Medication Administration

Principles of Medication Administration

I. “Six Rights” of drug administration

1. The Right Medication – when administering medications, the nurse compares the label of the medication container with medication form.
The nurse does this 3 times:

1. Before removing the container from the drawer or shelf
2. As the amount of medication ordered is removed from the container
3. Before returning the container to the storage

2. Right Dose –when performing medication calculation or conversions, the nurse should have another qualified nurse check the calculated  dose
3. Right Client – an important step in administering medication safely is being sure the medication is given to the right client.

1. To identify the client correctly:
2. The nurse checks the medication administration form against the client’s identification bracelet and asks the client to state his or      her name to ensure the client’s identification bracelet has the correct information.

4. Right Route – if a prescriber’s order neither does nor designates a route of administration, the nurse consult the prescriber. Likewise, if the specified route is not recommended, the nurse should alert the prescriber immediately.
5. Right Time

1. The nurse must know why a medication is ordered for certain times of the day and whether the time schedule can be altered
2. Each institution has are commended time schedule for medications ordered at frequent interval
3. Medication that must act at certain times are given priority (e.g insulin should be given at a precise interval before a meal)

6. Right Documentation –Documentation is an important part of safe medication administration

1. The documentation for the medication should clearly reflect the client’s name, the name of the ordered medication, the time, dose, route and frequency
2. Sign medication sheet immediately after administration of the drug

Client’s Right Related to Medication Administration

A client has the following rights:

1. To be informed of the medication’s name, purpose, action, and potential undesired effects.
2. To refuse a medication regardless of the consequences
3. To have a qualified nurses or physicians assess medication history, including allergies
4. To be properly advised of the experimental nature of medication therapy and to give written consent for its use
5. To received labeled medications safely without discomfort in accordance with the six rights of medication administration
6. To receive appropriate supportive therapy in relation to medication therapy
7. To not receive unnecessary medications

II. Practice Asepsis

• Wash hand before and after preparing the medication to reduce transfer of microorganisms.

III. Nurse who administers the medications is responsible for their own action

• Question any order that you considered incorrect (may be unclear or appropriate)

IV. Be knowledgeable about the medication that you administer

• A fundamental rule of safe drug administration is: “Never administer an unfamiliar medication”

V. Keep the Narcotics in locked place

VI. Use only medications that are in clearly labeled containers. Relabeling of drugs is the responsibility of the pharmacist.

VII. Return liquid that is cloudy in color to the pharmacy.

VIII. Before administering medication, identify the client correctly

IX. Do not leave the medication at the bedside. Stay with the client until he actually takes the medications.

X. The nurse who prepares the drug administers it. Only the nurse prepares the drug knows what the drug is. Do not accept endorsement of medication.

XI. If the client vomits after taking the medication, report this to the nurse in charge or physician.

XII. Preoperative medications are usually discontinued during the postoperative period unless ordered to be continued.

XIII. When a medication is omitted for any reason, record the fact together with the reason.

XIV. When the medication error is made, report it immediately to the nurse in charge or physician

• To implement necessary measures immediately. This may prevent any adverse effects of the drug.

Oral Administration

Advantages

1. The easiest and most desirable way to administer medication
2. Most convenient
3. Safe, does nor break skin barrier
4. Usually less expensive

Disadvantages

1. Inappropriate if client cannot swallow and if GIT has reduced motility
2. Inappropriate for client with nausea and vomiting
3. Drug may have unpleasant taste
4. Drug may discolor the teeth
5. Drug may irritate the gastric mucosa
6. Drug may be aspirated by seriously ill patient.

Drug Forms for Oral Administration

1. Solid– tablet, capsule, pill, powder
2. Liquid– syrup, suspension, emulsion, elixir, milk, or other alkaline substances.
3. Syrup– sugar-based liquid medication
4. Suspension– water-based liquid medication. Shake bottle before use of medication to properly mix it.
5. Emulsion– oil-based liquid medication
6. Elixir– alcohol-based liquid medication. After administration of elixir, allow 30 minutes to elapse before giving water. This allows maximum absorption of the medication.

“Never crush Enteric-Coated or Sustained Release Tablet”

• Crushing enteric-c-coated tablets – allows the irrigating medication to come in contact with the oral or gastric mucosa, resulting in mucositis or gastric irritation.
• Crushing sustained-released medication – allows all the medication to be absorbed at the same time, resulting in a higher than expected initial level of medication and a shorter than expected duration of action

Sublingual Administration

• A drug that is placed under the tongue, where it dissolves.
• When the medication is in capsule and ordered sublingually, the fluid must be aspirated from the capsule and placed under the tongue.
• A medication given by the sublingual route should not be swallowed, or desire effects will not be achieved

Advantages

1. Same as oral
2. Drug is rapidly absorbed in the bloodstream

Disadvantages

1. If swallowed, drug may be inactivated by gastric juices.
2. Drug must remain under the tongue until dissolved and absorbed

Buccal Administration

• A medication is held in the mouth against the mucous membranes of the cheek until the drug dissolves.
• The medication should not be chewed, swallowed, or placed under the tongue (e.g sustained release nitroglycerine, opiates, antiemetic, tranquilizer, sedatives)
• Client should be taught to alternate the cheeks with each subsequent dose to avoid mucosal irritation

Advantages

1. Same as oral
2. Drug can be administered for local effect
3. Ensures greater potency because drug directly enters the blood and bypass the liver

Disadvantages

• If swallowed, drug may be inactivated by gastric juice

Topical Administration

• Application of medication to a circumscribed area of the body.

1. Dermatologic – includes lotions, liniment and ointments, powder.

1. Before application, clean the skin thoroughly by washing the area gently with soap and water, soaking an involved site, or locally debriding tissue.
2. Use surgical asepsis when open wound is present
3. Remove previous application before the next application
4. Use gloves when applying the medication over a large surface. (e.g. large area of burns)
5. Apply only thin layer of medication to prevent systemic absorption.

