove from multidose vial first
Mixing medications (can you?) how many in 1 syringe
Never mix more than 2 drugs in 1 syringe
- Ensure the 2 drugs are compatible
AKA some insulins can be mixed (N and R) but lantus cannot mix
Insulin- What type of needle?
Insulin needle (orange syringe) 28-31
IV sites - peripheral
Basilic vein
Dorsal venous network
Dorsal metacarpal veins
Basilic vein
Median cubital vein
Accessory cephalic vein
Cephalic vein
Radial vein
Medial antebrachial vein
Start distally and work your way up; smallest to do the job
Avoid sites that move or bend a lot
Teaching - medication administration and IV sites
Medication side effects
effects from medication, but are not the desired effect
some are expected like headache, weight loss, hair growth
Medication toxic effects
Occurs from cumulative effect due to poor metabolism/excretion (one dose cannot be metabolized prior to the next dose)
Impairing an organ; bad effects
endangers health
risk for permanent damage or death
Medication adverse reactions
effects that are not intended
Priority framework - knowing how to assess priority patients need to find this
acute vs chronic - look this up
Apical HR - vital signs
measure for one minute at the 5th left ICS along MCL; should be in range of 60-100 bpm for normal healthy adult
can take with radial pulse too to determine any pulse deficit
Handwashing in asepsis and infection control: 5 moments for hand hygiene
- before touching a patient
- before a clean or aseptic procedure
- after body fluid exposure risk
- after touching a patient
- after touching patient surroundings
PPE - donning on
gown, then mask, then goggles, then gloves
PPE - doffing off
remove gloves, then goggles, then gown, then mask, then hand hygiene
Infection Cycle
Infectious Agent, Reservoir, Portal of Exit, Means of Transmission, Portal of Entry, Susceptible Host
SDOH - effect on nursing care
-Economic stability
food insecurity (not knowing where the next meal is coming from)
employment
housing instability
can the pt afford health insurance?
-Neighborhood and built environment
Crime and violence: probably not going out and walking to get exercise
Grocery acquisition: no transportation/ easier access to fast food
Environmental considerations: pollutants, soil, air quality, contaminated water =
potential food risks
-Health and healthcare
access to health care; access to primary care
-Education
early childhood and education development
access to higher education; high school graduation?
low literacy/ english not being primary language (needing an interpreter)
-Social and community context
civic participation; social cohesion (supportive community)
Prioritization of care
First-level priority- emergent, life threatening, and immediate
Second level priority -next in urgency, requiring attention to avoid further deterioration
Third level priority - important to pt’s health but can be addressed after more urgent problems are addressed
Maslow’s Hierarchy (5)
- physiologic needs
- safety needs
- love and belonging needs
- self-esteem needs
- self-actualization needs
Nursing Process
ADPIE → assessment, diagnosis, planning, implementation, evaluation
Hair care - hygiene
Daily brushing
- distributes oil along the hair shaft
- stimulates circulation to scalp
- if tangled, comb small section at a time
- braiding long hair decreases matting and tangling
- do not cut hair without permission!
Shampooing:
- special basins available if patient cannot perform this
- no rinse shampoo caps (dry shampoo)
Factors affecting personal hygiene
Culture: typical bathing practices, behaviors, and use of various hygiene products
Socioeconomic class: financial resources may limit hygiene options
Spiritual practices: ceremonial washings and purifications
Developmental level: practices change
Health state: disease, surgery, injury, weakness, dizziness, fear of falling, pain
Personal preferences: shower vs bath
Purpose of a wound dressing
- maintain a moist environment
- absorb drainage
- act as a bacterial barrier
- debride necrotic tissue
- provide comfort
- allow for pain-free removal
Effects of applying heat - heat therapy
- dilates peripheral blood vessels
– increases local blood flow
– increases supply of oxygen and nutrients to area - increases tissue metabolism
- decreases blood viscosity
- increases capillary permeability
- decreases muscle tension
- helps relieve pain
What are heat and cold therapy and what can be modified about them?
