Exam 2 Notes

Chapter 27 Patient Safety

Restraints and Electronic Monitoring Devices

Physical Restraints any manual method, physical or mechanical device, material or equipment that
immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely.

Chemical Restraints are medications.

Restraints are not a solution to a patients problems but rather a temporary means to maintain patient safety.
Should always focus on the cause and elimination of etiology of patients confused state.

Legislation emphasizes reducing restraint use.

o Must be clinically justified and part of the patients prescribed medical treatment and plan of
care.

o Physician order current, based on a face to face assessment, state type and location of restraint,
duration and circumstances under which to be used. Renewed within facility specified time
frame.

o Hospital renewal limited to: 4 hours adult, 2 hours for ages 9-17 and 1 hour for under 9.
o Orders may be renewed to the time limits for a max of 24 consecutive hours.
o Restraints are not ordered PRN.
o Ongoing assessment and removal periodically to determine if still necessary.
Restraints must meet one of the following objectives:
o Reduce the risk of patient injury from falls.
o Prevent interruption of therapy such as traction, IV infusion, NG tube feeding, or Foley
catheterization

o Prevent patients who are confused or combative from removing life-support equipment.
o Reduce the risk of injury to others by the patient.
Electronic Devices used as alternatives to restraints.
o Ambularm worn on leg and signals when patients leg is in a dependent position such as over
the side rails.

o Weight sensitive mats on mattresses or in chairs.

o Alarms on doors.
o Many health care facilities do not allow jackets (vest) restraints due to potential restricted
breathing and circulation or strangulation.

Side rails are not considered a restraint if patient has a route to safely exit bed and maneuver freely in bed.
Same applies with using side rails to prevent sedated patients from falling out of bed.
Persons Comfort Zone:

A patients comfort zone is between 65 and 75 F (18.3 23.9 C)

Temperature extremes that occur in summer and winter affect comfort, productivity, and safety.
Long exposure to cold can cause frostbite or accidental hypothermia. (body temp. below 95 F)
Exposure to extreme heat changes can result in heatstroke or heat exhaustion. Chronically ill patients, older
adults, and infants are at greater risk for injury from heat extremes.
Falls and Fall Preventions:

Falls are the leading cause of unintentional death in adults 64 years or older.
Many different fall prevention assessments are available; use the tool chosen by your health care agency.
It is important to inform family members and the patient about the risks of falling. Often patients are not
aware of how medications and treatments cause dizziness, orthostatic hypotension, or changes in balance.

Some assessment activities include: assessing the patients mobility, conduct a home hazard assessment,
observe gait and posture, assess muscle strength, assess visual acuity with corrective lenses.

It is important to set goals to correct any potential risk for falls, then to make sure the interventions are
carried out, and to follow up with an evaluation of the patients new reduced risk of falling. (Nursing
Process)
Equipment Related Accidents:

These accidents result from malfunction, disrepair, or misuse of equipment or from an electrical hazard.
To avoid accidents, do not operate monitoring or therapy equipment without adequate instruction.
If faulty equipment is discovered, place a tag on it to prevent it from being used on other patients and
promptly report any malfunctions.

Assess any potential electrical hazards to reduce risk of electrical fires, electrocution, or injury from faulty
equipment.

Patient Inherent Accidents:

These are accidents (other than falls) in which the patient is the primary reason for the accident.
Ex: self-inflicted cuts, injuries, and burns; ingestion or injection of foreign substances; self-mutilation or
fire setting; and pinching fingers in drawers or doors.

One of the more common precipitating factors for one of these accidents is a seizure.
Procedure Related Accidents:

These are accidents caused by health care providers and include medication and fluid administration errors,
improper application of external devices, and accidents related to improper performance of procedures
such as dressing changes or urinary catheter insertion.

Many of these are preventable by adhering to organizational policy and procedures and standards of
nursing practice.

All staff needs to be aware that distractions and interruptions contribute to procedure-related accidents and
need to be limited, especially during high risk procedures like med. administration.
Seizure:

Hyperexcitation and disorderly discharge of neurons in the brain leading to a sudden, violent, involuntary
series of muscle contractions that is paroxysmal and episodic, causing loss of consciousness, falling,
tonicity (rigidity), and clonicity (jerking) and incontinence.

Last approx. 2 min; no longer than 5 min.

Aura often a bright light, smell or taste proceeding the seizure. Can serve as a warning or sense that a
seizure is about to occur.

Postictal Phase occurs after the seizure and consists of amnesia or confusion and falls into a deep sleep.
Status Epilepticus indicated by prolonged or repeated seizures and is a medical emergency that requires
intensive monitoring and treatment.

