2026 STUDY GUIDE FOR NFDN 1002 Nursing Foundations II Basic Nursing NorQuest College

2026 STUDY GUIDE FOR NFDN 1002 Nursing Foundations II: Basic Nursing NorQuest College

NFDN 1002 STUDY GUIDE

UNIT 1: Foundations in Basic Nursing Practice Topic 1.1: The Adult and Older Adult 1. Describe major life events and developmental tasks of middle-aged and older adults and how they may differ across cultural groups.

Middle age (mid-late 20s – Mid 60s) •

Reproductive and physical health changes, begin to help aging parents, use leisure time in creative and satisfying ways.

Older adult (65+) • •

Declining health, retirement, death Things slow down in the older adult.

2. Describe common cognitive, physiological, sensory, and psycho-social changes associated with aging, including how the experience of change and loss may impact an older persons’ health.

Cognitive:

Misconceptions: Forgetfulness is not an expected finding.

Normal changes: Decreased brain cells, changes in the neurotransmitter levels.

Symptoms/signs of impairment: Disorientation, loss of language skills, poor judgement.

Common conditions: Delirium (acute), dementia (chronic), and depression (emotional state any age).

Physiological: Integumentary:

Wrinkles, loss of collagen and subcutaneous tissue.

Respiratory: Decreased cough reflex, risk of infection increases, decreased lung capacity.

Cardiovascular: Increased muscle hardness, less cardiovascular output, weaker generally.

GI: Decreased saliva, decreased peristalsis, increased constipation, increased bowel cancer, hemorrhoids.

MSK: Wasting of muscles (atrophy).

Neurological:

Sensory- eyes, ears, taste, smell, touch, proprioception: Decreased vision and hearing, Macular degeneration, glaucoma, decreased taste buds.

GU:

Reproductive:

Endocrine:

Immune:

Declines. Risk for infection.

Psycho-social: • Adaptation in roles and relationships Becoming a grandparent, adult children becoming caregivers • Retirement • Social isolation • Abuse • Sexuality • Housing and environment • Death 3. Describe nursing interventions related to the physiological, cognitive, and psycho-social changes of aging.

Physiological: •

Nursing to help prevent health conditions (HTN, diabetes, cataracts) Encourage: • Regular exercise • Weight reduction • Management of HTN • Smoking cessation • Immunizations • Health screenings (BP, cholesterol, rectal/breast exams, etc.)

• • • • • • • • • •

Nurse to provide education regarding: Cancer – early detection Heart disease – how to prevent, how to treat (medications) Smoking – risks, assistance with cessation Alcohol abuse – risks, assistance with cessation Nutrition – importance to overall health, eating habits Oral health – importance to overall health, healthy habits, proper care Arthritis – comfort, functional ability, safety Sensory problems – assistive devices (hearing aids, glasses) Pain – maximize function, improve quality of life

•

Medications – polypharmacy, ensure that medications are providing therapeutic effect

Cognitive: •

Cognitive stimulation – engage in games (improves cognition)

Psycho-social: •

Therapeutic communication – attentive, caring, knowledgeable

•

Touch – gentle touch to show respect and sensitivity

•

Reminiscence – recalling the past

•

Body image interventions – assist with grooming (shaving, combing hair, cleaning dentures, changing into street clothes)

4. Describe interventions for preventing sensory alterations.

Quiet room Sit facing the older adult If masks required, pay special attention to body language If applicable ensure older adult is using assistive devices (glasses, hearing aids) Speak slow and clear Speak in low tone Summarize older adults’ points to ensure you understood Ask the older adult to explain what they understood Decreased taste:

Enhance remaining taste perception, including oral hygiene.

Decreased smell (olfaction): Can lead to safety concerns, nutritional concrerns.

Decreased Tactile: Reduced sensation Decreased visual: Orientating to environment

5. Describe altered drug responses and implications in older adults.

At risk of adverse drug reactions related to: Changes in absorption, distribution, metabolism, excretion Drugs might cause: Confusion Imbalance Changes in mobility Dizziness Nausea/vomiting/constipation Urinary frequency/incontinence 6. Identify what nursing assessments and interventions are appropriate when altered drug responses occur.

Nursing role: •

Educate about OTC drug use

• • • • •

Educate about drug names, how to take them, desired and undesirable effects Educate both client and family Review client drugs each visit Encourage use of assistive devices Question physicians about prescriptions

7. List factors that may affect a client’s ability to perform self-care.

Functional status: ability to safely preform ADL’s F- Fluids A – Aeration N- Nutrition C – Communication A – Activity P – Pain E – Elimination S – Socialization FANCAPES** Need to assess to be safe and healthy Hydration and fluid level Gas exchange, breathing etc.

Ability to eat and grocery shop Ability to hear see and speak and comprehend Exercise balance etc Level of acceptable pain Assessing bowel and bladder function Relationship status’s, social interactions.

Topic 1.2: Setting Priorities and Organizational Plans 1. Determine the purpose of an organizational plan for nursing care.

Things can get busy Try to plan your day to get everything done Organize your thoughts

See what is already done and what needs to be done Prioritizing the most important over less important.

2. Describe methods to set priorities for client care/ Describe key strategies nurses use to manage their time.

High Priority Safety, oxygenation, circulation ABC’s Intermediate Priority Non-life threatening Low Priority Long-term care needs ▸ ▸ ▸ ▸ ▸ ▸

Assessment Identify problems and Prioritize Identify outcomes Identify interventions and Prioritize Deliver care Evaluate

▸ Developing lists ▸ Determine Priorities ▸ Delegating appropriate tasks 3. Describe how SBAR is used to implement nursing priorities.

Situation Background Assessment Recommendation

4. Explain the importance of time management when providing nursing care.

5. Utilize an organizational plan to practice priority-setting methods and time-management skills.

6. Critique the reflective practice model and discuss selfreflection as part of the nursing process.

Topic 1.3 Patient Education 1. Determine the goals of health teaching.

May vary based on the health care setting.

Teaching requires effective communication, this involves listening, observing, and speaking clearly.

Health promotion Restore health Chronic disease management Palliative care Maintain/ optimize quality of life Guide patients to make optimal health decisions.

Knowledge is limited, beliefs change, and conclusions are tiemporary Nonetheless, a well-designed, comprehensive teaching plan that meets a learner’s needs

• • • •

improve quality of care, help patients gain optimal wellness, increase their independence, reduce health care costs (Bastable, 2019).

• • • • • • •

What does the client need to know?

• PRIORITY Learning need Style of learning Learning domains Barriers Teaching methods (setting, timing, strategies) Materials/resources Readiness to learn.

Environment

2. Integrate the principles of learning as it applies to the role of the practical nurse in client education.

Active participation: Both are involved in the learning process, it is dynamic , and changing.

Provides opportunity for feedback, mutual goal setting, revision of the teaching plan.

At times client and families goal need to be in alignment, The more senses used, the better.

Use of your voice, changing tone, intensity , eye contact , gestures, asking questions, encouraging participation.

Can cause conflict if family not involved or understanding Can cause client/family to be more health conscious – likely to seek assistance earlier Greater knowledge, greater health Can assist with recovery

Be aware that family member may be reluctant to discuss.

Is patient able to understand (developmental stage, receiving narcotics, flooded with information) Learning environment:

• • • • • • • • • •

Be organized, Determine what is important What is the priority?

Look at immediate needs, Nursing dx, pt concerns, anxiety and time available to teach.

Progress from simple to complex Essential components need to be taught first. ( what do they need to know, versus what is nice to know) Summarize and review. Throughout.

Nurses need to assess the following factors when choosing a teaching environment: Setting is important, community locations, classroom, hospital room, trend toward digital health. And even self learning modules.

Lighting, noise, comfort, temperature, time of day Distractions or persistent noise (A quiet area should be set aside for teaching.)

Comfort of the room, including ventilation, temperature, lighting, and furniture, and Room facilities and available equipment Assess physical comfort- pain , hunger ?

3. Examine characteristics of cognitive, affective, and psychomotor domains of learning.

Cognitive domain: • • • • • • • •

Development of mental skills Intellectual ability to acquire knowledge Categories: Knowledge: ability to recall information Comprehension: ability to understand the meaning Application: ability to apply knowledge in a new situation Analysis: ability to differentiate facts and opinions Synthesis: ability to integrate concepts to form a pattern or structure in a new meaning

•

Evaluation: ability to come up with judgements about importance of concepts Teaching Methods Cognitive

• • • • • • •

Discussion Storytelling Lecture Questions and Answer Role Play and Discovery - this could be simulation Project ( computer or Field experience) Teach back Affective domain:

• • • • • • • • • • • •

Involves feelings, emotions, and attitudes Categories: Receiving phenomena: awareness of feelings and emotions and ability to use selected attention Responding to phenomena: active participation Valuing: ability to see worth and express it Organization: ability to prioritize value over another Characterization: ability to internalize values and control behaviour Role playing Willingness to listen, Simplest is receiving information.

If angry , not effective.

Anxious Respecting values Psychomotor domain:

▪ ▪ ▪ ▪ ▪ ▪ ▪

Using motor skills and coordinating Involves mental and physical ability Categories: Perception: ability to apply sensory information to motor activity Set: readiness to act Guided response: ability to imitate displayed behaviour Adaptation: ability to modify learned skills Simple to complex Adapt to changes

▪ ▪ ▪ ▪

Demonstration Practice Return Demonstration Independent projects Receiving: the willingness to attend to another person’s words Responding: active participation through listening and reacting verbally and nonverbally Valuing: attachment of worth to an object, concept, or behaviour, demonstrated by the learner’s actions Organizing: development of a value system by identifying and organizing values and resolving conflicts Characterizing: action and response with a consistent value system

4. Explain the importance of the client and family being active participants in health education and learning.

Patient-centered approach to patient education, - establishes a partnership with the client. nurses help patients actively participate in their education and better self-manage their needs and care with the support of health care providers across health care settings.

How do we provide Pt centered care? ( LEARNS Model ) • Listen to patient needs.

• Establish therapeutic relationships.

• Adopt an intentional approach to every learning encounter.

• Reinforce health literacy.

• Name new knowledge via teach-back.

• Strengthen self-management via links to community resources Using this approach, the patient is involved as a partner in the learning process.

5. Compare the elements of the nursing process and the teaching process.

Gather data about learning needs, learning needs from 3 domains, learning objectives/priorities/teaching method, teaching methods implemented/involve family, measure ability to learn objectives/ reinforce PRN Nursing Process Assessment •

Collect data about patient’s physical, psychological, social, cultural, developmental, and spiritual needs from patient, family, diagnostic tests, medical record, health history, learning style, and literature.

Analysis

•

Identify appropriate health concern based on assessment findings, including deficits. Identify patient’s learning needs in the three domains of learning.

Planning Develop individualized care plan.

•

Set diagnosis priorities according to patient’s immediate needs.

Collaborate with patient on care plan.

Implementation

• •

Perform nursing care therapies. Include patient as active participant in care.

Involve family or significant other in care as appropriate.

Evaluation- Identify success in meeting desired outcomes and goals of nursing care.

Alter interventions as needed when goals are not met.

Teaching

Assessment- Gather data about patient’s learning needs, motivation, ability to learn, and teaching resources from patient, family, learning environment, medical record, health history, and literature.

Analysis- Identify patient’s learning needs in the three domains of learning.

Planning-Establish learning objectives, stated in behavioral terms.

Prioritize learning needs. Collaborate with patient on teaching plan. Identify type of teaching method to use.

Implement teaching methods.

• •

Actively involve patient in learning activities.

Include family or significant other in learning activities as appropriate.

Evaluation- Determine outcomes of teaching–learning process.

Measure patient’s ability to achieve learning objectives. Reinforce information as needed.

6. Identify how the following factors have an impact on teaching and learning: o

Client behaviours: e.g., readiness to learn, noncompliance, sick role.

Desire to learn.

• • •

Social motive – need for social approval , self esteem.

Physical motives- desire to maintain and improve health Task master motive – desire achievement ( amputee learning to walk) There are 4 key motivators

• • • •

Severity of the health concern Vulnerability to the threat Effectiveness of the response in reducing the threat Ability of the person to execute the change.