2. Ophthalmic – includes instillation and irrigation

1. Instillation – to provide an eye medication that the client requires.
2. Irrigation – To clear the eye of noxious or other foreign materials.
3. Position the client either sitting or lying.
4. Use sterile technique
5. Clean the eyelid and eyelashes with sterile cotton balls moistened with sterile normal saline from the inner to the outer canthus
6. Instill eye drops into lower conjunctival sac.
7. Instill a maximum of 2 drops at a time. Wait for 5 minutes if additional drops need to be administered. This is for proper absorption of the     medication.
8. Avoid dropping a solution onto the cornea directly, because it causes discomfort.
9. Instruct the client to close the eyes gently. Shutting the eyes tightly causes spillage of the medication.
10. For liquid eye medication, press firmly on the nasolacrimal duct (inner cantus) for at least 30 seconds to prevent systemic absorption of    the medication.

3. Otic Instillation – to remove cerumen or pus or to remove foreign body

1. Straighten the ear canal:
2. Perform hand hygiene. Apply gloves if drainage is present.
3. Have the client assume a side-lying position (if not contraindicated) with ear to be treated facing up.
4. Warm the solution at room temperature or body temperature, failure to do so may cause vertigo, dizziness, nausea and pain.
   • 0-3 years old: pull the pinna downward and backward
   • Older than 3 years old: pull the pinna upward and backward
5. Instill eardrops on the side of the auditory canal to allow the drops to flow in and continue to adjust to body temperature
6. Press gently bur firmly a few times on the tragus of the ear to assist the flow of medication into the ear canal.
7. Ask the client to remain in side lying position for about 5 minutes
8. At times the MD will order insertion of cotton puff into outermost part of the canal. Do not press cotton into the canal. Remove cotton after 15 minutes.

4. Nasal – Nasal instillations usually are instilled for their astringent effects (to shrink swollen mucous membrane), to loosen secretions and facilitate drainage or to treat infections of the nasal cavity or sinuses. Decongestants, steroids, calcitonin.

1. Have the client blow the nose prior to nasal instillation
2. Assume a back lying position, or sit up and lean head back.
3. Elevate the nares slightly by pressing the thumb against the client’s tip of the nose. While the client inhales, squeeze the bottle.
4. Keep head tilted backward for 5 minutes after instillation of nasal drops.
5. When the medication is used on a daily basis, alternate nares to prevent irritations

5. Inhalation – use of nebulizer, metered-dose inhaler

1. Semi or high-fowler’s position or standing position. To enhance full chest expansion allowing deeper inhalation of the medication
2. Shake the canister several times. To mix the medication and ensure uniform dosage delivery
3. Position the mouthpiece 1 to 2 inches from the client’s open mouth. As the client starts inhaling, press the canister down to release one dose of the medication. This allows delivery of the medication more accurately into the bronchial tree rather than being trapped in the oropharynx then swallowed
4. Instruct the client to hold breath for 10 seconds to enhance complete absorption of the medication.
5. If bronchodilator, administer a maximum of 2 puffs, for at least 30 second interval. Administer bronchodilator before other inhaled medication. This opens airway and promotes greater absorption of the medication.
6. Wait at least 1 minute before administration of the second dose or inhalation of a different medication by MDI
7. Instruct client to rinse mouth, if steroid had been administered. This is to prevent fungal infection.

6. Vaginal – drug forms: tablet liquid (douches), jelly, foam and suppository.

1. Close room or curtain to provide privacy.
2. Assist client to lie in dorsal recumbent position to provide easy access and good exposure of vaginal canal, also allows suppository     to dissolve without escaping through orifice.
3. Use applicator or sterile gloves for vaginal administration of medications.

• Vaginal Irrigation – is the washing of the vagina by a liquid at low pressure. It is also called douche.
  1.  Empty the bladder before the procedure
  2. Position the client on her back with the hips higher than the shoulder (use bedpan)
  3. Irrigating container should be 30 cm (12 inches) above
  4. Ask the client to remain in bed for 5-10 minute following administration of vaginal suppository, cream, foam, jelly or irrigation

Rectal Administration

• Can be use when the drug has objectionable taste or odor.

1. Need to be refrigerated so as not to soften.
2. Apply disposable gloves.
3. Have the client lie on left side and ask to take slow deep breaths through mouth and relax anal sphincter.
4. Retract buttocks gently through the anus, past internal sphincter and against rectal wall, 10 cm (4 inches) in adults, 5 cm (2 in) in children and infants. May need to apply gentle pressure to hold buttocks together momentarily.
5. Discard gloves to proper receptacle and perform hand washing.
6. Client must remain on side for 20 minute after insertion to promote adequate absorption of the medication.

Parenteral Administration

• Administration of medication by needle.

Intradermal – under the epidermis.

1. The site are the inner lower arm, upper chest and back, and beneath the scapula.
2. Indicated for allergy and tuberculin testing and for vaccinations.
3. Use the needle gauge 25, 26, 27: needle length 3/8”, 5/8” or ½”
4. Needle at 10–15 degree angle; bevel up.
5. Inject a small amount of drug slowly over 3 to 5 seconds to form a wheal or bleb.
6. Do not massage the site of injection. To prevent irritation of the site, and to prevent absorption of the drug into the subcutaneous.

Subcutaneous– Vaccines, heparin, preoperative medication, insulin, narcotics.

Sites:

• outer aspect of the upper arms
• anterior aspect of the thighs
• Abdomen
• Scapular areas of the upper back
• Ventrogluteal
• Dorsogluteal

1. Only small doses of medication should be injected via SC route.
2. Rotate site of injection to minimize tissue damage.
3. Needle length and gauge are the same as for ID injections

• Use 5/8 needle for adults when the injection is to administer at 45 degree angle; ½ is use at a 90 degree angle.