Seizure Precautions protect patient from injury, move items out of the way, position for adequate
ventilation and drainage of oral secretions, provide privacy and support after the seizure.

Do no place anything in the patients mouth during a seizure.

Ch. 31 Medication Administration

Administer Ear Drops:

o Internal ear structures are very sensitive to temperature extremes. So instill eardrops at room
temperature to prevent vertigo, dizziness, or nausea.

o Use sterile solutions in case the eardrum is ruptured. Entrance of non-sterile solutions into middle
ear structures can result in infection. If patient has drainage, be sure that the eardrum is not
ruptured.

o Never occlude or block the ear canal with the dropper or irrigating syringe. Forcing medication
into an occluded ear canal creates pressure that injures the eardrum.

o Place patient in side-lying position with ear to be treated facing up.

o Straighten ear canal by pulling auricle upward and outward for children 4 years or older.

Straighten ear canal by pulling auricle down and back (children younger than 3
years).

o Instill prescribed drops holding dropper 1 cm (1/2 in) above ear canal.
o Ask patient to remain in side-lying position 2-3 minutes. If cotton ball is needed place in
outermost part of canal and remove after 15 minutes.

o Apply gentle massage or pressure to tragus of ear unless contraindicated due to pain.

Medication Dose Responses:

o Peak Time it takes for medication to reach its highest effective concentration.
o Trough Minimum blood serum concentration of medication reached just before the next
scheduled dose (lowest level).

Intramuscular Injections Administration and Implications:

o The IM route provides faster medication absorption than the subcutaneous route because of the
greater vascularity of the muscle.

o There are also many risks, so verify the injection is justified.

o The angle of administration is 90 degrees with a larger needle width and length to penetrate the
muscle tissue.

o Needles

Very Obese 3 inches; use a different route if possible

Thin in to 1 in

Adults 2 to 5 ml can be absorbed in a large muscle

Children, older adults, and thin tolerate up to 2 ml

Small children and infants no more than 1 ml

Smaller infants no more than 0.5 ml

o Amounts

o Assess the muscle and site before giving the injection

o Properly identify the site by palpating bony landmarks, and be aware of potential complications
with each site.

Area should be free of tenderness, hardened lesions, infection, and necrosis.

Are there local areas of bruising or abrasions?

What is the location of underlying bones, nerves, and major blood vessels?

Ventrogluteal preferred and safest site for IM in all patients, recommended for
volumes greater than 2 ml. To locate, place palm over the greater trochanter, point
thumb towards groin, and index finger toward the anterior superior iliac spine,
extend the middle finger back along the iliac crest toward the buttock. The index
finger, middle finger, and iliac crest form a triangle; the center of this is the site.

Vastus Lateralis located on the anterior lateral aspect of the thigh, extends from
one hand width above the knee and below the greater trochanter. Use middle 1/3 of
muscle for injection. Often used for infants and small children receiving biologicals
(immunoglobins, vaccines, or toxoids)

Deltoid potential for injury because the axillary, radial, brachial, and ulnar nerves,
as well as the brachial artery, lie within the upper arm. Use this site for small
injection volumes (2 ml or less). Used commonly for immunizations. Palpate lower
edge of acromion process, site is about 3-5 cm (1-2 in) below.

o Sites

o Z-Track Method

Used to minimize local skin irritation by sealing the medication in muscle tissue.
Protects subcutaneous tissue from irritating parenteral fluids.

Place ulnar side of non-dominant hand just below the site and pull the overlying skin
and subcutaneous tissues about 2.5-3.5 cm (1-1.5 in.) laterally or downward. Hold
skin here until you administer.

After preparing the site with antiseptic wipe, inject the needle deep into the muscle.
Grasp barrel of syringe with thumb and index finger of non-dominant hand and
slowly inject the medication at a rate of 10 sec/ml, if there was NO blood return on
aspiration.

Needle remains inserted for 10 sec. to allow the medication to disperse evenly rather
than channeling back up the needle track.

Release the skin after withdrawing the needle. Leaves a zigzag path that seals the
needle track where tissue planes slide across one another. Med. cannot escape from
muscle tissue.

Injections using this method result in less discomfort and decrease the occurrence of
lesions at the injection site.