Emotional capability – anxiety (little is good, lot is going to impact ability to learn) Motivation- desire to learn, health beliefs, attitude towards health providers Break it up if needed.

Most patient can identify their own learning.

Box 21.6 p 334 What do you want to know?

What do you know about your illness and your treatment plan?

How does (or will) your illness affect your current lifestyle?

What barriers currently exist that are preventing you from managing your illness the way you would like to manage it?

What cultural or spiritual beliefs do you have regarding your illness and the prescribed treatment?

What experiences have you had that are similar to what you are experiencing now?

Together we can choose the best way for you to learn about your disease. How can I best help you?

What role do you believe your health care provider should take in helping you manage your illness or maintain health?

When you learn new information, do you prefer to have the information given to you in pictures or written down in words?

When you give someone directions to your house, do you tell the person how to get there, write out the instructions, draw a map, or just give the person the address to enter in a smartphone for directions?

How involved do you want your family to be in the management of your illness?

Ask Caregivers When are you available to help, and how do you plan to help your loved one?

Your spouse needs some help. How do you feel about learning how to assist them? o

Barriers to learning ▪ Language ▪ Culture and Diversity ▪ Learning Climate/Environment ▪ Older Adult.

7. Explain the concepts of the teaching plan and of learning goals and SMART outcomes.

GOAL ▪ is general- regarding overall plan or priority ▪ Example: will report less pain ▪ ▪ ▪ ▪ ▪

OUTCOME The outcome is the desired result SMART (Specific, Measurable, Attainable, Realistic, Timely) One sentence that includes all 5 parts of SMART Use action verbs (list, demonstrate) Example: by the end of my shift on Monday the patient will rate their pain as less than 3/10 Related to factors cannot be medical diagnoses. Either treatment related, maturational, situational, biological or physiological (pain, etc.)

8. Describe strategies for implementing a teaching plan:

o

Teaching Approaches Role play and discovery – simulations – controlled environment Teaching- Developmental Strategy based upon age.

Toddler- use play, simple word like “yes” instead of “Concur School age- psychomotor skill, more complex takes more practice Adult – encourage participation , set mutual goals. Offer information so that the adult can evaluate effects of health.

Electronic resources Older adult

• • • • • •

Teach when patient is alert and rested.

Involve adult in discussion or activity.

Focus on wellness and the person’s strengths.

Involve adult in identifying electronic resources to facilitate their health and quality of life.

Use approaches that enhance sensorially impaired patients’ reception of stimuli (see Chapter 48).

Keep teaching sessions short Teaching plan is nursing plan learning diagnosis.

Intervention is teaching. o o

Teaching Methods Teach back Strategies.

8. Describe methods for evaluating learning.

Quizzes, reflection, teach back, demonstration, oral or written questioning, self-reflection 10. Identify documentation requirements related to health teaching.

What was taught

How do you know the client understood the teaching Anything that was provided during the teaching (Ex: pamphlet) Unit 2: Asepsis, Hygiene, Skin Integrity, and Wound Care.

Unit 2.1 Hygiene, Asepsis and Ear Care 1. Examine how the nursing metaparadigm, and the determinants of health may impact the care of a client regarding self-care needs. (ADLs and IADLs)

2. Apply the nursing process to the care of clients with hygiene needs.

• • • •

Assessment Physical Components ( e.g. Muscle strength) Activites of Daily Living Vital Signs and Pain Mood and Affect

• • •

Diagnosis What are your priorities Consider the patient in your determination.

Is there an area of concern, an At risk or a learning need?

• •

Planning ( Goals and Outcomes) Goal is general Outcomes always SMART

• •

Implementation ( Interventions) Should relate directly to Goals and Outcomes What are you going to do for the patient

• •

Evaluation How did it go ?

DO you need to change the plan?

3. Describe assessment, and skills to meet the hygiene needs of the client.

Care of clients: • • • • • • •

Oral care • Denture Eye care Ear care • Ear irrigation for wax Foot and Nail Care Skin Care Hair Care Washing and Grooming

Bed Making • •

Occupied bed making• Skill 39-5 Unoccupied bed making • Box 39-16 Care of feet and nails

• •

Patients with diabetes Patients with peripheral vascular disease

4. Explore the responsibilities of the practical nurse in collaborating with the client, family, and interdisciplinary team when providing hygiene care.

5. Describe approaches used to maintain a client's comfort and privacy during hygiene care.

Always remember to: Provide privacy.

Maintain safety.

Maintain warmth.

Promote independence.

Anticipate needs. benefits to the nurse performing self-care activities: • • • •

Engage in therapeutic communication Assessment Evaluation Rehabilitation

6. Identify strategies to promote patient self-care with regards to meeting hygiene needs.

Factors affecting self care: Cultural Influences self-care practices Different perspectives on cleanliness & hygiene Socioeconomic Financial resources to purchase hygiene products Homelessness Physiological State of health & illness Pain Weakness Cognitive impairment Psychological Affects attitude towards hygiene Depression Stress towards hygiene Depression Stress Patient Risk Factors for Hygiene Care Upper body weakness Dehydration – NPO status Oxygen and NG tubs Chemo – risks of ulcers and infection Medications ( antihistamines ) – decreases and thickens saliva OTC lozenges ) high sugar Radiation Oral surgery Immunosuppression: altered blood clotting.

Diabetes – prone to dryness, tooth disease.

Reduced dexterity 7. Integrate the nursing process to determine which method of bathing best suits a client's condition and abilities.

Assessment

•

Collect data about patient’s physical, psychological, social, cultural, developmental, and spiritual needs from patient, family, diagnostic tests, medical record, health history, learning style, and literature.

Analysis

•

Identify appropriate health concern based on assessment findings, including deficits. Identify patient’s learning needs in the three domains of learning.

Planning Develop individualized care plan.

•

Set diagnosis priorities according to patient’s immediate needs.

Collaborate with patient on care plan.

Implementation

• •

Perform nursing care therapies. Include patient as active participant in care.

Involve family or significant other in care as appropriate.

Evaluation- Identify success in meeting desired outcomes and goals of nursing care.

Alter interventions as needed when goals are not met.

8. Demonstrate an understanding of the following: ▪

Partial and complete bed bath Partial: Wash areas most likely to build up bacteria.

Complete: Washing everything from head to toe.

▪

Tepid sponge bath

▪

Perineal client care Clean to dirty approach.

Outer to inner.

Using different parts of cloth.

Urine activates bacteria in the stool.

Hair care and facial grooming Be sensitive to hair care practices, there are cultural considerations HAIR CARE - Frequency varies Techniques Assessments ?

SHAVING – Assess for bleeding risks (blood thinners) Correct technique Care of beards & mustaches ▪

o o o o o o o

Eye care to the conscious and unconscious adult Assess for any aids Warm water – no soap Inner to outer canthus Clean principles Using different parts of the cloth throughout ▪

o o o o o

Oral hygiene to a conscious and unconscious client Maintains health mouth , teeth and gums.

Enhances comfort Best to be done right after meals Teaching- dental checkups should be regular.

▪

o o o o

o o o

o o o o

o o o o o o

Brushing – 4 x day for most effective- night is the most important Teaching Avoid plaque forming foods – carbonated bev, bread, and starches Denture Care Fragile and expensive Always remove at night Cloth in sink, brush thoroughly and rinse Unconscious patient Assess gag reflex , Is there a chance o ral suctioning may be required.

Position patient- left lateral recumbent, turn pt head to side due to gag reflex and absent swallowing.

Explain procedure still Inspect and assess oral cavity.

Touchette swab with chlorohexidine , or water.

May be required up to every 2 hours, up to facility protocol and client individually.

Ear Care Assess for any aids Moistened face cloth No Q tips Back of ears important ▪

o o o o

Ear Irrigations o o o

Up to 5 times at once.

Up and out Can damage eardrum

▪

Foot and nail care

Risk factor for Foot and Nail • •

Age Diabetes and

• •

Heart Disease (do not soak feet due to higher risk of infection from lack of blood flow) CVA ( Stroke)

Assessments: Subjective • • • •

Knowledge and Practice re foot and nail Use of nail polish Ability to complete independently Home remedies ( herbal and aloe )

Objective • • • • •

See pg 928 Assess skin, pulses, inflammation, corns, calluses , open lesions, abnormalities of nail Cut or file straight across Check facility policy DO not cut nails of pt with Diabetes or Peripheral disease ( special foot care needed) Dry in between toes to prevent bacteria.

Clean toes, file nails.

CTEMPS ▪

Removal of lice p.632

Skin Care product use (Barriers, Protectants, Emollients, Moisturizers and Fluid managers Briefs) Soaps are harsh and can break down protective acid mantle of skin Emollients –soften skin Barriers – apply layer of protection Moisturizers add moisture to layers of skin.

Many types and brands ▪

o o o o o

•

9. Describe the assessments, rationale, and nursing procedure, and evaluations required for ear syringing.

Ear Wax build up More common with older adults and children Ear plugs and Ear buds Soften wax prior to irrigations – How? Assessments needed?

What would be a contra- indication?

Technique to complete Client position Position of the pinna Equipment needed Evaluations ?

•

10. Identify pertinent information for documentation and reporting regarding hygiene and ear syringing.

Documentation of Hygiene o Received into care o Patient safety ( bed, rails ) o How you left the patient

• •

Oral Care Type of care provided Assessments • Bleeding of gum, inflammation, pain, concerns with dentures, any choking during care, Dental Caries, Bathing

•

• •

Type of bath, condition of skin, patient mood and responses to care, and findings ( normal and abnormal- Think HEAS) , Odours, Incontinence, skin care provided- barriers, moisturizers etc, patient statements of mood and affect after.

Hair, Nail , Eye, Ear assessments and findings during care.

Placement of any Aids, Glasses, Hearing aids etc.

Unit 2.2 Skin Integrity, Wound Care Principles 1. Describe conditions that place clients at risk for impaired skin integrity.

Moisture Fecal And Urinary Incontinence Moisture promotes skin maceration and makes the epidermis susceptible to injury.

Digestive enzymes in feces, urea in urine, and gastric tube drainage also contribute to skin injury Excessive Body Heat Increases the metabolic rate, thus increasing the cells’ need for oxygen. This increased need is particularly severe in the cells of an area under pressure, which are already oxygen deficient.

Severe infections with accompanying elevated body temperatures may affect the body’s ability to deal with the effects of tissue compression.

Friction •

(Occurs with movement back and forth)

Shear •

(Occurs when the skin moves one way while the underlying bone moves in the opposite direction)

Nutrition

• • • • •

Causes weight loss, muscle atrophy, and the loss of subcutaneous tissue.

Inadequate intake of protein, carbohydrates, fluids, zinc, and vitamin C contributes to pressure ulcer formation.

Hypoproteinemia predisposes edema.

Other factors: • • • • • • • • • • • • • •

Perfusion Co morbidities Health of structures Poor lifting and transferring techniques by care providers Incorrect positioning Hard support surfaces Incorrect application of pressure-relieving devices Medical devices Wound Drainage Stoma drainage Incontinence Skin folds Environmental factors Circulation

IMMOBILITY: -Hinder a person’s ability to change positions independently and relieve the pressure.

-Condition may include: -Sensory loss (Conditions include: -Paralysis, stroke, or other neurologic disease) -extreme weakness, -Pain -Traumatic injuries -Decreased mental status, level of Consciousness

-(unconscious, heavily sedated, or have dementia) NOT all impaired skin injuries are pressure injuries and not all pressure injuries present with impaired skin.

Usually over a bony prominence Nurses have a key role in prevention , risk assessment and care.

Be aware of the skin associated changes of the older person.