1. For thin patients: 45 degree angle of needle
2. For obese patient: 90 degree angle of needle
3. For heparin injection: do not aspirate.
4. Do not massage the injection site to prevent hematoma formation
5. For insulin injection: Do not massage to prevent rapid absorption which may result to hypoglycemic reaction.
6. Always inject insulin at 90 degrees angle to administer the medication in the pocket between the subcutaneous and muscle layer. Adjust the length of the needle depending on the size of the client.
7. For other medications, aspirate before injection of medication to check if the blood vessel had been hit. If blood appears on pulling back of the plunger of the syringe, remove the needle and discard the medication and equipment.

Intramuscular

• Needle length is 1”, 1 ½”, 2” to reach the muscle layer
• Clean the injection site with alcoholized cotton ball to reduce microorganisms in the area.
• Inject the medication slowly to allow the tissue to accommodate volume.

Sites:
1. Ventrogluteal site

1. The area contains no large nerves, or blood vessels and less fat. It is farther from the rectal area, so it less contaminated.
2. Position the client in prone or side-lying.
3. When in prone position, curl the toes inward.
4. When side-lying position, flex the knee and hip. These ensure relaxation of gluteus muscles and minimize discomfort during injection.
5. To locate the site, place the heel of the hand over the greater trochanter, point the index finger toward the anterior superior iliac spine, and then abduct the middle (third) finger. The triangle formed by the index finger, the third finger and the crest of the ilium is the site.

2. Dorsogluteal site

1. Position the client similar to the ventrogluteal site
2. The site should not be use in infant under 3 years because the gluteal muscles are not well developed yet.
3. To locate the site, the nurse draw an imaginary line from the greater
4. trochanter to the posterior superior iliac spine. The injection site id lateral and superior to this line.
5. Another method of locating this site is to imaginary divide the buttock into four quadrants. The upper most quadrant is the site of injection. Palpate the crest of the ilium to ensure that the site is high enough.
6. Avoid hitting the sciatic nerve, major blood vessel or bone by locating the site properly.

3. Vastus Lateralis

1. Recommended site of injection for infant
2. Located at the middle third of the anterior lateral aspect of the thigh.
3. Assume back-lying or sitting position.

4. Rectus femoris site –located at the middle third, anterior aspect of thigh.
5. Deltoid site

1. Not used often for IM injection because it is relatively small muscle and is very close to the radial nerve and radial artery.
2. To locate the site, palpate the lower edge of the acromion process and the midpoint on the lateral aspect of the arm that is in line with the axilla. This is approximately 5 cm (2 in) or 2 to 3 fingerbreadths below the acromion process.

* IM injection – Z tract injection

1. Used for parenteral iron preparation. To seal the drug deep into the muscles and prevent permanent staining of the skin.
2. Retract the skin laterally, inject the medication slowly. Hold retraction of skin until the needle is withdrawn
3. Do not massage the site of injection to prevent leakage into the subcutaneous.

Intravenous

• The nurse administers medication intravenously by the following method:
  1. As mixture within large volumes of IV fluids.
  2. By injection of a bolus, or small volume, or medication through an existing intravenous infusion line or intermittent venous access (heparin or saline lock)
  3. By “piggyback” infusion of solution containing the prescribed medication and a small volume of IV fluid through an existing IV line.
• Most rapid route of absorption of medications.
• Predictable, therapeutic blood levels of medication can be obtained.
• The route can be used for clients with compromised gastrointestinal function or peripheral circulation.
• Large dose of medications can be administered by this route.
• The nurse must closely observe the client for symptoms of adverse reactions.
• The nurse should double-check the six rights of safe medication.
• If the medication has an antidote, it must be available during administration.
• When administering potent medications, the nurse assesses vital signs before, during and after infusion.

Nursing Interventions in IV Infusion

1. Verify the doctor’s order
2. Know the type, amount, and indication of IV therapy.
3. Practice strict asepsis.
4. Inform the client and explain the purpose of IV therapy to alleviate client’s anxiety.
5. Prime IV tubing to expel air. This will prevent air embolism.
6. Clean the insertion site of IV needle from center to the periphery with alcoholized cotton ball to prevent infection.
7. Shave the area of needle insertion if hairy.
8. Change the IV tubing every 72 hours. To prevent contamination.
9. Change IV needle insertion site every 72 hours to prevent thrombophlebitis.
10. Regulate IV every 15-20 minutes. To ensure administration of proper volume of IV fluid as ordered.
11. Observe for potential complications.

Types of IV Fluids

1. Isotonic solution – has the same concentration as the body fluid
   • D5 W
   • Na Cl 0.9%
   • Plain Ringer’s lactate
   • Plain Normosol M
2. Hypotonic – has lower concentration than the body fluids.
   • NaCl 0.3%
3. Hypertonic – has higher concentration than the body fluids.
   • D10W
   • D50W
   • D5LR
   • D5NM

Complication of IV Infusion

1. Infiltration – the needle is out of nein, and fluids accumulate in the subcutaneous tissues.
Assessment:

• Pain, swelling, skin is cold at needle site; pallor of the site, flow rate has decreases or stops.

Nursing Intervention:

• Change the site of needle
• Apply warm compress. This will absorb edema fluids and reduce swelling.

