Nursing Process
What are the 5 steps of the nursing process?
Assess - gather information about the patient’s condition
Diagnose - identify the patient’s problems
Plan - set goals of care and desired outcomes and identify appropriate nursing actions
Implement - perform the nursing actions identified in planning
Evaluate - determine if goals and expected outcomes are achieved
What kind of medications should not be cut or crushed?
sublingual/buccal, enteric-coated, and/or time-released medications, capsules
STAT
Give immediately
What angle should you use for an intramuscular injection?
90 degree angle
How many mLs are in 1 ounce?
30 mL/1oz
What does OLDCARTS stand for?
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Treatment
Severity
What is a rebound effect? Provide an example.
Rebound effect: the emergence or re-emergence of symptoms that were either absent or controlled while taking a medication
Example: Prolonged use of nasal sprays can increase mucosal swelling and nasal congestion
NPO
Nil per os
Nothing by mouth
What angle should you use for an insulin injection?
45 to 90 degree angle
How many lbs are in 1 kilo?
2.2 lbs/kg
What does MOVES stand for? What is its purpose?
Purpose: Establishes a formal, systematized SPHM program that will identify and mitigate risk during patient handling, movement, and mobility tasks through use of SPHM practices, including use of appropriate technology, equipment, and technique. The goal of the program is to avoid high risk patient handling tasks, whenever possible, with the exception of emergency situations. All staff should use SPHM technology for patient handling tasks > 15.9 kg (35lbs)
“Move often, very early, and safely”
Myocardial concerns-
new MI by EKG or elevated cardiac enzymes
antiarrhythmic infusion added within the last 12 hours
unstable dysrhythmia within the last 12 hours
changes to flolan or veletri dosing within the last 30 minutes
Oxygenation concerns -
Sustained desaturation <88% or patient specific goal
Increases in ventilator support within the last 4 hours
Current ventilator settings FiO2 > 80%, PEEP >16, and plateau pressures >30
Oxygenation requirements of FiO2 100% in non-ventilated patients
Vasoactive concerns -
Increase in vasoactive requirements over the last 2 hours
New vasoactive added in last 2 hours
Engagement concerns-
New undetermined/undiagnosed change in neuro status
Cervical or spinal injury without clearance
Special Considerations -
Hemi-crani that does not have a helmet
Neuromuscular blockade agents, epidurals, nerve blocks, special lines
Combative or violent behavior (RASS +3 - +5)
Give at least 3 situations in which you would not give an oral medication?
The patient is nauseated
The patient is vomiting
The patient has decreased intestinal motility
The patient is NPO
The patient cannot swallow
The patient has a nasogastric tube
Q
every
____ to ___mL can be injected into the deltoid.
0.5-2mL
How many milligrams are in 1 gram?
1000mg/g
Goals and outcomes should be...
HINT: It's an acronym
SMART
Specific
Measurable
Achievable/obtainable
Realistic
Timely/timed
Name two health conditions that may require the use of an inhaler or small-volume nebulizer
Asthma/COPD
IV
intravenous
___ to __mL can be injected into the vastus lateralis.
2-3mL
How many kilograms are in 1lb?
0.454 kg/lb
What are the ABCs of prioritization?
Airway
Breathing
Circulation
Disability
Exposure
What are the 10 rights of medication administration?
Right Medication
Right Patient
Right Dose
Right Time
Right Route
Right Documentation
Right Education
Right Assessment
Right Evaluation (Effect/Response)
Right to Refuse
PRN
as needed
When would you use the Z-track technique? What is its purpose?
Intramuscular injections
Used to prevent tissue irritation caused when medication leaks into subcutaneous tissues
How many mLs in 1TBSP?
15mL/TBSP