Subcutaneous Injections Administration and Implications:

o Subcutaneous injections involve placing medications into the loose connective tissue under the
dermis.

o Absorption is slower than with IM injections because subcutaneous tissue is not as richly supplied
with blood as the muscles. Patient may experience slight discomfort because subcutaneous
tissue has pain receptors.

o Sites

Outer posterior aspect of the upper arms

Abdomen from below the costal margins to the iliac crests (most common for
heparin)

Anterior aspects of the thighs

Alternative sites include scapular areas of the upper back and the upper ventral or
dorsal gluteal areas

o The site chosen should be free of skin lesions, bony prominences, and large underlying muscles or
nerves.

o The administration of low-molecular-weight heparin (LMWH) requires special considerations.

Use abdomen site 2 in. away from umbilicus (love handles) and pinch injection site. Use
prefilled syringe and attached needle and do not expel the air bubble in the syringe.

o Insulin considerations: use U-100 insulin syringes with preattached 25- to 31-gauage needles
when giving U-100 insulin and 1 ml tuberculin syringes when giving U-500 insulin. Rotating
injections within the same body part (intrasite rotation) provides more consistency for
absorption; new site should be 2.5 cm away from previous site. No injection site should be used
again for at least 1 month.

o Only small volumes (0.5 1.5 ml) of water-soluble medications are given subcutaneously because
tissue is sensitive. Collection of medications in the tissues causes sterile abscesses, which
appear as hardened, painful lumps under the skin.

o A patients body weight indicates the depth of the subcutaneous layer. Choose the needle length
and angle of insertion based on the patients weight and estimated amount of subcutaneous
tissue.

If you can grasp 2 in. of tissue, insert the needle at a 90 degree angle.

If you can grasp 1 in. of tissue, insert the needle at a 45 degree angle.

o If patient is obese, pinch the tissue and use needle long enough.
o Thin patients often do not have sufficient tissue for subcutaneous injections; the upper abdomen is
usually the best site in this case.

o When administering, hold skin taut or bunch the skin around the site. Inject needle quickly
at appropriate angle. Release the tissue, steady syringe with non-dominant hand, use
dominant hand to inject medication slowly. Withdraw needle at the same angle that it was
inserted. Apply gentle pressure with alcohol pad. Do not massage site. Apply bandage if
applicable.

Intradermal Injections Administration and Implications:

o Typically used for skin testing (Ex: tuberculin screening and allergy tests).
o Because these medications are potent, they are injected into the dermis, where blood supply is
reduced and medication absorption occurs slowly.

o Skin testing requires the nurse be able to clearly see the injection site for changes in color and
tissue integrity.

o Site needs to be lightly pigmented, free of lesions, and relatively hairless. Inner forearm and
upper back are ideal locations.

o Use a tuberculin or small hypodermic syringe for skin testing.

o Angle of insertion is 5-15 degrees with bevel up.

o As you inject, a small bleb will form. If bleb does not form or the site bleeds after needle
withdraw, there is a good chance that the medication entered the subcutaneous tissue. In this
case test results will not be valid.

Absorption Rates Related to way Medication is Administered:

o Absorption is the passage of medication molecules into the blood from the site of medication
administration.

o Factors influencing absorption:

Route of administration

Ability to dissolve

Blood flow to site of administration

Body surface area

Lipid solubility of medication

o Topical administration has the slowest rate of absorption.

o Mucous membranes and the respiratory tract have a quick rate of absorption.
o IV administration has the fastest absorption rate.
o The oral route takes some time owing to the passage of medications through the GI tract.
o When the site of administration contains a rich blood supply, the medication will be absorbed
quickly.

o Some medications interact with food; it is often appropriate to administer them before or after
meals, with meals, or on an empty stomach.

Types of Medication Action:

o Therapeutic Effects expected or predicted physiological response

Ex: Nitroglycerin reduces cardiac workload and increases myocardial oxygen supply

o Side Effects predictable and often unavoidable secondary effects produced at a usual therapeutic
dose, may be harmless or may cause injury

Ex: some antihypertensive medications cause impotence in men

o Adverse Effects unintended, undesirable, and often unpredictable severe responses to

medication, may be immediate or take months to develop, health care providers report adverse
effects to the FDA using the MedWatch program

Ex: penicillin has caused seizures and serum sickness in some cases

o Toxic Effects develop after prolonged intake of a medication or when a medication accumulates
in the blood because of impaired metabolism or excretion. Excessive amounts sometimes have
lethal effects

Ex: toxic levels of morphine cause severe respiratory depression and death;
antidotes are available like naloxone (Narcan) which reverse the effects of opiod
toxicity

o Idiosyncratic Reactions overreaction or under reaction or a different reaction from normal

Ex: a child who receives Benadryl (antihistamine) becomes extremely agitated or

excited instead of drowsy

o Allergic Reactions unpredictable responses, the medication or chemical acts as an antigen,

triggering the release of antibodies in the body

Ex: patient allergic to penicillin can develop symptoms of urticaria; individuals with
severe peanut allergies can have anaphylactic reactions when exposed

