FINAL EXAM Units 9-12 Flashcards
What factors must the psychiatric nurse consider when evaluating the patient’s ability to mobilize?
Body Alignment/Posture
Gait
Activity Tolerance
Motor Strength/Control
Level of Assistance
Use of Mobility Aids
** Assess cooperation, behavior, current medical status, pain & comfort, and vital signs **
What is Passive ROM
Patient is unable to move independently
Nurse moves joint manually
What is Active ROM
Patient is able to move all joints through ROM unassisted
What safety issues are present for the nurse and the patient when ambulating, positioning, and/or transferring patients?
Fall Risks
Injury
Fatigue
What are safety issues related to the use of hydraulic and ceiling lifts?
Proper use of equipment
Is it within your scope of practice
Client safety/concern
Correct application
What assistive devices can the psychiatric nurse utilize to make lifting, transferring, and moving patients safer and easier?
Transfer Sheet
Transfer Belt (provides support for nurse when mobilizing patient)
Equipment aids (Wheelchair, walker, cane etc)
Health care providers/caregivers
Mechanical Lifts
Slider Board
What nursing interventions would a psychiatric nurse implement if a patient had an unwitnessed fall?
Call for help
Ask and inspect for head injury (head impact)
Transfer to bed
Pain Management
Communicate and report (agency policy)
What nursing interventions would a psychiatric nurse implement if a patient had witnessed?
Witnessed: LOC, CWMS, Vitals, Injuries, Blood glucose levels
Transfer to bed
Pain Management
Communicate and report (agency policy)
If a patient was going to fall, how would the psychiatric nurse safely lower the patient to the ground?
Move behind patient. Take one step back
Support patient’s waist/hip. Put your leg between patient’s legs.
Slide patient down your leg lowering yourself at the same time.
Assess patient for injuries before moving them.
Reassure patient and seek help.
Document per agency policy.
What are the seven essential components of a medication order?
Date and time order was written
Name of Client
Name of Medication (Generic or trade name)
Dosage
Route
Frequency
Signature of Prescriber
What actions should the psychiatric nurse take if they are unable to read a medication order?
Do not administer!
Clarify with doctor first
What assessments should the psychiatric nurse perform prior to medication preparation and administration?
Allergy history
Diet history
Patient’s medical history
Patient’s current condition
Perceptual or coordination problems
Medication data
Attitude toward medication use
Knowledge and understanding of medication therapy
Learning needs
Where can the psychiatric nurse find patient allergy information?
Chart, noted on MAR or patient identifier
What are the 3 medication checks?
Before
During
After
What are the rights of medication administration?
The right medication
The right dose
The right patient
The right route
The right time and frequency
The right documentation
The right reason
The right to refuse*
The right patient education*
The right evaluation*
What are two patient identifiers?
Name
Hospital Number
DOB
What do you need to know about the medication that you are administering? (psychodynamics)
Reason the client is receiving the medication
Drug classification
Drug Action
Contraindications
Usual dosage range
Side effects
Special nursing considerations
What is the procedure for administering oral medications?
Sublingual (under tongue)
Buccal (inside cheek)
How do you maintain aseptic technique while preparing and administering medications?
Work on a clean surface
Hand hygiene
Avoid touching the medication with fingers (open med into cup)
What are the five essential components of a Medication Administration Record?
Two Patient Identifiers (Name, Hospital Number, DOB)
Date
Allergies
RN/RPN/LPN Signature
Medication name, dose, route, frequency & time
What could constitute a medication error?
A medication error is any event that could cause or lead to a patient either receiving inappropriate medication therapy or failing to receive appropriate medication therapy.
Omission
Incorrect Time
Incorrect Drug
Incorrect Dose
Incorrect Route
Incorrect Patient
Incorrect Preparation
What is the procedure for reporting and documenting medication errors?
Acknowledge and take responsibility for the error when it occurs
Patient safety is a top priority
Assess the patient
Notify the physician or prescriber ASAP
Document the incident
Report the incident
Reflect
What does a drugs generic name refer to? and example
the name given by the developer of the drug.
ex. ibuprofen
What a drugs brand name refer to? and example
name given by manufacturer
ex. advil
What is the sequence for writing a medication order?
- pt name and medical number
- write date and time
- generic drug name
- dosage
- route
- frequency of dosing
- signature, printed name, college ID number
What are the conversions for grams, milligrams, and micrograms?
gram to milligrams = divide by 1000
ex. 5.0/1000 = 0.05
What is the conversion factor method?
- if converting from smaller to larger unit, divide given quantity by conversion factor
- if converting from larger to smaller unit, multiply given quantity by conversion factor
What steps should you take prior to feeding?
Assess risk for aspiration, dietary restrictions and ability to feed self
Position patient into high fowlers/upright
Perform oral hygiene if required
Apply clothing protector, hearing aids, glasses/dentures if required
What steps should be performed during feeding?
Use rocking motions of utensils on patients tongue
Give small bites and offer water in between bites, 15 second intervals in between
Assess for dysphagia throughout
What steps should you take after feeding?
Maintain upright position 30 minutes post feeding
Perform oral hygiene
What are symptoms of dysphagia?
Coughing
Choking
Gagging
Drooling
Pocketing food in cheeks
Regurgitation
What’s the purpose of elastic stockings?
Prevent thrombus formation
What is the difference in the purpose of briefs for women VS men?
Women = urination & defecation
Men = mainly defecation
What is the formula for calculating medication dosages?
desired dose/quantity on hand = x
D/H=X
What is meant by the term enteric coated tablets?
- formulated to dissolve in intestine
- reduces gastric irritation
- reduces staining of mouth and oral mucosa
- prevents drug from being destroyed by stomach acid
- never crush, break or chew
What is meant by the term sustained release/controlled release/long acting?
- formulated to deliver the drug over a 24 hr period
- crushing may lead to overdose or insufficient drug levels
How do you apply elastic stockings?
like putting on tights
- turn inside out until heel
- place bottom of stocking on foot, pull the rest up
- make sure they are smooth and straight
What nursing assessments would the psychiatric nurse make in relation to the application of elastic stockings?
- integumentary: inspect for wounds, poor skin integrity, anything that would make the stockings uncomfortable or painful
- CV: check cap refill of toes, ensuring circulation, inspect/palpate edema
How does the psychiatric nurse apply and remove a bedpan?
applying: tell pt to bend at the knees, have them lift their buttocks or assist them in doing so, slide the bedpan underneath
removal: ensure the bed is in a flat position, instruct pt to lie on side, clean pt
When would a patient require the use of a bedpan?
- pts who are incontinent or immobile may require the use of a bedpan
What type of patient would use the fracture/slipper type of bedpan
- fracture: pts who have fractured bones in lower extremities/hips/spine cannot ambulate to bathroom