It is preventable Lethal complications Pain and discomfort Burden on preexisting conditions Pressure ulcers are a problem in both acute care settings and long-term care settings, including homes •

Pressure ulcers develop on bony prominences or as result of mechanical devices

2. Identify the stages of pressure injury and examine how they are assessed in all variations of skin tones.

“Injury to the skin and/or underlying tissue as a result of pressure, shear, friction or combination of these factors” ( Potter and Perry p. 1292) Etiology of Pressure Injury: Prolonged, unrelieved pressure damages the small blood vessels skin appears pale, as if the blood had been squeezed out of it when pressure is relieved, the skin takes on a bright red flush

if the redness disappears in some time, no tissue damage is anticipated If, the redness does not disappear, then tissue damage has occurred

Stages of Pressure Injury:

Provide consistency and standardization to describe the degree of tissue damage and the anatomical depth of the pressure ulcer at a specific time of examination.

Improve communication and reporting among the health care team NOTE: Do not ever backstage a pressure injury !!

Once a stage 3, always a stage 3. It can be a healing stage 3.

Stage 1: u Skin is not broken but is red or discolored. u Non blanchable .

Stage 2: u Epidermis (top layer) is broken, creating a shallow open sore. u Dermis (second layer) may also be broken. Superfical u Drainage may or may not be present.

Stage 3: u Extends through the dermis into the subcutaneous fat tissue. u Bone, tendon and muscle are not visible. u Slough and/or eschar may be visible. u Undermining and tunneling may occur u Look for signs of infection and possible necrosis.

Stage 4: u Extends into the muscle and can extend to the bone. u Dead tissue and drainage are present. u High possibility of infection- osteomyelitis u Often include undermining and tunneling.

Unstageable: u Full-thickness skin and tissue loss in which the extent of tissue damage cannot be determined. u Covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Suspected Deep Tissue Injury: u Purple or maroon localized area of discolored intact skin or bloodfilled blister due to damage of underlying soft tissue. u May be surrounded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to nearby tissue. u Difficult to detect in individuals with dark skin tones.

Darker Skin tones: Assess in well lit room Assess non injured skin first May have purplish hue Warm to touch Boggy to touch?

Tender around area?

3. Determine what assessments and nursing interventions can be done to prevent skin breakdown including the use of the Braden Scale.

Inspect skin daily Cleanse skin at time of soiling and at routine intervals Use mild cleansing agents Avoid hot water Apply moisturizers Reposition Lifting techniques Assess technique for friction and shearing Do not massage red or bony prominences Investigate sources of pressure – beds, cushion, toilet seats, stretchers.

Note size (length x width x depth)

Note color of wound base (red/ pink/ yellow/ black) and percentage of tissue Look at the wound edge Note if wound base is moist or dry Assess for drainage (sang/sero-sang/ serous/ purulent) Assess for undermining- indicates further damage Assess for signs of infection Braden scale score ( if appropriate ) Signs and Symptoms: • • • • • • • •

Pain & tenderness at wound site Erythema Edema; induration (increased firmness of tissue) Inflammation of wound edges Purulent discharge Warmth surrounding tissue Fever, chills, increased WBCs Delayed healing Assessment of skin: • Identify those patients at risk • Prevention strategies should be implemented immediately for high-risk patients.

• Regular reassessment should be done every shift or whenever the patient’s condition changes.

• The assessment should include the use of a validated risk assessment scale.

• Health History • Skin care practices

Objective Questions: • Inspection • Color Changes • Skin Temperature • Skin Moisture • Skin Texture • Turgor and mobility • Thickness • Hair and Scalp • Facial and Body Hair • Nails

4. Explain factors that promote wound healing.

Pressure Management • • • • • • • •

Avoid use of donut type devices, water-filled gloves, and IV bags for pressure reduction Preventative pressure management mattress/seat cushion.

Weight should be distributed over the entire seating surface so that pressure does not center on just one area.

Providing smooth, firm, and wrinkle-free surface to prevent skin trauma.

Avoid multiple layers of sheets, soakers, mattress toppers, overlays, etc.

Supports heels in bed such as wedges or pillows can be used to raise the heels completely off the bed.

Avoid raising head of bed greater than 30 degrees, ( if they slide, then too high) Implement a turning schedule • Difference repositioning needs in wheelchair vrs a bed.

Nutritonal Care:

u Consult dietitian as indicated u Adequate nutrients u Good hydration. u Increase Protein – if not contraindicated u Assess the need for a multivitamin with minerals u Additional micronutrients such as zinc and vitamin C may be considered u Underlying causes (e.g., need of dentures, swallowing difficulties; offer meal assistance etc.)

5. Summarize the chain of infection.

1. Infectious Agent 2. Source/reservoir 3. Portal of Exit 4. Mode of Transmission 5. Portal of Entry 6. Susceptible host 6. Identify factors that increase a client's risk for infection.

- Age - Medications - Inadequate defenses 1. Primary defenses 2. Secondary defenses - Nutrition - Stress - Disease Processes - Especially Immune response - Chronic disease - Stress Older Adult • • • •

Decline in Immune system Changes to response to infection Chronic disease Increase risk factors for infection

7. Examine the principles of clean dressing technique.

8. Explain the guidelines and rationale for foot care for the client with: ▪ Peripheral Vascular Disease/Diabetic foot care.

Diabetes is linked with poor circulation.

Inadequate blood flow increases the healing time for cuts and sores Peripheral vascular disease refers to compromised blood flow Poor blood flow increases the risk that infections will not heal Causing ulcers and gangrene Inspect the feet daily Wash the feet daily using lukewarm water; do not soak the feet. Thoroughly dry the feet and in between toes.

Do not cut corns or calluses or use commercial removers.

Do not apply lotion between the toes. Avoid excess amounts Podiatrist recommended. Do not trim as a nurse unless special training.

Avoid wearing constricting garments, such as elastic stockings, knee-high hose, and garters, and crossing the legs while sitting should be avoided,.

Wear clean, dry socks or stockings daily.

Do not walk barefoot.

Wear properly fitted shoes. The soles of shoes should be flexible and non slipping.

Do not wear high-heeled, open-toed, or pointed-toe shoes.

Do not apply hot water bottles or heating pads directly to the feet.

Wash minor cuts immediately and dry them thoroughly. Use only mild cleaners.

Contact an interprofessional foot-care team to treat cuts or lacerations (Diabetes Canada, 2020).

Diabetic foot ulcers 9. Identify pertinent information for documentation and reporting regarding skin integrity.

What did you assess 1. Skin – which would include areas of redness, location, drainage, history 2. Braden scale 3. Nutrition

4. Mobility 5. LOC and confusion 6. Mobility devices 7. Pain 8. Incontinence What did you do ? - Reposition, apply barrier, notify charge nurse, ask for nutrition consult?

What did you evaluate?

What did you teach?

How did you find and leave your patient?

• • • • • • • • • •

Location; drainage (colour/amt) Odour Colour of wound bed Peri-wound Tunnelling/undermining Solution used to cleanse Type of dressings applied Pain Patient comments Any possible signs of infection

UNIT 3: Medication Administration Unit 3.1 Medication Administration Principles and Responsibilities 1. Identify the practice standards, responsibilities of the practical nurse in safely preparing and administering medications and other therapeutic substances to the client.

Medication legislation & standards While the CLPNA has the authority to define the scope of practice for LPNs in Alberta, employer organizations define the role of the LPN specific to a practice environment.

Administration of med is performed in alignment with legislation, regulatory practice, policy, and individual competency.

LPN can administer meds under the following conditions:

• • • •

Education, knowledge and competence to accept, Transcribe Competence to safely prepare, initiate , administer, monitor and titrate Adhere to rights and checks of medication administration Always included the pt’s individual rights and needs ( including pt assessment and care) This policy follows the nursing process and refers to the assessment, planning, preparation, implementation, administration, evaluation, and documentation required in the management of medication.

While the CLPNA has the authority to define the scope of practice for LPNs in Alberta, employer organizations define the role of the LPN specific to a practice environment. T Medication legislation/standards: Drug standards: set standards for strength, quality, packaging etc

2. Integrate medication knowledge and pharmacology research into client care.

Medication Research: • • • • • • •

Pharmacological concepts • Drug names • Classification Medication forms Pharmacokinetics • Absorption, distribution, metabolism Medication action Medication interactions Medication dose responses Routes of administration Nursing process is the framework to organize your thoughts and actions when it comes to medication administration Pharmacological concepts: Drug names: can have up to 3 (chemical name-exact description of the composition/molecular structure); generic is given by manufacturer that first develops the medication (e.g.,

acetaminophen); trade name indicates that manufacturer has trademarked the name (Tylenol) Classification: indicates the effects of the medication of different body systems (e.g., sulfonylureas-classification for meds that control blood glucose). Medications can have more than 1 classification such as aspirin (pain relief, antipyretic, antiinflammatory) Medication forms: form of medication determines its route to administer and will enhance the absorption and metabolism Medication legislation/standards: Drug standards: set standards for strength, quality, packaging etc Provincial and local regulation of medication: that indicate who can dispense meds, order meds etc. CLPNA identifies in competency profile the indicators that LPNs can give medications to patients. Controlled substances are also regulated Pharmacokinetics: absorption: how the medication molecules get into the blood from the site of administration (absorption is affected by route e.g., IV rapid absorption, skin absorption is slow); distribution depends on circulation system of body, membrane permeability and protein binding and metabolism breakdown of the medication into a less active or inactive forme.g., liver, if damaged then can result in medication toxicity; excretion: once metabolized medication are excreted from body via kidneys, bowel, lungs (e.g., anesthetic gases deep breathing/coughing help to eliminate gases more rapidly) Medication action: way the drug acts within the body. Can be therapeutic-expected response; side effects are unintended or secondary effects; adverse effects are negative responses to medication; toxic effects that develop after prolonged intake of a medication; allergic reaction-unpredictable responses to a medication Medication interactions-when more than one medication interact and can cause increase or decrease/diminished action of a medication

Medication dose responses: when medications taken over time and enter bloodstream to obtain constant level of medication, being aware of serum half-life (time takes to excrete half medication concentration) Routes: multiple ways for meds to be given, look at prosperities, desired effect, and the patients condition

3. Examine the components of the nursing process as it relates to safe medication administration.

Assessment: Medical history Allergies Medication data Diet history Patient’s Perceptual or Coordination problems Patient’s current condition Physical & mental status Lab work Patient’s attitude toward medication use Knowledge & understanding of medication, Learning needs Review patient history so you know why a medication is being given as well as knowing when a medication may not want to be given (contraindication) (e.g., GI bleed, ulcers-prescribed aspirinthis can cause more bleeding)) History of allergies (contact, medication, food)-note on pt. record as well as wrist band

Medication data: know what each medication is, how long they have been taking, current dosage, any past adverse effects. Want to know action, purpose, normal dosages, routes, adverse effects and nursing implications (e.g., digoxin-need to make sure HR above 60) Diet history-know normal eating practices and also important for timing of some medications especially if not to be taken with food Patients ability to take medication or if nurses have to assist with medication Patient current condition-can indicate whether a medication is given or how it is given-change in patient status where they were taking oral medications but less alert and increased risk of aspiration so route may be changed Patients attitude can determine level of dependence or avoidance for medication taking Patients understanding of medication-what they know it is for, when they take it and how much Assess whether patient needs some education Lab work-some medications want to look at blood work (such as PT/PTT times for heparin/Coumadin; vancomycin for levels in body) Planning and Prep Nursing Considerations: Gather equipment required Check each medication against doctor’s order – facility policy Check medical record for allergies Know med actions Safe dose ranges

Purpose of administration; Adverse effects; Appropriateness of medication to be administered ***Prepare medications for 1 patient at a time Don’t Forget about Hand Hygiene Be organized, do not rush, think!

4. Discuss how culture, communication, and comfort impact the practice of medication administration.

There are visible and non-visible signs of culture. Visible signs include language, dress, food, and rituals. Non-visible indicators include perceptions of time, notions of modesty, reactions to physical space, and how emotions are managed.

Culture may influence, for example, beliefs about what causes disease, whether to engage in certain health promotion activities or seek advice regarding health concerns, as well as whether treatment options are followed. Culture can also impact a patient's approach to attending medical appointments in a timely manner.

