MED SURG FINAL STUDY GUIDE
Medication Administration
Administration of an ampule - Break ampule along pre-scored line, draw
medication from ampule using filter needle, replace filter needle with
appropriate sized needle before administering injection.
Administration of ear/eye drops -
Nose: - instruct PT to clear or blow nose gently unless contraindicated.
-Help PT to supine position, tilt PTs head back for posterior pharynx, place
pillow under PTs shoulder and tilt head back for sinus'
-support head with nondominanthand
-instruct PT to breathe through mouth
-hold dropper 1 cm above nares and instill drops toward midline of ethmoid
bone
-have PT remain supine for 5 mins
-caution PT against blowing nose for several minutes
-For Spray: prime spray, help PT place nozzle into appropriate nares and
point AWAY from center of nose closing the opposite nostril, spray while
inhaling and instruct PT to hold breathe for a few seconds and breath out of
mouth upon exhalation.
Ear: -Clean outer ear if drainage is present
-place PT in side lying position (if not contraindicated) with ear to be treated
facing up or have them sit in chair or at bedside. If eardrops are a cloudy
suspension, shake for 10 seconds
-straighten ear canal by pulling auricle upward and outward
-Instill drops holding dropper 1 cm above ear canal
-keep PT in side lying position for 2-3 mins. apply gentle massage to tragus
with finger unless contraindicated
-if cotton ball is needed, place it into outermost part of canal. Remove after
15 minutes.
Administration through NG tube -
If an ET feeding is infusing, hold the feeding and verify placement of tubes
entering through the nose and the mouth by observing gastric contents and
checking pH.
elevate bed to minimum of 30 degrees, preferably 45 degrees.
, Assess gastriv residual volume: draw up 30mL of air into a 60 mL syringe,
connect feeding tube, flush with air. pull back slowly to aspirate gastric
contents, is GRV is less than 250 mL return contents to stomach. If more than
250 mL hold gastric contents and medication and contact HCP for orders.
clamp enteral tube and remove syringe, draw up 30 mL of water and flush
tubing. clamp tube again.
Syringe method: Draw up liquid medication into syringe (Do not mix
medications), connect tip to end of enteral tubing, push medication through
tube. If resistance is felt, stop and contact HCP
Gravity method: Remove plunger from syringe and reinsert syringe tip into
feeding tube, pour liquid medication or dissolved crushed medicine into syringe
and allow it to flow freely using gravity. DO NOT MIX MEDICATIONS. If
medication does not flow freely raise the height of the syringe or have PT
change position slightly. if it still doesnt flow, reinsert plunger and follow
syringe method.
Flush tube with 15-30 mL of water between each medication. after giving all
medications, flush tubing with 30-60 mL of water
Restart feeding tube if appropriate. clamp end of feeding tube if feeding is
being held for medication interaction.
Medication administration - documentation
Always document medications accurately at the time of administration
and verify any inaccurate documentation before giving medications
before administering medication ensure that the MAR accurately
reflects the patients full name, the full name of the ordered medication, the
time of administration, and the dosage, route, and frequency.
never document incidents
6 rights
Right dose
Right medication - 3 checks: before removing from med from drawer
or shelf, as it is removed from container, at PTs bedside
right route and form
right time - give priority to time critical medications, which must be
administered within 30 minutes before or after the scheduled time.
right documentation
right patient - always use two identifiers before administration, match
identifiers to PTs armband and also to the MAR
Nursing skills and PT safety
, Urine specimen collection:
midstream or clean-voided:
Female - (1) Spread labia with thumb and forefinger of
nondominanthand (2) clean area with moist towelette/gauze moving from
front to back, using fresh towelette each time. (3) While continuing to hold
labia apart have PT initiate stream. After PT starts urine stream pass
container into stream and collect 30-60 mL.
Male - (1) Hold penis with one hand and cleanse glans using
circular motion from inside out. if uncircumsized, retract skin. (2) After PT
has initiated stream, pass container into stream and collect 30-60 mL
24 hr urine collection:
Time period begins after the PT urinates and ends with a final
voiding at end of time period. In most 24 hr collections, the first specimen is
discarded
PT voids into clean receptacle, then urine is transfered to
special container which also contains specimens
depending on test, urine may need to be kept cool by setting it
in ice
each specimen must be free of feces and toilet tissue
missed specimens make the whole collection inaccurate
PT education must include an explanation of the test, emphasis
on need to collect all urine during the prescribed time period, and urine
collection procedure.
Mobility
Friction and shear occur most often when PTs bed is elevated
above 60 degrees.