Types of Medication Orders and Nursing Implications:

o Standing or Routine Orders administer until the dosage is changed, another medication is
prescribed or the prescribed number of days elapses

Ex: Tetracycline 500 mg PO q6h

Ex: Decadron 10 mg daily X 5 days

o prn Orders to be given when patient requires it, use objective and subjective assessment and
discretion in determining whether or not the patient needs the medication

Ex: Morphine sulfate 2 mg IV q2h prn for incisional pain

When administering, document the assessment findings that show why the patient
need the medication and time of administration, frequently evaluate and document
effectiveness of medication

o Single (One-Time) Orders given one time only for a specific reason

Ex: Ativan 1 mg IV on call to MRI

o STAT Orders signifies that a single dose of medication is to be given immediately and only
once, usually written for emergencies

Ex: Apresoline 10 mg IV STAT

o Now Orders when a medication is needed quickly, but not STAT, nurse has up to 90 minutes to
administer, only administer now medications one time

Ex: Vancomycin 1 mg IV piggyback now

o Prescriptions written prescriptions for patients to take medications outside the hospital

Medication Errors and Nursing Implications and Responsibility of Care for Patient:

o Medication errors can cause or lead to inappropriate medication use or patient harm
o Medication Errors include

Inaccurate prescribing

Administering the wrong medication

Giving the medication using the wrong route or time interval

Administering extra doses or failing to administer a medication

o Report all medication errors!

o Patient safety is top priority when an error occurs.
o When an error occurs, the nurse must first assess and examine the patients condition and notifies
the health care provider of the incident as soon as possible. Once the patient is stable, the nurse
reports the incident to the appropriate person in the institution.

o Documentation is required, Incident Report, the nurse is responsible for preparing a written
incident report: an accurate, factual description of what occurred and what was done. (Within 24
hours)

o Reconciling the list of a patients medications is essential to medication safety, nurses play an
essential role in medication reconciliation.

6 Rights of Medication Administration:

o Right medication
o Right dose
o Right patient
o Right route
o Right time
o Right documentation

Nurse Critical Thinking for Adjusting Time of Medication Administration:

o Need to know why a med. is ordered for certain times of the day and whether you are able to alter
the time schedule.

o Prescriber often gives specific instructions about when to administer a medication

Preoperative med. to be given on call means the nurse gives the med. when the
OR staff members notify that there are coming to get the patient

Give meds. ordered PC (after meals) within half hour after meals

Give STAT meds. immediately

o Give priority to time-critical medications that must act and therefore be given at certain times.
Administer time-critical meds. within 30 mins. before or after their scheduled time.

Give insulin (time critical) at a precise interval before meals

Give antibiotics 30 mins. before or after they are scheduled, around the clock to
maintain therapeutic blood levels

Give all routinely ordered non-time-critical meds. within 1 to 2 hours before or after
scheduled time per agency policy

o Some require nurses clinical judgments:

Administer prn sleeping meds. when patient is ready for bed

Use judgment when administering analgesics, for example a nurse requires a STAT
order from prescriber if patient requires a med. before the prn interval has elapsed

o Before discharge, evaluate a patients need for home care especially if admitted because of a
problem with medication self-administration

o Help to plan schedules for self-administration when home, use charts or pill containers to make
organization easy.

Ways to Reduce Needle Sticks:

o Avoid using needles when effective needleless systems or sharps with engineered sharps injury
protection (SESIP) safety devices are available.

o Do not recap any needle.

o Plan safe handling and disposal of needles before beginning the procedure.
o Immediately dispose of needles, needleless systems, and SESIP into puncture-proof and leak-proof
sharps disposal containers.

o Maintain a sharps injury log that includes the following:

Type and brand of device involved in the incident

Location of the incident (department or work area)

Description of the incident

Privacy of the employees who have had sharps injuries

Topical Medication Administration and Implications:

o Medications forms commonly prepared for topical administration:

Ointment

Liniment

Lotion

Paste

Transdermal disk or patch

o Skin Applications

Use gloves

Use sterile technique if the patient has an open wound

Clean skin first

Follow directions for each type of medication

o Transdermal Patches

Remove old patch before applying new

Document the location of new patch

Ask about patches during the medication history

Apply a label to the patch if it is difficult to see

Document removal of patch as well

o Nasal Instillation

Spray, drops, or nasal tampons

Most common is decongestant sprays, caution overuse because can lead to rebound
effect in which nasal condition worsens