Culture can also influence eating and fasting rituals, even when nourishment is vital to recovery and overall function. It can also play a role in the level of family influence in patient care decisions. Gender differences in a given culture may also affect health and patient outcomes.

1 As well, there may be differences among men and women seeking treatment for mental health problems.

2 These are just some examples of the possible effects of culture on individual healthcare behaviours and choices.

It involves developing a relationship of trust between the Nurse and the patient, one that recognizes and respects individual differences. In many cases, both the healthcare provider and the patient need to understand and consider each other's diversity.

Minimizing risk Respect for patients is key to minimizing the risk of culturerelated disagreements or misunderstandings. Physicians should consider the following practices: Foster strong doctor-patient relationships by being "intentionally inclusive" in patient care. This decreases the likelihood of unknowingly being "accidentally exclusive."

Treat every patient encounter as potentially cross-cultural.

Watch for potential language barriers, particularly when communicating in a patient's second or third language. A trusted translator can help, when appropriate, however physicians should be cautious when relying on friends or family members who may add their own interpretation into the discussion.

Inquire about the patient's beliefs related to disease, the reasons for illness, and issues about treatment.

Ask patients how they want to be treated and how care can be provided in a culturally sensitive way.

Be aware of how professional boundaries (i.e. limits to the physician/nurse-patient relationship) are perceived.

Document any culture-driven patient accommodations in the medical record.

Rely on a third party or "cultural broker" when working in difficult or emotionally-charged situations that may be rooted in cultural differences, such as inter-generational value conflicts.

5. Identify the components of a medication order.

Abbreviations- Know the facility policy Must have ALL the following: • •

Patients full name Date

• • • • •

• • • • • •

•

Medication name no abbreviations Dose no abbreviations Route Frequency Signature

You must verify the order on your MAR to the doctor’s order sheet.

We talked about this in the first class Need diagnosis or indication for use There are different dispensing systems such as stock piles (certain meds are kept in bulk on the unit for nurses to use for patients as ordered Unit-dose systems-portable carts that have 24 hour supply of meds for each patient Automated dispensing systems-scan patient barcode and enter nurses security code to obtain medication and can have computer carts on wheels Abbreviations

6. Describe the different methods used to receive a medication order from a prescriber (written, verbal, telephone, electronic) Written Synergize scalable e-commerce Verbal Disseminate standardized metrics Telephone Coordinate e-business applications Electronic Foster holistically superior methodologies Prescription: Medication to be taken outside of the hospital

Routine Orders: Administered until the dosage is changed or another is prescribed Single (onetime): Given 1 time only for a specific reason Now: Medication is needed right away but not stat PRN: Given when the patient requires it (as needed) STAT: Given immediately Written - authorized prescriber . LPN need to know who is able to prescribe. Need to understand the components of a medication order and clarify if needed.

Verbal and Telephone • • • •

More error prone due to miscommunication or misunderstanding Should be limited Should be transcribed as per facility policy In addition to the standard criteria, the following additional info is required.

• Date and time order was transcribed • Notation that is was verbal or telephone order • LPN signature and credential • Name of Prescriber.

LPN must repeat the entire order back to prescriber, also facility policy Electronic All components of a complete medication order must be met regardless of the format. upholds the privacy and confidentiality of patient information.

A medication order received via technology must be transcribed in the appropriate manner. The LPN must follow employer requirements as to • when the receipt of orders transmitted via technology for medications are acceptable;

• how orders transmitted via technology are to be transcribed.

Processing Roles of Physician, Pharmacist, Co worker , Practical Nurse in medication administration Transcription The LPN must follow employer requirements as to • when the receipt of orders transmitted via technology for medications are acceptable; and • how orders transmitted via technology are to be transcribed.

The LPN must ensure accurate transcription and recording of all order instructions in a timely manner upon patient admission, end of service, transfer to another level of care, or, as otherwise required. The LPN must validate the accuracy, clarity, and completeness of the transcription of the order before assessing the patient and administering the medication.

Emergency -There could be emergency situations where it is not possible to obtain an order before implementing a medicationbased protocol and delay in treatment would place a patient at risk of serious harm. An LPN may implement the protocol according to Many types of medication orders that are used. Depends on frequency and urgency of medication needs Routine orders done until the prescriber cancels order or another is written PRN-as needed only when pat. Requires it-as nurses you are using your assessment and discretion to determine whether patient needs the medication Single-one time: when only given once such as preop medication Stat are used in emergencies-needed immediately

Now orders are not as emergent-one time when need a medication fairly quickly Prescripts-when a patient is going to take medication at home 7. Describe how to process a medication order.

Initial Verification: Details of Physician’s Order against MAR Check Allergies Correct Patient ( Minimum 2 IDs) from Physician and Mar Label First Check of Five Foundational Rights: Organize yourself Hand Hygiene Complete the First 5 Medication Rights Second Check of Five Foundational Rights: Complete the First 5 Medication Rights Create Patient Label if Appropriate Third Check of Five Foundational Rights: Complete the First 5 Medication Rights Tidy Med Cart Hand Hygiene Beside Verification: Patient Verification at Bedside Patient Education Patient Right to Refuse

Patient Right Assessment Administer Medication: Administer Medication Hand Hygiene Patient Comfort 8. Examine best practice in the use of medication abbreviations.

NO abbreviations: Morph 10 mg IV Q4H PRN Vitamin D 1000 IU po QD Digoxin .125mg po QD Diamicron XL 30.0 mg PO BID Can you see any problems here? “Morph” – what are we talking about?

Hydromorphone? Morphine? Iu – could be misinterpreted for “iv” qd – could be read as qid. No leading zero – could be interpreted as 125mg Likewise, if there is a zero following the decimal – it could be interpreted as 300 mg.

9. Describe the roles of the interdisciplinary team members of the prescriber, the pharmacist, and the practical nurse in medication administration.

Nurses' role: • • • •

Collect & interpret Assessment data Administer medications Correctly and Safely Monitor Effects of medication Assess ability to self-administer

Need to develop knowledge and skills to administer medication.

Need to determine that the medication ordered is correct by collecting and interpreting patient data, giving medications understanding the actions of that medication, expected responses, adverse effects, when to hold, etc.

Always provide patient teaching and always listen to patient! (e.g., dad) 10.

Describe essential medication research components prior to safe administration of medications.

Medication Labels: Most of the time this is not needed as medications will be already in a safe packaging with all of this identification information on it.

If not pre-packaged, • • • •

Multi-dose container Narcotic Liquid Parenteral (stay tuned)

Pt’s name, date of birth Medication name and dosage.

Time and date

Acetaminophen 325 mg.

14 jan 2024 EM

Students' initials.

Medication administration record (MAR): Sign the MAR with your initials • •

Indicate the time the medication was given under the correct day of the month Ensure that you sign any additional forms as needed.

• Anticoagulant • Insulin Records • PRN

Always sign MAR as soon as you administer the medication Record the med as soon as you have administered it Always document any other pre/post assessment data, any unusual responses etc Monitor for effectiveness (evaluation) of the medication

11.

Identify various forms of medication.

Caplets Capsules Tablets Enteric coated tablets Sustained release DO NOT CRUSH LIST Caplet is a mixture of medication ingredients but is in shape of a capsule

Capsules is medication that is enclosed in an outer shellthe shell is broken down in digestive tract and medication absorbed into bloodstream Tablets made by compressing powdered medication ingredients Enteric Coated Tablets – does not dissolve in the stomach; coating dissolves in the intestine where the medication is absorbed Sustained release allows drug to be delivered/released at a programmed rate over a longer period of time ADDD video about med crushing 12.

Describe factors to consider when choosing routes of medication administration.

Routes of administration: Oral Sublingual Buccal Topical (creams & lotions) Transdermal Patches Nasal Optic (Eye) Otic (Ear) Rectal (suppositories & enemas) Vaginal Oral is easiest and most common Sublingual under tongue to dissolve (e.g., nitro) Buccal- place medication on the mucous membranes of the cheek Topical- medications applied to skin Parental – inserted with the use of some form of needle into either the subcutaneous tissue,

Rectal/vaginal- inserted Factors to consider when choosing routes - what would be the contraindication? ( e.g… order for oral instead of G tube) ) Enteric wont be dissolved in stomach, will be dissolved in small intestine.

Sustained release: long term, trickles through body over long time.

13.

Examine the 10 rights of medication administration.

Right patient Right Medication Right Drug/ Dose Right Route Right Time The first 5 are foundational rights and will be completed 3 times during med admin Right Reason- from assessment findings.

Right to Refuse “are you okay taking this medication?”

Right Patient Education Right Documentation Right Evaluation The last 5 are foundational rights and will be completed once during med admin Right pt: we need to confirm that we have the right patient and the meds we are giving are for the right patient. ID pt. correctly, check the MAR, Pt. ID bracelet and ask them to say their name

Right med: that an order is written for every medication given, compare the MAR with the ordered medication, verify new orders, compare label of med container with the mediation form (check label against the medication form 3x (before removing container, when amount of medication is removed from container and before returning container to storage). Administer only medications that you prepare Right dose: when doing a calculation or conversion have it verified by another nurse, when crushing clean the equipment after so don’t get residual medication from another patient mixed in Right route: make sure you are giving the right preparation, medication and the route (e.g., people have used saline for eye drops as injection in past-always check) Right time/frequency: know why medication is ordered at the times listed, (q8h or 3 times a day-both over 24 hours-q8h give medication to maintain therapeutic levels-so around full 24 hours) Right reason: if you do not know the medication you have to understand the medication therefore look it up-part of your professional responsibility.

Right documentation – make sure the medication is ordered properly prior to giving a mediation if parts are missing-get confirmation of the order (verify); after medication given chart that you gave the medication (sign of on the MAR) and any appropriate assessment data that goes with medication Right to refuse – you can refuse a medication but the nurse is responsible to provide the education necessary so patient is making informed condition. the ONLY time we can give a patient medication against their will is if it’s intended to control their immediate behavior & that behavior is dangerous.

Right patient teaching – ensure your patient knows what the side effects are and when they should call you if there is a problem.

Right Evaluation – ensure that you follow up with the patient and assess for any side effects and or allergic reactions Follow up especially after administering medications that you are expecting a response in 30 – 40 minutes post administration i.e. of analgesics; antiemetic's; treatment of HTN; pulmonary edema (large dose of Lasix (Diuretic has been administered – Respiratory assessment; SPO2; respiratory rate); nebulizers (Ventolin/atrovent via nebulizer therapy; inhalation therapy (additional result) Right Assessment – Depending on the type medication you are administering i.e. when administering Antihypertensive agents – you need to assess the patients vital signs Particularly the BP and HR Patient who is receiving insulin – you need to know the blood glucose level Nursing assessment questions (Box 34-11 p. 749) Patient Refusal: Patient’s have the right to refuse medications Exception if it is intended to control their immediate, dangerous behavior Explain the importance of the medication to the patient Ask the patient if they are refusing for a specific reason Document the refusal and alert the charge nurse and care provider Find out from the patient if they are refusing for a particular reason.

If the patient says “that’s not how that pill usually looks,” always go back and check. Maybe you got the wrong medication

Sometimes, it’s just the case that the hospital uses a different brand or may have substituted another medication in the same class (e.g. omeprazole for rabeprazole Both are proton pump inhibitors - Rabeprazole is the newer agent 14.

Identify the three medication checks and client verification to be completed prior to medication administration.

Verification Check - Prior to Starting •

•

•

1st check (when medication is pulled out of the cupboard): • When pulling medication from medication drawer or stock supply.

• Check Expiry date • Complete the 1st 5 Foundational Rights.

2nd check (Prior to pouring medication): • Complete the Medication Calculation • Prepare Medication and Compare against the MAR and Medication Container • Complete 2 check of 5 Foundational Rights • Create Label rd 3 check (After medication is poured and before replacing it in cart.): • Depends on facility policy • At Norquest Complete 3 check of Foundation Rights before leaving Medication Cart • Recheck Medication, Label to MAR and Container prior to disposal or medication drawer.

• Ensure you have all the correct supplies Scan barcodes if using computerized system Skill 34-1 (starting p. 757) Check 1: when medication is pulled out of the cupboard Check 2: Prior to pouring medication Check 3: After medication is poured and before replacing it in cart.

