Test 2 Flashcards
Administer ear drops procedure
- Instill 1 cm (1/2 inch above ear canal) 2. People 4 years and older - pull auricle up and out People under 4 years - pull auricle down & back 3. Remain side-lying 2-3 minutes. If cotton ball used, remove after 15 minutes 4. Apply gentle massage or pressure to targus unless contraindicated due to pain
Peak level
Time at which a medication reaches its highest effective concentration
Trough level
Minimum blood serum concentration before next scheduled dose
Absorption rates related to way medication is administered, slowest to fastest
Oral and topical - slower Subq - a little faster, but still slowly absorbed IM - faster IV - fastest
Therapeutic effect
Expected or predicted physiological response
Side effect
Unavoidable secondary effect, predictable, may be harmless or may cause injury
Adverse effect
Unintended, undesirable, often unpredictable, effects are immediate, whereas others take weeks or months to develop.
Toxic effect
Accumulation of medication in the bloodstream develop after prolonged intake of medication, or wen a medication accumulates in the blood because of impaired metabolism or excretion. Excessive amounts sometimes have lethal effects.
Idiosyncratic reaction
over-reaction or under-reaction or different reaction from normal
Allergic reaction
unpredictable response to a medication. Medication or chemical acts as an antigen, triggering release of antibodies in the body
Types of medication orders
*Standing or routine: administered until the dosage is changed *prn: as needed *Single (one-time): given one time only for a specific reason *STAT: Single dose of a med given immediately in an emergency *Now: When a med is needed right away, but not STAT (within 90 minutes) *Prescriptions: medication to be taken outside of the hospital
Medication error and what are the nursing implications and responsibility of care for patient
*Report all medication errors - incident report *the nurse first assesses and examines the patient’s condition & notifies the health care provider asap. Then reports the incident to the appropriate person in the institution
Needle stick prevention
*After drawing medication into syringe, use the scoop method to place cap back on needle. After administering the injection, engage safety cap (if available) and immediately discard in sharps container
Topical medication administration
*Use gloves *Use sterile technique if pt has open wound *Clean skin first *Transdermal patches *Remove old patch *Document location of new patch *Apply label to new patch
Potential complications of immobility
metabolic, atelectasis & hypostatic pneumonia, orthostatic hypotension, loss of muscle mass, urinary stasis, pressure ulcer
Definition of stages of decubitus ulcer
*Stage I-intact skin with nonblanchable redness *Stage II-Partial-thickness skin loss involving epidermis, dermis or both *Stage III-Full-thickness tissue loss with visible fat *Stage IV-Full-thickness tissue loss with exposed bone, muscle, or tendon *Unstageable-if you can’t see how deep it is
Passive ROM
Patient is unable to move independently, and the nurse moves each joint through its ROM
Active ROM
Patient moves all joints through their ROM unassisted
Purpose of trochanter roll
Prevents external rotation of the hips when patient is in supine position.
Purpose of trapeze bar
Allows patient to pull with the upper extremities to raise the trunk off the bed, assist in transfer from bed to wheelchair, or perform upper-arm exercises
Purpose of hand rolls
Maintain the thumb in slight adduction and in opposition to the fingers, which maintain a functional position
Purpose of foot boots
to keep feet in proper alignment and to prevent foot drop
Purpose of compression devices or compression hose
decreases venous stasis by increasing venous return through the deep veins of the legs.
Procedure for logrolling patients
*Place pillow between patient’s knees *Cross patient’s arms on chest *Position two nurses on side of bed which patient will be turned. Third nurse is positioned on other side. *Fanfold or roll drawsheet along side of patient *Move patient as one unit in a smooth, continuous motion on the count of three *Nurse on opposite side of bed places pillows along the length of patient *Gently lean patient as a unit back towards pillows for support *Perform hand hygiene
What is footdrop?
Foot is permanently fixed in plantar flexion, patient cannot dorsiflex. Cannot correct it. Patient is no longer ambulatory.
What is primary intention?
Edges are approximated. Surgical incision, wound that is sutured or stapled
What is secondary intention?
Wound heals with scar tissue. (Pressure ulcer, severe laceration) Wound is left open until it becomes filled by scar tissue.
Tertiary intention
Wound left open for several days, then wound edges are approximated. (Wounds that are contaminated & require observation for signs of inflammation.)
Nutrition implications in wound healing, for example, what type of diet
Patients need 1500 kcal/day. Vitamins A & C, calories and proteins are needed to heal.
Braden scale
Total score range from 6 to 23. The lower the total score, the higher the risk for developing pressure ulcer
What is a hydrocolloid dressing and what is it used for?
Dressings with complex formulations of colloids, elastomeric, and adhesive components. The wound contact layer of this dressing forms a gel as fluid is absorbed; maintains a moist healing environment. PURPOSE: support healing in clean granulating wounds and autolytically debride necrotic wounds.
What type of drainage is this?
serous drainage-clear fluid
What type of drainage is this?
Sanguineous drainage-blood
What type of drainage is this?
serous sanguineous drainage-mixture of blood and serous
What type of drainage is this?
purulent drainage-infected; green, yellow, brown
Procedure to obtain wound culture
Never obtain culture from old drainage.
- Cleanse wound with sterile normal saline to remove old drainage and skin flora.
- Use sterile culture swab from culturette tube.
- Rotate swab in 1cm of clean tissue in the open wound.
- Apply pressure to swab to elicit tissue fluid.
- Insert swab into appropriate sterile container, label and send to lab.
What is Dehiscence
Partial or total separation of wound layers.
What is Desiscence?
Partial or total separation of wound layers. Nurse should place a folded thin blanket ro pillow over an abdominal wound when the patient is coughing
What is evisceration?
protrusion of visceral organs through a wound opening. This condition is an emergency. The nurse should place sterile towels soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues.
Restraints and electronic monitoring devices nursing implications, orders, procedures, documentation
Must be clinically justified and part of the patient’s prescribed medical treatment and plan of care.
Person’s comfort zone
between 65 and 75 degrees F
Falls, fall preventions and nursing implications
Falls are leading cause of deaths in adults 64 years or older
Fall Risk Prevention:
- Fall risk bracelet
- Hourly rounds
- Safety rails in bathroom
- Call lights
- Bed in low position
- Restraints as a last resort
- Restraint alternatives (Ambularm, posey bed)
What is equipment related accident?
Result from malfunction, disrepair, or misuse of equipment.
What is patient-inherent accident?
Self-induced; nothing medical personnel could have done to prevent
What is procedure-related accident?
occur during therapy; they include med admin errors, IV therapy errors, improper use of external devices, improper performance of procedure
Seizures (types) and nursing implications in the care of the patient, family teaching
Paroxysmal-
tonicity - rigidity
clonicity - jerking
Should not last more than 5 minutes.
Postictal phase - amnesia or confusion and falls into deep sleep
Status epilepticus - prolonged or repeated seizures - MEDICAL EMERGENCY THAT CAN LEAD TO DEATH
DO NOT PLACE ANYTHING IN THE PATIENT’S MOUTH DURING SEIZURE