Easier to have patient self-administer sprays because they are better able to control
the spray and inhale as it enters the nasal passages; check for irritation of nares

When instilling drops position the patient to permit the medication to reach the
affected sinus

Tilt head backward for access to posterior pharynx

For access to ethmoid and sphenoid sinuses, tilt head back over edge

For access to frontal and maxillary sinuses tilt head back over edge of
bed or pillow with head turned toward the side to be treted

Support patients head with nondominant hand

Instill drops toward midline of ethmoid bone, and have patient remain in
supine position for 5 minutes

Nosebleeds treated with nasal tampons (usually placed by physician)

o Eye Instillation

Eye drops and ointments

Avoid instilling any form of eye meds. directly onto cornea, many pain fibers

Avoid the eyelids with droppers or tubes to decrease the risk of infection

Use only on the affected eye

Never allow a patient to use another patients medication

Age-Related Problems:

Poor vision, hand tremors, difficulty grasping containers

Affect the older adults ability to self-administer

Instruct patients and family members about proper techniques for administration,
determine their ability to self-administer through demonstration of procedure, show
them each step to improve adherence

o Intraocular Instillation (Insertion into body cavity?)

Resembles a contact lens

Teach patients how to insert and remove the disk

Teach about adverse effects

o Ear Instillation

Structures are very sensitive to Temp; instill eardrops at room temp. to prevent
vertigo, dizziness, or nausea

Use sterile solutions

Drainage may indicate eardrum rupture

Never occlude the ear canal with dropper or irrigating syringe

Do not force medication into an occluded ear canal, creates pressure that injures the
eardrum

Instill 1 cm (1/2 in) above ear canal

Pull auricle back and up for adults because ear canal slants downward; for children 3
years and younger pull auricle back and down because canal slants upward.

Remain side lying for 2-3 mins.; if cotton ball used remove after 15 mins.

Apply gentle massage or pressure to targus unless contraindicated due to pain

o Vaginal Instillation

Suppositories, foam, jellies, or creams

Use gloved hand for suppository insertion; patient often prefer self-administration
and require privacy

Applicator used for foam, jellies, or creams

Dorsal recumbent position for administration

Suppository

Lubricate end of suppository and gloved index finger of dominant hand

Expose vaginal canal with nondominant hand pulling back labial folds

With gloved dominant hand gently insert rounded end of suppository

along posterior wall of vaginal canal entire fingerlength

Cream or Foam

Gently insert applicator 5 7.5 cm (2-3 in). Push applicator plunger to

deposit

o Rectal Instillation

Rounded end prevents trauma upon insertion, these suppositories contain meds. that
exert local effects such as promoting defecation or systemic effects such as reducing
nausea.

Help patient to Sims position, examine anal area condition

Apply new clean gloves, remove suppository and lubricate rounded end and index
finger of dominant hand

Ask patient to take slow deep breaths through mouth and relax anal sphincter

Retract buttocks with nondominant hand, insert suppository gently through anus,
past internal sphincter and against rectal wall, 10 cm (4 in) in adults, 5 cm (2 in) in
children and infants

Apply gentle pressure to hold buttocks together momentarily if needed to keep

medication in place

Ask patient to remain flat or on side for at least 5 mins. to prevent expulsion

Drawing up Medications from Vials and Ampules:

o Ampule:

Contain single doses of medication in liquid form

Ampule is made of glass with a constricted neck that must be snapped off to allow
access to the medication

A colored ring around the neck indicates where the ampule is prescored so you can
break it easily

Tap top of ampule lightly to move fluid from the neck of ampule

Wrap gauze pad or alcohol wipe just above neck and snap neck quickly and firmly
away from hands

Set open ampule on flat surface and draw up medication while not allowing needle
to touch rim of ampule

Carefully aspirate the medication into syringe using a filter needle

If air bubble aspirated, do not expel air into ampule

If excess liquid drawn up dispose of in sink or other specialized medication disposal

area

Replace filter needle with an appropriate-size needle

Label syringe with initial, medication and dose, date

Remove cap covering top of unused vial to expose sterile rubber seal. If multidose
vial has been used firmly and briskly wipe rubber seal with alcohol swab

o Vial

Pull back plunger of syringe to draw amount of air into syringe equal to volume of
medication to be aspirated from vial

With vial on flat surface, insert tip of needle through center of rubber seal

Inject air into the airspace of the vial, holding on to plunger

Invert vial holding with nondominant hand and grasp end of syringe barrel and
plunger with thumb and forefinger of dominant hand to counteract pressure in vial

Keep tip below fluid level

Allow air pressure to fill syringe gradually, if necessary pull back on plunger