Verification Check- At the Bedside 1. Take MAR, Supplies and Prepared Medication to Bedside 2. Check Patient Identifiers in 2 different ways • Check patient’s name • Date of Birth • Hospital ID • Photo NOTE: As you are checking the Patient Identifiers , you need to be referring to the MAR (not the handwritten label) For High-risk medication, there may be additional bedside checks Facility Policies may be slightly different.

Complete Further Medication Right • • •

Right Assessment Right to Refuse Right Education When in room want to confirm patient identify by 2 patient identifiers compare name with one other identifier (ID band, MAR, asking pat. Name, computer printout/screen) Compare medication with MAR at patients beside CHECK 5 FOUNDATIONAL RIGHTS at bedside Stay with patient until they have taken the medication to confirm that it has been taken

15.

Examine the common causes of medication errors and preventative methods the nurse can implement.

Alert- RE: Dosage Calculations: DO NOT WRITE A ZERO alone after a decimal point (e.g., 3 mg not 3.0 mg) always include a zero before decimal point (e.g., 0.1 mg)

Similar expressions are used for example – obscured decimal point – i.e. readings 3.1 gms instead of 31 grams Patient can be under dosed or over dosed (trailing zero can be overdosed 10-fold e.g., Coumadin 1.0 mg and instead received 10 mg in error) Prevent medication errors: Follow rights and Checks of medication administration Read labels and compare carefully– 3 times compare with MAR – before, during & after No distractions Double check calculations, verify with another nurse Clarify illegible handwriting with prescriber Proper storing • • • •

Use of Tallman lettering Do not crush list Avoid use of error-prone abbreviations (Table 35.7 p.739) Drug Names- Confusing All of these represent different factors that contribute to medication errors. The one thing they have in common is that they cannot usually be traced back to a specific individual. They are often the result of a system breakdown.

One example of medications that the names are very close – dimenhydrinate (Gravol)- antiemetic And diphenhydramine – antihistamine For students ask – What are some factors that impact the risk for medication errors?

1. Communication breakdown 2. Non-standard med time 3. Workload and distractions

4. Administering meds to multiple patients 5. Incorrect calculations 6. Similar medication names 7. Incorrect order (use of abbreviations) Names can be confusing , Illegible handwriting from physicians.

Similar packaging E.g. For example, the drugs Losec (omeprazole) and Lasix (furosemide) are problematic worldwide Use of difference colours and fonts •

Ef Tall man lettering TALLMAN LETTERS – I.E. hydrALAZINE; prednisone; NIFEdipine Tall man lettering (TML) is a technique that uses uppercase lettering to help differentiate look-alike drug names. ...

TML can be used along with color or bolding to draw attention to the dissimilarities between look-alike drug names, and alert healthcare providers that the drug name can be confused with another drug name. Apr 28, 2020 Verapamil – Naloxone look alike vials.

Practices to Reduce Medication Errors: • preparing medications only after an order has been verified as complete; • following appropriate hand hygiene when preparing any medication; • preparing medication when it is to be administered; • avoiding leaving medication unattended; • preparing medications in a space without interruptions and distractions to avoid medication

errors; • preparing medication for one patient at a time; • administering only the medications that the LPN prepared; and • following manufacturing guidelines for preparation and administration of the medication.

Coping with medication incidents/errors often causes feelings of guilt, shame, loss of confidence, concern for the patient, and fear, all which lead to the under-reporting of incidents. P&P p 741 See box 35.7 re: case study.

Decrease distractions – “Do not disturb” signs In the past, when medication errors occurred, the individual who caused it was usually blamed for the mishap. Medication errors related to employees may be due to the following: Negligence Forgetful Hurrying Poor motivation Vengeance Carelessness In such situations, disciplinary actions may include: Blame and shame Loss of privileges A threat of a medical malpractice lawsuit Relief from certain duties

This culture of blame has shifted, and medication errors are believed to be a systemic problem. (https://www.ncbi.nlm.nih.gov/books/NBK519065/) Type of Medication Errors: Prescribing Monitoring Improper Dose Deteriorating/ Expired Medication Compliance Omission Administration Error Time Factors Med Admin Right Errors • •

• • • • • •

•

Prescribing errors: “Typical errors include the healthcare provider writing the wrong medication, the wrong route or dose, or the wrong frequency.

These ordering errors account for almost 50% of medication errors.” (https://www.ncbi.nlm.nih.gov/books/NBK519065/) Deteriorated Drug Errors Examples include giving medications that are expired or were inappropriately stored. For example, administering insulin that has been frozen.

Expired medications Monitoring error: Administration errors include the incorrect route of administration, giving the drug to the wrong patient, extra dose, or wrong rate.

Monitoring errors such as failing to consider patient liver and renal function, failing to document allergy or potential for drug interaction. May 2, 2023 Compliance error

• • • • •

An error occurring when patients do not follow their dosing regimen.

Unauthorized drug error?

When a medication that was not prescribed by the doctor was administered.

Omission error: A drug omission occurs when a patient does not receive a medication that has been ordered or when a medication has not been ordered despite being appropriate for an underlying condition.

If an error occurs……

• • • •

Assess the patient Notify the charge nurse and the physician Fill out an incident report Apologize to the patient and family Start by assessing the patient. Did they miss a medication? Were they given the wrong medication?

Was too much given? Did they have side effects? Notify the charge nurse & physician regarding what happened Fill out an INCIDENT REPORT – AHS uses the RLS computer program for this Apologize to the patient and family. You are sorry about the error.

This is not an admission of guilt on your part; rather, it’s an apology that the occurrence happened.

What can you do?

Always follow 3 checks of the 10 rights Always use a calculator & double check dosage Be informed Never administer meds prepared by someone else Clarify orders/ Question orders

Chart only meds given by you Near Miss: • •

•

What does a “near miss mean?” Sometimes also called a “close call”.

“All medication incidents, even those that do not cause obvious or immediate harm and near misses, must be reported the employer…to avoid similar incidents in the future….reporting aims to shift negative perspectives and encourage reporting” P&P p. 741 This helps create a “culture of safety.”

WHO defines a near miss as “an error that has the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is intercepted” (2). “it has been estimated that for each preventable death, there are between 7–100 close calls that occur before it.” (https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications) Near misses are unsafe acts that have the potential to injure a patient, but do not. a common definition of a near miss is "An event or a situation that did not produce patient harm because it did not reach the patient, either due to chance or to capture before reaching the patient; or if it did reach the patient, due to robustness of the patient or to timely intervention (for example, an antidote was administered)."(2) Even more simply, some errors result in patient harm, while others do not. Close calls/near misses are errors that do not result in harm. (https://psnet.ahrq.gov/webmm/near-miss-bedside-medications) Aug 24/2023

16.

Demonstrate accurate medication calculations.

Systems of medication measurement: Nurse must be able to: compute medication doses accurately and correctly •

Metric system: • Kilograms (kg), grams (g), milligrams (mg)

• • •

•

•

• • • •

Solution • Liters (L), milliliters (mL) Household system • Drops, teaspoon, tablespoons Apothecary system: • Grain, fluid ounce

Nurses need to understand that metric, apothecary (based on the grain as a measurement of weight) and household systems of measurement can be used. Generally we use metric system as our standard.

Metric system: ORGANIZED INTO UNITS OF 10 – in multiplication we move the decimal to right and in division we move decimal to left (10 mg x 10=100 mg; 10 mg/10= 1 mg Meter (length), litre (volume), gram (weight), We use lowercase or uppercase letters (Gram=g or Gm, Litre=L or l) Lower case letters are used for abbreviations for other units (milligram=mg; mililitre=mL) See table 34-6 p. 737 that shows equivalents of measurement for metric and household Medication Calculation:

2, 7.5ml, 3, 1.5 17.

Documentation guidelines fro basic med admin scheduled med.

Received into care LOC and Orientation Vital Signs Pain Assessments based upon client situation and medication prescribed. What assessments for the administration, potential side-effect, what teaching would you need to do. ( Plan it out, this is what your med cards are for) (Example, if you were giving a BP medication you would need to check the BP, and whether the patient was experiencing any dizziness when standing up) If the medications was a scheduled med, you do not need to document that you gave the med, only the assessments findings.

PRN=DOCUMENT, SCHEDULED=ONLY EVAULATION FINDINGS. Document the effectiveness as a result of your med admin

Document the health teaching completed and the effectiveness How did you leave the your patient.

Sign ( first initial , last name and designation) Unit 3.2 Oral, Topical, Transdermal, Nasal, Optic, Otic, 1. Discuss influence of culture and the nursing

metaparadigm for the administration of medication through various routes.

Nursing Role in Medication Administration: Legal Responsibilities Safety: • • • • • •

Follow consistent procedure Reduce distractions Prepare separate Prepare one at a time.

IF in doubt double check, If high risk,

Knowledge: • • • • • • •

What meds are prescribed Purpose Correct dosage and routes Therapeutic and adverse effects Assessment and monitoring needs Education Rational for the Medication and if appropriate.

Influences related to Medication Administration:

➢ Patient Beliefs and Preferences ➢ Health beliefs vary within cultural , ethnic, spiritual, and religious practices ➢ Genetics ➢ Aging

2. Discuss the application of the nursing process for the

administration of Oral, Topical, Transdermal, Nasal, Optic, Otic, medications.

3.

Oral, (including Sublingual, Buccal) Most frequently used route Convenient and inexpensive Drug stability Types of Oral Meds Enteric Coated Extended Release Liquid

Pill Crushing • Existing Gastrointestinal Alterations What do we mean by this? GERD etc.

• Ability to swallow?

How do you assess this? Ask to have sip of water.

Check that medication was swallowed Provide water to help swallowing. ( sip before can help) • Position of Client What position should the patient be in? up right and sitting.

• Clean Technique Hand Hygiene Do not touch pills with your hand If can’t swallow, hold med. May be able to crush medication.

If throwing up, or GERD, make sure administered before they eat.

If hasn’t been absorbed and throws up immediately after and pill is visible, can re-administer.

Before pouring liquid, always check label, expiry date. Then put hand over label when pouring to avoid damaging label.

If more than 10ml, pour into med cup straight away.

Meniscus is at level of medication.

Sublingual and Buccal: Sublingual (SL) Do not swallow sublingual medication, will not get desired dose, slower absorption rate, more complications, etc.

Meant to dissolve in the mouth.

Buccal Do not eat or drink until medication dissolves. Need to make sure fully dissolved.

Topical: Includes ➢ Lotions ➢ Creams ➢ Ointment ➢ Transdermal Patches Can act locally or systematically • • • • • •

Application Consideration Gloves and applicators Assess skin prior to application Always clean site with soap & water prior to administration Review specific application technique for each medication Wear Gloves & use applicators Spread evenly- rubbing can cause irritation.

Transdermal patches: • • • • •

Apply to non-hairy ; non-sweaty area Rotate Do not write directly on the patch-write date; time; initials on tape and place in close proximity to the patch.

If replacing old patch – remove old one first Never cut a patch, fold and dispose in med disposal.

Document: Skin assessment, patch removal, patch application, etc.

Nasal: Blow nose prior to administration for clear airway.

May have preference for which nostril.

Need to know deviated septum, trauma, etc.

Roll bottle.

Nasal drops- Supine position Nasal Spray -High Fowlers/sitting position. If both nostrils occlude one at a time

Optic: Eye Drops • • • • • • • • • • • •

Assess eye for drainage, pain level, etc.

Always clean the eye before applying.

Instruct patient to lie down with head tilted backward Pull down on lower lid – creating pocket Instill solution into pocket Instruct patient to gently close eye Wait 5 minutes before instilling 2nd drop or another eye drop If instilling systemically acting drugs – apply pressure to inner canthus for 1 – 2 minutes (minimizes systemic absorption) Ointment: Hold tube in hand for few minutes to warm Squeeze (1/4-1/2 inch inside lower lid Instruct patient to close eyes & move eyes around Wait 10 minutes before instilling any other eye ointments

Otic: Ear drops: Why position inside lying position? So medication goes into ear appropriately.