ROM is maximum amount of movement available at a joint in
one of the three planes; tranverse (top and bottom), sagittal (left to right),
frontal (front to back)
Supination - palms facing forward, toes towards the outside.
Pronation - palms facing posterior, toes pointed inward.
Urinary catheter removal -
provide PT with waterproof pad under buttocks and cover with bath
blanket exposing only genital area and catheter. Position females in dorsal
recumbent position and male PTs supine.
Remove catheter securement device and free drainage tubing.
If needed provide hygiene to genital area with soap and water
, Move syringe plunger up and down to loosen and then withdraw plunger
to 0.5 mL. Insert hub of syringe into inflation valve. Allow balloon fluid to
drain into syringe by gravity. If balloon doesnt deflate fully notify health
care provider.
pull catheter out slowly and smoothly. examine it to ensure that it is
whole. do not use force to pull cath out. wrap contaminated catheter in
waterproof pad. unhook collection bag and drainage tubing from bed.
empty, measure, and record fluid present in drainage bag, and encourage
PT to increase fluid intake.
Administer an enema -
Place PT in Simms position
Add warmed solution to enema bag: warm tap water as it flows from
faucet, place saline in basin of hot water before adding saline to bag, check
temperature of solution on the inner wrist.
Raise container, release clamp, and allow solution to flow long enough
to fill tubing.
Reclamp tubing
lubricate 6-8 cm of tip of rectal tube with water soluble lubricating jelly
gently separate buttocks and locate anus. instruct PT to relax by
breathing out through mouth slowly.
insert tip of enema tube slowly by pointing tip in direction of PTs
umbilicus
hold tubing in rectum constantly until end of fluid instillation
open regulating clamp and allow solution to enter slowly while holding
container at PTs hip level
raise height of enema container slowly to appropriate level above anus.
-12-18 inches = high enema
-12 inches = regular enema
-3 inches = low enema
lower container or clamp tubing if PT complains of cramping or if fluid
escapes from around rectal tube
clamp tubing after all solution is instilled
Ask PT to retain solution as long as possible while lying in bed
Preventing constipation
Drink adequate fluids each day to maintain hydration
Eat a diet high in fiber to promote regular daily voiding
Move PT each day or encourage daily exercise to promote peristalsis
Medication Administration
Administration of an ampule - Break ampule along pre-scored line, draw
medication from ampule using filter needle, replace filter needle with
appropriate sized needle before administering injection.
Administration of ear/eye drops -
Nose: - instruct PT to clear or blow nose gently unless contraindicated.
-Help PT to supine position, tilt PTs head back for posterior pharynx, place
pillow under PTs shoulder and tilt head back for sinus'
-support head with nondominanthand
-instruct PT to breathe through mouth
-hold dropper 1 cm above nares and instill drops toward midline of ethmoid
bone
-have PT remain supine for 5 mins
-caution PT against blowing nose for several minutes
-For Spray: prime spray, help PT place nozzle into appropriate nares and
point AWAY from center of nose closing the opposite nostril, spray while
inhaling and instruct PT to hold breathe for a few seconds and breath out of
mouth upon exhalation.
Ear: -Clean outer ear if drainage is present
-place PT in side lying position (if not contraindicated) with ear to be treated
facing up or have them sit in chair or at bedside. If eardrops are a cloudy
suspension, shake for 10 seconds
-straighten ear canal by pulling auricle upward and outward
-Instill drops holding dropper 1 cm above ear canal
-keep PT in side lying position for 2-3 mins. apply gentle massage to tragus
with finger unless contraindicated
-if cotton ball is needed, place it into outermost part of canal. Remove after
15 minutes.
Administration through NG tube -
If an ET feeding is infusing, hold the feeding and verify placement of tubes
entering through the nose and the mouth by observing gastric contents and
checking pH.
elevate bed to minimum of 30 degrees, preferably 45 degrees.
, Assess gastriv residual volume: draw up 30mL of air into a 60 mL syringe,
connect feeding tube, flush with air. pull back slowly to aspirate gastric
contents, is GRV is less than 250 mL return contents to stomach. If more than
250 mL hold gastric contents and medication and contact HCP for orders.
clamp enteral tube and remove syringe, draw up 30 mL of water and flush
tubing. clamp tube again.