2. Circulatory Overload – Results from administration of excessive volume of IV fluids.
Assessment:

• Headache
• Flushed skin
• Rapid pulse
• Increase BP
• Weight gain
• Syncope and faintness
• Pulmonary edema
• Increase volume pressure
• SOB (shortness of breath)
• Coughing
• Tachypnea
• Shock

Nursing Interventions:

• Slow infusion to KVO
• Place patient in high fowler’s position. To enhance breathing
• Administer diuretic, bronchodilator as ordered

3. Drug Overload – the patient receives an excessive amount of fluid containing drugs.
Assessment:

• Dizziness
• Shock
• Fainting

Nursing Intervention:

• Slow infusion to KVO.
• Take vital signs
• Notify physician

4. Superficial Thrombophlebitis – it is due to o0veruse of a vein, irritating solution or drugs, clot formation, large bore catheters.
Assessment:

• Pain along the course of vein
• Vein may feel hard and cordlike
• Edema and redness at needle insertion site.
• Arm feels warmer than the other arm

Nursing Intervention:

• Change IV site every 72 hours
• Use large veins for irritating fluids.
• Stabilize venipuncture at area of flexion.
• Apply cold compress immediately to relieve pain and inflammation; later with warm compress to stimulate circulation and promotion absorption.
• “Do not irrigate the IV because this could push clot into the systemic circulation’

5. Air Embolism – Air manages to get into the circulatory system; 5 ml of air or more causes air embolism.
Assessment:

• Chest, shoulder, or back pain
• Hypotension
• Dyspnea
• Cyanosis
• Tachycardia
• Increase venous pressure
• Loss of consciousness

Nursing Intervention

• Do not allow IV bottle to “run dry”
• “Prime” IV tubing before starting infusion.
• Turn patient to left side in the trendelenburg position. To allow air to rise in the right side of the heart. This prevent pulmonary embolism.

6. Nerve Damage – may result from tying the arm too tightly to the splint.
Assessment

• Numbness of fingers and hands

Nursing Interventions

• Massage the are and move shoulder through its ROM
• Instruct the patient to open and close hand several times each hour.
• Physical therapy may be required

Note: apply splint with the fingers free to move.

7. Speed Shock – may result from administration of IV push medication rapidly.

• To avoid speed shock, and possible cardiac arrest, give most IV push medication over 3 to 5 minutes.

General Principles of Parenteral Administration

1. Check doctor’s order.
2. Check the expiration for medication – drug potency may increase or decrease if outdated.
3. Observe verbal and non-verbal responses toward receiving injection. Injection can be painful; client may have anxiety, which can increase the pain.
4. Practice asepsis to prevent infection. Apply disposable gloves.
5. Use appropriate needle size to minimize tissue injury.
6. Plot the site of injection properly to prevent hitting nerves, blood vessels, and bones.
7. Use separate needles for aspiration and injection of medications to prevent tissue irritation.
8. Introduce air into the vial before aspiration. To create a positive pressure with in the vial and allow easy withdrawal of the medication.
9. Allow a small air bubble (0.2 ml) in the syringe to push the medication that may remain.
10. Introduce the needle in quick thrust to lessen discomfort.
11. Either spread or pinch muscle when introducing the medication. Depending on the size of the client.
12. Minimized discomfort by applying cold compress over the injection site before introduction of medicati0n to numb nerve endings.
13. Aspirate before the introduction of medication. To check if blood vessel had been hit.
14. Support the tissue with cotton swabs before withdrawal of needle. To prevent discomfort of pulling tissues as needle is withdrawn.
15. Massage the site of injection to haste absorption.
16. Apply pressure at the site for few minutes. To prevent bleeding.
17. Evaluate effectiveness of the procedure and make relevant documentation.

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Maslow’s Hierarchy of Basic Human Needs

Definition

• Each individual has unique characteristics, but certain needs are common to all people.
• A need is something that is desirable, useful or necessary. Human needs are physiologic and psychological conditions that an individual must meet to achieve a state of health or well-being.

Physiologic

1. Oxygen
2. Fluids
3. Nutrition
4. Body temperature
5. Elimination
6. Rest and sleep
7. Sex

Safety and Security

1. Physical safety
2. Psychological safety
3. The need for shelter and freedom from harm and danger

Love and belonging

1. The need to love and be loved
2. The need to care and to be cared for.
3. The need for affection: to associate or to belong
4. The need to establish fruitful and meaningful relationships with people, institution, or organization

Self-Esteem Needs

1. Self-worth
2. Self-identity
3. Self-respect
4. Body image

Self-Actualization Needs

1. The need to learn, create and understand or comprehend
2. The need for harmonious relationships
3. The need for beauty or aesthetics
4. The need for spiritual fulfillment

Characteristics of Basic Human Needs

1. Needs are universal.
2. Needs may be met in different ways
3. Needs may be stimulated by external and internal factor
4. Priorities may be deferred
5. Needs are interrelated

Maslow’s Characteristics of a Self-Actualized Person

1. Is realistic, sees life clearly and is objective about his or her observations
2. Judges people correctly
3. Has superior perception, is more decisive
4. Has a clear notion of right or wrong
5. Is usually accurate in predicting future events
6. Understands art, music, politics and philosophy
7. Possesses humility, listens to others carefully
8. Is dedicated to some work, task, duty or vocation
9. Is highly creative, flexible, spontaneous, courageous, and willing to make mistakes
10. Is open to new ideas
11. Is self-confident and has self-respect
12. Has low degree of self-conflict; personality is integrated
13. Respect self, does not need fame, and possesses a feeling of self-control
14. Is highly independent, desires privacy
15. Can appear remote or detached
16. Is friendly, loving and governed more by inner directives than by society
17. Can make decisions contrary to popular opinion
18. Is problem centered rather than self-centered
19. Accepts the world for what it is

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Making an Unoccupied Bed

Objectives of Making an Unoccupied Bed

1. To meet the patient’s need by providing a safe comfortable bed.
2. For neatness and tidiness.

Principles of Bedmaking: (Techniques vary but principles are the same).

1. Have everything ready on hand before starting.
2. Remember that the bed is made for use, for durability and comfort and that it should have a finished appearance.
3. Place all linen on perfectly straight line on the bed, otherwise , it would be impossible to make bed tight and free from wrinkles.
4. All comes should look neat, smooth and firm.
5. Throughout the procedure, the nurse should study her movements so as to avoid waste of time and energy
6. When finished inspect the bed and see if it measures to the highest standard of health and comfort of the patient economy of time, effort and materials and smooth finished appearance

Note: Do not use torn linen and in private rooms avoid stained linen.