Why remain in position 2-3 min? to allow for absorption.

Why if refrigerated the solution must be warmed? To avoid ear infection, same if too hot, needs to be room temp.

What would you assess? Ruptured ear drum, tubes in ear, trauma to ear, may be contraindicated.

Know the technique for administration? Hold ear up and back.

Vaginal and Rectal instillation of creams and suppositories: Vaginal Medication: Cream, Foams, Jelly, Suppository • •

Fill applicator with cream and foam and insert Ovules

Body temperature causes melting of product that leads to absorption.

Enemas:

Fleet enemas- Promote defecation by stimulating peristalsis Insert gently and squeeze Encourage the client to hold for as long as they can (See P&P 1230 – 1232) Suppositories: Stimulant May be for constipation OR other uses (Tylenol, Gravol supps) Lubricate first ( muko) Insert with a gloved finger – 10 CM past anal sphincter

MAKE SURE PATIENT IS LEFT-SIMS POSITION DUE TO GI ANATOMY! 4. Examine the responsibility of the LPN when providing

nursing care related to o The safe preparation of medications administration of medication

o Pass and bridge medications.

Temporary self-administer meds until prescription can be filled.

Ensuring that all medication labels are complete and accurate is essential medications When Pharmacy is not available to dispense the medication A complete patient specific medication order from an authorized prescriber is present They do not charge the patient a fee, or receive payment, for the preparation and dispensing of medication

Follow employment and best practices Patient education completed Label drug container and packaging *

o Safe storage and disposal of meds

o Patient education needs

5. Discuss safe preparation, administration practices, and

disposal of various classification of medication.

(Cytotoxic, hormones, insulin, narcotic, vasodilators, bronchodilators) Narcotics: • • •

Narcotics can depress the CNS always assess LOC and respiratory status.

What other assessments should you make?

Always check when last dose given

• • • •

Always count the controlled med and confirm before removing ALWAYS have a COSIGN !!!

What teaching should you complete with your client?

Follow up on effectiveness of medication (patient response)

6. Determine priority nursing diagnosis related to

medication administration for oral, topical, transdermal, nasal, optic, otic.

7. When dispensing Pass and Bridge medication,

o Describe the role of the LPN. Ensuring that all medication labels are complete and accurate is essential medications Pharmacy is not available to dispense the medication A complete patient specific medication order from an authorized prescriber is present They do not charge the patient a fee, or receive payment, for the preparation and dispensing of medication Follow employment and best practices Patient education completed Label to drug container and packaging o Identify situations when an LPN may dispense.

o Identify safety concerns related to dispensing pass and bridge.

o Describe procedural steps related to preparation and dispensing of medications.

o Describe documentation required.

MAR – Medication administration record PRN - As per facility PRN records often have a spot to document evaluation of med.

Nursing/Client Care Record Insulin /BBIT Anticoagulant Review Documentation video posted on Elaine’s unit 3 video 8. Examine documents used in medication administration.

o MAR (Medication Administration Record)

o Client/Nursing Care record

o PRN

o Narcotic Records.

Wastage of narcotic….MUST be witnessed…why and where?

Removal of medication from count Shift count what if count is incorrect…what happens?

HINT: Don’t throw out any vials until third check is complete!

9. Identify relevant documentation and reporting

requirements related to medication administration including: o Scheduled Meds

∗ It is always safer to write out the term than to abbreviate it.

Follow your employer’s policy regarding the use of abbreviations.

See ISMP website: https://www.ismp.org/recommendations/error-proneabbreviations-list MAR

medication administration record o PRN meds As per facility PRN records often have a spot. o Controlled Meds.

Narcotics come in different forms (tablets in bottles, blister pads, vials).

Narcotic sheet, track every medication every shift.

Beginning of shift narcotic count is done and end of shift.

DONE IN RED. Sign sheet before leaving med cart and have a witness.

Every time med is taken, DONE IN BLACK. Don’t leave blank spaces on a narcotic sheet, line across.

High risk medications- need a co-sign and they need to witness preparation.

Date, drug, dose, patient, initials on label.

Unit 3.3: Parenteral Medication Administration 1. Discuss the nursing process and metaparadigm when

administering medications through the following routes.

Assessment- What need to be completions for the medication , patient health status, and the route of administration.

What will be your Goal/ Outcome _ Reduced Pain, Blood sugar risks Bleeding, ?

Interventions - correct technique, health teacing How will you evaluate.

Why?

•

Patient situation

•

Type of medication

•

Urgency

•

Rate of absorption and onset o

Subcutaneous

o

Subcutaneous Medication Port

o

Intramuscular

o

Intradermal

2. Examine safe use of the equipment used when

administering parenteral medication by subcutaneous, intramuscular, and intradermal routes.

Equipment/ Supplies Needed: • • • • • • • • •

Patient Chart MAR Medication Syringe Needle Alcohol swab Sharps container Gauze Gloves Syringe

❖ Insulin syringes (50, 100 Units) ❖ 1, 3, 5, 10ml syringes ❖ 20ml syringe (medication for IV bags or G-Tubes) ❖ Pre-filled Syringes

Parts of the Syringe: ❖ Tip ❖ Barrel ❖ Plunger

Needles ❖ Needle Gauge ( diameter) ) ❖ Needle Length – correct location ❖ Needle selection based upon: ❖ Muscle size ❖ Adipose tissue ❖ Volume /Dose

What is difference between a needle with a bevel and a blunt fill needle?

Blunt filled needle is all red- use for a vial (pierces rubber) then exchange needle tip following Purple tip for bevel- when using glass ampule. Filter needle What are the various parts called.?

Bigger the diameter, more pain.

LOWER GUAGE, BIGGER NEEDLE, VICE VERSA Do not want a needle lying on the counter. When attaching needle to tip want to keep clean to clean.

When pulling back medication do not touch plunger only top otherwise contaminating medication.

Most insulin given in pens instead of needles now.

If orange tip, insulin only.

Ampoule: Medication Supply ▪ ▪ ▪ ▪ ▪ ▪

Tap the top Use gauze or alcohol swab to hold the top Snap AWAY from you (dot or line) Use filter needle Withdraw medication Pull back plunger, discard filter needle (swoop) , and replace with needle to inject

Wrap around and snap away from you, using packaging.

Vials: Swab the top Pull air into syringe- How much air?

On flat surface Inject air into vial (not in solution) Withdraw desired amount NOTE: Clean the top of the vial after cap is removed!!

How do you prevent contaminations during preparation for ampoules and vials?

Mixing Medications: • Determine compatibility • Do not cross-contaminate • Check final dose • Aseptic technique

• Compatibility chart, Lexicomp (AHS), Call pharmacy

3. Discuss priority nursing diagnoses, client health

education needs related to a client receiving parenteral medications.

4. Compare factors to consider when choosing

subcutaneous, intramuscular, and intradermal routes of medication administration.

5. Describe what must be considered in safe preparation,

administration, storage, and disposal of the following medications. o Administration of All Parenteral Meds Position patient comfortably- expose only needed area Select correct site Cleanse skin- how long?

Distract patient Insert needle quickly and smoothly Hold barrel when inserting Push plunger to administer medication slow and steady Cover with gauze, not alcohol swab Reducing discomfort in all meds: Needle should be free of medication Use Z-track for IM

Inject into relaxed muscle Avoid hard or tender areas Only administer recommended

amount for site

Do not massage Rotate sites

o

Controlled/Narcotics

o

Subcutaneous including:

rotate sites, grasp skin fold, can be medication specific ▪ Use: into subcutaneous tissue, slower absorption than IM ▪ Sites: Arms, legs, abdomen, back ▪ Equipment: ▪ Insulin syringe or 1ml syringe ▪ Needle size: 25-30G, 3/8- 1in, 3/8 & 5/8 ▪ Max volume: 1ml ▪ Common medications: Insulin, Heparin, analgesics (narcotics) ▪ Angle: 45-90 degrees ▪

Insulin:

High Alert Treats type 1 and type 2 diabetes (IDDM) Must date the vial once opened Types o Rapid acting - Lispro, Humalog o Short acting - Regular/ Toronto, Novolin Regular, Humulin R o Intermediate - Novolin NPH, Humulin N o Long acting - Lantus, Levemir • Rotate vials between palms • Vials can be stored at room temperature for up to 31 days • Insulin pens can be stored at room temperature for up to 14 days

• ( some facilities and brands may say 28 days.)

• Both vials and pens can be stored in the fridge. – depending on type of insulin may be kept at room temperature for up to month (refer to Davis drug guide) • Do not expose to sunlight • Rotate vials between palms • Vials can be stored at room temperature for up to 31 days • Insulin pens can be stored at room temperature for up to 14 days • ( some facilities and brands may say 28 days.)

• Both vials and pens can be stored in the fridge. – depending on type of insulin may be kept at room temperature for up to month (refer to Davis drug guide) • Do not expose to sunlight Nursing Process – Insulin: Pre Assessment: • LOC and Orientation • Meal arrival ? Timing • Site assessment • Blood glucose Administration Technique: • Previous site/rotation • Angle of insertion • Pen? 90 • Syringe?

• Hold for 10 sec Post Assessment: • Documentation • Skin/Site Assessment • Health Teaching

• Adverse Effects?

What would you do if patient was nauseated???

mixing two types of insulin together Mixing of different insulins: Can mix Rapid acting/ Short acting (Clear) with Intermediate Acting (Cloudy) Cannot mix long acting with other insulins Some Insulins come premixed NPH (Humulin 30/70) P&P table 35-12 (Comparison of Insulins) • • • • • •

Clean both Vials Air into Cloudy Air into Clear Draw up Clear Ensure Clear is Accurate with NO bubbles Draw Up Cloudy (this must be accurate) What safety needs to be considered.

• • •

Don’t forget to complete your checks and rights.

Needle and accuracy of what is being pulling out of vial Verify both doses with another nurse when drawing up.

utilizing an insulin pen • Label pen with patient's name & date opened • For one patient only • Check cartridge prior to turning dial • Attach new needle • Prime with 2 units • Dial up dosage Video:https://www.youtube.com/watch?v=XTXzTDUf6rc

Blood Glucose Monitoring: • •

Assessment of Hyperglycemia/Hypoglycemia Normal levels are 4-6 mmol/L (fasting and before meals)

Equipment: lancet, test strip, glucometer meter, gauze, alcohol swab LancetVideo:https://www.youtube.com/watch?v=JXobmcVuvVE LTC Meter Video: (start at 2:47) https://www.youtube.com/watch? v=vM4EjRT15qM Acute care Meter video: https://www.youtube.com/watch? v=TKqE8XZqVwk What is a HBA1C test?

▪

venous thromboembolism (VTE) prophylaxis

Anticoagulant therapy:

Heparin • High Alert • Given Subcutaneously – check your Drug guide there are recommended locations and techniqe for this.

• Supplied in units • Anticoagulant therapy/ Venous Thromboembolism (VTE) Prophylaxis • Assess for bleeding • Where would you assess ?

• Monitor platelets q2-3 days, PTT and hematocrit • Patient teaching Nursing Process • • • •

Assessments?

Planning- Goals and Outcomes Interventions Evaluations

o

Subcutaneous Medication Port

• Size/ Access device: Butterfly needle (24g) or Safety-Intima Equipment •

Sites: Abdomen, thighs, arm, back, chest

• Always prime with medication before administering ordered dose • What areas would you avoid ?

• Each medication port is for one medication only.

Discontinuation of SC med port: 1. Position resident in bed or chair. Explain procedure to resident/family 2. Perform hand hygiene and don clean gloves 3. Clamp the indwelling subcutaneous catheter tubing 4. Remove the adherent dressing 5. Stabilize the skin and pull catheter out at the same angle that it was inserted 6. Apply pressure to the site if there is bleeding or oozing 7. 7. Cover insertion site with bandage or sterile gauze 8. Document the removal of the catheter, if tip was intact, integrity of the site and the resident tolerance in the Nursing Notes Unique considerations for SC Med Port:

What is the difference between a “ SC Medication Port & a SC injection?

o

Intramuscular

Rotate sites, ventrogluteal is preferred site, is dependant on volume o

Intradermal medications 3-4 finger widths below ani cubital space.