applied to local specific part of the body or all of the body
modified by:
- method and duration
- degree of heat and cold
- patient’s age and physical condition
- amount of body surface covered
Effects of applying cold - cold therapy
- constricts peripheral blood vessels
- decreases muscle spasms
- promotes comfort
- reduces blood flow to tissues
- decreases local release of pain producing substances
- decreases edema and inflammation
- alters tissue sensitivity - numbness
Considerations when using heat or cold therapy
- cardiovascular disease or PVD
- sensory impairment
- alterations in mental status
- do not apply directly to open wounds
Effects of exercise
- increases rate of CO2 excretion
- burns calories even when not exercising
- decreases heart rate
- decreases BP
- increases renal blood flow
- improves intestinal tone
- improves metabolic function
before sleep: try to exercise 2 or more hours beforehand
Exercise - Isotonic muscle contraction
- ex: walking
- muscle shortening
- active movement
Exercise - isometric muscle contraction
- muscle contraction
- minimal or no muscle shortening
“think isometric hold” in exercises
Exercise - isokinetic muscle contraction
- ex: weight lifting
- muscle contraction with resistance
Exercise: Types of body movement
Aerobic exercises: conditioning
Stretching exercises: flexibility
Strength and endurance exercises
Movement and ADLs
Effects of exercise on the cardiovascular system
- strengthens heart
- promotes immunity due to lymph flow
- decreased risk of CV disease
Effects of exercise on the respiratory system
- increased flow of oxygen
Effects of exercise on the GI system
- improves GI function
- helps eliminate waste
Effects of exercise on the nervous system
- calms nervous system
- may improve thinking and memory skills
- releases endorphins
Effects of exercise on the urinary system
- improved blood flow leads to enhanced filtration
- improved removal of toxins and wastes
Effects of exercise on musculoskeletal system
- strengthens bones
- helps prevent osteoporosis
Effects of exercise on metabolic system
- weight control
- helps manage blood glucose/insulin
- increases metabolism, even when not exercising
Effects of exercise on integumentary system
- improves blood flow
- lessens stress so improves chronic skin conditions
Effects of exercise on psychosocial outlook
- improves mental health
Effects of immobility on the cardiovascular system
- venous stasis
- thrombosis and embolism
- orthostatic hypotension (increased fall risk)
Effects of immobility on the respiratory system
- pooling of secretions
- difficulty mobilizing and expectorating secretions
- shallow respirations
- decreased vital capacity
Effects of immobility on GI system
- constipation
- impaction
Effects of immobility on urinary system
- retention
- calculi
Effects of immobility on musculoskeletal system
- bone loss of calcium
- osteoporosis and fractures
- impaired ROM
- muscle weakness and atrophy
Effects of immobility on metabolism
- decreased basal metabolic rate
- weight gain
Effects of immobility on integumentary system
- increased risk of skin breakdown
- increased risk of pressure ulcers
Effects of immobility on psychosocial outlook
- depression
- isolation
Patient positions
High Fowler’s
Low or semi-fowler’s
Supine or Dorsal Recumbent
Side-lying or lateral
Prone
Protective positioning
- important when positioning to always use correct positioning techniques
- remember to change position frequently, but at least every 2 hours
- incorporate exercise and assessment of pressure points during position changes
- if a patient is unable to turn independently, then use a turning schedule
What is Fowler’s position?
Used to promote cardiac and respiratory functioning
Good for eating, conversing, and eliminating
Buttocks bears the main weight
Heels, sacrum, and scapulae are at increased risk
High Fowler’s: HOB elevated 90 degrees
Low or Semi-Fowlers: HOB elevated 30 degrees
Normal temperatures for healthy adults
Oral
Rectal
Axillary
Tympanic
Temporal
(Rectal tympanic temporal are same
Oral: 37.0°C, 98.6°F
Rectal: 37.5°C, 99.5°F
Axillary: 36.5°C, 97.7°F
Tympanic: 37.5ºC, 99.5°F
Temporal: 37.5°C, 99.5°F
What are some nursing considerations with heat therapy?
Watch safety to make sure patient won’t get burnt; better to have it on the side than leg on top of heat therapy
Don’t want to attach it to the patient
Want to have it so the patient can’t control the temperature and make it higher
Schedule 1 Drugs
Research purposes only!
high potential for abuse; not allowed to use medically
- LSD, heroin
Schedule 2
HIGH POTENTIAL FOR ABUSE, NO TELEPHONE ORDERS, NO REFILLS
written prescription
labeling required!!! “federal law prohibits the use of this drug by any person other than the patient whom it was prescribed”
Narcotics
- hydrocodone
- opioids
Schedule 3-5
How many mg are ok?
LOWER ABUSE POTENTIAL, REWRITTEN EVERY 6 MONTHS, LABELING REQUIRED
written prescription
Ex: codeine in tylenol
anything less than 90mg – if it is more, then it is schedule 2
What is the therapeutic effect of a drug?
The intended effect of the drug; the physical effect
Can have more than one
6 actions: palliative, curative, supportive, substitutive, chemotherapeutic, restorative
Ex: giving antihypertensive -> therapeutic effect is lower BP
What is unintentional vs intention wound?