Equipments Needed:

• 2 large sheets
• Rubber sheet
• Draw sheet
• Pillow case
• Bath towel & wash cloth
• Pillow & mosquito net p.r.n
• Additional for private rooms
• Woolen blanket top sheet
• Extra pillow with pillow case
• Hand towel
• Bedspread or coverlet

Procedure:

1. Gather all equipment and place at the bedside table and arrange them in the order of their use.
2. Get bottom sheet and spread it lengthwise on mattress with the center fold at center of bed, with right side up and with narrow them even with foot of mattress. Tuck the head part and miter the corner nearest to you by bring the side of the sheet at night angle to the side of the mattress. Then tuck from the head part making a boxlike appearance going down to the foot part.
3. Place the rubber sheet 15 to 18 inches from the edge of the mattress. Put the draw sheet over the rubber sheet giving an allowance of one inch longer than the rubber sheet at the head part and luck both together.
4. Place the top sheet with the wrong side up wider harm at the head part in line with the upper edge of the mattress and with the centerfold along the middle of the bed. Tuck the foot part and miter the corner. Leave the side free.
5. Go to the other side of the bed.
6. Full the bottom sheets firmly, tuck at head part miter the corner and tuck the sides working towards the foot.
7. Adjust the rubber sheet and draw sheet, pull them firmly and tuck them in separately.
8. Tuck top sheet at food part and miter the corner. Leave side free. Fold back top part about 14 inches.
9. Put the pillowcase and lay pillow flat on bed with the open and of case away from the main door.
10. In the private room fold down the top sheet 18 inches away from the head part of the bed. Place a bedspread on top.
11. Hang the bath towel, hand towel and washcloth on rack
12. Straighten bed, bedside table and replace chair

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Making an Occupied Bed

Purpose

1. To change the linen with the least possible disturbance to the patient.
2. To draw or fix the sheets under the patients very firmly so that it would not wrinkle.
3. To remove crumbs from the bed.
4. To make patient feel comfortable.

Equipments

• Necessary linen.
• Tray for stripping and airing.
• Laundry bag or hamper

Procedure

1. Do the medical handwashing.
2. Gather equipments at bed side and arrange according to use. Explain procedure to patient and screen.
3. Loosen the linens starting at the foot part, then to the sides and around. Remove pillows unless contraindicated.
4. Place clean top sheet over dirty top sheet wider hem, wrong side out at the head part of bed. Spread, then remove the dirty linen without exposing the patient.
5. Turn patient towards one side of the bed.
6. Work on the unoccupied side of the bed. Roll dirty linens toward the patient (except rubber sheet).
7. Place bottom sheet following the principles, tuck head part miter corner tuck. Roll used rubber sheet towards you. Replace with a new one.
8. Place draw sheep over rubber sheet. Tuck together.
9. Turn patient towards made bed.
10. Work on the other side. Remove dirty linens.
11. Spread clean linens, tuck head part of the bottom sheet, miter at side, tuck all together. Do the same with rubber sheet and draw sheet.
12. Turn patient to the center of the bed.
13. Arrange top sheet, fold head part up to the patient’s chest.
14. Make a toe pleat.
15. Tuck foot part, miter corner.
16. Time limit, check features of a good bed and proper body mechanics.

Principles

1. Provision for privacy as situation requires.
2. Carefully turning the patient. So as to prevent over exertion and feeling or insecurity.
3. Provision of opportunity for patient to Participate.
4. Placement of top bedding so that shoulder may be covered and the necessary adjustments made over toes.
5. Careful observation of skin areas of the patient.

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Anxiety and Dizziness

Dizziness is actually a non-specific term used to describe certain symptoms, such as feeling lightheaded, faint, weak, nauseous, or unsteady. Most people see their doctors immediately when they experience any dizziness, and that is mainly because the symptoms can be very uncomfortable at times. While the condition can make you feel concerned, it is usually not due to anything very serious. In fact, anxiety and dizziness are related with each other.

Can Anxiety Cause Dizziness?

Yes, it is possible to feel dizzy when you have anxiety or are experiencing anxiety attacks. Anxiety can make you feel dizzy from the following aspects:

• Hyperventilation: It makes you feel dizzy because it disturbs your oxygen-carbon dioxide balance. During an anxiety attack, it is natural to feel hyperventilated as the result of breathing too quickly. You may also develop this condition if you have poor breathing patterns, which will then lead to insufficient supply of oxygen to your body.
• Panic: Dizziness may well be a symptom associated with panic attacks. When you panic, it is natural to feel the rush of adrenaline, which is responsible for making you feel dizzy and lightheaded.
• Vision Problems: You may notice lightheadedness and dizziness when you have certain vision problems. That happens because your brain has difficulties in interpreting your vision due to the problems you have.
• Dehydration: Not drinking enough water leads to dehydration, and dehydration can cause dizziness. Your dehydration symptoms become severe when you are also anxious or are experiencing panic attacks.

Anxiety and dizziness may be present at the same time, but you are less likely to feel dizzy for too long in this situation. If you feel dizzy more often and for extended time, it could be due to other underlying conditions such as multiple sclerosis or even low blood pressure. If you experienced lightheadedness for the first time in your life which was severe as well, you should see your doctor immediately to identify the underlying cause.

How to Overcome Dizziness Related with Anxiety

1. Deep Breathing

Deep breathing helps improve the supply of oxygen to your brain and relaxes your nervous system. This helps reduce dizziness quickly.

• Lie down on the floor with a hand on your abdomen and the thumb of your other hand placed against one nostril.
• Close your mouth and breathe in through your open nostril. Fill in your belly and feel your hand on the abdomen moving up.
• Hold your breath for a few seconds by closing your other nostril as well.
• Exhale slowly after 3 seconds. Do 10 reps.
• Be sure to sit quietly for 5 minutes after performing the exercise and breathe normally.

2. Drink Water

Not getting enough fluids can make you become dehydrated, which will lead to dizziness. You may experience the same when you engage in strenuous workouts and do not drink enough water to rehydrate your body. Diarrhea or vomiting can also cause excessive fluid loss.