Just under skin (practice with skin of a tomato) Nursing Considerations for intradermal:

• Use: Sensitivity for TB, allergy testing • Sites: inner forearm, upper back • Equipment: Tuberculin syringe • Angle: 5-15 degrees, bevel up.

• Needle tip often visible under skin

• Bleb… Will be “read” later • Do not massage.

• Should be free of lesions and discolourations…. Why? Do not rub injection sites following injections. o

Reconstitution of medication

Heparin is preferred in abdominal area.

What happens if not administered correctly?

• • •

Pain Tissue and Nerve damage Anxiety

6. Explain Basal Bolus insulin therapy (BBIT) and compare to

sliding scale insulin therapy.

Sliding Scale Insulin: Dr order Example: Give Humulin R, subcut as per sliding scale q4hr If c/s <4.0 call MD 4.1 – 8.0 – no insulin 8.1 – 10.0 – give 2 units 10.1 – 12.0 - give 4 units 12.1 – 14.0 – give 6 units 14.1 -16.0 give 8 units >16.1 – call MD •

Unstable BG levels

• •

Dose depends on BG level Still seen but slowly being replaced by Basal/Bolus therapy

Basal Bolus Insulin Therapy: • • • • •

Trying to replicate how the body produces insulin Aim to manage BG within target range Basal: long/Intermediate insulin. Given once or twice/day Bolus: Rapid/Short insulin. Given prior to meals and/or prior to bed Correction: Same type as the bolus (rapid/short). Given in addition to bolus to correct unanticipated hyperglycemia

Normal range for NorQuest for insulin is 4-6.

7. Describe relevant information to document and report to

members of the interdisciplinary team.

Unit 4: Nutrition and Hydration Unit 4.1 Nutritional Assessment 1. Explore the influence of culture and the nursing metaparadigm for clients with altered nutrition.

• Culture • First Nations • Newcomers to Canada • Food security • (ability to secure acceptable food) • Finances • Knowledge of good nutrition • Preferences in body size

• Availability of food due to environmental factors • Social Factors 2. Describe the components of Nutritional Assessment Screening.

Anthropometry • Study of human variation • Same time, scale, and clothes • Height and Weight • Ideal Body Weight (IBW) - rapid weight changes could indicate fluid shift • Body Mass Index (BMI) - height to weight ratio (kg/m squared) (18-24.9) • Waist/ Hip Circumference • Diet History • Laboratory Values Laboratory Tests • Plasma proteins: • Albumin • Transferrin • Prealbumin • Retinol Binding Protein • Total Iron binding Capacity • Hemoglobin • CBC (complete blood count)- RBC, Hgb, Hct, WBC, Platelet • LBC- Electrolytes ( Calcium, Magnesium, Phosphorus, Sodium, Potassium, Acetate, Chloride)

• BUN and Creatinine • Serum Iron, Total Iron Binding capacity, transferrin, Ferritin • HbA1C, Random Glucose vs Fasting, Blood Glucose Monitoring • B12, Folate • Vitamin D • Lipoprotein • Cholesterol (Total, Triglycerides, HDL, LDL) • Urinalysis What are the needs for wound healing ?

What would you be looking to assess Kidney function Dehydration ?

What about a Patient with Diabetes, High Blood Pressure, High Cholesterol?

Health History • Diet/ appetite, food intake • Medical history, medications, allergies • FASTCHECK • Food Practices • Allergies • Symptoms • Tracking • Chewing/swallowing • Hunger • Elimination patterns • Chemical substances • Knowledge

• Social history • Emotional status • E.g. stress= eat more/less • Weight fluctuations/consistencies • Fruit/Veggie intake • Physical assessment (Table 43.5) • Activity levels • Diagnostic studies Dietary History/ Patient Expectations Clinical Observation ( general survey) Physical Examinations 3. Describe factors that can put a client's nutritional and hydration status at risk.

4. Identify the functions, major sources and daily requirements for common nutrients including: o Carbohydrate main source of energy (carbs, fat, proteins) o

Fat

supplies energy & protects organs. Saturated vs Unsaturated.

What is the difference.?

What is a Trans Fat.? o

Fiber

o

Minerals

o

Protein (including its role in wound healing) tissues growth/repair. What is its role in wound healing?

Building.

o

Vitamins (including what deficiency in each may cause and what toxicity in each may cause) fat soluble (ADEK) , water soluble (C,B) , minerals (K+, Na+, Mg+…). What could happen if you were deficient? How about too much/toxicity?

Water

makes up 60-70% of body weight. What are the sources of water in our diet? Goal is that Intake of water = output of water 5. Explain the dietary requirements to meet nutritional needs (dietary reference intakes and Canada’s Food Guidelines)

• Recommends:

• Make water your drink of choice • 1/4 proteins • 1/4 Grains • 1/2 Fruits and Vegetables • Reduce processed meets ( hotdogs) 6. Compare the nutritional needs between younger and older adults.

• • • • • • •

Older adult: Age- teeth, saliva, thirst, taste Other diseases - dementia, depression, diabetes, dysphagia Financial, social, supplements (D), etc.

Determinants of health - income, education, loss, loneliness, transportation Medications- dryness of the mouth, impaired smell/taste Social Determinants of Health Vitamin deficiencies (calcium, Vit D, Phosphorus, Vit B12)

7. Examine the application of the nursing process with clients at risk for aspiration.

8. Explore the religion and cultural aspects that can impact dietary choices and nutritional status.

9. Examine the rationale for diet progression and the importance of therapeutic diets.

Why is it important to progress diets gradually?

• Diet types and progression: • NPO (not by mouth) • Clear Liquids/ Fluids (CF)

• • • •

Full Liquids/Fluids (FF) Pureed (applesauce) Mechanical Soft (flaked tuna) Regular

Textures: • Soft diet • Pureed Diet • Thickened Fluids • High Fiber • Low Sodium

10.

Describe the diet therapy for these common disorders: o Anemia

o

Celiac Disease

o

Constipation and Diarrhea

o

Diverticulosis

o

Type 2 Diabetes

o

Coronary Heart Disease (including the difference between HDL and LDL)

o

Gastroesophageal reflux Disease (GERD)

o

Hiatal Hernia

o

Hypertension

o

Lactose Intolerance

11.

Discuss the application of priority nursing diagnoses for clients with altered nutritional needs.

Risk for Aspiration Imbalance Nutrition: More than body requirements.

Ineffective individual coping Imbalanced nutrition: less than body requirements Risk for Aspiration Health maintenance, ineffective Fatigue Hopelessness Activity intolerance Risk for impaired cardiovascular function Social isolation

12.

Describe the special considerations to be consider in meeting nutritional needs of client populations including. o Arthritis

o

Confusion or Dementia

o

Dysphagia Trouble eating and swallowing.

o

Blindness Set protocol usually for food placement etc.

o

Gastric Feeding via Nasogastric tube or Gastrostomytube.

Many helping devices.

13.

Explore the differences between the administration intermittent and continuous tube feeds.

For people who are unable to swallow, temp or perm.

Food and medications have to go in Gtube Meds given one at a time, flushing in between Nasogastric Tube (NG) • Small bore tube inserted in nose to the stomach • Short-term • Used for feeding, medications, or to remove unwanted fluids in stomach • Monitor for bleeding • Possibly attached to suction Gastrostomy Tube (G-tube or PEG) • Inserted directly into the stomach • Long-term use • Used for medications and feeding Jejunostomy Tube (J-tube) • Directly into the small intestine • Smaller tube than G-tube • Lower volume of feedings

• Long-term

14.

Integrate the principles of clean dressing technique to G-tube site care.

Skin Care of Tube site • Prone to skin breakdown and infection. what are the S&S of infection ?

• Clean technique. Describe!

• Dressing to be changed daily - see policy • Clean gloves, cleaning solution, dressing • What would you be looking for ?

15.

Discuss the nursing process and metaparadigm related to: o Verification of enteral tube placement

o

Administrating medications through Enteral (G-tube and NG)

• Liquid or crushed, diluted in 15-30ml water • Use 60ml Syringe, Flush prior to and after with 30ml of water • Always check placement prior to admin • G-tube/J-tube- X-ray, Aspirate contents and check pH • NG- X-ray, aspirate contents and check pH NG and G-tube Medication Admin • Ensure medications are able to be crushed • Verify tube placement • Dissolved medication – mix in 30 ml • Flush before and after administration • P&P Box 35-17 • NEVER give SOLID tablets

o

Care of enteral feeds, ▪ Initiation Prior to tube Feed/Medications • Always check DOCTORs order!!

• Dr order: check Formula type (Isosource 1.2) amount (500ml at 100ml/hr) route (via G-tube) and frequency (3 times a day) • Assess placement & site • Assess residual volume (amount left over) • Elevate HOB 45 degrees during and 2hrs after feed • Assess bowel & lung sounds • Prime the tubing

• Test pH 1hr prior to med admin or intermittent feedings, q4hr when continuous feeding • Stomach pH usually 1-5 • pH >6 in the intestines • Continuous feeds usually pH >5 • Pleural fluid is usually ph >6 ▪

Monitoring • Change bag and tubing every 24 hour • Measure residual every 8-12 • Monitor intake and output • BG levels- recommended

• Weigh pt • Monitor lab values – which ones ?

WATER FLUSH • • • • ▪

Done usually every 4 hours Maintains patent tube Maintains F&E balance Prevents dehydration

Discontinuation Evaluation and Documentation • Assessments for placement • Formula administered • Skin • Weight changes • Intake and Output • Blood sugars • Risks • Hydration • Teaching • Any signs of complications • DON’T forget Intake and Output flow sheet.

Formulas • Composed of proteins, carbs, fats, vitamins, minerals • Used to supplement caloric intake and provide nutrition • Types: Isosource 1.2, Isosource 1.5 + Fibre, ect.

• Should be at room temp before administering Complications: • Aspiration • Coughing • Gagging • Drooling

• Voice changes • Diarrhea • Constipation • Tube occlusion or dislodgement • Abdominal cramping, N/V • Electrolyte imbalance • Fluid overload • Dehydration Unit 4.2 Hydration and Nutritional Diagnostics 1. Explain assessments, and care required when a client has hydration needs.

The Older Adult and Hydration factors: Changes in body composition Immobility Bladder control Loss of taste Changes to skin – skin turgor less reliable Thirst activation decreased Kidney function Cardiovascular changes Chronic disease – nausea / diarrhea Medications

2. Examine the application of the nursing process and priority nursing diagnoses regarding the client with hydration needs.

Nursing Assessments: Physician Orders

Urine Output Respiratory Hydration assessment Insertion site Patient LOC and Orientation Vital Signs Peripheral edema Skin • • •

Your patients baseline? Vitals, edema, lung sounds • When do we assess this?

Monitor insertion site: redness, pain, swelling, warmth • When do we assess this? How often?

Monitor for signs of fluid overload • HTN, Pulmonary crackles, Dyspnea, Peripheral edema • When do we assess this?

Nursing Diagnosis: Here are some Possible priority Nursing Diagnosis Risk for Imbalanced Fluid Deficit fluid balance Excess fluid volume Risk for deficit fluid volume Risk for Infection Evaluation: How long is this used for?

• • •

Until patient's hydration status has improved Change if site has swelling, signs of infection, or pain Can remain in place for 7 days - see policy • *Change site q24-48hrs or 1.5-2L of fluid • If intermittent: change tubing and solution q24hrs • If continuous: change tubing 72-96hrs and solution q96hrs

3. Compare the differences between Hypodermoclysis and Subcutaneous Medication Port.

Hypodermoclysis (HDC) HYPO = Under DERM = Skin CLYSIS = Infusion of fluid Used to maintain hydration Instills fluid into Subcutaneous tissue Used in patients with inadequate fluid intake: NPO Fluid losses Palliative care clients Sites for administration: Upper Chest Abdomen above iliac crests Anterior aspect of thigh Supra-scapular Types of Fluid Comparison: Hypertonic

Hypertonic Higher solute OUTSIDE Higher water INSIDE Water moves OUT Cell SHRINKS Isotonic Equal Solute Equal water No nmovement Cell normal Size stays the same Hypotonic Higher Solute INSIDE Higher water OUTSIDE Water moves IN Cell SWELLS Which Types of Fluid Can you Use in HDC?