Surgery is intentional; unintentional is trauma or like if you cut yourself when cooking
What are some things that can cause an increased risk for altered skin integrity?
Obesity? Yes, moisture and skin folds
Excessive sweating? Yes
High blood pressure? No
Low BMI? If malnourished, then yes
Jaundice? Yes
What is someone asks for a specific IV location site?
Can try to do that depending on the site and if it looks suitable, assess for limitations and best veins
Can’t use central line side or if they had a mastectomy
Try to honor, but need to make the safest decision
Pay attention to: __ with IV sites
Redness, swelling, leaking, coolness, infiltration of fluid into skin
What does TID mean?
three times a day
What does QID mean?
Four times a day
What does q6h mean?
Every 6 hours
When giving a transdermal patch, what is an important thing to do?
Wear gloves
Write date and time on patches so it can be seen
Make sure to fold the patch and throw away (pref in sharps container) when disposing
When would you not want to give an oral medication?
patient can’t swallow, too lethargic, unconscious
When you first get a medication, how do you verify it?
Razzi said - Look at original provider order and make sure they match
check against MAR; pharmacy does a check and nurse signs off
What type of medication works the fastest?
IV route
What do we do with some oral medications that might upset your stomach?
Enteric-coated
What are some benefits of a nurse helping with ADLs compared to delegating to a nursing assistant?
Education, skin assessment, helps with patient-nurse relationship and getting more time to talk with the patient
If someone has insomnia from smoking cessation, what would you recommend?
Usually it is short-term and temporary, so maybe a short-term medication to help them sleep nicotine patch or sleeping pill
What is stage 1 of a pressure ulcer?
Skin is unbroken but inflamed; non-blanchable erythema of intact skin
What is stage 2 of a pressure ulcer?
skin is broken to epidermis or dermis; partial-thickness skin loss
shallow, open ulcer
What is stage 3 of a pressure ulcer?
full-thickness skin loss - subcutaneous fat may be visible
ulcer extends to subcutaneous fat layer
What is stage 4 of a pressure ulcer?
full-thickness skin loss with exposure bone, tendon, or muscle
ulcer extends to muscle or bone; undermining is likely
What are things that increase the risk for pressure ulcers?
Immobility, being incontinent - moisture on skin, level of consciousness, malnutrition, diabetes
If you had someone that had a skin issue that you were questioning may be related to hygiene, what would be a good way to ask questions during health history?
Ask open-ended questions and have them tell you their routine
Do you have difficulty washing certain areas? How often do you bathe?
Do patients participate in their care or bathing?
Yes, they can. It is good to ask them to participate
What types of patients are at risk for oral health issues?
Those that are intubated, not taking things by mouth
Important to do a mouth assessment
Taking off compression socks - are you concerned if there’s an indentation if they’re too tight?
Yes, it can lead to lack of circulation
If someone comes in with a bigger indentation, remeasure compression stockings to get larger ones and remeasure edema
What would you do if someone has a lot of scratches on their body, what are you concerned about?
Something to do with itching - dialysis patients have dry, scaly skin and itch
Would be worried about infection, liver issues and jaundice, abuse, self-harm
Are we allowed to shave patients?
Can shave patients (not shaving off beards unless they ask)
If someone is on blood thinners - maybe electric razor because high risk for bleeding
If you’re working in the ER and someone comes in after an accident and their hair is all matted, what would you do?
Get hair out of their face with a hair tie, braid it
Can use dry shampoo or shower caps
When do you wear gloves?
When you come in contact with potentially infectious fluids - blood or body fluids (all except sweat)
Wear gloves when caring for dentures
Effects of insufficient sleep on children
- affects normal growth and development
- contributing factor in performance deficits and behavioral problems
- increased risk of obesity during childhood or later in life
Effects of insufficient sleep on adolescents
- decreased brain development
- affects growth
- leads to depression/drug use
Effects of insufficient sleep on adults
particularly during changing shifts/night shifts
- anxiety, loneliness, depression
- personal conflicts
- GI symptoms
- increased risk for breast and colorectal cancer
- increased risk for type II diabetes
- increased risk for HTN
- increased risk for CV disease - strokes
- increased risk for sleep-related MVCs
- increased risk for substance abuse
Effects of insufficient sleep on older adults
- poor quality
- shorter REM cycles
- fewer hours of sleep
- insomnia
Sleep Stage: N1 and body effects (vitals)
- heart and respiratory rates decrease
- muscles start to relax
- lasts a few minutes
Sleep stage: N2 light sleep and body effects (vitals)
- heart and respiratory rates decrease further
- body temperature decreases
- no eye movements
- brain produce “sleep spindles” NREM; person asleep
- lasts about 25 minutes
Sleep Stage NREM N3 and body effects (vitals)
- deepest sleep state
- heart and respiratory rates at their slowest
- tissue repair and growth, cell regeneration
- immune system strengthens
- no eye movement
- body fully relaxed
- delta brain waves
Sleep stage REM stage R and body effects (vitals)
- primary dreaming stage
- heart and respiratory rates increase
- can’t regulate body temperature
- limb muscles paralyzed
- rapid eye movements
- increased brain activity
Medication - Idiosyncratic reaction
unexpected; abnormal or peculiar
patient’s unique responses
over or under responses
What is drug tolerance
pharmacological concept describing subjects’ reduced reaction to a drug following its repeated use
What are the 7 components of medication order?