• Be sure to drink a glass of water when you feel dizzy. This helps rehydrate your body and prevent dizziness.
• Try including herbal tea in your diet. You can also drink fruit juices, soups, and broths.

3. Eat Something

Anxiety and dizziness are related, and being hungry for extended hours can lower your blood sugar levels and can also make you feel dizzy. This is especially common in people who have diabetes. To resolve the issue, you should eat something when you feel dizzy and ensure you do not remain hungry for extended hours to prevent dizziness. You can opt for the following:

• Have a snack high in sugar or carbs like a banana or a chocolate bar.
• Enjoy any fruit with high water content to prevent dehydration.
• Have a bowl of yogurt with any fruit.
• Eat a handful of roasted nuts like almonds, cashews, or walnuts.

4. Change Your Position

When you feel lightheaded, you should change your position. Sit if you are standing and lie down if you are sitting. You should not try to walk when you are feeling dizzy because there is an increased risk of an injury. Here is what you should do:

• Put your head in a lower position in case you are sitting down and are feeling lightheaded.
• Be sure to remain lying down or seated for a couple of minutes or until the dizziness has passed completely.

5. Focus on a Spot

You should find a particular spot and focus on it to get dizziness under control. The technique helps dancers maintain a better control over their bodies while dancing. You can try the same.

• Just focus on a spot like a speck of dirt on the floor or a crack on the wall to lessen the sensation of spinning around.

6. Try the Epley Maneuver

The maneuver involves titling your neck and head in a specific way to treat symptoms of dizziness or vertigo. Here is how to do it:

• Sit down and tile your head towards one side. Maintain a 45 degrees angle.
• Lie back while keeping your head at the same angle and maintain this position for a couple of minutes.
• Now, turn your head again but towards the other side. You should keep your head tilted at a 90-degree angle. Slowly roll your body towards the same direction until you are looking at the floor.
• Maintain the position for another minute or so and then return to a seated position.

7. Overcome Anxiety

Dealing with stress and anxiety is never easy, and that is why you may have a hard time to solve the problem of anxiety and dizziness. Nevertheless, you can take certain steps to avoid becoming overwhelmed in your daily life. For instance:

• Try something that reduces stress. It could be a change of job, a different working schedule, reduced hours, or spending more time working from home.
• Try natural stress-relieving methods, such as yoga, meditation, deep breathing, and tai chi. 

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captopril

Generic Name : captopril

Brand Name: Apo-Capto (CAN), Capoten, Gen-Captopril (CAN), Novo-Captopril (CAN), Nu-Capto (CAN)

Classification: ACE inhibitor,  Antihypertensive
Pregnancy Category C (first trimester)
Pregnancy Category D (second and third trimesters) 

Dosage & Route

• PO HTN Initial: 12.5 mg twice daily. Maintenance: 25-50 mg twice daily. Max: 50 mg 3 times/day. Heart failure Initial: 6.25-12.5 mg 2-3 times/day. Max: 50 mg 3 times/day. Post MI Start 3 days after MI. Initial: 6.25 mg/day, may increase after several wk to 150 mg/day in divided doses if needed and tolerated. Diabetic nephropathy 25 mg 3 times/day.

Therapeutic actions

• Captopril competitively inhibits the conversion of angiotensin I (ATI) to angiotensin II (ATII), thus resulting in reduced ATII levels and aldosterone secretion. It also increases plasma renin activity and bradykinin levels. Reduction of ATII leads to decreased sodium and water retention. By these mechanisms, captopril produces a hypotensive effect and a beneficial effect in congestive heart failure.
  • Absorption: 60-75% absorbed from the GI tract (oral); peak plasma concentrations after 1 hr. Absorption may be reduced in the presence of food.
  • Distribution: Protein-binding: 30%; crosses the placenta and enters breast milk at about 1% of maternal blood concentrations.
  • Excretion: Via urine (40-50% as unchanged, the rest as disulfide and other metabolites); 2-3 hr (elimination half-life), may be increased in renal impairment. Removed by hemodialysis.

Indications

• Treatment of hypertension alone or in combination with thiazide-type diuretics
• Treatment of CHF in patients unresponsive to conventional therapy; used with diuretics and digitalis
• Treatment of diabetic nephropathy
• Treatment of left ventricular dysfunction after MI
• Unlabeled uses: Management of hypertensive crises; treatment of rheumatoid arthritis; diagnosis of anatomic renal artery stenosis, hypertension related to scleroderma renal crisis; diagnosis of primary aldosteronism, idiopathic edema; Bartter’s syndrome; Raynaud’s syndrome

Adverse effects

• Hypotension, tachycardia, chest pain, palpitations, pruritus, hyperkalemia. Proteinuria; angioedema, skin rashes; taste disturbance, nonproductive cough, headache.
• Potentially Fatal: Neutropenia, usually occurs within 3 mth of starting therapy especially in patients with renal dysfunction or collagen diseases. Hyperkalaemia. Anaphylactic reactions.

Contraindications

• Known hypersensitivity to the drug. Bilateral renal artery stenosis, hereditary angioedema; renal impairment; pregnancy.

Nursing considerations

Assessment

• History: Allergy to captopril, history of angioedema, impaired renal function, CHF, salt or volume depletion, pregnancy, lactation
• Physical: Skin color, lesions, turgor; T; P, BP, peripheral perfusion; mucous membranes, bowel sounds, liver evaluation; urinalysis, LFTs, renal function tests, CBC and differential

Interventions

• Administer 1 hr before meals.
• WARNING: Ensure that patient is not pregnant before beginning treatment. Encourage use of contraceptives; if pregnancy is detected, stop drug.
• WARNING: Alert surgeon and mark patient’s chart with notice that captopril is being taken; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion.
• Monitor patient closely for fall in BP secondary to reduction in fluid volume (due to excessive perspiration, and dehydration, vomiting, or diarrhea); excessive hypotension may occur.
• Reduce dosage in patients with impaired renal function.