4. Discuss the use of hypodermoclysis for palliative clients and older adults.

5. Explain the rationale, equipment (including solutions), procedure used for initiation and discontinuation of Hypodermoclysis.

Equipment Needed: Winged infusion set Dressing HDC solution Drip tubing *ALWAYS prime line first

Alcohol swab(s) LABEL – What would you put on the label?

Insertion of SC Catheter: • • • • • • • • • •

Check Physician orders, Expiry dates Gather supplies and Don clean gloves Chose appropriate site, Cleanse site with alcohol swab x 30 S Hold wings together between thumb and index finger Insert at 30-45 degree angle, bevel up Release wings, lay flat and secure butterfly with occlusive transparent dressing over insertion site Remove needle portion and discard in sharps ( for Safety Intima only) Include date, time, initials, and solution on dressing/ IV line Patient Assessment may change the angle of insertion Discontinuation Hypodermoclysis:

•

Shut off flow and disconnect

❑ Loosen dressing edges and then remove ❑ Hold butterfly wings together and remove catheter tip ❑ Inspect Catheter that it is intact ❑ Cover with 2x2 gauze and discard in sharps container X 30 or bleeding has stopped ❑ Assess skin for what?

Gravity Lines To set drip rate on a gravity line….

Count the drops in the drip chamber until the number of drops falling in a minute equal your drops per minute calculation.

You can divide the number by 2 and counting for only 30 seconds (Example 12 gtt/min = 6 gtt/30 seconds) OR Divide the number by 4 and only count for 15 seconds (Example 12 gtt/min = 3 gtt/15 seconds) 6. Describe the diagnostic tests that may be ordered to determine a client's nutrition and hydration status: o CBC

o

Electrolytes (Calcium, Magnesium, Phosphorus, Sodium, Potassium, Acetate, & Chloride)

o

Blood Glucose monitoring (random and fasting)

o

HbAIC (hemoglobin AIC)

o

BUN, Creatinine

o

Serum iron and TIBC (total iron binding capacity)

o

Ferritin and Transferrin

o

Hematocrit and Hemoglobin

o

HbAIC (hemoglobin AIC)

o

Albumin

o

B12

o

Folate

o

Lipoprotein

o

Cholesterol (total, triglycerides, HDL, LDL)

o

Urinalysis

o

Vitamin D

7. Describe relevant information for documentation and reporting with regard to client's nutritional and hydration status including. o Fluid Therapy flow sheet

▪

Intake and Output (shift) Flow sheet

▪

Think of the following circumstances, what would you document ?

• • • •

For insertion • When it is already in-situ • When fluid is infusing • When removing •

(MIDTERM ENDS)

Unit 5: Elimination: Urinary and Bowel

1. Examine how the nursing metaparadigm and cultural considerations influence elimination needs of the client.

2. Discuss the factors that influence client's elimination (urinary and bowel)

3. Examine the application of the nursing process and priority nursing diagnoses regarding the client with altered elimination needs.

4. Compare the rationale and process for the collections of o Urine Culture and Sensitivity (C&S)

o

Routine Urinalysis

o

Urinary Specimen and Catheter

o

Stool Specimen

o

FIT test /Occult Blood

5. Examine the importance and relationship of specific lab values as they relate to client's elimination status.

6. o Urinalysis

o

Urine for C&S

o

BUN

o

Calcium

o

Creatinine

o

GFR-Glomerular Filtration Rate

o

Glucose

o

Hemoglobin

o

Ketone bodies

o

Microalbumin

o

PH

o

Protein

o

Specific Gravity

o

Uric Acid

o

Occult Blood (Stool)

o

Fecal Fat (Stool)

o

Stool (C&S)

o

Stool Ova and Parasite

o

Stool- D-Diff toxin.

o

Carcinoembryonic Antigen (CEA) p 1221

7. Identify diagnostic tests specific to a client's elimination status including: o Xray (Abdominal Roentgenogram)

o

CT scan

o

Cystoscopy

o

Cystogram

o

Intravenous Pyelogram (IVP)

o

Pelvic Ultrasound (Renal and Bladder)

o

Urodynamic testing

o

Upper GI (Barium Swallow)

o

Barium enema

o

Colonoscopy

o

Colorectal Transit Study

o

ERCP-Endoscopic Retrograde Cholangiopancreatography

o

MRI

o

Gastroscopy (upper GI endoscopy)

o

Sigmoidoscopy

8. Describe the effects of aging on urinary and bowel elimination.

9.

o

Urinary Incontinence

▪

o

TOILETED acronym

Bowel elimination problems

10.

Describe the effects of aging on urinary and bowel elimination.

11.

Discuss psychosocial considerations when caring for a client with altered elimination needs.

12.

Discuss health teaching strategies to improve elimination health. o Instructions for Kegel exercises

o

Bladder training

o

Bowel training

o

Constipation

13.

Examine the nursing responsibilities as it relates to medication administration for clients with altered elimination needs. o Laxatives and cathartics

o

Opioids

o

Antidiarrheal

o

Enemas and Suppositories

14.

Describe the types of urinary and bowel diversions and the nursing care required for: o Ileostomy

o

Colostomy

o

Urostomy

o

Continent ileostomy (Koch pouch)

o

Ureterostomy

o

Nephrostomy

o

Vesicostomy

o

Neobladder

15.

Describe the assessment, nursing care (including elimination products) for the following. o Application of Incontinence products

o

Care of urinary catheters (Indwelling and suprapubic)

o

Bowel Diversion (ileostomy and Colostomy)

o

Urinary Diversion (urostomy)

o

Application of condom catheter

o

Administration of enemas

o

Administration of a suppository

16.

Apply the nursing process to clients with altered elimination needs.

17.

Indicate pertinent information to document and report regarding client's eliminations status including. o Intake and Output

o

Stool Chart

Unit 6: Oxygenation 1. Describe factors that impact a client's oxygen status.

2. Describe the assessment techniques and observations required to assess holistic oxygen needs of the client.

3. Examine the application of the nursing process and priority nursing diagnoses regarding the client with oxygenation needs.

4. Describe diagnostic tests to determine a client's pulmonary function and oxygenation.

5. Describe age-related changes that may be seen in an older adult’s respiratory assessment.

6. Describe approaches used to maintain and improve a client's oxygenation status.

7. Describe related theory and safety precautions when preparing and administering inhalation medications.

8. Identify health education and teaching strategies related to a client with oxygenation needs.

9. Describe the safety precautions, nursing care, and skills associated with a client's oxygenation, including oxygen cylinder.

10.

Explain how to instruct a client on the following interventions to promote airway clearance: ▪ Positioning

▪

deep breathing and coughing techniques

▪

diaphragmatic and pursed lip breathing

▪

using an incentive spirometer

▪

monitor hydration.

▪

chest physiotherapy

▪

postural drainage

▪

medications

11.

Compare different oxygen delivery devices and guidelines for their use: ▪ nasal prongs/canula, (standard and high flow)

▪

simple mask

▪

non-rebreather mask

▪

venturi mask

12.

Describe clean technique in oropharyngeal and nasopharyngeal suctioning of an adult.

13.

Describe nursing responsibilities for preparation, administration, and health education needs for clients requiring inhalation medication by the following routes.

▪

Oxygen

▪

MDI (metered dose inhaler)

▪

DPI (dry powdered inhaler)

▪

Nebulizers

14.

Indicate pertinent information to document and report regarding a client's oxygenation status.

Unit 7: Mobility, Sleep, and Safety.

1. Describe principles of safe body mechanics.

2. Describe factors that may impact the sleep, activity, and mobility needs of a client.

3. Differentiate between sleep and rest.

4. Describe the techniques/ tools used to assess. o Sleep, and sleep disorders.

o

Activity and mobility needs

5. Explore the physical and emotional effects of inactivity/immobility on the client's physical and emotional health.

6. Examine the application of the nursing process and priority nursing diagnoses in the care for the client with mobility, safety, and sleep needs.

7. Discuss the importance of collaboration with client and family to ensure client safety during activity and rest.

8. Discuss the nursing role in assisting clients with mobility including. o Repositioning

o

Passive range of motion

o

Use of Canes

o

Use of Walkers

o

Use of Crutches

o

Application of anti-embolic stocking

o

Use of transfer belts

9. Describe assessment activities to determine a client's risk for injury and the factors increase susceptibility.

10.

Describe nursing interventions that promote the safety of older adults and reduce the risk of falls or minimize injury after a fall.

11.

Identify Health education applicable related to the use of mobility aids. (include anti-embolic stocking/compression stockings)

12.

Describe the purpose and legal, ethical, and moral implications of using protective and safety measures to restrain a client.

13.

Compare the principles, guidelines, and policies of "no restraint" and "least restraint".

14.

Explain the nurse's role in safe application and monitoring for a client in the use of

15. o

Chemical restraints

o

Environmental restraints

o

Physical restraints

o

Ambulation

16.

Describe relevant information to document and report to members of the interdisciplinary team regarding. o Sleep

o

Activity

o

Mobility

o

Client Safety

o

Restraints

Unit 8: Promoting Comfort and Managing Pain 1. Explore the concept of pain, including various classifications of pain.

2. Integrate pain assessment tools, into the application of the nursing process when caring for a client with pain.

3. Describe factors that impact a client's pain status: 4.

▪ explain the importance of understanding a patients' interpretation of pain.

▪

outline common responses to pain.

▪

describe the various terms patients may use to describe their pain.

▪

identify interventions and approaches that promote patient comfort including complementary and alternative therapies.

5. Examine the effects of culture and learned behaviours in the holistic assessment and client response to pain.

6. Explore the differences between drug seeking behaviours and client centered pain needs.

7. Identify pharmacology and non-pharmacological interventions that promote patient comfort.

8. Using the principles of pain management, discuss the responsibilities of the practical nurse in collaborating with the client, family, and interdisciplinary team in meeting a patient's pain needs.

9. Examine common sensory changes that take place as an individual ages.

10.

Explain the rationale for progression in the use of the WHO Opioid Pain Ladder

11.

Describe health education and nursing strategies to maintain a safe environment for a client with sensory deficits.

12.

Describe relevant information to document and report to members of the interdisciplinary team regarding client's sensory status and pain status.

Unit 9: Loss, Death, and Grief.

1. Articulate the significance of exploring your personal beliefs and thoughts about living, dying and death and the impact on your development as a nurse.

2. Describe factors that may impact the care of the palliative client.

3. Compare grief and bereavement.

4. Describe theories of grief, types of grief, phases of grief, and grief reactions.

5. Using the metaparadigm of nursing describe the assessment techniques and observations required to assess holistic needs of the client experiencing loss, grief, or death.

6. Describe factors that impact loss, grief, or death: o Stage of development

o

Psychosocial perspectives

o

Socioeconomic status

o

Personal relationships

o

Meaning of the loss

o

Culture and ethnicity

o

Spiritual beliefs

o

Hope

7. Describe approaches used to help a client cope with loss and grief.

8. Describe the principles of palliative care.

9. Discuss how goals of care influence nursing care of the palliative client.

10.

Describe approaches to promote comfort in clients receiving palliative care.

11.

Discuss the nursing role in MAID (Medical Assistance in Dying)

12.

Examine communication strategies for patients who are unresponsive and dying.

13.

Explain how the F.I.C.A. Model of Spiritual Assessment addresses clients' spiritual needs and influences or impacts your care.

14.

Explore ways to integrate client's traditions and practices into the nursing care received.

15.

Describe nursing care and skills associated with a client's death.

16.

Describe relevant information to document and report to members of the interdisciplinary team regarding a client's loss, grief, or death.

(FINAL EXAM ENDS)