- Patient’s full name
- date and time order is written
- drug name
- dosage
- route of administration
- time and frequency
- signature of person writing order
Intramuscular needle, gauge, and angle
5/8 to 1 1/2 inches (based on site and patient age)
needle gauge: 18-25
angle of insertion: 72-90 degrees
Intramuscular injection sites
Vastus lateralis (thigh) - 4mL max
Deltoid (upper arm) - 1mL max
Ventrogluteal (hip area) - 4mL max
Subcutaneous injection needle, gauge, and angle (how many ml)
length: 3/8 to 1 inch (based on subcutaneous tissue)
25-30 gauge (dose no more than 1 mL)
angle: 45-90 degrees (based on needle length/adipose tissue)
Subcutaneous injection sites
upper arm, anterior thigh, abdomen, upper back and upper dorsogluteal
be sure to rotate sites
Subcutaneous injection info
- administered into the adipose tissue layer just below the epidermis/dermis
- slow, sustained rate of absorption
- bunch skin, no aspiration or massage
- most common: insulin and heparin
be sure to rotate sites
Subcutaneous injection: special considerations
Heparin: abdomen; avoid 2 inches around umbilicus and belt line
Insulin: insulin syringe with own needle; orange cap
Insulin pens
Insulin pumps
Intramuscular injection info
- administration into the muscle
- faster absorption due to greater number of blood vessels
- careful identification of sites due to nerves, bones, blood vessels
Intradermal injection info
- into the dermis, just below epidermis
- longest absorption time
- skin testing for allergy/presence of disease (TB)
procedure: skin taut, bevel up, cover entire bevel, inject and create wheel/blister, no massage
Intradermal injection sites
inner surface of forearm, upper arm, upper back (no hair)
Intradermal injection needle, gauge, angle
1/4 to 1/2 inch needle
gauge: 25-28
dose small, less than 0.5 mL
angle: 5-15 degrees
IV complications - phlebitis s/s
- local acute tenderness
- warmth, redness, edema above insertion site
IV complications - thrombus s/s
- IV infusion sluggish or may cease
- heat, redness, tenderness at site
IV complications - infiltration s/s
- edema, pain, and coolness at site
- significant decrease in flow rate
IV complications - sepsis s/s
- red, tender insertion site
- fever, malaise, other vital changes
IV complications - fluid overload s/s
- increased BP
- distended jugular veins
- rapid breathing
- dyspnea
IV complications - air embolus s/s
- respiratory distress
- increased HR
- cyanosis
- decreased BP
- change in level of consciousness
AC
before meals
PC
after meals
daily (QD?)
every day
bid
two times a day
tid
three times a day
qid
four times a day
qh
every hour
ad lib
as desired
stat
immediately
q2h
every 2 hours
q4h
every 4 hours
hs
at bedtime
PO
by mouth
IM
intramuscularly
PR
per rectum
SubQ
subcutaneously
SL
sublingual
ID
intradermal
IV
intravenous
IVP
intravenous push
IVPB
intravenous piggyback
NG
nasogastric tub
EC
enteric coated
SR
sustained released
Grading for pulse
0 absent, unable to palpate
+1 diminished (weaker)
+2 brisk (normal)
+3 bounding
Normal blood pressure level for healthy adults
normal: <120/<80
Abnormal blood pressure in adults (wants us to know normal, but adding in abnormal too)
Elevated: 120-129/<80
Hypertension Stage 1: 130-139 OR 80-89
Hypertension Stage 2: >+140 OR >+90
Hypertensive crisis: >180 AND/OR >120
Normal breathing rate for adults
12-20 breaths per min
Normal HR range for adults
60-100 BPM