Syringe method: Draw up liquid medication into syringe (Do not mix
medications), connect tip to end of enteral tubing, push medication through
tube. If resistance is felt, stop and contact HCP
Gravity method: Remove plunger from syringe and reinsert syringe tip into
feeding tube, pour liquid medication or dissolved crushed medicine into syringe
and allow it to flow freely using gravity. DO NOT MIX MEDICATIONS. If
medication does not flow freely raise the height of the syringe or have PT
change position slightly. if it still doesnt flow, reinsert plunger and follow
syringe method.
Flush tube with 15-30 mL of water between each medication. after giving all
medications, flush tubing with 30-60 mL of water
Restart feeding tube if appropriate. clamp end of feeding tube if feeding is
being held for medication interaction.
Medication administration - documentation
Always document medications accurately at the time of administration
and verify any inaccurate documentation before giving medications
before administering medication ensure that the MAR accurately
reflects the patients full name, the full name of the ordered medication, the
time of administration, and the dosage, route, and frequency.
never document incidents
6 rights
Right dose
Right medication - 3 checks: before removing from med from drawer
or shelf, as it is removed from container, at PTs bedside
right route and form
right time - give priority to time critical medications, which must be
administered within 30 minutes before or after the scheduled time.
right documentation
right patient - always use two identifiers before administration, match
identifiers to PTs armband and also to the MAR
Nursing skills and PT safety
, Urine specimen collection:
midstream or clean-voided:
Female - (1) Spread labia with thumb and forefinger of
nondominanthand (2) clean area with moist towelette/gauze moving from
front to back, using fresh towelette each time. (3) While continuing to hold
labia apart have PT initiate stream. After PT starts urine stream pass
container into stream and collect 30-60 mL.
Male - (1) Hold penis with one hand and cleanse glans using
circular motion from inside out. if uncircumsized, retract skin. (2) After PT
has initiated stream, pass container into stream and collect 30-60 mL
24 hr urine collection:
Time period begins after the PT urinates and ends with a final
voiding at end of time period. In most 24 hr collections, the first specimen is
discarded
PT voids into clean receptacle, then urine is transfered to
special container which also contains specimens
depending on test, urine may need to be kept cool by setting it
in ice
each specimen must be free of feces and toilet tissue
missed specimens make the whole collection inaccurate
PT education must include an explanation of the test, emphasis
on need to collect all urine during the prescribed time period, and urine
collection procedure.
Mobility
Friction and shear occur most often when PTs bed is elevated
above 60 degrees.
ROM is maximum amount of movement available at a joint in
one of the three planes; tranverse (top and bottom), sagittal (left to right),
frontal (front to back)
Supination - palms facing forward, toes towards the outside.
Pronation - palms facing posterior, toes pointed inward.
Urinary catheter removal -
provide PT with waterproof pad under buttocks and cover with bath
blanket exposing only genital area and catheter. Position females in dorsal
recumbent position and male PTs supine.
Remove catheter securement device and free drainage tubing.
If needed provide hygiene to genital area with soap and water
, Move syringe plunger up and down to loosen and then withdraw plunger
to 0.5 mL. Insert hub of syringe into inflation valve. Allow balloon fluid to
drain into syringe by gravity. If balloon doesnt deflate fully notify health
care provider.
pull catheter out slowly and smoothly. examine it to ensure that it is
whole. do not use force to pull cath out. wrap contaminated catheter in
waterproof pad. unhook collection bag and drainage tubing from bed.
empty, measure, and record fluid present in drainage bag, and encourage
PT to increase fluid intake.
Administer an enema -
Place PT in Simms position
Add warmed solution to enema bag: warm tap water as it flows from
faucet, place saline in basin of hot water before adding saline to bag, check
temperature of solution on the inner wrist.
Raise container, release clamp, and allow solution to flow long enough
to fill tubing.
Reclamp tubing
lubricate 6-8 cm of tip of rectal tube with water soluble lubricating jelly
gently separate buttocks and locate anus. instruct PT to relax by
breathing out through mouth slowly.
insert tip of enema tube slowly by pointing tip in direction of PTs
umbilicus
hold tubing in rectum constantly until end of fluid instillation
open regulating clamp and allow solution to enter slowly while holding
container at PTs hip level
raise height of enema container slowly to appropriate level above anus.
-12-18 inches = high enema
-12 inches = regular enema
-3 inches = low enema
lower container or clamp tubing if PT complains of cramping or if fluid
escapes from around rectal tube
clamp tubing after all solution is instilled
Ask PT to retain solution as long as possible while lying in bed
Preventing constipation
Drink adequate fluids each day to maintain hydration
Eat a diet high in fiber to promote regular daily voiding
Move PT each day or encourage daily exercise to promote peristalsis