Teaching points

• Take drug 1 hour before meals; do not take with food. Do not stop without consulting your health care provider.
• Be careful of drop in blood pressure (occurs most often with diarrhea, sweating, vomiting, or dehydration); if light-headedness or dizziness occurs, consult your health care provider.
• Severe fetal damage can occur if captopril is taken during pregnancy. Use of contraceptives is advised; if pregnancy should occur, stop drug and notify health care provider.
• Avoid over-the-counter medications, especially cough, cold, allergy medications that may contain ingredients that will interact with ACE inhibitors. Consult your health care provider.
• You may experience these side effects: Cough, GI upset, loss of appetite, change in taste perception (limited effects, will pass); mouth sores (frequent mouth care may help); rash; fast heart rate; dizziness, light-headedness (usually passes after the first few days; change position slowly, and limit your activities to those that do not require alertness and precision).
• Report mouth sores; sore throat, fever, chills; swelling of the hands or feet; irregular heartbeat, chest pains; swelling of the face, eyes, lips or tongue; difficulty breathing.

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calcitonin

Calcitonin (Cibacalcin) is an hormonal agent indicated for patients with Paget’s disease.

Generic Names & Brand Names

calcitonin
(kal si toe’ nin)
calcitonin, human
Cibacalcin
calcitonin, salmon
Calcimar, Caltine (CAN), Miacalcin, Miacalcin Nasal Spray, Osteocalcin

Pregnancy Category C (human) 
Pregnancy Category B (salmon)

Drug classes

• Hormonal agent
• Calcium regulator

Therapeutic actions

The calcitonins are polypeptide hormones secreted by the thyroid; human calcitonin is a synthetic product classified as an orphan drug; salmon calcitonin appears to be a chemically identical polypeptide but with greater potency per milligram and longer duration; inhibits bone resorption; lowers elevated serum calcium in children and patients with Paget’s disease; increases the excretion of filtered phosphate, calcium, and sodium by the kidney.

Indications

• Human and salmon calcitonin: Paget’s disease
• Salmon calcitonin: Postmenopausal osteoporosis in conjunction with adequate calcium and vitamin D intake to prevent loss of bone mass
• Salmon calcitonin: Hypercalcemia, emergency treatment

Contraindications and cautions

• Contraindicated with allergy to salmon calcitonin or fish products, lactation.
• Use cautiously with renal insufficiency, osteoporosis, pernicious anemia.

Available forms

Injection (human)—1 mg/mL; injection (salmon)—200 IU/mL; nasal spray (salmon)—200 IU/actuation

Dosages

ADULTS

Calcitonin, human

• Paget’s disease: Starting dose of 0.5 mg/day subcutaneously; some patients may respond to 0.5 mg two to three times per week or 0.25 mg/day. Severe cases may require up to 1 mg/day for 6 mo. Discontinue therapy when symptoms are relieved.

Calcitonin, salmon

• Skin testing: 0.1 mL of a 10 IU/mL solution injected subcutaneously.
• Paget’s disease: Initial dose 100 IU/day IM or subcutaneously. For maintenance dose, 50 IU/day or every other day. Actual dose should be determined by patient response.
• Postmenopausal osteoporosis: 100 IU/day IM or subcutaneously, with supplemental calcium (calcium carbonate, 1.5 g/day) and vitamin D (400 units/day) or 200 IU intranasally daily.
• Hypercalcemia: Initial dose, 4 IU/kg q 12 hr IM or subcutaneously. If response is not satisfactory after 1–2 days, increase to 8 IU/kg q 12 hr; if response remains unsatisfactory after 2 more days, increase to 8 IU/kg q 6 hr.

PEDIATRIC PATIENTS

Safety and efficacy not established.

Pharmacokinetics

Route	Onset	Peak	Duration
IM, SC	15 min	16–25 min	8–24 hr
Nasal	Rapid	31–39 min	8–24 hr

Metabolism: Renal; T_1/2: 43 min (salmon), 1 hr (human)
Distribution: May enter breast milk
Excretion: Urine

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Making a Recovery or Anesthetic Bed (Post-Operative Bed)

I. Purpose

1. To provide warmth and comfort for the patient.
2. To provide protection for the bed.
3. To arrange the bed and other furniture in order to facilitate the transfer of the patient from stretcher to bed.

II. Equipment

• The same linen as those used for making on occupied bed plus the following”
• Bath towel
• Small robber sheet
• Woolen blanket
• 3 hot water bags w/cover p.r.n.

On the Bedside Table:

• Stethoscope
• Sphygmomanometer
• Kidney basin
• Swipes
• Padded tongue depressor
• p.r.n.
• Observation Sheet

In the Room

• Oxygen tank with complete
• Tubbings, humidifier and nassal catheter
• Suction apparatus
• Stand
• Drainage bottles

III. Procedure:

1. Strip on the bed and turn the mattress.
2. Make an ordinary bed with the top sheet untucked at the foot part. (If weather is cold, place bath blanket over the top sheet.) Fold back lop side of the sheet about 14 inches and the bottom side folded back even with the foot of the mattress.
3. Fanfold together the top sheet and blanket towards the side away from the door.
4. Place the small rubber sheet across the hood part of the bed.
5. Place the bath towel over the small rubber sheet.
6. Slip the pillowcase and put the pillow upright against the bars of the head of the bed.
7. Put the hot water bags at the foot and center of the bed if the weather is cold.
8. Place the necessary articles on the bedside table and the irrigating stand, suction machine and oxygen set-up adjacent to the bed.
9. Arrange unit.

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Lifting and Moving Patient from Bed

A. MOVING TO THE SIDE OF THE BED

1. Stand facing patient at the side of the bed.
2. Assume a broad stance, one leg forward of the other with knees and hips flexed, bring arms to the level of the bed.
3. Place one arm under shoulders and neck pf patient and another arm under small of patient’s back.
4. Shift body weight from front to back foot, rock backward to a crouch position, bringing patients towards his side. Nurse’s hips come downwards as he rocks backwards. Patient should be pulled.

B. HELPING THE PATIENT TURN ON HIS SIDE

1. Stand at the side of the bed towards which patient is to be turned. Place patient’s far arm across his chest and far leg over near leg, near arm is lateral to and away from his body.
2. Stand opposite to the patient’s waist and face side of the bed with one foot a step in front of the other.
3. Place one hand on patient’s far shoulder and one hand on his far hip.
4. Shift weight from forwarded leg to rear leg, patient is turned towards the nurse hips come downward.
5. Patient is stopped by nurse’s elbows, which come to rest on mattress at the edge of the bed.

C. RAISING SHOULDERS OF THE HELPLESS PATIENT

1. Stand at side of the side of the bed and face patient head.
2. Assume a wide stance with foot next to bed behind the other foot.
3. Pass arm over the patient’s near shoulders and rest hand between patient’s shoulder blades.
4. Rock backward, shift weight from forwarded foot to rear foot, hips coming straight down.

 D. RAISING THE SHOULDERS OF TH SEMI HELPLESS PATIENT

1. Stand at one side of the bed facing the head of the patient. Foot next to bed is to rear and the other foot forward. Provide wide base of support.
2. Bend knees to bring arm next to bed down to a level with a surface of the bed.
3. With elbow on the patient‘s bed grasps the nurse’s arm in the same manner.
4. Rock forward, shift weight from forwarded foot to rear foot to bring hips downward. Elbow remains on bed, which serves as fulcrum.

E. MOVING THE HELPLESS PATIENT UP IN BED

1. Stand at the side of the bed and face the far corner of the foot of the bed.
2. Flex knees so that arms are leveled with the bed. Put arm under patient, one arm under patient’s head and shoulders, one hand under small of his back.
3. Rock forward. Shift weight from forwarded foot to rear foot, hips coming downward. Patient will slide diagonally across the bed towards the head and side of the bed.
4. Repeat from tuck and legs of patient.
5. Go to the other side of the bed and repeat number 1 – 3. Continue this process until patient is satisfactorily positioned.

F. MOVING THE SEMI HELPLESS PATIENT UP IN BED

1. Patient flexes knees, bringing heels up to his buttocks.
2. Stand at the side of the bed, turn slightly towards patient’s head. One foot is stepped in front of the other foot closer to bed. Feet are directed towards the head of the bed.
3. Place one arm under patient’s shoulders, one arm under thighs. Flex knees to bring arms to the level of the surface of the bed.
4. Patient places chin on his chest and pushes with his feet. Nurse shifts weight from rear foot to forwarded foot. Patient grasps the head of the bed with his hands to pull on his own weight.

 G. HELPING THE SEMI HELPLESS: PATIENT RAISE HIS BUTTOCKS

1. Patient flexes knees and brings heels towards the buttocks.
2. Nurse faces the side of the bed and stands opposite to the patient’s buttocks. Assume a board stance.
3. Flex knees to bring arms to the level of the bed, place one hand under sacral area of the patient. The elbow is resting firmly on the 3 bed.
4. As the patient raises his hips, the nurse comes to a crouching position by bending his knees while his arms act as a lever to help support the patient’s buttocks. Nurse’s hips come straight down. While supporting patient in this position, free hand can place bedpan under the patient’s sacral area.

 H. ASSISTING THE PATIENT TO A SITING POSITION ON THE SIDE OF THE BED

1. Patient is turned to the side towards the edge of the bed.
2. The nurse ensures that the patient does not fall out of the bed by raising the head of the bed.
3. Face the far bottom corner of the bed, support the shoulders of the patient with one arm and the other arm helps patient extend lower legs over the side of the bed top the rear of the other foot.
4. Bring patient to a natural sitting position on the bed; support the patient’s shoulders and legs over the side of the bed. Pivot body to lower legs of the patient. Patient’s legs are swung downward. Nurse’s weight is shifted form front to rear leg.

I. ASSISTING THE PATIENT TO GET OF BED AND INTO A CHAIR

1. The patient assumes a suiting position on the edge of the bed, put on shoes/slipper and gown.
2. Place the chair at the side of the bed with back towards foot of the bed.
3. Stand facing patient with foot closer to the chair and a step in front of the other to give the nurse a wide base of support.
4. Place patient’s hands on the nurses shoulders and the nurse grasps patient’s waist.
5. Patient steps on the floor and the nurse flexes her knees, forwarded knee is against the patient knee. This provides patient’s knees bending involuntarily.
6. Turn with the patient while maintaining a wide base of support. Bend knees as the patient sits on chair.

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Leavell and Clark’s Three Levels of Prevention

Primary Prevention

• Seeks to prevent a disease or condition at a prepathologic state; to stop something from ever happening.

Health Promotion

• health education
• marriage counseling
• genetic screening
• good standard of nutrition adjusted to developmental phase of life

Specific Protection

• use of specific immunization
• attention to personal hygiene
• use of environmental sanitation
• protection against occupational hazards
• protection from accidents
• use of specific nutrients
• protections from carcinogens
• avoidance to allergens

Secondary Prevention

• Also known as “Health Maintenance”. Seeks to identify specific illnesses or conditions at an early stage with prompt intervention to prevent or limit disability; to prevent catastrophic effects that could occur if proper attention and treatment are not provided

Early Diagnosis and Prompt Treatment

• case finding measures
• individual and mass screening survey
• prevent spread of communicable disease
• prevent complication and sequelae
• shorten period of disability

Disability Limitations

• Adequate treatment to arrest disease process and prevent further complication and sequelae.
• Provision of facilities to limit disability and prevent death.

Tertiary Prevention

• Occurs after a disease or disability has occurred and the recovery process has begun; Intent is to halt the disease or injury process and assist the person in obtaining an optimal health status. To establish a high-level wellness. “To maximize use of remaining capacities’

Restoration and Rehabilitation

• Work therapy in hospital
• Use of shelter colony

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